Background: Early oral feeding after major abdominal surgery has been clearly shown to be safe and not a risk factor for anastomotic dehiscence. Within the Enhanced Recovery after Surgery protocol, it is the nutritional plan A. Nonetheless, one must consider that postoperative protein and energy requirements will often be not covered by oral food intake alone. Because nutritional status has been shown to be a prognostic factor in patients undergoing major abdominal surgery, the preoperative identification of patients at risk may be mandatory. Malnutrition may be underestimated in an overweight society. With special regard to patients with cancer and those with preexisting malnutrition, an accumulating caloric gap may be harmful in the early and late postoperative periods. Furthermore, complications requiring reoperation and intensive care treatment may occur. Summary: Therefore, a plan B for postoperative nutrition therapy is needed, using preferentially the enteral route. The European Society for Clinical Nutrition and Metabolism recently addressed perioperative nutritional management and the indications for enteral and even parenteral supplementation to achieve caloric requirements in the postoperative course. In the first months after surgery, persisting weight loss is common in patients with upper gastrointestinal resections, even in those with an uncomplicated course. This may delay the initiation of adjuvant chemotherapy, increase toxicity, and worsen long-term outcomes.

The nutritional status goes along with the clinical outcomes in surgical patients [1-3]. A poor nutritional status and body composition can decline both short- and long-term outcomes. Malnutrition as a modifiable risk factor should be treated carefully not only in the early stage of disease but also in the early and late postoperative periods. Cumulative effects may be expected from small gains [4].

In times of Enhanced Recovery after Surgery (ERAS) protocols as the standard of care, oral food intake is supposed to be interrupted as short as possible. Nonetheless, nutritional therapy may not be ignored in the metabolic concept of ERAS [5]. Nutritional status plays an emergent role in the process of recovery from surgery and disease. Particularly in oncological or inflammatory diseases with the indication for surgery, malnutrition may be prevalent in many patients and must be addressed early. Additionally, although oral feeding is allowed, energy and protein requirements are often not met through normal diets perioperatively. Studies showed that oral energy intake is often insufficient after gastrointestinal surgery, particularly in patients with cancer [6]. Several barriers lead to insufficient postoperative nutrition intake, like the lack of knowledge regarding nutrition management, and unnecessary postoperative fasting periods. Patient-related factors may include abdominal discomfort caused by nausea, malaise, bloating, ileus, gastroparesis, or pain. Furthermore, psychological factors, such as delirium and depression, may contribute as well [6].

Persisting postoperative weight loss may often be observed in patients undergoing upper gastrointestinal surgery and can be considered a “bariatric effect.” This additionally impairs the long-term outcome because of physical decline, prolonged postoperative rehabilitation, and less tolerance with increased toxicity in the case of adjuvant chemotherapy [7, 8].

Therefore, postoperative nutrition therapy means monitoring patients food intake and supplementing the primarily oral diet by oral nutritional supplements (ONS) and enteral or even parenteral nutrition to cover energy and protein requirements, if necessary. While early oral food intake without enteral or even parenteral supplementation is the plan A, a plan B is required in case of insufficient oral intake or complications and reoperations. This raises the question “who needs what?.”

To achieve appropriate individualized postoperative nutritional management, the preoperative identification of patients at risk is essential. In an overweight society, the prevalence of sarcopenia and malnutrition may be underestimated [9]. For elderly individuals in particular, this should also include functional capacity and nutritional status in the framework of “complex geriatric assessment” [10]. Nutritional risk and malnutrition must be differentiated. The screening tool for malnutrition, the Nutritional Risk Score (NRS) according to Kondrup et al. [11], has been well validated for surgical patients (Table 1). Nevertheless, there is some limitation. An NRS of 3 is considered severe. According to the NRS, a 71-year-old patient without any weight loss undergoing laparoscopic sigmoidectomy for cancer will be at risk with a score of 3. Unless this patient is monitored, there is no rationale for conditioning or even prehabilitation. Therefore, regarding the surgical risk, the European Society for Clinical Nutrition and Metabolism (ESPEN) working group has defined severe nutritional risk (Table 1).

Table 1.

