Preoperative malnutrition assessments as predictors of postoperative mortality and morbidity in colorectal cancer: an analysis of ACS-NSQIP

Hypoalbuminemia is Associated with Mortality in Patients Undergoing Lower Extremity Amputation

BACKGROUND

Poor nutritional status is common among patients undergoing lower extremity amputation (LEA). In this study, the association between preoperative hypoalbuminemia, a marker for malnutrition, and postoperative mortality in patients undergoing LEA was explored.

METHODS

Data on patients undergoing LEA between 2005 and 2017 were retrospectively analyzed from the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into clinically relevant categories based on their serum albumin level (<2.5, 2.5-3.39, ≥3.4 g/dl) and were further stratified according to amputation level. Operative death was compared across groups and multivariable logistic regression was performed to estimate risk-adjusted odds ratio (AOR).

RESULTS

In 35,383 patients, the rate of 30-day postoperative mortality was 7.6% (n = 2693). Mortality rate was highest in patients with very low albumin levels (11%) as compared to low (6.8%) and normal levels (3.9%). On multivariable analysis, lower albumin levels emerged as a risk-adjusted independent predictor of mortality. After risk-adjustment, patients with very low albumin levels (AOR [95% CI]: 2.25 [1.969-2.56], P < 0.001) and low albumin levels (AOR [95% CI]: 1.42 [1.239-1.616], P < 0.001) had higher odds of mortality when compared to patients with normal albumin levels. On sensitivity analysis, a similar trend was seen in patients undergoing above knee amputation but not in patients undergoing minor amputations.

CONCLUSIONS

In patients undergoing major LEA, hypoalbuminemia is associated with an increased risk of postoperative mortality in a dose response manner, specifically in above knee amputations. Monitoring and optimizing patients' nutritional status before surgery, when possible, may be warranted and should be further explored.

Malnutrition is Associated with Poor Postoperative Outcomes Following Laparoscopic Hysterectomy

Background:

Malnutrition continues to be pervasive among the general population, with rates as high as 50% of patients undergoing surgical procedures. Data is limited about women undergoing surgery for non-malignant gynecologic indications (generally elective laparoscopic hysterectomies, after failed conservative measures). With the significant increase in benign gynecologic surgery, it is of the upmost importance that surgeons optimize modifiable risk factors for patients undergoing laparoscopic hysterectomy. The purpose of this study is to identify the impact of malnutrition on postoperative outcomes in patients undergoing laparoscopic hysterectomy for benign conditions.

Methods:

A retrospective cohort study was conducted utilizing data that was collected through the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP) Database. All patients that underwent laparoscopic hysterectomy for benign indications were identified. Patients with malnutrition were identified by either low albumin (≤ 3.5 g/dL), low body mass index (≤ 18.5), or 10% weight loss within 6 months. The frequency of postoperative complications was evaluated with univariate and multivariate analyses where appropriate.

Results:

Following adjustment, multivariate analysis illustrated pre-operative malnutrition to be a risk factor for the following complications: any complication, death, bleeding requiring transfusion, wound, cardiac, pulmonary, renal, thromboembolic, sepsis complications, extended length of stay, and reoperation (p ≤ 0.05 for all).

Conclusion:

Malnourished patients were at significantly higher risk of developing postoperative complications during the acute postoperative period. With elective laparoscopic hysterectomies, pre-operative evaluation and intervention for malnutrition should be considered to improve nutritional status.

The impact of body composition on treatment in ovarian cancer: a current insight

INTRODUCTION

Epithelial ovarian cancer (EOC) remains the most lethal of gynecological cancers. Sarcopenia and low Skeletal Muscle Radiodensity (SMD) are highly prevalent in EOC. Cross sectional imaging via MRI and CT are considered the gold standard for quantification of muscle mass and muscle density. Skeletal Muscle Index (SMI) and SMD-based thresholds for sarcopenia in EOC vary significantly and specific EOC thresholds for sarcopenia have not been defined.

AREAS COVERED

Sarcopenia and low SMD are highly prevalent in EOC affecting between 11-68% and 21-35% of women, respectively. SMD may be a better prognostic biomarker in ovarian cancer than SMI. Reduced SMI and SMD may also influence the risk of postoperative complications but further studies are required. There is increasing evidence that sarcopenia increases during neoadjuvant chemotherapy.

EXPERT COMMENTARY

Prehabilitation studies in surgical oncology indicate encouraging results, such as, maintenance of SMI, reduced length of stay and surgical complication rates, improved health-related quality of life and functional capacity. Early identification of body composition abnormalities would permit targeted intervention prior to, and after surgery. Cross-sectional imaging is routinely used for staging and surveillance of EOC patients and hence assessment of body composition abnormalities is possible and an underutilized resource.

Adverse perioperative outcomes among patients undergoing gastrointestinal cancer surgery: Quantifying attributable risk from malnutrition

BACKGROUND

Preoperative malnutrition adversely impacts perioperative outcomes among patients with gastrointestinal (GI) cancer. The attributable risk (AR) that nutrition status contributes towards negative outcomes is poorly understood.

METHODS

Adults undergoing GI cancer surgeries were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2017). Emergency surgeries, outpatients, and cases with an American Society of Anesthesiologists status above III were excluded. Adjusted multivariable models were constructed to determine the associations between markers of nutrition status (body mass index, >10% weight loss in last 6 months, functional status, and serum albumin level) and adverse perioperative outcomes (presence and number of complications, death, 30-day readmission, and length of stay). Predictive accuracy statistics and population AR (PAR) were determined.

RESULTS

The final sample included 78,662 cases. Patients with >10% weight loss 6 months preceding surgery (compared with those who did not), had a significantly increased risk of complications (Relative Risk = 1.28; 95% CI, 1.20-1.37) and odds of death (odds ratio [OR] = 1.37; 95% CI, 1.18-1.59). A totally dependent functional status (compared with independent status) was associated with a 3.3-times higher odds of death (OR = 3.30; 95% CI, 1.53-7.15). Multivariable models were not predictive of adverse outcomes; PAR from the markers ranged 1%-2%.

CONCLUSION

Ten percent weight loss in preceding 6 months was associated with increased risk of adverse perioperative outcomes among adults undergoing GI cancer surgery. The contribution of nutrition status markers to surgical outcomes as assessed by PAR was small (1%-2%), a finding not previously reported. Future intervention studies should include validated nutrition risk markers, control for effects of perioperative variables, and evaluate PAR within the immediate/long-term postoperative periods.

Prospective multicentre study of a new bowel obstruction treatment in colorectal surgery: Reduced morbidity and mortality

INTRODUCTION

Bowel obstruction patients are at increased risk of emergency surgery and have poor nutritional and physical conditions. These patients could benefit from prehabilitation and prevention of emergency surgery. This study assessed the effect of a multimodal obstruction treatment for bowel obstruction patients in colorectal surgery on the risk of emergency surgery and postoperative morbidity and mortality.

MATERIALS AND METHODS

This multicenter observational cohort study included all consecutive bowel obstruction patients who received obstruction treatment (obstruction protocol) in the period 2019-2020 in two Dutch hospitals. Benign and malignant causes of bowel obstruction were included. Treatment consisted of 1. dietary adjustments, 2. postponing surgery for three weeks, 3. laxatives, and 4. prehabilitation. We compared emergency surgery and postoperative morbidity and mortality rates to known rates from the literature.

RESULTS

Eighty-nine patients were included: obstruction treatment was successful in 77 patients (87%) who underwent elective surgery and unsuccessful in 12 patients (13%) who underwent emergency surgery. Sixty-six (74%) had colorectal cancer, and 22 (25%) had benign disease. Thirty-day mortality of 0% in our study was significantly lower than the national average of 4% in colorectal cancer patients in the Netherlands (p = 0.049). Anastomotic leakage rate was 3%, severe complications (Clavien-Dindo ≥ III) 8%, and bowel perforation 0%. These rates did not differ significantly from rates reported in literature.

CONCLUSION

The obstruction treatment prevented emergency surgery in most patients with bowel obstruction and reduced postoperative morbidity and mortality. The obstruction treatment seems to be a safe and efficient alternative to emergency surgery.

Preparation and Evaluation of Lipid Emulsion Containing 13 Vitamins for Injection Without Anaphylactoid Reactions

Objective

Multivitamins containing Tween 80 can cause anaphylactoid reactions. The objective of this study was to develop a new lipid emulsion containing 13 fat- and water-soluble vitamins for injection (13V-LE) that were simultaneously dissolved in one bottle and to evaluate the stability of and anaphylactoid reactions to 13V-LE.

Methods

Particle size, ζ-potential, and polydispersity of 13V-LE were assayed with a Zetasizer Nano ZS. Entrapment efficiency of 13V-LE was determined with HPLC. Behavior, histamine, and blood pressure of beagle dogs were investigated by observation, fluorospectrophotometry, and sphygmomanometry.

