Effects of malnutrition on complication rates, length of hospital stay, and revenue in elective surgical patients in the G-DRG-system

Risk Factors of Malnutrition among In-School Children and Adolescents in Developing Countries: A Scoping Review

Malnutrition among in-school children is a complex issue influenced by socio-economic, environmental, and health-related factors, posing significant challenges to their well-being and educational trajectories in developing countries. This review synthesized evidence on the multifaceted aspects of child malnutrition within the educational setting in developing countries. This review followed the six steps outlined by Arksey and O'Malley's framework. Four main databases (PubMed, CENTRAL, JSTOR, and Scopus) were searched. Additional searches were conducted in WHO Library, ProQuest, HINARI, Google Scholar, and Google. Reference lists of eligible papers were checked. This review found that low family income, varying family sizes, parental employment status, and educational levels significantly impact malnutrition among in-school children and adolescents. Environmental elements, including rural/urban residence, household sanitation, and living conditions, also influence malnutrition. In addition, nutrition knowledge, dietary habits, nutrient deficiencies, physical activity, and prevalent health conditions compound the risk of malnutrition. This study underscores the extensive health impact of malnutrition on general health, specific nutrient deficiencies, fetal/maternal health concerns, and overall morbidity. Also, malnutrition affects school performance and attendance, impacting cognitive abilities, and academic achievements. Addressing these challenges requires comprehensive policy actions aligned with Sustainable Development Goals, emphasizing poverty alleviation, health literacy, and gender equity.

Preoperative nutrition therapy in people undergoing gastrointestinal surgery

BACKGROUND

Poor preoperative nutritional status has been consistently linked to an increase in postoperative complications and worse surgical outcomes. We updated a review first published in 2012.

OBJECTIVES

To assess the effects of preoperative nutritional therapy compared to usual care in people undergoing gastrointestinal surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, three other databases and two trial registries on 28 March 2023. We searched reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of people undergoing gastrointestinal surgery and receiving preoperative nutritional therapy, including parenteral nutrition, enteral nutrition or oral nutrition supplements, compared to usual care. We only included nutritional therapy that contained macronutrients (protein, carbohydrate and fat) and micronutrients, and excluded studies that evaluated single nutrients. We included studies regardless of the nutritional status of participants, that is, well-nourished participants, participants at risk of malnutrition, or mixed populations. We excluded studies in people undergoing pancreatic and liver surgery. Our primary outcomes were non-infectious complications, infectious complications and length of hospital stay. Our secondary outcomes were nutritional aspects, quality of life, change in macronutrient intake, biochemical parameters, 30-day perioperative mortality and adverse effects.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. We assessed risk of bias using the RoB 1 tool and applied the GRADE criteria to assess the certainty of evidence.

MAIN RESULTS

We included 16 RCTs reporting 19 comparisons (2164 participants). Seven studies were new for this update. Participants' ages ranged from 21 to 79 years, and 62% were men. Three RCTs used parenteral nutrition, two used enteral nutrition, eight used immune-enhancing nutrition and six used standard oral nutrition supplements. All studies included mixed groups of well-nourished and malnourished participants; they used different methods to identify malnutrition and reported this in different ways. Not all the included studies were conducted within an Enhanced Recovery After Surgery (ERAS) programme, which is now current clinical practice in most hospitals undertaking GI surgery. We were concerned about risk of bias in all the studies and 14 studies were at high risk of bias due to lack of blinding. We are uncertain if parenteral nutrition has any effect on the number of participants who had a non-infectious complication (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.36 to 1.02; 3 RCTs, 260 participants; very low-certainty evidence); infectious complication (RR 0.98, 95% CI 0.53 to 1.80; 3 RCTs, 260 participants; very low-certainty evidence) or length of hospital stay (mean difference (MD) 5.49 days, 95% CI 0.02 to 10.96; 2 RCTs, 135 participants; very low-certainty evidence). None of the enteral nutrition studies reported non-infectious complications as an outcome. The evidence is very uncertain about the effect of enteral nutrition on the number of participants with infectious complications after surgery (RR 0.90, 95% CI 0.59 to 1.38; 2 RCTs, 126 participants; very low-certainty evidence) or length of hospital stay (MD 5.10 days, 95% CI -1.03 to 11.23; 2 RCTs, 126 participants; very low-certainty evidence). Immune-enhancing nutrition compared to controls may result in little to no effect on the number of participants experiencing a non-infectious complication (RR 0.79, 95% CI 0.62 to 1.00; 8 RCTs, 1020 participants; low-certainty evidence), infectious complications (RR 0.74, 95% CI 0.53 to 1.04; 7 RCTs, 925 participants; low-certainty evidence) or length of hospital stay (MD -1.22 days, 95% CI -2.80 to 0.35; 6 RCTs, 688 participants; low-certainty evidence). Standard oral nutrition supplements may result in little to no effect on number of participants with a non-infectious complication (RR 0.90, 95% CI 0.67 to 1.20; 5 RCTs, 473 participants; low-certainty evidence) or the length of hospital stay (MD -0.65 days, 95% CI -2.33 to 1.03; 3 RCTs, 299 participants; low-certainty evidence). The evidence is very uncertain about the effect of oral nutrition supplements on the number of participants with an infectious complication (RR 0.88, 95% CI 0.60 to 1.27; 5 RCTs, 473 participants; very low-certainty evidence). Sensitivity analysis based on malnourished and weight-losing participants found oral nutrition supplements may result in a slight reduction in infections (RR 0.58, 95% CI 0.40 to 0.85; 2 RCTs, 184 participants). Studies reported some secondary outcomes, but not consistently. Complications associated with central venous catheters occurred in RCTs involving parenteral nutrition. Adverse events in the enteral nutrition, immune-enhancing nutrition and standard oral nutrition supplements RCTs included nausea, vomiting, diarrhoea and abdominal pain.

AUTHORS' CONCLUSIONS

We were unable to determine if parenteral nutrition, enteral nutrition, immune-enhancing nutrition or standard oral nutrition supplements have any effect on the clinical outcomes due to very low-certainty evidence. There is some evidence that standard oral nutrition supplements may have no effect on complications. Sensitivity analysis showed standard oral nutrition supplements probably reduced infections in weight-losing or malnourished participants. Further high-quality multicentre research considering the ERAS programme is required and further research in low- and middle-income countries is needed.

The Role of Amino Acid Supplementation in Orthopaedic Surgery

The nutritional status of patients undergoing orthopaedic surgery has started to garner increasing attention in published literature. Notable previous evidence has demonstrated the negative effect of malnutrition on outcomes after orthopaedic procedures. Although there has been increased recognition of malnutrition as a risk factor for suboptimal outcomes, the use of nutritional supplementation to mitigate those risks is not well understood. The purpose of this review of most current literature on the topic is to introduce and elucidate the role of amino acid supplementation as a countermeasure to muscle loss and improvement of nutritional status in orthopaedic patients to improve results and outcomes after orthopaedic surgery.

Nutritional risk predicts postoperative complications and length of stay, whereas sarcopenia risk predicts need for step-down care in a mixed elective surgery population

BACKGROUND

Malnutrition and poor functional reserves place patients at risk for negative surgical outcomes. In this prospective study we aimed to measure preoperative nutritional and sarcopenia risk and evaluate their impact on postoperative outcomes.

METHODS

Adults scheduled to undergo elective general and gastrointestinal surgery were screened for nutrition risk using the Malnutrition Universal Screening Tool screening tool. Sarcopenia risk was measured using the SARC-F tool and hand-grip strength. Patients were followed postoperatively. Incidence of complications, length of stay (LOS), readmission rates, and need for step-down care were recorded.

RESULTS

One hundred and twenty-two patients were included. Mean age was 53.8 years (standard deviation [SD] 16.44). Sixty-six (54%) were scheduled for day-case procedures, and 56 (46%) for nonday-case procedures. About 18.9% (n = 23) were at nutritional risk preoperatively. Ten patients (8.2%) had probable sarcopenia based on SARC-F, whereas seven (5.7%) had measurably reduced HG. Incidence of postoperative complications was 23.8% (n = 29). Nutrition risk was associated with the development of complications (p = 0.018). In the nonday-case group, nutritional risk was associated with greater LOS (p = 0.013). Older age was associated with need for step-down care (p = 0.002) as was SARC-F (p = 0.003).

CONCLUSIONS

Preoperative nutritional screening can predict postoperative complications and LOS, whereas sarcopenia screening is predictive of the need for step-down care after discharge. Screening tools are quick and inexpensive and could provide valuable information to clinicians and allow patients the opportunity to enhance their physical preparedness for surgery thereby mitigating their risk for negative surgical outcomes.

Preparing for and Not Waiting for Surgery

Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.

Defining and predicting textbook outcomes for perihilar cholangiocarcinoma: analysis of factors improving achievement of desired postoperative outcomes

BACKGROUND

Definition of textbook outcome (TO), defined as a single indicator combining the most advantageous short-term outcomes, is still lacking for perihilar cholangiocarcinoma (PHC). The primary endpoint of the present study is to analyze the rate of achievement of a disease-specific TO for PHC within a high volume tertiary referral centre. Secondary endpoints are to identify predictive factors of TO-achievement and to analyze the impact of achieving TO on long-term results.

METHODS

Between 2010 and 2022, a total of 237 patients undergoing combined liver and biliary resection for PHC at tertiary referral centre were included. Disease-specific TO were defined as: no 90-day mortality, no postoperative complications, no readmission, no intraoperative transfusions and resection margins. A logistic regression model was developed to identify predictors associated with TO-achievement. Kaplan-Meier curves were designed to determine TO's impact on survival.

