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The Role of Perioperative Nutrition Support in Postoperative Recovery

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A special issue of Nutrients (ISSN 2072-6643). This special issue belongs to the section "Clinical Nutrition".

Deadline for manuscript submissions: closed (25 November 2021) | Viewed by 52212

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Dr. Antonio Arroyo Sebastián

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Head of General and Digestive Surgery Service. Elche University General Hospital. Professor of Surgery. Deputy Director of the Department of Pathology and Surgery. UMH School of Medicine
Interests: colorectal disease; obesity surgery; colon cancer; perioperative immunonutrition; nutritional intervention; cancer surgery

Special Issue Information

Dear colleagues,

Malnutrition is closely related to disease and aging, leading to a significant increase in postoperative complications, hospital stay, and readmission rates.

Therefore, rectification is essential to improve the results of surgery. Questions about supplementary nutrition, such as “for how long?”, “before, during, and/or after surgery?”, “enteral or parenteral?” “immunonutrition—yes or no?” are still being debated, with resolution open to considerations based on future evidence.

On the other hand, nutrition in the surgical patient has gained momentum within the ERAS (enhanced recovery surgery) programs where we are “obliged” to carry out nutritional screening of all surgical patients and, consequently, treat potential malnutrition.

Within the ERAS programs, the concept of “trimodal prehabilitation” has recently emerged, where the patient prepares for surgery through physical exercise and nutritional and psychological support. As part of these preparations, the implementation of oral enteral nutrition is proposed, even in a normally nourished patient to enhance the results of physical exercise and to correct states of protein malnutrition or sarcopenia in patients theoretically labeled as normally nourished in nutritional screening, anthropometric tests, lab work, and mass indices for normal bodies. That is why we must also propose new diagnostic methods and reliable measurements that are readily accessible to rule out sarcopenia.

With this Special Issue, we would like to present, to readers, the state-of-the-art in the field of perioperative nutrition support in postoperative recovery. Original research articles and reviews (systematic reviews and meta-analyses) are welcome.

Dr. Antonio Arroyo Sebastián
Guest Editors

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Keywords

diagnostic methods of sarcopenia
immunonutrition
parenteral nutrition
enteral nutrition
prehabilitation
enhanced recovery surgery
sarcopenia
nutritional screening

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Published Papers (11 papers)

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Research

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12 pages, 941 KiB

Open AccessArticle

Postoperative Dietary Intake Achievement: A Secondary Analysis of a Randomized Controlled Trial

by Chiou Yi Ho, Zuriati Ibrahim, Zalina Abu Zaid, Zulfitri Azuan Mat Daud, Nor Baizura Mohd Yusop, Mohd Norazam Mohd Abas and Jamil Omar

Nutrients 2022, 14(1), 222; https://doi.org/10.3390/nu14010222 - 5 Jan 2022

Cited by 2 | Viewed by 3452

Abstract

Sufficient postoperative dietary intake is crucial for ensuring a better surgical outcome. This study aimed to investigate the postoperative dietary intake achievement and predictors of postoperative dietary intake among gynecologic cancer patients. A total of 118 participants were included in this secondary analysis. Postoperative dietary data was pooled and re-classified into early postoperative dietary intake achievement (EDIA) (daily energy intake (DEI) ≥ 75% from the estimated energy requirement (EER)) and delay dietary intake achievement (DDIA) (DEI < 75% EER) There was a significant difference in postoperative changes in weight (p = 0.002), muscle mass (p = 0.018), and handgrip strength (p = 0.010) between the groups. Postoperative daily energy and protein intake in the EDIA was significantly greater than DDIA from operation day to discharged (p = 0.000 and p = 0.036). Four significant independent postoperative dietary intake predictors were found: preoperative whey protein-infused carbohydrate loading (p = 0.000), postoperative nausea vomiting (p = 0.001), age (p = 0.010), and time to tolerate clear fluid (p = 0.016). The multilinear regression model significantly predicted postoperative dietary intake, F (4, 116) = 68.013, p = 0.000, adj. R² = 0.698. With the four predictors’ recognition, the integration of a more specific and comprehensive dietitian-led supportive care with individualized nutrition intervention ought to be considered to promote functional recovery. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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13 pages, 2131 KiB