Nutritional Risk Screening (NRS) [8] and severe metabolic risk as defined by the ESPEN working group surgery [1]

Nutritional Risk Screening (NRS) [8] and severe metabolic risk as defined by the ESPEN working group surgery [1]
Nutritional Risk Screening (NRS) [8] and severe metabolic risk as defined by the ESPEN working group surgery [1]

Recently, malnutrition has been defined according to the Global Leadership Initiative on Malnutrition (GLIM) phenotypic criteria (i.e., involuntary loss of body weight, diminished body mass index (BMI), and low muscle mass) and etiological criteria (i.e., low food intake or absorption and disease burden/inflammation) [12]. One phenotypic and one etiological criterion must be fulfilled for the diagnosis of malnutrition.

During the past few years, computed tomography (CT)-based measurement of the body composition has been introduced for the determination of muscle mass and the calculation of the skeletal muscle index (SMI). Impaired radiodensity is considered a parameter of muscle quality. In numerous studies, CT-derived reduced muscle mass (i.e., sarcopenia) has shown a prognostic impact [13-15]. Considering CT-derived reduced muscle mass, the GLIM criteria have been reported to be correlated with surgical outcomes in patients undergoing major abdominal surgery [16].

A new risk classification according to BMI and SMI has been recently proposed – low-risk: high SMI, excluding patients with BMI ≥35 kg/m2 and high-risk: low SMI plus patients with BMI ≥35 kg/m2 [17].

In cases where NRS screening and muscle mass measurement are unavailable preoperatively, the definition of severe nutritional risk according to the ESPEN surgical guidelines may be helpful and has been proven to have a prognostic value [1, 17, 18].

In patients with severe nutritional risk or malnutrition, preoperative nutrition therapy or even trimodal prehabilitation, including nutrition, should be considered [19, 20]. Significant improvements in functional capacity measured using the 6-min walk distance and shortened hospital stay have been shown in a recent meta-analysis [21]. Nevertheless, as shown by a recent umbrella review of 55 systematic reviews, the overall evidence of the impact of prehabilitation on improving postoperative outcomes is low [22]. Data from randomized controlled trials involving high-risk patients remain scarce.

Unless early oral feeding is allowed and encouraged, oral intake of protein and energy may often be inadequate for the coverage of the metabolic demands in the early postoperative catabolic phase. To prevent protein catabolism and maintain muscle mass, protein and energy supplementation is essential. While early mobilization requires appropriate muscle mass, there is no evidence for detailed recommendations from CT-derived SMI.

Recommendations for Postoperative Oral Diet

  • Very low in fat (max. 30 g fat/day)

  • Use of easily digestible, lean protein carriers

  • High carbohydrate

  • Easily digestible (low fiber content)

The current ESPEN guidelines [1] provide a “Good Clinical Practice (GCP)” recommendation for the indication for nutrition therapy without delay:

  1. In patients with malnutrition and those at a nutritional risk.

  2. In patients anticipated to be unable to eat for more than 5 days perioperatively.

  3. In patients anticipated to have low oral intake who cannot maintain >50% of the recommended intake for more than 7 days.

A prospective cohort study involving patients undergoing major abdominal surgery assessed the energy and protein intake in the first week after surgery [6]. In that study, 90% of the patients did not meet the recommended protein intake and 82% did not meet the energy requirements as recommended by the ESPEN guidelines (1.5 g/kg protein and 25 kcal/kg energy) (Fig. 1) [24]. Furthermore, patients with severe complications (Clavien-Dindo ≥ III) consumed less protein in the first week after surgery than patients without complications or those with mild complications (Clavien-Dindo I–II). Those findings highlight the necessity of careful postoperative nutritional monitoring and the early initiation of nutrition therapy, particularly in patients with complications. Particularly, in the case of complications in the postoperative period, nutritional therapy must be addressed. In patients with an extra need for protein and energy, oral feeding in most cases is insufficient. Of course, this requires the awareness of the entire staff, including the expertise of a dietitian.

Fig. 1.

Recommendations for adequate energy and protein intake in patients undergoing major abdominal surgery pre- and postoperatively [23].

Fig. 1.

Recommendations for adequate energy and protein intake in patients undergoing major abdominal surgery pre- and postoperatively [23].