RESULTS

TO was achieved in 60 (25.3%) patients. At multivariate logistic regression, preoperative biliary drainage [odds ratio (OR) 2.90 (1.13-3.40), P =0.026], high prognostic nutritional index [OR 7.11 (6.71-9.43), P =0.007[ and minimally invasive approach [OR 3.57 (2.31-3.62), P =0.013] were identified as independent predictors of TO. High ASA score [OR 0.38 (0.17-0.82), P =0.013] decreased the odds of TO. A significant improvement in both overall survival and disease-free survival was associated to TO fulfilment.

CONCLUSION

Since the achievement of TO correlates with better disease-free and overall survival, every effort should be made to ameliorate modifiable aspects prior to surery: management within referral centres with dedicated experience in biliary tract cancer and preoperative optimization protocol may positively contribute to improve postoperative outcomes, increasing the chance to obtain TO. Moreover, the implementation of advanced minimally invasive programs plays as well.

Impact of Preoperative Factors in Patients With IBD on Postoperative Length of Stay: A National Surgical Quality Improvement Program-Inflammatory Bowel Disease Collaborative Analysis

BACKGROUND

Patients with IBD are challenging to manage perioperatively because of disease complexity and multiple comorbidities.

OBJECTIVE

To identify whether preoperative factors and operation type were associated with extended postoperative length of stay after IBD-related surgery, defined by 75th percentile or greater (n = 926; 30.8%).

DESIGN

This was a cross-sectional study based on a retrospective multicenter database.

SETTING

The National Surgery Quality Improvement Program-Inflammatory Bowel Disease Collaborative captured data from 15 high-volume sites.

PATIENTS

A total of 3008 patients with IBD (1710 with Crohn's disease and 1291 with ulcerative colitis) with a median postoperative length of stay of 4 days (interquartile range, 3-7) from March 2017 to February 2020.

MAIN OUTCOME MEASURES

The primary outcome was extended postoperative length of stay.

RESULTS

On multivariable logistic regression, increased odds of extended postoperative length of stay were associated with multiple demographic and clinical factors (model p < 0.001, area under receiver operating characteristic curve = 0.85). Clinically significant contributors that increased postoperative length of stay were rectal surgery (vs colon; OR, 2.13; 95% CI, 1.52-2.98), new ileostomy (vs no ileostomy; OR, 1.50; 95% CI, 1.15-1.97), preoperative hospitalization (OR, 13.45; 95% CI, 10.15-17.84), non-home discharge (OR, 4.78; 95% CI, 2.27-10.08), hypoalbuminemia (OR, 1.66; 95% CI, 1.27-2.18), and bleeding disorder (OR, 2.42; 95% CI, 1.22-4.82).

LIMITATIONS

Retrospective review of only high-volume centers.

CONCLUSIONS

Patients with IBD who were preoperatively hospitalized, who had non-home discharge, and who underwent rectal surgery had the highest odds of extended postoperative length of stay. Associated patient characteristics included bleeding disorder, hypoalbuminemia, and ASA classes 3 to 5. Chronic corticosteroid, immunologic, small molecule, and biologic agent use were insignificant on multivariable analysis. See Video Abstract.

IMPACTO DE LOS FACTORES PREOPERATORIOS EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL EN LA DURACIN DE LA ESTANCIA POSTOPERATORIA UN ANLISIS COLABORATIVO DEL PROGRAMA NACIONAL DE MEJORA DE LA CALIDAD QUIRRGICAENFERMEDAD INFLAMATORIA INTESTINAL

ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal son difíciles de manejar perioperatoriamente debido a la complejidad de la enfermedad y a múltiples comorbilidades.OBJETIVO:Este estudio tuvo como objetivo identificar si los factores preoperatorios y el tipo de operación se asociaron con una estadía postoperatoria prolongada después de una cirugía relacionada con enfermedad inflamatoria intestinal, definida por el percentil 75 o mayor (n = 926, 30.8%).DISEÑO:Este fue un estudio transversal basado en una base de datos multicéntrica retrospectiva.ESCENARIO:Datos capturados de quince sitios de alto volumen en El Programa Nacional de Mejoramiento de la Calidad de la Cirugía-Enfermedad Intestinal Inflamatoria en colaboración.PACIENTES:Un total de 3,008 pacientes con enfermedad inflamatoria intestinal (1,710 con enfermedad de Crohn y 1,291 con colitis ulcerosa) con una mediana de estancia postoperatoria de 4 días (RIC 3-7) desde marzo de 2017 hasta febrero de 2020.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la extensión de la estancia postoperatoria.RESULTADOS:En la regresión logística multivariable, el aumento de las probabilidades de prolongar la estancia postoperatoria se asoció con múltiples factores demográficos y clínicos (modelo p<0.001, área bajo la curva ROC - 0.85). Los contribuyentes clínicamente significativos que aumentaron la duración de la estancia postoperatoria fueron la cirugía rectal (frente al colon) (OR 2.13, IC del 95 %: 1.52 a 2.98), una nueva ileostomía (frente a ninguna ileostomía) (OR 1.50, IC del 95 %: 1.15 a 1.97), hospitalización preoperatoria (OR 13.45, IC 95% 10.15-17.84), alta no domiciliaria (OR 4.78, IC 95% 2.27-10.08), hipoalbuminemia (OR 1.66, IC 95% 1.27-2.18) y trastorno hemorrágico (OR 2.42, IC 95% 1.22-4.82).LIMITACIONES:Revisión retrospectiva de solo centros de alto volumen.CONCLUSIONES:Los pacientes con enfermedad inflamatoria intestinal que fueron hospitalizados antes de la operación, que tuvieron alta no domiciliaria y que se sometieron a cirugía rectal tuvieron las mayores probabilidades de prolongar la estancia postoperatoria. Las características asociadas de los pacientes incluyeron trastorno hemorrágico, hipoalbuminemia y clases ASA 3-5. El uso crónico de corticosteroides, inmunológicos, agentes de moléculas pequeñas y de agentes biológicos no fue significativo en el análisis multivariable. (Traducción-Dr. Jorge Silva Velazco ).

Factors Associated with 1-Year Mortality in Elderly Patients (Age ≥ 80 Years) with Cancer Undergoing Major Abdominal Surgery: A Retrospective Cohort Study

BACKGROUND

The number of elderly patients undergoing major abdominal surgery is increasing, but the factors affecting their postoperative outcomes remain unclear. This study aimed to identify the factors associated with 1-year mortality among elderly patients (age ≥ 80 years) with cancer undergoing major abdominal surgery.

METHODS

This retrospective cohort study was conducted from March 2009 to December 2020. The study enrolled 378 patients 80 years old or older who underwent major abdominal surgery. The main outcome was 1-year mortality, and the factors associated with mortality were analyzed.

RESULTS

Of the 378 patients, 92 died at 1 year (24.3%), whereas the 30-day mortality rate was 4% (n = 15). In the multivariate analysis, the factors independently associated with 1-year mortality were preoperative Eastern Cooperative Oncology Group (ECOG) performance status (PS) score higher than 1 (odds ratio [OR], 3.189; 95% confidence interval [CI], 1.595-6.377; p = 0.001), preoperative weight loss greater than 3 kg (OR, 2.145; 95% CI, 1.044-4.404; p = 0.038), use of an intraoperative vasopressor (OR, 3.090; 95% CI, 1.188-8.042; p = 0.021), and postoperative red blood cell units (OR, 1.212; 95% CI, 1.045-1.405; p = 0.011). Survival was associated with perioperative management according to an enhanced recovery after surgery (ERAS) protocol (OR, 0.370; 95% CI, 0.160-0.854; p = 0.006) and supramesocolic surgery (OR, 0.371; 95% CI, 0.158-0.871; p = 0.023).

CONCLUSION

The study identified several factors associated with an encouraging 1-year mortality rate in this setting. These results highlight the need for identification of suitable targets to optimize pre-, intra-, and postoperative management in order to improve outcomes for this vulnerable population.

Improving physician documentation for malnutrition: A sustainable quality improvement initiative

This study compares documentation and reimbursement rates before and after provider education in nutritional status documentation. Our study aimed to evaluate accurate documentation of nutrition status between registered dietitian nutritionists and licensed independent practitioners before and after the implementation of a dietitian-led Nutrition-Focused Physical Exam intervention at an academic medical center in the southeastern US. ICD-10 codes identified patients from 10/1/2016-1/31/2018 with malnutrition. The percentage of patients with an appropriate diagnosis of malnutrition and reimbursement outcomes attributed to malnutrition documentation were calculated up to 24 months post-intervention. 528 patients were analyzed. Pre-intervention, 8.64% of patients had accurate documentation compared to 46.3% post-intervention. Post-intervention, 68 encounters coded for malnutrition resulted in an estimated $571,281 of additional reimbursement, sustained at 6, 12, 18, and 24 months. A multidisciplinary intervention improved physician documentation accuracy of malnutrition status and increased reimbursement rates.

Preoperative Nutritional Status and Enhanced Recovery after Surgery (ERAS) Prior to Radical Cystectomy: A Review of the Literature

Preoperative nutritional status is an important and modifiable risk factor of a patient's recovery and outcome after radical cystectomy. There are multiple malnutrition screening tools and treatment options. In this review, we discuss the best indicators of this condition and how to optimize nutrition status prior to radical cystectomy.

Impact of age on short-term outcomes after pancreaticoduodenectomy: A retrospective case-control study of 260 patients

Background

Although the increase of perioperative complications in the elderly undergoing pancreaticoduodenectomy (PD) surgery has been recognized, the definition of the “old patient” of PD in the studies is different and there is no accepted cut-off value at present.

