Postoperative nasogastric tube feeding in patients with head and neck cancer: a prospective assessment of nutritional status and well-being

ESPEN practical guideline: Clinical nutrition in surgery

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

A Necessary Evil? Patients' Experiences Receiving Tube Feeding in Acute Care

BACKGROUND

Tube feeding (TF) is frequently prescribed for adults admitted to acute care facilities to prevent or ameliorate malnutrition, yet little is known about patients' needs and experiences with receiving this therapy. Patients' perspectives regarding the factors influencing their experiences, as well as their information and support needs, are required to inform healthcare providers' (HCPs') patient-centered practices.

METHODS

Based on an interpretive description qualitative approach, 12 unstructured face-to-face interviews were conducted with participants admitted to acute care hospitals in Northwestern Ontario, Canada.

RESULTS

Analysis of data revealed variations in participants' perceptions of the necessity for TF and the discomfort resulting from this therapy. Perceived necessity was influenced by interrelated themes: the meaning of TF (beyond necessity), the trust held in HCPs, and the resilience of participants in response to all that they were experiencing. Collectively, these findings are encompassed within the central theme, phrased as a question, about the experience of TF: "A necessary evil?" Participants' answers to this question revealed the nature of their overall response throughout TF therapy (ie, indifferent, resistant, relieved, or tolerant).

CONCLUSIONS

The range of perceptions and the complexity of patients' experiences during TF revealed in the data can inform HCPs' patient-centered approaches to TF care. Assessing and incorporating patients' values, beliefs, needs, and goals into, and exploring their choices in, nutrition care planning can promote resilience in response to TF therapy. HCPs may then well enhance patients' comfort and overall experience with TF therapy.

Recommended European Society of Parenteral and Enteral Nutrition protein and energy intakes and weight loss in patients with head and neck cancer

BACKGROUND

Information regarding attenuation of weight loss in patients with head and neck cancer consuming energy and protein intakes at levels recommended by the European Society of Parenteral and Enteral Nutrition (ESPEN) is limited.

METHODS

Newly diagnosed patients with head and neck cancer (n = 38) consuming food orally had weight and 3-day diet records prospectively collected at baseline, the end of treatment, and at the 2.5-month follow-up. Weight loss of patients consuming the ESPEN recommendations of ≥30 kcal/kg/d energy and 1.2 g/kg/d protein versus those consuming less were compared. Weight loss of oral nutrition supplement consumers versus oral nutrition supplement nonconsumers was also compared.

RESULTS

Despite ≥30 kcal/kg/d intakes at posttreatment and follow-up, mean weight loss was 10.3% from baseline to posttreatment, and 4.0% from posttreatment to follow-up. At posttreatment, oral nutrition supplement consumers with intakes ≥30 kcal/kg/d lost twice as much weight as nonconsumers with intakes of ≥30 kcal/kg/d (p = .001).

CONCLUSION

Current ESPEN recommendations may not attenuate weight loss in patients with head and neck cancer, especially those consuming oral nutrition supplements. © 2016 Wiley Periodicals, Inc. Head Neck 38:1248-1257, 2016.

Different experiences and perspectives between head and neck cancer patients and their care-givers on their daily impact of a gastrostomy tube

BACKGROUND

Gastrostomy feeding in head and neck cancer patients is recognised standard practice in some cancer centres with beneficial effects on outcomes for appropriately selected patients. However, the impact on patients and care-givers needs consideration. The present study aimed to understand the daily impact of gastrostomy feeding on head and neck cancer patients and their care-givers to identify improvements to services.

METHODS

Twenty-one adult patients were randomly selected from the Head and Neck centre at University College London Hospital. Six head and neck cancer patients and three care-givers participated in focus groups. The sessions were recorded, fully transcribed and qualitatively thematically analysed, and the resulting data were tabulated.

RESULTS

Patients and care-givers expressed opposite experiences within knowledge and understanding of why the tube was necessary; their personal perceptions and objectives of nutritional support. Themes expressing similar experiences included: developing positive coping strategies; preventing nutritional decline; tube dependency; dentures; finance; active care; and psychological support. Furthermore, both groups expressed the benefits of retaining a support network for rehabilitation with the hospital-based specialist team. Also patients and carers recognised that the gastrostomy tube helped patient survival and, with timely dietetic management, helped them wean off the tube reliance with more confidence.

CONCLUSIONS

It is essential that patients and care-givers attend pretreatment clinics to discuss nutritional support via the artificial route; their quality of life can be enhanced if guided through a specialist support pathway based at the clinical site where they initiated their care, with links to key agencies.

Surgery and transplantation - Guidelines on Parenteral Nutrition, Chapter 18

In surgery, indications for artificial nutrition comprise prevention and treatment of catabolism and malnutrition. Thus in general, food intake should not be interrupted postoperatively and the re-establishing of oral (e.g. after anastomosis of the colon and rectum, kidney transplantation) or enteral food intake (e.g. after an anastomosis in the upper gastrointestinal tract, liver transplantation) is recommended within 24 h post surgery. To avoid increased mortality an indication for an immediate postoperatively artificial nutrition (enteral or parenteral nutrition (PN)) also exists in patients with no signs of malnutrition, but who will not receive oral food intake for more than 7 days perioperatively or whose oral food intake does not meet their needs (e.g. less than 60–80%) for more than 14 days. In cases of absolute contraindication for enteral nutrition, there is an indication for total PN (TPN) such as in chronic intestinal obstruction with a relevant passage obstruction e.g. a peritoneal carcinoma. If energy and nutrient requirements cannot be met by oral and enteral intake alone, a combination of enteral and parenteral nutrition is indicated. Delaying surgery for a systematic nutrition therapy (enteral and parenteral) is only indicated if severe malnutrition is present. Preoperative nutrition therapy should preferably be conducted prior to hospital admission to lower the risk of nosocomial infections. The recommendations of early postoperative re-establishing oral feeding, generally apply also to paediatric patients. Standardised operative procedures should be established in order to guarantee an effective nutrition therapy.

