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|The impact of preoperative total parenteral nutrition on the surgical complications of Crohn's disease: A retrospective cohort study
Thamer A Bin Traiki1, Sulaiman A Alshammari1, Nadia A Aljomah2, Monirah M Alsalouli2, Esraa S Altawil3, Maha-Hamadien Abdulla1, Noura S Alhassan1, Khayal A Alkhayal1
1 Department of Surgery, Colorectal Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Pharmacy Department, Clinical Pharmacy Services, King Saud University Medical City, Riyadh, Saudi Arabia
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|Date of Submission||23-Sep-2022|
|Date of Acceptance||23-Oct-2022|
|Date of Web Publication||30-Dec-2022|
| Abstract|| |
Background: Crohn's disease (CD) is associated with malnutrition, an independent risk factor for surgical morbidity and mortality in more than 65% of patients, with a significant impact on disease outcomes. In this single-center retrospective cohort study, we aimed to investigate the impact of total parenteral nutrition (TPN) on the surgical outcomes of patients with CD.
Methods: This study included patients with CD who underwent abdominal surgery. We compared patients who received preoperative total parenteral nutrition (TPN group) to those who did not (non-TPN group). Prolonged oral intolerance, albumin level <30 g/L, and body mass index <18.5 were the main indications for TPN. We evaluated postoperative surgical complications in both groups.
Results: Between January 2010 and October 2018, 169 eligible patients underwent abdominal surgery. The TPN and non-TPN groups included 40 and 129 patients, respectively. The mean albumin level was significantly lower in the TPN group (P = 0.013). Laparoscopic surgery was performed in 76.9% of the patients, with a conversion rate of 11.6%. Infectious and non-infectious complications developed in 8.9% and 16% of patients, respectively. Surgical complications were comparable between the groups (P >0.05).
Conclusions: Despite oral intake intolerance and severe disease in the TPN group, the surgical complications were comparable between the groups.
Keywords: Crohn's disease, malnutrition, oral intake intolerance, surgical complications, total parenteral nutrition
|How to cite this URL:|
Traiki TA, Alshammari SA, Aljomah NA, Alsalouli MM, Altawil ES, Abdulla MH, Alhassan NS, Alkhayal KA. The impact of preoperative total parenteral nutrition on the surgical complications of Crohn's disease: A retrospective cohort study. Saudi J Gastroenterol [Epub ahead of print] [cited 2023 Feb 2]. Available from: https://www.saudijgastro.com/preprintarticle.asp?id=366286
| Introduction|| |
Crohn's disease (CD) is an autoimmune inflammatory bowel disease that can affect any part of the gastrointestinal tract. Malnutrition affects a large proportion of patients with inflammatory bowel disease; an estimated 65%–75% of patients with CD are malnourished. In most patients, malnutrition is primarily responsible for chronic weight loss and contributes significantly to disease morbidity and mortality. Immunomodulators and biological medications are the cornerstones of treatment. However, half the patients with CD will require surgery within 10 years of diagnosis. A high number of surgical complications, long hospital stays, decreased quality of life, and high health costs have been reported in malnourished patients.,, More than 10% of body mass loss over a 3-month period indicates severe malnutrition and mandates preoperative enteral or parenteral nutritional optimization.
Preoperative nutritional optimization in malnourished patients has been approved to improve postoperative outcomes in gastrointestinal surgeries. Nutritional support should begin at least 7–10 days before surgery. Preoperative exclusive enteral nutrition results in few surgical complications, low reoperation rates, and extension of the immunomodulator-free interval. Total parenteral nutrition (TPN) is an intravenous nutrition solution that provides the daily requirement of macronutrients, vitamins, minerals, and electrolytes. The ECCO-ESCP guidelines advise that the administration of TPN be considered for malnourished patients with CD who cannot tolerate oral intake. However, TPN has several complications that may be related to the solution itself or to the technique of intravenous administration. These complications can be potentially prevented with good awareness and surveillance.
