ABSTRACT
Surgeons have known for more than a half-century that a patient who is malnourished is more likely to suffer complications and die following an operation than is a patient who is well nourished (1), The development of total parenteral nutrition (TPN) in 1968 (2) provided surgeons with the means to feed a patient even when the gastrointestinal tract did not function, Over the past quarter-century, enthusiasm for the use of TPN during the perioperative period has fluctuated widely, Initial reports documenting the safety and efficacy of TPN described its use in patients with permanent or prolonged gut dysfunction who would otherwise starve, and during the mid-1970s, TPN use was sporadic and largely limited to such patients, During the late 1970s and early 1980s, enthusiasm increased as numerous epidemiological reports appeared in the nutrition and surgical literature documenting the previously unrecognized high incidence of protein-calorie malnutrition in surgical patients and the close association between this and increased operative morbidity and mortality (3-19), During the early 1980s surgeons became increasingly willing to delay nonemergency operations to permit a period of preoperative nutritional support, believing that this would reduce operative morbidity, This approach was intuitively attractive and was supported by results of numerous nonrandomized studies, which suggested a benefit of preoperative TPN in patients with varying degrees of malnutrition (20-23). Many surgeons believed that if one required definitive proof of the efficacy of perioperative TPN, one had only to wait for the appropriate well-designed clinical trials to be performed and published. By the late 1980s, however, it became increasingly clear that such definitive proof was not forthcoming. Although a limited number of randomized clinical studies had, in fact, been performed, they were, in general, inconclusive. This failure to document clinical efficacy occurred at a time when fiscal and political pressures in many countries demanded such documentation to justify the use of expensive clinical technologies; hence the clinical use of perioperative nutritional
support, especially TPN, declined. During the last several years, a reassessment of existing data and publication of additional data have served to better define the appropriate role of nutritional support during the perioperative period. Perioperative TPN and perioperative nutritional support in general have been the subjects of rather intense scrutiny in recent years. TPN has joined a limited set of medical technologies for which there are now available rather extensive data assessing efficacy, cost, and cost-effectiveness.
