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Hung I, Wischmeyer PE, Kain ZN. Fueling Healing: Tackling Challenges in Integrating Nutrition Screening and Therapy Into Perioperative Care in the United States. Anesth Analg 2024; 139:660-664. [PMID: 38386596 DOI: 10.1213/ane.0000000000006766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Affiliation(s)
- Isaac Hung
- From the Department of Anesthesiology & Perioperative Care, University of California, Irvine, Orange, California
- Center on Stress & Health, Department of Anesthesiology & Perioperative Care, University of California, Irvine, Orange, California
| | - Paul E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Zeev N Kain
- From the Department of Anesthesiology & Perioperative Care, University of California, Irvine, Orange, California
- Center on Stress & Health, Department of Anesthesiology & Perioperative Care, University of California, Irvine, Orange, California
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Beichmann B, Henriksen C, Paur I, Paulsen MM. Barriers and facilitators of improved nutritional support for patients newly diagnosed with cancer: a pre-implementation study. BMC Health Serv Res 2024; 24:815. [PMID: 39010098 PMCID: PMC11251100 DOI: 10.1186/s12913-024-11288-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 07/08/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Disease-related malnutrition affects a significant number of patients with cancer and poses a major social problem worldwide. Despite both global and national guidelines to prevent and treat malnutrition, the prevalence is high, ranging from 20 to 70% in all patients with cancer. This study aimed to explore the current practice of nutritional support for patients with cancer at a large university hospital in Norway and to explore potential barriers and facilitators of the intervention in the Green Approach to Improved Nutritional support for patients with cancer (GAIN), prior to implementation in a clinical setting. METHODS The study used individual interviews and a focus group discussion to collect data. Study participants included different healthcare professionals and patients with cancer treated at a nutrition outpatient clinic. The Consolidated Framework for Implementation Research (CFIR) was used to guide the thematic data analysis. RESULTS Barriers connected to the current nutritional support were limited resources and undefined roles concerning responsibility for providing nutritional support among healthcare professionals. Facilitators included a desire for change regarding the current nutritional practice. The GAIN intervention was perceived as feasible for patients and healthcare professionals. Potential barriers included limited knowledge of technology, lack of motivation among patients, and a potential added burden experienced by the participating patients. CONCLUSIONS The identification of the potential barriers and facilitators of the current nutritional support to patients with cancer will be used to plan the implementation of improved nutritional support in a randomized controlled trial for patients with cancer prior to clinical implementation. The current findings may be of value to others trying to implement either or both nutritional support and digital application tools in a clinical healthcare setting. TRIAL REGISTRATION The study was registered in the National Institutes of Health Clinical trials 08/09/22. The identification code is NCT05544318.
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Affiliation(s)
- Benedicte Beichmann
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, P.O. Box 1110, Blindern, Oslo, 0317, Norway.
- Section for Clinical Nutrition, Department of Clinical Services, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway.
| | - Christine Henriksen
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, P.O. Box 1110, Blindern, Oslo, 0317, Norway
| | - Ingvild Paur
- Norwegian Advisory Unit on Disease-Related Undernutrition, Oslo, Norway
- Section for Clinical Nutrition, Department of Clinical Services, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Mari Mohn Paulsen
- Department of Food Safety, Norwegian Institute of Public Health, Oslo, Norway
- Centre for Sustainable Diets, Norwegian Institute of Public Health, Oslo, Norway
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Bellafronte NT, Nasser R, Gramlich L, Carli F, Liberman S, Santa Mina D, Schierbeck G, Ljungqvist O, Gillis C. A survey of preoperative surgical nutrition practices, opinions, and barriers across Canada. Appl Physiol Nutr Metab 2024; 49:687-699. [PMID: 38241662 DOI: 10.1139/apnm-2023-0195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
Malnutrition is prevalent among surgical candidates and associated with adverse outcomes. Despite being potentially modifiable, malnutrition risk screening is not a standard preoperative practice. We conducted a cross-sectional survey to understand healthcare professionals' (HCPs) opinions and barriers regarding screening and treatment of malnutrition. HCPs working with adult surgical patients in Canada were invited to complete an online survey. Barriers to preoperative malnutrition screening were assessed using the Capability Opportunity Motivation-Behaviour model. Quantitative data were analyzed using descriptive statistics and qualitative data were analyzed using summative content analysis. Of the 225 HCPs surveyed (n = 111 dietitians, n = 72 physicians, n = 42 allied HCPs), 96%-100% agreed that preoperative malnutrition is a modifiable risk factor associated with worse surgical outcomes and is a treatment priority. Yet, 65% (n = 142/220; dietitians: 88% vs. physicians: 40%) reported screening for malnutrition, which mostly occured in the postoperative period (n = 117) by dietitians (n = 94). Just 42% (48/113) of non-dietitian respondents referred positively screened patients to a dietitian for further assessment and treatment. The most prevalent barriers for malnutrition screening were related to opportunity, including availability of resources (57%, n = 121/212), time (40%, n = 84/212) and support from others (38%, n = 80/212). In conclusion, there is a gap between opinion and practice among surgical HCPs pertaining to malnutrition. Although HCPs agreed malnutrition is a surgical priority, the opportunity to screen for nutrition risk was a great barrier.
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Affiliation(s)
| | - Roseann Nasser
- Clinical Nutrition Services, Saskatchewan Health Authority, Regina, SK, Canada
| | - Leah Gramlich
- Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montreal, Canada
| | - Sender Liberman
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | | | - Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, Canada
- Department of Anesthesia, McGill University, Montreal, Canada
- Department of Surgery, McGill University, Montreal, QC, Canada
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Power S, Maarof A, Power A, Feehan S, Whelan M. Nutritional risk predicts postoperative complications and length of stay, whereas sarcopenia risk predicts need for step-down care in a mixed elective surgery population. J Hum Nutr Diet 2024; 37:308-315. [PMID: 37908178 DOI: 10.1111/jhn.13256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Malnutrition and poor functional reserves place patients at risk for negative surgical outcomes. In this prospective study we aimed to measure preoperative nutritional and sarcopenia risk and evaluate their impact on postoperative outcomes. METHODS Adults scheduled to undergo elective general and gastrointestinal surgery were screened for nutrition risk using the Malnutrition Universal Screening Tool screening tool. Sarcopenia risk was measured using the SARC-F tool and hand-grip strength. Patients were followed postoperatively. Incidence of complications, length of stay (LOS), readmission rates, and need for step-down care were recorded. RESULTS One hundred and twenty-two patients were included. Mean age was 53.8 years (standard deviation [SD] 16.44). Sixty-six (54%) were scheduled for day-case procedures, and 56 (46%) for nonday-case procedures. About 18.9% (n = 23) were at nutritional risk preoperatively. Ten patients (8.2%) had probable sarcopenia based on SARC-F, whereas seven (5.7%) had measurably reduced HG. Incidence of postoperative complications was 23.8% (n = 29). Nutrition risk was associated with the development of complications (p = 0.018). In the nonday-case group, nutritional risk was associated with greater LOS (p = 0.013). Older age was associated with need for step-down care (p = 0.002) as was SARC-F (p = 0.003). CONCLUSIONS Preoperative nutritional screening can predict postoperative complications and LOS, whereas sarcopenia screening is predictive of the need for step-down care after discharge. Screening tools are quick and inexpensive and could provide valuable information to clinicians and allow patients the opportunity to enhance their physical preparedness for surgery thereby mitigating their risk for negative surgical outcomes.
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Affiliation(s)
- Siobhán Power
- Department of Nutrition and Dietetics, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Asryaf Maarof
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Aoibheann Power
- UCD School of Agriculture and Food Science, University College Dublin, Belfield, Dublin, Ireland
| | - Sinéad Feehan
- Department of Nutrition and Dietetics, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Maria Whelan
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
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Reed WT, Jiang R, Ohnuma T, Kahmke RR, Pyati S, Krishnamoorthy V, Raghunathan K, Osazuwa-Peters N. Malnutrition and Adverse Outcomes After Surgery for Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2024; 150:14-21. [PMID: 37883116 PMCID: PMC10603580 DOI: 10.1001/jamaoto.2023.3486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/10/2023] [Indexed: 10/27/2023]
Abstract
Importance Patients with head and neck cancer (HNC) have an increased risk of malnutrition, partly due to disease location and treatment sequelae. Although malnutrition is associated with adverse outcomes, there is little data on the extent of outcomes and the sociodemographic factors associated with malnutrition in patients with HNC. Objectives To investigate the association of race, ethnicity, and payer type with perioperative malnutrition in patients undergoing HNC surgery and how malnutrition affects clinical outcomes. Design, Setting, and Participants This retrospective cohort study used data from the Premier Healthcare Database to assess adult patients who had undergone HNC surgery from January 2008 to June 2020 at 482 hospitals across the US. Diagnosis and procedure codes were used to identify a subset of patients with perioperative malnutrition. Patient characteristics, payer types, and hospital outcomes were then compared to find associations among race, ethnicity, payer type, malnutrition, and clinical outcomes using multivariable logistic regression models. Analyses were performed from August 2022 to January 2023. Exposures Race, ethnicity, and payer type for primary outcome, and perioperative malnutrition status, race, ethnicity, and payer type for secondary outcomes. Main Outcomes and Measures Perioperative malnutrition status. Secondary outcomes were discharge to home after surgery, hospital length of stay (LOS), total cost, and postoperative pulmonary complications (PPCs). Results The study population comprised 13 895 adult patients who had undergone HNC surgery during the study period; they had a mean (SD) age of 63.4 (12.1) years; 9425 male (67.8%) patients; 968 Black (7.0%), 10 698 White (77.0%), and 2229 (16.0%) individuals of other races; and 887 Hispanic (6.4%) and 13 008 non-Hispanic (93.6%) individuals. Among the total sample, there were 3136 patients (22.6%) diagnosed with perioperative malnutrition. Compared with White patients and patients with private health insurance, the odds of malnutrition were higher for non-Hispanic Black patients (adjusted odds ratio [aOR], 1.31; 95% CI, 1.11-1.56), Medicaid-insured patients (aOR, 1.68; 95% CI, 1.46-1.95), and Medicare-insured patients (aOR, 1.24; 95% CI, 1.10-1.73). Black patients and patients insured by Medicaid had increased LOS, costs, and PPCs, and lower rates of discharge to home. Malnutrition was independently associated with increased LOS (β, 5.20 additional days; 95% CI, 4.83-5.64), higher costs (β, $15 722 more cost; 95% CI, $14 301-$17 143), increased odds of PPCs (aOR, 2.04; 95% CI, 1.83-2.23), and lower odds of discharge to home (aOR, 0.34; 95% CI, 0.31-0.38). No independent association between malnutrition and mortality was observed. Conclusions and Relevance This retrospective cohort study found that 1 in 5 patients undergoing HNC surgery were malnourished. Malnourishment disproportionately affected Black patients and patients with Medicaid, and contributed to longer hospital stays, higher costs, and more postoperative complications.