Results

The 13V-LE with the smallest particles and highest entrapment efficiency with stable ζ-potential was composed of soybean oil, glycerin (2.25%, w:v), egg lecithin (1.2%, w:v), and purified water. There was no obvious change in characteristics of the 13V-LE samples in terms of appearance, size distribution, ζ-potential, pH value, or concentration over 6 months. In anaphylactoid reactions tests, when being administered with the multivitamin Infuvite Adult containing Tween 80, six beagles showed grade IV symptoms (P<0.01 vs control), low blood pressure, and high plasma-histamine concentrations (P<0.05 or P<0.01). However, there were no significant differences in behavior, blood pressure, or histamine concentration in the dogs before and after administration in the 13V-LE group.

Conclusion

The 13V-LE formulation is a suitable intravenous lipid emulsion without anaphylactoid reactions.

Geriatric Nutritional Risk Index Predicts Poor Prognosis of Patients After Curative Surgery for Gastric Cancer

Background

The Geriatric Nutritional Risk Index (GNRI) is a nutritional measure for predicting the risk of morbidity and mortality in hospitalized patients. We evaluated the utility of the GNRI to predict the short-term and long-term outcomes after curative surgery for gastric cancer (GC).

Patients and Methods

Patients who underwent curative surgery for GC between 2008 and 2016 were reviewed (n=795). We classified patients into two groups according to the GNRI (high GNRI: low and no risk; low GNRI: major and moderate risk) and compared the utility of the GNRI.

Results

A low GNRI was an independent prognostic factor for poorer overall survival (hazard ratio=2.34, p<0.001). The GNRI tended to be a better prognostic indicator in elderly patients with GC. Low GNRI was associated with postoperative complications (odds ratio=2.27, p=0.002), especially in patients aged ≥75 (odds ratio=2.26, p=0.042).

Conclusion

Low GNRI was associated with poor prognosis and occurrence of postoperative complications in patients with GC, especially in elderly patients.

The clinical impact of malnutrition on the postoperative outcomes of patients undergoing colorectal resection surgery for colon or rectal cancer: Propensity score matched analysis of 2011-2017 US hospitals

BACKGROUND & AIMS

Malnutrition can be prevalently found in patients with significant-to-advanced colorectal cancer, who potential require colorectal resection procedures; to accurately describe the postoperative risks, we used a propensity-score matched comparison of national database to analyze the effects of malnutrition on post-colectomy outcomes.

METHODS

2011-2017 National inpatient Sample was used to isolate inpatient ceases of colorectal resection procedures, which were stratified using malnutrition into malnutrition-present cohort and malnutrition-absent controls; the controls were propensity-score matched with the study cohort using 1:1 ratio and compared to the following endpoints: mortality, length of stay, costs, postoperative complications.

RESULTS

After matching, there were 11357 with and without malnutrition who underwent colorectal resection surgery; in comparison, malnourished patients had higher rates of in-hospital mortality (6.14 vs 3.22% p < 0.001, OR 1.96 95%CI 1.73-2.23), length of stay (15.4 vs 9.61d p < 0.001), costs ($163, 962 vs $102,709 p < 0.001), and were more likely to be discharged to non-routine discharges, including short term hospitals, skilled nursing facilities, and home healthcare. In terms of complications, malnourished patients had higher bleeding (2.87 vs 1.68% p < 0.001, OR 1.73 95%CI 1.44-2.07), wound complications (4.31 vs 1.34% p < 0.001, OR 3.32 95%CI 2.76-3.99), infection (6 vs 2.62% p < 0.001, OR 2.38 95%CI 2.07-2.73), and postoperative respiratory failure (7.27 vs 3.37% p < 0.001, OR 2.25 95%CI 1.99-2.54).

CONCLUSION

This study demonstrates the presence of malnutrition to be associated with adverse postoperative outcomes including mortality and complications in patients undergoing colorectal resection surgery for colon cancer.

Preoperative nutritional status impacts clinical outcome and hospital length of stay in pelvic exenteration patients - a retrospective study

BACKGROUND

Preoperative malnutrition is common in surgical oncology patients and can have negative effects on postoperative outcomes. Pelvic exenteration is major surgery associated with high morbidity rates. Associations between preoperative malnutrition, determined using the patient-generated subjective global assessment, and postoperative outcomes in this patient cohort has not yet been investigated.

AIM

To determine if preoperative nutritional status is associated with postoperative surgical and quality of life (QoL) outcomes after pelvic exenteration surgery.

METHODS

A retrospective cohort study was conducted at a quaternary hospital investigating 123 patients who had pelvic exenteration surgery from January 2017 to August 2019. Preoperative nutritional status and postoperative surgical and QoL outcomes were collected and analysed to determine any associations.

RESULTS

Overall, 49.6% of patients were female with a median age of 59 years. Forty patients (32.5%) were malnourished and 83 (67.5%) were well nourished before surgery. Well-nourished patients had a shorter length of hospital stay (p = 0.034) and at 6 months post-surgery, presented with a significantly better physical and mental QoL score (p = 0.038 and p = 0.001 respectively). The regression analyses showed that intensive care unit (ICU) readmission rates were 7.19 times more likely to occur in malnourished patients (p = 0.022).

CONCLUSIONS

Preoperative malnutrition is associated with increased length of stay, ICU readmissions and poorer QoL following pelvic exenteration. Nutrition screening, assessment and optimisation of management are essential in this patient cohort to improve patient outcomes. Future studies are needed to measure the effect of interventions and identify the most beneficial model of care for this complex patient group.

Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States

Malnutrition, particularly under-nutrition, is highly prevalent among adult patients with a diagnosis of gastrointestinal (GI) cancer and negatively affects patient outcomes. Malnutrition is associated with clinical and surgical complications for patients undergoing therapy for GI cancers and the costs associated with those complications is a high burden for the US health system. Our objective was to identify high-quality evidence for nutrition support interventions associated with cost savings for patient care, followed by a complex economic value analysis to project cost savings for the US health system. A narrative literature search was conducted in which combined keywords in the areas of therapeutic nutrition (nutrition, malnutrition), a specific therapeutic area [GI cancer (esophageal, gastric, gallbladder, pancreatic, liver/hepatic, small and large intestine, colorectal)], and clinical outcomes and healthcare cost, to look for nutrition interventions that could significantly improve clinical outcomes. Medicare claims data were then analyzed using the findings of these identified studies and this modeling exercise supported identifying the cost and healthcare resource utilization implications of specific populations to determine the impact of nutrition support on reducing these costs as reflected in the summary of the evidence. Eight studies were found that provided clinical outcomes and health cost savings data, 2 of those had the strongest level of evidence and were used for Value Analysis calculations. Nutrition interventions such as oral diet modifications, enteral nutrition (EN) supplementation, and parenteral nutrition (PN) have been studied especially in the peri-operative setting. Specifically, peri-operative immunonutrition administration and utilization of enhanced recovery pathways after surgery have been associated with significant improvement in postoperative complications and decreased length of hospital stay (LOS). Utilizing economic modeling of Medicare claims data from GI cancer patients, potential annual cost savings of $242 million were projected by the widespread adoption of these interventions. Clinical outcomes can be improved with the use of nutrition interventions in patients with GI cancers. Healthcare costs can be reduced as a result of fewer in-hospital complications and shorter lengths of hospital stay. The application of nutrition intervention provides a positive clinical and economic value proposition to the healthcare system for patients with GI cancers.

The Prognostic Role of Body Mass Index in Survival of Non-metastatic Postoperative Patients with Colorectal Cancer

Background: Rather body mass index (BMI) has a potential prognostic role in determining the outcome of patients suffering from colorectal cancer or not should be clear. Objectives: We aimed at determining the potential effects of BMI on the prognosis of patients with colorectal cancer. Methods: In this cohort study, documents of 1550 patients with colorectal cancer between 2002 and 2020 from Omid hospital and Emam Reza hospital (Mashhad, Iran) databases were evaluated, retrospectively. The multivariable logistic regression and Cox proportional hazard regressions were used at the significance level of P < 0.05. Results: Nine hundred twenty patients included in the current study. Most of patients were categorized as normal weight (38.91%). The prevalence of underweight and overweight/obese were 26.19% and 34.9%, respectively. There was no significant difference in the overall survival (OS) and disease-free survival (DFS) based on BMI (OS: 108.2 ± 7.0 months for underweight, 124.0 ± 6.2 months for normal weight, and 130.9 ± 4.5 months for overweight/obese patients; P = 0.2 and DFS: 97.0 ± 6.5, 110.0 ± 5.6, and 113.7 ± 5.0, respectively; P = 0.3). Conclusions: The BMI had no significant effect on long-term outcomes of patients with colorectal cancer. However, there was an insignificant trend to better outcome in patients with higher BMI comparing the underweight group.

