INTRODUCTION

Complications after colorectal surgery prolong hospital stay and increase morbidity and mortality. Measures to minimize the risks of postsurgical complications are essential. Various risk factors associated with increased postsurgical complications have been identified. Malnutrition is common in hospitalized patients, and it is also common in individuals undergoing colorectal surgery. Malnutrition predisposes to prolonged hospitalization, perioperative complications, morbidity, and mortality. Most importantly, it is one of the few modifiable factors that could alter surgical outcomes. Nutritional repletion in malnourished patients prior to surgery decreases postoperative complications and improves the outcome. After surgery, nutrition promotes wound healing and attenuates the catabolic process due to the disease process and surgery. When complications arise following the surgery, maintaining adequate oral intake often becomes challenging, and nutritional management becomes critical to the patient’s recovery.

It is paramount for clinicians to understand the role of nutrition in perioperative management. Identifying patients in need of nutritional therapy and providing optimal nutritional care when complications occur are critical in colorectal surgery.

PREOPERATIVE NUTRITION AND NUTRITION SCREENING

Multiple studies in gastrointestinal (GI) surgeries have identified malnutrition as a risk factor for predisposing patients to perioperative complications such as wound infections, anastomosis leaks, and intra-abdominal sepsis. Nutritional intervention on the malnourished patients before surgery improves the outcome and decreases complications. Patients at high risk for malnutrition are more likely to benefit from early enteral nutrition with improved outcomes than those at low nutrition risk. When planning colorectal surgery, it is important to identify the patient that would benefit most from nutritional intervention. The goals of preoperative nutritional therapy aim to improve the nutritional status and reduce perioperative complications with the multidisciplinary approach.

It is well known that malnutrition is prevalent in hospitalized patients. Nevertheless, clinicians may not always recognize the need to provide nutrition therapy to the patients. An effective screening tool for malnutrition for clinicians should be easy and simple. Clinical history including significant unintentional weight loss, poor food intake, and severity of the disease are useful markers; they allow clinicians to quickly identify patients at risk for malnutrition who may benefit from timely nutritional therapy. A low body mass index (BMI) and hypoalbuminemia should raise the red flags. Wagner and Rombeau defined preoperative malnutrition as serum albumin levels of less than 3.5 g/dL and/or a 15% nonvolitional weight loss over 3 to 4 months. Despite that serum albumin is a poor marker for nutrition, it is a good indicator of perioperative outcomes. Preoperative serum albumin below 3.5 g/dL is associated with anastomotic breakdown and postoperative complications in patients undergoing elective colorectal surgery. Hypoalbuminemia is also associated with an increased hospital stay, infection, and mortality.

The guideline from the American College of Gastroenterology recommends using NRS-2002 (the Nutrition Risk Screening 2002) for nutrition screening in hospitalized patients ( Table 34.1 ). It is a scoring system developed originally by Kondrup et al. ^, It is based on both components of undernutrition and the severity of the disease. It includes four prescreening questions: BMI <20.5, weight loss in the last 3 months, decrease in food intake, and presence of critical illness. If one of these is answered positively, a nutrition screening follows. A scoring system is then assigned based on the degree of nutrition impairment, the severity of the disease, and age. A total score of ≥3 points classified that the patient is at risk of malnutrition or already malnourished, and nutritional intervention is indicated. NRS-2002 has been validated as a predictor of postoperative complications in surgical patients. It can also be used to identify patients who are most likely to benefit from nutritional support.

The severity of malnutrition is expected to have prognostic importance. However, there is no consensus about the definition of severe malnutrition. Severe malnutrition generally is defined by a BMI <16 to 18.5, unintentional weight loss of >0% in the past 3 to 6 months or >5% in the past 1 month, albumin less than 2, or NRS-2000 score ≥5. Overview of the nutrition screening tools for hospitalized patients was critically reviewed and summarized.