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Affiliation(s)
- William T. Reed
- Department of Head and Neck Surgery & Communication Sciences, Duke University Health System, Durham, North Carolina
| | - Rong Jiang
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Russel R. Kahmke
- Department of Head and Neck Surgery & Communication Sciences, Duke University Health System, Durham, North Carolina
| | - Shreyas Pyati
- Stony Brook University School of Medicine, Stony Brook, New York
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University Health System, Durham, North Carolina
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina
- Duke Cancer Institute, Duke University, Durham, North Carolina
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Ke Y, Ng RRG, Elangovan S, Leong YH, Goh ZH, Graves N, Shannon NB, Abdullah HR. Prehabilitation programs - a systematic review of the economic evidence. Front Med (Lausanne) 2023; 10:1281843. [PMID: 38105890 PMCID: PMC10722222 DOI: 10.3389/fmed.2023.1281843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Prehabilitation, which involves improving a patient's physical and psychological condition before surgery, has shown potential benefits but has yet to be extensively studied from an economic perspective. To address this gap, a systematic review was conducted to summarize existing economic evaluations of prehabilitation interventions. Methods The PRISMA Protocols 2015 checklist was followed. Over 16,000 manuscripts were reviewed, and 99 reports on preoperative interventions and screening tests were identified, of which 12 studies were included in this analysis. The costs are expressed in Pounds (GBP, £) and adjusted for inflation to December 2022. Results The studies were conducted in Western countries, focusing on specific surgical subspecialties. While the interventions and study designs varied, most studies demonstrated cost savings in the intervention group compared to the control group. Additionally, all cost-effectiveness analysis studies favored the intervention group. However, the review also identified several limitations. Many studies had a moderate or high risk of bias, and critical information such as time horizons and discount rates were often missing. Important components like heterogeneity, distributional effects, and uncertainty were frequently lacking as well. The misclassification of economic evaluation types highlighted a lack of knowledge among physicians in prehabilitation research. Conclusion This review reveals a lack of robust evidence regarding the economics of prehabilitation programs for surgical patients. This suggests a need for further research with rigorous methods and accurate definitions.
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Affiliation(s)
- Yuhe Ke
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Roderica Rui Ge Ng
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Shalini Elangovan
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Yun Hao Leong
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Zhao Han Goh
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Nicholas Graves
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Nicholas B. Shannon
- Duke-NUS Medical School, Singapore, Singapore
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Hairil Rizal Abdullah
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
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Reece L, Moran B, Ferrie S, Ansari N, Koh C, Allman-Farinelli M, Carey S. A global analysis of nutrition support practices in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancy. Clin Nutr ESPEN 2023; 57:297-304. [PMID: 37739672 DOI: 10.1016/j.clnesp.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/10/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Perioperative nutritional care has been identified as an important factor in the management of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Nevertheless, there is no published consensus on best practice for nutritional management specific to this patient group. The purpose of this study was to identify the current nutrition care practices among international centres performing CRS and HIPEC for patients with peritoneal malignancy. METHODS An online survey was developed and sent to experienced CRS and HIPEC centres. The survey questions covered clinician and institution demographics, formal nutrition care pathways, pre-operative nutrition care, post-operative nutrition support and post-discharge nutritional follow-up. RESULTS Eighty-two centres were contacted, and 42 responses were received. Respondents were from 20 different countries and were mostly dietitians (71%). Nutrition assessments were frequently completed (52% pre-operatively and 86% post-operatively) and most centres used a validated nutrition screening or assessment tool (79%). Perioperative nutrition support with respect to the use of enteral nutrition, parenteral nutrition and enhanced recovery after surgery varied widely between centres. The use of routine parenteral and enteral nutrition was significantly higher in Europe compared with other locations (p = 0.028). CONCLUSIONS Nutrition care is pivotal and has been positively integrated into the complex management of patients undergoing CRS and HIPEC globally, however variation in practice is evident. The findings highlight a unique opportunity to collaboratively investigate the role nutrition plays in determining outcomes and to identify the most appropriate nutrition support methods to achieve improved clinical outcomes for these high-risk patients.
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Affiliation(s)
- Lauren Reece
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia.
| | - Brendan Moran
- Peritoneal Malignancy Institute, Hampshire Hospital Foundation Trust, Basingstoke, United Kingdom
| | - Suzie Ferrie
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia
| | - Nabila Ansari
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and the University of Sydney, Sydney, NSW, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and the University of Sydney, Sydney, NSW, Australia
| | - Margaret Allman-Farinelli
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
| | - Sharon Carey
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and the University of Sydney, Sydney, NSW, Australia
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Joshi UM, Ratz D, Frankel TL, Dobrosotskaya I. Longitudinal Dynamic in Weight Loss Impacts Clinical Outcomes for Veterans Undergoing Curative Surgery for Colorectal Cancer. Fed Pract 2023; 40:S24-S33. [PMID: 37727831 PMCID: PMC10506501 DOI: 10.12788/fp.0377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Background Definitions of malnutrition imperfectly reflect nutritional status or predict perioperative consequences. We sought to identify predictive nutritional trends by examining the effect of preoperative weight on postoperative outcomes in patients with colorectal cancer (CRC). Methods This retrospective review examined 148 patients with CRC treated with curative-intent surgery at the Veterans Affairs Ann Arbor Healthcare System in Michigan from January 1, 2015 to December 31, 2019. We evaluated weight dynamics of patients, starting 1 year before cancer diagnosis until 1 year after surgery. We evaluated the association of these weight dynamics with surgical outcomes. Primary outcomes observed were hospital readmission and length of stay (LOS), chemotherapy completion, and delayed recovery defined as abnormal clinical developments. Results There were 115 patients in the colon cancer (CC) cohort and 33 in the rectal cancer (RC) cohort. Low preoperative albumin (< 3.5 g/dL) was present in 25 patients with CC (22%) and 11 patients with RC (33%). Six-month preoperative weight loss of at least 3% occurred in 32 patients with CC (36%). Delayed recovery was observed in 35 patients with CC (30%) and 21 patients with RC (64%). Nutrition consultation rates for the CC and RC groups were 15% and 36%, respectively, before the operation; 95% and 100%, respectively, for postoperative inpatients; and 12% and 73%, respectively, for postoperative outpatients. Six-month preoperative weight loss of ≥ 3% was significantly associated with delayed recovery (P < .001) and 60-day readmissions (P = .015) but not increased LOS or chemotherapy noncompletion. Conclusions A ≥ 3% weight loss 6 months preceding curative surgery for CRC was associated with adverse outcomes. An intensive nutrition prehabilitation program initiated at the time of cancer diagnosis is needed and may reduce associated complications.
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Affiliation(s)
- Urvashi M. Joshi
- University of Michigan Health System, Ann Arbor
- Veterans Affairs Ann Arbor Healthcare System, Michigan
- University of Pittsburgh Medical Center, Pennsylvania
| | - David Ratz
- University of Michigan Health System, Ann Arbor
- Veterans Affairs Ann Arbor Healthcare System, Michigan
| | - Timothy L. Frankel
- University of Michigan Health System, Ann Arbor
- Veterans Affairs Ann Arbor Healthcare System, Michigan
| | - Irina Dobrosotskaya
- University of Michigan Health System, Ann Arbor
- Veterans Affairs Ann Arbor Healthcare System, Michigan
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Khan A, Laing E, Beaumont A, Warrier S, Riedel B, Heriot A. Immunonutrition in cancer surgery: a missed opportunity? ANZ J Surg 2023. [DOI: 10.1111/ans.18431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Affiliation(s)
- A. Khan
- Cancer Surgery Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | - E. Laing
- Nutrition and Speech Pathology Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | - A. Beaumont
- Nutrition and Speech Pathology Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | - S. Warrier
- Cancer Surgery Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | - B. Riedel
- Anaesthetics Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | - A. Heriot
- Cancer Surgery Peter MacCallum Cancer Centre Melbourne Victoria Australia
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Kutnik P, Wichowska O, Sysiak-Sławecka J, Szczukocka M, Rypulak E, Piwowarczyk P, Borys M, Czuczwar M. Malnutrition risk in elective surgery patients and effectiveness of preoperative nutritional interventions at a pre-anaesthetic clinic: a 4-year apart, single-centre, observational study. Anaesthesiol Intensive Ther 2023; 55:179-185. [PMID: 37728445 PMCID: PMC10496095 DOI: 10.5114/ait.2023.130632] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/27/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION Approximately 44% of all patients hospitalised for an elective surgical procedure have a malnutrition risk. In this study, we assessed the prevalence of malnutrition risk at a pre-anaesthetic clinic and the feasibility of introducing nutritional support. The primary objective of this study was to assess malnutrition risk prevalence in patients referred to a pre-anaesthetic clinic. MATERIAL AND METHODS This was a prospective observational study. The study was divided into two phases: one in 2020 and the other in 2023. Consecutive patients scheduled for an elective surgical procedure at a pre-anaesthetic clinic were asked to participate in the study by filling out the questionnaire. We divided the patients into two groups based on the GLIM criteria. RESULTS We included a total of 467 patients, including 214 from 2020 and 253 from 2023. In the total sample, 93 (19.9%) patients met the GLIM criteria for malnutrition risk, and 37 (7.9 %) fulfilled the ESPEN criteria for preoperative nutritional support. Out of 93 patients at malnutrition risk, 41 (44%) had BMI > 25 kg m -2 . The number of patients with indications for preoperative nutritional support in all departments remained similar across both time points. However, the number of patients receiving preoperative ONS almost doubled over the study period (36.8% in 2020 vs. 72.2% in 2023). CONCLUSIONS Malnutrition risk was consistently high among our elective surgery patients. Not all patients with indications for preoperative nutritional support received it. As such, pre-anaesthetic clinics might be one of the major links in the nutritional programme chains of hospitals.
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Affiliation(s)
- Paweł Kutnik
- II Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
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A’zim AZA, Zaid ZA, Yusof BNM, Jabar MF, Shahar ASM. Effectiveness of intensive perioperative nutrition therapy among adults undergoing gastrointestinal and oncological surgery in a public hospital: study protocol for a pragmatic randomized control trial. Trials 2022; 23:961. [DOI: 10.1186/s13063-022-06898-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/09/2022] [Indexed: 11/28/2022] Open
Abstract
Abstract
Background
Perioperative malnutrition is common in patients undergoing gastrointestinal-oncology surgery and is associated with longer hospital stays, increased postoperative complications, poorer quality of life, and lower survival rates. Current practice emphasizes the role of early perioperative nutrition therapy as an early intervention to combat the postoperative complications of patients and the implementation is now widely adopted. However, there is still a lack of research on determining the effectiveness of intensive nutrition therapy and providing ONS perioperative locally. This becomes the significance of this study and serves as a basis for management and guideline in the local hospital settings.
Methods
This is a pragmatic randomized control trial study where elective admitted patients will be randomly divided into the intervention (SS) or control (NN) group. All data will be collected during a face-to-face interview, anthropometric measurement, blood sampling (albumin, white blood count, hemoglobin, and c-reactive protein), handgrip strength, and postoperative complications. Group SS will be receiving a tailored lifestyle and intensively supplemented with oral nutrition support as compared to Group NN that will receive standard medical care. The primary outcome for this study is the length of stay in the hospital. Additional outcome measures are changes in biochemical profile and nutritional and functional status. The effects of intervention between groups on the outcome parameters will be analyzed by using the SPSS General Linear Model (GLM) for the repeated measure procedure.
Discussion
The intervention implemented in this study will serve as baseline data in providing appropriate nutritional management in patients undergoing gastrointestinal and oncological surgery.
Trial registration
ClinicalTrials.gov Protocol Registration and Results System (PRS) NCT04347772. Registered on 20 November 2019.