Impact of anastomotic leakage on postoperative survival of patients with colorectal cancer: A meta-analysis using propensity score matching studies

OBJECTIVE

To explore the influence of anastomotic leakage (AL) on postoperative survival in patients with colorectal cancer (CRC).

BACKGROUND

Although several studies have compared the postoperative survival of patients with CRC with and without AL, the background characteristics of the two groups were not aligned in most studies.

METHODS

We performed a comprehensive electronic search of the literature up to March 2020 to identify propensity score matching (PSM) studies that compared postoperative survival between CRC patients with and without AL. A meta-analysis was performed using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI), and heterogeneity was analyzed using I (Akiyoshi et al., 2011) [2] statistics.

RESULTS

Four PSM studies involving a total of 1676 patients with CRC undergoing surgery were included in this meta-analysis. Among 234 patients who had AL, 163 (69.7%) survived at 5 years after surgery, whereas among 1422 patients who did not have AL, 1156 (81.3%) survived at 5 years after surgery. Background characteristics of the two groups were adjusted with PSM in all 4 studies. The result of the meta-analysis revealed a significant difference between the two groups (RR, 1.63; 95% CI, 1.09-2.45; P = 0.02; I² = 66%) in 5-year overall survival (OS).

CONCLUSIONS

The results of this meta-analysis demonstrate a significantly decreased 5-year OS in patients with CRC who had AL compared with patients with CRC who did not have AL.

Research Progress of Preoperative FPR, FAR or AFR in Patients with Colorectal Cancer

Research has confirmed that plasma albumin (Alb), prealbumin (PA) and fibrinogen (Fib) are involved in regulating the occurrence and development of various tumors. Their levels in peripheral blood are related to the survival outcome and treatment response of patients, but the accuracy and specificity of single application have yet to be fully realized. A growing amount of evidence indicates that predictors such as preoperative fibrinogen to prealbumin ratio (FPR), fibrinogen to albumin ratio (FAR) or albumin to fibrinogen ratio (AFR) are emerging as comprehensive indicators. Indeed, their components play a key regulatory role in the progression of colorectal cancer (CRC). Preoperative FPR, FAR or AFR levels, therefore, are expected to become new biomarkers for prognosis evaluation and curative effect prediction for CRC patients and are significant in the guidance they could provide for the development of individualized treatment strategies.

The Role of Obesity in the Development and Management of Gynecologic Cancer

Importance

Endometrial cancer is the most common gynecologic malignancy, with an estimated 54,000 new cases and 10,000 deaths in the United States in 2015. The obesity epidemic directly contributes to the escalating prevalence of chronic diseases, including obesity-related cancers. Patient body weight and nutritional status markedly impact perioperative oncologic care, chemotherapy administration, recurrence risk, and survivorship goals.

Objectives

The objective of this review is to explore the association between obesity and the development, treatment, and survival outcomes of gynecologic cancers.

Evidence Acquisition

A systematic literature review was performed utilizing PubMed and ClinicalTrials.gov.

Conclusions and Relevance

Caring for obese women with gynecologic cancers presents unique challenges. A coordinated multidisciplinary and system effort is required to address the prevention and treatment of obesity, as the sequela of this disease is a clear risk factor for the development of gynecologic malignancy and other comorbidities. Health care providers must be ready to address this worldwide health problem.

Preoperative inflammation is an independent factor of worse prognosis after colorectal cancer surgery

BACKGROUND

We know that inflammation is related to colorectal cancer prognosis and to the onset of postoperative infections.

OBJECTIVE

This study aimed to understand the relationship between preoperative inflammation and the prognosis of colorectal cancer and to elucidate whether the impact of inflammation on cancer prognosis was related to an increased risk of surgical infection or was independent of it.

METHODS

Patients who underwent elective colorectal cancer surgery between November 2011 and April 2014 were included in a prospective database (IMACORS). Preoperative c reactive protein was collected for each patient. Patients were followed up according to the French national guidelines. A cut-off of preoperative CRP of 5mg/L was chosen. Clinical characteristics were compared according to CRP using Chi² and Mann-Whitney tests. The Overall Survival (OS) and Disease-Free-Survival (DFS) were compared by Kaplan-Meier curves. A Cox proportional hazards regression model was applied to perform a multivariate analysis of OS and DFS's predictors.

RESULTS

A total of 254 patients were included. The median age was 68 years old. The median follow up was 41.8 months. The overall median preoperative CRP was 5mg/L. Preoperative CRP was significantly associated with N status; CRP being significantly higher among patients with colonic cancer and with patients who didn't receive a neoadjuvant treatment. Multivariate analyse revealed that preoperative CRP is an independent prognostic factor of OS and DFS respectively (HR=2.34 (1.26-4.31), P=0.006 and HR=1.83 (1.15-2.90), P=0.01).

CONCLUSION

Preoperative inflammation measured by CRP is independently related with overall and disease-free survival of colorectal cancer.

Preoperative Improvement in Physical Function by Comprehensive Rehabilitation Leads to Decreased Postoperative Complications in Gastrointestinal Cancer Patients

Objectives:

The aim of this study was to investigate how baseline laboratory data and changes in physical function due to preoperative rehabilitation training in gastrointestinal cancer (GIC) patients can influence the frequency of postoperative complications (PCs).

Methods:

We enrolled 45 patients who were scheduled for elective surgery for GIC (27 men and 18 women, mean age 63.6±9.5 years). All patients underwent a medical examination and received general instruction from a rehabilitation physician and exercise instruction from a physical therapist from 7 to 34 days before the surgery. PCs were graded using the Clavien-Dindo classification based on the medical records 1 month postoperatively. We measured the grip strength and the isometric knee extension torque and conducted the 6-min walk test (6MWT) at baseline and just before surgery. The surgical duration, blood loss, and blood transfusion data were collected. Baseline laboratory information, including C-reactive protein levels, serum albumin levels, platelet count, white blood cell count, and the estimated glomerular filtration rate, was recorded.

Results:

The frequency of PCs was negatively correlated to the change in the 6MWT (β=−0.36) and positively correlated to the surgical duration (β=0.41). Baseline albumin was positively correlated to the change in the 6MWT distance (β=0.35). This model demonstrated an acceptable fit to the data (goodness of fit index=0.980, comparative fit index=1.000, root mean square error of approximation=0.000).

Conclusions:

The improvement of gait ability achieved with preoperative rehabilitation training in patients undergoing elective GIC surgery led to decreased PCs.

Low Preoperative Serum Albumin Levels Are Associated With Impaired Outcome After Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies

Preoperative hypoalbuminemia is known to be associated with postoperative morbidity and mortality, as well as with poor survival after gastrointestinal cancer surgery. However, limited data exist regarding the prognostic significance of hypoalbuminemia in patients with peritoneal metastases undergoing cytoreductive surgery, combined with perioperative intraperitoneal chemotherapy. We performed a systematic literature review of the previously published studies addressing the potential association between preoperative albumin levels and overall surgical outcomes after the performance of cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal surface malignancies. Our research yielded a total of nine retrospective studies which met our inclusion criteria, and despite their heterogeneity; and we can conclude that preoperatively low albumin levels are associated with greater likelihood of overall and major morbidity, as well as less favorable oncological outcome after the performance of cytoreductive surgery and perioperative intraperitoneal chemotherapy.

Impact of Artificial Nutrition on Postoperative Complications

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.

Clinical Significance of Prognostic Nutritional Index in the Treatment of Esophageal Squamous Cell Carcinoma

BACKGROUND/AIM

The prognostic nutritional index (PNI) is reported to affect postoperative complications and survival of patients with esophageal squamous cell carcinoma (ESCC). The aim of this study is to investigate the clinical significance of PNI in treatment of ESCC.

PATIENTS AND METHODS

Two hundred and sixty-three patients who underwent radical esophagectomy were retrospectively analyzed. PNI was calculated in the pretreatment (pre-Tx), post-neoadjuvant chemotherapy (post-NAC), and postoperative periods.

RESULTS

Pre-Tx PNI positively correlated with prognosis irrespective of undergoing NAC (p<0.05). In the patients with NAC, pre-Tx PNI was one of the independent prognostic factors (p=0.04). In patients with low pre-Tx PNI, the prognosis was improved by increase of PNI after NAC (p=0.08), and two cycles of NAC significantly correlated with high post-NAC PNI (p=0.04).

CONCLUSION

Pre-Tx PNI is an independent prognostic factor irrespective of NAC. Patients in whom the post-NAC PNI can be improved have a high probability of obtaining a good prognosis.

