Influence of an elevated nutrition risk score (NRS) on survival in patients following gastrectomy for gastric cancer

The Relationship between Unintentional Weight Loss, Grading System and Overall Survival in Gastric Cancer Patients

Cancer patients are highly vulnerable to weight loss and malnutrition, before chemotherapy, thus reducing overall survival (OS). The objective was assessing weight loss and OS prognostication in gastric cancer patients at baseline of chemotherapy treatment. Observational retrospective study with patients who were treating in cancer public clinic in Brazil, was evaluated weight loss and cachexia. It was evaluated by sex, BMI, grade system classification (GSC) and stage the OS by Kaplan-Meier method and Cox proportional hazards model. Ninety-two patients, 73.9% were male. At baseline chemotherapy patients have presented 15.3% of body weight loss, 28.3% were malnourished, 86.8% classified witch cachexia, 80.3% were grade 3-4 in GSC and 86.9% at cancer stage 3-4. OS was lower for male (15.9 mo.), malnourished (12.0 mo.), GCS-4 (16.3 mo.) and Stage 4 (13.3 mo.) patients. GSC grade four and BMI classification to underweight comparing obesity are associated with reduced OS, together to male sex and cancer stage 4, have gotten together shown that seems to confer a survival disadvantage to other patients in these parameters too. Cox regression analysis have not shown statistical significance for sex, Initial BMI Class, GSC, cancer stage. Gastric cancer patients at chemotherapy treatment outset present high weight loss, cachexia prevalence and OS reduction.

Prevention of underfeeding during enteral nutrition after gastrectomy in adult patients with gastric cancer: an evidence utilization project

BACKGROUND

Enteral nutrition is commonly used in patients with gastric cancer after a partial or full gastrectomy since it is safe to use and nutrient delivery is in line with human physiological characteristics. However, enteral feeding often leads to deficiency, when the actual intake of the patient is lower than the target demand, which seriously affects the recovery of patients.

OBJECTIVE

To implement the best practice for preventing and managing underfeeding during enteral nutrition, and to improve the nutritional status of patients with gastric cancer.

METHODS

The current study was conducted following the Joanna Briggs Institute Practical Application of Clinical Evidence System program. Phase one referred to the development of the project, consisting of the generation of the best evidence, mainly based on literature review and discussions within a panel of experts. Phase two was the implementation of the project, including baseline audit, training of enteral nutrition and change of clinical practice. Phase three was a postimplementation reaudit. The intake of enteral nutrition was observed in the first 3 days, and feeding intolerance of enteral nutrition was observed within the first week of enteral nutrition. Data were collected using self-designed questionnaires. The nutritional status of patients was measured using Patient-Generated Subjective Global Assessment (PG-SGA) at admission, and 1 week after surgery.

RESULTS

A total of 60 patients with gastric cancer and 10 registered nurses were enrolled in this study. The compliance rate for all audit criteria increased postimplementation. The feeding rate of enteral nutrition postimplementation was higher than the baseline audit on the third day, 54.29% (±12.01) vs. 42.89% (±10.63), and the incidence of underfeeding was lower (30%, n = 30) than the baseline audit (76.67%, n = 30). Furthermore, the feeding intolerance postimplementation (26.67%, n = 30) was lower than the baseline audit (76.67%, n = 30) within 1 week of enteral nutrition. The PG-SGA scores were not significantly different between the baseline audit and postimplementation on the day of admission, while the scores were lower postimplementation (12.90 ± 1.47) compared with the baseline audit (14.00 ± 1.82).

CONCLUSION

In this study, we performed an audit of the clinical nursing quality, which can guide nurses to accurately identify obstacles to the implementation of enteral nutrition, and standardize the implementation and management process, thereby improving the quality of nursing and the nutritional status of patients.

RELEVANCE TO CLINICAL PRACTICE

The evidence-based practice might optimize the enteral nutrition process, enhance the efficacy of enteral nutrition, and improve the nutritional status of patients. Medical staff should develop an individualized nutritional support protocol for patients based on the results of nutritional status assessments.