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The preferred route is oral or enteral. Parenteral nutrition should be considered if oral or enteral feeding is contraindicated, unfeasible, or insufficient. The advantages of enteral nutrition have been shown many times. In a recent randomized trial comparing patients with cholangiocarcinoma undergoing surgery who received enteral plus parenteral nutrition with those who received total parenteral nutrition, the enteral nutrition group had significant benefits regarding intestinal recovery, length of hospital stay, and immune function [25]. In another randomized controlled trial comparing parenteral nutrition with trophic enteral feeding in patients undergoing pelvic exenteration surgery, postoperative ileus occurred significantly less in patients who were enterally fed [26]. The advantages of enteral feeding could be shown again in this study as in the regression analysis, a time restriction from an oral diet was significantly associated with the first bowel movement and the postoperative complication rate.

The early initiation of oral feeding after surgery is an essential part of the ERAS protocol. Recent guidelines recommend initiating oral or enteral nutrition within 24 h after surgery [1, 5, 24]. This includes reducing factors that impair gastrointestinal motility and function and early mobilization to stimulate protein synthesis and to maintain muscle function [1]. Oral food intake should be adapted according to gastrointestinal tolerance and monitored carefully in the first days after surgery. Special care should be provided for the elderly. Early enteral nutrition may overcome postoperative ileus. Two recent meta-analyses of 11 and 30 randomized controlled trials, respectively, with 1,095 and 3,854 patients undergoing gastrointestinal surgery showed that early enteral nutrition decreased the incidence of infectious and noninfectious complications and may shorten the length of hospital stay [27, 28]. Immune-enhanced nutrition seems to be even more beneficial [28]. Additionally, adequate protein intake postoperatively improves surgical outcomes [29].

Nevertheless, in patients undergoing upper gastrointestinal surgery, oral feeding is traditionally delayed due to the concern of anastomotic leakage and aspiration pneumonia. Recently, this issue was addressed for patients undergoing upper gastrointestinal surgery. A multicenter randomized controlled trial compared immediately starting oral feeding with receiving nil-by-mouth and tube feeding for 5 days postoperatively in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis. The results showed no difference in the incidence of anastomotic leakage, pneumonia, and other morbidities [30]. Therefore, early oral feeding may be considered safe even after esophagectomy. A recent meta-analysis also showed that the timing of oral feeding has no impact on anastomotic healing [31]. Similar results were found in another meta-analysis of five randomized controlled trials [32]. Even in emergency major abdominal surgery, early enteral nutrition was safe and associated with reduced mortality.

Standard Diet or Immunonutrition

A recent umbrella review of 20 meta-analyses showed that immune-enhanced nutrition has beneficial effects on patients undergoing visceral surgery with special regard to a decrease in infectious complications. While the optimal timing of immune-enhanced nutrition is a matter of debate, the exclusive postoperative use has also shown benefits. Most data are available for gastrointestinal surgery [33]. Only one randomized study has compared the perioperative use of a standard supplementation with immunonutrition in patients undergoing colorectal surgery within an ERAS program [34]. This study also supports immunonutrition with a significant decrease in infectious complications.

Enteral nutrition supplementation is the favored route. Even if oral feeding is safe, the protein and calorie targets will often be only covered by supplementation. According to the guidelines, the intraoperative placement of a nasojejunal tube or fine-needle catheter jejunostomy (FNCJ) should be considered with special regard to malnourished patients and those with severe metabolic risk undergoing major upper gastrointestinal surgery [1]. In the case of complications, this is also a step for a nutritional plan B.