PREOPERATIVE NUTRITION: ENTERAL NUTRITION VERSUS PARENTERAL NUTRITION

Enteral nutrition (EN) is the preferred route for preoperative nutrition therapy when it is feasible. EN is considered more physiological, as it preserves intestinal mucosal integrity and is easier to administer and manage. Eating orally is the preferred form of enteral feeding. However, some patients may need tube feeding via different routes to maintain nutrition needs. There is no additional benefit by giving parenteral nutrition (PN) while the patient can achieve nutrition goals by enteral routes. PN is applied when patients have an intestinal obstruction, are severely malnourished, cannot meet nutrition needs by enteral route, or require PN for more than 7 to 10 days.

It can be challenging to decide the ideal length of nutrition therapy and timing for surgery. A minimum of 5 to 7 days of PN before surgery is required for effective nutritional intervention to improve outcomes. ^, Data are not as clear regarding the benefits of postoperative PN and whether the preoperative PN should continue through the postoperative period. A meta-analysis showed a significant 10% decrease in infectious morbidities with PN applied in this manner when compared to standard care therapy.

There are conflicting data on the safety and potential pro-inflammatory effects of PN in colorectal surgery. Previous studies in EN and PN showed fewer infections, complications, and shorter stays in the intensive care unit (ICU) than EN. Hospital length of stay and mortality were not significantly different between the EN and PN groups. However, the benefit of PN over standard therapy was demonstrated in patients undergoing major upper GI surgery. The nutritional support benefits especially the patients with preexisting malnutrition or at high nutrition risk. There have been advancements in the knowledge of PN, glycemic control, lipid and protein formulations, and increased use of indirect calorimetry. The safety of PN is believed to have much improved and can be used as a safe alternative to EN. ^,

Vascular access for PN is essential for patient care and prevention of line infection and deep vein thrombosis. Peripherally inserted central catheter line is used in short-term central PN while tunnel catheter and port are recommended for long-term use usually longer than several weeks.

PREOPERATIVE NUTRITION IN INFLAMMATORY BOWEL DISEASE

Colorectal surgery for patients with inflammatory bowel disease (IBD) is often complex and challenging. Due to the progressive and systemically inflammatory nature of the disease, the lifetime surgical need is high in IBD. It is estimated that between 70% and 90% of patients with Crohn’s disease (CD) will need surgery during their disease. Approximately 25% to 50% of patients with CD will require surgery within the first 5 and 10 years of diagnosis. ^, Approximately 15% to 40% of patients with ulcerative colitis (UC) will require surgery within the first 10 to 20 years after diagnosis. Although the surgical risk has decreased in IBD with advances in medical therapy with biological and small-molecule agents, it remains high. Some patients with IBD may require emergent surgery due to bowel perforation, intra-abdominal abscess, ischemia, toxic megacolon, or refractory intestinal bleeding; these patients pose additional challenges for surgical, medical, and nutritional management.

The commonly performed surgeries in IBD include small bowel resection, ileocecal resection, stricturoplasty, colectomy, total proctocolectomy, ileoanal pouch, ileostomy, and colostomy. Perioperative complications in IBD patients are among the highest in colorectal surgeries. As the surgical techniques and medical management have improved, the mortality rate of IBD surgery has decreased to less than 1%, and the complication rates have also decreased but were still high and reported around 30%. Anastomosis leak and intra-abdominal abscess are the major and most devastating complications in IBD surgery. Patients with these complications often require reoperation, stoma creation, prolonged hospitalization, and delayed recovery. With the advancement of biological agents, patients undergoing colorectal surgery usually have exhausted the medical options and are refractory to medical treatments. These patients tend to be extremely ill and severely malnourished.

The prevalence of malnutrition in hospitalized IBD patients was significantly higher than in the general inpatient population. The prevalence is higher in patients with CD than in those with UC. Malnutrition is one of the most important risk factors for perioperative complications in IBD surgery. Severely malnourished patients with CD who underwent urgent surgery developed more anastomosis complications and the need for stoma creation. Patients with IBD with malnutrition carry a higher risk for wound infection, readmission, longer hospital stays, and increased mortality than controls. ^, Malnutrition is also linked to increased venous thromboembolism in hospitalized patients with IBD. Poor nutrition, intra-abdominal abscess discovered during surgery, steroid use, and recurrent episodes of CD were the risk factors linked to anastomosis leak and intra-abdominal abscess. Studies further demonstrated that nutritional repletion improved outcomes in malnourished patients but not in patients without malnutrition.