Muscle mass, assessed at diagnosis by L3-CT scan as a prognostic marker of clinical outcomes in patients with gastric cancer: A systematic review and meta-analysis

BACKGROUND & AIMS

Computed tomographic (CT) imaging at third lumbar vertebra (L3), routinely used by oncologists, represents a reliable tool to quantify muscle mass. A systematic review and meta-analysis was performed to assess the efficacy of CT scan to define muscle mass as a prognostic marker in gastric cancer (GC) patients undergoing gastrectomy and/or chemotherapy. The primary outcomes were overall survival (OS) and recurrence-free survival (RFS) and the secondary outcomes included postoperative length of hospital stay (P-LOS), total and severe complications in GC patients undergoing gastrectomy.

METHODS

Three electronic bibliographic databases - MEDLINE, Web of Science and Cochrane Central Register of Controlled Trials - were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria, until April 2019. The adjusted and unadjusted hazard ratio (HR), odds ratio (OR) and mean difference (MD) with 95% confidence interval (CI) were used to analyse the dichotomous variables (OS, RFS, total and severe complications) and continuous variables (P-LOS). Random- and fixed effects models were used according to the heterogeneity.

RESULTS

A total of 5610 GC patients from 20 studies were identified. Low muscle mass at diagnosis was found in 32.7% of GC patients and was significantly associated with poorer OS (HR 2.02, 95% CI 1.71-2.38, p < 0.00001, I² = 47%) and worse RFS (HR 1.97, 95% CI 1.71-2.26, p < 0.00001, I² = 0%). Meta-analysis of adjusted HR from multivariable analyses confirmed the association between OS and low muscle mass (HR 1.89, 95% CI 1.68-2.12, p < 0.00001, I² = 36%). Furthermore, low muscle mass and poorer OS were significantly associated in metastatic GC patients exclusively undergoing chemotherapy (HR 1.61, 95% CI 1.23-2.11, p < 0.0006, I² = 18%). Moreover, preoperative low muscle mass was significantly associated with longer P-LOS (MD 1.19, 95% CI 0.68-1.71, p < 0.00001, I² = 0%), higher risk of postoperative complications (OR 1.76, 95% CI 1.17-2.66, p = 0.007, I² = 77%) and severe complications (OR 1.54, 95% CI 1.03-2.29, p = 0.04, I² = 49%) in GC patients undergoing gastrectomy.

CONCLUSIONS

Low muscle mass, assessed by L3 CT-scan, affects almost 1/3 of GC patients at diagnosis and acts as a negative prognostic marker on many clinical outcomes. Therefore, identifying GC patients with low muscle mass at diagnosis or at follow-up visit should be recommendable. Clinical nutritionists should be part of tumor boards meetings to screen low muscle mass in order to prompt personalized nutritional support.

Experience with a simplified feeding jejunostomy technique for enteral nutrition following major visceral operations

Background

Background: Perioperative nutrition support has been shown to impact on outcomes for patients with gastrointestinal cancer. Postoperative benefits of feeding tubes must be weighed against morbidity related to placement and use. A simplified jejunostomy tube technique was evaluated for outcomes.

Methods

A 16-Fr rubber tube is secured at the jejunal entry site without Witzel tunnel, followed by a continuous, circumferential and alternating suture between jejunal wall and parietal peritoneum. Prospectively collected data were analyzed.

Results

The technique was performed in 343 of 803 major hepatopancreatobiliary and upper gastrointestinal (GI) resections (43%). Of these patients (male =57%, median age: 65.8 years, range, 24.0-98.0 years), 89% had a cancer diagnosis. The procedures included pancreatectomy (n=189, 55%), gastrectomy (n=109, 32%), esophagectomy (n=19, 6%) and others (n=26, 7%). The operative intent was curative in 78%, palliative in 10%, or combined in 12% of patients. Postoperative morbidity rate was 40%, with 19 lethal events (5.5%), and a median length of stay of 10 days (range, 4-111 days). Tube feeds were administered in 139 patients (41%), and in 17% continued beyond discharge. Use of the feeding tube was linked to treatment interval, length of stay, major complication grade (all at P<0.0001), metastatic stage (P=0.0007) and noncurative intent (P=0.001). Tube feeds beyond discharge were associated with time interval (P<0.0001), length of stay (P=0.0006) and noncurative intent (P=0.014). Tube-specific events in 38 patients (11%) were all minor, without any intraabdominal leak, infection or obstruction.