Methods

279 consecutive patients who have undergone PD in our center between January 2012 and May 2020 were analyzed. Demographic features, clinical-pathological data and short-term outcomes were collected. The patients were divided into two groups, and the cut-off value (62.5 years) is picked based on the highest Youden Index. Primary endpoints were perioperative morbidity and mortality, and complications were classified according to the Clavien-Dindo Score.

Results

A total of 260 patients with PD were included in this study. Postoperative pathology confirmed pancreatic tumors in 62 patients, bile duct tumor in 105, duodenal tumor in 90, and others in 3. Age (OR = 1.09, P &lt; 0.01), and albumin (OR = 0.34, P &lt; 0.05) were significantly correlated with postoperative Clavien-Dindo Score ≥3b. There were 173 (66.5%) patients in the younger group (&lt;62.5 years) and 87 (33.5%) in the elderly group (≥62.5 years). Significant difference between two groups was demonstrated for Clavien-Dindo Score ≥3b (P &lt; 0.01), postoperative pancreatic fistula (P &lt; 0.05), and perioperative deceases (P &lt; 0.05).

Conclusions

Age and albumin were significantly correlated with postoperative Clavien-Dindo Score ≥3b, and there was no significant difference in predicting the grade of Clavien-Dindo Score. The cut-off value of elderly patients with PD was 62.5 years old and there were useful in predicting Clavien-Dindo Score ≥3b, pancreatic fistula, and perioperative death.

Effect of Body Mass Index on Early Outcomes of Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

This study compares the presentation, management, and outcomes of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR), based on their weight status as defined by their body mass index (BMI).

METHODS

Patients with primary EVAR for ruptured and intact abdominal aortic aneurysm (AAA) were identified in the National Surgical Quality Improvement Program database (2016-2019). Patients were categorized by weight status (underweight: BMI < 18.5 kg/m², normal weight: 18.5-24.9 kg/m², overweight: 25-29.9 kg/m², Obese I: 30-34.9 kg/m², Obese II: 35-39.9 kg/m², Obese III: > 40 kg/m²). Preoperative characteristics and 30-day outcomes were compared.

RESULTS

Of 3,941 patients, 4.8% were underweight, 24.1% normal weight, 37.6% overweight, and 22.5% with Obese I, 7.8% Obese II, and 3.3% Obese III status. Underweight patients presented with larger (6.0 [5.4-7.2] cm) and more frequently ruptured (25.0%) aneurysms than normal weight patients (5.5 [5.1-6.2] cm and 4.3%, P < 0.001 for both). Pooled 30-day mortality was worse for underweight (8.5%) compared to all other weight status (1.1-3.0%, P < 0.001), but risk-adjusted analysis demonstrated that aneurysm rupture (odds ratio [OR] 15.9, 95% confidence interval [CI] 8.98-28.0) and not underweight status (OR 1.75, 95% CI 0.73-4.18) accounted for increased mortality in this population. Obese III status was associated with prolonged operative time and respiratory complications after ruptured AAA, but not 30-day mortality (OR 0.82, 95% CI 0.25-2.62).

CONCLUSIONS

Patients at either extreme of the BMI range had the worst outcomes after EVAR. Underweight patients represented only 4.8% of all EVARs, but 21% of mortalities, largely attributed to higher incidence of ruptured AAA at presentation. Severe obesity, on the other hand, was associated with prolonged operative time and respiratory complications after EVAR for ruptured AAA. BMI, as an independent factor, was however not predictive of mortality for EVAR.

Combination of sarcopenia and prognostic nutritional index to predict long-term outcomes in patients undergoing initial hepatectomy for hepatocellular carcinoma

OBJECTIVE

To determine if preoperative sarcopenia and prognostic nutritional index (PNI) could accurately predict the postoperative outcomes of patients with hepatocellular carcinoma (HCC) undergoing initial hepatectomy.

METHODS

Three hundred three patients who underwent curative hepatectomy for HCC between January 2010 and August 2021 were enrolled and their data were retrospectively analyzed. Sarcopenia was determined from computed tomography images obtained 3 weeks prior to surgery, and PNI was calculated from preoperative albumin and whole lymphocyte count data in receiver operating characteristic (ROC) curve analysis, with a cutoff value of 46.2 to categorize high and low groups.

RESULTS

One hundred six (35%) patients had sarcopenia prior to surgery. Kaplan-Meier analysis revealed that sarcopenia and low PNI were associated with significantly worse overall survival (OS) compared with no sarcopenia and high PNI, respectively (P = 0.023 and P = 0.035, respectively). In addition, patients with sarcopenia had worse OS than those without sarcopenia in the high and low PNI groups (P = 0.058 and P = 0.038, respectively). Sarcopenia (hazard ratio [HR] 1.66; 95% confidence interval [CI] 1.00-2.76; P = 0.048) and PNI ≤46.2 (HR 1.96; 95% CI 1.17-3.27; P = 0.011) were independent prognostic factors on multivariate analysis, and combined sarcopenia and PNI had a higher AUC value (AUC = 0.722, P < 0.001) than either one alone in ROC analysis.

CONCLUSION

Combined sarcopenia and PNI as a prognostic marker can better predict the postoperative prognostic outcomes of HCC patients following hepatectomy than either sarcopenia or PNI alone.

Preoperative dysphagia risk in community-dwelling adults aged ≥50 years: Prevalence and risk factors

BACKGROUND

Preoperative dysphagia screening is rare. The purpose of this study was to assess the prevalence and potential risk factors of preoperative dysphagia risk in adults preparing for surgery.

METHODS

The Eating Assessment Tool (EAT-10), Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), and Sarcopenia Screening Tool (SARC-F) were self-administered in adults preparing for surgery to identify dysphagia, malnutrition, and sarcopenia risk, respectively. Other variables collected include clinical demographics, fall risk, and surgical history associated with increased dysphagia risk. Descriptive summary statistics, univariate analysis, and logistic regression were performed as appropriate.

RESULTS

The median age was 69 years and preoperative dysphagia risk was 9.6%. Among 357 patients completing both EAT-10 and PG-SGA SF or SARC-F, 7.3% had preoperative dysphagia and malnutrition risk and 7.2% had preoperative dysphagia and sarcopenia risk. Preoperative dysphagia risk was 2.7 times greater in those with prior surgical history associated with increased risk of dysphagia, 2.2 times higher in women, and almost twice as high in Black patients and patients with fall risk. Logistic regression revealed significant odds ratios (ORs) for prior surgical history associated with increased risk of dysphagia (OR, 2.95; 95% CI, 1.62-5.40) and male sex (OR, 0.52; 95% CI, 0.29-0.94), and a significant relationship between preoperative dysphagia and malnutrition risk (OR, 4.56; 95% CI, 2.02-10.28) when controlling for clinical variables.

CONCLUSION

The high prevalence of dysphagia risk alone and in combination with malnutrition and sarcopenia risk in community-dwelling adults underscores the need for standardized preoperative screening and optimization prior to surgery.

Nascent to novel methods to evaluate malnutrition and frailty in the surgical patient

Preoperative nutrition status is an important determinant of surgical outcomes, yet malnutrition assessment is not integrated into all surgical pathways. Given its importance and the high prevalence of malnutrition in patients undergoing surgical procedures, preoperative nutrition screening, assessment, and intervention are needed to improve postoperative outcomes. This narrative review discusses novel methods to assess malnutrition and frailty in the surgical patient. The Global Leadership Initiative for Malnutrition (GLIM) criteria are increasingly used in surgical settings although further spread and implementation are strongly encouraged to help standardize the diagnosis of malnutrition. The use of body composition (ie, reduced muscle mass) as a phenotypic criterion in GLIM may lead to a greater number of patients identified as having malnutrition, which may otherwise be undetected if screened by other diagnostic tools. Skeletal muscle loss is a defining criterion of malnutrition and frailty. Novel direct and indirect approaches to assess muscle mass in clinical settings may facilitate the identification of patients with or at risk for malnutrition. Selected imaging techniques have the additional advantage of identifying myosteatosis (an independent predictor of morbidity and mortality for surgical patients). Feasible pathways for screening and assessing frailty exist and may determine the cost/benefit of surgery, long-term independence and productivity, and the value of undertaking targeted interventions. Finally, the evaluation of nutrition risk and status is essential to predict and mitigate surgical outcomes. Nascent to novel approaches are the future of objectively identifying patients at perioperative nutrition risk and guiding therapy toward optimal perioperative standards of care.

Low Preoperative Albumin Associated With Increased Risk of Superficial Surgical Site Infection Following Midfoot, Hindfoot, and Ankle Fusion

BACKGROUND

This study investigates the effect of malnutrition, defined by hypoalbuminemia, on rates of complication, readmission, reoperation, and mortality following midfoot, hindfoot, or ankle fusion.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2019 to identify 500 patients who underwent midfoot (n = 233), hindfoot (n = 261), or ankle (n = 117) fusion. Patients were stratified into normal (n = 452) or low (n = 48) albumin group, which was defined by preoperative serum albumin level <3.5 g/dL. Demographics, medical comorbidities, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. The mean age of the cohort was 58.7 (range, 21-89) years.

RESULTS

Hypoalbuminemia patients were significantly more likely to have diabetes (P < .001), be on dialysis (P < .001), and be functionally dependent (P < .001). The LOS was significantly greater among the low albumin group (P < .001). The hypoalbuminemia cohort also exhibited a significantly increased likelihood of superficial infection (P = .048). Readmission (P = .389) and reoperation (P = .611) rates did not differ between the groups.