The etiologies of malnutrition in IBD are complex and multifactorial. Decreased food intake is one of the major contributing factors to malnutrition in patients with IBD. Disease severity and the inflammatory burden of the disease also play a significant role. IBD patients frequently adopt certain diet practices that may be restrictive and nutritionally inadequate. Some patients develop a fear of eating. It was estimated that about 50% of the IBD patients were afraid to eat and 60% of the patients had abnormal patterns of diet.

Studies have demonstrated that EN by supplementing with elemental or polymeric formulae can induce remission in patients with CD. Enteral nutrition supplementation before operation in malnourished patients improves preoperative nutritional status in IBD patients. PN is recommended for malnourished IBD patients who cannot obtain adequate nutrition by enteric route or are severely malnourished. Some studies have shown that preoperative PN decreased the length of the small bowel resected, improved healing and anastomoses, and decreased postoperative complications in IBD.

Patients with IBD are also at risk for micronutrient and vitamin deficiencies, especially when the disease is active. Vitamin D deficiency is associated with severe disease in IBD and is possibly related to the treatment outcomes. ^, Deficiencies in iron, zinc, vitamin B12, vitamin B6, calcium, selenium, magnesium, or fat-soluble vitamins are also common. IBD patients with primary sclerosing cholangitis are prone to a deficiency in fat-soluble vitamins. Despite the importance of these nutrients being well known, the prevalence and effect of these nutrient deficiencies are not well studied. All patients with IBD undergoing colorectal surgery should be evaluated for nutrition status and need for nutritional intervention and repletion of nutritional deficits.

PREOPERATIVE NUTRITION IN PATIENTS WITH INTESTINAL FISTULA

Gastrointestinal fistulae may develop as complications from CD, diverticular disease, radiation injury, and malignancy, but are more often related to surgical intervention. Intestinal fistulae, including enterocutaneous fistula (ECF), are associated with significant morbidity and mortality. The estimated mortality rate of untreated colonic fistulae estimate was 16%, in which small bowel fistulae could be as high as 54%. High-output ECF, defined as output exceeding 500 mL/24 hours has higher mortality rates when compared to low-output ECF.

Approximately 75% to 85% of intestinal fistula and ECF are complications associated with GI surgery. ^, The prevalence of postoperative fistula formation in CD is high and reported between 15% and 35%. Risk factors that predispose surgical patients to fistula formation include malnutrition, hypoalbuminemia, anastomotic leak, infection, corticosteroid use, and cardiopulmonary diseases. ^, On the contrary, patients suffering ECF are prone to malnutrition, fluid and electrolyte deficits, renal injury, and sepsis. The prevalence of malnutrition in patients who do not receive nutritional support is high, ranging from 20% to 74% depending on the location of the fistula.

The management of these patients involves multidisciplinary teams and includes nutrition repletion, control of fistula output, correction of fluid and electrolyte deficits, and frequently the drainage of the intra-abdominal abscess also. The prognosis mainly depends on the nutritional status of the patient and the presence or absence of sepsis. The serum albumin level is of predictive importance in patients with ECF for mortality and fistula closure. Fazio et al. reported no patient mortality when the serum albumin was >3.5 g/dL, whereas mortality was 42% when the serum albumin was less than 2.5 g/dL. Recently, Kuvshinoff et al. reported that the serum transferrin level was also a strong factor influencing mortality and fistula closure.

The preferred route of nutrition therapy in patients with ECF is EN if the enteral feed is tolerable and nutritionally sufficient. If the location of the fistula is more distal in the GI tract and the fluid is manageable, oral diet and EN are applied and the fistula output is monitored. In patients with high-output ECFs, a high-calorie, high-salt, low-residue diet, and oral protein supplements may be attempted if they are deemed to have adequate absorption capacity and ability to maintain fluid and electrolytes. A minimum of 60 to 100 cm healthy and nonobstructed small bowel with an intact ileocecal valve and colon is essential in these patients. ^, Patients should receive education about diet and fluid choices and oral rehydration solutions. Hypotonic and hypertonic drinks may exacerbate fistula output.