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Knowledge and Practices of Digestive Surgeons concerning Specialized Nutritional Support in Cancer Patients: A Survey Study. Nutrients 2022; 14:nu14224764. [PMID: 36432451 PMCID: PMC9698070 DOI: 10.3390/nu14224764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/30/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022] Open
Abstract
A survey study based on a 21-item questionnaire was conducted to assess knowledge and practices of digestive surgeons focused on nutritional support in gastrointestinal cancer patients. At least 5 staff digestive surgeons from 25 tertiary care hospitals throughout Spain were invited to participate and 116 accepted. Malnutrition was correctly defined by 81.9% of participants. In patients undergoing major abdominal surgery, 55.2% considered that preoperative nutritional support is indicated in all patients with malnutrition for a period of 7-14 days. For the diagnosis of malnutrition, only 18.1% of participants selected unintentional weight loss together with a fasting or semi-fasting period of more than one week. Regarding the advantages of enteral infusion, 93.7% of participants considered preservation of the integrity of the intestinal mucosa and barrier function, and in relation to peripheral parenteral nutrition, 86.2% selected the definition of nutrient infusion through a peripheral vein and 81.9% its indication for less than 7 days. Digestive surgeons had a limited knowledge of basic aspects of clinical nutrition in cancer patients, but there was some variability regarding clinical practice in individual cases. These findings indicate the need to develop standardized clinical protocols as well as a national consensus on nutrition support in cancer patients.
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Corriveau J, Alavifard D, Gillis C. Demystifying Malnutrition to Improve Nutrition Screening and Assessment in Oncology. Semin Oncol Nurs 2022; 38:151336. [PMID: 35995630 DOI: 10.1016/j.soncn.2022.151336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Patients with cancer and malnutrition are more likely to experience poor treatment tolerance, prolonged length of hospital stay, and decreased quality of life. Early and sustained nutrition risk screening is the first step to tackling this patient and health care burden. Yet, malnutrition remains largely overlooked and undertreated. Malnutrition mismanagement could be indicative of a systemic misunderstanding. With this narrative review, we aimed to (1) define malnutrition, (2) address common malnutrition misconceptions, and (3) summarize nutrition recommendations for patients with cancer. DATA SOURCES PubMed and international clinical practice guidelines were used. CONCLUSION Malnutrition represents an unbalanced nutritional state that alters body composition and diminishes function. Malnutrition is not always physically obvious, and albumin is not a reliable marker of nutritional status; therefore, systematically screening all patients with a validated nutrition risk screening tool at time of cancer diagnosis, and periodically throughout treatment, is necessary to provide optimal, equitable care. Nutrition risk screening takes less than 1 minute to complete and can be completed by any health care professional. Patients that screen positive for nutrition risk should be referred to a registered nutritionist or dietitian for comprehensive nutritional assessment, diagnosis, and treatment. IMPLICATIONS FOR NURSING PRACTICE All health care professionals can and should be responsible for preventing and treating malnutrition. Registered nurses can actively participate in improving patient outcomes by screening patients for nutrition risk, weighing patients at every visit, referring patients to dietitians for nutrition treatment, and providing supportive medical management of nutrition impact symptoms such as nausea.
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Affiliation(s)
- Jade Corriveau
- Department of Nutrition, McGill University Health Centre, Montreal, QC, Canada
| | - Dorsa Alavifard
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Chelsia Gillis
- Department of Anesthesia, McGill University, Montreal, QC, Canada; Department of Surgery, McGill University, Montreal, QC, Canada; School of Human Nutrition, McGill University, McGill University, Montreal, QC, Canada.
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14
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Knight SR, Qureshi AU, Drake TM, Lapitan MCM, Maimbo M, Yenli E, Tabiri S, Ghosh D, Kingsley PA, Sundar S, Shaw C, Valparaiso AP, Bhangu A, Brocklehurst P, Magill L, Morton DG, Norrie J, Roberts TE, Theodoratou E, Weiser TG, Burden S, Harrison EM. The impact of preoperative oral nutrition supplementation on outcomes in patients undergoing gastrointestinal surgery for cancer in low- and middle-income countries: a systematic review and meta-analysis. Sci Rep 2022; 12:12456. [PMID: 35864290 PMCID: PMC9304351 DOI: 10.1038/s41598-022-16460-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/11/2022] [Indexed: 12/24/2022] Open
Abstract
Malnutrition is an independent predictor for postoperative complications in low- and middle-income countries (LMICs). We systematically reviewed evidence on the impact of preoperative oral nutrition supplementation (ONS) on patients undergoing gastrointestinal cancer surgery in LMICs. We searched EMBASE, Cochrane Library, Web of Science, Scopus, WHO Global Index Medicus, SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) databases from inception to March 21, 2022 for randomised controlled trials evaluating preoperative ONS in gastrointestinal cancer within LMICs. We evaluated the impact of ONS on all postoperative outcomes using random-effects meta-analysis. Seven studies reported on 891 patients (446 ONS group, 445 control group) undergoing surgery for gastrointestinal cancer. Preoperative ONS reduced all cause postoperative surgical complications (risk ratio (RR) 0.53, 95% CI 0.46-0.60, P < 0.001, I2 = 0%, n = 891), infection (0.52, 0.40-0.67, P = 0.008, I2 = 0%, n = 570) and all-cause mortality (0.35, 0.26-0.47, P = 0.014, I2 = 0%, n = 588). Despite heterogeneous populations and baseline rates, absolute risk ratio (ARR) was reduced for all cause (pooled effect -0.14, -0.22 to -0.06, P = 0.006; number needed to treat (NNT) 7) and infectious complications (-0.13, -0.22 to -0.06, P < 0.001; NNT 8). Preoperative nutrition in patients undergoing gastrointestinal cancer surgery in LMICs demonstrated consistently strong and robust treatment effects across measured outcomes. However additional higher quality research, with particular focus within African populations, are urgently required.
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Affiliation(s)
- Stephen R Knight
- Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX, UK.
| | - Ahmad U Qureshi
- Department of Surgery, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Thomas M Drake
- Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX, UK
| | - Marie Carmela M Lapitan
- Department of Surgery, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Mayaba Maimbo
- Department of General Surgery, Kitwe Teaching Hospital, Kitwe, Zambia
| | - Edwin Yenli
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Stephen Tabiri
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
- Dean of School of Medicine, University for Development Studies, Tamale, Ghana
| | - Dhruva Ghosh
- Department of Paediatric Surgery, Christian Medical College, Ludhiana, India
| | - Pamela A Kingsley
- Department of Radiation Oncology Department, Christian Medical College, Ludhiana, India
| | - Sudha Sundar
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Catherine Shaw
- Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX, UK
| | - Apple P Valparaiso
- Department of Surgery, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Aneel Bhangu
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Laura Magill
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Dion G Morton
- Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - John Norrie
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Tracey E Roberts
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Evropi Theodoratou
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, USA
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Sorrel Burden
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX, UK
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15
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Grieco M, Delrio P, Lorenzon L, Agnes AL, Caccialanza R, Pedrazzoli P, Santoro G, Roviello F, Carlini M. Nutritional support in surgical oncology: A survey by SICO in collaboration with the Intersociety Italian Working Group for Nutritional Support in Cancer Patients. Surg Oncol 2022; 43:101788. [PMID: 35749913 DOI: 10.1016/j.suronc.2022.101788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/06/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Nutritional support is a keystone component in perioperative care in patients undergoing oncological surgery with a direct impact on surgical outcomes. This study aimed to evaluate how nutritional support in the surgical setting is managed and applied in Italian hospitals. METHODS A national survey was designed by the Italian Society of Surgical Oncology (SICO) and disseminated in early 2021. The results were analyzed for the entire population and for comparing the following different subgroups: northern vs. southern regions; high-volume vs. low-volume centers; and junior vs. senior surgeons. RESULTS Out of the 141 responses collected from all Italian regions, 43.2% of the participants worked in a surgical unit where nutritional status evaluations and interventions were not routinely practiced, although the key features (nutritional counseling, oral supplementation, enteral and parenteral nutrition) were available in 77.3% of the hospitals. Among the participating centers, the ERAS protocol was systematically applied in only 29.5% of cases, and in 25.5% of cases, most of the items were followed, although not systematically. Among the surgeons who practiced in compliance with the ERAS pathways, almost half of the participants declared that the protocol was applied only for low-risk patients. No significant differences were documented when comparing Italian regions, high-volume vs. low-volume institutions or junior vs. senior participants. CONCLUSION Nutritional support in oncological surgery is frequently neglected in Italian hospitals, regardless of the geographic distribution and volumes of the institutions. A cultural change and an improvement in the availability of nutritional services are needed for widespread implementation.
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Affiliation(s)
- Michele Grieco
- General Surgery Unit, S. Eugenio Hospital, Rome, Italy. https://twitter.com/MicheleGriecoMD
| | - Paolo Delrio
- Colorectal Surgical Oncology-Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione Giovanni Pascale IRCCS, Naples, Italy
| | - Laura Lorenzon
- General Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy
| | - Amedea Luciana Agnes
- Endocrine Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paolo Pedrazzoli
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo and Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Gloria Santoro
- General Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy
| | - Franco Roviello
- Surgical Oncology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Durán-Poveda M, Bonavina L, Reith B, Caruso R, Klek S, Senkal M. Nutrition practices with a focus on parenteral nutrition in the context of enhanced recovery programs: An exploratory survey of gastrointestinal surgeons. Clin Nutr ESPEN 2022; 50:138-147. [DOI: 10.1016/j.clnesp.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 10/18/2022]
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17
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Role of prehabilitation following major uro-oncologic surgery: a narrative review. World J Urol 2022; 40:1289-1298. [PMID: 33128596 DOI: 10.1007/s00345-020-03505-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 10/15/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Functional status and physical independence play a key role in terms of quality of life, access to treatment, and continuity of care. Surgery, a central component of cancer treatments, leads to detrimental effects on functional capacity, which can be peculiarly relevant in vulnerable patients undergoing major procedures. Prehabilitation is a multidisciplinary intervention that uses the preoperative period to prevent or attenuate treatment-related functional decline and its subsequent consequences. This paper narratively reviews the rationale and the evidence of prehabilitation for uro-oncologic surgery. METHODS A narrative review was conducted in August 2020, aiming to: (1) identify and discuss the impact of modifiable determinants of postoperative outcomes in urology and (2) review randomized controlled trials (RCT) exploring the role of preoperative exercise, nutrition, and psychological interventions in uro-oncologic surgery. RESULTS Eight RCTs on preoperative conditioning interventions met the inclusion criteria, focusing on radical cystectomy for bladder cancer (RC) and radical prostatectomy for prostate cancer (RP). There is strong evidence that poor physical, nutritional and psychosocial status negatively impacts on surgical outcomes. Single modality interventions, such as preoperative exercise or nutrition alone, had no effect on 'traditional' surgical outcomes as length of stay or complication. However, multimodal approaches targeting postoperative functional status have shown to be effective and safe. CONCLUSION There is initial evidence on the effectiveness and safety of multimodal prehabilitation in preserving functional capacity following RC and RP. However, to date, outcomes such as complications and length of stay seem to be not affected by prehabilitation.