CONCLUSION

This study shows that malnourished patients have an increased risk of superficial infection following foot and ankle fusions but are not at an increased risk of readmission or reoperation, suggesting that low albumin confers an elevated risk of surgical site infection.

LEVELS OF EVIDENCE

Level III, Retrospective cohort study.

Association of standardized liver volume and body mass index with outcomes of minimally invasive liver resections

INTRODUCTION

While minimally invasive liver resections (MILR) have demonstrated advantages in improved post-operative recovery, widespread adoption is hampered by inherent technical difficulties. Our study attempts to analyze the role of anthropometric measures in MILR-related outcomes.

METHODS

Between 2012 and 2020, 676 consecutive patients underwent MILR at the Singapore General Hospital of which 565 met study criteria and were included. Patients were stratified based on Body Mass Index (BMI) as well as Standardized Liver Volumes (SLV). Associations between BMI and SLV to selected peri-operative outcomes were analyzed using restricted cubic splines.

RESULTS

A BMI of ≥ 29 was associated with increase in blood loss [Mean difference (MD) 69 mls, 95% CI 2 to 137] as well as operative conversions [Relative Risk (RR) 1.63, 95% CI 1.02 to 2.62] among patients undergoing MILR while a SLV of 1600 cc or higher was associated with an increase in blood loss (MD 30 mls, 95% CI 10 to 49). In addition, a BMI of ≤ 20 was associated with an increased risk of major complications (RR 2.25, 95% 1.16 to 4.35). The magnitude of differences observed in these findings increased with each unit change in BMI and SLV.

CONCLUSION

Both BMI and SLV were useful anthropometric measures in predicting peri-operative outcomes in MILR and may be considered for incorporation in future difficulty scoring systems for MILR.

Implementation of an electronic solution to improve malnutrition identification and support clinical best practice

BACKGROUND

Routine malnutrition risk screening of patients is critical for optimal care and comprises part of the National Australian Hospital Standards. Identification of malnutrition also ensures reimbursement for hospitals to adequately treat these high-risk patients. However, timely, accurate screening, assessment and coding of malnutrition remains suboptimal. The present study aimed to investigate manual and digital interventions to overcome barriers to malnutrition identification for improvements in the hospital setting.

METHODS

Retrospective reporting on malnutrition identification processes was conducted through two stages: (1) manual auditing intervention and (2) development of a digital solution - the electronic malnutrition management solution (eMS). Repeated process audits were completed at approximately 6-monthly intervals through both stages between 2016 and 2019 and the results were analysed. In Stage 2, time investment and staff adoption of the digital solution were measured.

RESULTS

Overall, the combined effect of both regular auditing and use of the eMS resulted in statistically significant improvements across all six key measures: patients identified (97%-100%; p < 0.001), screened (68%-95%; p < 0.001), screened within 24 h (51%-89%; p < 0.001), assessed (72%-95%; p < 0.001), assessed within 24 h (66%-93%; p < 0.001) and coded (81%-100%; p = 0.017). The eMS demonstrated a reduction in screening time by over 60% with user adoption 100%. Data analytics enabled automated, real-time auditing with a 95% reduction in time taken to audit.

CONCLUSIONS

A single digital solution for management of malnutrition and automation of auditing demonstrated significant improvements where manual or combinations of manual and electronic systems continue to fall short.

The impact of preoperative nutrition status on abdominal surgery outcomes: A prospective cohort study

BACKGROUND

The European Society for Clinical Nutrition and Metabolism recommends nutrition screening using the Mini Nutritional Assessment Short-Form (MNA-SF) in older adult patients preoperatively. However, the association of nutrition condition with postoperative complications is poorly documented. We aimed to identify preoperative nutrition status using the MNA-SF and to determine whether preoperative nutrition status affects postoperative outcomes.

METHODS

Inpatients aged ≥55 years who underwent elective abdominal surgery under general anesthesia between April 1, 2016, and December 28, 2018, were included. We assessed nutrition status using the MNA-SF before surgery. Multiple logistic regression including the MNA-SF score was applied to determine associated factors with our primary outcome, postoperative complications defined as Clavien-Dindo classification ≥3a. Secondary outcomes including length of hospital stay and unplanned readmission were compared between normal, at risk, and malnourished patients.

RESULTS

The data of 1248 patients with a mean age of 69 years were analyzed. The prevalence of at risk and malnutrition was 33.0% (412 of 1248) and 6.9% (87 of 1248), respectively. Overall, 12.4% (155 of 1248) had major postoperative complications, and the MNA-SF score was a significant predictor (odds ratio: 0.92, 95% CI: 0.86-0.99) after adjusting for confounders. Patients at risk of malnutrition and those with malnutrition had a longer hospital length of postoperative stay than normal patients (P = 0.001); however, there was no statistical significance in unplanned readmission rate between the three groups (P = 0.14).

CONCLUSION

Preoperative nutrition disorder was common, and it affected postoperative adverse outcomes. The MNA-SF score was associated with major postoperative complications.

Modified BEST-J Score Model Predicts Bleeding after Endoscopic Submucosal Dissection with Fewer Factors

This study constructed a simplified post-endoscopic submucosal dissection (ESD) prediction model with a prognostic nutritional index (PNI). A total of 449 patients who underwent gastric ESD was included, divided with a ratio of 2:1, and assigned to the model or validation cohort. A prediction model of post-ESD (modified BEST-J score) was constructed using the model cohort. The modified BEST-J score was evaluated by comparing its accuracy to the BEST-J score in the validation cohort. Within 4 weeks of ESD, melena, hematemesis, or a 2 g/dL or greater decrease in hemoglobin level that required esophagogastroduodenoscopy was defined as post-ESD bleeding. In the model cohort, 299 patients were enrolled and 25 (8.4%) had post-ESD bleeding. Independent risk factors for post-ESD bleeding were use of P2Y12RA, tumor size > 30 mm, location of lesion at lower one-third of the stomach, and PNI ≤ 47.9. Constructing the modified BEST-J score based on these variables, the sensitivity, specificity, and positive likelihood ratio were 73.9%, 78.1%, and 3.37. When comparing the modified BEST-J score to the BEST-J score in the validation cohort, no significant difference was observed by ROC-AUC (0.77 vs. 0.75, p = 0.81). Modified BEST-J score can predict post-ESD bleeding more simply, with the same accuracy as the BEST-J score.

Nutritional status and out-of-hospital mortality in vascular surgery patients

Background

Malnutrition is often present in vascular surgery patient during hospital admission. The present evidence of the consequence malnutrition has on morbidity and mortality is limited.

Aim

The purpose of this study was to determine the effect of nutritional status on out-of-hospital mortality in vascular surgery patients.

Methods

An observational cohort study was performed, studying non-cardiac vascular surgery patients surviving hospital admission 18 years or older treated in Boston, Massachusetts, USA. The exposure of interest was nutritional status categorized as well nourished, at-risk for malnutrition, nonspecific malnutrition or protein-energy malnutrition. The all cause 90-day mortality following hospital discharge was the primary outcome. Adjusted odds ratios were estimated by multivariable logistic regression models.

Results

This cohort included 4432 patients comprised of 48% women and a mean age 61.7 years. After evaluation by a registered dietitian, 3819 patients were determined to be well nourished, 215 patients were at-risk for malnutrition, 351 had non-specific malnutrition and 47 patients had protein-energy malnutrition. After adjustment for age, sex, ethnicity, medical versus surgical Diagnosis Related Group type, Deyo-Charlson index, length of stay, and vascular Current Procedural Terminology code category, the 90-day post-discharge mortality odds ratio for patients with non-specific malnutrition OR 1.96 (95%CI 1.21, 3.17) and for protein-energy malnutrition OR 3.58 (95%CI 1.59, 8.06), all relative to patients without malnutrition.

Discussion

Nutritional status is a strong predictor of out-of-hospital mortality. This suggests that patient with vascular disease suffering from malnutrition could benefit from more intensified In-hospital and out-of-hospital dietary guidance and interventions.

Combination of Geriatric Nutritional Risk Index and Carcinoembryonic Antigen to Predict the Survival of Patients With Colorectal Cancer

Background

This study explored the value of the combination of Geriatric Nutritional Risk Index (GNRI) and carcinoembryonic antigen (CEA) for the prognosis assessment of CRC patients.

Methods

This study retrospectively enrolled 1,014 CRC patients who underwent surgery between 2012 and 2014. Kaplan-Meier and log-rank tests were used to compare survival differences. Cox proportional hazards regression analysis was used to assess risk factors associated with progression-free survival (PFS) and overall survival (OS). Nomograms were constructed to predict the prognosis of CRC patients. Randomized internal validation was used to confirm the predictive accuracy of the prognostic nomograms.

Results

The GNRI-CEA score was established by combining GNRI and CEA. Compared with patients with normal GNRI-CEA scores, patients with mild/moderate/severe GNRI-CEA scores had significantly lower survival (PFS, 68.99% vs. 57.75% vs. 41.34% vs. 31.36%, p < 0.001; OS, 68.99% vs. 57.75% vs. 41.34% vs. 31.36%, p < 0.001). The GNRI-CEA score is an independent factor predicting the prognosis of CRC patients. The risk of death was twofold higher in patients with low GNRI and high CEA than in those with both normal GNRI and CEA [PFS, hazard ratio (HR), 2.339; 95% confidence interval (CI), 1.656–3.303; p < 0.001; OS, HR, 2.340; 95% CI, 1.645–3.329; p < 0.001]. Prognostic nomograms had good resolution and accuracy in predicting 1–5 year PFS and OS. Randomized internal validation showed that the nomograms were reliable.