Conclusions

The technique described is safe and expedient, and the overall tube-related morbidity is low. This procedure can be recommended in cases at risk for major morbidity and nutrition support needs.

The Impact of Postoperative Enteral Immunonutrition on Postoperative Complications and Survival in Gastric Cancer Patients - Randomized Clinical Trial

BACKGROUND

Immunomodulating enteral nutrition in the perioperative period may reduce postoperative complications in cancer patients. Little is known if this effect translates to the better survival. The aim of study was to assess the impact of postoperative immunomodulating enteral nutrition on postoperative complications and survival of gastric cancer patients.

METHODS

A group of 98 gastric cancer patients was randomly assigned for postoperative immunomodulating enteral nutrition n = 44 (Reconvan, Fresenius Kabi, Bad Homburg, Germany), or standard enteral nutrition n = 54 (Peptisorb, Nutricia, Schipol, The Netherlands). Postoperative complications, mortality, 6-mo and 1-yr survival were analyzed.

RESULTS

The overall postoperative morbidity did not differ between the groups. The rate of pulmonary complications (excluding pneumonia) was significantly lower in immunomodulation group (0% vs 9.3%, p = 0.044), as well as 60-day mortality (0% vs. 11.1%, p = 0.037). There was no difference in 6-mo and 1-yr survival between the groups.

CONCLUSIONS

Postoperative immunomodulating enteral nutrition may reduce respiratory complications and postoperative mortality in comparison to standard enteral nutrition. Despite this effect, it did not improve 6-mo and 1-yr survival in immunomodulation group. Probably the beneficial effect of immunomodulating enteral nutrition is too weak to be significant in such a number of patients.

The prognostic role of nutrition risk score (NRS) in patients with metastatic or recurrent esophageal squamous cell carcinoma (ESCC)

The purpose of this study was to elucidate the prognostic value of nutritional risk score (NRS) in patients with metastatic or recurrent ESCC. A total of 187 patients who undergoing S1 based or paclitaxel based salvage chemotherapy were enrolled in this retrospective study. Nutritional status was evaluated by NRS. The relationship between NRS and clinicopathological variables and post-treatment outcomes were assessed by univariate and multivariate analysis. NRS was significantly associated with weight loss (P<0.001), BMI (P<0.001), chemotherapy regimens (P=0.038) and treatment response (P=0.013). The Kaplan-Meier survival curves indicated that patients with NRS ≥ 3 had worse overall survival (OS) compared to patients with NRS < 3 (P<0.001). Multivariable regression revealed that weight loss, NRS and treatment response were three prognostic factors (P<0.05). These results suggest that NRS is a promising indicator of poor prognosis in patients with metastatic or recurrent ESCC who received S1 based or paclitaxel based salvage chemotherapy.

Long-Term Trends in Hematological and Nutritional Status After Gastrectomy for Gastric Cancer

BACKGROUND

This study investigated long-term trends in hematological and nutritional parameters after gastrectomy for gastric cancer and evaluated the influence of the reconstruction type on these trends.

METHODS

The medical records of 558 patients who underwent curative gastrectomy with standard lymph node dissection for stage I gastric cancer between January 2006 and December 2013 were reviewed. The hematological and nutritional parameters evaluated included hemoglobin, ferritin, vitamin B₁₂, total protein, albumin, total cholesterol, triglyceride, and calcium. The patients were followed up for 6 months postoperatively and then annually until death, cancer recurrence, or follow-up loss.