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18
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Martínez-Ortega AJ, Piñar-Gutiérrez A, Serrano-Aguayo P, González-Navarro I, Remón-Ruíz PJ, Pereira-Cunill JL, García-Luna PP. Perioperative Nutritional Support: A Review of Current Literature. Nutrients 2022; 14:1601. [PMID: 35458163 PMCID: PMC9030898 DOI: 10.3390/nu14081601] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/27/2022] [Accepted: 04/09/2022] [Indexed: 02/04/2023] Open
Abstract
Since the beginning of the practice of surgery, the reduction of postoperative complications and early recovery have been two of the fundamental pillars that have driven the improvement of surgical techniques and perioperative management. Despite great advances in these fields, the rationalization of antibiotic prophylaxis, and other important innovations, postoperative recovery (especially in elderly patients, oncological pathology or digestive or head and neck surgery) is tortuous. This can be explained by several reasons, among which, malnutrition has a major role. Perioperative nutritional support, included within the ERAS (Enhanced Recovery After Surgery) protocol, has proven to be a main element and a critical step to achieve better surgical results. Starting with the preoperative nutritional assessment and treatment in elective surgery, we can improve nutritional status using oral supplements and immunomodulatory formulas. If we add early nutritional support in the postoperative scenario, we are able to significantly reduce infectious complications, need for intensive care unit (ICU) and hospital stay, costs, and mortality. Throughout this review, we will review the latest developments and the available literature.
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Affiliation(s)
| | | | | | | | | | - José Luís Pereira-Cunill
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Seville, Spain; (A.J.M.-O.); (A.P.-G.); (P.S.-A.); (I.G.-N.); (P.J.R.-R.); (P.P.G.-L.)
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19
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Riso S, Para O, Collo A, Campanini M, Rotunno S, Giorgetti G, Zanetti M. CLINICAL NUTRITION IN INTERNAL MEDICINE: AN ITALIAN SURVEY BY THE SCIENTIFIC SOCIETIES FADOI AND SINPE. Nutrition 2022; 98:111623. [DOI: 10.1016/j.nut.2022.111623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 11/17/2022]
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20
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Deftereos I, Yeung JMC, Arslan J, Carter VM, Isenring E, Kiss N, Cardamis A, Dorey A, Ottaway A, Maguire B, Cleeve B, Davis C, Zoanetti C, Gray C, Choong C, Douglas C, Nixon C, Platt D, Quinn E, Simpson E, Hamdorf E, McNamara E, Whelan E, Jegendran G, Moore G, Lockwood G, McNamara J, Corrigan J, Haaksma K, Fox K, Furness K, Cochrane KW, Huynh K, Lee KC, Hames N, Hendricks N, Page N, Brooks N, Nevin L, Parfrey L, Putrus E, Pons R, Hoevenaars R, Singh S, McCoy S, Wallin S, Mexias S, Daniells S, Storr T, Robertson T, Brown T. Adherence to ESPEN guidelines and associations with postoperative outcomes in upper gastrointestinal cancer resection: results from the multi-centre NOURISH point prevalence study. Clin Nutr ESPEN 2022; 47:391-398. [DOI: 10.1016/j.clnesp.2021.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 12/23/2022]
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21
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Williams DGA, Wischmeyer PE. Nutrition Status Optimization for Improved Perioperative Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00504-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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22
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Deftereos I, Kiss N, Brown T, Carey S, Carter VM, Usatoff V, Ananda S, Yeung JM. Awareness and perceptions of nutrition support in upper gastrointestinal cancer surgery: A national survey of multidisciplinary clinicians. Clin Nutr ESPEN 2021; 46:343-349. [PMID: 34857218 DOI: 10.1016/j.clnesp.2021.09.734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/08/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients undergoing surgery for upper gastrointestinal (UGI) cancer are at high risk of malnutrition, and a multidisciplinary approach to management is recommended. This study aimed to determine practices, awareness and perceptions of multi-disciplinary clinicians with regards to malnutrition screening and provision of nutrition support. METHODS A national survey of dietitians, surgeons, oncologists and nurses was conducted using a 30-item online REDCap survey, including questions regarding self-reported malnutrition screening/nutrition support practices, awareness and perceptions, and barriers and enablers. The survey was distributed via professional organisations/networks between 1st September and 30th November 2020. Results are presented as counts and percentages. RESULTS There were 130 participants (56% dietitians, 25% surgeons, 11% nurses, 8% oncologists). The majority reported that dietitians and nurses performed malnutrition screening, and dietitians and surgeons prescribed nutrition support. Most participants reported that their health service had dietetics support available overall (98%), however only 41% reported having an outpatient service. Participants (>90%) demonstrated very high awareness of the significance of malnutrition and the importance of early nutrition support. Participants mostly perceived dietitians, nurses and surgeons to be responsible for malnutrition screening, whilst responsibility of prescription of nutrition support was mostly dietitians and surgeons. There were a higher number of barriers for the outpatient setting (48%) than the inpatient setting (38%). CONCLUSIONS Participants identified a high awareness of the importance of identification and treatment of malnutrition in UGI cancer surgery. However reported practices varied and appear to be lacking in the outpatient setting, with significant barriers identified to providing optimal nutrition care.
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Affiliation(s)
- Irene Deftereos
- Department of Surgery, Western Precinct, Melbourne Medical School, The University of Melbourne, St Albans, VIC 3021, Australia; Department of Nutrition and Dietetics, Western Health, Footscray, VIC 3011, Australia.
| | - Nicole Kiss
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC 3220, Australia; Allied Health Research, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia.
| | - Teresa Brown
- Department of Nutrition and Dietetics, Royal Brisbane & Women's Hospital, Brisbane, QLD 4029, Australia; School of Human Movement and Nutritional Sciences, The University of Queensland, Brisbane, QLD 4029, Australia.
| | - Sharon Carey
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
| | - Vanessa M Carter
- Department of Nutrition and Dietetics, Western Health, Footscray, VIC 3011, Australia.
| | - Val Usatoff
- Department of Surgery, Western Precinct, Melbourne Medical School, The University of Melbourne, St Albans, VIC 3021, Australia.
| | - Sumitra Ananda
- Department of Medicine, The University of Melbourne, Parkville, VIC 3010, Australia.
| | - Justin Mc Yeung
- Department of Surgery, Western Precinct, Melbourne Medical School, The University of Melbourne, St Albans, VIC 3021, Australia; Department of Colorectal Surgery, Western Health, Footscray, VIC 3011, Australia; Western Health Chronic Disease Alliance, Western Health, Footscray, VIC 3011, Australia.
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23
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Williams DG, Aronson S, Murray S, Fuller M, Villalta E, Haines KL, Wischmeyer P. Validation of the Perioperative Nutrition Screen (PONS) for Prediction of Postoperative Outcomes. JPEN J Parenter Enteral Nutr 2021; 46:1307-1315. [PMID: 34850403 DOI: 10.1002/jpen.2310] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Preoperative nutrition risk is often underrecognized and undertreated. The Perioperative Nutrition Screen (PONS) was recently introduced as an efficient tool to rapidly screen for preoperative nutritional risk. The relationship between identification of "nutritional risk" via PONS and adverse outcomes postoperatively remains undescribed. METHODS Preoperative nutrition risk was assessed via PONS from 1/1/2019-9/30/2020. Key clinical outcomes were compared with individual and composite PONS components. RESULTS 3,151 patients with PONS evaluations were analyzed. Multivariate regression analysis adjusted for key co-variates demonstrated positive responses for specific PONS component questions was associated with adverse clinical outcomes as follows: 1) Unplanned weight loss (>10% in 6-months preoperatively) associated with a 22.4% increased length of stay (LOS) (95%CI: 13.3%-32.1%, p<0 .0001) and increased 30-day readmission rate (OR 2.44, 95%CI: 1.73-3.44, p<0.001); 2) History of < 50% of previous oral intake in past week associated with a 25% increased LOS (95%CI: 15.7%-35.2%, p<0.001); 3) Preoperative albumin <3.0g/l associated with a 29.9% increased LOS (p< 0.001) and increased 30-day readmission rate (OR 2.66 (95% CI: 1.63-4.35, p<0.001); 4) Low BMI (<18.5 kg/m2 ≤65 years old or <20 kg/m2 in ≥65 years old) was not associated with increased LOS by adjusted analysis although was predictive by univariate analysis. CONCLUSIONS The PONS and its individual components appear to predict risk of adverse postoperative outcomes, even independent of a validated malnutrition diagnosis. Further studies are needed to assess the impact of specific preoperative nutrition interventions on adverse outcomes predicted by PONS when delivered to patients identified via PONS screen. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Solomon Aronson
- Departments of Anesthesiology, Duke University School of Medicine.,Population Health, Duke University School of Medicine
| | - Sutton Murray
- Departments of Anesthesiology, Duke University School of Medicine
| | - Matt Fuller
- Departments of Anesthesiology, Duke University School of Medicine
| | | | | | - Paul Wischmeyer
- Departments of Anesthesiology, Duke University School of Medicine
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Antonescu I, Haines KL, Agarwal S. Role of Nutrition in the Elderly Surgical Patient – Review of the Literature and Current Recommendations. CURRENT GERIATRICS REPORTS 2021. [DOI: 10.1007/s13670-021-00367-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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25
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Assessment of Nutritional Status and Nutrition Impact Symptoms in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study. Nutrients 2021; 13:nu13103349. [PMID: 34684353 PMCID: PMC8539371 DOI: 10.3390/nu13103349] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Identification and treatment of malnutrition are essential in upper gastrointestinal (UGI) cancer. However, there is limited understanding of the nutritional status of UGI cancer patients at the time of curative surgery. This prospective point prevalence study involving 27 Australian tertiary hospitals investigated nutritional status at the time of curative UGI cancer resection, as well as presence of preoperative nutrition impact symptoms, and associations with length of stay (LOS) and surgical complications. METHODS Subjective global assessment, hand grip strength (HGS) and weight were performed within 7 days of admission. Data on preoperative weight changes, nutrition impact symptoms, and dietary intake were collected using a purpose-built data collection tool. Surgical LOS and complications were also recorded. Multivariate regression models were developed for nutritional status, unintentional weight loss, LOS and complications. RESULTS This study included 200 patients undergoing oesophageal, gastric and pancreatic surgery. Malnutrition prevalence was 42% (95% confidence interval (CI) 35%, 49%), 49% lost ≥5% weight in 6 months, and 47% of those who completed HGS assessment had low muscle strength with no differences between surgical procedures (p = 0.864, p = 0.943, p = 0.075, respectively). The overall prevalence of reporting at least one preoperative nutrition impact symptom was 55%, with poor appetite (37%) and early satiety (23%) the most frequently reported. Age (odds ratio (OR) 4.1, 95% CI 1.5, 11.5, p = 0.008), unintentional weight loss of ≥5% in 6 months (OR 28.7, 95% CI 10.5, 78.6, p < 0.001), vomiting (OR 17.1, 95% CI 1.4, 207.8, 0.025), reduced food intake lasting 2-4 weeks (OR 7.4, 95% CI 1.3, 43.5, p = 0.026) and ≥1 month (OR 7.7, 95% CI 2.7, 22.0, p < 0.001) were independently associated with preoperative malnutrition. Factors independently associated with unintentional weight loss were poor appetite (OR 3.7, 95% CI 1.6, 8.4, p = 0.002) and degree of solid food reduction of <75% (OR 3.3, 95% CI 1.2, 9.2, p = 0.02) and <50% (OR 4.9, 95% CI 1.5, 15.6, p = 0.008) of usual intake. Malnutrition (regression coefficient 3.6, 95% CI 0.1, 7.2, p = 0.048) and unintentional weight loss (regression coefficient 4.1, 95% CI 0.5, 7.6, p = 0.026) were independently associated with LOS, but no associations were found for complications. CONCLUSIONS Despite increasing recognition of the importance of preoperative nutritional intervention, a high proportion of patients present with malnutrition or clinically significant weight loss, which are associated with increased LOS. Factors associated with malnutrition and weight loss should be incorporated into routine preoperative screening. Further investigation is required of current practice for dietetics interventions received prior to UGI surgery and if this mitigates the impact on clinical outcomes.