The value of preoperative controlling nutritional status score in evaluating short-term and long-term outcomes of patients with colorectal cancer following surgical resection

Background: This study aimed to explore the value of controlling nutritional status (CONUT) score in assessing short-term and long-term outcomes of colorectal cancer (CRC) patients, and construct CONUT-based nomograms to predict risk of postoperative comorbidities and survival.

Methods: We retrospectively enrolled 512 patients from 2012 to 2014. Patients were categorized into low-CONUT and high-CONUT groups. Logistic regression analysis was used to determine characteristics influencing postoperative comorbidities. Kaplan-Meier survival curve and Cox proportional hazards analysis were used to determine characteristics affecting prognosis. The receiver operating characteristic was used to compare ability of the CONUT score with other immune-nutritional indicators to predict prognosis.

Results: Logistic regression analysis suggested that high CONUT score was an independent risk factor affecting postoperative comorbidities (odds ratio, 1.792; 95% confidence interval [CI], 1.113-2.886; P = 0.016). Patients with low-CONUT score had longer disease-free survival (DFS) (P < 0.001) and overall survival (OS) (P < 0.001) compared to those with high-CONUT score, especially at the early stage. CONUT score was an independent factor affecting both DFS (hazard ratio [HR], 1.820; 95% CI, 1.204-2.752; P = 0.005) and OS (HR, 1.815; 95% CI, 1.180-2.792; P = 0.007). The area under the curve of CONUT score was higher than for other immune-nutritional indicators. The CONUT-based nomograms had good predictive capability.

Conclusions: CONUT score is a strong independent predictor of postoperative comorbidities and long-term outcomes in CRC patients, and might be a better prognostic factor than other immune-nutritional indicators. The CONUT-based nomograms are conducive to the individualized formulation of follow-up strategies and treatment plans.

Presence of dynapenia and association with anthropometric variables in cancer patients

Background

Dynapenia is defined as an age-related loss of muscle strength. There is little information on dynapenia in cancer patients and on how it relates to anthropometric variables. The aim of this study was to analyze the presence of dynapenia and its association with anthropometric variables in hospitalized cancer patients.

Methods

Participants comprised adult and elderly cancer patients evaluated within the first 48 h of hospital admission to a tertiary public hospital, a referral center for gastrointestinal tract surgery. Anthropometric variables were measured according to standardized protocols. Dynapenia was identified based on handgrip strength (HGS), according to the cutoff points defined by the European Working Group on Sarcopenia in Older People (EWGSOP2), with values for women < 16 kg and for men < 27 kg. Statistical analysis was performed using SPSS software, version 22.0, with a significance level of 5%.

Results

This study included 158 patients aged in average 59.5 ± 14.0 years; of these, 53.6% were elderly, 58.9% non-white and 59.5% had some degree of malnutrition. The most prevalent type of cancer was that of the lower gastrointestinal tract (33.5%). The presence of dynapenia was observed in 23.4% of the patients and cachexia in 36.1%. There was an association between dynapenia with age (p < 0.001), life stage (p = 0.002) and race/color (p = 0.027), and also with body mass index (BMI) (p = 0.001) and adductor pollicis muscle thickness (APMT) of both hands (p < 0.05). After logistic regression analysis, adjusted for the sociodemographic variables, the APMT of the dominant hand and the low weight determined by body mass index remained associated with the occurrence of dynapenia (p < 0.05).

Conclusions

In this study we confirmed that dynapenia was present in cancer patients, being associated with APMT of the dominant hand and low weight. HSG was proven to be a reliable and complementary measure to be added to the process of assessing nutritional status, contributing to the nutritional diagnosis of these patients and to the detection of early muscle depletion.

Which Objective Nutritional Index Is Better for the Prediction of Adverse Medical Events in Elderly Patients Undergoing Spinal Surgery?

OBJECTIVE

The relationship of preoperative malnutrition with perioperative adverse medical events (PAMEs) has not been well studied in elderly patients undergoing spinal surgery (SS). We aimed to compare the Prognostic Nutritional Index (PNI), Controlling Nutritional Status (CONUT) score, and Geriatric Nutritional Risk Index (GNRI) for prediction of PAMEs in elderly patients undergoing SS.

METHODS

Data of 454 patients ≥65 years old undergoing SS were reviewed. PAMEs were defined as death, cardiopulmonary complications, respiratory failure, acute kidney injury, pneumonia, delirium, cerebrovascular events, and sepsis. The area under the receiver operating characteristic curve was used to compare the predictive value of each nutritional index for PAMEs.

RESULTS

Incidence of PAMEs was 15.3%. Patients who had PAMEs had significantly lower GNRI and PNI but higher CONUT score before surgery compared with patients without PAMEs. Multivariate analysis showed that age (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.01-4.75, P = 0.014), chronic renal failure (OR 1.34, 95% CI 1.03-3.82, P = 0.002), coronary artery disease (OR 1.12, 95% CI 1.11-3.54, P = 0.028), PNI <45.4 (OR 2.12, 95% CI 1.16-4.80, P = 0.011), CONUT score >5 (OR 2.17, 95% CI 1.03-3.76, P = 0.001), and GNRI <92 (OR 2.68, 95% CI 1.20-6.45, P < 0.001) were significant predictors of PAMEs. The receiver operating characteristic curve showed that GNRI had much greater discriminatory ability regarding PAMEs than PNI and CONUT score.

CONCLUSIONS

Preoperative malnutrition is associated with PAMEs in elderly patients undergoing SS. GNRI had the highest accuracy for predicting PAMEs among the nutritional indices studied.

Older frail prehabilitated patients who cannot attain a 400 m 6-min walking distance before colorectal surgery suffer more postoperative complications

INTRODUCTION

Recent efforts to prehabilitate intermediately frail and frail (Fried frailty criteria ≥2) elective colorectal cancer patients did not influence clinical nor functional outcomes. The objective of this secondary analysis was to describe the subset of intermediately frail and frail prehabilitated patients who could not attain a minimum 400 m (a prognostic cut-point used in other patient populations) 6-min walking distance (6MWD) before elective surgery.

MATERIALS AND METHODS

Secondary analysis of a randomized controlled trial. Patients participated in multimodal prehabilitation at home and in-hospital for approximately four weeks before colorectal surgery. Primary outcome was incidence of postoperative complications within 30 days of hospital discharge.

RESULTS

Sixty percent of the patients who participated in prehabilitation did not reach a minimum walking distance of 400 m in 6 min before surgery. Compared to the group that attained ≥400 m 6MWD (n = 19), the <400 m group (n = 28) were older, had higher percent body fat, lower physical function, lower self-reported physical activity, higher American Society of Anesthesiologists (ASA) classification, and twice as many were in critical need of a nutrition intervention at baseline. No group differences were observed regarding frailty status (P = 0.775). Sixty-one percent of the <400 m 6MWD group experienced at least one complication within 30 days of surgery compared to 21% in the ≥400 m group (P = 0.009).

CONCLUSION

Several preoperative characteristics were identified in the <400 m 6MWD group that could be useful in screening and targeting future prehabilitative treatments. Future trials should investigate use of a 400 m standard for the 6MWD as a minimal treatment target for prehabilitation.

Which Nutritional Scoring System Is More Suitable for Evaluating the Short- or Long-Term Prognosis of Patients with Gastric Cancer Who Underwent Radical Gastrectomy?

OBJECTIVE

To evaluate the effects of three nutritional scoring systems: Prognostic Nutritional Index (PNI), Controlling Nutritional Status (CONUT), and Naples Prognostic Score (NPS) on the short- or long-term prognosis of gastric cancer (GC) patients who underwent radical gastrectomy.

METHODS

The clinicopathological data of 2182 patients who underwent radical gastrectomy at the Fujian Medical University Union Hospital (FMUUH) from 2009 to 2014 were retrospectively analyzed. The effects of the PNI, CONUT, and NPS on the short- or long-term prognosis of GC patients were analyzed.

RESULTS

Overall, 359 (16.5%) patients had postoperative complications. There was no significant association between the PNI, CONUT, and NPS and postoperative complications (P > 0.05); however, high CONUT and NPS were significantly associated with severe postoperative complications (P < 0.05). Univariate analysis showed that PNI, CONUT, and NPS were all associated with overall survival (OS) (P < 0.001). However, multivariate analysis showed that only PNI was an independent risk factor for OS (P = 0.004), and the 5-year OS rate in the low PNI group was significantly lower than that in the normal PNI group (55.5% vs 75.4%, P < 0.05). The area under the curve (AUC) and the c-index of PNI were significantly higher than those of CONUT and NPS. The prognostic efficiency of combining PNI and TNM stage was also significantly better than that of TNM staging alone (P < 0.05).

