The Role of Pre-Surgical Nutritional Programs

The Role of Pre-Surgical Nutrition Programs

When we talk about surgery, most would consider the final post-operative results - whether a surgery is successful or not. Unfortunately, we fail to acknowledge one of the most vital elements that plays a role in determining whether a patient is safe and if the patient would acquire the most optimised recovery. Seen most throughout children and infants, the lack of its presence contributes to the deaths of over 3.1 million children annually.

This is the indispensable role of pre-surgical nutrition programs.

Coinciding with Operation Smile’s commitments to forward “beyond surgery” pre-surgical nutrition programs offers the patients augments in physical strengths, decreased risks of mortality and enhances the quality of life. Though a medical necessity, nutrition programs are often looked past leaving 3 quarters of the UK’s elderly to undergo surgery without pre nutritional assessments, where approximately 60% of the patients were detected with malnutrition later on. On account of these facts, Operation Smile’s advocacy to nutritional programs directly aligns into addressing mortality risks and improving surgical outcomes whilst retaining their commitment to go "beyond surgery”, dedicating a sector of their comprehensive care purely to nutrition.

Operation Smile’s devotion to this topic and their utmost priorities summarises in this quote,

“Ensure that patients receive safe, timely and efficient surgery”

Operation Smile and Nutritional Programs

Operation smile is a global non-profit organization that is dedicated to delivering effective, timely and safe surgeries whilst offering comprehensive care to patients who suffer with cleft lips and cleft plates with a mission to go “beyond surgery”; addressing needs of the patient and restoring a smile! As of now, Operation Smile has expanded across 29 countries and has provided nutritional care to over 5000 patients who received surgery.

Importance of Nutrition

Nutrition is fundamental within life processes, especially towards captivating energy. However, its importance extends beyond flavourful foods but of the patient’s health, surgical eligibility and strength.

Primarily, to the patient’s health, a commonly identifiable link is towards sarcopenia. Though a common factor of sarcopenia is aging, lack of nutrition (specifically proteins) is also one of the 5 main factors of this musculoskeletal disease. Sarcopenia is a direct component of fatigue as the disease relates to the loss of muscle mass and strength. Furthermore, the Visceral Medicine article suggests that, in critical care, sarcopenia led to 32% mortality throughout trauma patients compared to the 14% in non-sarcopenia patients. Frail status for post-operative recovery is extremely unfavorable as the patient may not be able to fight possible infections after their body’s loss of functional reserve. Additionally, Operation Smile’s assistance towards patients with cleft conditions is faced with difficulties such as the infant’s eligibility for surgery due to their inability to reach necessary weight and systematic health without nutrition. Subsequently, due to their cleft lips, they face severe mortality risks of coordinating swallowing and sucking - leaving them with nine times the odds of dying within the first year of life and, without surgery, living is highly unlikely, highlighting the importance of nutrition both to the patient and towards surgery.

Expanding on surgical safety, without timely intervention and involvement towards nutrition, patients are at a “higher risk of complications from surgery”. Nonetheless, the goal of pre-surgical nutrition is to ultimately induce an anabolic state, which is a state in which the patient builds up tissues in their body, counteracting the catabolic state (a state in which tissues are broken down) the surgery imposes. To reach an anabolic state, nutrition plays 3 crucial roles in enhancing the immune system, optimising post-operative wound healing and tissue repair and increasing the patient’s functional capacity.

Enhancing the immune system

Nutrients, especially proteins, Zinc and Vitamins A and C, are essential for fabricating immune cells (leukocytes) and antibodies, where proteins are also needed to synthesize immune-modulating compounds. With these resources, the patient is able to fight off bacteria and decrease the risk of complications within surgery such as developing Surgical Site Infections, Sepsis (the body’s extreme reaction to an infection which is life threatening) and Pneumonia (a lung infection that inflames the alveoli).

Optimising post-operative wound healing

Proteins, such as whey proteins, are recommended at 1.2 grams per body weight (kg) for it to be broken down into collagen that is necessary for closing and strengthening the incision site. Lacking this would result in delayed wound healing, opening up opportunities for bacteria entry and infections.

Increasing functional capacity

It is worth acknowledging that food is converted to ATP (Adenosine Triphosphate) through respiration and is the universal energy currency of the cells, which makes adequate calorie intake to be vital in ensuring enough glycogen and fat storage for energy demands. Subsequently, proteins, combined with exercise, increases the patient’s lean body mass and improves their functional capacity, which are tested in the 6 minute walking distance. Overall, this increase in functional capacity allows for higher stress tolerance of the surgical procedure and anesthesia.

Ultimately, pre-operative nutrition is the very currency that safely qualifies a patient to the operation. Without it, the patient is met with unacceptable risks of complications and death, which is why its role is an indispensable intervention of shifting high-risk patients towards a safe, timely and efficient surgery.

Operation smile’s intervention towards nutrition

Operation smile begins with early identifications of infants with cleft conditions through employing specialised nutritional care providers who would then conduct assessments of the infant's feeding challenges and the mother’s capacity. This then extends to personalised meal plans that are designed for each patient’s specific calorie and protein needs.

