The gastrointestinal immune system: Implications for the surgical patient.

Approximately one-half million uncontrolled infections occur per year, costing the United States annual health care budget $10-20 billion; sepsis remains the leading cause of death. In these patients, the mortality rate averages 30% and ranges from 20% to 60% depending upon the study. Over the past 3 decades, current medical therapies have not reduced the mortality from sepsis. Prevention is the most effective means to reduce morbidity and mortality; the administration of nutrition, in particular enteral feedings (ENTs), decreases the incidence of sepsis. Advanced medical and surgical care prolongs life but at the price of longer hospital stays and increased cost to society. An aging American population compounds these issues. Postoperative complications remain a major reason for the increase in health care expenditures and the etiology of these complications is multifactorial. Each operation carries its own risk of complications, ranging from low-risk procedures such as an inguinal hernia repair to major risks such as a pancreaticoduodenectomy or esophagectomy. However, a patient's inherent ability to heal remains a critical factor in overall outcome. It has long been recognized that a deteriorating or a poor preoperative nutritional state increases the risk of postoperative complications. Patients are commonly admitted with preexisting weight loss, compromised protein compartments and energy stores, and a weakened immune status. Unfortunately, with a shift to outpatient evaluation and same day surgery over the past 3 decades, preoperative evaluation frequently neglects even a cursory nutritional assessment. At our institution, 99.6% of operative patients underwent nutritional assessment with approximately 80% of assessments performed postoperatively on the first day precluding any opportunity to reverse nutritional deficiencies and reduce nutrition-related postoperative risk. The few patients that received assessments preoperatively had been admitted for cardiovascular evaluation, management of significant comorbidities, or complex diagnostic testing. However, impaired nutritional status develops in several additional ways other than preoperatively. Many patients admitted with reasonable nutritional status sustain progressive deterioration of their body composition postoperatively