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Deftereos I, Yeung JMC, Arslan J, Carter VM, Isenring E, Kiss N. Preoperative Nutrition Intervention in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study. Nutrients 2021; 13:nu13093205. [PMID: 34579082 PMCID: PMC8467838 DOI: 10.3390/nu13093205] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/09/2021] [Accepted: 09/09/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Preoperative nutrition intervention is recommended prior to upper gastrointestinal (UGI) cancer resection; however, there is limited understanding of interventions received in current clinical practice. This study investigated type and frequency of preoperative dietetics intervention and nutrition support received and clinical and demographic factors associated with receipt of intervention. Associations between intervention and preoperative weight loss, surgical length of stay (LOS), and complications were also investigated. Methods: The NOURISH Point Prevalence Study was conducted between September 2019 and May 2020 across 27 Australian tertiary centres. Subjective global assessment and weight were performed within 7 days of admission. Patients reported on preoperative dietetics and nutrition intervention, and surgical LOS and complications were recorded. Results: Two-hundred patients participated (59% male, mean (standard deviation) age 67 (10)). Sixty percent had seen a dietitian preoperatively, whilst 50% were receiving nutrition support (92% oral nutrition support (ONS)). Patients undergoing pancreatic surgery were less likely to receive dietetics intervention and nutrition support than oesophageal or gastric surgeries (p < 0.001 and p = 0.029, respectively). Neoadjuvant therapy (p = 0.003) and malnutrition (p = 0.046) remained independently associated with receiving dietetics intervention; however, 31.3% of malnourished patients had not seen a dietitian. Patients who received ≥3 dietetics appointments had lower mean (SD) percentage weight loss at the 1-month preoperative timeframe compared with patients who received 0–2 appointments (1.2 (2.0) vs. 3.1 (3.3), p = 0.001). Patients who received ONS for >2 weeks had lower mean (SD) percentage weight loss than those who did not (1.2 (1.8) vs. 2.9 (3.4), p = 0.001). In malnourished patients, total dietetics appointments ≥3 was independently associated with reduced surgical complications (odds ratio 0.2, 95% confidence interval (CI) 0.1, 0.9, p = 0.04), and ONS >2 weeks was associated with reduced LOS (regression coefficient −7.3, 95% CI −14.3, −0.3, p = 0.04). Conclusions: Despite recommendations, there are low rates of preoperative dietetics consultation and nutrition support in this population, which are associated with increased preoperative weight loss and risk of increased LOS and complications in malnourished patients. The results of this study provide insights into evidence–practice gaps for improvement and data to support further research regarding optimal methods of preoperative nutrition support.
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Affiliation(s)
- Irene Deftereos
- Department of Surgery, Western Precinct, Melbourne Medical School, The University of Melbourne, St Albans, VIC 3021, Australia; (J.M.-C.Y.); (J.A.)
- Department of Nutrition and Dietetics, Western Health, Footscray, VIC 3011, Australia;
- Correspondence: ; Tel.: +61-3-8395-8116
| | - Justin M.-C. Yeung
- Department of Surgery, Western Precinct, Melbourne Medical School, The University of Melbourne, St Albans, VIC 3021, Australia; (J.M.-C.Y.); (J.A.)
- Department of Colorectal Surgery, Western Health, Footscray, VIC 3011, Australia
- Western Health Chronic Disease Alliance, Western Health, Footscray, VIC 3011, Australia
| | - Janan Arslan
- Department of Surgery, Western Precinct, Melbourne Medical School, The University of Melbourne, St Albans, VIC 3021, Australia; (J.M.-C.Y.); (J.A.)
| | - Vanessa M. Carter
- Department of Nutrition and Dietetics, Western Health, Footscray, VIC 3011, Australia;
| | - Elizabeth Isenring
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD 4226, Australia;
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, QLD 4102, Australia
| | - Nicole Kiss
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC 3220, Australia;
- Allied Health Research, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia
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Lopez-Betancourt R, Afonso AM. Carbohydrate loading and fluid management within enhanced recovery. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Martin L, Gillis C, Ljungqvist O. Preoperative nutrition care in Enhanced Recovery After Surgery programs: are we missing an opportunity? Curr Opin Clin Nutr Metab Care 2021; 24:453-463. [PMID: 34155154 DOI: 10.1097/mco.0000000000000779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW A key component of Enhanced Recovery After Surgery (ERAS) is the integration of nutrition care elements into the surgical pathway, recognizing that preoperative nutrition status affects outcomes of surgery and must be optimized for recovery. We reviewed the preoperative nutrition care recommendations included in ERAS Society guidelines for adults undergoing major surgery and their implementation. RECENT FINDINGS All ERAS Society guidelines reviewed recommend preoperative patient education to describe the procedures and expectations of surgery; however, only one guideline specifies inclusion of routine nutrition education before surgery. All guidelines included a recommendation for at least one of the following nutrition care elements: nutrition risk screening, nutrition assessment, and nutrition intervention. However, the impact of preoperative nutrition care could not be evaluated because it was rarely reported in recent literature for most surgical disciplines. A small number of studies reported on the preoperative nutrition care elements within their ERAS programs and found a positive impact of ERAS implementation on nutrition care practices, including increased rates of nutrition risk screening. SUMMARY There is an opportunity to improve the reporting of preoperative nutrition care elements within ERAS programs, which will enhance our understanding of how nutrition care elements influence patient outcomes and experiences.
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Affiliation(s)
- Lisa Martin
- Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Chelsia Gillis
- Department of Anesthesia, McGill University Health Center, Québec, Canada
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
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Matthews LS, Wootton SA, Davies SJ, Levett DZH. Screening, assessment and management of perioperative malnutrition: a survey of UK practice. Perioper Med (Lond) 2021; 10:30. [PMID: 34433498 PMCID: PMC8390283 DOI: 10.1186/s13741-021-00196-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/31/2021] [Indexed: 01/04/2023] Open
Abstract
Background Perioperative malnutrition is common and is associated with increased mortality, complications and healthcare costs. Patients having surgery for cancer and gastro-intestinal disease are at particular risk. It is a modifiable pre-operative risk factor and perioperative clinicians are well placed to identify those at risk and instigate interventions shown to improve outcome. Thus, we conducted a survey of Perioperative Medicine Leads with the aim of assessing the current provision of nutritional screening and intervention pathways in the UK. Methods Perioperative Medicine Leads registered with the Royal College of Anaesthetists were asked to complete an online survey exploring current practice in screening, assessment and management of malnutrition in the perioperative period. The survey included a mixture of open and closed questions, graded response questions and options for free text. Where a response was not received, departments were phoned directly and e-mails sent to non-responders. Results We received 121 completed questionnaires from 167 Perioperative Medicine Leads (response rate of 72.5%). Seventy respondents (57.9%) reported using the Malnutrition Universal Screening Tool to screen patients; however, only 61 (50.4%) referred patients at nutritional risk onto a dietitian. Sixty (49.6%) lacked confidence in local ability to identify and manage malnutrition perioperatively, with 28 (23.1%) reporting having a structured pathway for managing malnourished patients. One hundred eleven respondents (91.7%) agreed that malnutrition impacts on quality of life after surgery and 105 (86.8%) felt adopting a standard protocol would improve outcomes for patients. Those reporting a lack of confidence in dealing with malnutrition perioperatively cited a lack of organisational support, patients being seen too close to surgery and lack of clarity around responsibility as key reasons for difficulties in managing this group of patients. Conclusions Malnutrition in the perioperative period is a modifiable risk factor which is common and results in increased morbidity for patients and increased cost to healthcare systems. This survey highlights areas of practice where perioperative clinicians can improve the assessment and management of patients at nutritional risk prior to elective surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-021-00196-2.
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Affiliation(s)
- L S Matthews
- Department of Perioperative Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK. .,University of Southampton, Southampton, UK.
| | - S A Wootton
- University of Southampton, Southampton, UK.,National Institute for Health Research Cancer and Nutrition Collaboration, Southampton, UK
| | - S J Davies
- Department of Dietetics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - D Z H Levett
- Department of Perioperative Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK.,University of Southampton, Southampton, UK
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AlleaBelle Gongola M, Reif RJ, Cosgrove PC, Sexton KW, Marino KA, Steliga MA, Muesse JL. Preoperative nutritional counselling in patients undergoing oesophagectomy. J Perioper Pract 2021; 32:183-189. [PMID: 34197238 DOI: 10.1177/17504589211006026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients undergoing surgery for oesophageal cancer are at high risk of malnutrition due to pathology and neoadjuvent therapy. This study sought to determine if oesophageal cancer patients undergoing oesophagectomy achieve superior clinical outcomes when preoperative nutritional counselling is performed. METHODS Oesophageal cancer patients undergoing oesophagectomy were retrospectively divided into cohorts based on those who received (n = 48) and did not receive (n = 58) preoperative nutritional counselling. We compared weight loss, length of stay, 30-day readmission related to nutrition or feeding tube problems, and 90-day mortality. RESULTS Per cent weight loss was less in patients who received preoperative nutritional counselling. There was a trend toward decreased mean length of stay and there were fewer readmissions for feeding tube-related complications in patients who received counselling. CONCLUSIONS Nutritional counselling before surgery may lead to decreased weight loss and reduced readmissions for feeding tube-related complications in patients with oesophageal cancer undergoing oesophagectomy.
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Affiliation(s)
- M AlleaBelle Gongola
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rebecca J Reif
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Peggy C Cosgrove
- Department of Surgery, Division of Thoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kevin W Sexton
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Katy A Marino
- Department of Surgery, Division of Thoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Matthew A Steliga
- Department of Surgery, Division of Thoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jason L Muesse
- Department of Surgery, Division of Thoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Brown M, Rosenthal M, Yeh DD. Implementation Science and Nutrition: From Research to Practice. Nutr Clin Pract 2021; 36:586-597. [PMID: 34021636 DOI: 10.1002/ncp.10677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/09/2021] [Indexed: 11/11/2022] Open
Abstract
Implementation science (IS) is a young field that seeks to minimize the gap between what we know and what we practice, otherwise known as the "know-do gap." Recently, IS has focused on research that expedites the dissemination of evidence-based knowledge, accelerates the translation of interventions to improve knowledge gaps, shrinks healthcare disparities, enhances care of complex medical conditions, and narrows variation in clinical practice and policy. This article seeks to review theoretical frameworks of IS and demonstrate how IS can be utilized to improve nutrition care. Specific examples in this article include implementation of initiatives to improve documentation of malnutrition, increase provision of oral nutrition supplements, increase use of Enhanced Recovery After Surgery protocols, and increase energy and protein delivery. Clinical nutrition is a growing field with more and more research findings pointing to new therapies. In implementing these new therapies, practitioners should recognize the complex system present in healthcare and lean on IS findings to speed implementation and more rapidly improve clinical outcomes.
