Leitlinien Update Leitlinien Update

Chirurgie und Transplantation Chirurgie und Transplantation

Modelle der Outcome-Bewertung

• Modell 1: Das biomedizinische Modell (klassische Endpunkte)

• Modell 2: Das gesundheitsökonomische Modell (Kosten)

• Modell 3: Das entscheidungstheoretische Modell (medical decision making)

• Modell 4: Das patientenzentrierte Modell (Lebensqualität)

• Modell 5: Das Drei-Komponenten-Modell (Integration von klassischen und patienten-zentrierten Endpunkten)

Koller M et al. Outcome models in clinical studieKoller M et al. Outcome models in clinical studie s: implications for evaluating , Clin Nutr 2012 s: implications for evaluating , Clin Nutr 2012

1.1. Is preoperative fasting necessary? Is preoperative fasting necessary?

Preoperative fasting from midnight is unnecessary Preoperative fasting from midnight is unnecessary in most patients. in most patients. Patients undergoing surgery, who are considered to Patients undergoing surgery, who are considered to have no specific risk of aspiration, shall drink cl ear have no specific risk of aspiration, shall drink cl ear fluids until two hours before anaesthesia. fluids until two hours before anaesthesia. Solids shall be allowed until six hours before Solids shall be allowed until six hours before anaesthesia (A) (BM, MC, QL). anaesthesia (A) (BM, MC, QL).

2.2. Is preoperative metabolic preparation of the Is preoperative metabolic preparation of the elective patient using carbohydrate treatment usefu l?elective patient using carbohydrate treatment usefu l?

In order to reduce perioperative dyscomfortIn order to reduce perioperative dyscomfort preoperative preoperative carbohydrate loading (instead of overnight fasting, carbohydrate loading (instead of overnight fasting, the night before and two hours before surgery) shal l bethe night before and two hours before surgery) shal l beadministeredadministered (A).(A). (QL). With regard to(QL). With regard to body composition body composition and hospital length of stayand hospital length of stay further advantages further advantages should be considered (B) (BM). should be considered (B) (BM).

Mathur et al, Br J Surg 2010; 97: 485 Mathur et al, Br J Surg 2010; 97: 485 -- 494494

Metabolische KonditionierungMetabolische KonditionierungMetabolische Konditionierung

Mathur et al, Br J Surg 2010; 97: 485 Mathur et al, Br J Surg 2010; 97: 485 -- 494494

Metabolische KonditionierungMetabolische KonditionierungMetabolische Konditionierung

DockDock --Nascimento et al, JPEN 2012; 36: 43 Nascimento et al, JPEN 2012; 36: 43

Metabolic conditioningMetabolic conditioningMetabolic conditioningMetabolische und immunologische KonditionierungGlukose + Glutamin

Metabolische und immunologische KonditionierungMetabolische und immunologische KonditionierungGlukose + Glutamin Glukose + Glutamin

DockDock --Nascimento et al, JPEN 2012; Nascimento et al, JPEN 2012; 36: 43 36: 43 -- 5252

Metabolische und immunologische KonditionierungGlukose + Glutamin

Metabolische und immunologische KonditionierungMetabolische und immunologische KonditionierungGlukose + Glutamin Glukose + Glutamin

Braga et al, Nutrition 2012; 28: 160 Braga et al, Nutrition 2012; 28: 160 -- 164164

Metabolische und immunologische KonditionierungGlukose + Glutamin + Antioxidanzien + grüner Tee

Metabolische und immunologische KonditionierungMetabolische und immunologische KonditionierungGlukose + Glutamin + Antioxidanzien + grGlukose + Glutamin + Antioxidanzien + gr üüner Tee ner Tee

3.3. Is postoperative interruption of oral nutritional Is postoperative interruption of oral nutritional intake generally necessary after surgery?intake generally necessary after surgery?

In general,In general, oral nutritional intake shall not be oral nutritional intake shall not be interruptedinterrupted after surgery (A) (BM, MC) after surgery (A) (BM, MC) It is recommended to adapt oral intakeIt is recommended to adapt oral intake accordingaccordingto individual tolerance and to the type of surgery to individual tolerance and to the type of surgery carried out (C). carried out (C).