CONCLUSION

The current study demonstrated that CONUT and NPS are important for assessing the risk of severe postoperative complications. However, PNI is an independent risk factor for the long-term prognosis of GC patients who underwent radical gastrectomy and can improve the prognostic efficiency of TNM staging.

Skeletal Muscle Mass Loss During Cancer Treatment: Differences by Race and Cancer Site

OBJECTIVES

To examine skeletal muscle mass change in a racially diverse sample of patients undergoing cancer treatment, determine significant predictors of muscle mass loss, and explore the interaction of race and cancer site.

SAMPLE & SETTING

A retrospective analysis was conducted for 212 patients seeking treatment at a university hospital clinic.

METHODS & VARIABLES

Skeletal muscle mass index (SMI) was determined by computed tomography at the time of cancer diagnosis and with cancer treatment.

RESULTS

One hundred thirty-four patients (63%) had SMI loss with cancer treatment. Race and cancer site were found to be significant predictors of SMI loss. Compared to other racial groups, non-Hispanic Black (NHB) patients had the greatest SMI loss (p < 0.001) with cancer treatment. NHB patients with rectal cancer experienced the greatest SMI loss compared to patients of other races and cancer types.

IMPLICATIONS FOR NURSING

To improve survivorship care for patients with cancer, it is essential to develop strategies for assessing and managing skeletal muscle mass loss throughout treatment, particularly for NHB patients with rectal cancer.

The effect of trimodal prehabilitation on the physical and psychological health of patients undergoing colorectal surgery: a randomised clinical trial

Prehabilitation aims to increase the endurance capacity of patients who are awaiting major surgery. However, there are no studies investigating the implementation of this demanding and expensive intervention in low-income countries. This study aimed to assess the impact of a 4-week trimodal prehabilitation program on the physical and psychological health of patients waiting for colorectal surgery compared with a control group managed according to enhanced recovery after surgery principles supplemented by nutritional care. This study was a single-centre, randomised controlled trial. The primary outcome measures for the physical aspects were 6-minute walking distance (6MWD) and incentive spirometry, whereas the psychological elements were measured using the 36-item short form survey questionnaire and the hospital anxiety and depression score. In total, data from 149 patients were analysed (77 in the prehabilitation group and 72 in the control group). At the time of surgery, patients in the prehabilitation group had improved 6MWD and incentive spirometry compared with the control group (median (IQR [range]) percentage improvement 131% (112-173 [68-376]) vs. 107% (99-120 [63-163]); p < 0.001 and 113% (100-125 [75-200]) vs. 100% (100-112 [86-167]); p < 0.001 respectively). Patients in the prehabilitation group also had reduced anxiety scores compared with the control group (mean (SD) anxiety score (4 (3) vs. 5 (3) respectively; p = 0.032). However, these effects did not translate into improvements in postoperative mortality and morbidity, or a reduction in duration of hospital stay. Trimodal (physical, emotional and nutritional) prehabilitation is able to improve functional status as well as some parameters of emotional and physical well-being of patients waiting for colorectal surgery.

The Geriatric Nutritional Risk Index is a powerful predictor of adverse outcome in the elderly emergency surgery patient

BACKGROUND

The degree to which malnutrition impacts perioperative outcomes in the elderly emergency surgery (ES) patient remains unknown. We aimed to study the relationship between malnutrition, as measured by the Geriatric Nutritional Risk Index (GNRI), and postoperative outcomes in elderly patients undergoing ES.

METHODS

Using the 2007 to 2016 American College of Surgeons National Surgical Quality Improvement Program database, all patients 65 years or older undergoing ES were included in our study. The GNRI, defined as (1.489 × albumin [g/L]) + (41.7 × [weight/ideal weight]) was calculated for each patient in the database. Patients with missing height, weight, or preoperative albumin data were excluded. Patients were divided into four malnutrition groups: very severe (GNRI < 73), severe (GNRI, 73-82), moderate (GNRI, 82-92), and mild (GNRI, 92-98). Geriatric Nutritional Risk Index greater than 98 constituted the normal nutrition group. Risk-adjusted multivariable logistic regressions were performed to study the relationship between malnutrition-measured using either GNRI, albumin level, or body mass index less than 18.5 kg/m-and the following postoperative outcomes: 30-day mortality, 30-day morbidity (including infectious and noninfectious complications), and hospital length of stay. The relationship between GNRI score and 30-day mortality for six common ES procedures was then assessed.

RESULTS

A total of 82,725 patients were included in the final analyses. Of these, 55,214 were malnourished with GNRI less than 98 (66.74%). Risk-adjusted multivariable analyses showed that, as malnutrition worsened from mild to very severe, the risk of mortality, morbidity, and the hospital length of stay progressively increased (all p < 0.05). Patients with very severe malnutrition had at least a twofold increased likelihood of mortality (odds ratio [OR], 2.79; 95% confidence interval [CI], 2.57-3.03), deep vein thrombosis (OR, 2.07; 95% CI, 1.77-2.42), and respiratory failure (OR, 1.95; 95% CI, 1.81-2.11). Geriatric Nutritional Risk Index predicted mortality better than albumin or body mass index alone for ES.

CONCLUSION

Malnutrition, measured using GNRI, is a strong independent predictor of adverse outcomes in the elderly ES patient and could be used to assess the nutrition status and counsel patients (and families) preoperatively.

LEVEL OF EVIDENCE

Prognostic study, Level IV.

Risk Factors for Prolonged Length of Stay and Readmission After Parathyroidectomy for Renal Secondary Hyperparathyroidism

BACKGROUND

Population-based analyses of 30-day outcomes after parathyroidectomy for renal secondary hyperparathyroidism are limited. We sought to identify risk factors associated with prolonged length of stay (LOS) and readmission in this patient population.

METHODS

Patients with secondary hyperparathyroidism who underwent parathyroidectomy were reviewed in the ACS-NSQIP database (2011-2016). Patients were identified by ICD codes specific to secondary hyperparathyroidism of renal origin and the ACS-NSQIP variable for current preoperative dialysis. Multivariable logistic regression was used to identify independent factors associated with prolonged LOS and 30-day readmission after parathyroidectomy.

RESULTS

The cohort included 1846 patients with secondary hyperparathyroidism on dialysis who underwent parathyroidectomy. There were 416 (22.5%) patients classified under the prolonged LOS group. On multivariable analysis, factors associated with prolonged LOS included elevated preoperative alkaline phosphatase [OR 3.13 (95%-CI 2.09-4.70), p < 0.001], decreased preoperative hematocrit [OR 1.83 (95%-CI 1.25-2.68), p = 0.002], unplanned reoperation (OR 5.02 [95%-CI 2.22-11.3], p < 0.001) and any postoperative complication [OR 6.12 (95%-CI 3.31-11.3), p < 0.001]. The overall 30-day readmission rate was 15.0%. Hypocalcemia and hungry bone syndrome accounted for 47.0% (n = 93/198) of readmissions. On multivariable analysis, patients with a history of hypertension and those undergoing unplanned reoperation were at risk of readmission [2.16 (95%-CI 1.21-3.87), p = 0.009, and 2.40 (95%-CI 1.15-5.02), p = 0.020, respectively], whereas reoperative parathyroidectomy was inversely associated with readmission (OR 0.24, 95%-CI 0.07-0.80, p = 0.021).

CONCLUSION

In patients undergoing parathyroidectomy for renal secondary hyperparathyroidism, several readily available preoperative biochemical markers, including those of increased bone turnover and anemia, are associated with prolonged postoperative LOS. Unplanned reoperation was predictive of both increased LOS and readmission.

Preoperative Nutritional Status Predicts Major Morbidity After Primary Rectal Cancer Resection

BACKGROUND

Malnutrition has been associated with adverse surgical outcomes, but data regarding its impact specifically in rectal cancer are sparse. The goal of this study was to use national data to determine the effects of malnutrition on surgical outcomes in rectal cancer resection.

METHODS

Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from the years 2012-2015. Patients were included on the basis of International Classification of Disease 9/10 and Current Procedural Terminology codes for rectal cancer and proctectomy. Malnutrition was defined as body mass index <18.5 kg/m², weight loss >10% in 6 mo, or preoperative albumin <3.5 mg/dL. Associations between malnutrition and postoperative outcomes were assessed by the Student t-test and chi-square test. Multivariate regression models were constructed to adjust for potential confounders of the association between malnutrition and surgical outcomes.

RESULTS

Of the 9289 patients with primary rectal cancer who underwent resection, 1425 (15%) were in a state of malnutrition at the time of surgery. Patients with malnutrition had longer mean length of stay (LOS), and higher rates of 30-d mortality, wound infection, organ-space infection, sepsis, reoperation, prolonged LOS (>30 d), failure to wean off ventilator, renal failure, and cardiac arrest. With the exception of LOS, renal failure, and organ-space infection, malnutrition was still significantly associated with higher rates of these adverse outcomes after adjustment for confounders in multivariate regression models.