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Affiliation(s)
- Michelle Brown
- Clinical Nutrition, UF Health Shands Hospital, Gainesville, Florida, USA
| | - Martin Rosenthal
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - D Dante Yeh
- Surgery, General Surgery Residency, Division of Trauma and Surgical Critical Care, The DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital, Miller School of Medicine, University of Miami, Coral Gables, Florida, USA
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Gillis C, Richer L, Fenton TR, Gramlich L, Keller H, Culos-Reed SN, Sajobi TT, Awasthi R, Carli F. Colorectal cancer patients with malnutrition suffer poor physical and mental health before surgery. Surgery 2021; 170:841-847. [PMID: 33966805 DOI: 10.1016/j.surg.2021.04.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND To determine whether there is an association between preoperative nutritional status and preoperative physical function, patient-reported quality of life, and body composition in colorectal cancer patients awaiting elective surgery. METHODS We conducted a pooled analysis of individual baseline patient data (n = 266) collected from 5 prehabilitation trials in colorectal cancer surgery. All data were collected approximately 4 weeks before surgery. Each patient's nutritional status was evaluated using the Patient-Generated Subjective Global Assessment: scores 4-8 indicated need for nutritional treatment, whereas ≥9 indicated critical need for a nutrition intervention. Physical function was measured with the 6-minute walk test; patient-reported quality of life was captured with the SF-36; body mass and composition were determined using multifrequency bioelectrical impedance. RESULTS Mean Patient-Generated Subjective Global Assessment score was 5.3 (standard deviation: 3.9). Approximately two-thirds of patients had a Patient-Generated Subjective Global Assessment of 4-8 or ≥9 (n = 162/266). The 6-minute walk test was progressively worse with higher Patient-Generated Subjective Global Assessment scores (PG-SGA <4: 471(119) m; PG-SGA 4-8: 417(125) m; PG-SGA ≥9: 311(125) m, P < .001). Every component of the SF-36 was lower in those with a Patient-Generated Subjective Global Assessment ≥9 compared to Patient-Generated Subjective Global Assessment <4, indicating that malnourished patients suffer worse quality of life. Interestingly, only the male patients with a Patient-Generated Subjective Global Assessment ≥9 presented with statistically significant lower body mass, reduced fat-free mass index, and a lower percent body fat relative to those with Patient-Generated Subjective Global Assessment <4, in part due to the higher variability among the females. CONCLUSION The consequences of malnutrition are far-reaching and are strongly associated with the physical and mental health of colorectal cancer patients awaiting elective resection.
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Affiliation(s)
- Chelsia Gillis
- Department of Anesthesia, McGill University, Montreal, Canada.
| | - Lauren Richer
- Department of Anesthesia, McGill University, Montreal, Canada
| | - Tanis R Fenton
- Department of Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada; Nutrition Services, Alberta Health Services, Calgary, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Heather Keller
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada; Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - S Nicole Culos-Reed
- Faculty of Kinesiology and Department of Oncology, Cumming School of Medicine, University of Calgary; Psychosocial Resources, Tom Baker Cancer Centre, Cancer Care, Alberta Health Services, Calgary, Alberta, Canada
| | - Tolulope T Sajobi
- Cumming School of Medicine, Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Rashami Awasthi
- Department of Anesthesia, McGill University, Montreal, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montreal, Canada
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Senkal M, Bonavina L, Reith B, Caruso R, Matern U, Duran M. Perioperative peripheral parenteral nutrition to support major gastrointestinal surgery: Expert opinion on treating the right patients at the right time. Clin Nutr ESPEN 2021; 43:16-24. [PMID: 34024508 DOI: 10.1016/j.clnesp.2021.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND & AIMS Patients undergoing major gastrointestinal surgery may be in particular need of nutritional therapy due to potential pre-existing disease-related malnutrition and the impact of surgical procedures. Peripheral parenteral nutrition (PPN), delivered via a peripheral catheter, is aligned with the Enhanced Recovery After Surgery (ERAS) concept of minimally invasive interventions where possible. However, uncertainties regarding perioperative PPN for patients undergoing major gastrointestinal surgery arise, in part, due to lack of clinical guidelines. This paper aims to provide practical guidance on perioperative PPN, within the framework of ERAS. METHODS A panel of surgeons and nurses convened to identify knowledge gaps and share their best practice experience regarding PPN provision for patients undergoing major gastrointestinal surgery. Clinical needs were identified and addressed based on the panel's experience and a narrative review. RESULTS Key topics addressed include how PPN can support ERAS nutritional recommendations, identifying gastrointestinal surgery patient subgroups who are likely to benefit from PPN, perioperative timepoints when PPN may be required, and optimizing the delivery of PPN. An algorithm to support the identification and management of patients' perioperative nutritional needs was developed. CONCLUSIONS This paper aims to assist healthcare providers by addressing best practice questions related to the use of PPN during the critical perioperative period within the ERAS concept. This may facilitate timely nutritional intervention to help improve postoperative clinical outcomes and quality of life for patients undergoing major gastrointestinal surgery.
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Affiliation(s)
| | - Luigi Bonavina
- University of Milan Medical School, Milan, Italy; IRCCS Policlinico San Donato, Division of General and Foregut Surgery, San Donato Milanese, Milan, Italy.
| | - Bernd Reith
- Agaplesion Diakonie Clinic, Kassel, Germany.
| | - Rosario Caruso
- IRCCS Policlinico San Donato, Health Professions Research and Development Unit, San Donato Milanese, Milan, Italy.
| | | | - Manuel Duran
- King Juan Carlos University Hospital, Faculty of Health Sciences, King Juan Carlos University, Madrid, Spain.
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Ferreira V, Lawson C, Gillis C, Scheede-Bergdahl C, Chevalier S, Carli F. Malnourished lung cancer patients have poor baseline functional capacity but show greatest improvements with multimodal prehabilitation. Nutr Clin Pract 2021; 36:1011-1019. [PMID: 33786870 DOI: 10.1002/ncp.10655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE The objective is to characterize the presence of malnutrition, examine the association between malnutrition and baseline functional capacity (FC), and the extent to which patients benefit from preoperative multimodal prehabilitation in patients undergoing lung resection for cancer. METHODS Data from 162 participants enrolled in multimodal prehabilitation or control before lung cancer surgery were analyzed. Malnutrition was measured using the Patient-Generated Subjective Global Assessment (PG-SGA) according to triage levels: low-nutrition-risk (PG-SGA 0-3), moderate-nutrition-risk (4-8) and high-nutrition-risk (≥9). Baseline differences in FC, measured by the 6-minute walk test (6MWT), were compared. Factorial analysis of covariance (ANCOVA) was conducted to examine the effect of nutrition status and intervention on mean change in 6MWT preoperatively. RESULTS 51.2% patients were considered low-nutrition-risk, 37.7% moderate-nutrition-risk, and 11.1% high-nutrition-risk. Low-nutrition-risk patients had significantly higher 6MWT at baseline (mean of 484 m [standard deviation (SD) = 88]) compared with moderate-nutrition-risk (432 m [SD = 107], P = .005) and high-nutrition-risk groups (416 m [SD = 90], P = .022). The adjusted mean change in 6MWT between prehabilitation vs control was 18.1 (95% confidence interval, 3.8 to 32.3) vs 5.6 m (-14.1 to 25.4) in low-nutrition-risk (P = .309), 28.5 (11 to 46) vs -4 m (-31.3 to 23.4) in moderate-nutrition-risk (P = .053), and 58.9 (16.7 to 101.2) vs -39.7 m (-80.2 to 0.826) in high-nutrition-risk group (P = .001). CONCLUSIONS Lung cancer patients at high-nutrition-risk awaiting surgery had significantly lower baseline FC compared with low-nutrition-risk patients but experienced significant improvements in preoperative FC upon receiving multimodal prehabilitation.
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Affiliation(s)
- Vanessa Ferreira
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Claire Lawson
- School of Human Nutrition, McGill University, Montreal, Quebec, Canada
| | - Chelsia Gillis
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Celena Scheede-Bergdahl
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | | | - Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
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Surgical patients and the risk of malnutrition: preoperative screening requires assessment and optimization. Can J Anaesth 2021; 68:606-610. [DOI: 10.1007/s12630-021-01932-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 12/30/2022] Open
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Williams DGA, Ohnuma T, Haines KL, Krishnamoorthy V, Raghunathan K, Sulo S, Cassady BA, Hegazi R, Wischmeyer PE. Association between early postoperative nutritional supplement utilisation and length of stay in malnourished hip fracture patients. Br J Anaesth 2021; 126:730-737. [PMID: 33516455 DOI: 10.1016/j.bja.2020.12.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/05/2020] [Accepted: 12/12/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Malnutrition in older hip fracture patients is associated with increased complication rates and mortality. As postoperative nutrition delivery is essential to surgical recovery, postoperative nutritional supplements including oral nutritional supplements or tube feeding formulas can improve postoperative outcomes in malnourished hip/femur fracture patients. The association between early postoperative nutritional supplements utilisation and hospital length of stay was assessed in malnourished hip/femur fracture patients. METHODS This is a retrospective cohort study of malnourished hip/femur fracture patients undergoing surgery from 2008 to 2018. Patients were identified through International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes and nutritional supplement utilisation via hospital charge codes. The primary outcome was hospital length of stay. Secondary outcomes included infectious complications, hospital mortality, ICU admission, and costs. Propensity matching (1:1) and univariable analysis were performed. RESULTS Overall, 160 151 hip/femur fracture surgeries were identified with a coded-malnutrition prevalence of 8.7%. Early postoperative nutritional supplementation (by hospital day 1) occurred in 1.9% of all patients and only 4.9% of malnourished patients. Propensity score matching demonstrated early nutritional supplements were associated with significantly shorter length of stay (5.8 [6.6] days vs 7.6 [5.8] days; P<0.001) without increasing hospital costs. No association was observed between early nutritional supplementation and secondary outcomes. CONCLUSION Malnutrition is underdiagnosed in hip/femur fracture patients, and nutritional supplementation is underutilised. Early nutritional supplementation was associated with a significantly shorter hospital stay without an increase in costs. Nutritional supplementation in malnourished hip/femur fracture patients could serve as a key target for perioperative quality improvement.
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Affiliation(s)
- David G A Williams
- CAPER Unit, Department of Anesthesiology, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | - Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | | | | | | | | | - Paul E Wischmeyer
- CAPER Unit, Department of Anesthesiology, USA; Duke Clinical Research Institute, Durham, NC, USA.
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Donahue BS. Commentary: Preoperative nutritional status and mortality from cardiac surgery: Do we have your attention yet? J Thorac Cardiovasc Surg 2021; 164:1150-1151. [PMID: 34561101 DOI: 10.1016/j.jtcvs.2021.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/27/2022]
Affiliation(s)
- Brian S Donahue
- Division of Pediatric Cardiac Anesthesia, Departments of Anesthesiology and Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn.
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Impact of Artificial Nutrition on Postoperative Complications. Healthcare (Basel) 2020; 8:healthcare8040559. [PMID: 33327483 PMCID: PMC7764968 DOI: 10.3390/healthcare8040559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 12/26/2022] Open
Abstract
Malnutrition is common in surgical cancer patients and it is widely accepted that it can adversely affect their postoperative outcome. Assessing the nutritional status of every patient, in particular care of elderly and cancer patients, is a crucial feature of the therapeutic pathway in order to optimize every strategy. Evidence exists that the advantages of perioperative nutrition are more significant in malnourished patients submitted to major surgery. For patients recognized as malnourished, preoperative nutrition therapies are indicated; the choice between parenteral and enteral nutrition is still controversial in perioperative malnourished surgical cancer patients, although enteral nutrition seems to have the best risk–benefit ratio. Early oral nutrition after surgery is advisable, when feasible, and should be administered in all the patients undergoing elective major surgery, if compliant. In patients with high risk for postoperative infections, perioperative immunonutrition has been proved in some ways to be effective, even if operations including those for cancer have to be delayed.