Retrospectively, Zhuang et al. [35] analyzed the outcomes of their patients after esophagectomy with and without intraoperative FNCJ. The feeding tube was implanted only in those patients considered at a high-risk of anastomotic leakage. No significant differences in the length of hospital stay, short-term mortality, and overall survival were observed. The FNCJ group tended to have faster healing of an anastomotic leakage (27.2 days vs. 37.4 days; p = 0.073). The results showed that FNCJ is safe and is particularly suitable for high-risk patients [35]. A meta-analysis of 10 studies comparing jejunostomy with nasojejunal tubes after esophagectomy showed significant advantages in favor of jejunostomy in terms of postoperative pneumonia, length of hospital stay, and risk of dislocation [36]. No significant differences in the incidence of anastomotic leakage and complications were observed. However, a significantly higher risk of bowel obstruction was observed in the jejunostomy group. In a retrospective analysis of 847 patients with esophagectomy from the Swedish National Registry for Esophageal and Gastric Carcinoma, patients with and without FNCJ were also compared. Among patients with anastomotic leaks, patients with jejunostomy had a significantly lower rate of serious complications (Clavien-Dindo ≥ IIIb) than those without jejunostomy. There was no increased risk of FNCJ-associated complications [36]. Another recent meta-analysis of 18 studies in patients undergoing esophagectomy emphasized the risk of ileus, catheter dysfunction due to occlusion and dislodgement, and site infection [37]. These results showed that carefully selected patients at risk of anastomotic leakage, increased overall morbidity, or postoperative weight loss may benefit from the insertion of feeding jejunostomy [38]. The higher risk of early dislodgement and patient discomfort of nasojejunal tubes are also concerns regarding the use of FNCJ. Furthermore, FNCJ is the first step to plan B, providing access in patients for long-term enteral nutrition after discharge. Since preoperative assessment may not predict anastomotic leakage, our own approach is to offer FNCJ regularly to patients undergoing esophagectomy, gastrectomy, and partial pancreaticoduodenectomy. Nevertheless, enteral nutrition via FNCJ should also consider limited gastrointestinal tolerance.

In cases where no feeding tube was placed during surgery and there is an indication for enteral nutrition with special regard to patients requiring intensive/intermediate care, the endoscopic placement of a tube with three lumina may be considered. For jejunal application, enteral feeding should be continuously administered via a pump.

Despite the provision of the best perioperative care according to the ERAS protocol, complications may occur, which may require reoperation and intensive care treatment. Then, a nutritional plan B is required to attenuate the deterioration of the nutritional status, resulting in a loss of lean body mass and prolonged rehabilitation [39]. Figure 2 shows a pathway for the indications for nutritional therapy.

Fig. 2.

Pathway for nutritional therapy in the early period after gastrointestinal surgery.

Fig. 2.

Pathway for nutritional therapy in the early period after gastrointestinal surgery.

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Indications for Parenteral Nutrition

For GCP, the ESPEN guidelines recommend a combination of enteral and parenteral nutrition if it is expected that the oral and enteral intake of energy and nutrients cannot cover more than 50% of the requirements for >7 days [1]. To achieve the caloric and protein requirements, parenteral nutrition may be indicated even in uncomplicated course after major abdominal surgery. Parenteral supplementation may also be useful via the peripheral route.

The question of when to start postoperative parenteral nutrition supplementation in patients undergoing abdominal surgery was recently addressed in a multicentric randomized trial involving 230 patients [40]. Early start of parenteral supplementation on postoperative day (POD) 3 was compared with late parenteral supplementation started on POD 8. The primary endpoint was the number of nosocomial infections. The early supplemented group received considerably more energy between POD 3 and POD 7 than the late supplemented group (26.5 ± 7.4 vs. 15.1 ± 4.8 kcal/kg daily; p < 0.001). In the early supplemented group, significantly fewer infectious complications were observed (10/115 [8.7%] vs. 21/114 [18.4%]; risk difference 9.7%; 95% confidence interval [CI]: 0.9–18.5; p = 0.04). A significant difference in the number of therapeutic antibiotic days was also found (early 6.0 ± 0.8 vs. late 7.0 ± 1.1 days; mean difference 1.0 days; 95% CI: 0.2–1.9; p = 0.01). The number of noninfectious complications, total adverse events, and other secondary outcomes were without significant difference.

In a recent study, 156 patients with normal nutritional status undergoing colorectal surgery under the ERAS protocol were randomized for peripheral parenteral nutrition 1 day before surgery and for peripheral parenteral nutrition 3 days after surgery. Furthermore, the patients were classified as high- or low-risk patients according to BMI and SMI derived from CT measurement of muscle mass. Among patients receiving peripheral parenteral nutrition, the high-risk group with low SMI had significantly fewer complications, which was not observed in the low-risk group [17].

For parenteral nutrition in patients receiving intensive care, there are current guidelines recommended by the German Society for Nutritional Medicine, which differentiate acute and post-acute phases with convalescence from chronic phases, defining the maximum limits for the substrate supply per day [41] (see Table 2). Indirect calorimetry is recommended for the individualized measurement of caloric needs [41].

Table 2.