In this study, we evaluated the impact of preoperative TPN on the surgical complications of CD patients who underwent abdominal surgery.
| Patients and Methods|| |
This retrospective study was conducted at a single university hospital. All adult patients with CD who underwent abdominal surgery between January 2010 and October 2018 were included. Patients who underwent abdominal surgery without bowel resection were excluded. Also, patients who underwent diverting stoma or strictureplasty without bowel resection were excluded as well. The patients were divided into two groups based on their preoperative TPN use, i.e. those in the TPN group who received the solution and those in the non-TPN group who did not. Indications for TPN in our study were an inability to tolerate oral administration, an albumin level of <30 g/L, or a body mass index of <18.5. The study was approved by the institutional review board committee of King Saud University (Project number: E-19-4078).
Patient data was accessed through medical records. Baseline demographics, disease characteristics, and surgical intervention data were collected. Data on infectious and non-infectious postoperative complications were collected and analyzed to assess whether treatment with TPN impacted the surgical outcomes of patients with CD.
TPN was started based on the patient's condition and after an agreement was reached between the surgeon and the clinical pharmacist. TPN was given to patients with active CD and severe nutritional deficits one or two weeks before surgery, to reduce postoperative complications and to establish conditions that allowed for more conservative surgical procedures.
The patients were given a customized 2-in-1 TPN formula (consisting of dextrose, amino acids, electrolytes, vitamins, and trace elements with intravenous fat emulsion administered on a separate line) via central catheter, using a peripherally inserted central catheter (PICC) line. Macronutrient doses were calculated based on patients' actual body weight, with 1.5–1.8 g/kg of amino acids, 4–5 mg/kg/min of dextrose, and 1–1.5 g/kg of lipids as targets. TPN administration was started slowly, with daily macronutrient advancement over 3–4 days until targets were reached. The target total calories for well-nourished patients were 25–30 kcal/kg, while preoperative malnourished patients required 35–45 kcal/kg.
Glutamine is a conditionally essential amino acid that has a significant trophic effect on the intestinal mucosa, as it is considered an energy source for enterocytes. Unless otherwise indicated, glutamine was added to the TPN formula at a dose of 1.5 mL/kg.
TPN patients rely on an adequate supply of micronutrients. Furthermore, antioxidant vitamins and cofactors such as selenium are required, especially in cases of active inflammatory bowel disease (IBD) where antioxidant requirements are extremely high. The multivitamin and trace element doses were given in accordance with the manufacturer's recommendations.
Categorical variables were compared using Person's Chi-square test or Fisher's exact test, as appropriate. Continuous parametric variables were compared using Student's t-test. Univariate and multivariate analyses were conducted using logistic regression. Statistical significance was set at P < 0.05, and all tests were two-tailed. Stata version 15.0 (Stata Corp, College Station, TX, USA) was used for all statistical analyses.
| Results|| |
A total of 169 patients with CD underwent major gastrointestinal resection between January 2010 and October 2018. Preoperative TPN was administered in 40 (23.7%) patients. [Table 1] presents a basic descriptive analysis. The mean albumin level was significantly lower in the TPN group (P = 0.013) than in the non-TPN group. The stricturing form of the disease occurred most commonly (in 84 [49.7%] patients), followed by the fistulizing form (in 73 [43.2%] patients). The most common procedure was ileocecal resection (75.7%) followed by hemi/total colectomy (23.1%). Temporary (14.2%) and permanent stomas (4.1%) were created in addition to bowel resection. Strictureplasty was performed only in two patients (1.6%) of the non-TPN group. Laparoscopy was performed in 130 (76.9%) patients, and 13.1% of laparoscopies were converted to open surgery.
|Table 1: Baseline demographics, disease characterization, and surgical intervention|
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TPN formula and related complications
The most common indications for TPN in our study were the inability to tolerate orally or prolonged nil peroral (NPO). The average duration of TPN use was 12 days, and the majority of patients met their calorie targets, with a mean of 32 kcal/kg. [Table 2] shows the TPN formula's contents.