Open AccessArticle

Assessment of Body Composition as an Indicator of Early Peripheral Parenteral Nutrition Therapy in Patients Undergoing Colorectal Cancer Surgery in an Enhanced Recovery Program

by Francisco López-Rodríguez-Arias, Luis Sánchez-Guillén, Cristina Lillo-García, Verónica Aranaz-Ostáriz, M José Alcaide, Álvaro Soler-Silva, Leticia Soriano-Irigaray, Xavier Barber and Antonio Arroyo

Nutrients 2021, 13(9), 3245; https://doi.org/10.3390/nu13093245 - 18 Sep 2021

Cited by 11 | Viewed by 3515

Abstract

Background: A poor body composition (BC) has been identified as a risk factor for patients with colorectal cancer (CRC). This study was performed to assess the effect of early peripheral parenteral nutrition (PPN) on BC in patients undergoing CCR surgery within an enhanced recovery program. Methods: Patients with normal nutritional status were prospectively included between October 2016 and September 2019, randomized into two groups (PPN with periOlimel N4-E versus conventional fluid therapy) and subsequently classified according to their preoperative CT scan into high- or low-risk BC groups. Postoperative complications and length of hospital stay (LOS) were assessed. Results: Of the 156 patients analyzed, 88 patients (56.4%) were classified as having high-risk BC according to CT measurements. PPN led to a 15.4% reduction in postoperative complications in high-risk vs. 1.7% in low-risk BC patients. In the multivariate analysis, high-risk BC was related to an OR (95% CI) of 2 (p = 0.044) of presenting complications and of 1.9 (p = 0.066) for major complications, and was associated with an increase in LOS of 3.6 days (p = 0.039). Conclusions: The measurement of patients’ BC can allow for the identification of target patients where PPN has been proven to be an effective tool to improve postoperative outcomes. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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15 pages, 962 KiB

Open AccessArticle

Prehabilitation for Bariatric Surgery: A Randomized, Controlled Trial Protocol and Pilot Study

by Yaiza García-Delgado, María José López-Madrazo-Hernández, Dácil Alvarado-Martel, Guillermo Miranda-Calderín, Arantza Ugarte-Lopetegui, Raúl Alberto González-Medina, Alba Hernández-Lázaro, Garlene Zamora, Nuria Pérez-Martín, Rosa María Sánchez-Hernández, Adriana Ibarra-González, Mónica Bengoa-Dolón, Carmen Teresa Mendoza-Vega, Svein Mikael Appelvik-González, Yurena Caballero-Díaz, Juan Ramón Hernández-Hernández and Ana María Wägner

Nutrients 2021, 13(9), 2903; https://doi.org/10.3390/nu13092903 - 24 Aug 2021

Cited by 15 | Viewed by 4260

Abstract

Bariatric surgery is the most efficacious treatment for obesity, though it is not free from complications. Preoperative conditioning has proved beneficial in various clinical contexts, but the evidence is scarce on the role of prehabilitation in bariatric surgery. We describe the protocol and pilot study of a randomized (ratio 1:1), parallel, controlled trial assessing the effect of a physical conditioning and respiratory muscle training programme, added to a standard 8-week group intervention based on therapeutical education and cognitive-behavioural therapy, in patients awaiting bariatric surgery. The primary outcome is preoperative weight-loss. Secondary outcomes include associated comorbidity, eating behaviour, physical activity, quality of life, and short-term postoperative complications. A pilot sample of 15 participants has been randomized to the intervention or control groups and their baseline features and results are described. Only 5 patients completed the group programme and returned for assessment. Measures to improve adherence will be implemented and once the COVID-19 pandemic allows, the clinical trial will start. This is the first randomized, clinical trial assessing the effect of physical and respiratory prehabilitation, added to standard group education and cognitive-behavioural intervention in obese patients on the waiting list for bariatric surgery. Clinical Trial Registration: NCT0404636. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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10 pages, 427 KiB