Conclusion

The combination of GNRI and CEA can effectively stratify the prognosis of CRC patients. The nomogram established based on the two indices can provide a personalized reference for prognostic assessment and clinical decision-making for CRC patients.

Effect of Household Income on Short-Term Outcomes Following Cerebellopontine Angle Tumor Resection

Objectives  The objective of this study is to elucidate the impact of income on short-term outcomes in a cerebellopontine angle (CPA) tumor resection population. Design  This is a retrospective regression analysis. Setting  This study was done at a single, multihospital, urban academic medical center. Participants  Over 6 years (from June 7, 2013, to April 24, 2019), 277 consecutive CPA tumor cases were reviewed. Main Outcome Measures  Outcomes studied included readmission, emergency department evaluation, unplanned return to surgery, return to surgery after index admission, and mortality. Univariate analysis was conducted among the entire population with significance set at a p -value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (quartile 1 [Q1]) and highest (quartile 4 [Q4]) socioeconomic quartiles, with significance set at a p -value <0.05. Stepwise regression was conducted to determine the correlations among study variables and to identify confounding factors. Results  Regression analysis of 273 patients demonstrated decreased rates of unplanned reoperation ( p  = 0.015) and reoperation after index admission ( p  = 0.035) at 30 days with higher standardized income. Logistic regression between the lowest (Q1) and highest (Q4) socioeconomic quartiles demonstrated decreased unplanned reoperation ( p  = 0.045) and decreasing but not significant reoperation after index admission ( p  = 0.15) for Q4 patients. No significant difference was observed for other metrics of morbidity and mortality. Conclusion  Higher socioeconomic status is associated with decreased risk of unplanned reoperation following CPA tumor resection.

Perioperative Nutritional Support: A Review of Current Literature

Since the beginning of the practice of surgery, the reduction of postoperative complications and early recovery have been two of the fundamental pillars that have driven the improvement of surgical techniques and perioperative management. Despite great advances in these fields, the rationalization of antibiotic prophylaxis, and other important innovations, postoperative recovery (especially in elderly patients, oncological pathology or digestive or head and neck surgery) is tortuous. This can be explained by several reasons, among which, malnutrition has a major role. Perioperative nutritional support, included within the ERAS (Enhanced Recovery After Surgery) protocol, has proven to be a main element and a critical step to achieve better surgical results. Starting with the preoperative nutritional assessment and treatment in elective surgery, we can improve nutritional status using oral supplements and immunomodulatory formulas. If we add early nutritional support in the postoperative scenario, we are able to significantly reduce infectious complications, need for intensive care unit (ICU) and hospital stay, costs, and mortality. Throughout this review, we will review the latest developments and the available literature.

Taiwan Society of Colon and Rectum Surgeons (TSCRS) Consensus for Anti-Inflammatory Nutritional Intervention in Colorectal Cancer

Malnutrition and systemic inflammatory response (SIR) frequently occur in patients with colorectal cancer (CRC) and are associated with poor prognosis. Anti-inflammatory nutritional intervention is not only a way to restore the malnourished status but also modulate SIR. Nine experts, including colorectal surgeons, physicians and dieticians from 5 hospitals geographically distributed in Taiwan, attended the consensus meeting in Taiwan Society of Colon and Rectum Surgeons for a 3-round discussion and achieved the consensus based on a systematic literature review of clinical studies and published guidelines. The consensus recommends that assessment of nutritional risk and SIR should be performed before and after CRC treatment and appropriate nutritional and/or anti-inflammatory intervention should be adapted and provided accordingly.

Nutritional Status According to the Short-Form Mini Nutritional Assessment (MNA-SF) and Clinical Characteristics as Predictors of Length of Stay, Mortality, and Readmissions Among Older Inpatients in China: A National Study

Background

Studies are scarce in China that explore the association of nutritional status, measured using the Short-Form Mini Nutritional Assessment (MNA-SF) and biochemical data, on adverse clinical outcomes among older inpatients. In this study, we aimed to determine the prevalence of malnutrition in tertiary hospitals of China and the associations between malnutrition and adverse clinical outcomes.

Methods

This prospective study involved 5,516 older inpatients (mean age 72.47 ± 5.77 years) hospitalized in tertiary hospitals between October 2018 and February 2019. The tertiary hospitals refer to the hospital with more than 500 beds and can provide complex medical care services. The MNA-SF was used to assess nutritional status. Multiple logistic regression and negative binomial regression were used to analyze the relationship between nutritional parameters and risk of hospital length of stay (LoS), mortality, and rehospitalization.

Results

We found that 46.19% of hospitalized patients had malnutrition or malnutrition risk, according to the MNA-SF. Death occurred in 3.45% of patients. MNA-SF scores 0–7 (odds ratio [OR] 5.738, 95% confidence interval [CI] 3.473 to 9.48) were associated with a six-fold higher likelihood of death, and scores 8–11 (OR 3.283, 95% CI 2.126–5.069) with a three-fold higher likelihood of death, compared with MNA-SF scores 12–14 in the logistic regression model, after adjusting for potential confounders. A low MNA-SF score of 0–7 (regression coefficient 0.2807, 95% CI 0.0294–0.5320; P < 0.05) and a score of 8–11 (0.2574, 95% CI 0.0863–0.4285; P < 0.01) was associated with a significantly higher (28.07 and 25.74%, respectively) likelihood of increased LoS, compared with MNA-SF score 12–14. MNA-SF scores 0–7 (OR 1.393, 95% CI 1.052–1.843) and 8–11 (OR 1.356, 95% CI 1.124–1.636) were associated with a nearly 1.5-fold higher likelihood of 90-day readmission compared with MNA-SF scores 12–14 in the logistic regression model. Moreover, hemoglobin level, female sex, education level, former smoking, BMI 24–27.9 kg/m², age 75 years and above, and current alcohol consumption were the main factors influencing clinical outcomes in this population.

Conclusions

Malnutrition increases the risk of hospital LoS, mortality, and 90-day readmission. The use of nutritional assessment tools in all hospitalized patients in China is needed. The MNA-SF combined with hemoglobin level may be used to identify older inpatients with a high risk of adverse clinical outcomes. These findings may have important implications for the planning of hospital services.

The composite risk index based on frailty predicts postoperative complications in older patients recovering from elective digestive tract surgery: a retrospective cohort study

Background

Limitations exist in available studies investigating effect of preoperative frailty on postoperative outcomes. This study was designed to analyze the association between composite risk index, an accumulation of preoperative frailty deficits, and the risk of postoperative complications in older patients recovering from elective digestive tract surgery.

Methods

This was a retrospective cohort study. Baseline and perioperative data of older patients (age ≥ 65 years) who underwent elective digestive tract surgery from January 1, 2017 to December 31, 2018 were collected. The severity of frailty was assessed with the composite risk index, a composite of frailty deficits including modified frailty index. The primary endpoint was the occurrence of postoperative complications during hospital stay. The association between the composite risk index and the risk of postoperative complications was assessed with a multivariable logistic regression model.

Results

A total of 923 patients were included. Of these, 27.8% (257) developed postoperative complications. Four frailty deficits, i.e., modified frailty index ≥0.27, malnutrition, hemoglobin < 90 g/L, and albumin ≤30 g/L, were combined to generate a composite risk index. Multivariable analysis showed that, when compared with patients with composite risk index of 0, the odds ratios (95% confidence intervals) were 2.408 (1.714–3.383, P <  0.001) for those with a composite risk index of 1, 3.235 (1.985–5.272, P <  0.001) for those with a composite risk index of 2, and 9.227 (3.568–23.86, P <  0.001) for those with composite risk index of 3 or above. The area under receiver-operator characteristic curve to predict postoperative complications was 0.653 (95% confidence interval 0.613–0.694, P <  0.001) for composite risk index compared with 0.622 (0.581–0.663, P <  0.001) for modified frailty index.

Conclusion

For older patients following elective digestive tract surgery, high preoperative composite risk index, a combination of frailty deficits, was independently associated with an increased risk of postoperative complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01549-6.

Nutritional Risk, Health Outcomes, and Hospital Costs Among Chinese Immobile Older Inpatients: A National Study

Purpose: Evidence of the impact of nutritional risk on health outcomes and hospital costs among Chinese older inpatients is limited. Relatively few studies have investigated the association between clinical and cost outcomes and nutritional risk in immobile older inpatients, particularly those with neoplasms, injury, digestive, cardiac, and respiratory conditions.

Methods: This China-wide prospective observational cohort study comprised 5,386 immobile older inpatients hospitalized at 25 hospitals. All patients were screened for nutritional risk using the Nutrition Risk Screening (NRS 2002). A descriptive analysis of baseline variables was followed by multivariate analysis (Cox proportional hazards models and generalized linear model) to compare the health and economic outcomes, namely, mortality, length of hospital stay (LoS), and hospital costs associated with a positive NRS 2002 result.

