Lippincott Williams & Wilkins
Supplemental Appendix #1- Key Perioperative Nutrition Questions within context of an ERAS/ERP ProgramBased on both pre-conference discussions and key literature, the following questions were considered most relevant to perioperative nutrition management:Prior to Surgery:i) What are the optimal methods to routinely incorporate preoperative nutritional evaluation into an ERP to predict surgical risk and identify patients in need of preoperative nutritional optimization?ii) What are the key goals of pre-operative nutritional optimization? Specifically, what is the role of achieving protein delivery goals in perioperative nutrition?iii) When should high protein oral nutrition supplements (ONS), enteral nutrition (EN), and parenteral nutrition (PN) be initiated in the pre-operative setting?iv) What is the appropriate practice to minimize preoperative fasting and what is the role of preoperative oral intake of clear carbohydrate loading solutions up to 2 h prior to the induction of anesthesia?Before and After Surgery:v) What is the role of immunonutrition (IMN) in optimizing patient outcomes when utilized before and after surgery?After Surgery:vi) When should feeding be initiated after surgery? What should the goals of post-operative nutritional optimization include? Specifically, what is the role of protein delivery in postoperative nutrition? vii) What is the role of specific interventions such as high protein oral nutrition supplements (ONS), enteral nutrition (EN), and parenteral nutrition (PN) in the post-operative setting and when should these therapies be initiated?viii) What nutrition intervention(s) should be utilized to optimize recovery from surgery following hospital discharge?#2- Future Pre-Operative Assessments: Sarcopenia and Vitamin D Sarcopenia is traditionally defined as age-related loss of muscle mass though newer definitions include the loss of muscle strength as well. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DcnV6LUplbnRvZnQ8L0F1dGhvcj48WWVhcj4yMDE0PC9Z
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ADDIN EN.CITE.DATA 5, ADDIN EN.CITE <EndNote><Cite><Author>Nishigori</Author><Year>2016</Year><RecNum>328</RecNum><DisplayText><style face="superscript">6</style></DisplayText><record><rec-number>328</rec-number><foreign-keys><key app="EN" db-id="evd55ffwtvxvazepf5yxtz9z2sfax90f259d" timestamp="1488381851">328</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nishigori, T.</author><author>Tsunoda, S.</author><author>Okabe, H.</author><author>Tanaka, E.</author><author>Hisamori, S.</author><author>Hosogi, H.</author><author>Shinohara, H.</author><author>Sakai, Y.</author></authors></contributors><auth-address>Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan. tsunoda@kuhp.kyoto-u.ac.jp.
Department of Surgery, Otsu Municipal Hospital, Shiga, Japan.
Department of Surgery, Kobe City Medical Center West Hospital, Hyogo, Japan.</auth-address><titles><title>Impact of Sarcopenic Obesity on Surgical Site Infection after Laparoscopic Total Gastrectomy</title><secondary-title>Ann Surg Oncol</secondary-title><alt-title>Annals of surgical oncology</alt-title></titles><periodical><full-title>Ann Surg Oncol</full-title><abbr-1>Annals of surgical oncology</abbr-1></periodical><alt-periodical><full-title>Ann Surg Oncol</full-title><abbr-1>Annals of surgical oncology</abbr-1></alt-periodical><pages>524-531</pages><volume>23</volume><number>Suppl 4</number><edition>2016/07/07</edition><dates><year>2016</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1068-9265</isbn><accession-num>27380646</accession-num><urls></urls><electronic-resource-num>10.1245/s10434-016-5385-y</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>6, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TbWl0aDwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 7. Additionally, sarcopenia is associated with higher payer costs and negative margins after surgery. ADDIN EN.CITE <EndNote><Cite><Author>Sheetz</Author><Year>2013</Year><RecNum>330</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>330</rec-number><foreign-keys><key app="EN" db-id="evd55ffwtvxvazepf5yxtz9z2sfax90f259d" timestamp="1488381915">330</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sheetz, K. H.