Open AccessFeature PaperArticle

Impact of Sarcopenia on Acute Kidney Injury after Infrarenal Abdominal Aortic Aneurysm Surgery: A Propensity Matching Analysis

by Ji-Yeon Bang, In-Gu Jun, Jeong-Bok Lee, You-Sun Ko, Kyung-Won Kim, Jun-Hyeop Jeong, Sung-Hoon Kim and Jun-Gol Song

Nutrients 2021, 13(7), 2212; https://doi.org/10.3390/nu13072212 - 27 Jun 2021

Cited by 11 | Viewed by 2265

Abstract

Background: Sarcopenia contributes to increased morbidity and mortality in patients undergoing surgery for abdominal aortic aneurysms (AAA). However, few reports have demonstrated whether sarcopenia would affect the development of postoperative acute kidney injury (AKI) in these patients. This study aimed to examine whether sarcopenia is associated with AKI and morbidity and mortality after infrarenal AAA operation. Methods: We retrospectively analysed 379 patients who underwent infrarenal AAA surgery. The diagnosis of sarcopenia was performed using the skeletal muscle index, which was calculated from axial computed tomography at the level of L3. The patients were separated into those with sarcopenia (n = 104) and those without sarcopenia (n = 275). We applied multivariable and Cox regression analyses to evaluate the risk factors for AKI and overall mortality. A propensity score matching (PSM) evaluation was done to assess the postoperative results. Results: The incidence of AKI was greater in sarcopenia than non-sarcopenia group before (34.6% vs. 15.3%; p < 0.001) and after the PSM analysis (34.6% vs. 15.4%; p = 0.002). Multivariable analysis revealed sarcopenia to be associated with AKI before (p = 0.010) and after PSM (p = 0.016). Sarcopenia was also associated with overall mortality before (p = 0.048) and after PSM (p = 0.032). A Kaplan–Meier analysis revealed that overall mortality was elevated patients with sarcopenia before and after PSM than in those without (log-rank test, p < 0.001, p = 0.022). Conclusions: Sarcopenia was associated with increased postoperative AKI incidence and overall mortality among individuals who underwent infrarenal AAA operation. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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13 pages, 1218 KiB

Open AccessArticle

NutriCatt Protocol Improves Body Composition and Clinical Outcomes in Elderly Patients Undergoing Colorectal Surgery in ERAS Program: A Retrospective Cohort Study

by Emanuele Rinninella, Alberto Biondi, Marco Cintoni, Pauline Raoul, Francesca Scialanga, Eleonora Persichetti, Gabriele Pulcini, Roberto Pezzuto, Roberto Persiani, Domenico D’Ugo, Antonio Gasbarrini and Maria Cristina Mele

