Nutritional assessment and the role of preoperative parenteral nutrition in the colon cancer patient

A case report on multidisciplinary approach towards management of gastrojejunocolic fistula secondary to adenocarcinoma of the colon

INTRODUCTION

Gastrojejunocolic fistula is an abnormal communication between a portion of the stomach, jejunum and the transverse colon. Gastrojejunocolic (GJC) fistula is an outcome resulting from the surgical procedures of gastrectomy and gastrojejunostomy used to address recurrent peptic ulcer disease and secondary to malignancy. Patients present with the typical symptoms of diarrhea, belching with fecal odor or fecal vomiting and weight loss. Gastrojejunocolic fistula is a rare complication of adenocarcinoma of the colon. En-bloc resection followed by adjuvant chemotherapy helps in managing GJC fistula secondary to adenocarcinoma of colon.

CASE RESENTATION

A 55-year-old male from a rural area presented with a two months history of black stool, vomiting, loose stools, and abdominal pain. He had a history of significant weight loss, chronic alcohol use, and smoking. Investigations revealed anemia, hyponatremia, hypoalbuminemia, and a large exophytic mass on Contrast-Enhanced Computed Tomography (CECT), suggestive of gastrojejunocolic fistula from a carcinoma. Upper gastrointestinal endoscopy showed an ulcero-proliferative growth with high-grade dysplasia. Biochemical tests revealed elevated carcinoembryonic antigen (CEA) levels. The patient underwent surgery for en bloc resection of the stomach, jejunum and transverse colon. Histology confirmed adenocarcinoma of colon with TNM stage IIIC. Post-operative gastrocutaneous fistula was managed conservatively and colostomy reversal was done for prolapse colostomy. He has completed the chemotherapy Capecitabine-Oxaliplatin (CAPOX) regimen. He is doing well and under follow-up for six months post-surgery.

DISCUSSION

Gastrojejunocolic fistula secondary to carcinoma is a rare finding. Gastrojejunocolic fistula originate from the direct spread of the tumor across the gastrocolic omentum or an ulcer in the tumor could trigger an inflammatory peritoneal response, resulting in adhesion and the formation of a fistula.

CONCLUSION

This case highlights the successful management of a gastrojejunocolic fistula secondary to adenocarcinoma of colon through three stage surgery; diverting stoma, en bloc resection, colostomy reversal surgery along with chemotherapy. Despite post-operative complications, including a gastro-cutaneous fistula and prolapsed colostomy, the patient responded well to treatment. Multidisciplinary approaches and careful monitoring are essential in resource-limited settings for improved patient outcomes.

Management of complications in surgery of the colon

BACKGROUND

General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly.

METHODS

We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads).

RESULTS

Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision®, Ligasure®) as well as a well coordinated team help to reduce complications and duration of surgery.

CONCLUSIONS

To avoid is better than to repair. If complications do occur, appropriate surgical and intensive - care measures should be taken immediately.

Adequate nourishment through total parenteral nutrition treatment may augment immune function in patients with colon cancer

BACKGROUND

Our objective was to evaluate immune function after total parenteral nutrition (TPN) treatment in colorectal cancer patients.

METHODS

Data were collected from 11 patients with colorectal cancer who received total parenteral nutrition. Healthy medical staff volunteers were used as controls. Delay hypersensitivity skin test with eight agents tested was used before total parenteral nutrition (TPN) treatment. Phytohemagglutinin (PHA)-stimulated lymphocyte proliferation and mononuclear cytokine production (IL-1 beta, IL-2, IFN gamma), serum ICAM-1 and IL-6, and lymphocyte subpopulation including CD4, CD8, and CD4/CD8 ratio were measured before and after TPN treatment.

RESULTS

Each patient had at least four of seven positive skin tests. After TPN treatment, lymphocyte proliferation increased remarkably (27,450 +/- 16,800 vs. 41,738 +/- 28,484, p=0.0168) and showed no significant difference to control group (p=0.0269). Levels of IL-1beta, IL-2, and IFN gamma after LPS-stimulation showed no significant difference before and after TPN treatment. Serum ICAM-1 showed a significant difference (388 +/- 158 vs. 481 +/- 210, p=0.0023) before and after TPN treatment. IL-6 was significantly different between patient and control groups but not different between patients before and after TPN treatment.

CONCLUSIONS

This study showed a significant increase of mitogen-stimulated lymphocyte proliferation and intercellular adhesion molecular 1 (ICAM-1) level after TPN supply. Adequate nutrition through TPN may augment immune function.

Nutritional status and cytokine-related protein breakdown in elderly patients with gastrointestinal malignancies

BACKGROUND

Age-related factors affecting cytokine-related whole-body protein breakdown and their relation to clinical outcomes in cancer patients were investigated.

METHODS

For assessment of protein-calorie malnutrition and protein breakdown, the creatinine height index (CHI) and daily urinary excretion of 3-methylhistidine (3-MH) were measured in 70 patients with gastrointestinal malignancies. Perioperative cytokine profile was evaluated to assess its relation to perioperative protein catabolism.

RESULTS

In elderly patients, daily 3-MH excretion during the stable preoperative period decreased with the increase of tumor interleukin (IL)-6 production, suggestive of the activation of a metabolic compensation mechanism. However, these patients showed significant increases in postoperative 3-MH excretion in accord with perioperative systemic IL-6 response, and this deterioration of the compensating mechanism seemed to be associated with poor clinical outcome. An increase in 3-MH excretion under surgical stress was positively correlated with postoperative consumption of IL-6 soluble receptor (sR) in elderly patients with nutritional depletion.

