Specialised Nutrition enhances patients’ recovery from upper GI cancer surgery
- Malnutrition is a major risk factor in these patients and needs to be treated more effectively
- Evidence shows pre-operative immunonutrition decreases post-operative infection risk, reduces hospital length of stay and minimises costs
- Nutritional aspects of Enhanced Recovery Programme involve pre-operative immunonutrition and carbohydrate loadingy
Vevey, Switzerland, July 2012 – At a Nestlé Nutrition Institute Satellite Symposium recently held at the Digestive Disorders Federation Conference 20121 in Liverpool, UK, leading international experts affirmed the important role nutrition plays in the successful treatment of patients undergoing upper GI surgery.
Post-surgical infections are reduced with specialised nutrition support
Up to 80% of patients with upper GI cancer have already experienced a degree of weight loss at diagnosis2. A 10% decrease in body weight is a strong predictor of post-operative complications, specifically for general infections such as pneumonia and sepsis, which can lead to an increased hospital length of stay3,4. Clinical trials, mostly carried out in patients undergoing gastro-intestinal surgery have shown a significant reduction of both post-operative infections and hospital length of stay when fed pre-operatively with enteral formula containing additional nutrients such as arginine, omega-3 fatty acids and nucleotides defined as immunonutrition.
Professor Christophe Mariette, Professor of Surgery, Lille (France), commented, “If we look at the decreased rate of post-operative complications in patients receiving immunonutrition there is
- a 50% decrease of the risk of abdominal abscesses,
- a 39% decreased risk of wound infection, and
- an important decreased risk of 48% for anastomotic leaks.”5
Citing the ESPEN Guidelines on Nutrition 20066, Professor Mariette endorsed the recommendation of immunonutritional support in the pre-operative setting at least for seven days and the same in the post-operative setting in order to achieve a significant impact on the post-operative outcomes, specifically on infectious complications.
In summary Professor Mariette said, “We have a high rate of malnutrition in surgery. It has been clearly shown that it is a strong risk factor for post-operative complications, especially for infections. The enteral route should be preferred for nutritional support, even if it's before any surgery or before any treatment administration. In that situation immunonutrition with a Grade A level of evidence has been shown to be responsible for a decreased post-operative infection rate, a decrease in hospital length of stay, allowing a substantial cost saving and being cost-effective overall.”
Specialised nutrition is an important part of Enhanced Recovery Programme in Upper GI surgery
Clare Shaw, Consultant Dietitian, The Royal Marsden, London (UK), explained how the hospital has integrated nutrition into a multidisciplinary Enhanced Recovery Programme that is based upon the following:
1. Pre-operative assessment, planning and preparation
2. Reducing the physical stress of the operation
3. A structured approach to the immediate post-operative and peri-operative management
4. Early mobilisation
Enhanced recovery programmes for cancer surgery is a national initiative that commenced in 2009. Although Upper GI surgery is not targeted as a national priority, The Royal Marsden was keen to see if the principles could be applied to this group of patients to improve outcomes. The nutritional aspects involve not only pre-operative immunonutrition, but also carbohydrate loading. At the time of their pre-operative assessment patients not only collect immunonutrition but also receive their carbohydrate sachets. She commented, “There is good evidence that carbohydrate loading has been demonstrated to improve intra-operative liver glycogen stores, reduce insulin resistance and assist in the maintenance of nitrogen balance.”
She also added, “A structured approach to the immediate post-operative and peri-operative nutrition management should be considered for all patients who are going to be unable to take adequate food or fluids orally for five days. This is in accordance with NICE guidance.” Revealing the results of an initial audit of the Enhanced Recovery Programme in patients who underwent upper GI surgery, Dr Shaw said, “Overall we have seen a reduction in our overall length of stay by three days. We were very conscious that we did not want to be fast-tracking patients at the expense of quality and good patient outcomes. So it was quite nice to see that actually we have reduced their length of stay.”
The Enhanced Recovery Programme has involved a number of changes in clinical practice including approaches for patients undergoing pre-operative chemotherapy. These patients have an assessment with a dietitian prior to chemotherapy after which a plan is developed to optimise their nutritional status.
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1. 2012 BAPEN Meeting in association with BSG,AUGIS & BASL, combined as the Digestive Disorders Federation Conference: http://www.bapen.org.uk/professionals/meetings/annual-conference
2. Muscaritoli M et al. Prevention and treatment of cancer cachexia: New insight into an old problem. Europ J Cancer 2006;24:31-41
3. Van Bokhorst-de van der Schueren, M.A.E. et al. Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications. Head and Neck 1997;19:419-425.
4. Van Bokhorst-de van der Schueren, M.A.E. et al. The impact of nutritional status on the prognosis of patients with advanced head and neck cancer. Cancer 1999;86(3):519-27.
5. Waitzberg, D, Saito H, Plank L et al. Postsurgical Infections are Reduced with Specialized Nutrition Support. World J Surg; 30: 1592-1604.