(Oral intake, including clear liquids, shall(Oral intake, including clear liquids, shall be initiated be initiated within hours after surgery in most patients includi ng within hours after surgery in most patients includi ng those undergoing colon resections (A) )those undergoing colon resections (A) )

Früh enterale Ernährung und postoperative Rekonvale szenzFrFrüüh enterale Ernh enterale Ern äährung und postoperative Rekonvaleszenzhrung und postoperative Rekonvaleszenz

HanHan--Geurts et al, Br J Surg 2007; 94: 555 Geurts et al, Br J Surg 2007; 94: 555 -- 561561

Osland et al, JPEN 2011; 35: 473Osland et al, JPEN 2011; 35: 473 --485485

Perioperative ErnährungPerioperative ErnPerioperative Ern äährunghrung

Osland et al, JPEN 2011; 35: 473Osland et al, JPEN 2011; 35: 473 --485485

Perioperative ErnährungPerioperative ErnPerioperative Ern äährunghrung

Varadhan et al, Clin Nutr 2010; 29: 434Varadhan et al, Clin Nutr 2010; 29: 434 --440440

ERAS and early enteral nutrition ERAS and early enteral nutrition ERAS and early enteral nutrition

4.4. When isWhen is nutritional support indicated in the nutritional support indicated in the surgical patient ?surgical patient ?

4.14.1 It is recommended to assess the nutritionalIt is recommended to assess the nutritionalstatus before and after major surgerystatus before and after major surgery (C).(C).

Schwegler et al, Br J Surg 2010; 97: 92 Schwegler et al, Br J Surg 2010; 97: 92 -- 9797

Perioperative ErnährungPerioperative ErnPerioperative Ern äährunghrung

Hekimian et al, Akt Ernähr Med 2011; 36: 103 - 107

Perioperative Ernährung

Charakterisierung des hohen ernährungsmedizinischen Risikos

Charakterisierung des hohen Charakterisierung des hohen ernern äährungsmedizinischen Risikoshrungsmedizinischen Risikos

•••• Subjective Global Assessment Grad C

•••• BMI < 18.5 kg/m 2

•••• Gewichtsverlust größer 10 % in den letzten 6 Monaten

•••• Serum-Albumin < 30 g/l (sofern Ausschluß einer Leber- oder Nierenerkrankung)

DGEMDGEM--Arbeitsgruppe Chirurgie und TransplantationArbeitsgruppe Chirurgie und TransplantationESPEN ESPEN –– Guidelines Enteral Nutrition 2006Guidelines Enteral Nutrition 2006

4.1a Nutritional support is indicated in patients wi th malnutrition and even in patients withoutsignificant malnutrition, if it is anticipated that the patient will be unable to eat for more than seven days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60-75% of recommended intake for more than ten days. In these situations, it is recommended to initiate nutritional support (preferably by the enteral route) without delay (C).

4.1b 4.1b -- If the energy and nutrient requirements cannot If the energy and nutrient requirements cannot be met by oral and enteral intake alone be met by oral and enteral intake alone (<60% of caloric requirement), a combination (<60% of caloric requirement), a combination of enteral and parenteral nutrition is of enteral and parenteral nutrition is recommended (C). recommended (C).

-- Total PN (TPN) shall be started if nutritional Total PN (TPN) shall be started if nutritional support is indicated and there is an support is indicated and there is an contraindication for enteral nutrition, such as contraindication for enteral nutrition, such as in intestinal obstruction (A). (BM)in intestinal obstruction (A). (BM)

4.1c4.1c For administration of TPN a threeFor administration of TPN a three --chamber bag chamber bag (all(all --inin --one) should be preferred instead of a one) should be preferred instead of a multibottle system. (B) (HE)multibottle system. (B) (HE)

4.1d Standardised operative procedures for nutriti onal 4.1d Standardised operative procedures for nutriti onal support are recommendedsupport are recommended to secure an effective to secure an effective nutrition therapy (C) (cf. Advice and examples nutrition therapy (C) (cf. Advice and examples for postoperative PN on general wards, below). for postoperative PN on general wards, below).

4.2 Is there an indication for supplementing 4.2 Is there an indication for supplementing i.v. glutaminei.v. glutamine-- Currently,Currently, postoperative parenteral postoperative parenteral

supplementation of glutamine dipeptide supplementation of glutamine dipeptide solutions should be startedsolutions should be started only in severely only in severely malnourished patients who cannot be malnourished patients who cannot be adequately fed enterally and, therefore, adequately fed enterally and, therefore, require PN (B) (BM, HE).require PN (B) (BM, HE).