RESULTS

In the long term, ferritin and triglyceride gradually decreased after gastrectomy, while the other parameters decreased slightly or were stable. In the comparisons according to reconstruction type, the Roux-en-Y group had the lowest levels of hemoglobin, ferritin, vitamin B12, total protein, albumin, and total cholesterol beginning 6 months postoperatively compared with the Billroth I and II groups. However, only ferritin and vitamin B₁₂ had significant differences in the 5-year cumulative incidences of deficiency/reduction according to the reconstruction type, whereas albumin, triglyceride, total cholesterol, and calcium did not.

CONCLUSIONS

Although malabsorption and malnutrition are common in patients after a gastrectomy, most nutritional parameters were stable or decreased slightly in the long-term and were not markedly influenced by the reconstruction type or extent of gastrectomy. Therefore, for more accurate nutritional assessment after gastrectomy, multidirectional monitoring should be considered rather than simply measuring biochemical parameters.

Associations Between Nutritional Parameters and Clinicopathologic Factors in Patients with Gastric Cancer: A Comprehensive Study

The aim of this study was to assess and analyze the nutritional status of gastric cancer (GC) patients. The analysis included 207 patients with GC treated in a large center of oncology. Patients were divided into two groups according to the cutoff value of the mean prognostic nutritional index (PNI): those with a PNI < 52.78 and those with a PNI ≥ 52.78. The higher PNI was associated with lower age and higher total protein and hemoglobin levels (P < 0.01). The total lymphocyte count (P = 0.02), albumin, total protein and PNI (P < 0.01) were significantly higher in stable-weight patients and lower in the group with weight loss > 10% (P = 0.000031). Body mass index (BMI) after disease recognition, albumin and total protein (0.003) levels, total lymphocyte count, and PNI were significantly lower in patients with nutritional risk. Significantly lower BMI before disease and BMI after disease recognition were noted in smoking patients. Significantly higher total lymphocyte count was observed in smoking patients (P < 0.01). Significantly lower PNI was noted in tumors with lymph node metastasis (N+). G3 tumors were associated with the lowest total lymphocyte count (P = 0.01). Assessment of nutritional status using PNI calculation should be the standard management of patients with GC before treatment.

Severe weight loss during preoperative chemoradiotherapy compromises survival outcome for patients with locally advanced rectal cancer

Purpose

In addition to tumor factors, poor nutritional status before and during anti-tumor treatment might compromise prognosis in several types of cancer. This study was done to determine the impact of weight loss during preoperative chemoradiotherapy (CRT) on the survival outcome of patients with locally advanced rectal cancer (LARC).

Methods

The retrospective study examined consecutive patients with LARC who underwent preoperative CRT followed by radical resection in a single institute, between 2003 and 2013. Correlation of proportional body mass index (BMI) change after preoperative CRT and patient’s demographics, tumor characteristics, treatment parameters, CRT-related toxicity, disease-free survival (DFS) and overall survival (OS) were investigated.

Results

A total of 364 patients were enrolled, and BMI loss was found in 243 patients (66.2 %) after preoperative CRT. Severe weight loss (SWL) was defined as BMI loss ≥7 %. Thirty-nine (10.7 %) cases were enrolled in SWL cohort and found to have higher incidence of diarrhea (P = 0.033), renal disorder (P = 0.033) and grade 3–4 radiation proctitis (P = 0.041). Although no significant difference was found in 3-year DFS, patients in SWL cohort showed significantly worse 3-year OS rate (71.8 vs 88.0 %, P = 0.030) than the others. In univariate analysis, BMI loss ≥7 %, completed dose of preoperative chemotherapy, pathologic T and N stages were correlated with OS (all P < 0.05). In multivariable analysis, BMI loss ≥7 % (HR 1.984; 95 % CI 1.061–3.709; P = 0.032) remained the independent prognostic factor for OS.

Conclusions

Our results demonstrate that SWL during preoperative CRT indeed compromises survival outcome in patients with LARC. Routine nutritional monitoring and nutritional support during preoperative CRT are suggested as the integral part of the multidisciplinary approach for these patients.