Preoperative and postoperative nutritional status of patients following pelvic exenteration surgery for rectal cancer

Nutrition-related predictors of complications and length of hospital stay following total pelvic exenteration surgery

BACKGROUND & AIMS

Pelvic exenteration (PE) surgery is now a widely accepted procedure that is increasingly being performed worldwide but has significant morbidity. Although nutrition status, body mass index (BMI) and postoperative nutrition support practices are modifiable risk factors, few studies have examined the relationship of these with clinical outcomes following PE. The aim of this study was therefore to investigate the impact of these factors on postoperative complications and length of hospital stay (LOHS) following PE.

METHODS

This was a retrospective cohort study of all patients having total PE surgery at a tertiary teaching hospital from 2012 to 2021 (n = 69). Multivariable analyses were undertaken to confirm univariate associations and adjust for confounding variables. Binary logistic regression was undertaken to explore predictors of infectious and Grade III or above Clavien-Dindo complications, and negative binomial regression to identify predictors of LOHS.

RESULTS

Patients who were malnourished according to the Subjective Global Assessment were 5.66 (OR 5.66, 95% CI 1.07-29.74, p = 0.041) times more likely to develop an infectious complication. Increasing BMI was independently associated with development of Grade III or above Clavien-Dindo complications (p = 0.040). For each additional day until full diet commencement, there was a 19% (OR: 1.19, 95% CI 1.05-1.34, p = 0.005) increased incidence of significant complications and a 5.6% (IRR: 1.056, 95% CI: 1.02-1.09, p = 0.002) longer LOHS on multivariable analysis. There was a high rate of prolonged postoperative ileus (78%). The implementation of a nutrition support pathway with routine postoperative parenteral nutrition (PN) resulted in patients achieving adequate nutrition 7 days faster (p < 0.001) with minimal line-related complications (1.4% line-related thrombus). Routine PN did not impact ileus rates (p = 0.33) or time to diet commencement (p = 0.6).

CONCLUSIONS

Preoperative malnutrition and higher BMI were associated with complications following PE. Delay to full diet commencement was associated with increased complications and longer LOHS. Routine postoperative PN appears safe and resulted in patients achieving adequate nutrition faster.

Is preoperative sarcopenia associated with postoperative complications after pelvic exenteration surgery?

PURPOSE

Pelvic exenteration (PE) involves radical surgical resection of pelvic organs and is associated with considerable morbidity. Sarcopenia is recognised as a predictor of poor surgical outcomes. This study aimed to determine if preoperative sarcopenia is associated with postoperative complications after PE surgery.

METHODS

This retrospective study included patients who underwent PE with an available preoperative CT scan between May 2008 and November 2022 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia. Total Psoas Area Index (TPAI) was estimated by measuring the cross-sectional area of the psoas muscles at the level of the third lumbar vertebra on abdominal CT, normalised for patient height. Sarcopenia was diagnosed based on gender-specific TPAI cut-off values. Logistic regression analyses were performed to identify risk factors for major postoperative complications with a Clavien-Dindo (CD) grade ≥ 3.

RESULTS

In total, 128 patients who underwent PE were included, 90 of whom formed the non-sarcopenic group (NSG) and 38 the sarcopenic group (SG). Major postoperative complications (CD grade ≥ 3) occurred in 26 (20.3%) patients. There was no detectable association with sarcopenia and an increased risk of major postoperative complications. Preoperative hypoalbuminemia (P = 0.01) and a prolonged operative time (P = 0.002) were significantly associated with a major postoperative complication on multivariate analysis.

CONCLUSION

Sarcopenia is not a predictor of major postoperative complications in patients undergoing PE surgery. Further efforts aimed specifically at optimising preoperative nutrition may be warranted.

Effects of Postdischarge High-Protein Oral Nutritional Supplements and Resistance Training in Malnourished Surgical Patients: A Pilot Randomized Controlled Trial

The presence of malnutrition is increasingly becoming a postdischarge problem in surgical patients. We aimed to investigate whether oral nutritional supplements combined with resistance training could minimize skeletal muscle atrophy in surgical patients after discharge. This randomized controlled study was conducted at the Department of Surgery, National Hospital of Faroe Islands from 2018 to 2020. A total of 45 patients aged 37−74 years participated and were allocated to one of three groups: diet (DI; n = 13), exercise and diet (EX + DI; n = 16), or control (CON; n = 16). The intervention period lasted 8 weeks. The intervention groups received individual dietary counselling and a protein-rich oral nutritional supplement twice a day containing 22 g of protein/day. Patients in the EX + DI group were assigned to resistance training sessions. Patients in the CON group received standard care. The primary outcome was change in lean body mass (LBM). Secondary outcomes were change in body weight, handgrip strength, quality of life, surgery-related side effects, energy and protein intake, length of stay and one-year mortality. To estimate within-group changes, linear mixed models including group−time interactions as fixed effects and patients as random effects were fitted. Within-group change in LBM was 233, 813 and 78 g in the DI, EX + DI and CON groups, respectively, with no significant between-group difference (p > 0.05). Pain score declined more (p = 0.04) in the EX + DI group compared with the CON group. Body weight, handgrip strength, quality of life and surgery-related side effects did not differ between groups. At the end of study, mean cumulative weight change in the DI and EX + DI groups was 0.4% and 1.6%, respectively, whereas the CON group experienced a weight loss of −0.6%. No significant difference in primary outcome between groups was noted. However, our results indicate some benefits from exercise and nutrition for malnourished surgical patients.