Hyperglycemia (25%), hypertriglyceridemia (15%), steatosis (12.5%), bloodstream infections (10%), and cholestasis (7.5%) were the most common complications in our study [Figure 1].
The surgical complications experienced are shown in [Table 3] and [Figure 2]; surgical complications were documented in 42 patients (24.9%). Infectious complications occurred in 9.3% of the non-TPN group and 7.5% of the TPN group. There were no significant differences between the two groups in terms of surgical complications.
The univariate and multivariate logistic regression analyses of predictors of complications are shown in [Table 4] and [Table 5]. Anastomotic leak was the only significant predictor of infectious complications in the univariate analysis; however, the confidence interval was wide due to the small sample size.
|Table 4: Predictability of non-infectious complications using multivariate and univariate logistic regression analysis|
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|Table 5: Predictability of infectious complications using multivariate and univariate logistic regression analysis|
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| Discussion|| |
In the present study, we evaluated the impact of preoperative TPN on patients with CD who underwent major abdominal surgery. Although the TPN group had oral intolerance and more severe disease, the surgical complications in this group were comparable to those in the non-TPN group.
Infectious complications are a concern when TPN is used: a lower number of infectious complications has been reported in patients receiving nutritional support via the enteral route., However, multiple studies have documented fewer infectious complications with preoperative TPN administration in malnourished patients undergoing general surgery.,, Central line-related infections range from 9% to 15% in recent studies,, and higher than 30% in older studies., Central lines that are inserted for parenteral nutrition carry a higher risk of line infection than other insertion indications.,,, The number of infectious surgical complications was lower in the TPN group in our study than in the non-TPN group; however, this difference was not statistically significant. Line infection was documented in four (10%) patients, which is in accordance with previous studies.
Patients with CD have an increased risk of malnutrition and surgical complications,,; postoperative morbidity was reported to be 20%–30% with an anastomotic leak rate of 2.8%–3.7%., In our study, 75% of the population had a body mass index of <18.5, and more than half of the patients had albumin levels of <30 g/L. Surgical complications were found in 24.9% of the patients, and anastomotic leakage occurred at a rate of 3.4%.
Before the era of biological treatment of CD, multiple studies during the 1980s reported that when administered preoperatively, TPN had a positive impact on surgical outcomes.,, Rombeau et al. and Gouma et al. reported fewer postoperative complications in the preoperative TPN group compared to patients who did not receive TPN. Lashner et al.'s study did not show a significant difference in postoperative complications between the TPN and non-TPN groups; however, a shorter length of bowel resection was noted in the TPN group. A study published in 2012 compared 15 patients with CD who received preoperative TPN to 105 controls. None of the patients in the TPN group developed complications, but the control group had a 28% incidence of postoperative complications. In a multicenter study, preoperative TPN did not show better postoperative morbidity in patients with CD following ileocecal resection. Ayoub et al. assessed the impact of preoperative TPN on 55 of 144 patients with CD. There were no significant differences in the postoperative complications between the two groups. However, patients who received TPN for >60 days had fewer non-infectious postoperative complications, with no increase in infectious complications. In our study, the mean TPN duration was 12.9 (±9.2) days. Postoperative complications were comparable between the preoperative TPN and non-TPN groups. The duration of TPN did not show any predictability in multivariate and univariate regression analyses.
Minimally invasive laparoscopic surgery is the preferred approach for CD. Recent studies have revealed fewer postoperative complications, faster recovery, and shorter hospital stays with the laparoscopic approach, than with open surgery. The ECCO guidelines recommend laparoscopic surgery as the first-line surgical approach. The rate of laparoscopic surgery in patients with CD ranges from 49% to 83.3%, with a conversion rate of 7.1% to 12.3%.,,, Similar to previous studies, the rate of laparoscopic approach in our study was 77%, with a conversion rate of 11.6%. Our results, similar to Ayoub et al.'s results, revealed that preoperative TPN had no influence on the laparoscopic approach rate.