Results: The prevalence of a positive NRS 2002 result was 65.3% (n = 3,517). The prevalence of “at-risk” patients (NRS 2002 scores of 3+) was highest in patients with cardiac conditions (31.5%) and lowest in patients with diseases of the respiratory system (6.9%). Controlling for sex, age, education, type of insurance, smoking status, the main diagnosed disease, and Charlson comorbidity index (CCI), the multivariate analysis showed that the NRS 2002 score = 3 [hazard ratio (HR): 1.376, 95% CI: 1.031–1.836] were associated with approximately a 1.5-fold higher likelihood of death. NRS 2002 scores = 4 (HR: 1.982, 95% CI: 1.491–2.633) and NRS scores ≥ 5 (HR: 1.982, 95% CI: 1.498–2.622) were associated with a 2-fold higher likelihood of death, compared with NRS 2002 scores <3. An NRS 2002 score of 3 (percentage change: 16.4, 95% CI: 9.6–23.6), score of 4 (32.4, 95% CI: 24–41.4), and scores of ≥ 5 (36.8, 95% CI 28.3–45.8) were associated with a significantly (16.4, 32.4, and 36.8%, respectively) higher likelihood of increased LoS compared with an NRS 2002 scores <3. The NRS 2002 score = 3 group (17.8, 95% CI: 8.6–27.7) was associated with a 17.8%, the NRS 2002 score = 4 group (31.1, 95% CI: 19.8–43.5) a 31.1%, and the NRS 2002 score ≥ 5 group (44.3, 95% CI: 32.3–57.4) a 44.3%, higher likelihood of increased hospital costs compared with a NRS 2002 scores <3 group. Specifically, the most notable mortality-specific comorbidity and LoS-specific comorbidity was injury, while the most notable cost-specific comorbidity was diseases of the digestive system.

Conclusions: This study demonstrated the high burden of undernutrition at the time of hospital admission on the health and hospital cost outcomes for older immobile inpatients. These findings underscore the need for nutritional risk screening in all Chinese hospitalized patients, and improved diagnosis, treatment, and nutritional support to improve immobile patient outcomes and to reduce healthcare costs.

Prehabilitation before surgery: Is it for all patients?

PURPOSE

To evaluate the role of prehabilitation interventions in adult patients before elective major surgery.

RECENT FINDINGS

Exercise training before elective adult major surgery is feasible and safe. Efficacy has been determined but the clinical effectiveness remains uncertain. Early data suggest a reduction in morbidity, length of stay, and an improvement in the quality of life. Nutritional and psychological interventions are less well evaluated, and when they are, it is often in combination with exercise interventions as part of multimodal prehabilitation.

SUMMARY

Studies evaluating multimodal prehabilitation interventions before elective major surgery in adults are producing encouraging early results, but definitive clinical effectiveness is currently very limited. Future research should focus on refining interventions, exploring mechanisms, establishing minimum dosage, interrogating interactions between therapies, and urgent implementation of large-scale clinical effectiveness studies.

Prevalence of undernutrition in surgical patients and the effect on length of hospital stay

BACKGROUND

Low nutritional status is common among surgical patients. A low nutrition profile is related to muscle weakness and immune suppression, which may be associated with negative outcomes. In this study, we evaluated the prevalence of low nutrition and assessed the relationship between nutritional status and length of hospital stay in surgical patients.

METHODS

The study participants were patients who underwent abdominal surgery between 2016 and 2018 at our hospital. The Mini Nutritional Status Short-Form score and patient demographics, including current medical status, were extracted from the medical records. Data on anesthesia time, blood loss, and use of epidural anesthesia were also recorded. The primary study outcome was the difference in length of hospitalization from the standard duration (hospitalization = actual length of hospitalization-standard length of hospitalization).

RESULTS

Eight hundred and thirty five patients met the inclusion criteria. Their nutritional status was classified as normal (59.0%), at risk (29.6%), or malnutrition (11.4%). Linear regression analysis revealed that nutritional status, serum albumin level, and anesthesia time were associated with the length of hospital stay.

CONCLUSION

Our results suggest that a low nutrition profile before surgery is associated with a prolonged hospital stay.

From clinical guidelines to practice: The nutrition elements for enhancing recovery after colorectal surgery

The Enhanced Recovery After Surgery (ERAS) Care System improves patient outcomes. The ERAS Protocol describes multimodal, evidence-based processes that are bundled into >20 care elements, and the ERAS Implementation Program provides strategies to guide the successful adoption of the care elements. Although formal training is essential to implement ERAS correctly, with this article we aim to bridge the gap between the nutritionally relevant care elements of the protocol and their implementation for colorectal surgery. This article also describes how dietitians can support optimal patient outcomes by playing an active role in implementing, monitoring, and evaluating ERAS practices.

Determinación de los factores predictivos para complicaciones en cirugía electiva de pacientes con cáncer colorrectal. Experiencia del Instituto de Cancerología Las Américas Auna (Colombia, 2016-2019)

Introducción. El pilar fundamental del tratamiento del cáncer colorrectal es la cirugía, situación que expone a los pacientes a la posible presentación de complicaciones, morbimortalidad, pobre calidad de vida, recurrencia tumoral o la muerte. El objetivo de este estudio fue determinar las variables clínicas y quirúrgicas que inciden en el riesgo de la aparición de complicaciones en los pacientes con cáncer colorrectal llevados a cirugía electiva entre los años 2016 y 2019. Métodos. Estudio observacional, descriptivo, transversal y retrospectivo. Se incluyeron pacientes mayores de 18 años con cáncer colorrectal sometidos a cirugía electiva. Se realizó un análisis multivariado para determinar los factores que se relacionan con las complicaciones postquirúrgicas. Resultados. Se incluyeron 298 pacientes, 68 % mayores de 60 años, 52,3 % mujeres, 74,2 % presentaban comorbilidades y 48,3 % fueron diagnosticados en estadio III. El 48,3 % presentó complicaciones postoperatorias. De ellos, el 68,1 % no tenía tamización nutricional y el 61,8 % no tenía preparación del colon; un 55 % fueron cirugías del recto, 69,1 % de las cirugías fueron por vía laparoscópica y 71,8 % presentaron sangrado inferior a 500 ml. La mayoría de las complicaciones fueron clasificadas como Clavien-Dindo I-III. Discusión. Las características de los pacientes fueron similares a los presentados en otros estudios, aunque hubo mayor incidencia de íleo postoperatorio. El análisis multivariado mostró una mayor probabilidad de presentar una complicación en pacientes con diabetes mellitus, hipertensión arterial, falta de tamización nutricional o preparación de colon, cirugía de recto y el sangrado mayor a 500 ml.

Low Food Consumption Interferes with the Nutritional Status of Surgical Patients with Neoplasia of the Gastrointestinal Tract

Nutritional support strongly influence the nutritional status of the surgical neoplastic patients. This study aimed to evaluate the influence of food consumption on the perioperative nutritional status of hospitalized patients with neoplasia of the upper (UGIT) and lower (LGIT) gastrointestinal tract. Methods: Observational, longitudinal, and prospective study. Data collected: food consumption, Subjective Global Assessment, anthropometry, laboratory tests. Results: Eighty patients were followed up: 43 (54%) in the UGIT and 37 (46%) in the LGIT. The consumption in the perioperative period was lower than the usual consumption in the UGIT and LGIT groups, respectively, of energy (14.2 ± 6.5; 22.8 ± 11.2 Kcal/kg/d, p < 0.001; 13.6 ± 1.2; 19.0 ± 2.0 Kcal/kg/d; p = 0.014), protein (1.1 ± 0.7; 0.6 ± 0.3 g/kg/d, p < 0.001; 0.8 ± 0.1; 0.5 ± 0.1 g/kg/d; p = 0.058), selenium, zinc and copper. Most patients presented in the UGIT and LGIT groups, respectively, worsening malnutrition and muscle depletion according to the Subjective Global Assessment (61.9%; 51.4%) and hypoalbuminemia, mainly in the UGIT in the postoperative. Conclusion: Low food consumption during the perioperative period associated with prolongation of the postoperative fasting period worsens the nutritional status of patients undergoing surgery of the gastrointestinal tract for neoplasia, especially in the UGIT group.

Identifying and Managing Malnutrition, Frailty and Sarcopenia in the Community: A Narrative Review

Malnutrition, frailty and sarcopenia are becoming increasingly prevalent among community-dwelling older adults; yet are often unidentified and untreated in community settings. There is an urgent need for community-based healthcare professionals (HCPs) from all disciplines, including medicine, nursing and allied health, to be aware of, and to be able to recognise and appropriately manage these conditions. This paper provides a comprehensive overview of malnutrition, frailty and sarcopenia in the community, including their definitions, prevalence, impacts and causes/risk factors; and guidance on how these conditions may be identified and managed by HCPs in the community. A detailed description of the care process, including screening and referral, assessment and diagnosis, intervention, and monitoring and evaluation, relevant to the community context, is also provided. Further research exploring the barriers/enablers to delivering high-quality nutrition care to older community-dwelling adults who are malnourished, frail or sarcopenic is recommended, to inform the development of specific guidance for HCPs in identifying and managing these conditions in the community.

Comparison of Two Malnutrition Assessment Scales in Predicting Postoperative Complications in Elderly Patients Undergoing Noncardiac Surgery

Background: The present study was designed to investigate the relationship between two malnutrition assessment scales, perioperative nutrition screen (PONS) and Nutritional Risk Screening 2002 (NRS2002), with postoperative complications in elderly patients after noncardiac surgery.

Methods: This was a secondary analysis of a prospective cohort study. Elderly patients (65–90 years) undergoing noncardiac surgery were enrolled in Peking University First Hospital. Malnutrition was screened by PONS and NRS2002 at the day before surgery. Multivariable analysis was employed to analyze the relationship between PONS and NRS2002 and postoperative 30-day complications. Receiver operating characteristic (ROC) curve was generated to evaluate the predictive value of PONS and NRS2002 in predicting postoperative complications.

Results: A total of 915 patients with mean age of 71.6 ± 5.2 years were consecutively enrolled from September 21, 2017, to April 10, 2019. The incidence of malnutrition was 27.3% (250/915) by PONS ≥ 1 and 53.6% (490/915) by NRS2002 ≥ 3. The overall incidence of complications within postoperative 30 days was 45.8% (419/915). After confounders were adjusted, malnutrition by PONS ≥ 1 (OR 2.308, 95% CI 1.676–3.178, P < 0.001), but not NRS2002 ≥ 3 (OR 1.313, 95% CI 0.973–1.771, P = 0.075), was related with an increased risk of postoperative complications. ROC curve analysis showed that the performances of PONS [area under the ROC curve (AUC) 0.595, 95% CI 0.558–0.633] showed very weak improvement in predicting postoperative complications than NRS2002 score (AUC 0.577, 95% CI 0.540–0.614).