Wang et al, JPEN 2010; 34: 521 Wang et al, JPEN 2010; 34: 521 -- 529529

Glutamin parenteral Glutamin parenteral Glutamin parenteral

4.3 Is there an indication for supplementing 4.3 Is there an indication for supplementing i.v. omega.i.v. omega. --33--fatty acids?fatty acids?

Currently,Currently, postoperative parenteral supplementation postoperative parenteral supplementation of omegaof omega --33--fatty acidsfatty acids should be started only inshould be started only inmalnourished patients who cannot be adequately malnourished patients who cannot be adequately fed enterally and, therefore, require PN (B) (BM, H E).fed enterally and, therefore, require PN (B) (BM, H E).

4.3 Is there an indication for supplementing4.3 Is there an indication for supplementingi.v. omega.i.v. omega. --33--fatty acids?fatty acids?-- Currently,Currently, postoperative parenteral postoperative parenteral supplementation of omegasupplementation of omega --33--fatty acidsfatty acidsshould be started only inshould be started only in malnourished malnourished patients who cannot be adequately fed patients who cannot be adequately fed enterally and, therefore, require PN (B) (BM, HE).enterally and, therefore, require PN (B) (BM, HE).

Chen et al, JPEN 2010; 34: 387 Chen et al, JPEN 2010; 34: 387 -- 394394

Fish oil containing lipid emulsion in parenteral nu tritionFish oil containing lipid emulsion in parenteral nu tritionFish oil containing lipid emulsion in parenteral nu trition

4.4 When is preoperative nutritional support indica ted?

4.4.1 Patients with severe nutritional risk shall be nefit from nutritional support prior to major surgery (A) even if surgery has to be delayed (BM).

Präoperative ErnährungPrPrääoperative Ernoperative Ern äährunghrung

4.4.2 When is preoperative enteral nutrition indicate d?

Whenever feasible, the oral route shall be preferre d (A) (BM, HE, QL) .

4.4.3 Because many patients do not meet their 4.4.3 Because many patients do not meet their energy needs from normal foodenergy needs from normal food it is it is recommended torecommended to encourage them to takeencourage them to takeONS during the preoperative period (C). ONS during the preoperative period (C).

4.4.44.4.4 Preoperatively, ONS shall be given to all Preoperatively, ONS shall be given to all malnourished cancer and highmalnourished cancer and high --risk patients risk patients undergoing major abdominal surgeryundergoing major abdominal surgery (A) (BM, HE). (A) (BM, HE).

4.4.5 Immune modulating diets4.4.5 Immune modulating diets including including (arginine, omega(arginine, omega --3 fatty acids and nucleotides)3 fatty acids and nucleotides)should be preferred (B) (BM, HE) andshould be preferred (B) (BM, HE) andadministered for five to seven days.administered for five to seven days.

Stableforth et al, Int J Oral Maxillofac Surg 2009; 38: 103Stableforth et al, Int J Oral Maxillofac Surg 2009; 38: 103--110110

ImmunonutritionImmunonutrition

Surgery for head and neck cancerSurgery for head and neck cancer

--3.5d3.5d

Marik et al, Marik et al, JPEN 2010; JPEN 2010; 34: 378 34: 378 -- 386386

ImmunonutritionImmunonutritionImmunonutrition

Cerantola et al, Br J Surg 2011; 98: 37 Cerantola et al, Br J Surg 2011; 98: 37 -- 4848

ImmunonutritionImmunonutrition

Drover et al, J Am Coll Surg 2011; 212: 385Drover et al, J Am Coll Surg 2011; 212: 385 --399399

ImmunonutritionImmunonutritionImmunonutrition

ImmunonutritionImmunonutritionImmunonutrition

Analyse von Metaanalysen zur perioperativen Analyse von Metaanalysen zur perioperativen klinischen Ernklinischen Ern äährung hrung

•••••••• Die vorliegende Evidenz erscheint aufgrund der Die vorliegende Evidenz erscheint aufgrund der beschriebenen Inkonsistenzen fbeschriebenen Inkonsistenzen f üür eine starker eine starkeLeitlinienempfehlung nicht geeignetLeitlinienempfehlung nicht geeignet ..