ESPEN Guidelines on Parenteral Nutrition: surgery

In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.

ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation

Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

BACKGROUND

Malnourished head and neck cancer patients are at increased risk of postoperative complications.

OBJECTIVE

We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss >10% of body weight) head and neck cancer patients undergoing major surgery.

DESIGN

Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding.

RESULTS

Patients in both prefed groups received approximately 9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1, 2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor alpha and P = 0.042 for interleukin 6) at the start of the study than did patients who died.

CONCLUSIONS

Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses.

Quality of life and home enteral tube feeding: a French prospective study in patients with head and neck or oesophageal cancer

A prospective study was conducted to evaluate the impact of home enteral tube feeding on quality of life in 39 consecutive patients treated for head and neck or oesophageal cancer at the Centre François Baclesse in Caen, France. Patients were taken as their own controls. Quality of life was evaluated using the EORTC QLQ-C30 core questionnaire, and the EORTC H&N35 and OES24 specific questionnaires. The feeding technique tolerance was evaluated using a questionnaire specifically developed for this study. Two evaluations were made, the first a week after hospital discharge (n = 39) and the second 3 weeks later (n = 30). Overall, the global health status/quality of life scale score slightly improved; among symptoms, scale scores that significantly improved (P < 0.05) concerned constipation, coughing, social functioning and body image/sexuality. The physical feeding technique tolerance was acceptable while the technique was psychologically less tolerated with two-thirds of the patients longing to have the tube removed. One third of the patients was also uncomfortable about their body image. Home enteral tube feeding was responsible for not visiting family or close relations in 15% of patients, and not going out in public in 23%. We conclude that home enteral tube feeding is a physically well accepted technique although a substantial proportion of patients may experience psychosocial distress.

The change in serum protein concentration in response to the stress of total joint surgery: a comparison of older versus younger patients

OBJECTIVE

To investigate whether the physiological response to surgery-induced stress, as measured by changes in serum secretory proteins, is more profound on older than in younger total joint arthroplasty patients.

DESIGN

Retrospective study.

SETTING

A 267-bed teaching hospital.

PARTICIPANTS

A total of 220 ambulatory patients with normal admission serum albumin levels, of whom 106 were 65 years of age or older (mean age 73.3 +/- 6.2 years) and 114 less than age 65 (mean age 48.8 +/- 12.2 years).

METHODS

Serum albumin and transferrin levels obtained at admission an on the fifth and tenth postoperative days were compared in the two age groups.

RESULTS

In both age groups, admission serum albumins were significantly higher than on the corresponding postoperative Day 5 levels (40.4 +/- 3.7 g/L vs 25.0 +/- 3.3 g/L, P < .0001 and 39.5 +/- 2.5 g/L vs 23.9 +/- 3.1 g/L, P < .001 in older and younger patients, respectively). The drop in the serum concentration of albumin by postoperative Day 5 in the older patients was not significantly different from that of the younger patients (a drop of 15.6 +/- 3.3 g/L in older vs 15.4 +/- 4.4 g/L for the younger, P = .740). Among the 64 patients who remained in the hospital 10 days subsequent to surgery, the average postoperative Day 10 serum albumin concentration was significantly lower in the older patients when compared with the younger (26.2 vs 29.1 g/L P = .016). Similar results were obtained for serum transferrin.

CONCLUSIONS

Subsequent to elective arthroplasty, the magnitude of change in serum albumin and transferrin concentrations is similar in older compared with younger, patients, suggesting that this stress response to surgery is nor age dependent. In contrast, the rate of recovery of the serum protein concentrations to preoperative levels may be slower in the older patients. However, this issue needs to be investigated further.

Nutritional support and prognosis in patients with head and neck cancer

We retrospectively studied the relationship between nutritional status as indicated by the presence or absence of the cutaneous delayed hypersensitivity response and treatment-related morbidity, disease recurrence, and survival at 2 years in 67 consecutive patients with head and neck carcinoma. Serial nutritional assessments were conducted throughout the course of combined initial antineoplastic treatment and nutritional support. The presence of cell-mediated immunity at the end of treatment was associated with a 2-year survival rate of 100%, whereas patients who were anergic at the end of treatment had a 2-year survival rate of 48% (P < 0.01). Morbidity due to surgical therapy and tumor recurrence rates were also higher in the anergic group (P < 0.01). Prognosis in head and neck cancer is based on many factors, but vigorous nutritional support during initial treatment may have some effect on morbidity, tumor recurrence, and survival time.

Strategies and needs for nutritional support in cancer surgery

Nutritional therapy in tumor patients undergoing surgery should be regarded as a supportive therapy. They render the operation tolerable or even feasible, and they have a positive effect on postoperative progress and wound healing. Malnourished patients definitely profit from nutritional therapy. However, the effectiveness of a nutritional regimen should not be overestimated: postoperative progress, wound healing, and complication rate depend not only on nutritional status but also on the nature of the operation, age, and preoperative treatment. As a rule, parenteral feeding is superior to enteral feeding directly after surgery. Enteral nutritive regimens are to be favored when long-term feeding is indicated: in this case the advantages of this type of feeding prevail.