CONCLUSIONS

Malnutrition is a practical marker associated with a variety of adverse outcomes after rectal cancer surgery, and it represents a potential target for nutritional therapies to improve surgical outcomes.

The impact of preoperative nutritional status on post-surgical complication and mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review of the literature

PURPOSE

To investigate the impact of preoperative nutritional factors [body mass index (BMI)], hypoalbuminemia (< 3.5 g/dL, sarcopenia) on complication and mortality rates after radical cystectomy (RC) for bladder cancer.

METHODS

The PubMed database was systematically searched for studies investigating the effect of nutritional status on postoperative outcomes after RC. English-language articles published between March 2010 and March 2020 were reviewed. For statistical analyses odds ratios (ORs) and hazard ratios (HRs) weighted mean was applied.

RESULTS

Overall, 81 studies were included. Twenty-nine studies were enrolled in the final analyses. Patients with a 25-29.9 kg/m² BMI (OR 1.55, 95% confidence interval [CI] 1.14-2.07) and those with a BMI ≥ 30 kg/m² (OR 1.73, 95% CI 1.29-2.40) had a significantly increased risk of 30 day complications after RC. Preoperative hypoalbuminemia increased the risk of 30 day complications (OR 1.56, 95% CI 1.07-2.35); it was a predictor of worse 3 year overall survival (OS) (HR 1.86, 95% CI 1.32-2.66). Sarcopenic patients had a higher risk of 90 day complications than non-sarcopenic ones (OR 2.49, 95% CI 1.22-5.04). Sarcopenia was significantly associated with unfavorable 5 year cancer-specific survival (CSS) (HR 1.73, 95% CI 1.07-2.80), and OS (HR 1.60, 95% CI 1.13-2.25).

CONCLUSION

High BMI, hypoalbuminemia, and sarcopenia significantly increased the complication rate after RC. Hypoalbuminemia predicted worse 3 year OS and sarcopenia predicted unfavorable 5 year CSS and OS. Preoperative assessment of RC patients' nutritional status is a useful tool to predict perioperative and survival outcomes.

The value of L3 skeletal muscle index in evaluating preoperative nutritional risk and long-term prognosis in colorectal cancer patients

L3 skeletal muscle index (L3SMI) was reportedly related to postoperative outcomes. We aimed to investigate the value of L3SMI in evaluating preoperative nutritional risk and long-term prognosis in colorectal cancer (CRC) patients. We retrospectively enrolled 400 CRC patients who underwent surgery from January 2012 to December 2014. The L3SMI was calculated by preoperative computed tomography (CT) and classified into two groups by gender quartile method. We found that the CT diagnostic criteria of sarcopenia in South China population was: male ≤38.89cm²/m², female ≤33.28cm²/m². Multivariate logistic regression analysis showed that low L3SMI was an independent risk factor for preoperative nutritional risk (p < 0.001). Kaplan-Meier survival curves showed that low status group had significantly lower disease-free survival (p = 0.004) and overall survival (p = 0.001), especially in TNM II stage. Multivariate Cox regression analysis revealed preoperative low L3SMI adversely affected disease-free survival (p < 0.001, HR 1.894 (95% CI: 1.330–2.698)), and overall survival (p < 0.001, HR 2.030 (95% CI: 1.420–2.902)). In conclusion, L3SMI is a useful supplement for screening preoperative nutritional risk and diagnosing sarcopenia, and a potential clinical indicator that can be used to predict the prognosis of CRC patients, especially TNM stage II patients.

Utility of nutritional indices in preoperative assessment of cancer patients

BACKGROUND

Malnutrition is an important but neglected predictor for outcomes and healthcare costs in cancer patients. A simple screening tool for detecting malnutrition may have clinical utility in their preoperative assessment.

OBJECTIVES

This study compared three validated indices, for their predictive ability for prolonged length of stay (LOS) and 30-day postsurgical complications in malignancies in a tertiary hospital in South India.

METHODS

342 cancer patients admitted for elective surgery were stratified on their preoperative day using MUST - Malnutrition Universal Screening Tool, SGA - Subjective Global Assessment and NRI - Nutritional Risk Index. The postoperative LOS and 30-day morbidity as per Clavien-Dindo classification (CDC) were compared to calculate the predictive accuracy of the various nutritional indices.

RESULTS

In our study, 44% patients were classified as malnourished by SGA. SGA was found to have maximum correlation coefficient with LOS (σ = 0.410), followed by MUST (σ = 0.401) and NRI (σ = 0.36). On logistic regression, MUST, NRI and SGA were all found to be significant independent predictors of LOS and CDC class. Age, acute illness and comorbidities were found to have significant confounding effects. Sensitivity of MUST and SGA to predict prolonged LOS (>10 d) were.

DISCUSSION

Our study showed that surgical cancer population was at high risk for malnutrition. MUST and SGA were good risk-stratification tools with independent predictive ability for prolonged LOS and postoperative complications. Patients having higher MUST and SGA scores fared poorly postoperatively with significant prolongation of stay. MUST had 88% agreement with SGA, and took shorter time to administer in the in-patient setting.

CONCLUSION

Routine preoperative nutritional assessment is important in cancer patients. SGA and MUST were found to be reliable tools, with MUST being the simplest and quickest tool for preoperative nutritional assessment. Patients stratified to be at risk for malnutrition may benefit with nutritional therapy.

Prevalence and risk factors for colorectal polyps in a Chinese population: a retrospective study

The incidence of colorectal polyps is rising. Certain types of polyps are considered to be the precursor lesions for colorectal cancers. To investigate the prevalence and related factors of colorectal polyps in Chinese subjects, we first performed a cross-sectional study. A total of 3066 subjects were documented, and the prevalence of colorectal polyps was 18.1%. Then we evaluated the incidence and risk factors of polyps via a retrospective cohort study in the same population. 561 subjects who received at least twice surveillance colonoscopies with available reports during the study period and had no polyp at the first endoscopy were included in the retrospective cohort study, of whom 19.1% developed colorectal polyps. Regular smoking was independently associated with the presence and development of colorectal polyps. Further analyses indicated that polyps were associated with smoking status, daily cigarette consumption, and drinking habit. Moreover, smoking tends to be more relavent to rectal, small and single polyp. In conclusion, colorectal polyp is a common disease in China. Exploring the epidemiology and risk factors may improve the prevention of colorectal polyps, even colorectal cancer.

Influence of chemoradiotherapy on nutritional status in locally advanced rectal cancer: Prospective multicenter study

OBJECTIVE

The aim of this study was to investigate the influence of chemoradiotherapy (CRT) on nutritional status and the association between changes in nutritional status and clinical outcomes (treatment completion, adverse events, perioperative complications, and relapse-free survival [RFS]) in patients with locally advanced rectal cancer (LARC).

METHODS

In this multicenter, phase II study, 41 patients with LARC underwent CRT for 5 wk, followed by a 6- to 8-wk interval before surgery. Body weight, body mass index (BMI), lean body mass, serum albumin, and prealbumin levels were measured before (pre-), during, and after CRT, and before surgery. Changes in these data and scores on the Malnutrition Universal Screening Tool (MUST) were calculated based on pre-CRT status.

RESULTS

Twelve patients (29.3%) experienced body weight loss (BWL) ≥5% (defined as malnutrition) after CRT (P < 0.001) and before surgery (P = 0.035). Significant changes were seen in serum albumin levels and BMI during and after CRT (P < 0.001), and in MUST scores after CRT (P = 0.003) and before surgery (P = 0.035). Treatment completion was significantly associated with BWL (P = 0.028), MUST score (P = 0.013), and decreased serum albumin level (P = 0.001) after CRT. Regarding adverse events, MUST score before surgery (P = 0.009) and serum albumin level after CRT (P = 0.002) were significantly associated with diarrhea severity. Serum albumin level during CRT was associated with the onset of neutropenia (P = 0.005). No association was found between BWL and RFS.

CONCLUSIONS

These findings suggest that malnutrition and changes in nutritional status are not only commonly observed after CRT, but also associated with treatment completion and adverse events.

Sarcopenia is associated with increased mortality but not complications following resection and reconstruction of sarcoma of the extremities

BACKGROUND AND OBJECTIVES

Evidence regarding the impact of sarcopenia on operative outcomes in patients with sarcoma is lacking. We evaluated the relationship between sarcopenia and postoperative complications or mortality among patients undergoing tumor excision and reconstruction. ​ METHODS: We retrospectively reviewed 145 patients treated with tumor excision and limb reconstruction for sarcoma of the extremities. Sarcopenia was defined as psoas index (PI) < 5.45 cm² /m² for men and <3.85 cm² /m² for women from preoperative axial CT. Regression analyses were used to assess the association between postoperative complications or mortality with PI, age, gender, race, body mass index, tumor histology, grade, depth, location, size, and neoadjuvant/adjuvant therapy.