Nothacker M, Evidenzbericht Mai 2012: Nothacker M, Evidenzbericht Mai 2012: ÄÄrztliches Zentrum frztliches Zentrum füür Qualitr Qualitäät in der Medizin t in der Medizin

HHüübner et al, Eur J Clin Nutr 2012; 66: 850 bner et al, Eur J Clin Nutr 2012; 66: 850 -- 855855

Immunonutrition surgical patients at nutritional risk - NRS > 3

Immunonutrition Immunonutrition surgical patients at nutritional risk surgical patients at nutritional risk -- NRS > 3NRS > 3

HHüübner et al, Eur J Clin Nutr 2012; 66: 850 bner et al, Eur J Clin Nutr 2012; 66: 850 -- 855855

ImmunonutritionImmunonutritionImmunonutrition

HHüübner et al, bner et al, Eur J Clin Nutr 2012; Eur J Clin Nutr 2012; 66: 850 66: 850 -- 855855

ImmunonutritionImmunonutritionImmunonutrition

Marimuthu et al, Ann Surg 2012; 225: 1060 Marimuthu et al, Ann Surg 2012; 225: 1060 -- 10681068

ImmunonutritionImmunonutritionImmunonutrition

Marimuthu et al, Ann Surg 2012; 225: 1060 Marimuthu et al, Ann Surg 2012; 225: 1060 -- 10681068

ImmunonutritionImmunonutritionImmunonutrition

4.4.6 Preoperative EN / ONS should preferably be 4.4.6 Preoperative EN / ONS should preferably be administered prior toadministered prior to hospitalhospital admissionadmission to to avoid unnecessary hospitalization and to avoid unnecessary hospitalization and to lower the risk of nosocomial infections (GCP) lower the risk of nosocomial infections (GCP) (BM, HE, QL)(BM, HE, QL)

4.5 When is preoperative PN indicated?4.5 When is preoperative PN indicated?

Preoperative PNPreoperative PN shall be administered onlyshall be administered only in in patients with severe nutritional risk where energy patients with severe nutritional risk where energy requirement cannot be adequately met by enteral requirement cannot be adequately met by enteral nutrition (A) (BM).nutrition (A) (BM).

Präoperative ErnährungPrPrääoperative Ernoperative Ern äährunghrung

McClave et al, JPEN 2009; 33: 277 McClave et al, JPEN 2009; 33: 277 -- 316316

If a patient is expected to undergo major upper GI surge ry and EIf a patient is expected to undergo major upper GI surge ry and E N is not N is not

feasible, PN should be provided under very specific conditions:feasible, PN should be provided under very specific conditions:

•••••••• If the patient is malnourished, PN should be initiat ed 5 If the patient is malnourished, PN should be initiat ed 5 –– 7 days 7 days

preoperatively and continued into the postoperative pe riod. (Grapreoperatively and continued into the postoperative pe riod. (Gra de: B)de: B)

SCCM / A.S.P.E.N. SCCM / A.S.P.E.N. –– GuidelinesGuidelines

Nutrition support therapy in the adult critically i ll patientNutrition support therapy in the adult critically i ll patient

G.L. Hill, Clin Nutr 1994; 13: 331 G.L. Hill, Clin Nutr 1994; 13: 331 -- 340340

Präoperative ErnährungPrPrääoperative Ernoperative Ern äährunghrung

4.5.1 Glucose should be given intravenously4.5.1 Glucose should be given intravenously during during the night before surgery in patients who cannotthe night before surgery in patients who cannotbe enterally fed.be enterally fed. (B) (BM) (B) (BM) –– see 2.1.see 2.1.