CONCLUSIONS

In elderly cancer patients with protein-calorie malnutrition, metabolic compliance against intrinsic IL-6 may be compensated for in the preoperative stable period, but deteriorate from surgical insults. This mechanism might involve increased affinity of IL-6 with IL-6sR under surgical stress.

Respiratory complications associated with anesthesia

Adverse pulmonary outcomes that follow anesthesia and surgery are often attributed to anesthesia care. PPCs are a significant concern for anesthesia caregivers because they use drugs and techniques that temporarily decrease lung volume, impair airway reflexes, limit immune function, and depress secretion mobilization. A significant component of perioperative risk derives from the surgical site, postoperative pain, and effects of pharmacologic pain management. Rapidly evolving surgical and anesthesia techniques and the introduction of newer pharmaceutical agents make it difficult to identify best practice from retrospective experience reported in the perioperative literature. Prospective studies that deal with specific patient populations, incomparable patient groups or techniques, and unique practice bias have limited validity of claims regarding several promising approaches to perioperative risk reduction. In the absence of clear scientific principles, a perioperative pulmonary risk management strategy for the early part of this century is based on the consensus practice of informed clinicians (Box 4).

Nutritional support of the cancer patient: issues and dilemmas

Malnutrition in cancer patients results from multifactorial events and is associated with an alteration of quality of life and a reduced survival. A simple nutritional assessment program and early counselling by a dietitian are essential to guide nutritional support and to alert the physician to the need for enteral (EN) or parenteral nutrition (PN). A daily intake of 20-35 kcal/kg, with a balanced contribution of glucose and lipids, and of 0.2-0.35 g nitrogen/kg is recommended both for EN and PN, with an adequate provision of electrolytes, trace elements and vitamins. EN, always preferable for patients with an intact digestive tract, and PN are both safe and effective methods of administering nutrients. The general results in clinical practice suggest no tumor growth during nutritional support. The indiscriminate use of conventional EN and PN is not indicated in well-nourished cancer patients or in patients with mild malnutrition. EN or PN is not clinically efficacious for patients treated with chemotherapy or radiotherapy, unless there are prolonged periods of GI toxicity, as in the case of bone marrow transplant patients. Severely malnourished cancer patients undergoing major visceral surgery may benefit from perioperative nutritional support, preferably via enteral access. Nutritional support in palliative care should be based on the potential risks and benefits of EN and PN, and on the patient's and family's wishes. Research is currently directed toward the impact of nutritional pharmacology on the clinical outcome of cancer patients. Glutamine-supplemented PN is probably beneficial in bone marrow transplant patients. Immune diets are likely to reduce the rate of infectious complications and the length of hospital stay after GI surgery. Further studies are needed to determine the efficacy of such novel approaches in specific populations of cancer patients, and should also address the question of the overall cost-benefit ratio of nutritional pharmacology, and the effect of nutritional support on length and quality of life.

The Swedish version of the patient-generated subjective global assessment of nutritional status: gastrointestinal vs urological cancers

PURPOSE

To translate and evaluate the Patient-Generated Subjective Global Assessment (PG-SGA) a method for the assessment of nutritional status.

METHOD

Eighty-seven patients with gastrointestinal and urological tumours completed four sections and the remaining sections were independently completed by a doctor and a dietician. Patients were classified as SGA A (well nourished), SGA B (moderately/suspected of being malnourished) or SGA C (severely malnourished).

RESULTS

Interobserver agreement was complete in 90% of the cases. More patients with gastrointestinal cancers than with urological cancers were classified as SGA B and C. Mean levels of S-albumin and P-prealbumin differed between the SGA-classes. Multivariate logistic regression analyses showed independent contributions to the overall classification by weight loss in the last 6 months, level of food intake, problems with eating, physical activity and muscle wastage. Survival was significantly higher in SGA A than in SGA B+C, P < 0.001.

CONCLUSION

The PG-SGA is useful for the assessment of nutritional status. Patients had no problems in answering the questions. The PG-SGA also carried prognostic information.

Preoperative oral supplement with immunonutrients in cancer patients

BACKGROUND

Early postoperative enteral nutrition with immune-enhancing supplements has helped to restore immune function and reduce infectious complications in patients with cancer undergoing major gastrointestinal operations. The aim of this study was to evaluate the effectiveness of similar supplements (containing arginine and arginine plus omega-3 fatty acids) given preoperatively for 1 week before cancer surgery.

METHODS

In this randomized, double-blinded study, patients scheduled to undergo elective resection of upper gastrointestinal tumors were given one of three different oral liquid supplemental diets (control, arginine, arginine plus omega-3 fatty acids) to be taken each day for 7 days before surgery. Blood samples were obtained upon enrollment, on the morning of surgery, and on postoperative day 1 for analysis of immunologic function.

RESULTS

Mean serum ornithine (a metabolite of arginine) levels were significantly higher compared with controls, but no significant increase in mean serum arginine levels was noted on the morning of surgery for those patients who received arginine as part of the supplement. In conjunction with these findings, there were no differences among groups in mean lymphocyte mitogenesis, mean peripheral blood mononuclear cell production of cytokines, or clinical outcomes.

CONCLUSIONS

Use of oral liquid supplements in this fashion did not improve lymphocyte proliferation or monocyte functions in patients with cancer undergoing major surgery.