</author><author>Waits, S. A.</author><author>Terjimanian, M. N.</author><author>Sullivan, J.</author><author>Campbell, D. A.</author><author>Wang, S. C.</author><author>Englesbe, M. J.</author></authors></contributors><auth-address>Morphomic Analysis Group, University of Michigan, Ann Arbor, MI.</auth-address><titles><title>Cost of major surgery in the sarcopenic patient</title><secondary-title>J Am Coll Surg</secondary-title><alt-title>Journal of the American College of Surgeons</alt-title></titles><alt-periodical><full-title>Journal of the American College of Surgeons</full-title><abbr-1>J Am Coll Surgeons</abbr-1></alt-periodical><pages>813-8</pages><volume>217</volume><number>5</number><edition>2013/10/15</edition><keywords><keyword>Aged</keyword><keyword>Costs and Cost Analysis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Postoperative Complications/economics/epidemiology/etiology</keyword><keyword>Retrospective Studies</keyword><keyword>*Sarcopenia/complications</keyword><keyword>Surgical Procedures, Operative/*economics</keyword></keywords><dates><year>2013</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1072-7515</isbn><accession-num>24119996</accession-num><urls></urls><custom2>PMC3809011</custom2><custom6>NIHMS517950</custom6><electronic-resource-num>10.1016/j.jamcollsurg.2013.04.042</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>8 It has been advocated as an additional factor to consider for preoperative risk assessment, as sarcopenic patients can have normal and even high BMIs. Skeletal muscle mass has traditionally been quantified using computed tomography (CT) scans at the third lumbar vertebra, as this area correlates with whole-body muscle mass. ADDIN EN.CITE <EndNote><Cite><Author>Moisey</Author><Year>2013</Year><RecNum>324</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>324</rec-number><foreign-keys><key app="EN" db-id="evd55ffwtvxvazepf5yxtz9z2sfax90f259d" timestamp="1488381749">324</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moisey, L. L.</author><author>Mourtzakis, M.</author><author>Cotton, B. A.</author><author>Premji, T.</author><author>Heyland, D. K.</author><author>Wade, C. E.</author><author>Bulger, E.</author><author>Kozar, R. A.</author></authors></contributors><titles><title>Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients</title><secondary-title>Crit Care</secondary-title><alt-title>Critical care (London, England)</alt-title></titles><periodical><full-title>Crit Care</full-title></periodical><pages>R206</pages><volume>17</volume><number>5</number><edition>2013/09/21</edition><keywords><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>*Hospital Mortality/trends</keyword><keyword>Humans</keyword><keyword>*Intensive Care Units/trends</keyword><keyword>Male</keyword><keyword>Muscle Strength/physiology</keyword><keyword>Muscle, Skeletal/*diagnostic imaging/physiology</keyword><keyword>Predictive Value of Tests</keyword><keyword>Respiration, Artificial/*mortality/trends</keyword><keyword>Sarcopenia/*diagnostic imaging/*mortality</keyword><keyword>Tomography, X-Ray Computed/methods</keyword></keywords><dates><year>2013</year><pub-dates><date>Sep 19</date></pub-dates></dates><isbn>1364-8535</isbn><accession-num>24050662</accession-num><urls></urls><custom2>PMC4055977</custom2><electronic-resource-num>10.1186/cc12901</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>9. In surgical patients, a rapidly growing body of literature demonstrates low baseline skeletal muscle mass may be an independent risk factor for surgical complications in patients undergoing colorectal PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb2VyPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 10,11, diverticular ADDIN EN.CITE <EndNote><Cite><Author>Matsushima</Author><Year>2017</Year><RecNum>136</RecNum><DisplayText><style face="superscript">12</style></DisplayText><record><rec-number>136</rec-number><foreign-keys><key app="EN" db-id="xsfvz5w0va0esdeeev5p2sagsztwxtt0avpz" timestamp="1494607699">136</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Matsushima, Kazuhide</author><author>Inaba, Kenji</author><author>Jhaveri, Vidhi</author><author>Cheng, Vincent</author><author>Herr, Keith</author><author>Siboni, Stefano</author><author>Strumwasser, Aaron</author><author>Demetriades, Demetrios</author></authors></contributors><titles><title>Loss