Surgical Preparation

Other Nutrients That Enhance Surgical Outcomes

In addition to the specific immunonutrients discussed above, supplementation with many other biologically active materials can help prepare a person for upcoming surgery. Assuring that the body is replete with antioxidants is one easy and powerful way to avoid the antioxidant depletion that occurs during the surgical procedure (Pechan I et al 2004). Maximizing the anti-inflammatory status and boosting immune function to achieve the proper balance of host defense against infection while minimizing the exaggerated inflammatory response to surgery is another. And, of course, ensuring adequate protein intake prior to surgery is an important way of providing the soon-to-be-healing body with the building blocks of new tissue. All of these effects can be achieved with a reasonable program of supplementation in the weeks prior to surgery.

Amino acids are the building blocks of proteins, which are themselves the chief components of structural tissue. The enzymes that catalyze all biological processes are also proteins. Surgery dramatically increases the daily requirement of protein, particularly if there is substantial blood loss; and supplements containing amino acids or whole proteins have been shown both in animal models and human clinical trials to enhance the outcomes of surgical procedures (Collins CE et al 2005; MacKay D et al 2003; Scholl D et al 2001). Supplements may improve wound healing (Collins CE et al 2005), reduce the rate and severity of pressure ulcers (Frias SL et al 2004; Bourdel-Marchasson I et al 2000; Breslow RA et al 1993), and improve fat mass (a good thing following surgery; de Luis DA et al 2005).

Almost all of the known vitamins are essential in each of the phases of surgery, either as vital cofactors in protein or nucleic acid synthesis for rapidly healing tissue or as potent antioxidants that can minimize tissue damage and the heightened inflammatory response caused by surgery. Blood levels of many of the vitamins are markedly reduced during surgery, and there is good evidence for both pre- and postoperative supplementation.

Vitamin C. This vitamin is an antioxidant that is also an absolute requirement for protein synthesis, making it indispensable in wound and fracture healing; fractures in animal models heal faster when the animals receive vitamin C supplementation (Sarisozen B et al 2002; Yilmaz C et al 2001). In humans, vitamin C contributes to the strength of healing wounds and reduces the degree and severity of postoperative pressure ulcers (Desneves KJ et al 2005; Frias SL et al 2004; MacKay D et al 2003).

Vitamin E. Vitamin E is a potent antioxidant and fat-soluble vitamin that is found in large amounts in skin, where it may improve wound healing and scar appearance (Chen MA et al 2005; MacKay D et al 2003). By scavenging reactive oxygen species, vitamin E can reduce tissue damage caused by free radicals, thereby reducing surgically induced inflammation. Like vitamin A, vitamin E levels are depleted during surgical procedures, especially those that require the use of a heart-lung machine (Schindler R et al 2003). In animal models, supplements containing vitamin E promote fracture healing (Turk C et al 2004; Sarisozen B et al 2002) and mitigate the deleterious effects of hyperbaric (high pressure) oxygen (Patel V et al 2005). In humans, vitamin E also assists in the healing of bone necrosis following radiation treatment (Delanian S et al 2005). Vitamin E has even been administered directly into coronary blood vessels during open-heart surgery, where it was shown to reduce reperfusion oxidative injury to cardiac muscle cells (Canbaz S et al 2003).

Because vitamin E can inhibit platelet aggregation, patients should discuss vitamin E supplementation with their surgeons well in advance of the surgery to determine whether the benefit exceeds the risk in their specific cases. Another way to enhance vitamin E function without direct vitamin E supplementation is to consider alpha-lipoic acid, which has been shown to support vitamin E’s antioxidant function in patients undergoing hyperbaric oxygen treatment (Alleva R et al 2005).

Vitamin A. This vitamin is essential for surgical patients; it stimulates the production of transforming growth factor beta-1, which accelerates skin and intestinal wound healing (Yuen DE et al 2004). Supplements containing vitamin A have been especially useful in the prevention of pressure ulcers (Singer P 2002) and in treatment of burn patients (Grau CT et al 2005). Vitamin A has also been shown to mitigate the effects of inflammation caused by radiation treatments that often accompany cancer surgery (Ehrenpreis ED et al 2005).

Lipoic acid. Lipoic acid is an effective antioxidant that may have a role in preoperative care. In a rat model of skin injury, pretreatment with lipoic acid sped the healing of skin wounds by protecting skin cells from oxidant damage (Lateef H et al 2005). In humans, lipoic acid helped combat the free radical damage caused by high tissue concentrations of oxygen (Alleva R et al 2005).

In addition to vitamins, a number of other micronutrients and conditionally essential nutrients, many with antioxidant or anti-inflammatory effects, have been found to improve surgical outcomes and prevent complications.

Omega-3 fatty acids. These have already been mentioned as key components of immunonutrient formulas. Fish oil supplements have independently been documented to reduce the exaggerated inflammatory response caused by surgery, producing decreased cytokine levels (Aiko S et al 2005; Babcock TA et al 2005; Bansal V et al 2005). Supplementation with fish oil rich in omega-3 fatty acids reduced infection rates and showed promise for shortening hospital length of stay (Heller A et al 2000). The same group of investigators also demonstrated improvements in liver and pancreatic function postoperatively in cancer patients supplemented with fish oil (Heller AR et al 2004). Cancer patients given five days of omega-3 supplementation before their surgery had dramatically reduced blood levels of inflammatory mediators in the postoperative days (Nakamura K et al 2005). Perhaps the most dramatic demonstration of fish oil’s efficacy is a 2004 study of preoperative supplementation, which demonstrated a decrease in deaths following surgery in the group that received preoperative fish oil supplements (Tsekos E et al 2004). This study also showed a lower requirement for mechanical ventilation postoperatively and a shorter length of hospital stay in the group supplemented preoperatively.