Parenteral nutrition is indicated when there is a proximal small bowel fistula, high fistula output (>500 mL/d), insufficient EN intake, and severe malnutrition. PN provides bowel rest, reduces fistula output, and promotes spontaneous closure of the fistula. Fistuloclysis is a technique by returning fistula fluids or infusing enteral feeding distal to the fistula opening. It could potentially replace PN in high-output fistulae and preserve bowel integrity, but the process tends to be challenging and labor-intensive.

Patients with ECF frequently require continuing home EN or PN for nutrition repletion while allowing the fistula to close. Surgery is usually reserved for a high-output fistula that fails to close after aggressive nutritional therapy. The patient’s nutrition should be optimized before the surgery. The duration of nutrition therapy and the optimal time for surgery may vary from a few weeks to a couple of months. Factors that are associated with failure to spontaneous closure include inflamed bowel, radiation, intestinal discontinuity, adjacent abscess, strictures, foreign bodies, or distal bowel obstruction.

Acid suppression with histamine 2 blockers or proton pump inhibitors can reduce gastric acidity and decrease fistula output. ^, Antimotility agents such as loperamide may be used and are recommended, among others. When using Diphenoxylate with atropine, codeine, or tincture of opium, it is important to be cautious of their narcotic central nervous system side effects and dependency potentials. Somatostatin and octreotide have been tried along with total PN to promote the closure of ECFs and to reduce complications. ^, It is important to monitor and supplement micronutrients as the ECF and the underlying disease predispose patients to micronutrient deficiencies. Repleting the deficits promotes healing and improves nutrition status. A complete survey of the vitamins and micronutrients at the beginning of the nutrition intervention followed by periodical monitoring is recommended. American Society for Parenteral and Enteral Nutrition (ASPEN) and Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE) outline clinical guidelines for nutrition management in patients with ECF.

POSTOPERATIVE NUTRITION

The goal of postoperative nutrition is to replete nutrition deficits, attenuate the catabolic process, minimize postsurgical tissue breakdown, and promote wound healing. Data are lacking on whether postoperative nutrition therapy benefits the high-risk patients for complications more than it does the lower-risk patients. While hypoalbuminemia is a good marker for surgical outcomes, it serves no role in the assessment of nutrition therapy postoperatively. Expert consensus suggests using NRS-2002 score as markers of nutrition states postoperatively and recommends against using visceral protein levels such as serum albumin, prealbumin, and transferrin.

Ample data support the benefit of early EN postsurgery. Enteral nutrition should be provided when feasible within 24 hours after surgery. The need for enteral access usually is addressed in the operating room when possible. A meta-analysis of control trials shows early enteral feeding resulted in a reduction in infections and shorter length of hospital stays. There is also a trend of risk reduction in anastomosis dehiscence, intra-abdominal abscess, pneumonia, and mortality. The results from a meta-analysis also favor early EN over standard therapy with no worsening effect on anastomotic dehiscence. When EN is not feasible, PN should be administered to the patients. However, for the noncritically ill patient without preoperative malnutrition, the provision of PN should be deferred until 5 to 7 days after the surgery. In contrast, patients with preoperative severe malnutrition and anticipate prolonged ileus or bowel rest may benefit from early PN postsurgically. Supplemental PN is given to the patient unable to meet >60% of the energy and protein requirements by the enteral route.

IMMUNO-NUTRITION

Immuno-enhanced nutrition in surgical patients is a key area of nutrition research. Studies have demonstrated the beneficial effects of immuno-nutrition in decreasing infection, length of hospital stay, and mortality in GI and colon cancers. The expert consensus from ASPEN recommends the use of an immunomodulating formula containing arginine and fish oil in surgical ICU patients. They cited meta-analysis studies that demonstrated postoperative use of an arginine/fish oil-containing formula reduced infection and hospital stay when compared with the use of a standard enteral formula. A reduction in total complications was shown with the use of postoperative immunomodulating formulas. A reduction in anastomotic dehiscence is seen only when the immunomodulating formula was given both pre- and postoperatively. On the contrary, the ASPEN and FENLANPE Guidelines do not recommend the use of immuno-nutrition in patients with ECF. More research is needed to learn about the effects of immuno-nutrition in colorectal surgery.