of muscle mass: a significant predictor of postoperative complications in acute diverticulitis</title><secondary-title>Journal of Surgical Research</secondary-title></titles><periodical><full-title>Journal of Surgical Research</full-title></periodical><pages>39-44</pages><volume>211</volume><dates><year>2017</year></dates><isbn>0022-4804</isbn><urls></urls></record></Cite></EndNote>12, and pancreaticPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW5kaW5pPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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ADDIN EN.CITE.DATA 13 oncological surgery. Muscle mass loss pre-post oncological surgery is an additional risk factor for complications ADDIN EN.CITE <EndNote><Cite><Author>Otsuji</Author><Year>2017</Year><RecNum>139</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>139</rec-number><foreign-keys><key app="EN" db-id="xsfvz5w0va0esdeeev5p2sagsztwxtt0avpz" timestamp="1494607699">139</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Otsuji, H.</author><author>Yokoyama, Y.</author><author>Ebata, T.</author><author>Igami, T.</author><author>Sugawara, G.</author><author>Mizuno, T.</author><author>Yamaguchi, J.</author><author>Nagino, M.</author></authors></contributors><auth-address>Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan. yyoko@med.nagoya-u.ac.jp.</auth-address><titles><title>Surgery-Related Muscle Loss and Its Association with Postoperative Complications After Major Hepatectomy with Extrahepatic Bile Duct Resection</title><secondary-title>World J Surg</secondary-title></titles><periodical><full-title>World J Surg</full-title></periodical><pages>498-507</pages><volume>41</volume><number>2</number><dates><year>2017</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1432-2323 (Electronic)
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ADDIN EN.CITE.DATA 15,16. Thus, we suggest evaluation of lean body mass via CT scan, when available, to assist with nutritional risk prediction prior to surgery. Further studies on the role of objective measures of sarcopenia, such as CT scan or lean body mass ultrasound, are needed. A major limitation of these studies is their retrospective nature. While evidence from observational studies of baseline muscle mass and quality continues to grow, sufficient data to justify intervention development based on these measures exists and is desperately needed. Primary outcomes should likely focus on function and/or complications as opposed to mortality ADDIN EN.CITE <EndNote><Cite><Author>Wischmeyer</Author><Year>2017</Year><RecNum>170</RecNum><DisplayText><style face="superscript">17</style></DisplayText><record><rec-number>170</rec-number><foreign-keys><key app="EN" db-id="2w0ezvt9ytvxrdewdx7vt50nxw90aparr5a5" timestamp="1497698662">170</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wischmeyer, P.E.</author><author>Puthucheary, Z.</author><author>San Milan, I. </author><author>Butz, D. </author><author>Grocott, M. </author></authors></contributors><titles><title>Muscle Mass and Physical Recovery in ICU: Innovations for Targeting of Nutrition and Exercise</title><secondary-title>Curr Opin Crit Care</secondary-title></titles><periodical><full-title>Curr Opin Crit Care</full-title></periodical><pages>Accpeted for Publication.</pages><dates><year>2017</year></dates><urls></urls><electronic-resource-num>10.1097/MCC.0000000000000431</electronic-resource-num></record></Cite></EndNote>17.Finally, increasing data demonstrates a significant portion of the U.S. population is Vitamin D deficient ADDIN EN.CITE <EndNote><Cite><Author>Holick</Author><Year>2007</Year><RecNum>156</RecNum><DisplayText><style face="superscript">18</style></DisplayText><record><rec-number>156</rec-number><foreign-keys><key app="EN" db-id="2w0ezvt9ytvxrdewdx7vt50nxw90aparr5a5" timestamp="1488910019">156</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Holick, M. F.