Early enteral feeding is beneficial for patients after pelvic exenteration surgery: A randomized controlled trial

BACKGROUND

Postoperative feeding practices vary after pelvic exenteration surgery because of the lack of nutrition research in this specific surgical area. Postoperative ileus (POI) is common after pelvic exenteration surgery, and early enteral feeding is often avoided because of the lack of evidence and the belief that this may induce POI in this patient cohort. The aim of this study was to determine the effects of early enteral feeding after pelvic exenteration surgery on return of bowel movement and POI.

METHODS

A randomized controlled trial was conducted with patients undergoing pelvic exenteration surgery from November 2018 to June 2020. Forty participants received standard nutrition care (parenteral nutrition) and 47 participants received trophic enteral feeding (20 ml/h) via a nasogastric tube, in addition to standard care, until participants were upgraded to free fluids. Time to first bowel movement and rates of POI were the main outcome measures.

RESULTS

There was no significant difference between arms for time to first bowel movement; however, POI rates were significantly less in participants who were enterally fed (P = .036) in the per-protocol analysis. Regressions showed that the longer patients were restricted from an oral diet after surgery, the greater the time was to first bowel movement and the greater the postoperative complication rates (P < .0005).

CONCLUSIONS

Early enteral feeding can be commenced safely to improve gastrointestinal function after pelvic exenteration surgery.

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.

Assessing the Effect of Preoperative Nutrition on Upper Body Function in Elderly Patients Undergoing Elective Abdominal Surgery

BACKGROUND

Malnutrition among elderly surgical patients has been associated with poor postoperative outcomes and reduced functional status. Although previous studies have shown that nutrition contributes to patient outcomes, its long-term impact on functional status requires better characterization. This study examines the effect of nutrition on postoperative upper body function over time in elderly patients undergoing elective surgery.

METHODS

This is a 2-year prospective study of elderly patients (≥70 years) undergoing elective abdominal surgery. Preoperative nutrition status was determined with the Subjective Global Assessment (SGA). The primary outcome was handgrip strength (HGS) at 1, 4, 12, and 24 weeks postsurgery. Repeated measures analysis was used to determine whether SGA status affects the trajectory of postoperative HGS.

RESULTS

The cohort included 144 patients with a mean age of 77.8 ± 5.0 years and a mean body mass index of 27.7 ± 5.1 kg/m² . The median (interquartile range) Charlson Comorbidity Index was 3 (2-6). Participants were categorized as well-nourished (86%) and mildly to moderately malnourished (14%), with mean preoperative HGS of 25.8 ± 9.2 kg and 19.6 ± 7.0 kg, respectively. At 24 weeks, 64% of well-nourished patients had recovered to baseline HGS, compared with 44% of mildly to moderately malnourished patients. Controlling for relevant covariates, SGA did not significantly affect the trajectory of postoperative HGS.

CONCLUSION

While HGS values over the 24 weeks were consistently higher in the well-nourished SGA group than the mildly to moderately malnourished SGA group, no difference in the trajectories of HGS was detected between the groups.

Systematic review of exercise training in colorectal cancer patients during treatment

Colorectal cancer surgery results in considerable postoperative morbidity, mortality and reduced quality of life. As many patients will undergo additional (neo)adjuvant therapy, it is imperative that each individual optimize their physical function. To elucidate the potential of exercise in patient optimization, we investigated the evidence for an exercise program before and after surgical treatment in colorectal cancer patients. A systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions, the guidelines of the Physical Therapy Journal and the PRISMA guidelines. No literature pertaining to exercise training during preoperative neoadjuvant treatment was found. Seven studies, investigating the effects of regular exercise during adjuvant chemotherapy for patients with colorectal cancer or a mixed population, were identified. A small effect (effect size (ES) 0.4) of endurance/interval training and strength training (ES 0.4) was found in two studies conducted in patients with colorectal and gastrointestinal cancer. In five studies that included a mixed population of cancer patients, interval training resulted in a large improvement (ES 1.5; P≤.05). Endurance training alone was found to increase both lower extremity strength and endurance capacity. The effects of strength training in the lower extremity are moderate, whereas, in the upper extremity, the increase is small. There is limited evidence available on exercise training during treatment in colorectal cancer patients. One study concluded exercise therapy may be beneficial for colorectal cancer patients during adjuvant treatment. The possible advantages of training during neoadjuvant treatment may be explored by prehabilitation trials.