This study has some limitations such as the small sample size, the retrospective nature, the lack of accurate malnutrition severity assessment, and single-center enrollment. These limitations mandate further studies and randomized trials with better malnutrition assessment and comparable groups to evaluate and generalize our results.
In conclusion, although patients in the TPN group in our study had oral intake intolerance and low albumin levels, preoperative nutritional optimization with TPN resulted in comparable postoperative complications to those in patients who did not receive TPN treatment. The use of preoperative TPN may be beneficial in malnourished CD patients who cannot tolerate orally.
The authors are grateful to the Deanship of Scientific Research, King Saud University, for funding through the Vice Deanship of Scientific Research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Molodecky NA, Soon IS, Rabi DM, Ghali WA, Ferris M, Chernoff G, et al
. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology 2012;142:46-54 e42; quiz e30.
Scaldaferri F, Pizzoferrato M, Lopetuso LR, Musca T, Ingravalle F, Sicignano LL, et al
. Nutrition and IBD: Malnutrition and/or sarcopenia? A practical guide. Gastroenterol Res Pract 2017;2017:8646495.
Frolkis AD, Dykeman J, Negron ME, Debruyn J, Jette N, Fiest KM, et al
. Risk of surgery for inflammatory bowel diseases has decreased over time: A systematic review and meta-analysis of population-based studies. Gastroenterology 2013;145:996-1006.
Bischoff SC, Escher J, Hebuterne X, Klek S, Krznaric Z, Schneider S, et al
. ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2020;39:632-53.
Casanova MJ, Chaparro M, Molina B, Merino O, Batanero R, Duenas-Sadornil C, et al
. Prevalence of malnutrition and nutritional characteristics of patients with inflammatory bowel disease. J Crohns Colitis 2017;11:1430-9.
Grass F, Pache B, Martin D, Hahnloser D, Demartines N, Hubner M. Preoperative nutritional conditioning of Crohn's patients-Systematic review of current evidence and practice. Nutrients 2017;9:562.
Bemelman WA, Warusavitarne J, Sampietro GM, Serclova Z, Zmora O, Luglio G, et al
. ECCO-ESCP consensus on surgery for Crohn's disease. J Crohns Colitis 2018;12:1-16.
Abunnaja S, Cuviello A, Sanchez JA. Enteral and parenteral nutrition in the perioperative period: State of the art. Nutrients 2013;5:608-23.
Li Y, Zuo L, Zhu W, Gong J, Zhang W, Gu L, et al
. Role of exclusive enteral nutrition in the preoperative optimization of patients with Crohn's disease following immunosuppressive therapy. Medicine (Baltimore) 2015;94:e478.
Caio G, Lungaro L, Caputo F, Zoli E, Giancola F, Chiarioni G, et al
. Nutritional treatment in Crohn's disease. Nutrients 2021;13:1628.
Rombeau JL, Barot LR, Williamson CE, Mullen JL. Preoperative total parenteral nutrition and surgical outcome in patients with inflammatory bowel disease. Am J Surg 1982;143:139-43.
Peter JV, Moran JL, Phillips-Hughes J. A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med 2005;33:213-20; discussion 60-1.
Weimann A, Braga M, Carli F, Higashiguchi T, Hubner M, Klek S, et al
. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017;36:623-50.
Heyland DK, Montalvo M, MacDonald S, Keefe L, Su XY, Drover JW. Total parenteral nutrition in the surgical patient: A meta-analysis. Can J Surg 2001;44:102-11.
Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: A meta-analysis. Am J Clin Nutr 2001;74:534-42.
Comerlato PH, Stefani J, Viana MV, Viana LV. Infectious complications associated with parenteral nutrition in intensive care unit and non-intensive care unit patients. Braz J Infect Dis 2020;24:137-43.