RESULTS

There were 101 soft tissue tumors and 44 primary bone tumors. Sarcopenia was present in 38 patients (26%). Sarcopenic patients were older (median age: 72 vs 59 years, P = .0010) and had larger tumors (86.5%, >5 cm vs 77.7%, P = .023). Seventy-three patients experienced complications (51%) and 18 patients died within 1 year. Sarcopenia and metastatic disease were associated with increased 12-month mortality (hazard ratio [HR] = 6.68, P < .001; HR: 8.51, P < .001, respectively) but not complications (HR 1.45, P = .155, odds ratio, 1.32, P = .426, respectively).

CONCLUSIONS

Sarcopenia and metastatic disease were independently associated with postoperative mortality but no complications following surgery.

Comparison of Novel, Bach Mai Boston Tool (BBT) and the Patient-Generated Subjective Global Assessment (PG-SGA) for Oncology Inpatients

Oncology inpatients are at high risk of malnutrition. Identification of at risk patients by nutrition screening requires a practical and easy to use tool. The aim of this study was to determine the validity of the Bach Mai Boston Tool (BBT) compared to a ‘gold standard’ full nutrition assessment using the Patient-Generated Subjective Global Assessment (PG-SGA). A cross-sectional study was conducted on 270 oncology inpatients from January to December 2016. Cohen’s Kappa, sensitivity, specificity and ROC analyses were performed. 270 inpatients were included in this study with a mean age of 56.3 ± 12.1 years old. Of these patients, 51.8% were male, and 74.1% had gastrointestinal cancer. The mean body mass index of patients was 20.6 ± 3.0 kg/m². The PG-SGA tool identified 146 (54.1%) malnourished patients, while the BBT identified 105 (39.9%) malnourished patients. The BBT had a medium consistency, with a Kappa value of 0.6. Using a cut-off point of ≥ 4, the BBT had a sensitivity of 87.7% and a specificity of 72.6%. On the other hand, a BBT with a cut-off point ≥ 5 resulted in a sensitivity of 67.1%, a specificity of 94.4%, and an AUC of 0.81. The BBT is a practical, informative and valid tool for detecting malnutrition in hospitalized oncology patients. We recommend using a cut-off point of 4 for screening the risk of malnutrition for oncology inpatients.

Hypoalbuminemia and Obesity in Orthopaedic Trauma Patients: Body Mass Index a Significant Predictor of Surgical Site Complications

The purpose of this investigation was to identify the prevalence of hypoalbuminemia and obesity in orthopaedic trauma patients with high-energy injuries and to investigate their impact on the incidence of surgical site complications. Patients 18 years of age and older undergoing intramedullary nail fixation of their femoral shaft fractures at a university-based level-1 trauma centre were assessed. Malnutrition was measured using serum markers (albumin <3.5 g/dL) as well as body mass index (BMI) as a marker of obesity (BMI > 30 kg/m²). The primary outcome measure was surgical wound complications. A total of 249 patients were included in this study. Ninety-eight patients (39.4%) presented with hypoalbuminaemia and 80 patients (32.1%) were obese. The overall incidence of wound complications in our study population was 9.65% (n = 25/259). A logistic regression model showed that non-obese patients (BMI < 30 kg/m²) were at significantly reduced risk for perioperative wound complications (Odds Ratio 0.400 [95% confidence interval 0.168, 0.954], p = 0.039). This study demonstrated a substantial prevalence of hypoalbuminemia and obesity among orthopaedic trauma patients with high-energy injuries. Obesity may increase the risk of surgical site complications. Future studies are required to further define malnutrition and its correlation with surgical site complications in orthopaedic trauma patients.

Body Mass Index and Modified Glasgow Prognostic Score Are Useful Predictors of Surgical Site Infection After Spinal Instrumentation Surgery: A Consecutive Series

STUDY DESIGN

Retrospective observational study.

OBJECTIVE

To analyze a large consecutive cohort of patients who had undergone spinal instrumentation surgery, to characterize a patient population with surgical site infections (SSI), and to identify preoperative risk factors associated with SSI.

SUMMARY OF BACKGROUND DATA

Malnutrition is a risk factor for SSI in many health conditions; however, the evidence connecting preoperative malnutrition with SSI in spinal instrumentation surgery is limited because of the small number of retrospective studies. While the modified Glasgow prognostic score (mGPS), C-Reactive protein (CRP)-albumin ratio (CAR), controlling nutritional status index (CONUT), prognostic nutritional index (PNI), platelet-lymphocyte ratio (PLR), and neutrophil-lymphocyte ratio (NLR) are established methods for evaluating nutritious status, little has been reported on the predictive value of these indicators with respect to postoperative spinal infection.

METHODS

We retrospectively investigated 384 patients who underwent spinal instrumentation surgery. We evaluated the significance of risk factors, including mGPS, CAR, CONUT, PNI, PLR, and NLR. We then performed stepwise logistic regression analysis to analyze the concurrent effects of various factors on the prevalence of SSI.

RESULTS

Of the 384 patients analyzed, 14 were diagnosed with SSIs. Univariate analysis showed that preoperative BMI, lymphocyte count, albumin, erythrocyte sedimentation rate, CRP, CONUT, mGPS, CAR, and PNI were risk factors for SSI. Stepwise logistic regression analysis revealed that higher mGPS and lower BMI before surgery were independent risk factors for SSI. A receiver operating characteristic curve showed that the cut-off values of mGPS and BMI were 1 and 20.39, respectively.

CONCLUSION

The risk factors for SSI after spinal instrumentation surgery were mGPS more than or equal to 1 and BMI less than or equal to 20.39 kg/m. These findings could help to identify patients at higher risk of SSI after spinal instrumentation surgery.

LEVEL OF EVIDENCE

4.

When and how should surgery be performed in senior colorectal cancer patients?

Older studies reported high rates of postoperative morbidity and mortality in the senior population, which lead to a tendency to withhold curative surgery in the older population. However, more recent studies showed impressing developments in postoperative outcomes in seniors. Probably, these improvements are due to enhancements in both surgical and non-surgical aspects in the pre-, peri- and postoperative period, such as minimally invasive techniques and anesthesiological insights. The postoperative survival gap seen earlier between younger and older patients is fading. For optimal treatment in the older population, special awareness and care on several aspects is needed. As only a minority of the seniors are frail, a quick frailty assessment is crucial to distinguish the fit from the frail in the decision-making process. In addition, it could be valuable to improve the lacks in physical condition in the preoperative period with the use of prehabilitation programs. Furthermore, it is important to evolve an emergency to an elective setting by postponing emergency surgery to prevent any high-risk situation. In conclusion, based on modern insights, surgery is a valid option in the curative treatment of colorectal cancer in seniors, however individual attention and care is required.

The relation between Malnutrition Universal Screening Tool (MUST), computed tomography-derived body composition, systemic inflammation, and clinical outcomes in patients undergoing surgery for colorectal cancer

BACKGROUND

Nutritional status is an important factor affecting a patient's clinical outcomes. Early identification of patients who are at risk of malnutrition is important to improve clinical outcomes and reduce health cost. The Malnutrition Universal Screening Tool (MUST) has been recommended as part of the routine nursing assessment for all patients at hospital admission.

OBJECTIVE

The aim of this study was to examine the association between nutritional status (MUST), systemic inflammatory response (SIR), body composition, and clinical outcomes in patients undergoing surgery for colorectal cancer.

METHODS

The malnutrition risk was examined using MUST in patients admitted for surgery for colorectal cancer between March 2013 and June 2016. Preoperative computed tomography scans were used to define the body composition. The presence of SIR was evidenced by the modified Glasgow prognostic score and the neutrophil to lymphocyte ratio. Postoperative complications, severity of complication, length of hospital stay, and mortality were considered as outcome measures.

RESULTS

The study included 363 patients (199 males, 164 females); 21% of the patients presented with a medium or high nutritional risk. There were significant associations between MUST and subcutaneous adiposity (P < 0.001), visceral obesity (P < 0.001), and low skeletal muscle index (P < 0.001). No statistically significant association was identified between MUST score and presence of any complication or severity of complication. On multivariate analysis, MUST remained independently associated with the length of hospital stay (OR: 2.17; 95% CI: 1.45, 3.26; P < 0.001). Kaplan-Meier survival curves showed an increased number of deaths for patients at medium or high risk of malnutrition (P < 0.001). This association was found to be independent of other confounding factors (HR: 1.45; 95% CI: 1.06, 1.99; P = 0.020).

CONCLUSIONS

MUST score is an independent marker of risk in those undergoing surgery for colorectal cancer and should remain a key part of preoperative assessment.