PROLONGED POSTOPERATIVE ILEUS

Prolonged ileus is one of the common postsurgical complications in colorectal surgery, with a prevalence being as high as 25%. It leads to prolonged hospitalization, increased anastomotic leak, and intra-abdominal infections. Nutrition in these patients is compromised, and there is increased patient dissatisfaction. Delayed EN was identified as one of the important risk factors that predispose to prolonged ileus.

Traditionally, ileus is considered physiological after abdominal surgery; oral feeding is held with the concern of food intolerance, aspiration, and anastomosis leak. However, the return of GI motility and function following surgery is shorter than previously thought. Gastric and small intestinal function return within hours of surgery, and colonic activity returns in 2 to 4 days following surgery. ^, The majority of the patients tolerate oral intake in the immediate postoperative period, regardless of whether they pass flatus or bowel movements. A delay in resuming EN is associated with a slower return of bowel function when compared with early EN. Early EN decreases postoperative ileus, reaches nutrition goals sooner, and shortens hospital stay.

Programs to enhance recovery after surgery use all measures to optimize physiological function and facilitate postoperative recovery; early feeding is an essential component of the programs. Other risk factors that predispose to prolonged ileus in colorectal surgeries include narcotic use, prolonged operations, excessive intestine manipulation, systemic inflammation, resection at urgent operation, and disseminated cancer. ^{, ,} Management of prolonged ileus also includes electrolyte and fluid optimization, narcotic avoidance, and early ambulation.

Patients with postoperative ileus who are unable to tolerate adequate EN will need PN until they can be transitioned to oral feedings. PN should be initiated immediately after the surgery in patients who are severely malnourished and expected to have prolonged ileus.

There were efforts to find a meaningful and clinically practical definition of prolonged ileus or complicated ileus. Experts reached a consensus using the Delphi process and defined postoperative ileus as temporary inhibition of GI motility after surgical intervention due to nonmechanical causes and preventing sufficient oral intake. Abdominal distension and tenderness are the most relevant clinical signs. Despite the efforts, they failed to reach a consensus on the diagnosis of postoperative ileus, the ranking of the symptoms, and the imaging modality of the choice.

ANASTOMOSIS LEAK AND INTRA-ABDOMINAL ABSCESS

Anastomosis leak is defined as a defect of the intestinal wall at the anastomotic site leading to communication between the intra- and extraluminal compartments. It is a major and most serious complication of colorectal surgery, affecting 2% to 15% of patients undergoing GI surgery. ^, At least one-third of the mortality after colorectal surgery is attributed to leaks. Intra-abdominal sepsis due to anastomotic leakage significantly affects the outcomes of the surgery. In patients with colon cancer, the overall mortality of bowel resection is about 3.7% and rises to 14.3% when anastomosis leakage occurs. The need for stoma after sphincter-saving resection surgery for cancer is low (3%) but rises to 22% after the development of symptomatic anastomosis leaks.

Malnutrition impairs anastomotic healing. Preoperative serum albumin levels below 3.5 g/dL are associated with an anastomotic breakdown in patients undergoing elective colorectal surgery. ^, Compromised preoperative nutritious status is defined as anemia or hypoalbuminemia (hemoglobin ≤10.0 g/dL or albumin ≤3.2 g/dL) associated with increased anastomosis leak in patients undergoing low anterior resection for cancer. Postoperatively, low serum albumin level was also linked to increased anastomosis leakage. CD, preoperative steroid use, and low anastomosis were other significant risk factors for developing clinical anastomotic leakage in colorectal surgery. ^,

A multivariate analysis of patients with CD undergoing elective ileocecal resection identify poor nutrition, intra-abdominal abscess, steroid use, and recurrent episodes of CD as risk factors of anastomosis leak and intra-abdominal abscess. The use of oral corticosteroids significantly increases the odds of developing an abdominal abscess. A significantly high percentage of patients (65.6%) with anastomotic fistulae have medical comorbidities.