</author></authors></contributors><auth-address>Department of Medicine, Section of Endocrinology, Nutrition, and Diabetes, the Vitamin D, Skin, and Bone Research Laboratory, Boston University Medical Center, Boston, MA 02118, USA. mfholick@bu.edu</auth-address><titles><title>Vitamin D deficiency</title><secondary-title>N Engl J Med</secondary-title></titles><periodical><full-title>N Engl J Med</full-title></periodical><pages>266-81</pages><volume>357</volume><number>3</number><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Bone and Bones/metabolism</keyword><keyword>Calcium/metabolism</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Kidney Failure, Chronic/drug therapy</keyword><keyword>Male</keyword><keyword>Osteoporosis/prevention & control</keyword><keyword>Phosphorus/metabolism</keyword><keyword>Prevalence</keyword><keyword>Vitamin D/*administration & dosage/metabolism/therapeutic use</keyword><keyword>Vitamin D Deficiency/*complications/epidemiology/metabolism/*therapy</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul 19</date></pub-dates></dates><isbn>1533-4406 (Electronic)
0028-4793 (Linking)</isbn><accession-num>17634462</accession-num><urls><related-urls><url> and data in surgical patients shows that Vitamin D Deficiency has a significant relationship to postoperative complications ADDIN EN.CITE <EndNote><Cite><Author>Iglar</Author><Year>2015</Year><RecNum>157</RecNum><DisplayText><style face="superscript">19</style></DisplayText><record><rec-number>157</rec-number><foreign-keys><key app="EN" db-id="2w0ezvt9ytvxrdewdx7vt50nxw90aparr5a5" timestamp="1488910233">157</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Iglar, P. J.</author><author>Hogan, K. J.</author></authors></contributors><auth-address>Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 707 WARF Building, 610 North Walnut Street, Madison, WI 53726 USA.
Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B/6 319 Clinical Sciences Center, Madison, WI 53792-3272 USA.</auth-address><titles><title>Vitamin D status and surgical outcomes: a systematic review</title><secondary-title>Patient Saf Surg</secondary-title></titles><periodical><full-title>Patient Saf Surg</full-title></periodical><pages>14</pages><volume>9</volume><keywords><keyword>1,25-dihydroxyvitamin D3 (calcitriol)</keyword><keyword>1,25-dihydroxyvitamin D3 (calcitriol) level</keyword><keyword>25(OH)D (calcifediol)</keyword><keyword>25(OH)D (calcifediol) level</keyword><keyword>Postoperative complication</keyword><keyword>Postoperative outcome</keyword><keyword>Surgery complication</keyword><keyword>Surgery outcome</keyword><keyword>Vitamin D</keyword></keywords><dates><year>2015</year></dates><isbn>1754-9493 (Linking)</isbn><accession-num>25926889</accession-num><urls><related-urls><url>. Further, a recent randomized controlled trial published in JAMA showed in ICU patients with Vitamin D levels < 12 ng/ml experienced a significant improvement in hospital survival when vitamin D was aggressively supplementedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbXJlaW48L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 20. Thus, it is possible to consider checking vitamin D levels prior to all major surgery and repletion of 50,000 units once weekly for the period prior to surgery in patients found to be deficient (< 30 ng/ml). More data is needed on the role of vitamin D supplementation on surgical outcomes.#3 – Special Populations: ObesityFor patients that are found to have a BMI > 40 or a BMI > 35 with weight related co-morbidity such as diabetes, hypertension, sleep apnea or gastroesophageal reflux disease, referral for weight management, including surgery should be considered to minimize overall morbidity and mortality ADDIN EN.CITE <EndNote><Cite><Author>Kim</Author><Year>2016</Year><RecNum>163</RecNum><DisplayText><style face="superscript">21</style></DisplayText><record><rec-number>163</rec-number><foreign-keys><key app="EN" db-id="2w0ezvt9ytvxrdewdx7vt50nxw90aparr5a5" timestamp="1488923803">163</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kim, J.</author><author>Eisenberg, D.</author><author>Azagury, D.</author><author>Rogers, A.</author><author>Campos, G. M.</author></authors></contributors><auth-address>Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts. Electronic address: jkim7@.