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The Influence of Pretherapeutic and Preoperative Sarcopenia on Short-Term Outcome after Esophagectomy. Cancers (Basel) 2020; 12:cancers12113409. [PMID: 33213090 PMCID: PMC7698549 DOI: 10.3390/cancers12113409] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/08/2020] [Accepted: 11/14/2020] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Although introducing minimally invasive surgery reduced postoperative morbidity after esophagectomy esophageal cancer still is a malignancy with poor prognosis. This study aimed to investigate whether preoperative sarcopenia has an influence on short-term postoperative outcome after esophagectomy in esophageal cancer patients. Our findings suggest that preoperative sarcopenia is no independent prognostic factor for postoperative outcome after esophagectomy but that patients’ nutritional status consists of more factors than only body mass index (BMI) and muscle mass. Prehabilitation and preoperative optimization of the patients’ nutritional status seems to be an important factor for short-term postoperative outcome after esophagectomy. Abstract By introducing minimally invasive surgery the rate of postoperative morbidity in esophageal cancer patients could be reduced. But esophagectomy is still associated with a relevant risk of postoperative morbidity and mortality. Patients often present with nutritional deficiency and sarcopenia even at time of diagnosis. This study focuses on the influence of skeletal muscle index (SMI) on postoperative morbidity and mortality. Fifty-two patients were included in this study. SMI was measured using computer tomographic images at the time of diagnosis and before surgery. Then, SMI and different clinicopathological and demographic features were correlated with postoperative morbidity. There was no correlation between SMI before neoadjuvant therapy (p = 0.5365) nor before surgery (p = 0.3530) with the short-term postoperative outcome. Regarding cholesterol level before surgery there was a trend for a higher risk of complications with lower cholesterol levels (p = 0.0846). Our findings suggest that a low preoperative SMI does not necessarily predict a poor postoperative outcome in esophageal cancer patients after esophagectomy but that there are many factors that influence the nutritional status of cancer patients. To improve nutritional status, cancer patients at our clinic receive specialized nutritional counselling during neoadjuvant treatment as well as after surgery.
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Huq S, Khalafallah AM, Botros D, Oliveira LAP, White T, Dux H, Jimenez AE, Mukherjee D. The Prognostic Impact of Nutritional Status on Postoperative Outcomes in Glioblastoma. World Neurosurg 2020; 146:e865-e875. [PMID: 33197633 DOI: 10.1016/j.wneu.2020.11.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The clinical impact and optimal method of assessing nutritional status (NS) have not been rigorously examined in glioblastoma. We investigated the relationship between NS and postoperative survival (PS) in glioblastoma using 4 nutritional indices and identified which index best modeled PS. METHODS NS was retrospectively assessed for patients with glioblastoma undergoing surgery at our institution from 2007 to 2019 using the albumin level, albumin/globulin ratio (AGR), nutritional risk index (NRI), and prognostic nutritional index (PNI). Optimal cut points for each index were identified using maximally selected rank statistics and previously established criteria. The predictive value of each index on PS was determined using Cox proportional hazards models adjusted for prognostic variables. The best-performing model was identified using the Akaike Information Criterion. RESULTS Our analysis included 242 patients (64% male) with a mean age of 57.6 years, Karnofsky Performance Status of 77.6, 5-factor modified frailty index of 0.59, albumin level of 4.2 g/dL, AGR of 1.9, NRI of 105.6, and PNI of 47.4. Median PS after index and repeat surgery was 12.7 and 7.8 months, respectively. On multivariable analysis, low albumin level (hazard ratio [HR], 2.09; 95% confidence interval [CI], 1.52-2.89; P < 0.001), mild NRI (HR, 1.61; 95% CI, 1.04-2.49; P = 0.032), moderate/severe NRI (HR, 2.51; 95% CI, 1.64-3.85; P < 0.001), and low PNI (HR, 2.51; 95% CI, 1.78-3.53; P < 0.001), but not low AGR (HR, 1.17; 95% CI, 0.89-1.54; P = 0.270), predicted decreased PS. PNI had the lowest Akaike Information Criterion. CONCLUSIONS NS predicts PS in glioblastoma. PNI may provide the best model for assessing NS. NS is an important modifiable aspect of brain tumor management that warrants increased attention.
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Affiliation(s)
- Sakibul Huq
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adham M Khalafallah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Botros
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leonardo A P Oliveira
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Taija White
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hayden Dux
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Pasechnik IN, Rybintsev VY, Markelov KM. [Perioperative nutritional support for surgical patients]. Khirurgiia (Mosk) 2020:95-103. [PMID: 33047592 DOI: 10.17116/hirurgia202010195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The article presents an algorithm for perioperative nutritional support of surgical patients operated on as planned. Today, planned surgical care is provided in accordance with the canons of the accelerated rehabilitation Program (ARP). The relevance of the problem of nutritional insufficiency, which is an important component of ARP, is due to the dependence of the results of surgical treatment on the initial nutritional status of the patient. Methods of screening for nutritional deficiency and options for correcting protein-energy disorders are described. The predominant method is the enteral delivery of nutrients and energy. Oral supplemental nutrition by sipping is a convenient way to correct nutritional disorders at all stages of the perioperative period.
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Affiliation(s)
- I N Pasechnik
- Central State Medical Academy of the President of the Russian Federation, Moscow, Russia
| | - V Yu Rybintsev
- Central State Medical Academy of the President of the Russian Federation, Moscow, Russia
| | - K M Markelov
- Central State Medical Academy of the President of the Russian Federation, Moscow, Russia
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Cancer-related malnutrition management: A survey among Italian Oncology Units and Patients’ Associations. Curr Probl Cancer 2020; 44:100554. [DOI: 10.1016/j.currproblcancer.2020.100554] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/24/2019] [Accepted: 01/15/2020] [Indexed: 12/14/2022]
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Lorenzon L, Brandl A, Guiral DC, Hoogwater F, Lundon D, Marano L, Montagna G, Polom K, Primavesi F, Schrage Y, Gonzalez-Moreno S, Kovacs T, D'Ugo D, Sandrucci S. Nutritional assessment in surgical oncology: An ESSO-EYSAC global survey. Eur J Surg Oncol 2020; 46:2074-2082. [PMID: 32938568 DOI: 10.1016/j.ejso.2020.08.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/21/2020] [Accepted: 08/28/2020] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION The majority of cancer patients report malnutrition, with a significant impact on patient's outcome. This study aimed to compare how nutritional assessment is conducted across different surgical oncology sub-specialties. METHODS Survey modules were designed for breast, hepato-pancreato-biliary (HPB), upper-gastrointestinal (UGI), sarcoma, peritoneal and surface malignancies (PSM) and colorectal cancer (CRC) surgeries to describe 4 domains: participants' setting, evaluation of clinical factors, use of screening tools and clinical practice. Results were compared among sub-specialties and according to human development index (HDI) in the largest cohorts. RESULTS Out of 457 answers from 377 global participants (62% European), 35.0% were from breast and 28.9% were from CRC surgeons. Although MDTs management is consistently reported (64-88%), the presence of a nutritionist/dietician ranges from 14.1% to 44.2%. Breast surgeons seldom evaluate albumin (25.6%) and weight loss (30.6%), opposite to HPB, PSM and UGI groups (>70%, p 0.044). Overall, responders declared that the use of screening tools is largely neglected, that nutritional status is often assessed by the surgeons and that nutrition is not consistently modified according to risk factors (range among groups respectively: 1.9%-25.6%, 33.1%-51.4%, 33.1%-60.5%). Less than 20% of breast surgeons assess patients before/after surgery, comparing to >60% of PSM surgeons. However, no statistical differences were documented comparing groups for the majority of the items of the 4 domains. Nutritional evaluation is more often conducted by breast surgeons in medium/low HDI countries comparing very high/high HDI (p 0.04). CONCLUSIONS Nutritional assessment is largely neglected. These results identify target-issues for the implementation of clinical practice.
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Affiliation(s)
- Laura Lorenzon
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy.
| | - Andreas Brandl
- Champalimaud Centre for the Unknown, Digestive Unit, Lisbon, Portugal
| | - Delia Cortes Guiral
- Universitary Hospital Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Frederik Hoogwater
- University Medical Center, Department of Surgery, Groningen, Netherlands
| | - Dara Lundon
- The Conway Institute, University College Dublin, Dublin, Ireland
| | - Luigi Marano
- University of Siena, Department of Medicine, Surgery, and Neurosciences, Siena, Italy
| | - Giacomo Montagna
- Universitätsspital Basel Switzerland, Department of Surgery, Basel, Switzerland
| | - Karol Polom
- Medical University of Gdansk, Department of Surgical Oncology, Gdansk, Poland
| | - Florian Primavesi
- Medical University of Innsbruck, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck, Austria
| | - Yvonne Schrage
- Leiden University Medical Center, Department of Surgery, Leiden, Netherlands
| | | | - Tibor Kovacs
- Breast Surgery Unit, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Domenico D'Ugo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
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Evaluation of malnutrition via modified GLIM criteria for in patients undergoing emergent gastrointestinal surgery. Clin Nutr 2020; 40:1367-1375. [PMID: 32938549 DOI: 10.1016/j.clnu.2020.08.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/13/2020] [Accepted: 08/19/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Malnutrition remains a critical public health issue in the US, particularly in surgery where perioperative malnutrition is commonly underdiagnosed and undertreated. In 2016, the Global Leadership Initiative on Malnutrition (GLIM) proposed a set of consensus criteria for the diagnosis of malnutrition. Our project aims to assess the post-operative outcomes of patients meeting a modified GLIM-defined (mGLIM) malnutrition criteria undergoing emergent gastrointestinal surgery (EGS) in the NSQIP database. Current GLIM-criteria were modified with addition of admission albumin (a NSQIP-defined malnutrition variable). METHODS Adapting NSQIP data, mGLIM criteria are (1) BMI of ≤20 for age ≤ 70 and BMI ≤22 for age ≥ 71, (2) weight loss > 10% within the past 6 months, (3) admission albumin ≤ 3.5, and (4) emergent bowel surgery as etiologic criteria of acute disease/injury. All patients undergoing emergent small bowel, colon, and rectal procedures were extracted from the NSQIP database and included in the study. Multivariate linear and logistic regression models controlling for relevant covariates were developed to evaluate mGLIM criteria on length of stay (LOS), mortality, and overall complication rates. RESULTS We included 31,029 patients who underwent emergent bowel surgeries from years 2011-2016. Demographically, 53.6% (n = 16,622) were female, 13.0% (n = 4023) were African American, and 78.3% (n = 24,292) were Caucasian. Case composition included 71.5% colon operations, 28.0% small bowel, and 0.5% rectal cases. Overall, 1.7% (n = 517) had data necessary to qualify as malnourished as per mGLIM. Controlling for covariates, multivariate linear and logistic regression analyses show that these patients have significantly higher mortality for both colon (p < 0.001, CI 1.55 | 2.61) and small bowel (p = 0.022, CI 1.08 | 2.67) procedures, longer LOS for colon (p < 0.001, CI 1.93 | 4.33) operations, and higher post-operative complications for both colon (p < 0.001, CI 1.61 | 2.62) and small bowel (p < 0.001, CI 1.57 | 3.37) cases. CONCLUSION This analysis shows that mGLIM criteria malnutrition is associated with poor clinical outcomes following EGS affecting LOS and mortality. Our data indicates the new mGLIM criteria can be a powerful and simple predictive score for malnutrition that can be used to predict malnutrition-related risk of poor outcomes after EGS.