Parenteral nutrition in surgical intensive care patients – Maximum limits for macronutrients supply per day and kg body weight (BW)

Parenteral nutrition in surgical intensive care patients – Maximum limits for macronutrients supply per day and kg body weight (BW)
Parenteral nutrition in surgical intensive care patients – Maximum limits for macronutrients supply per day and kg body weight (BW)

In non-obese patients (BMI ≤30 kg/m2), the actual body weight can be used as a basis for the calculation of energy requirements. In patients with a BMI >30 kg/m2, adjustment for a BMI of 22 kg/m2 may be appropriate [41].

Supplementation of Parenteral Nutrition

Parenteral nutrition supplementation with omega-3-fatty acids and glutamine – the so-called immunonutrition – has been controversially discussed. Two recent meta-analyses of randomized trials support the enrichment of parenteral nutrition with omega-3 fatty acids with regard to immune function, the reduction of the inflammatory response with the risk of infection and sepsis, and the shortening of the length of intensive care unit (ICU) and hospital stay [42, 43]. Despite numerous meta-analyses and one umbrella review favoring the use of glutamine, no significant differences in the 6-month mortality rate and other outcome parameters were observed in a large randomized multicentric trial involving 150 surgical ICU patients [44].

Overall the recommendations for “who needs what” are summarized in Table 3.

Table 3.

Who needs what in the early postoperative period

Who needs what in the early postoperative period
Who needs what in the early postoperative period

Nutrition Therapy after a Longer Period of Intensive Care Treatment

From a metabolic viewpoint, the period after the transfer from the ICU to a normal ward is a vulnerable period. Even if oral intake is feasible, inappetence and fatigue may cause diminished oral food intake. Particularly after a longer period of severe catabolism, the shift to anabolism should be addressed with an additional supply of energy and protein. Otherwise, there is a high-risk of further deterioration and delayed recovery with negative impact on long-term outcome.

In a small cohort study, 32 patients were followed up, with their food intake measured according to their energy requirements (2,000 kcal/day; range 1,650–2,550 kcal/day) and protein (112 g/day; range 84–129 g/day) after they had been transferred from the ICU. A median of 1,238 kcal/day (range 869–1,813 kcal/day) and 60 g/day (range 35–89 g/day) of energy and protein, respectively, were consumed for >227 days. Most patients were fed exclusively oral (55%) or combined enteral (42%). The energy and protein intake was lower than those estimated or even measured using indirect calorimetry. It was shown that the energy and protein requirements could only be achieved with a combination of oral and enteral nutrition. The supplementation of an oral diet with ONS only covered approximately 70% of the requirements [45].

After discharge from the hospital, a follow-up on the nutritional status must be considered in patients who are at risk of a nutritional decline. This applies particularly in patients who underwent surgery in the upper gastrointestinal tract (“bariatric effect”) or after a complicated postoperative course with prolonged stay or need for re-laparotomy. Dietary counseling and follow-up monitoring of the nutritional status (minimum: BMI), including the documentation of the amount of oral food intake, are essential. In cases where FNCJ has been placed during surgery, leaving FNCJ in place may be considered at the time of discharge.

A decrease in skeletal muscle mass from the baseline to 4 weeks after esophagectomy measured using CT was an independent risk factor for lower overall survival and recurrence-free survival [3]. In a systematic review, a 5–12% weight loss was observed in the first 6 months after esophagectomy [46]. Twelve months postoperatively, >50% of the patients lost >10% of their body weight. Furthermore, 27–95% of the patients were unable to regain their baseline weight, and inadequate energy and protein intake was observed up to 3 years after surgery. These data highlight the postoperative risk in those patients of losing weight, although oral feeding is allowed. Our own data support these findings. Furthermore, 40% of the patients who underwent upper gastrointestinal surgery for esophageal, gastric, or pancreatic cancer lost >10% of their body weight 6 months after surgery, despite postoperative continuation of nutritional therapy via feeding jejunostomy [47].

Postoperative loss of body weight and lean body mass additionally increases the risk of toxicity of adjuvant chemotherapy in patients with gastric cancer [2], resulting in an early termination of adjuvant therapy and bearing the risk of tumor recurrence and a worse overall survival [48]. A cutoff point of 15% body weight loss was suggested to have an influence.

