Commonly cited society guidelines supporting the use of preoperat

Commonly cited society guidelines supporting the use of preoperative IN were created using the results of other meta-analyses that did not account for this heterogeneity as in the current meta-analysis.1 and 2 Preoperative supplementation with standard ONS has not been studied extensively. Although our results suggest the similarity of standard and immune-modulating supplements, we cannot absolutely conclude that preoperative standard ONS will result in improved outcomes. One study evaluating preoperative supplementation with standard ONS vs nonsupplemented control diet demonstrated less postoperative weight loss and fewer

minor complications with preoperative supplementation.40 Doxorubicin cost Several past studies have failed see more to identify a major benefit from the use of standard preoperative ONS.41, 42 and 43 This might be due to the lack of a clear definition of “malnutrition” and inclusion of well-nourished patients. Adherence to the new definitions of malnutrition, as is being popularized by several societies,44 may serve to identify which patients will benefit the most from preoperative supplements. Future studies of preoperative nutrition should incorporate these new definitions. Additionally,

the varied composition and individual nutrients of the standard ONS, particularly the amount and biologic value of protein contained, might explain these conflicting results. Dietary protein

is critical to help promote muscle protein synthesis and decrease inflammation-associated loss of lean body mass and function. A meta-analysis by Cawood and colleagues of 36 RCTs (3,790 patients) showed that the use of high-protein Dynein supplements (>20% of calories from protein) was associated with reduced complications and readmission to hospital, improved grip strength, increased intake of protein and energy, and improvements in weight.45 Given the lack of a significant difference between IN and standard ONS in the preoperative setting, and the fact that standard ONS are less expensive and widely available, we recommend use of standard ONS for nutritional optimization of the surgical patient. Cost and accessibility are key factors to patient compliance. As with smoking cessation or exercise, achieving patient buy-in is crucial to any successful preoperative optimization regimen. Study conception and design: Hegazi, Evans Acquisition of data: Hegazi, Hustead, Evans Analysis and interpretation of data: Hegazi, Hustead, Evans Drafting of manuscript: Hegazi, Hustead, Evans Critical revision: Hegazi, Hustead, Evans The authors wish to thank Lianbo Yu, PhD, Center for Biostatistics, The Ohio State University for his help reviewing the analysis.

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