5. POSTOPERATIVE NUTRITION5. POSTOPERATIVE NUTRITION

5.1 Which patients benefit from early postoperative TF?5.1 Which patients benefit from early postoperative TF?

Early TF (within 24 h) shall be initiated in patien ts in Early TF (within 24 h) shall be initiated in patien ts in whom early oral nutrition cannot be started whom early oral nutrition cannot be started (see table 1), in case of(see table 1), in case of-- patients undergoing major head and neck or patients undergoing major head and neck or

gastrointestinal surgery for cancer (A) (BM)gastrointestinal surgery for cancer (A) (BM)-- patients with severe trauma including brain patients with severe trauma including brain

injury( A)injury( A) (BM) (BM) -- patients with obvious malnutrition at the time patients with obvious malnutrition at the time

of surgery (A) (BM)of surgery (A) (BM)-- patients in whom oral intake will be inadequate patients in whom oral intake will be inadequate

(<60%) for more than 10 days (C)(<60%) for more than 10 days (C)

5.2 Which formulae should be used?5.2 Which formulae should be used?

In most patients a standard whole protein formula i s In most patients a standard whole protein formula i s appropriate (C).appropriate (C). For technicalFor technical reasons with tube clotting and reasons with tube clotting and the risk of infection the use of homethe risk of infection the use of home made diets for tube made diets for tube feeding cannot be recommended (C).feeding cannot be recommended (C).

In patients with obvious severe nutritional risk at the time In patients with obvious severe nutritional risk at the time of surgery as well as those undergoing major head a nd of surgery as well as those undergoing major head a nd neck or gastrointestinal surgery for cancer or seve re trauma, neck or gastrointestinal surgery for cancer or seve re trauma, the immune modulating formulae (enriched with argin ine, the immune modulating formulae (enriched with argin ine, ωω--3 fatty acids and nucleotides) should be used (B)3 fatty acids and nucleotides) should be used (B) (BM, HE).(BM, HE).Whenever possible administration of these supplemen ted Whenever possible administration of these supplemen ted formulae should be started before surgery (B) and c ontinued formulae should be started before surgery (B) and c ontinued postoperatively for five to seven days after uncomp licatedpostoperatively for five to seven days after uncomp licatedsurgery (C).surgery (C).

5.3 How should patients be tube fed after surgery?5.3 How should patients be tube fed after surgery?

5.3.1 Placement of a needle catheter jejunostomy 5.3.1 Placement of a needle catheter jejunostomy or nasoor naso --jejunal tube should be routinejejunal tube should be routine for all for all candidates for TF undergoing major upper GIcandidates for TF undergoing major upper GI --and pancreaticand pancreatic surgery (B). (BM)surgery (B). (BM)

5.3.2 TF shall be initiated within 24 hours 5.3.2 TF shall be initiated within 24 hours after surgery (A). (BM)after surgery (A). (BM)

5.3.3 It is recommended to start TF with a low 5.3.3 It is recommended to start TF with a low flow rate (e.g. 10 flow rate (e.g. 10 –– max. 20 ml/h) due to max. 20 ml/h) due to limited intestinal tolerance (C). It may takelimited intestinal tolerance (C). It may takefive to seven days to reach the target intake (C).five to seven days to reach the target intake (C).

5.3.4 If long term TF (>4 weeks) is necessary, 5.3.4 If long term TF (>4 weeks) is necessary, e.g. in severe head injury, placement of a e.g. in severe head injury, placement of a percutaneous tube (e.g. percutaneous percutaneous tube (e.g. percutaneous endoscopic gastrostomy endoscopic gastrostomy -- PEG) is PEG) is recommended (C). recommended (C).

5.4 Which patients will benefit from EN after 5.4 Which patients will benefit from EN after discharge from the hospital?discharge from the hospital?

Regular reassessment of nutritional status during Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuatio n the stay in hospital and, if necessary, continuatio n of nutritional support including dietary counseling of nutritional support including dietary counseling after discharge , is advised for patients who have after discharge , is advised for patients who have received nutritional support perioperatively (C).received nutritional support perioperatively (C).

6. ORGAN TRANSPLANTATION6. ORGAN TRANSPLANTATION

6.1 When is EN necessary before solid organ 6.1 When is EN necessary before solid organ transplantation?transplantation?

6.1.1 Malnutrition is a major factor influencing ou tcome after 6.1.1 Malnutrition is a major factor influencing ou tcome after transplantation, so optimising nutritional status i s transplantation, so optimising nutritional status i s recommended (C). recommended (C). In malnutrition, additional ONS or even TF is advis ed (In malnutrition, additional ONS or even TF is advis ed (C). C).

Regular assessment of nutritional status shall be Regular assessment of nutritional status shall be required while monitoring patients on the waiting required while monitoring patients on the waiting list before transplantation (GCP) (C)list before transplantation (GCP) (C)

Recommendations for the living donor and recipient Recommendations for the living donor and recipient are no different from those for patients undergoing are no different from those for patients undergoing major abdominal surgery (C). major abdominal surgery (C).

