S3-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) in Zusammenarbeit mit der GESKES, der AKE, der DGCH, der DGAI und der DGAV

International study on the prevalence of malnutrition in centralized care for colorectal cancer patients

Objectives

Patients with different diseases may show signs of malnutrition both before and during the hospital stay. The presence of malnutrition may impact the recovery and length of stay and consequently the costs. Early identification of malnutrition is thus a critical factor. The objective of this multicenter study is to determine the prevalence of malnutrition in colorectal cancer centers. Another objective is to investigate possible consequences, such as complications or length of stay. In addition, the study aims to demonstrate the relevance of nutrition management in colorectal cancer centers. At the same time, relevant requirements clearly demanded by the Certification Commission for Certified Colorectal Cancer Centers are met through implementation of the study.

Methods

Between 2019 and 2021, patients in colorectal cancer centers were examined in the preoperative phase. In addition to questions about patients' state of health and nutrition, the validated screening forms-Subjective Global Assessment (SGA) and Nutritional Risk Screening Tool 2002 (NRS 2002)-were used to assess malnutrition. The data were processed by univariate analysis.

Results

In total, data records of 3,102 patients were evaluated. The mean age of the participants was 68.5 ± 11.9 years, and their average body mass index (BMI) was 26.8 ± 5.3 kg/m2. The SGA questionnaire indicated that 23 % of the participants suffered from malnutrition and 38 % were at risk of malnutrition (NRS≥3). Malnutrition was found more frequently in patients with colorectal carcinomas than in patients with rectal carcinomas (53.1 vs. 32.1 %). The length of stay in hospital and the rate of complications were significantly higher when malnutrition was identified.

Conclusions

Approximately one in three to four patients with a colorectal carcinoma has an increased risk of malnutrition. The two screening methods calculated a different prevalence (23 and 38 %). Any malnutrition that is present demonstrably has a significant impact both on the rate of complications and the length of stay and may therefore have a decisive influence on the costs. The results of this multicenter study underscore the need for systematic screening for malnutrition and at the same time should increase clinics awareness of the importance of establishing a nutrition management policy.

Prehabilitation in elective surgical interventions - what must the general and abdominal surgeon know

Objectives

For years, many efforts have been invested to prepare patients, in particular, those with reduced physical and psychic status, much better to provide and finally achieve better outocme if there is time available to provide several beneficial measures.

Methods

Therefore, the objective was to illustrate the concept and various single elements of a complex prehabilitation concept based on (i) selective references from the medical literature and (ii) own clinical experiences from clinical practice in general and abdominal surgery.

Results

Prehabiliation can be considered the solution of the efforts to improve preoperative status for patients in a disadvantageous status for almost all types of surgery and all other operative and/or interventional procedures. It is the targeted process to improve individual functionality and organ function before a planned (elective) surgical intervention; P. comprises basically nutritional, physical and psychological measures; P. focusses especially onto the elderly, frail and malnourished patients before a planned surgical intervention; the overall aim is to significantly improve final outcome characterized by shorter length of stay, lower complication rate and mortality as well as cost efficiency; P. is especially important in cancer surgery, in which the beneficial effects can be particularly implemented; P. programs and/or "Standard Operating Protocols" (SOP) may help to establish and materialize its single aspects and enhanced recovery after surgery (ERAS). There is still further potential to reliably establish and to utilize the options of prehabilitation measures as listed above.

Conclusions

Prehabiliation is an indispensable aspect in today's preparation for elective surgery, which needs to become obligatory part of the preparation measures to planned surgical interventions, which can further contribute to a better final outcome and ERAS as well as, in addtion, needs to be further developed and accomplished.

Präoperatives Ernährungsmanagement in der großen Tumorchirurgie des Bauchraumes an deutschen Kliniken. Eine explorative Strukturanalyse