C-Reactive Protein-to-Albumin Ratio as Prognostic Marker for Anal Squamous Cell Carcinoma Treated With Chemoradiotherapy

Background: Definitive chemoradiotherapy (CRT) is the primary treatment for non-metastatic anal squamous cell carcinoma (ASCC). Despite favorable treatment outcomes in general, failure rates up to 40% occur in locally advanced disease. For treatment escalation or de-escalation strategies easily assessable and valid biomarkers are needed. Methods: We identified 125 patients with ASCC treated with standard CRT at our department. C-reactive protein (CRP) to albumin ratio (CAR) was calculated dividing baseline CRP by baseline albumin levels. We used maximally selected rank statistics to dichotomize patients to high and low risk groups. Associations of CAR with clinicopathologic parameters were evaluated and the prognostic impact was tested using univariate and multivariate cox regression analysis. In a subset of 78 patients, pretreatment tumor tissue was available and CD8+ tumor infiltrating lymphocytes (TILs) and p16^INK4a status were scored by immunohistochemistry and correlated with CAR. Results: Advanced T-stage and male gender were significantly associated with higher baseline CAR. Using the calculated cutoff of 0.117, a high baseline CAR was also associated with worse locoregional control (p = 0.002), distant metastasis-free survival (p = 0.01), disease-free survival (DFS, p = 0.002) and overall survival (OS, p < 0.001). A combined risk score incorporating N-stage and CAR, termed N-CAR score, was associated with worse outcome across all endpoints and in multivariate analysis independent of T-stage and Gender (HR 4.27, p = 0.003). In the subset of 78 patients, a strong infiltration with intratumoral CD8+ TIL was associated with a significantly lower CAR (p = 0.007). CAR is an easily accessible biomarker that is associated with DFS. Our study revealed a possible link between chronic systemic inflammation and an impaired intratumoral immune response.

Validation of CIPA nutritional screening through prognostic clinical variables in hospitalized surgical patients

INTRODUCTION

CIPA (Control of Food Intake, Protein, and Anthropometry) nutritional screening is positive when one of the following conditions is met: Control of Food Intake for 48-72h <50%; Albumin <3g/dL, Body Mass Index <18.5kg/m² or Arm Circumference ≤22.5cm. Following its validation in non-surgical inpatients, the same process was performed with surgical inpatients.

OBJECTIVES

Validity of the CIPA screening tool in surgical inpatients by comparison with Subjective Global Assessment (SGA) and analysis of clinical outcomes.

MATERIAL AND METHODS

A prospective study of hospitalized surgical patients, evaluating the prevalence or risk of malnutrition through CIPA and SGA. Analysis of hospital malnutrition according to CIPA screening and association with the clinical outcomes of median length of stay, mortality and early readmission. Concordance between both screening methods by Kappa Index (κ), sensitivity (S) and specificity (SP).

RESULTS

A total of 226 patients were analysed. The prevalence of malnutrition or risk of malnutrition was identified by CIPA in 35.40% and by SGA in 30.08%. CIPA is capable of detecting patients at a greater risk of mortality during hospitalization (5% vs. 0%, P=.006), unlike the SGA (2.94% vs. 1.27%, P=.385). CIPA also detected patients with higher median length of stay (21 days [IQR 14-34 days] vs. 14.5 days [IQR 9-27 days], P=.002) and rate of early readmissions (25.3% vs. 8.2%, P<.001). S and SP of CIPA vs. SGA was 70.59% and 79.75%, respectively; Kappa index was 0.479 (P<.001).

CONCLUSIONS

Using CIPA nutritional screening, the prevalence and risk of malnutrition in surgical patients is high, and they present poorer clinical outcomes, making CIPA valid and effective in this type of patients.

Nutritional, immunological and antioxidant defense status of outpatients diagnosed with colorectal cancer - a case-control study of the little-studied population

This cross-sectional study was conducted to investigate nutritional and immunological status of colorectal cancer (CRC) patients in a little-studied population from developing country, Pakistan. Data on 81 CRC patients and 37 healthy controls (HCs) were collected on nutritional status, nutrient intake, percent body fat (%BF), selected immunological parameters, phytochemical index (PI), healthy eating index (HEI), and prognostic nutrition index (PNI). Blood samples were used for immunological and antiradical defense potential (expressed as 50% hemolysis time; HT₅₀). Results show 40/81 (49.4%) patients reported weight loss in past 3-6 mo, Significant differences were found in HEI values between patients vs. HCs, and between patients in low vs. high PNI groups (P, for all trends <0.05). Patients in the higher PNI group were heavier, had higher % BF, higher energy intake, and higher PI score as compared to patients in the low PNI group (P < 0.05). Low PNI was positively associated with non-significantly lower CD4:CD8 ratios, higher B-cells and NK cells (P, for all trends >0.05), but with significantly higher hs-CRP levels, and lower HT₅₀ values (P, for all trends <0.001). In conclusion, CRC patients in a little-studied population have compromised nutritional and immunological health with lower HEI and PNI scores.

Weight loss and BMI criteria in GLIM's definition of malnutrition is associated with postoperative complications following abdominal resections - Results from a National Quality Registry

BACKGROUND & AIMS

Although malnutrition is thought to be common among patients with intraabdominal diseases and is recognized as a risk factor for postoperative complications, diagnostic criteria for malnutrition have not been consistent. Thus, the Global Leadership Initiative in Malnutrition (GLIM) has recently published new criteria for malnutrition. The aims of this study were to investigate the prevalence of malnutrition according to weight loss and BMI criteria in GLIM's second step for the diagnosis and their association with severe postoperative complications in patients undergoing gastrointestinal resections.

METHOD

The current study includes adult patients who were prospectively included in the Norwegian Registry for Gastrointestinal Surgery in the period between 2015 and 2018. Exclusion criteria were acute surgery and lack of information regarding preoperative weight and/or postoperative complications. Severe surgical complications were classified according to the Revised Accordion Classification system and malnutrition with the GLIM criteria. Associations were assessed by logistic regression analyses, and the adjusted odds ratio included age (continuous), gender (male/female) and scores from the American Society of Anesthesiologists Physical Status Classification System and the Eastern Cooperative Oncology Group.

RESULTS

Out of 6110 patients, 2161 (35.4%) were classified as with malnutrition, 1206 (19.7%) with moderate and 955 (15.6%) with severe malnutrition. Malnourished patients were 1.29 (95% CI: 1.13-1.47) times more likely to develop severe surgical complications, and 2.15 (95% CI: 1.27-3.65) times more likely to die within 30 days, as compared to those who were not.

CONCLUSION

Preoperative malnutrition is common among patients having gastrointestinal resections and is associated with an increased risk of severe surgical complications.

Clinical Factors Associated with Longer Hospital Stay Following Ovarian Cancer Surgery

Background: Ovarian cancer (OC) is the leading cause of death from gynecologic malignancy and is treated with a combination of cytoreductive surgery and platinum-based chemotherapy. Extended length of stay (LOS) after surgery can affect patient morbidity, overall costs, and hospital resource utilization. The primary objective of this study was to identify factors contributing to prolonged LOS for women undergoing surgery for ovarian cancer. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify women from 2012-2016 who underwent hysterectomy for ovarian, fallopian tube and peritoneal cancer. The primary outcome was LOS >50th percentile. Preoperative and intraoperative variables were examined to determine which were associated with prolonged LOS. Results: From 2012-2016, 1771 women underwent elective abdominal surgery for OC and were entered in the ACS-NSQIP database. The mean and median LOS was 4.6 and 4.0 days (IQR 0-38), respectively. On multivariate analysis, factors associated with prolonged LOS included: American Society of Anesthesiologists (ASA) Classification III (aOR 1.71, 95% CI 1.38-2.13) or IV (aOR 1.88, 95% CI 1.44-2.46), presence of ascites (aOR 1.88, 95% CI 1.44-2.46), older age (aOR 1.23, 95% CI 1.13-1.35), platelet count >400,000/mm3 (aOR 1.74, 95% CI 1.29-2.35), preoperative blood transfusion (aOR 11.00, 95% CI 1.28-94.77), disseminated cancer (aOR 1.28, 95% CI 1.03-1.60), increased length of operation (121-180 min, aOR 1.47, 95% CI 1.13-1.91; >180 min, aOR 2.78, 95% CI 2.13-3.64), and postoperative blood transfusion within 72 h of incision (aOR 2.04, 95% CI 1.59-2.62) (p < 0.05 for all). Conclusions: Longer length of hospital stay following surgery for OC is associated with many patient, disease, and treatment-related factors. The extent of surgery, as evidenced by perioperative blood transfusion and length of surgical procedure, is a factor that can potentially be modified to shorten LOS, improve patient outcomes, and reduce hospital costs.