Nutritional consequences of major gastrointestinal surgery. Patient outcome and starvation

Review of Nutrition Guidelines and Evidence on Diet and Survival Outcomes for Cancer Survivors: Call for Integrating Nutrition into Oncology Care

Several organizations have published nutrition guidelines for cancer survivors during and after treatment. This review compared nutrition guidelines for cancer survivors published in the United States for the topics that are covered in the guidelines and evaluated the evidence that these guidelines are based upon. A team of researchers, patient stakeholders, and healthcare providers collectively identified 5 nutrition guidelines for cancer survivors in the United States: the 2022 American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors, the 2018 American Institute for Cancer Research Cancer Nutrition Guide, the 2022 National Cancer Institute Physician Data Query and Eating Hints, the 2024 National Comprehensive Cancer Network Guidelines for Cancer Survivors, and the 2020 American Society for Clinical Oncology Guidelines. The 5 guidelines cover a comprehensive list of nutrition topics but overall promote to follow those recommendations for cancer prevention. This review also evaluated the current evidence from meta-analyses on dietary patterns and intakes of foods and nutrients in relation to survival outcomes among cancer survivors. Although the evidence on dietary patterns is strong, the evidence on most dietary factors is still limited and the current research was primarily conducted among breast and colorectal cancer survivors. Although nutrition recommendations are available for cancer survivors, practical strategies need to be implemented to integrate nutrition into oncology care and help cancer survivors follow these recommendations. Further research is warranted to provide additional evidence on the role of nutrition in the health outcomes of cancer survivors and guide the development of evidence-based nutrition recommendations. The protocol is registered in PROSPERO: CRD42023429240.

Gastrointestinal motility after pancreatoduodenectomy

Pancreatoduodenectomy (PD) is a major surgical procedure which is accompanied by a high morbidity of between 30 and 50%. A large part of this morbidity is caused by delayed gastric emptying (DGE), which is reported to have an incidence of between 30 and 40% and is associated with prolonged hospital stay. Several pathophysiological mechanisms are thought to cause this complication. Peroperative trauma of the pylorus and the occurrence of intra-abdominal abscesses play a role. Neuronal changes and disruption of the gastrointestinal (GI) intramural nervous plexus may be especially important regarding the pivotal role of the duodenum in the initiation and coordination of antroduodenal motor activity. Another important factor is the postoperative administration of enteral nutrition. Recently, it was demonstrated that cyclic enteral nutrition through a catheter jejunostomy led to a faster return to normal diet and shorter hospital stay than patients on continuous enteral nutrition; this might be partly caused by continuously elevated cholecystokinin levels. The effect of prokinetic agents has not been studied extensively, but a beneficial action on the return of postoperative gastric function after gastrointestinal surgery seems limited.

Prospective, randomized trial on the effect of cyclic versus continuous enteral nutrition on postoperative gastric function after pylorus-preserving pancreatoduodenectomy

OBJECTIVE

The effect of a cyclic versus a continuous enteral feeding protocol on postoperative delayed gastric emptying, start of normal diet, and hospital stay was assessed in patients undergoing pylorus-preserving pancreatoduodenectomy (PPPD).

SUMMARY BACKGROUND DATA

Delayed gastric emptying occurs in approximately 30% of patients after PPPD and causes prolonged hospital stay. Enteral nutrition through a catheter jejunostomy is used to provide postoperative nutritional support. Enteral infusion of fats and proteins activates neurohumoral feedback mechanisms and therefore can potentially impair gastric emptying and prolong postoperative gastroparesis.

METHODS

From September 1995 to December 1996, 72 consecutive patients underwent PPPD at the Academic Medical Center, Amsterdam. Fifty-seven patients were included and randomized for either continuous (CON) jejunal nutrition (0-24 hr; 1500 kCal/24 hr) or cyclic (CYC) enteral nutrition (6-24 hr; 1125 kCal/18 hr). Both groups had an equal caloric load of 1 kCal/min. The following parameters were assessed: days of nasogastric intubation, days of enteral nutrition, days until normal diet was tolerated orally, and hospital stay. On postoperative day 10, plasma cholecystokinin (CCK) levels were measured during both feeding protocols.