Bis zu 80% der PatientInnen vor Tumorresektionen des oberen Gastrointestinaltrakts sind mangelernährt. Dabei hat schon der präoperative Ernährungszustand einen signifikanten Einfluss auf den perioperativen Verlauf. Ein adäquater präoperativer Ernährungszustand, der unter anderem die Komplikationsrate und die Krankenhausliegedauer reduzieren kann, ist daher erstrebenswert. Zwar empfehlen einschlägige Leitlinien Maßnahmen zur Erkennung und Behandlung einer Mangelernährung, jedoch fehlt es bislang an Vorschlägen zur Planung eines strukturieren präoperativen Ernährungsmanagements auf die BehandlerInnen zurückgreifen können. Innerhalb dieser Arbeit wurden 40 Krankenhäuser in Deutschland deshalb zu individuell vorhandenen Strukturen und Maßnahmen zum präoperativen Ernährungsmanagement von PatientInnen vor Tumorresektionen des oberen Gastrointestinaltrakts befragt. Die Befragungen zeigen, dass Maßnahmen zur Erkennung und Therapie einer präoperativen Mangelernährung mehrheitlich bekannt und akzeptiert sind. So befürworten 35 der 40 TeilnehmerInnen eine präoperative Ernährungstherapie bei mangelernährten PatientInnen, 26 TeilnehmerInnen erwägen hierfür sogar einen Aufschub der Operation. Eine flächendeckende Umsetzung an den Kliniken scheitere jedoch häufig an Hinderungsgründen, wie fehlender Sichtbarkeit der Ernährung als Therapiebaustein unter BehandlerInnen, labilen Verantwortlichkeiten sowie unzureichenden finanziellen und personellen Ressourcen. Mögliche Lösungsvorschläge zum Abbau der Hindernisse reichen von Refinanzierungsmöglichkeiten der klinischen Ernährungstherapie bis hin zu Forderungen auf gesundheitspolitischer Ebene. Aus den Erkenntnissen aktueller Studien und Leitlinien, sowie den Ergebnissen der Befragung, unterbreitet diese Arbeit einen Vorschlag zur Implementierung eines präoperativen Ernährungsmanagements. Dessen Umsetzbarkeit im klinischen Alltag sollte dabei durch wissenschaftliche Verfahren begleitet werden.

Bilanzierte Diäten – Schlüsselfragen für die Verkehrsfähigkeit: Definition von Diätmanagement und wissenschaftlicher Beleg der Zweckbestimmung

Lebensmittel für besondere medizinische Zwecke (bilanzierte Diät) werden für die Ernährung von Patienten entwickelt und sind für das Diätmanagement bei einer Erkrankung/Beschwerde/Störung bestimmt. Über die Verkehrsfähigkeit dieser Lebensmittelkategorie, vor allem der Untergruppe der bilanzierten Diäten, die nicht zur ausschließlichen Ernährung gedacht sind (sogenannte ergänzende bilanzierte Diäten), wird seit einigen Jahren kontrovers diskutiert. Dabei geht es vorrangig um die Frage, was unter den Begriffen „Diätmanagement“ sowie „sonstiger medizinisch bedingter Nährstoffbedarf“ zu verstehen ist. Aufgrund des Fehlens klarer Definitionen in den EU-weit gültigen Regularien ist aus sachverständiger Sicht der Begriff „Diätmanagement“ synonym mit „diätetische Behandlung“ bzw. „Ernährungsintervention“ zu sehen. Das Diätmanagement dient dazu, den besonderen Anforderungen gerecht zu werden, die bei den betroffenen Patienten an die Ernährung bzw. an bestimmte Nährstoffe gestellt werden. Angelehnt an Empfehlungen in medizinischen Leitlinien ist darunter eine individualisierte, definierte und gezielte Ernährungsmaßnahme mithilfe herkömmlicher oder künstlicher Ernährung zu verstehen. Ziel des Diätmanagements ist es, ein Nährstoffdefizit zu beheben/vorzubeugen oder eine (durch die Krankheit beeinträchtigte) Körperfunktion mit Hilfe von Nährstoffen aufrechtzuerhalten/zu verbessern. Wesentlich für diese spezielle Produktkategorie ist die notwendige Begründung der diätetischen Zweckbestimmung gemäß allgemein anerkannten wissenschaftlicher Daten. Die Ausgestaltung dieses Beleges liegt in der Verantwortung des Inverkehrbringers, die Entscheidung über die Verkehrsfähigkeit und die Eignung der Daten zur wissenschaftlichen Absicherung erfolgt durch die Überwachungsbehörden der einzelnen Bundesländer. Es ist empfehlenswert, sich bereits bei der Produktentwicklung mit den Anforderungen vertraut zu machen und im Vorfeld ein Dossier zu erstellen, das sich an den Leitlinien der EFSA orientiert.

[Patient optimization before hip revision arthroplasty: : How to handle comorbidities]

Preoperative optimization of the therapeutic regime of comorbidities can lead to an improvement of the postoperative outcome and has the potential to reduce the financial burden on the health care system in revision hip arthroplasty. Patient-related factors and an increasing incidence of comorbidities lead to a higher risk of implant failure and revision for all causes. Important and potentially modifiable risk factors like preoperative anemia, coagulopathy, infectious disease (dental status, urinary tract infections, colonization with staphylococcus), metabolic conditions (obesity, malnutrition, diabetes mellitus, osteoporosis), and smoking need to be addressed. To achieve an optimal preoperative condition a multidisciplinary approach should be applied.

Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery

Aim

This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM).

Methods

With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given.

Results

An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimization of concurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications.

Conclusion

Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.

[Development and Implementation of a Nutrition Medicine Strategy to optimize Medical Service for Malnourished Patients at a Tertiary Referral Centre]

BACKGROUND

Malnutrition in hospitalised patients is an important and underestimated problem, with a negative impact on outcome and survival - not only in surgical patients. There is a discrepancy between optimal treatment as defined in relevant guidelines on clinical nutrition and the clinical reality. The Main reason for this discrepancy is the lack of established structures for nutrition medicine as an integral part of clinical routines. The necessary structural development is impaired mainly by the lack of resources, but in isolated cases also by the lack of appreciation of the problem. Therefore, practicability and feasibility with regard to local conditions are pivotal for sustainable improvement in a nutrition strategy in hospitalised patients.

METHODS

We describe the institutional and procedural measures taken at a tertiary referral centre to implement a nutrition medicine strategy. The underlying nutrition medicine methodology and definitions are introduced and practical implementation at our centre is illustrated by four examples of ongoing projects.

RESULTS

Using the described systematics, structural changes were implemented at our centre within one year that allowed malnutrition screening, the treatment of patients with complex nutritional care and improvements in the nutritive status of hospitalised patients by ongoing and future project initiatives.

SUMMARY

The successfully implemented structural change at the University Hospital of Bonn described here may serve as a modular example for other hospitals striving to improve clinical nutrition and outcome in hospitalised patients.

Anaesthesia for the elderly: a narrative review

As octogenarians in the operation room are no longer an exemption but the norm, perioperative management needs to be adopted to meet the special requirements of this group of patients. Anaesthesia does not need to be re-invented to fit the elderly. However, as elderly patients are among those most affected by adverse postoperative outcomes, the same diligence that is as a matter of course exercised in anaesthesiologic care of the youngest patients needs to be exercised for the eldest as well. Aging is associated with characteristic physiologic changes and an overall reduction in compensation width. However, the individual relevance of these changes varies distinctly. A comprehensive preoperative assessment is therefore essential to identify those at high risk. Maintaining functionality and preventing cognitive decline are central elements of perioperative care for frail elders, often only requiring unspectacular, but effective adjustments to established routine care processes. This review focuses on current recommendations in the perioperative anaesthesiologic management of elderly patients with a view towards assisting clinical anaesthesiologists in implementing respective structures in their setting and adjusting care pathways to meet the needs of this vulnerable but growing group of patients and improve their postoperative outcome.

Effects of therapy modifications during the last decade on the outcome of patients undergoing esophagectomy for esophageal cancer

BACKGROUND

During the last decade, numerous therapeutic regimes were assessed to improve the outcome of patients with esophageal carcinoma. We analyzed the impact of therapy alterations, including the establishment of a standardized clinical pathway and the introduction of an interdisciplinary tumor conference on the outcome of patients undergoing esophagectomy because of esophageal cancer.

METHODS

Three hundred one patients were included (204 adenocarcinoma and 97 squamous cell carcinoma) who underwent an esophagectomy between 2006 and 2015. Patients were divided into 3 groups: interval A (2006-2008), interval B (2009-2011) and interval C (2012-2015) and evaluated separately focusing on therapy management and patients' outcome.

RESULTS

Over the time periods, the incidence of tumor entity of adenocarcinoma increased from 61% to 76.2% (P=0.059). Patients with an initial tumor stage uT1 increased significantly from 4% to 15.9% over the intervals (P=0.002), while positive nodal involvement remained comparable (P=0.237). Patients in the later interval suffered from greater physical impairments preoperatively, represented by a significantly increased American Society Anesthesiologists (ASA) score (P=0.023) and a reduced Karnofsky Index (P<0.001). The tumor conference was accompanied by an increasing implementation of neoadjuvant therapy (27.1% vs. 42.2%, P=0.097). After establishing the clinical pathway 30-day mortality decreased (P=0.67). Grad III anastomotic leakage decreased significantly from 6.5% to 2% (P=0.01). However, gastrointestinal (P=0.007), pulmonary complications (P<0.001) including pneumonia (P<0.001) increased. Over the past ten years both overall survival and relapse-free survival prolonged (P=0.056 and P=0.063, respectively).

CONCLUSIONS

Patients' collective suffering from esophageal cancer has changed over the last decade. Continuous further developments of the therapy regimes are needed to meet the requirements of reducing perioperative mortality and extending survival time.