Coenzyme Q10. Coenzyme Q10 (CoQ10) is an antioxidant molecule intimately involved in intracellular energy management. Like other antioxidants, its levels plummet sharply during surgery, presumably because of rapid consumption by oxidant species (Pechan I et al 2004). Diminished levels of CoQ10 and other conditionally essential antioxidants may also worsen cardiac output, especially in people with preexisting heart disease (Sole MJ et al 2002). Poor cardiac output results in poor perfusion of other organs and can delay healing and set the stage for other complications. Preoperative treatment with CoQ10 can restore cardiac muscle function and protect against hypoxic (low oxygen) damage (Keith M et al 2005; Rosenfeldt F et al 2005). One study of a supplement containing CoQ10, taurine, and carnitine demonstrated improved cardiac blood volumes in cardiac surgery patients (Jeejeebhoy F et al 2002).

Zinc. This mineral functions as an important coenzyme in the production of collagen, the chief protein in healing wound tissue; it has also recently been determined to have an important antioxidant function in skin (Rostan EF et al 2002). The earliest sign of zinc deficiency in humans is often the development of skin breakdown, and topical zinc treatments have been used for centuries with good effect (Schwartz JR et al 2005). Animals made zinc deficient have slower rates of collagen accumulation in wounds and diminished wound strength, while zinc supplementation prior to creation of the wound (preoperatively) increased the strength of the healing wound (Kaplan B et al 2004; Iriyama K et al 1982). Quantitative studies of the effects of zinc supplementation in mice demonstrate that adequate zinc has an antioxidant function and hastens wound healing, while deficiency or very high doses delay healing (Lim Y et al 2004; Cario E et al 2000). Zinc may help in the healing, not only of skin wounds, but also of bone: one study demonstrated that zinc supplementation hastened the healing of leg fractures in rats (Igarashi A et al 1999).

In studies of patients who already had pressure ulcers, supplementation with a combination of zinc, arginine, and vitamin C produced significant improvement in treated patients compared with controls given placebo (Desneves KJ et al 2005; Frias SL et al 2004). A similar supplement was shown to delay the onset of pressure ulcers in a group of patients recovering from hip surgery (Houwing RH et al 2003). This combination is now widely recognized for patients undergoing surgery of any kind (Singer P 2002).

Melatonin. This is a pineal gland hormone that also has antioxidant functions (Macchi MM et al 2004). It appears to fundamentally affect a variety of brain functions related to relaxation, sleep, and anxiety, and its natural secretion is perturbed both by surgery (Guo X et al 2002) and by anesthesia (Karkela J et al 2002). These disturbances may contribute to the well-known phenomena of postoperative delirium (Shigeta H et al 2001) and “ICU psychosis,” in which patients become agitated, confused, and combative while in intensive care. Melatonin supplementation has been suggested in this setting (Miyazaki T et al 2003), though no clinical trials have been conducted.

Melatonin has recently been demonstrated to be as effective at reducing anxiety before a procedure as the commonly used benzodiazepine drug midazolam (Acil M et al 2004). As a premedication, melatonin has the added advantage of not producing postoperative impairments in mental function, as do the benzodiazepines (Samarkandi A et al 2005). There is emerging clinical evidence that melatonin may positively modify surgically induced general inflammation. In a study of newborns, melatonin given postoperatively significantly reduced inflammatory cytokine levels (Gitto E et al 2004).

Curcumin. Curcumin is a major component of turmeric. It is an antioxidant and a potent inhibitor of nuclear factor kappa beta, which plays a central role in “translating” inflammatory stimuli into activation of the inflammatory response. There has been tremendous recent interest in the role of nuclear factor kappa beta inhibition as a means of reining in overactive inflammatory reactions in sepsis, cancer, and autoimmune diseases (Maheshwari RK et al 2006).

A study of topical curcumin delivered in a collagen-based film demonstrated enhanced wound healing and tissue proliferation in wounds covered with the film, as well as more-efficient free radical scavenging than in wounds covered with a non-curcumin-containing film (Gopinath D et al 2004). In an animal model of radiation-induced impaired wound healing, pretreatment with curcumin enhanced wound closure compared with controls (Jagetia GC et al 2004). This study has profound implications for human cancer surgeries that are often complicated by the effects of radiation treatment.

Curcumin has also demonstrated powerful antioxidant effects on skin cells in culture, protecting cells against damage caused by hydrogen peroxide (Phan TT et al 2001). These mechanisms together may explain the more rapid healing of experimentally-produced surgical wounds in animals treated with curcumin (Sidhu GS et al 1998, 1999). There are as yet no human trials of curcumin in the context of surgery, but it has been observed to be safe and well tolerated in human trials for other uses as an anti-inflammatory and chemoprotective agent (Holt PR et al 2005; Cheng AL et al 2001).

Product Availability

All the nutrients and supplements discussed in this section are available through the Life Extension Foundation Buyers Club, Inc. For ordering information, call anytime toll-free 1-800-544-4440, or visit us online at www.LifeExtension.com.

The blood tests discussed in this section are available through Life Extension National Diagnostics, Inc. For ordering information, call anytime toll-free 1-800-208-3444, or visit us online at www.LifeExtension.com.