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Troesch B, Eggersdorfer M, Laviano A, Rolland Y, Smith AD, Warnke I, Weimann A, Calder PC. Expert Opinion on Benefits of Long-Chain Omega-3 Fatty Acids (DHA and EPA) in Aging and Clinical Nutrition. Nutrients 2020; 12:E2555. [PMID: 32846900 PMCID: PMC7551800 DOI: 10.3390/nu12092555] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 12/13/2022] Open
Abstract
Life expectancy is increasing and so is the prevalence of age-related non-communicable diseases (NCDs). Consequently, older people and patients present with multi-morbidities and more complex needs, putting significant pressure on healthcare systems. Effective nutrition interventions could be an important tool to address patient needs, improve clinical outcomes and reduce healthcare costs. Inflammation plays a central role in NCDs, so targeting it is relevant to disease prevention and treatment. The long-chain omega-3 polyunsaturated fatty acids (omega-3 LCPUFAs) docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are known to reduce inflammation and promote its resolution, suggesting a beneficial role in various therapeutic areas. An expert group reviewed the data on omega-3 LCPUFAs in specific patient populations and medical conditions. Evidence for benefits in cognitive health, age- and disease-related decline in muscle mass, cancer treatment, surgical patients and critical illness was identified. Use of DHA and EPA in some conditions is already included in some relevant guidelines. However, it is important to note that data on the effects of omega-3 LCPUFAs are still inconsistent in many areas (e.g., cognitive decline) due to a range of factors that vary amongst the trials performed to date; these factors include dose, timing and duration; baseline omega-3 LCPUFA status; and intake of other nutrients. Well-designed intervention studies are required to optimize the effects of DHA and EPA in specific patient populations and to develop more personalized strategies for their use.
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Affiliation(s)
- Barbara Troesch
- Nutrition Science and Advocacy, DSM Nutritional Products, 4303 Kaiseraugst, Switzerland; (B.T.); (I.W.)
| | - Manfred Eggersdorfer
- Department of Internal Medicine, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands;
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, 00185 Rome, Italy;
| | - Yves Rolland
- Gérontopôle de Toulouse, Institut du Vieillissement, INSERM 1027, Centre Hospitalo-Universitaire de Toulouse, 31300 Toulouse, France;
| | - A. David Smith
- Department of Pharmacology, University of Oxford, Oxford OX1 2JD, UK;
| | - Ines Warnke
- Nutrition Science and Advocacy, DSM Nutritional Products, 4303 Kaiseraugst, Switzerland; (B.T.); (I.W.)
| | - Arved Weimann
- Clinic for General, Visceral and Oncological Surgery, St. Georg gGmbH Clinic, 04129 Leipzig, Germany;
| | - Philip C. Calder
- Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton SO16 6YD, UK
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Haider S, Wood K, Bui A, Leitman IM. Racial Disparities in Outcomes After Common Abdominal Surgical Procedures-The Impact of Access to a Minimally Invasive Approach. J Surg Res 2020; 257:85-91. [PMID: 32818788 DOI: 10.1016/j.jss.2020.07.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/15/2020] [Accepted: 07/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND It is presently considered the standard of care to perform many routine intra-abdominal operations using a minimally invasive approach. The authors recently identified a racial disparity in access to a laparoscopic approach to inguinal hernia repair, cholecystectomy, appendectomy, and colectomy. The present study further evaluates this patient cohort to assess the relationship between the race and postoperative complications and test the mediating effect of the selected surgical approach. METHODS After institutional review board approval, patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent inguinal hernia repair, cholecystectomy, appendectomy, or colectomy in 2016 were identified. Patient demographics, including the self-reported race and ethnicity, as well as clinical, operative, and postoperative variables were recorded. After the exclusion of cases associated with diagnoses of cancer, a 4:1 propensity score matching algorithm generated a clinically balanced cohort of patients of white and black self-reported race. The mediating effect of an open approach to surgery on the relationship between black self-reported race and postoperative complications was evaluated via a series of regressions. RESULTS There were 41,340 unilateral inguinal hernia repairs, 3182 bilateral inguinal hernia repairs, 60,444 cholecystectomies, 50,523 appendectomies, and 58,012 colectomies included in the database in 2017. Exclusion of cases associated with cancer and subsequent propensity score matching returned 17,540 unilateral hernia repairs, 890 bilateral hernia repairs, 23,865 cholecystectomies, 11,660 appendectomies, and 12,320 colectomies. On mediation analysis, any complication, severe complication, and death were significant when regressed on black self-reported race (any: odds ratio [OR] = 1.210, 95% confidence interval [CI] = 1.132-1.291, P < 0.001; severe: OR = 1.352, 95% CI = 1.245-1.466, P < 0.001; death: OR = 1.358, 95% CI = 1.000-1.818, P = 0.044), and open surgery was a significant mediator in the incidence of any complication and severe complication (any: OR = 1.180, 95% CI = 1.105-1.260, P < 0.001 and severe: OR = 1.307, 95% CI = 1.203-1.418, P < 0.001). CONCLUSIONS These findings underscore the importance of access to a minimally invasive approach to surgery. However, other factors may contribute to racial disparities in postoperative complications after common abdominal operations.
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Affiliation(s)
- Syed Haider
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Kasey Wood
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Anthony Bui
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
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Causes of nutrition deficit during immediate postoperative period after free flap surgery for cancer of the head and neck. Eur Arch Otorhinolaryngol 2020; 278:1171-1178. [PMID: 32666293 PMCID: PMC7954733 DOI: 10.1007/s00405-020-06206-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/08/2020] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of the present of study was to examine nutrition deficit during the immediate postoperative in-hospital period following free flap surgery for cancer of the head and neck (HNC). Underfeeding and malnutrition are known to be associated with impaired short- and long-time recovery after major surgery. METHODS This single-center retrospective cohort study included 218 HNC patients who underwent free flap surgery in Oulu University Hospital, Finland between the years 2008 and 2018. Nutrition delivery methods, the adequacy of nutrition and complication rates were evaluated during the first 10 postoperative days. RESULTS A total of 131 (60.1%) patients reached nutritional adequacy of 60% of calculated individual demand during the follow-up period. According to multivariate analysis, nutrition inadequacy was associated with higher ideal body weight (OR 1.11 [1.04-1.20]), whereas adequate nutrition was associated with higher number of days with oral food intake (OR 0.79 [0.67-0.93]). CONCLUSION Inadequate nutrition is common after HNC free flap surgery. The present results suggest that more adequate nutrition delivery might be obtained by the early initiation of oral food intake and close monitoring of nutrition support.
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Williams DGA, Ohnuma T, Krishnamoorthy V, Raghunathan K, Sulo S, Cassady BA, Hegazi R, Wischmeyer PE. Postoperative Utilization of Oral Nutrition Supplements in Surgical Patients in US Hospitals. JPEN J Parenter Enteral Nutr 2020; 45:596-606. [DOI: 10.1002/jpen.1862] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/29/2020] [Indexed: 12/11/2022]
Affiliation(s)
- David G. A. Williams
- CAPER Unit Department of Anesthesiology Duke University School of Medicine Durham North Carolina USA
- Duke Clinical Research Institute Durham North Carolina USA
| | - Tetsu Ohnuma
- CAPER Unit Department of Anesthesiology Duke University School of Medicine Durham North Carolina USA
| | - Vijay Krishnamoorthy
- CAPER Unit Department of Anesthesiology Duke University School of Medicine Durham North Carolina USA
| | - Karthik Raghunathan
- CAPER Unit Department of Anesthesiology Duke University School of Medicine Durham North Carolina USA
| | | | | | - Refaat Hegazi
- Abbott Nutrition Columbus Ohio USA
- Faculty of Medicine Mansoura University Mansoura Egypt
| | - Paul E. Wischmeyer
- CAPER Unit Department of Anesthesiology Duke University School of Medicine Durham North Carolina USA
- Duke Clinical Research Institute Durham North Carolina USA
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Deftereos I, Yeung JMC, Carter VM, Isenring E, Kiss NK. Nutritional Outcomes of patients Undergoing Resection for upper gastroIntestinal cancer in AuStralian Hospitals (NOURISH): protocol for a multicentre point prevalence study. BMJ Open 2020; 10:e035824. [PMID: 32385064 PMCID: PMC7228529 DOI: 10.1136/bmjopen-2019-035824] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Nutritional intervention and prevention of malnutrition is significantly important for patients with upper gastrointestinal oesophageal, pancreatic and gastric cancer. However, there is limited information regarding nutritional status, and perioperative nutritional interventions that patients receive when undergoing curative surgery. METHODS AND ANALYSIS Patients diagnosed with upper gastrointestinal cancer, planned for curative intent resection across 27 Australian hospitals will be eligible to participate in this point prevalence study. The primary aim is to determine the prevalence of malnutrition in patients with upper gastrointestinal cancer at the time of surgery using subjective global assessment. Secondary aims are to determine the type and frequency of perioperative nutritional intervention received, the prevalence of clinically important weight loss and low muscle strength, and to investigate associations between the use of an evidence-based nutrition care pathway or protocol for the nutritional management of upper gastrointestinal surgical oncology patients and malnutrition prevalence. Data collection will be completed using a purpose-built data collection tool. ETHICS AND DISSEMINATION Ethical approval was granted in May 2019 (LNR/51107/PMCC-2019). The design and reporting of this study comply with the Strengthening the Reporting of Observational Studies in Epidemiology checklist for reporting of observational cohort studies. Findings will be published in peer-reviewed scholarly journals and presented at relevant conferences. Results will assist in defining priority areas for research to improve patient outcomes.
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Affiliation(s)
- Irene Deftereos
- Department of Surgery Western Health, The University of Melbourne, Melbourne, Victoria, Australia
- Nutrition and Dietetics, Western Health, Footscray, Victoria, Australia
| | - Justin M C Yeung
- Department of Surgery Western Health, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Colorectal Surgery, Western Health, Footscray, Victoria, Australia
- Western Chronic Disease Alliance, Western Health, Melbourne, Victoria, Australia
| | - Vanessa M Carter
- Nutrition and Dietetics, Western Health, Footscray, Victoria, Australia
| | - Elizabeth Isenring
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Nicole K Kiss
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, Victoria, Australia
- Department of Cancer Experiences Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Saad M, Le Clec'h B, Dhonneur G. Hypoalbuminemia-Related Prolonged Sedation After General Anesthesia: A Case Report. A A Pract 2020; 14:e01180. [PMID: 32224688 DOI: 10.1213/xaa.0000000000001180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 69-year-old man underwent total laryngopharyngectomy with radial forearm free flap reconstruction. He had lost 15 kg over a period of 6 months and did not receive any preoperative nutritional workup or management. The patient had a general total intravenous anesthetic with ketamine, lidocaine, and propofol, which was uneventful for an 8-hour surgery. The patient remained deeply sedated for 4 hours after discontinuation of all sedative medications. Diagnostic workup only revealed hypoalbuminemia and hypoproteinemia. We hypothesized relative overdosage of sedative anesthetic drugs due to preoperative malnutrition accentuated by intraoperative fluid administration.
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Affiliation(s)
- Mary Saad
- From the Department of Anesthesia, Institut Curie, Saint-Cloud, France
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