As many of the IBD patients undergoing colorectal surgery have been exposed to biological agents; the effect of the agents on the surgical outcome is of concern to IBD specialists. Data have been conflicting. The study suggested that exposure to infliximab did not increase the risk of postoperative infectious complications, anastomotic leaks, infection, or thrombotic complications. A meta-analysis demonstrated an increased risk of short-term postoperative complications associated with preoperative infliximab use in UC.

Fecal diversion is a way to reduce the risk of anastomotic leak after ileocolonic, colocolonic, ileorectal, or colorectal anastomoses. Although the construction of a diverting stoma is a low-risk surgical procedure from a technical standpoint, it still carries postoperative morbidity and delayed recovery. It is most beneficial when used selectively in high-risk patients for anastomosis leaks. Endoscopic treatments are increasingly used as an alternative or complementary treatment to surgical treatment.

PN and fasting are the conventional treatments for leakage in the absence of peritonitis. Elemental diet jelly is a completely digested formula and is easily absorbed. It is successfully applied in a Japanese study to patients who develop anastomosis leaks after elective surgery for left-sided colorectal cancer without the creation of a diverting stoma. Further studies are needed to identify patient characteristics to allow safe use of EN in the treatment of anastomosis leaks.

STOMA

The permanent or temporary stoma is created for various diseases and conditions in colorectal surgery. Constructing a stoma can be associated with perioperative complications, increased morbidity, and mortality. ^, Some defined the complications associated with a stoma as early or late complications. Complications that take place early after surgery are often related to technical issues and include stoma ischemia, bleeding, retraction, and infection. Poor nutritional status, older age, obesity, tobacco use, underlying malignancy, and comorbid conditions predispose to early complications after stoma construction. Risk factors for late complications include duration of stoma, increases in intra-abdominal pressures, emergency surgery, and inadequate mobilization of the bowel. Common complications are peristomal skin breakdown, infections, parastomal hernia, stenosis, retraction, prolapse, and peristomal varices. When a stoma complication occurs, patients may need to return to the operation.

Patients with an ileostomy tend to have low body weight, BMI, and bone mineral density. They are also prone to low urine volumes, and some have a depletion of sodium, calcium, and magnesium. Patients with an ileostomy should be educated about the risks of fluid and electrolyte deficit and subsequent risk for renal injury and the importance of fluids. They should learn how to keep track of the liquid intake and ostomy output.

The ostomy nutrition guide recommends a low-residue, high-protein diet commencing immediately after surgery and a regular diet resumed as soon as the bowel adapts. In the transitional period, small meals every 3 to 4 hours and consumption of six to eight cups of water per day are recommended. In 6 to 8 weeks after surgery, fiber-containing food items should be started, and new food items should be tested in terms of intestinal rehabilitation. ^,

Food blockage can occur in patients with an ileostomy. Common offenders include leafy and stringy vegetables, foods with skin and seeds, corn, and nuts. The study showed that many patients with ileostomy modify their diet and avoid certain foods, which may increase their risks for nutritional deficiencies. Strategies for patients with ileostomy include eating small and frequent meals, chewing food well and eating slowly, separating solid foods from liquids, drinking 8 to 10 glasses of fluids daily, and introducing food back one at a time.

The volume of the stoma output is determined by the location of the stoma. High stoma output is usually defined when the output exceeds 1.5 L/day. Patients with high output stoma face challenges in dehydration, electrolyte imbalances, nutrient deficiencies, and malnutrition. Patients with high-output stoma have significantly longer hospital stays and readmission rates. Most readmissions are due to dehydration and altered electrolyte balance; about one-third of patients with high output stoma have hypomagnesemia.