Particular issues regarding the influence of EN on Particular issues regarding the influence of EN on the course/progression of liver disease are the course/progression of liver disease are discussed in the hepatology chapter.discussed in the hepatology chapter.

6.2 6.2 When is nutritional support indicated after When is nutritional support indicated after solid organ transplantation?solid organ transplantation?

6.2.1 After heart, lung, liver, pancreas, and kidne y 6.2.1 After heart, lung, liver, pancreas, and kidne y transplantation, early intake of normal food or transplantation, early intake of normal food or EN is recommended within 24 hrs (C). EN is recommended within 24 hrs (C).

6.2.2 Even after transplantation of the small inte stine, 6.2.2 Even after transplantation of the small inte stine, nutritional support can be initiated early, nutritional support can be initiated early, but should be increased very carefully within but should be increased very carefully within the first week.the first week.

6.2.3 If necessary enteral and parenteral nutritio n 6.2.3 If necessary enteral and parenteral nutritio n should be combinedshould be combined (C). (C). Longterm nutritional monitoring and advice Longterm nutritional monitoring and advice is recommended for all transplants (C). is recommended for all transplants (C).

7. Specific aspects in Paediatric Surgery7. Specific aspects in Paediatric Surgery

The recommendations on early postoperative The recommendations on early postoperative reestablishing of oral feeding generally apply also reestablishing of oral feeding generally apply also to infants, children and adolescents (C). to infants, children and adolescents (C).

CHIR 10.1 Do patients benefit from micronutrient supplementation in acute wounds with regard to wound healing?

• Supplementation of trace elements, such as zinc, vitamin A and C, carotin, and/or other micronutrients is recommended for normal wound healing (C) (MC)

• Patients: normal wound patients, not malnourished, with acute wounds

• Supplementation with commercial available drug preparations

11. Coerper S, Beckert S, Becker HD: Possible interve ntions in imp. Coerper S, Beckert S, Becker HD: Possible interve ntions in imp aired wound healing (2004), Der Chirurg 75, S471aired wound healing (2004), Der Chirurg 75, S471 --7762. 7762. 2. 2. Mayers S: ErnMayers S: Ern äährungstherapie bei Dekubitus (2000) J. f. Ernhrungstherapie bei Dekubitus (2000) J. f. Ern äährungsmedizin, S 11hrungsmedizin, S 11 --12123. Kurmann S, Burrowes JD: Ern3. Kurmann S, Burrowes JD: Ern äährung des nicht kritisch kranken Wundpatienten hrung des nicht kritisch kranken Wundpatienten –– spezielle Supplemente (2009) Aktuelle spezielle Supplemente (2009) Aktuelle ErnErnäährungsmedizin 34, S269hrungsmedizin 34, S269 --277277

CHIR 10.2 Do patients benefit from enteral nutrition in wound h ealing and LOS after head/neck surgery?

• A study from head and neck surgery for cancer• Immunonutrition versus standard protein formula

in 90 patients. • No significant differences in plasma levels of

proteins, such as albumin, prealbumin. • Significant results for a lesser number of

fistulas, however the over-all rate of wound complications showed no differences. Also there was a significant reduction of hospital length of stay (25,8 vs. 35 days). (B) (BM)

De Luis DA, Izaola O, Cuellar L, Terroba MC, Aller R: RandomizedDe Luis DA, Izaola O, Cuellar L, Terroba MC, Aller R: Randomized clinical trial with an enteral arginineclinical trial with an enteral arginine --enhanced formula in early enhanced formula in early postsurgical head and neck cancer patients (2004) E ur J Clin Nutpostsurgical head and neck cancer patients (2004) E ur J Clin Nut r 58, S1505r 58, S1505--150150

CHIR 10.3 Will additional EN prevent pressure ulcer development ?

• EN on a regular base shall be effective to prevent the development of pressure ulcer (A)

• 28 ICU patients with an acute lung injury (ALI) were randomized to additional EN (EPA and GLA) for 7 days versus a standard diet.

• A study includes 103 patients after hip fracture. The results showed lesser pressure ulcer in patients in the therapy group. Stage I pressure ulcer 55% versus 59%, but for stage II 18 % versus 28 %.