RESULTS

Nasogastric intubation was 9.1 days in the CON group (n = 30) and 6.7 days in the CYC group (n = 27) (not statistically significant). First day of normal diet was earlier for the CYC group (15.7 vs. 12.2 days, p < 0.05). Hospital stay was shorter in the CYC group (21.4 vs. 17.5 days, p < 0.05). CCK levels were lower in CYC patients, before and after feeding, compared with CON patients (p < 0.05).

CONCLUSIONS

Cyclic enteral feeding after PPPD is associated with a shorter period of enteral nutrition, a faster return to a normal diet, and a shorter hospital stay. Continuously high CCK levels could be a cause of prolonged time until normal diet is tolerated in patients on continuous enteral nutrition. Cyclic enteral nutrition is therefore the feeding regimen of choice in patients after PPPD.

Enteral nutrition and the critically ill

Critically ill patients invariably require nutritional intervention. Traditionally, enteral nutrition has not been widely employed in this patient population. This is due in part to the success of present-day parenteral nutrition, and to difficulties encountered with enteral feeding. Recent evidence has demonstrated that enteral is preferable to parenteral nutrition in terms of cost, complications, gut mucosal maintenance, and metabolic and immune function. Enterally administered nutritional support can and should be utilised as the preferred route of nourishment for the critically ill. The appropriate choice of access and formula, as well as a rational strategy for implementation, should improve the likelihood of success. This article describes the unique features of critical illness as they pertain to nutritional support, the benefits of enteral nutrition, and the obstacles to success, and offers suggestions which may improve the ability to provide nutrients adequately via the intestinal tract.

Resting energy expenditure and nitrogen loss after surgery in chronically undernourished patients

Chronically undernourished patients (n = 10) undergoing elective abdominal surgery were assessed with regard to their energy expenditure and urinary nitrogen loss. These measurements were made for 1 week after the surgery, and stress factors for each parameter were computed. The responses of the chronically undernourished patients were compared to those of relatively well nourished patients (n = 10) undergoing comparable surgeries. It was found that the postoperative resting energy expenditure (REE) of the chronically undernourished patients was not significantly elevated when compared to their preoperative values (mean +/- SEM): 1210.66 +/- 88.13, 1354.91 +/- 86.61, 1215.09 +/- 89.68, and 1188.23 +/- 86.61 kcal/day preoperatively and on postoperative days 1, 4, and 8, respectively. On the other hand, the postoperative REE of the controls was significantly elevated (p < 0.05) over their baseline values: 1357.18 +/- 70.81, 1574.66 +/- 100.35, 1502.89 +/- 109.44, and 1477.23 +/- 83.52; kcal/day, respectively, for the same days. The stress factors for the controls were higher than those for the undernourished (1.16 versus 1.12, 1.11 versus 1.00, and 1.09 versus 0.98 on postoperative days 1, 4, and 8, respectively). The urinary nitrogen excretion in both groups (for the 4 days) was not significantly elevated over baseline (6.23 +/- 0.87, 7.72 +/- 0.71, 8.36 +/- 0.87, and 8.04 +/- 1.56 grams/day in the undernourished; and 7.59 +/- 1.03, 9.57 +/- 1.33, 9.49 +/- 1.03, and 8.67 +/- 0.76 grams/day in the controls. The stress factors for nitrogen excretion were slightly higher in the undernourished group.(ABSTRACT TRUNCATED AT 250 WORDS)

Motility studies of the cervical esophagus with intrathoracic gastric conduit after esophagectomy

Gastric emptying, upper esophageal sphincter pressure and intrathoracic gastric motility were studied in esophagectomized patients, ten with a gastric conduit in the posterior mediastinum and ten with a conduit in the retrosternal space. In addition, the clinical state was reassessed more than 6 months after esophageal reconstruction. Gastric emptying, assessed with Tc-99m Sn colloid in a semisolid test meal, did not differ between the two groups. In manometric studies a high-pressure zone distal to the upper esophageal sphincter was associated with dysphagia. A high-pressure zone at the anastomosis was found in 60% of the retrosternal group and 20% of the posterior mediastinal group. As regards food intake, the posterior mediastinal route seems to be preferable in esophageal replacement, since it permits more physiologic motility of the conduit.