[Medical nutrition therapy in intensive care medicine : Summary of the updated DGEM guideline]

The course of a critical illness is divided into several phases (early and late acute phase, post-acute phase) in which different metabolic processes take place. Accordingly, the medical nutrition therapy needs to be adapted to the patient's metabolic tolerance in each phase. When indicated, it should be started within 24 h. If oral administration is not possible, an enteral diet should be used. In individuals with contraindications, parenteral nutrition should be started. The target values for the diet of nonobese patients in the late acute phase are 24 kcal and 1.0 g protein (or 1.2 g amino acid) per kilogram bodyweight. The individual metabolic tolerance can be estimated based on the extent of insulin resistance and serum phosphate levels, and the nutrition therapy is adjusted accordingly.

[Enhanced recovery after surgery-a concept, also in pediatrics]

Enhanced recovery after surgery (ERAS) protocols are widely established in adult urology, especially for cystectomies and procedures involving the (small) bowel. However, data concerning pediatric surgery and pediatric urologic surgery are scarce. Individual items of ERAS protocols have been well-studied and significant benefits have also been shown for children without increased risk of complications. In a number of small series the safety and efficacy of implementing ERAS protocols have been reported recently. A broad consensus and a guideline for a common pediatric ERAS protocol is not yet available.

Prognostic Factors Influencing Infectious Complications after Cytoreductive Surgery and HIPEC: Results from a Tertiary Referral Center

Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) showed promising results in selected patients. High morbidity restrains its wide application. The aim of this study was to report postoperative infectious complications and investigate possible correlations with the preoperative nutritional status and other prognostic factors in patients with peritoneal metastases treated with CRS and HIPEC.

Methods

For the study, we reviewed the clinical records of all patients with peritoneal metastases from different primary cancers treated with CRS and HIPEC in our Institution from November 2000 to December 2017. Patients were divided according to their nutritional status (SGA) into groups A (well-nourished) and B/C (mild or severely malnourished, respectively). Possible statistical correlations between risk factors and postoperative complication rates have been investigated by univariate and multivariate analysis.

Results

Two hundred patients were selected and underwent CRS and HIPEC during the study period. Postoperative complications occurred in 44% of the patients, 35.3% in SGA-A patients, and 53% in SGA-B/C patients. Cause of complications was infective in 42, noninfective in 37, and HIPEC related in 9 patients. Infectious complications occurred more frequently in SGA-B/C patients (32.6% vs. 9.8% of SGA-A patients). The most frequent sites of infection were surgical site infections (SSI, 35.7%) and central line-associated bloodstream infections (CLABSI, 26.2%). The most frequent isolated species was Candida (22.8%). ASA score, blood loss, performance status, PCI, large bowel resection, postoperative serum albumin levels, and nutritional status correlated with higher risk for postoperative infectious complications.

Conclusions

Malnourished patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are more prone to postoperative infectious complications, and adequate perioperative nutritional support should be considered, including immune-enhancing nutrition. Sequential monitoring of common sites of infection, antifungal prevention of candidiasis, and careful patient selection should be implemented to reduce the complication rate.

The Perioperative Care of Older Patients

BACKGROUND

Elderly patients are a growing and vulnerable group with an elevated perioperative risk. Perioperative treatment pathways that take these patients' special risks and requirements into account are often not implemented in routine clinical practice.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, the AWMF guideline database, and the Cochrane database for guidelines from Germany and abroad, meta-analyses, and Cochrane reviews.

RESULTS

The care of elderly patients who need surgery calls for an interdisciplinary, interprofessional treatment concept. One component of this concept is preoperative preparation of the patient ("prehabilitation"), which is best initiated before hospital admission, e.g., correction of deficiency states, optimization of chronic drug treatment, and respiratory training. Another important component consists of pre-, intra-, and postoperative measures to prevent delirium, which can lower the frequency of this complication by 30-50%: these include orientation aids, avoidance of inappropriate drugs for elderly patients, adequate analgesia, early mobilization, short fasting times, and a perioperative nutrition plan. Preexisting cognitive impairment predisposes to postoperative delirium (odds ratios [OR] ranging from 2.5 to 4.5). Frailty is the most important predictor of the postoperative course (OR: 2.6-11). It follows that preoperative assessment of the patient's functional and cognitive status is essential.

CONCLUZION

The evidence-based and guideline-consistent care of elderly patients requires not only close interdisciplinary, interprofessional, and cross-sectoral collaboration, but also the restructuring and optimization of habitual procedural pathways in the hospital. Elderly patients' special needs can only be met by a treatment concept in which the entire perioperative phase is considered as a single, coherent process.