Clinical Nutrition in surgery guidelines

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery.

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Bevacizumab and Surgical Wound Healing

“Bevacizumab has been associated with multiple complications in regard to wound healing, such as dehiscence, ecchymosis, surgical site bleeding, and wound infection. Current literature suggests patients should wait at least 6 to 8 weeks (40 days) after cessation to have surgery (half-life 20 days). In addition, postoperative reinitiation of bevacizumab must wait 28 days to prevent an increased risk of wound healing complications, and the surgical incision should be fully healed”

(Gordon)
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ketorolac use and the risk of anastomotic leak after colorectal surgery.

“This meta-analysis included seven studies with 400,822 patients. Our results demonstrated that ketorolac administration after surgery increases the risk of anastomotic leak [OR = 1.41, 95% CI: 0.81–2.49, Z = 1.21, P = 0.23].”

(Chen)

“Anastomotic leak is a serious complication that occurs after colorectal surgery, which can lead to increased morbidity and mortality. Non-selective NSAIDs (such as ketorolac) may affect the healing of the intestine by inhibiting the action of cyclooxygenase. NSAIDs have been shown to weaken granulocyte function, which is an essential part of the acute phase of wound healing. NSAIDs may also inhibit epithelial cell migration and mucosal recovery, which are important in the pathophysiology of intestinal ulcer healing. These findings suggest a potential biological mechanism that may explain the association identified in this study.”

Chen W, et al Administration After Colorectal Surgery Increases Anastomotic Leak Rate: A Meta-Analysis and Systematic Review. Front Surg. 2022 Feb 9;9:652806. Free Full Text

Management of Anorectal Abscess

A generally accepted explanation for the etiology of anorectal abscess and fistula-in-ano is that the abscess results from obstruction of an anal gland and the fistula is due to chronic infection and epithelialization of the abscess drainage tract. Anorectal abscesses are defined by the anatomic space in which they develop and are more common in the perianal and ischiorectal spaces and less common in the intersphincteric, supralevator,and submucosal locations.

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Diverting ileostomy in colorectal surgery: when is it necessary?

“The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice”

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Diverting Ostomy: For Whom, When, What, Where, and Why

“Fecal diversion is an important tool in the surgical armamentarium. There is much controversy regarding which clinical scenarios warrant diversion. Some of the most common applications for the use of a diverting stoma include construction of diverting ileostomy or colostomy, ostomy for low colorectal/coloanal anastomosis, inflammatory bowel disease, diverticular disease, and obstructing colorectal cancer with the conclusion that diverting loop ileostomy is preferred to loop colostomy” (Plasencia)

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The Landmark Series: Pancreatic Neuroendocrine Tumors

“Pancreatic neuroendocrine tumors (PNETs) comprise a heterogeneous group of neoplasms arising from pancreatic islet cells that remain relatively rare but are increasing in incidence worldwide. While significant advances have been made in recent years with regard to systemic therapies for patients with advanced disease, surgical resection remains the standard of care for most patients with localized tumors. Although formal pancreatectomy with regional lymphadenectomy is the standard approach for most PNETs, pancreas-preserving approaches without formal lymphadenectomy are acceptable for smaller tumors at low risk for lymph node metastases.”

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