Theilla M, Singer P, Cohen J, DeKeyser F: a diet en riched in eicTheilla M, Singer P, Cohen J, DeKeyser F: a diet en riched in eic opentanoic acid, gammaopentanoic acid, gamma --linolenic acid and antioxidants in the prevention o f new ulcer linolenic acid and antioxidants in the prevention o f new ulcer formation in critically ill patients with acute lun g injury: a rformation in critically ill patients with acute lun g injury: a r andomized, prospective, controlled study (2007) Cli nical Nutritiandomized, prospective, controlled study (2007) Cli nical Nutriti on, 26, S 752on, 26, S 752 --757757Houwing RH, Rozendaal M, WoutersHouwing RH, Rozendaal M, Wouters --Wesseling W, Beulens JWJ, Buskens E, Haalboom JR: A randomized, Wesseling W, Beulens JWJ, Buskens E, Haalboom JR: A randomized, doubledouble --blind assessment of the effect of blind assessment of the effect of nutritional supplementation on the prevention of pr essure ulcer nutritional supplementation on the prevention of pr essure ulcer in hipin hip --fracture patients (2003) Clinical Nutrition, 22, S 401fracture patients (2003) Clinical Nutrition, 22, S 401--405405

CHIR 10.4 Will pressure ulcer healing be better with additional application of 4,5g arginine for 3 weeks?

• Arginin supplementation of 4.5g for 3 weeks and standard hospital diet benefits in pressure ulcer healing (B)

• 23 patients with pressure ulcer stage II to IV. 4,5g or 9g arginine-enriched supplement for 3 weeks

• No differences in expected healing in both groups, 4.5 g arginine is as effective as 9g. Malnourished patients showed significant impaired healing rates.

Leigh, B et al: The effect of different doses of an arginineLeigh, B et al: The effect of different doses of an arginine --containing supplement on the healing of pressure ul cer. J Wound containing supplement on the healing of pressure ul cer. J Wound Care 21 (2012) 150Care 21 (2012) 150--156156

CHIR 10.5 Is wound healing of pressure ulcer more effective when using supplemental EN?

• Supplemental EN leads to a higher intake of energy and also of proteins and trace elements. EN shall be adminis tered in order to achieve - earlier and better wound healing (A)- better exsudate management (A)- and an improvement in energy related blood paramet ers (A).In case of a pressure ulcer the daily calories inta ke should be 30-35 kcal/kg body weight (B).

Ohura T, Nakajo T, Okada T, Omura K, Adachi K: Eval uation of effOhura T, Nakajo T, Okada T, Omura K, Adachi K: Eval uation of eff ects of nutrition intervention on healing of pressu re ulcers andects of nutrition intervention on healing of pressu re ulcers and nutritonal states nutritonal states (randomized controlled trail (2011) Wound Repair Re g., 19, S330(randomized controlled trail (2011) Wound Repair Re g., 19, S330--336336Van Anholt RD, Sobotka L, Meijer EP, Heymann H, Gro en HW, TopinkVan Anholt RD, Sobotka L, Meijer EP, Heymann H, Gro en HW, Topink ovov àà E, van Leen M, Schols JMGA: Specific nutritional su pport acceleE, van Leen M, Schols JMGA: Specific nutritional su pport accele rates pressure rates pressure ulcer healing and reduces wound care intensity in n onulcer healing and reduces wound care intensity in n on --malnourished patients (2010) Nutrition 26: S867malnourished patients (2010) Nutrition 26: S867 --872872Stratton TJ, Engfer M et al: Enteral nutrition supp ort in prevenStratton TJ, Engfer M et al: Enteral nutrition supp ort in preven tion and treatment of pressure ulcers: a systematic review and mtion and treatment of pressure ulcers: a systematic review and m etaeta--analysis (2005) Age analysis (2005) Age Res Rev., 4, S422Res Rev., 4, S422 --450450

CHIR 10.6 ONS improve wound healing in patients w ith major burns?

• The additional supplementation of EN in patients wi th major burns can be recommended in order to improve wound healing (C)

• Different studies from Berger et al in 2007 and also a Cochrane analysis from 2009 focused on trace elements in major burn patients. The interpretation is difficult. Small studies demonstrating early recovery and better wound healing. The Cochrane analysis showed no significant results, however only 3 RCT’s are valuable for the analysis.