Department of Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
Department of Surgery, Stanford University School of Medicine, Palo Alto, California.
Department of Surgery, Penn State University, Hershey, Pennsylvania.
Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia.</auth-address><titles><title>American Society for Metabolic and Bariatric Surgery position statement on long-term survival benefit after metabolic and bariatric surgery</title><secondary-title>Surg Obes Relat Dis</secondary-title></titles><periodical><full-title>Surg Obes Relat Dis</full-title></periodical><pages>453-9</pages><volume>12</volume><number>3</number><dates><year>2016</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>1878-7533 (Electronic)
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ADDIN EN.CITE.DATA 24. #4- Future Research Questions: Question #1: The PONS scoring system was created due to a need for a simple, objective definition of surgical malnutrition. The questions in the score are based on previously well-validated nutrition risk variables. However, prospective validity and reliability testing along with a usability assessment needs to be performed to evaluate the utility the PONS score as a clinical and research tool.Question #2: Further research is needed to identify a gold standard point-of-care (POC) and/or laboratory test that can assist in determining malnutrition/nutrition risk. POC tests for anemia, diabetes, and other chronic conditions have been developed yet there is no reliable POC indicator for malnutrition. Albumin, which is clearly correlated to surgical outcomes, ADDIN EN.CITE <EndNote><Cite><Author>Gibbs</Author><Year>1999</Year><RecNum>171</RecNum><DisplayText><style face="superscript">25</style></DisplayText><record><rec-number>171</rec-number><foreign-keys><key app="EN" db-id="2w0ezvt9ytvxrdewdx7vt50nxw90aparr5a5" timestamp="1497699817">171</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gibbs, J.</author><author>Cull, W.</author><author>Henderson, W.</author><author>Daley, J.</author><author>Hur, K.</author><author>Khuri, S. F.</author></authors></contributors><auth-address>Cooperative Studies Program Coordinating Center, the Edward Hines, Jr, VA Hospital, Hines, Ill 60141-5151, USA. jgibbs@nwu.edu</auth-address><titles><title>Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study</title><secondary-title>Arch Surg</secondary-title></titles><periodical><full-title>Arch Surg</full-title></periodical><pages>36-42</pages><volume>134</volume><number>1</number><keywords><keyword>Female</keyword><keyword>Humans</keyword><keyword>Logistic Models</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Postoperative Complications/*epidemiology</keyword><keyword>Predictive Value of Tests</keyword><keyword>Prognosis</keyword><keyword>Prospective Studies</keyword><keyword>Reproducibility of Results</keyword><keyword>Serum Albumin/*analysis</keyword></keywords><dates><year>1999</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0004-0010 (Print)
0004-0010 (Linking)</isbn><accession-num>9927128</accession-num><urls><related-urls><url> has been used to quickly and inexpensively measure nutritional risk has unfortunately been misconstrued as a universal marker of malnutrition. It is well-known that Albumin is an acute-phase reactant that gets depleted during inflammation ADDIN EN.CITE <EndNote><Cite><Author>Ferguson</Author><Year>1999</Year><RecNum>131</RecNum><DisplayText><style face="superscript">26</style></DisplayText><record><rec-number>131</rec-number><foreign-keys><key app="EN" db-id="2w0ezvt9ytvxrdewdx7vt50nxw90aparr5a5" timestamp="1488906347">131</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ferguson, M.</author><author>Capra, S.</author><author>Bauer, J.</author><author>Banks, M.</author></authors></contributors><auth-address>Centre for Public Health Research, Queensland University of Technology, Brisbane, Australia. mferguso@.au</auth-address><titles><title>Development of a valid and reliable malnutrition screening tool for adult acute hospital patients</title><secondary-title>Nutrition</secondary-title><alt-title>Nutrition (Burbank, Los Angeles County, Calif.)</alt-title></titles><periodical><full-title>Nutrition</full-title></periodical><pages>458-64</pages><volume>15</volume><number>6</number><edition>1999/06/23</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mass Screening/*methods</keyword><keyword>Middle Aged</keyword><keyword>Nutrition Disorders/*diagnosis</keyword><keyword>*Nutritional Status</keyword><keyword>*Patient Admission</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Surveys and Questionnaires</keyword></keywords><dates><year>1999</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0899-9007 (Print)