Nutrients 2021, 13(6), 1781; https://doi.org/10.3390/nu13061781 - 23 May 2021

Cited by 2 | Viewed by 2946

Abstract

Background: A poor body composition, often found in elderly patients, negatively impacts perioperative outcomes. We evaluated the effect of a perioperative nutritional protocol (NutriCatt) on body composition and clinical outcomes in a cohort of elderly patients undergoing colorectal surgery in a high-volume center adopting the ERAS program. Methods: 302 out of 332 elderly (>75 years) patients from 2015 to 2020 were identified. Patients were divided according to their adherence, into “NutriCatt + ERAS” (n = 166) or “standard ERAS” patients (n = 136). Anthropometric and bioelectrical impedance analysis data were evaluated for NutriCatt + ERAS patients. Complications, length of hospital stay (LOS), and other postoperative outcomes were compared between both groups. Results: In NutriCatt + ERAS patients, significant improvements of phase angle (pre-admission vs. admission 4.61 ± 0.79 vs. 4.84 ± 0.85; p = 0.001; pre-admission vs. discharge 4.61 ± 0.79 vs. 5.85 ± 0.73; p = 0.0002) and body cell mass (pre-admission vs. admission 22.4 ± 5.6 vs. 23.2 ± 5.7; p = 0.03; pre-admission vs. discharge 22.4 ± 5.6 vs. 23.1 ± 5.8; p = 0.02) were shown. NutriCatt + ERAS patients reported reduced LOS (p = 0.03) and severe complications (p = 0.03) compared to standard ERAS patients. A regression analysis confirmed the protective effect of the NutriCatt protocol on severe complications (OR 0.10, 95% CI 0.01–0.56; p = 0.009). Conclusions: The NutriCatt protocol improves clinical outcomes in elderly patients and should be recommended in ERAS colorectal surgery. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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13 pages, 1492 KiB

Open AccessArticle

Body Composition Changes in Gastric Cancer Patients during Preoperative FLOT Therapy: Preliminary Results of an Italian Cohort Study

by Emanuele Rinninella, Antonia Strippoli, Marco Cintoni, Pauline Raoul, Raffaella Vivolo, Mariantonietta Di Salvatore, Enza Genco, Riccardo Manfredi, Emilio Bria, Giampaolo Tortora, Antonio Gasbarrini, Carmelo Pozzo and Maria Cristina Mele

Nutrients 2021, 13(3), 960; https://doi.org/10.3390/nu13030960 - 16 Mar 2021

Cited by 18 | Viewed by 3315

Abstract

Background: The impact of the new chemotherapy, fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) on body composition in gastric cancer (GC) patients remains unknown. We assessed body composition changes of GC patients receiving the FLOT regimen and their impact on treatment outcomes. Methods: Preoperative pre- and post-FLOT computed tomography (CT) scans of advanced GC patients were studied. Lumbar skeletal muscle index (SMI) and adipose indices were calculated before and after FLOT. Results: A total of 26 patients were identified between April 2019 and January 2020. Nineteen patients were sarcopenic at diagnosis. The mean BMI decreased (from 24.4 ± 3.7 to 22.6 ± 3.1; p < 0.0001) as well as the SMI (from 48.74 ± 9.76 to 46.52 ± 9.98; p = 0.009) and visceral adipose index (VAI) (from 49.04 ± 31.06 to 41.99 ± 23.91; p = 0.004) during preoperative FLOT therapy. BMI, SMI, and VAI variations were not associated with toxicity, Response Evaluation Criteria in Solid Tumors (RECIST), response, delay and completion of perioperative FLOT chemotherapy, and the execution of gastrectomy; a decrease of SMI ≥ 5% was associated with a higher Mandard tumor regression grade (p = 0.01). Conclusions: Almost three-quarters (73.1%) of GC patients were sarcopenic at diagnosis. Preoperative FLOT was associated with a further reduction in SMI, BMI, and VAI. These changes were not associated with short-term outcomes. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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Review

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18 pages, 390 KiB

Open AccessReview

Perioperative Nutritional Support: A Review of Current Literature

by Antonio Jesús Martínez-Ortega, Ana Piñar-Gutiérrez, Pilar Serrano-Aguayo, Irene González-Navarro, Pablo Jesús Remón-Ruíz, José Luís Pereira-Cunill and Pedro Pablo García-Luna