Conclusion: The present study found that malnutrition diagnosed by PONS was related with an increased risk of postoperative complications. The performances of PONS and NRS2002 were poor in predicting overall postoperative complications.

Clinical Trial Registration:www.chictr.org.cn, identifier: ChiCTR-OOC-17012734.

The influence of modifiable risk factors on short-term postoperative outcomes following cervical spine surgery: A retrospective propensity score matched analysis

BACKGROUND

Modifiable risk factors (MRFs) represent patient variables associated with increased complication rates that may be prevented. There exists a paucity of studies that comprehensively analyze MRF subgroups and their independent association with postoperative complications in patients undergoing cervical spine surgery. Therefore, the purpose of this study is to compare outcomes between patients receiving cervical spine surgery with reported MRFs.

METHODS

Retrospective analysis of the Nationwide Readmissions Database (NRD) from the years 2016 and 2017, a publicly available and purchasable data source, to include adult patients undergoing cervical fusion. MRF cohorts were separated into three categories: substance abuse (alcohol, tobacco/nicotine, opioid abuse); vascular disease (hypertension, dyslipidemia); and dietary factors (malnutrition, obesity). Three-way nearest-neighbor propensity score matching for demographics, hospital, and surgical characteristics was implemented.

FINDINGS

We identified 9601 with dietary MRFs (D-MRF), 9654 with substance abuse MRFs (SA-MRF), and 9503 with vascular MRFs (V-MRF). Those with d-MRFs had significantly higher rates of medical complications (9.3%), surgical complications (8.1%), and higher adjusted hospital costs compared to patients with SA-MRFs and V-MRFs. Patients with d-MRFs (16.3%) and V-MRFs (14.0%) were independently non-routinely discharged at a significantly higher rate compared to patients with SA-MRFs (12.6%) (p<0.0001 and p = 0.0037). However, those with substance abuse had the highest readmission rate and were more commonly readmitted for delayed procedure-related infections.

INTERPRETATION

A large proportion of patients who receive cervical spine surgery have potential MRFs that uniquely influence their postoperative outcomes. A thorough understanding of patient-specific MRF subgroups allows for improved preoperative risk stratification, tailored patient counseling, and postoperative management planning.

FUNDING

None.

Assessment of an integrated knowledge translation intervention to improve nutrition intakes among patients undergoing elective bowel surgery: a mixed-method process evaluation

BACKGROUND

A large evidence-practice gap exists regarding provision of nutrition to patients following surgery. The aim of this study was to evaluate the processes supporting the implementation of an intervention designed to improve the timing and adequacy of nutrition following bowel surgery.

METHODS

A mixed-method pilot study, using an integrated knowledge translation (iKT) approach, was undertaken at a tertiary teaching hospital in Australia. A tailored, multifaceted intervention including ten strategies targeted at staff or patients were co-developed with knowledge users at the hospital and implemented in practice. Process evaluation outcomes included reach, intervention delivery and staffs' responses to the intervention. Quantitative data, including patient demographics and surgical characteristics, intervention reach, and intervention delivery were collected via chart review and direct observation. Qualitative data (responses to the intervention) were sequentially collected from staff during one-on-one, semi-structured interviews. Quantitative data were summarized using median (IQR), mean (SD) or frequency(%), while qualitative data were analysed using content analysis.

RESULTS

The intervention reached 34 patients. Eighty-four percent of nursing staff received an awareness and education session, while 0% of medical staff received a formal orientation or awareness and education session, despite the original intention to deliver these sessions. Several strategies targeted at patients had high fidelity, including delivery of nutrition education (92%); and prescription of oral nutrition supplements (100%) and free fluids immediately post-surgery (79%). Prescription of a high energy high protein diet on postoperative day one (0%) and oral nutrition supplements on postoperative day zero (62%); and delivery of preoperative nutrition handout (74%) and meal ordering education (50%) were not as well implemented. Interview data indicated that staff regard nutrition-related messages as important, however, their acceptance, awareness and perceptions of the intervention were mixed.

CONCLUSIONS

Approximately half the patient-related strategies were implemented well, which is likely attributed to the medical and nursing staff involved in intervention design championing these strategies. However, some strategies had low delivery, which was likely due to the varied awareness and acceptance of the intervention among staff on the ward. These findings suggest the importance of having buy-in from all staff when using an iKT approach to design and implement interventions.

Malnutrition is not related with emergence delirium in older patients after noncardiac surgery

Background

Delirium is one of the most common complications in older surgical patients. Although previous studies reported that preoperative malnutrition was related with postoperative delirium (POD), there was lack of evidence to illustrate the relationship between malnutrition and emergency delirium (ED). The objective of this study was to investigate the relationship between preoperative malnutrition and ED in older patients undergoing noncardiac surgery.

Methods

The study was carried out in accordance with STROBE guidelines. This was a secondary analysis of a prospective cohort study. Older patients (65–90 years) who underwent noncardiac surgery under general anesthesia were enrolled in Peking University First Hospital.

Results

915 patients were enrolled. The incidence of malnutrition was 53.6 % (490/915). The incidence of emergency delirium was 41.8 % (205/490) in malnutrition group and 31.5 % (134/425) in control group, P < 0.001. After adjusting confounding factors (i.e., age, cognitive impairment, American Society of Anesthesiologists classification (ASA), duration of surgery, pain score, low body temperature and allogeneic blood transfusion), malnutrition was not associated with increased risk of emergency delirium (OR = 1.055, 95 % CI 0.767–1.452, P = 0.742).

Conclusions

Malnutrition was common in older patients undergoing non-cardiac surgery, but it’s not related with emergence delirium after adjusted for confounders.

Trial registration

Chinese Clinical Trial Registry (http://www.chictr.org.cn) (ChiCTR-OOC-17,012,734).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02270-2.

Pre- and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery

Nutritional status is a strong predictor of postoperative outcomes and is recognized as an important component of surgical recovery programs. Adequate nutritional consumption is essential for addressing the surgical stress response and mitigating the loss of muscle mass, strength, and functionality. Especially in older patients, inadequate protein can lead to significant muscle atrophy, leading to a loss of independence and increased mortality risk. Current nutritional recommendations for surgery primarily focus on screening and prevention of malnutrition, pre-surgical fasting protocols, and combating post-surgical insulin resistance, while recommendations regarding macronutrient composition and timing around surgery are less established. The goal of this review is to highlight oral nutrition strategies that can be implemented leading up to and following major surgery to minimize atrophy and the resultant loss of functionality. The role of carbohydrate and especially protein/essential amino acids in combating the surgical stress cascade and supporting recovery are discussed. Practical considerations for nutrient timing to maximize oral nutritional intake, especially during the immediate pre- and post- surgical periods, are also be discussed.

Nutritional Assessment in Adult Patients with Dysphagia: A Scoping Review

Malnutrition negatively affects the quality of life of patients with dysphagia. Despite the need for nutritional status assessment in patients with dysphagia, standard, effective nutritional assessments are not yet available, and the identification of optimal nutritional assessment items for patients with dysphagia is inadequate. We conducted a scoping review of the use of nutritional assessment items in adult patients with oropharyngeal and esophageal dysphagia. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched to identify articles published in English within the last 30 years. Twenty-two studies met the inclusion criteria. Seven nutritional assessment categories were identified: body mass index (BMI), nutritional screening tool, anthropometric measurements, body composition, dietary assessment, blood biomarkers, and other. BMI and albumin were more commonly assessed in adults. The Global Leadership Initiative on Malnutrition (GLIM), defining new diagnostic criteria for malnutrition, includes the categories of BMI, nutritional screening tool, anthropometric measurements, body composition, and dietary assessment as its required components, but not the blood biomarkers and the “other” categories. We recommend assessing nutritional status, including GLIM criteria, in adult patients with dysphagia. This would standardize nutritional assessments in patients with dysphagia and allow future global comparisons of the prevalence and outcomes of malnutrition, as well as of appropriate interventions.

Quality of life, symptoms and dietary habits in oncology outpatients with malnutrition: A cross-sectional study

Cancer-related malnutrition has a high prevalence, reduces survival and increases side effects. The aim of this study was to assess oncology outpatients and risk of malnutrition. Reported symptoms and quality of life (QoL) in patients found to be at risk of malnutrition or malnourished were compared to patients without malnutrition. Using a standardized questionnaire, the European Organization for Research and Treatment of Cancer Questionnaire for Quality of Life and the Mini Nutritional Assessment (MNA), patients in an outpatient cancer clinic undergoing chemotherapy treatment at a German University Hospital were assessed for nutrition, risk of malnutrition and quality of life. Based on the MNA, 39 (45.9%) patients were categorized as malnourished or at risk for malnutrition. Loss of appetite (n = 37.6%, p < 0.001) and altered taste sensation (n = 30,3%, p < 0.001) were the symptoms most frequently associated with reduced food intake. Patients with risk of malnutrition scored lower on the global health status (n = 48.15%, p = 0.001). Side effects of cancer treatments lead to a higher risk of malnutrition and as a consequence lower QoL. These side effects should be addressed more efficiently in cancer care.