Here is an example of how a personalised meal may look like for a 5 year old with a cleft lip:

Breakfast

Morning Snack
- Greek yogurt (protein)

Lunch

Afternoon snack
- Smoothie (hydration + calories)

Dinner

However, this feeding is not only fabricated through nutritional specialists but also through breastfeeding education. For many new mothers within rural areas, breastfeeding can be quite challenging, especially with children with cleft lips or palates. Globally, nearly 600,000 children under the age of 5 die from inadequate breastfeeding annually, making specialised support vital. To resolve this, volunteers and pediatricians, such as those sent from Operation Smiles, deliver breastfeeding education that consists of safe breastmilk expression instructions as early as possible within the perinatal period (time surrounding birth). Despite this, infants with cleft conditions may not be able to breastfeed, calling for feeding devices. To build parental confidence, instructions and assistance in educating each parent on how to use these devices are also included.

Finally, the last step to ensuring effective nutrition intake is monitoring for growth through vigorous follow - up sessions. These sessions must be taken often to ensure immediate adjustments to warnings or signs that may require changes in feeding devices for the patient. With a purpose of preventing the possible worsening of conditions, these follow up sessions are measured through factors such as weight, length and head circumference.

Measuring outcomes

Measuring outcomes for each patient are through the increase in surgical eligibility, surgical safety and cost effectiveness. First, addressing the increase in surgical eligibility rate, an example would be conducted at the Operation Smile Durgapur Cleft Center (DCC), India, where, under intervention, a total of 183 out of 236 patients (77.5%) became surgically eligible successfully. Along this line, nutritional programs also allowed 228 patients (96.6%) to either improve or maintain their baseline nutritional status. Furthermore, patients with severe malnutrition, who stayed for a total of 276 days within the program, gained the greatest average weight gain of 4.1 kilograms!

Understanding the possibilities of surgical complexities, these programs have effectively reduced structural failure and 30% of infectious complications through the accumulation of collagen synthesis and the patient themselves entering an anabolic state. On the other hand, when there is poor preoperative care before surgery, a common complication is the postoperative fistula, where an abnormal connection between 2 body parts forms after surgery. Additionally, studies from the DDC found that younger patients who took earlier intakes were more likely to see nutritional improvement, empathising on the importance of early screening and the intervention of pre-operative nutrition.

Some may be inclined to conclude that these programs are a waste of money and resources, and that is the case for many parts of the world, where nutrition is overlooked and surgery is the only component sought for. However, if we were to add the cost of mending post operative complications (more surgeries), hospitalized days and further care needed - the initial cost of the pre-operative program would be much less than the stress and expenses of complications after the surgery! After all, healing the whole patient, whether it may be mentally or physically, and ensuring long-term, stable health is much more significant than cutting costs on essentials to later risk the possibility of developing life-threatening infections or complications!

Conclusion

Behind the surgery, many have been terrified of undergoing surgery, new mothers have been struggling to feed their infants, many have suffered silently under growing stigmas and empty stomachs. Beyond the surgery, many have to endure the pain of surgery, many do not make it out alive and some would suffer under countless complications. And, through all these factors, pre-operative care remains as a medical necessity many are unable to receive, however this statement is adjustable. Throughout all aspects of surgery, comprehensive care, such as this program, and enhancing parental confidence, Operation Smile is devoted to offering the best surgical experience to all patients. With an aim of completing 60,000 surgeries by the next 5 years, you can help in reaching this goal, adjusting the statement and improve the lives of millions of children, care takers and vulnerable patients. In conclusion, pre-operative nutritional programs are not merely an addition to surgery and cleft care, but the fundamental pillar that ensures safe surgery towards all patients.

Works Cited

Borloni, Birgit, et al. “Preoperative Nutritional Conditioning: Why, When and How.” Visceral Medicine, vol. 35, no. 5, Oct. 2019, pp. 299–304, https://doi.org/10.1159/000503041.

Cleveland Clinic. “Sarcopenia (Muscle Loss): Symptoms & Causes.” Cleveland Clinic, 2022, my.clevelandclinic.org/health/diseases/23167-sarcopenia.

Matsui, Ryota, et al. “Impact of Perioperative Immunonutrition on Postoperative Outcomes in Patients with Upper Gastrointestinal Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.” Nutrients, vol. 16, no. 5, Multidisciplinary Digital Publishing Institute, Feb. 2024, pp. 577–77, https://doi.org/10.3390/nu16050577.

“Nutrition | Operation Smile.” Operation Smile, 23 Jan. 2025, www.operationsmile.org/transformational-care/surgery-beyond/nutrition/. Accessed 2 Jan. 2026.

O’Brien, Devon, et al. “Preoperative Nutrition Intervention Program Increases Cleft Surgery Eligibility in the Low- and Middle-Income Country Setting.” BMC Nutrition, vol. 11, no. 1, Apr. 2025, p. 48, https://doi.org/10.1186/s40795-025-01031-3.

World Health Organization. “Nutrition.” World Health Organization, 2022, www.who.int/health-topics/nutrition#tab=tab_1.

Zabaglo, Mate, and Tariq Sharman. “Postoperative Wound Infection.” PubMed, StatPearls Publishing, 5 Mar. 2024, www.ncbi.nlm.nih.gov/books/NBK560533/.

WRITTEN BY:

Alice Kaewrat

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