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ADDIN EN.CITE.DATA 28. The utility of albumin as a modifiable risk factor has not been thoroughly explored and deserves further research. Further, although albumin is a very useful of surgical risk, which may be related to malnutrition, a more specific, objective laboratory marker is needed. The development of a cost-effective perioperative marker of nutritional status will also assist in addressing the question of potential endpoints of nutritional therapy prior to surgery. This will be essential in order to provide the most “cost-effective” and timely perioperative nutritional therapy, where the goal is not likely to be “normalization” of nutritional status pre-operatively, but an attempt to define optimal nutritional “readiness” for surgery. Question #3: The role of IMN was an area of great controversy in our discussions. Without question, additional definitive clinical trials comparing IMN to high protein ONS in the preoperative setting and pre-op IMN alone versus pre- and post-op IMN versus post-op IMN alone are needed. Further, additional trials of IMN within ERAS pathways are needed. Ultimately, a definitive, adequately-powered, randomized, multi-center trial of IMN is needed to finally define the previously observed benefits of perioperative IMN in many smaller trials. Question #4: As stated, much of the perioperative nutrition literature is based on studies conducted outside the context of ERAS. Thus, the role of nutritional assessment and intervention in patients who receive care in a structured pathway are needed. Trials on the role of preoperative and postoperative optimization with PN, when indicated, can now be conducted more confidently in ERPs, given the newly described safety and lack of infectious risk with PN. Further, the ideal amount of protein to optimize surgical outcomes and post-operative physical functional in ERPs need to be better determined. Recent trials, such as the study demonstrating receiving > 60% of protein needs over first 3 post-operative days associating with a 4.4-day reduction in length of stay are encouragingPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5ZZXVuZzwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 29. Without doubt, additional trials examining effect of specific nutrition therapy in ERP/ERAS pathways should be a focus of future research. Question #5: The role of protein versus total caloric delivery and potential combination with exercise to improve perioperative outcomes will need continued exploration. Our recommendation to prioritize protein intake over consumption of calories in the pre-operative period is based on studies showing that the addition of protein to a diet can has an anabolic effectPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EZXV0ejwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 30, as does consumption of food sources that consist primarily of proteinPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TeW1vbnM8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 31. There is at least one prospective randomized controlled trial in critically ill surgical patients demonstrating that a hyperproteineic hypocaloric diet leads to improved sequential organ failure assessment (SOFA) scores despite receiving similar amounts of calories prior to surgery ADDIN EN.CITE <EndNote><Cite><Author>Rugeles</Author><Year>2013</Year><RecNum>189</RecNum><DisplayText><style face="superscript">32</style></DisplayText><record><rec-number>189</rec-number><foreign-keys><key app="EN" db-id="2w0ezvt9ytvxrdewdx7vt50nxw90aparr5a5" timestamp="1500016334">189</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rugeles, S. J.</author><author>Rueda, J. D.</author><author>Diaz, C. E.</author><author>Rosselli, D.</author></authors></contributors><auth-address>Department of Surgery, Pontificia Universidad Javeriana, Medical School, Bogota, Colombia.
Department of Surgery, Pontificia Universidad Javeriana, Medical School, Bogota, Colombia ; Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Medical School, Bogota, Colombia.
Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Medical School, Bogota, Colombia.</auth-address><titles><title>Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial</title><secondary-title>Indian J Crit Care Med</secondary-title></titles><periodical><full-title>Indian J Crit Care Med</full-title></periodical><pages>343-9</pages><volume>17</volume><number>6</number><keywords><keyword>Colombia</keyword><keyword>critical care</keyword><keyword>hypocaloric enteral nutrition</keyword><keyword>permissive underfeeding</keyword><keyword>randomized controlled trial</keyword></keywords><dates><year>2013</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0972-5229 (Print)
0972-5229 (Linking)</isbn><accession-num>24501485</accession-num><urls><related-urls><url>. Further as described previously colo-rectal surgery patients within an ERAS/ERP pathway demonstrated in patients receiving high protein ONS post-operatively that consumption of > 60% of protein needs over first 3 post-operative days was associated with a 4.4-day reduction in length of stay (p < 0.001).PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5ZZXVuZzwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 29 In non-surgical patients, the addition of a structured exercise regimen to a high protein diet increases both lower extremity muscle mass and strengthPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LaW08L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA 36. Reconciling this data with the protein “ceiling effect” described above will take additional research.Appendix References: ADDIN EN.REFLIST 1.Cruz-Jentoft AJ, Landi F, Schneider SM, et al. Prevalence of and interventions for sarcopenia in ageing adults: a systematic review. Report of the International Sarcopenia Initiative (EWGSOP and IWGS). Age and ageing. 2014;43(6):748-759.2.Malietzis G, Currie AC, Athanasiou T, et al. Influence of body composition profile on outcomes following colorectal cancer surgery. The British journal of surgery. 2016;103(5):572-580.3.Lee JS, He K, Harbaugh CM, et al. Frailty, core muscle size, and mortality in patients undergoing open abdominal aortic aneurysm repair. Journal of vascular surgery. 2011;53(4):912-917.4.Lieffers JR, Bathe OF, Fassbender K, Winget M, Baracos VE. Sarcopenia is associated with postoperative infection and delayed recovery from colorectal cancer resection surgery. 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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.25.Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134(1):36-42.26.Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458-464.27.Kondrup J, Rasmussen HH, Hamberg O, Stanga Z. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clinical nutrition (Edinburgh, Scotland). 2003;22(3):321-336.28.Nelson CL, Elkassabany NM, Kamath AF, Liu J. Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA. Clinical orthopaedics and related research. 2015;473(10):3163-3172.29.Yeung SE, Hilkewich L, Gillis C, Heine JA, Fenton TR. Protein intakes are associated with reduced length of stay: a comparison between Enhanced Recovery After Surgery (ERAS) and conventional care after elective colorectal surgery. The American journal of clinical nutrition. 2017.30.Deutz NE, Safar A, Schutzler S, et al. Muscle protein synthesis in cancer patients can be stimulated with a specially formulated medical food. Clinical nutrition (Edinburgh, Scotland). 2011;30(6):759-768.31.Symons TB, Sheffield-Moore M, Wolfe RR, Paddon-Jones D. A moderate serving of high-quality protein maximally stimulates skeletal muscle protein synthesis in young and elderly subjects. Journal of the American Dietetic Association. 2009;109(9):1582-1586.32.Rugeles SJ, Rueda JD, Diaz CE, Rosselli D. Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial. Indian J Crit Care Med. 2013;17(6):343-349.33.Kim HK, Suzuki T, Saito K, et al. Effects of exercise and amino acid supplementation on body composition and physical function in community-dwelling elderly Japanese sarcopenic women: a randomized controlled trial. J Am Geriatr Soc. 2012;60(1):16-23.34.Tieland M, van de Rest O, Dirks ML, et al. Protein supplementation improves physical performance in frail elderly people: a randomized, double-blind, placebo-controlled trial. Journal of the American Medical Directors Association. 2012;13(8):720-726.35.Tieland M, Dirks ML, van der Zwaluw N, et al. Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a randomized, double-blind, placebo-controlled trial. Journal of the American Medical Directors Association. 2012;13(8):713-719.36.Bouillanne O, Curis E, Hamon-Vilcot B, et al. Impact of protein pulse feeding on lean mass in malnourished and at-risk hospitalized elderly patients: a randomized controlled trial. Clinical nutrition (Edinburgh, Scotland). 2013;32(2):186-192. ................
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