With supplemental nutrition via ONS or feeding jejunostomy, a worse weight loss and nutritional decline could be prevented. Chen et al. [49] demonstrated significant benefits from home enteral nutrition for at least 8 weeks for BMI, Patient-Generated Subjective Global Assessment scores (PG-SGA), serum albumin, and immune parameters in patients undergoing esophagectomy. With special regard to malnourished patients, the ESPEN guidelines recommend the implantation of feeding jejunostomy during surgery [1].

In patients undergoing surgery for esophageal cancer, severe weight loss after discharge from the hospital may be associated with a significantly lower 5-year survival [2]. However, in this retrospective study, no significant difference in the number of patients with weight loss was found between patients with and without feeding jejunostomy [3]. In a recent meta-analysis, 15 randomized controlled trials involving 1,059 patients undergoing upper gastrointestinal resection for malignancy were compared in terms of home enteral nutrition and ONS [50]. Home enteral nutrition seemed to be superior by significantly diminished weight loss (−3.95 kg vs. −5.82 kg; standardized mean difference: 1.98 kg; 95% CI: 1.24–2.73) and the reduction in the incidence of malnutrition or latent malnutrition (risk ratio = 0.54; p < 0.01). Note that in the subgroup analysis, no significant difference could be observed between the ONS subgroup and the control group. Physical function (weighted mean difference [WMD]: 5.29; 95% CI: 1.86–8.73) and fatigue (WMD: −8.59; 95% CI: −12.61 to −4.58) as dimensions in quality of life were significantly better in the home enteral group.

In a randomized study, significantly less body weight loss was observed when ONS was administered until 12 weeks after surgery in patients undergoing total gastrectomy, which was not found in patients undergoing subtotal resection [51]. In another randomized study involving patients undergoing gastrectomy, dietary counseling with ONS for 3 months significantly reduced weight loss with a higher BMI and SMI than dietary counseling alone. Furthermore, the prevalence of sarcopenia was significantly lower in the dietary counseling and ONS groups, as were fatigue and appetite. In patients receiving postoperative chemotherapy, there were also significantly fewer modifications due to delayed or limited tolerance [52]. A recent multicentric randomized trial involving 1,003 patients undergoing gastrectomy compared the impact of ONS 400 kcal/day on weight loss 1 year after gastrectomy. In the ONS group, 50.4% of the patients had an intake of >200 kcal/day (average 301 mL) and significantly less body weight loss after 1 year (8.2% ± 7.2%) [53].

Therefore, patients undergoing major abdominal surgery are at risk of not fulfilling their energy and protein requirements and should receive dietary counseling postoperatively [1]. Furthermore, ONS supplementation should be considered, and in patients with severe metabolic risk, if available, feeding jejunostomy should be used even after discharge.

Because malnutrition and sarcopenia are prognostic factors, preoperative assessment of the nutritional status is mandatory. Particularly in patients with cancer, CT-derived body composition analysis with the calculation of SMI must be implemented in clinical practice and may provide additional information for the definition of high-risk patients with benefit from perioperative nutrition therapy. In cases of high metabolic risk/severe malnutrition, surgery should be postponed, and nutritional therapy should be administered enterally for 10–14 days, if possible, and prehabilitation should be considered. Early oral intake is safe and feasible even after esophagectomy and gastrectomy. If oral calorie intake is expected to be insufficient (<50% of the requirement for >7 days), ONS and enteral supplementation may be started without delay. If oral and enteral calorie intake is below 50% for 7 days, supplemental parenteral nutrition should be started. Patients with metabolic risk, particularly after upper gastrointestinal tract surgery, should receive dietary counseling at the time of discharge and follow-up nutritional care as prolonged weight loss with a possible impact on long-term outcome is rather common.

  • Early oral feeding after visceral surgery is safe.

  • Energy requirements are often not covered by normal diet days up to months after surgery.

  • Nutritional therapy should be adapted to the needs and tolerance of the patient.

  • The enteral route is preferred.

  • In high-risk patients undergoing upper gastrointestinal surgery, the placement of feeding jejunostomy is recommended.

Arved Weimann: Lecture fees: Baxter, B.Braun/Melsungen, Fresenius Kabi, Falk Foundation. Research grant: B. Braun, Mucos. Maria Wobith: Lecture fees: Fresenius Kabi. Research grant: B Braun.

There were no funding sources for this review.

Maria Wobith: writing. Arved Weimann: Editing, supervision.

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