S3-Leitlinie Klinische Ernährung in der Chirurgie der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) e. V.

 

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Zusammenfassung

Die Vermeidung einer ausgeprägten Katabolie nach chirurgischen Eingriffen mit frühem postoperativen Kostaufbau und Mobilisierung zur raschen Rekonvaleszenz ist heute der Standard des perioperativen Management im so genannten Enhanced Recovery After Surgery (ERAS) Konzept. So ist die frühe orale Nahrungszufuhr auch die bevorzugte Form der postoperativen Ernährung. Gemessen am Kalorienbedarf ist jedoch gerade nach Eingriffen am oberen Gastrointestinaltrakt für längere Zeit von einer verminderten Nahrungsaufnahme auszugehen. Dies birgt grundsätzlich das Risiko eines fortschreitenden Gewichtsverlusts und einer Unterernährung der Patienten während des postoperativen Verlaufs. Mangel- und Unterernährung stellen signifikante Risikofaktoren für postoperative Komplikationen dar. So ist die frühe enterale Ernährung besonders für chirurgische Patienten mit einem bereits bestehenden Ernährungsrisiko wichtig. Der Fokus dieser Leitlinie liegt besonders auf den ernährungstherapeutischen Aspekten des ERAS Konzeptes (Plan A). Dies betrifft präoperativ Strategien zur Konditionierung („Prähabilitation“). Postoperativ können trotz bestmöglicher Versorgung schwere Komplikationen mit der Notwendigkeit zur Reoperation und Intensivtherapie eintreten, die eine besondere, auch medizinische (künstliche) Ernährungstherapie erforderlich machen (Plan B)

Aus der Stoffwechsel- und Ernährungsperspektive sind folgende Aspekte in der perioperativen Versorgung zentral:

Integration der Ernährung in das gesamte perioperative Management des Patienten

Vermeidung von längeren perioperativen Nüchternheitsperioden

▪ Möglichst frühe Wiederaufnahme der oralen Ernährung nach chirurgischen Eingriffen

▪ früher Start einer Ernährungstherapie bei Patienten mit metabolischem Risiko

▪ metabolische Kontrolle z. B. des Blutzuckers

▪ Reduzierung von Faktoren, die Stress und Katabolie induzieren oder die gastrointestinale Funktion beeinträchtigen

▪ Zurückhaltende Gabe von Medikamenten mit ungünstigem Einfluss auf die Darmperistaltik

▪ frühe Mobilisation zur Stimulierung der Proteinsynthese und der Muskelfunktion

Diese Leitlinie präsentiert insgesamt Empfehlungen für die tägliche klinische Praxis

Abstract

The avoidance of pronounced catabolism after surgical interventions with early postoperative diet build-up and mobilization for rapid convalescence is today the standard of perioperative management in the so-called Enhanced Recovery After Surgery (ERAS). Thus, early oral nutrition is also the preferred form of postoperative nutrition. However, measured in terms of caloric requirements, reduced food intake can be assumed for a longer period of time, especially after surgery on the upper gastrointestinal tract. This fundamentally carries the risk of progressive weight loss and patient malnutrition during the postoperative course. Malnutrition and undernutrition are significant risk factors for postoperative complications. Thus, early enteral nutrition is particularly important for surgical patients at pre-existing nutritional risk. The focus of this guideline is particularly on the nutritional aspects of the ERAS concept (Plan A). This relates preoperatively to strategies for conditioning (“prehabilitation”). Postoperatively, despite the best possible care, severe complications may occur with the need for reoperation and intensive therapy, requiring special nutritional therapy, including medical (artificial) nutrition (Plan B).

From a metabolic and nutritional perspective, the following aspects are central to perioperative care:

▪ Integration of nutrition into the overall perioperative management of the patient.

▪ Avoidance of prolonged perioperative fasting periods

▪ Resumption of oral nutrition as early as possible after surgical interventions

▪ Early start of nutrition therapy in patients at metabolic risk

▪ Metabolic control, e. g., of blood glucose

▪ Reduction of factors that induce stress and catabolism or impair gastrointestinal function

▪ Restrained administration of drugs with unfavorable influence on intestinal peristalsis

▪ Early mobilization to stimulate protein synthesis and muscle function

This guideline presents overall recommendations for daily clinical practice

Publication History

Article published online:
22 August 2023

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