Nutrients 2022, 14(8), 1601; https://doi.org/10.3390/nu14081601 - 12 Apr 2022

Cited by 40 | Viewed by 8101

Abstract

Since the beginning of the practice of surgery, the reduction of postoperative complications and early recovery have been two of the fundamental pillars that have driven the improvement of surgical techniques and perioperative management. Despite great advances in these fields, the rationalization of antibiotic prophylaxis, and other important innovations, postoperative recovery (especially in elderly patients, oncological pathology or digestive or head and neck surgery) is tortuous. This can be explained by several reasons, among which, malnutrition has a major role. Perioperative nutritional support, included within the ERAS (Enhanced Recovery After Surgery) protocol, has proven to be a main element and a critical step to achieve better surgical results. Starting with the preoperative nutritional assessment and treatment in elective surgery, we can improve nutritional status using oral supplements and immunomodulatory formulas. If we add early nutritional support in the postoperative scenario, we are able to significantly reduce infectious complications, need for intensive care unit (ICU) and hospital stay, costs, and mortality. Throughout this review, we will review the latest developments and the available literature. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

11 pages, 983 KiB

Open AccessReview

Cystine and Theanine as Stress-Reducing Amino Acids—Perioperative Use for Early Recovery after Surgical Stress

by Takashi Tsuchiya and Shigekazu Kurihara

Nutrients 2022, 14(1), 129; https://doi.org/10.3390/nu14010129 - 28 Dec 2021

Cited by 8 | Viewed by 3004

Abstract

Perioperative nutritional therapy requires the consideration of metabolic changes, and it is desirable to reduce stress aiming at early metabolic normalization. Glutathione (GSH) is a tripeptide composed of glutamic acid, cysteine, and glycine. It is one of the strongest antioxidants in the body and important for adjusting immune function. Cystine and theanine (γ-glutamylethylamide) provide substrates of GSH, cysteine and glutamic acid, promoting the synthesis of GSH. It has been reported that the ingestion of cystine (700 mg) and theanine (280 mg) exhibits inhibitory effects against excess inflammation after strong exercise loads in athletes, based on which its application for invasive surgery has been tried. In patients undergoing gastrectomy, ingestion of cystine (700 mg) and theanine (280 mg) for 10 days from 5 days before surgery inhibited a postoperative increase in resting energy expenditure, promoted recovery from changes in interleukin-6, C-reactive protein, lymphocyte ratio, and granulocyte ratio and inhibited an increase in body temperature. In a mouse small intestine manipulation model, preoperative 5-day administration of cystine/theanine inhibited a postoperative decrease in GSH in the small intestine and promoted recovery from a decrease in behavior quantity. Based on the above, cystine/theanine reduces surgical stress, being useful for perioperative management as stress-reducing amino acids. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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31 pages, 832 KiB

Open AccessReview

Nutritional Support Indications in Gastroesophageal Cancer Patients: From Perioperative to Palliative Systemic Therapy. A Comprehensive Review of the Last Decade

by Giulia E.G. Mulazzani, Francesca Corti, Serena Della Valle and Maria Di Bartolomeo

Nutrients 2021, 13(8), 2766; https://doi.org/10.3390/nu13082766 - 12 Aug 2021

Cited by 23 | Viewed by 5540

Abstract

Gastric cancer treatments are rapidly evolving, leading to significant survival benefit. Recent evidence provided by clinical trials strongly encouraged the use of perioperative chemotherapy as standard treatment for the localized disease, whereas in the advanced disease setting, molecular characterization has improved patients’ selection for tailored therapeutic approaches, including molecular targeted therapy and immunotherapy. The role of nutritional therapy is widely recognized, with oncologic treatment’s tolerance and response being better in well-nourished patients. In this review, literature data on strategies or nutritional interventions will be critically examined, with particular regard to different treatment phases (perioperative, metastatic, and palliative settings), with the aim to draw practical indications for an adequate nutritional support of gastric cancer patients and provide an insight on future directions in nutritional strategies. We extensively analyzed the last 10 years of literature, in order to provide evidence that may fit current clinical practice both in terms of nutritional interventions and oncological treatment. Overall, 137 works were selected: 34 Randomized Clinical Trials (RCTs), 12 meta-analysis, 9 reviews, and the most relevant prospective, retrospective and cross-sectional studies in this setting. Eleven ongoing trials have been selected from clinicaltrial.gov as representative of current research. One limitation of our work lies in the heterogeneity of the described studies, in terms of sample size, study procedures, and both nutritional and clinical outcomes. Indeed, to date, there are no specific evidence-based guidelines in this fields, therefore we proposed a clinical algorithm with the aim to indicate an appropriate nutritional strategy for gastric cancer patients. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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17 pages, 514 KiB