Berger MM, Binnert C, Chiolero RL, Taylor W, Raffou l W, Cayeux MBerger MM, Binnert C, Chiolero RL, Taylor W, Raffou l W, Cayeux M C, Benathan M, Shenkin A, Tappy L: Trace element su pplementationC, Benathan M, Shenkin A, Tappy L: Trace element su pplementation after major burns after major burns increases burned skin trace element concentrations and modulatesincreases burned skin trace element concentrations and modulates local protein metabolism but not wholelocal protein metabolism but not whole --body substrate metabolism (2007) Am J Clin body substrate metabolism (2007) Am J Clin Nutr, 85, S1301Nutr, 85, S1301 --13061306Berger MM, Baines M, Raffoul W, Benathon M, Chioler o RL, Reeves Berger MM, Baines M, Raffoul W, Benathon M, Chioler o RL, Reeves C, Revelly JP, Cayeux MC, Senechaud I, Shenkin A: T race element C, Revelly JP, Cayeux MC, Senechaud I, Shenkin A: T race element supplementation supplementation after major burns modulates antioxidant status and clinical courafter major burns modulates antioxidant status and clinical cour se by way of increased tissue trace element concent ration(2007) se by way of increased tissue trace element concent ration(2007) Am J Clin Nutr, 85, Am J Clin Nutr, 85, S1293S1293--13001300Wasiak J, Cleland H, Jeffery R: Early versus delaye d enteral nutWasiak J, Cleland H, Jeffery R: Early versus delaye d enteral nut rition support for burn injuries (2009)Cochrane Dat abase of systrition support for burn injuries (2009)Cochrane Dat abase of syst ematic reviews, Issue 1ematic reviews, Issue 1

CHIR 10.7 Do ONS influence wound healing ?

• Additional EN should be considered for improvement of wound healing and a lesser number of anastomotic complications (B).

• Wound healing in an elderly home-nursed population were studied. With EN (237 ml per day) two groups were randomized towards 1 or 2 kcal per ml for 4 weeks. The 2kcal group has improved healing and a better mental status.

• 66 gastric cancer patients. EN (Immunonutrition) demonstrates significant differences (0 versus 8 patients with wound healing complications).

Collins CE, Kershaw J, Brockington S: Effect of nut ritional suppCollins CE, Kershaw J, Brockington S: Effect of nut ritional supp lements on wound healing in homelements on wound healing in home --nursed elderly: a randomized trial (2005) Nutrition , 21, nursed elderly: a randomized trial (2005) Nutrition , 21, S147S147--155155Farreras N, Artigas V, Cardona D, Rius X, Trias M, Gonzales JA: Farreras N, Artigas V, Cardona D, Rius X, Trias M, Gonzales JA: Effect of early postoperative enteral Immunonutriti on on wound hEffect of early postoperative enteral Immunonutriti on on wound h ealing in patients ealing in patients undergoing surgery for gastric cancer (2005) Clin N utr 24, S55undergoing surgery for gastric cancer (2005) Clin N utr 24, S55 --6565

CHIR 10.7 Do ONS influence the healing of anasto mosis in colo-rectal cancer?

• By supplementation of additional EN a better wound healing and a lesser number of anastomotic complications ma y be obtained (B).

• Post-surgical patients with EN resulted in better outcome, lesser complication rates in the treatment group.

• Pre- and postsurgical Immunonutrition is associated with a lesseranastomotic leakage rate.

• EN in an early postoperative period leads to lesser complicationrate.

Campos ACL, Groth AK, Branco A: Assessment and nutr itional aspecCampos ACL, Groth AK, Branco A: Assessment and nutr itional aspec ts of wound healing (2008)11, S281ts of wound healing (2008)11, S281 --288288Kudsk KA: Immunonutrition in surgery and critical c are (2006) AnKudsk KA: Immunonutrition in surgery and critical c are (2006) An nu Rev Nutrition, 26, S463nu Rev Nutrition, 26, S463 --479479Stechmiller JK: Understanding the Role of Nutrition and Wound HeStechmiller JK: Understanding the Role of Nutrition and Wound He aling (2010) Nutrition in Clin Prac, 25, S61aling (2010) Nutrition in Clin Prac, 25, S61 --6868