Approaches to patient satisfaction measurement of the healthcare food services: A systematic review

BACKGROUND & AIMS

Monitoring consumer's satisfaction is important in ensuring effective foodservice improvements and to provide a patient-centred foodservice experience. The aim of this study is to systematically review available patient foodservice satisfaction survey instruments developed and validated within the acute and long-term care settings.

METHODS

A literature search of four scientific databases was performed to identify relevant studies with 50 participants or greater. Study characteristics, such as identifying information, contexts, and descriptive data regarding the tool and its evaluation study, were extracted and synthesised. Quality appraisal of individual studies was undertaken to assess the risk of bias during data collection.

RESULTS

Majority of the survey instruments included utilised a quantitative research approach in the form of self- or interview-administered questionnaires. Tools within the long-term care settings were more likely to be administered via interviews using a shorter and even rating scale, potentially resulting in a higher degree of bias and reduced data sensitivity. Food quality was consistently shown to be the main predictor of the overall satisfaction in food services. Factors that are context-specific to the settings, opportunities to allow open-ended comments, and the involvement of patients' perspectives in instrument development were also critical in improving survey quality.

CONCLUSION

The available validated survey instruments are generally valid and of acceptable quality, enabling effective foodservice satisfaction measurement in the healthcare settings. Nonetheless, gaps have been identified in the literature with limited evidence available for foodservice satisfaction measurement within the paediatric settings, supporting the value of future research in this field.

[Nutritional screening in hospitalized patients with vascular disease - The relationship of nutritional risk with clinical and economic outcomes in a surgery department]

Introduction

Introduction: disease-related malnutrition has a negative impact on the outcome in surgical patients. Our objective was to assess the prevalence of nutritional risk in the field of vascular surgery, as well as its consequences on patient outcome and health expenditure. Patients and methods: this is a prospective, observational study conducted during 6 months in a vascular surgery ward at the University Hospital of León, Spain. The Malnutrition Universal Screening Tool was used to obtain data on admission and then every 7 days until hospital discharge. Clinical variables, surgical intervention performed, medical-surgical complications, hospital stay, healthcare costs, and early readmissions were studied. Results: a total of 104 patients, 84.6 % males, with a mean age of 69 (SD: 13) years were enrolled. Of these, 46.2 % were admitted due to peripheral arterial disease; 10.6 % had a positive MUST at the time of admission and 19.2 % at discharge; 100 % of malnourished patients at admission remained in the same situation at discharge. During hospitalization, in 29 patients (27.9 %) the nutritional situation worsened. In all, 81.25 % of patients who experienced worsening of their MUST score had been admitted urgently (p < 0.05). Patients who required urgent surgery significantly worsened in terms of their nutritional status (p < 0.001). Patients with worsening nutritional status obtained higher rates for: surgical reintervention (p < 0.05), pharmaceutical expense (p = 0.017), total hospital expense (€1,000/patient/admission), transfers to chronic care centers (p = 0.0002), and number of early readmissions (p = 0.017). Conclusion: patients with nutritional risk suffered an increase in medical-surgical complications, hospital stay, healthcare costs, and re-admission rates. Therefore, we consider that an implementation of screening procedures and the development of further studies in the vascular surgery setting are necessary.

Malnutrition in Acute Care Surgery Patients in Rwanda

INTRODUCTION

Malnutrition is prevalent in hospitalized surgical patients and has been shown to significantly alter outcomes including length of hospital stay, complications, and mortality. Different tools for nutrition assessment were developed and are being used. The aim of this study was to characterize the nutritional status of acute care surgery patients, determine risk factors for malnutrition, and describe outcomes in patients with malnutrition.

METHODS

This was a prospective, descriptive study of malnutrition in acute care surgery patients at CHUK. Over a 6-month time period, we collected data on demographics, diagnosis, operation, and patient outcomes. We assessed the incidence of malnutrition using the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines and Subjective Global Assessment (SGA). We reported frequencies and percentages for categorical variables and median and interquartile range (IQR) for continuous variables.

RESULTS

We analyzed data for 279 acute care surgery patients. Most (n = 209, 73%) patients were male. The median duration of symptoms was 5 days (IQR 2, 14). The most common diagnoses were trauma (n = 83, 30%), intestinal obstruction (n = 76, 27%), and peritonitis (n = 49, 18%). Most (n = 210, 73%) patients underwent operation. The median length of hospital stay was 6 days (IQR 4, 11). Using ASPEN guidelines, 99 (35%) patients had evidence of malnutrition on hospital admission and 76 (27%) had evidence of malnutrition using SGA. After 1 week of hospital stay, 48 (41%) patients had evidence of malnutrition. Overall mortality was 3%, with higher mortality seen in patients with malnutrition (8% vs. 0.6%, p = 0.001). The length of hospital stay was longer in patients with malnutrition on hospital admission (6 days vs. 5 days, p = 0.044).

CONCLUSIONS

Acute care surgical patients present to the hospital at high-risk for malnutrition. Efforts are needed to ensure that surgical patients receive adequate nutrition support to improve patient outcomes and minimize complications.

Predictors of Dietitian Referrals in Hospitals

Dietitian involvement has considerable benefits for hospitalized patients, resulting in better health outcomes and improved quality of life. However, dietitian referral routines are often inappropriate in hospitals. The aim of this study was to identify predictors for dietitian referrals in hospitalized patients. This study was performed on data collected in an annually conducted cross-sectional study (in the years 2017, 2018, 2019). A standardized questionnaire was used to collect data, and logistic regression and a generalized estimating equation (GEE) model were used to calculate the associations between the patient characteristics and dietitian referrals. In the final GEE model, the following predictors for dietitian referrals remained significant: diabetes diagnosis (OR 1.80), cancer diagnosis (OR 1.76), digestive disease diagnosis (OR 2.03), presence of a pressure injury (OR 1.58), risk of malnutrition based on body mass index (BMI) and weight loss (OR 1.72), risk of malnutrition based on the malnutrition universal screening tool (MUST) (2.55), and the application of any malnutrition screening at admission to hospital (2.20). Total dietitian referral rate was 16.8%. The highest rate of dietitian referrals was found in patients with a risk of malnutrition (37%). This study included a large sample of hospitalized adult patients and revealed a low dietitian referral rate among these patients. These results indicate that dietitian involvement in hospitalized patients with nutrition-related conditions urgently needs to be improved.

Evaluation of an intervention to improve nutrition intake in patients undergoing elective colorectal surgery: A mixed-methods pilot study

OBJECTIVES

Timely and adequate nutrition after surgery is important. The aim of this study was to evaluate the effects of an intervention, developed using an integrated knowledge translation approach, designed to improve oral intake among postoperative colorectal patients.

METHODS

A pre/post, mixed-methods pilot study was undertaken at a tertiary teaching hospital in Australia. Patients who had undergone elective colorectal surgery and were admitted to the ward where 10 nutrition-related strategies had been implemented were included. Quantitative data, including patient demographics, timing and type of nutrition consumed, and protein and energy intake were collected pre- and post-intervention via chart audits, direct observations, and verbal clarification. Qualitative data on patient (n = 18) responses to the intervention were collected through one-on-one, semistructured interviews and analyzed using inductive content analysis.

RESULTS

Sixty-four patients were observed (30 pre- and 34 post-intervention). Significant improvements were seen for the following outcomes (presented as median [interquartile range], pre- versus post-intervention): time (h) to first dietary intake (15.7 [7.4-22.5] versus 4.9 [3.7-14.2]); patient energy intakes (kJ) on day 1 (1719 [947-2200] versus 3530 [2192-5169]) and day 2 (2506 [1071-3749] versus 4144 [2987-5889]); and patient protein intake (g) on day 1 (3.3 [1.8-11.2] versus 30.3 [20-45]) and day 2 (10.8 [3.5-29.9] versus 39.6 [30.7-59]). Prescription of free fluids as first diet type increased from 13% to 79% pre- and post-intervention, respectively. There were no significant differences in time (h) to first solid dietary intake (86.1 [60.1-104] versus 69.2 [46.1-115.5]) and overall proportion of patients who met both their estimated energy and protein requirements while in hospital pre- and post-intervention (22 versus 37%). Patients reported positive experiences with the intervention.

CONCLUSION

A multifaceted intervention developed using an integrated knowledge translation approach has the potential to improve oral intake in patients who undergo colorectal surgery. A larger-scale trial is required to confirm these findings and assess the effects of the intervention on clinical outcomes and costs.

Prospective study to evaluate the prognostic value of different nutritional assessment scores in liver surgery: NURIMAS Liver (DRKS00006340)

Background

Malnutrition is recognised as a preoperative risk factor for patients undergoing hepatic resection. It is important to identify malnourished patients and take preventive therapeutic action before surgery. However, there is no evidence regarding which existing nutritional assessment score (NAS) is best suited to predict outcomes of liver surgery.

Methods

All patients scheduled for elective liver resection at the surgical department of the University Hospital of Heidelberg and the Municipal Hospital of Karlsruhe were screened for eligibility. Twelve NASs were calculated before operation, and patients were categorised according to each score as being either at risk or not at risk for malnutrition. The association of malnutrition according to each score and occurrence of at least one major complication was the primary endpoint, which was achieved using a multivariate logistic regression analysis including established risk factors in liver surgery as covariates.

Results

The population consisted of 182 patients. The percentage of patients deemed malnourished by the NAS varied among the different scores, with the lowest being 2.20% (Mini Nutritional Assessment) and the highest 52.20% (Nutritional Risk Classification). Forty patients (22.0%) had a major complication. None of the scores were significantly associated with major complications.

Conclusions

None of the twelve investigated NAS defined a state of malnutrition that was independently associated with postoperative complications. Other means of measuring malnutrition in liver surgery should be investigated prospectively.