Open AccessFeature PaperReview

Polypharmacy and Malnutrition Management of Elderly Perioperative Patients with Cancer: A Systematic Review

by Eiji Kose, Hidetaka Wakabayashi and Nobuhiro Yasuno

Nutrients 2021, 13(6), 1961; https://doi.org/10.3390/nu13061961 - 7 Jun 2021

Cited by 33 | Viewed by 7832

Abstract

Malnutrition, which commonly occurs in perioperative patients with cancer, leads to decreased muscle mass, hypoalbuminemia, and edema, thereby increasing the patient’s risk of various complications. Thus, the nutritional management of perioperative patients with cancer should be focused on to ensure that surgical treatment is safe and effective, postoperative complications are prevented, and mortality is reduced. Pathophysiological and drug-induced factors in elderly patients with cancer are associated with the risk of developing malnutrition. Pathophysiological factors include the effects of tumors, cachexia, and anorexia of aging. Metabolic changes, such as inflammation, excess catabolism, and anabolic resistance in patients with tumor-induced cancer alter the body’s ability to use essential nutrients. Drug-induced factors include the side effects of anticancer drugs and polypharmacy. Drug–drug, drug–disease, drug–nutrient, and drug–food interactions can significantly affect the patient’s nutritional status. Furthermore, malnutrition may affect pharmacokinetics and pharmacodynamics, potentiate drug effects, and cause side effects. This review outlines polypharmacy and malnutrition, the impact of malnutrition on drug efficacy, drug–nutrient and drug–food interactions, and intervention effects on polypharmacy or cancer cachexia in elderly perioperative patients with cancer. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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12 pages, 828 KiB

Open AccessReview

The Effect of Perioperative Administration of Probiotics on Colorectal Cancer Surgery Outcomes

by Louise Pitsillides, Gianluca Pellino, Paris Tekkis and Christos Kontovounisios

Nutrients 2021, 13(5), 1451; https://doi.org/10.3390/nu13051451 - 25 Apr 2021

Cited by 17 | Viewed by 4063

Abstract

The perioperative care of colorectal cancer (CRC) patients includes antibiotics. Although antibiotics do provide a certain protection against infections, they do not eliminate them completely, and they do carry risks of microbial resistance and disruption of the microbiome. Probiotics can maintain the microbiome’s balance postoperatively by maintaining intestinal mucosal integrity and reducing bacterial translocation (BT). This review aims to assess the role of probiotics in the perioperative management of CRC patients. The outcomes were categorised into: postoperative infectious and non-infectious complications, BT rate analysis, and intestinal permeability assessment. Fifteen randomised controlled trials (RCTs) were included. There was a trend towards lower rates of postoperative infectious and non-infectious complications with probiotics versus placebo. Probiotics reduced BT, maintained intestinal mucosal permeability, and provided a better balance of beneficial to pathogenic microorganisms. Heterogeneity among RCTs was high. Factors that influence the effect of probiotics include the species used, using a combination vs. single species, the duration of administration, and the location of the bowel resection. Although this review provided evidence for how probiotics possibly operate and reported notable evidence that probiotics can lower rates of infections, heterogeneity was observed. In order to corroborate the findings, future RCTs should keep the aforementioned factors constant. Full article

(This article belongs to the Special Issue The Role of Perioperative Nutrition Support in Postoperative Recovery)

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