The management of high stoma output usually consists of a high-calorie, protein, and salt diet. Patients are advised to have small and frequent meals and the separation of solids from liquids. They should avoid excessive caffeine, alcohol, and acidic foods. They should be encouraged to use oral rehydration fluids and avoid hypotonic or hypertonic fluids. Antisecretory agents such as proton pump inhibitors or histamine-2 blockers and antimotility agents such as loperamide, diphenoxylate with atropine, cholestyramine, octreotide, or tincture opium are recommended if the stoma output is not adequately controlled. Some patients may require additional intravenous fluid or electrolytes, while others may need PN if they cannot meet their caloric and protein requirements to sustain their weight or regain weight.

ILEAL POUCH-ANAL ANASTOMOSIS

Restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory UC, UC-associated neoplasia, or familial adenomatous polyposis. Complications associated with IPAA include anastomosis leak, stricture, fistula, pelvic abscess, and small bowel obstruction. Risk factors include prolonged corticosteroid use, anemia, hypoalbuminemia, and hypoxemia. Patients undergoing surgery due to refractory UC are frequently severely malnourished because of decreased oral intake, weight loss, and severely inflamed colon. Many patients have received steroids, biologic agents, and immunomodulating agents, raising concerns about increased risks for perioperative complications.

In malnourished patients with a history of chronic use of corticosteroids, biological agents, or other immunosuppressants, the usual operative approach is to perform a staged proctocolectomy and IPAA procedure. The three-stage approach started with subtotal colectomy and end ileostomy provides the opportunity for patients to improve their nutritional status and decrease potential complications for this and subsequent operations. After resection of the inflamed and diseased colon, patients usually resume appetite and improve their nutrition status. Many patients after the first stage of the surgery were malnourished and suffered from multiple nutrient deficiencies including vitamin D, iron, zinc, and copper. Micronutrient and vitamin status should be evaluated perioperatively in patients with UC and replete if needed.

The frequency of anastomosis leaks following IPAA was reported around 5% to 18%. The leak typically arises from the site of the ileal-anal anastomosis or the tip of the J-pouch. Pelvic abscess or presacral abscess is a common finding with the anastomosis leak in IPAA. Bowel rest with PN, drainage, and antibiotic therapy are important measures in managing leaks and abscesses.

Patients with IPAA typically have five to six bowel movements a day. Some patients may develop chronic diarrhea and should undergo investigation for underlying etiology. Patients with IPAA should receive periodic monitoring of their fluid status, electrolytes, vitamins, and micronutrients. Some patients may develop vitamin B12 deficiency due to decreased absorptive capacity from the surgery, bacterial overgrowth, pouchitis, cuffitis, or even CD of the pouch along with other autoimmune processes. Iron deficiency may develop related to chronic pouchitis, anastomosis ulcers, or CD of the pouch. Bile acid and fat malabsorption have been reported in patients with IPAA. Fructose intolerance is also common among patients with IPAA. These patients should see dieticians for nutritional evaluation and diet advice. These patients may benefit from small and frequent meals, soluble fibers, and complex carbohydrates. They should avoid refined sugar foods and beverages, acidic foods, spicy foods, and greasy foods. Alcohol and caffeinated drinks may also increase diarrhea. Some patients may also be intolerant to dairy products. Education about fluid and hydration should be included in the care of these patients.

SUMMARY AND RECOMMENDATIONS

Failure to recognize malnutrition and the need for prompt nutritional intervention is associated with increased perioperative complications and adverse outcomes in patients undergoing colorectal surgery. Clinical features including changes in oral intake, unintentional weight loss, low body mass index, disease severity, and hypoalbuminemia are useful markers to identify patients at risk of malnutrition and surgical complications. Perioperative nutrition care should encompass knowledge of the disease and surgical process on nutrition and the understanding of the role of nutrition in perioperative care. A multidisciplinary approach is essential to incorporate nutrition care into the clinical and surgical plan. Patient education plays a significant role in the success of nutrition care programs. Evidence-based practice, however, is frequently lacking in perioperative nutrition therapy. More research is required in the areas of diet and nutrition needs, monitoring tools, and targeted nutrition goals for best clinical and surgical outcomes.