Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period

Nutritional care in patients undergoing laparoscopic/minimally invasive surgeries for gastrointestinal tumours

The introduction of minimally invasive surgeries for gastrointestinal tumours has been associated with many favourable postoperative outcomes and a reduced impact on nutritional status. The literature review begins by discussing the impact of minimally invasive procedures on the nutritional status of patients with gastrointestinal tumours, followed by indications for enteral nutrition (EN) in this population, including preoperative nutritional support and postoperative nutritional support. The review then examines the evidence that favours the use of EN in this population, including studies demonstrating improved outcomes with preoperative EN and reduced postoperative complications with postoperative EN. It also discusses potential strategies for improving outcomes with EN, such as early initiation of feeding and individualized nutrition plans. Overall, current evidence shows that EN improves outcomes, reduces complications, and enhances the quality of life. However, the optimal timing, composition of EN, and long-term outcomes are still unclear, indicating the need for future investigations.

Actuation technologies for magnetically guided catheters

Due to their wide range of clinical application possibilities, magnetic actuation technologies have grabbed the attention of researchers worldwide. The design, execution, and analysis of magnetic catheter systems have advanced significantly during the last decade. The review focuses on magnetic actuation for catheter steering and control of the device, which will be explored in detail in the following sections. There is a discussion of future work and the challenges of the review systems, and the conclusions are finally addressed.

Magnetically steerable catheters: State of the art review

Magnetically steerable catheters (MSCs) have caught the interest of researchers due to their various potential uses in clinical applications, for example, minimally invasive surgery. Many significant advances in the design, implementation and analysis of MSCs have been accomplished in the last decade. This review concentrates on the configurations of current MSCs with an in depth look at control of the device and the specific workspace. This review also evaluates MSCs and references possible future system designs and difficulties. The concept of magnetic manipulation is briefly presented. Then, by category, the MSC is introduced. Following that, a discussion of future works and challenges of the review systems is provided. The conclusions are finally addressed.

ESPEN Guidelines on Clinical nutrition in surgery - Special issues to be revisited

The ESPEN Guidelines on Clinical nutrition in Surgery from 2017 has been also available as practical guideline with algorithms since 2021 (www.espen.org). An update will be perfomed in the near future. This review focuses on recent data with regard to special issues and topics to be revisited in the guidelines: These are nutritional assessment, sarcopenic obesity, prehabilitation, oral/enteral immunonutrition, postoperative oral supplementation in hospital and after discharge.

Postoperative Nutrition Management: Who Needs What?

Background

Early oral feeding after major abdominal surgery has been clearly shown to be safe and not a risk factor for anastomotic dehiscence. Within the Enhanced Recovery after Surgery protocol, it is the nutritional plan A. Nonetheless, one must consider that postoperative protein and energy requirements will often be not covered by oral food intake alone. Because nutritional status has been shown to be a prognostic factor in patients undergoing major abdominal surgery, the preoperative identification of patients at risk may be mandatory. Malnutrition may be underestimated in an overweight society. With special regard to patients with cancer and those with preexisting malnutrition, an accumulating caloric gap may be harmful in the early and late postoperative periods. Furthermore, complications requiring reoperation and intensive care treatment may occur.

Summary

Therefore, a plan B for postoperative nutrition therapy is needed, using preferentially the enteral route. The European Society for Clinical Nutrition and Metabolism recently addressed perioperative nutritional management and the indications for enteral and even parenteral supplementation to achieve caloric requirements in the postoperative course. In the first months after surgery, persisting weight loss is common in patients with upper gastrointestinal resections, even in those with an uncomplicated course. This may delay the initiation of adjuvant chemotherapy, increase toxicity, and worsen long-term outcomes.

Unresolved issues in perioperative nutrition: A narrative review

Surgical patients are at an increased risk of negative outcomes if they are malnourished or at risk of malnutrition preoperatively. Optimisation of nutritional status should be a focus throughout the perioperative continuum to promote improved surgical outcomes. Enhanced Recovery after Surgery (ERAS) protocols are increasingly applied in the surgical setting but are not yet widespread. This narrative review focused on areas of perioperative nutrition that are perceived as controversial or are lacking in agreement. A search for available literature was conducted on 1 March 2022 and relevant high-quality articles published since 2015 were considered for inclusion. Most malnutrition screening tools are not specific to the surgical population except for the Perioperative Nutrition Screen (PONS) although more large-scale initiatives are needed to improve the prevalence of preoperative nutrition screening. Poor muscle health is common in patients with malnutrition and further exacerbates negative health outcomes indicating that prevention, detection and treatment is of high importance in this population. Although a lack of consensus remains for who should receive preoperative nutritional therapy, evidence suggests a positive impact on muscle health. Additionally, postoperative nutritional support benefits surgical outcomes, with some patients requiring enteral and/or parenteral feeding routes and showing benefit from immunonutrition. The importance of nutrition extends beyond the time in hospital and should remain a priority post-discharge. The impact of individual or personalised nutrition based on select patient characteristics remains to be further investigated. Overall, the importance of perioperative nutrition is evident in the literature despite select ongoing areas of contention.