Fonseca G, Burgermaster M, Larson E, Seres DS. The relationship between parenteral nutrition and central line-associated bloodstream infections: 2009-2014. JPEN J Parenter Enteral Nutr 2018;42:171-5.
Ioannides-Demos LL, Liolios L, Topliss DJ, McLean AJ. A prospective audit of total parenteral nutrition at a major teaching hospital. Med J Aust 1995;163:233, 235-7.
Yilmaz G, Koksal I, Aydin K, Caylan R, Sucu N, Aksoy F. Risk factors of catheter-related bloodstream infections in parenteral nutrition catheterization. JPEN J Parenter Enteral Nutr 2007;31:284-7.
Parienti JJ, Mongardon N, Megarbane B, Mira JP, Kalfon P, Gros A, et al
. Intravascular complications of central venous catheterization by insertion site. N Engl J Med 2015;373:1220-9.
Lin KY, Cheng A, Chang YC, Hung MC, Wang JT, Sheng WH, et al
. Central line-associated bloodstream infections among critically-ill patients in the era of bundle care. J Microbiol Immunol Infect 2017;50:339-48.
Ippolito P, Larson EL, Furuya EY, Liu J, Seres DS. Utility of electronic medical records to assess the relationship between parenteral nutrition and central line-associated bloodstream infections in adult hospitalized patients. JPEN J Parenter Enteral Nutr 2015;39:929-34.
Fumery M, Seksik P, Auzolle C, Munoz-Bongrand N, Gornet JM, Boschetti G, et al
. Postoperative complications after ileocecal resection in Crohn's disease: A Prospective study from the REMIND Group. Am J Gastroenterol 2017;112:337-45.
Celentano V, Pellino G, Spinelli A, Selvaggi F; SICCR Current status of Crohn's disease surgery collaborative, Celentano V, et al
. Anastomosis configuration and technique following ileocaecal resection for Crohn's disease: A multicentre study. Updates Surg 2021;73:149-56.
Gouma DJ, von Meyenfeldt MF, Rouflart M, Soeters PB. Preoperative total parenteral nutrition (TPN) in severe Crohn's disease. Surgery 1988;103:648-52.
Lashner BA, Evans AA, Hanauer SB. Preoperative total parenteral nutrition for bowel resection in Crohn's disease. Dig Dis Sci 1989;34:741-6.
Jacobson S. Early postoperative complications in patients with Crohn's disease given and not given preoperative total parenteral nutrition. Scand J Gastroenterol 2012;47:170-7.
Ayoub F, Kamel AY, Ouni A, Chaudhry N, Ader Y, Tan S, et al
. Pre-operative total parenteral nutrition improves post-operative outcomes in a subset of Crohn's disease patients undergoing major abdominal surgery. Gastroenterol Rep (Oxf) 2019;7:107-14.
Patel SV, Patel SV, Ramagopalan SV, Ott MC. Laparoscopic surgery for Crohn's disease: A meta-analysis of perioperative complications and long term outcomes compared with open surgery. BMC Surg 2013;13:14.
Wan J, Liu C, Yuan XQ, Yang MQ, Wu XC, Gao RY, et al
. Laparoscopy for Crohn's disease: A comprehensive exploration of minimally invasive surgical techniques. World J Gastrointest Surg 2021;13:1190-201.
Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J, Armuzzi A, et al
. ECCO guidelines on therapeutics in Crohn's disease: Surgical treatment. J Crohns Colitis 2020;14:155-68.
de Buck van Overstraeten A, Eshuis EJ, Vermeire S, Van Assche G, Ferrante M, D'Haens GR, et al
. Short- and medium-term outcomes following primary ileocaecal resection for Crohn's disease in two specialist centres. Br J Surg 2017;104:1713-22.
Sulaiman A Alshammari,
Colorectal Research Chair, Department of Surgery, College of Medicine, King Saud University, Riyadh - 11461
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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