Towards catheter steering using magnetic tractor beam coupling

Catheters are used in various clinical applications, and the ability to direct the catheter to the desired location is critical for clinical outcomes. Steerable catheters assist clinicians to access targeted areas, notably the vascular bundles and major vessels, while causing no damage to the surrounding tissue. A novel catheter actuation technology for catheter steering is presented in this study. The technique is simple and relies on three magnetic couples interacting with one another to generate steering motions. A proof-of-concept catheter prototype demonstrated the capacity to remotely steer a catheter over 100 mm of distance and ±45° of angular positioning, showing the potential manoeuvrability for clinical applications. It is feasible to steer a catheter using this three-magnet pair approach with the great potential to be used for catheterisation procedures. The presented mechanism's kinematics and a near-form solution for catheter steering regardless of design factors will be studied in the future.

Oral Nutritional Supplements and Enteral Nutrition in Patients with Gastrointestinal Surgery

Nowadays, patients undergoing gastrointestinal surgery are following perioperative treatment in enhanced recovery after surgery (ERAS) protocols. Although oral feeding is supposed not to be stopped perioperatively with respect to ERAS, malnourished patients and inadequate calorie intake are common. Malnutrition, even in overweight or obese patients, is often underestimated. Patients at metabolic risk have to be identified early to confirm the indication for nutritional therapy. The monitoring of nutritional status postoperatively has to be considered in the hospital and after discharge, especially after surgery in the upper gastrointestinal tract, as normal oral food intake is decreased for several months. The article gives an overview of the current concepts of perioperative enteral nutrition in patients undergoing gastrointestinal surgery.

ESPEN practical guideline: Clinical nutrition in surgery

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Postoperative Changes in Nutritional and Functional Status of Gastroesophageal Cancer Patients

OBJECTIVE

Disease-related malnutrition is a debilitating condition frequently observed in patients with cancer. The aim of the current study was to prospectively examine postoperative changes in nutritional and functional status of patients undergoing surgery for gastric, esophageal, and gastroesophageal junction cancer.

METHODS

Participants were prospectively recruited from September 2015 to September 2019. The assessment of malnutrition was based on the Patient-Generated Subjective Global Assessment tool. The functional assessment included the evaluation of muscle strength and physical performance, while muscle mass assessment was based on Skeletal Muscle Mass Index (SMI) derived from the analysis of computed tomography scans. The follow up of patients was scheduled at six months postoperatively.

RESULTS

A total of 98 patients were analyzed. Mean patient age was 60.79 ± 10.19 years and 80.6% were males. The mean unintentional weight loss at 6 months was 11.7 ± 8.0%. Patients who underwent McKeown esophagectomy reported the greatest weight loss postoperatively (16.2 ± 9.6%), whereas the lowest rate of weight loss was observed in patients who underwent partial gastrectomy (5.6 ± 6.7%). The rate of severe malnutrition declined at six months postoperatively (39.7% vs 27%). Muscle strength and physical performance were significantly deteriorated at 6 months postoperatively, except for the group of partial gastrectomy, while SMI significantly decreased in all groups of patients except for McKewon esophagectomy group. Finally, the prevalence of low muscle mass increased significantly from 43.5% in the preoperative period to 66.7% at the follow-up.

CONCLUSIONS

Our study revealed a significant deterioration in gastroesophageal cancer patient nutritional and functional status at six months postoperatively. The high prevalence of malnutrition and low muscle mass requires systematic follow-up and multidirectional monitoring in order to ensure the successful rehabilitation of these patients.

[Perioperative nutritional supplementation-what is really evidence based?]

For patients undergoing major surgery, perioperative management according to an early recovery after surgery (ERAS) protocol focusing on early oral food intake is the strategy of choice. So-called perioperative nutritional (artificial) support now seems to be very traditional and outdated. Nevertheless, even in an overweight and obese society the prevalence of combined malnutrition and/or sarcopenia should not be underestimated. This results in the necessity for identification of patients at metabolic risk and the indications for nutritional therapy. This article provides a review of the current concepts of perioperative nutritional supplementation and discusses the available evidence and guideline recommendations.