IMMEDIATE PREOPERATIVE NUTRITIONAL STATUS OF PATIENTS WITH COLORECTAL CANCER: a warning

Transthyretin and Nutritional Status in Critically Ill Adults on Parenteral Nutrition: A Prospective Cohort Study

BACKGROUND AND AIMS

Correctly characterizing malnutrition is a challenge. Transthyretin (TTR) rapidly responds to adequate protein intake/infusion, which could be used as a marker to identify malnutrition. Nutritional therapy is used to prevent malnutrition. Parenteral nutrition (PN) requires daily monitoring to determine whether what is being offered is adequate. This article aims to investigate whether the practice of measuring TTR is justified.

METHODS

Data from patients admitted to the ward or intensive care unit (ICU) were collected at three different times: within the first 72 h (T1) of PN use, on the 7th day (T2), and the 14th day (T3) after the initial assessment.

RESULTS

302 patients were included; the average age was 48.3 years old; the prevalence of death was 22.2%, and 61.6% of the sample were male. TTR values and the effectiveness of nutritional support in these patients were not associated with the outcome; however, meeting caloric needs was related to the outcome (p = 0.047). No association was found when TTR values were compared to the nutritional status. Thus, TTR was not a good indicator of nutritional risk or nutritional status in hospitalized patients.

CONCLUSIONS

Undoubtedly, the TTR measurement was inversely proportional to CRP measurements. It was possible to conclude in this follow-up cohort of hospitalized patients that TTR values were not useful for determining whether the patient was malnourished, predicting death or effectiveness of nutritional support, yet based upon our analyses, a decrease in TTR greater than 0.024 units for every 1 unit increase in CRP might be due to ineffective nutritional supply.

Applicability of five nutritional screening tools in Chinese patients undergoing colorectal cancer surgery: a cross-sectional study

OBJECTIVES

To identify the most appropriate nutritional risk screening tool for patients undergoing colorectal cancer surgery, five nutritional screening tools, including the Nutritional Risk Screening 2002 (NRS 2002), Short Form of Mini Nutritional Assessment (MNA-SF), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST) and Nutritional Risk Index (NRI), were employed to evaluate the nutritional risk at admission and short-term clinical outcome prediction.

DESIGN

A cross-sectional study.

SETTING

A comprehensive affiliated hospital of a university in Shenyang, Liaoning Province, China.

PARTICIPANTS

301 patients diagnosed with colorectal cancer were continuously recruited to complete the study from October 2020 to May 2021.

PRIMARY AND SECONDARY OUTCOME MEASURES

Within 48 hours of hospital admission, five nutritional screening tools were used to measure the nutritional risk and to determine their relationship with postoperative short-term clinical outcomes.

RESULTS

The nutritional risk assesed by the five tools ranged from 25.2% to 46.2%. Taking the Subject Global Assessment as the diagnostic standard, MNA-SF had the best consistency (κ=0.570, p<0.001) and MST had the highest sensitivity (82.61%). Multivariate Logistic regression analysis after adjusting confounding factors showed that the NRS 2002 score ≥3 (OR 2.400, 95% CI 1.043 to 5.522) was an independent risk factor for postoperative complications and was the strongest predictor of postoperative complications (area under the curve 0.621, 95% CI 0.549 to 0.692). The scores of NRS 2002 (r=0.131, p<0.001), MNA-SF (r=0.115, p<0.05) and NRI (r=0.187, p<0.05) were poorly correlated with the length of stay. There was no correlation between the five nutritional screening tools and hospitalisation costs (p>0.05).

CONCLUSIONS

Compared with the other four nutritional screening tools, we found that NRS 2002 is the most appropriate nutritional screening tool for Chinese patients with colorectal cancer.

Poor Physical Performance Is Associated with Postoperative Complications and Mortality in Preoperative Patients with Colorectal Cancer

Introduction: Poor physical performance has been shown to be a good predictor of complications in some pathologies. The objective of our study was to evaluate, in patients with colorectal neoplasia prior to surgery, physical performance and its relationship with postoperative complications and in-hospital mortality, at 1 month and at 6 months. Methods: We conducted a prospective study on patients with preoperative colorectal neoplasia, between October 2018 and July 2021. Physical performance was evaluated using the Short Physical Performance Battery (SPPB) test and hand grip strength (HGS). For a decrease in physical performance, SPPB < 10 points or HGS below the EWGSOP2 cut-off points was considered. Nutritional status was evaluated using subjective global assessment (SGA). The prevalence of postoperative complications and mortality during admission, at 1 month, and at 6 months was evaluated. Results: A total of 296 patients, mean age 60.4 ± 12.8 years, 59.3% male, were evaluated. The mean BMI was 27.6 ± 5.1 kg/m2. The mean total SPPB score was 10.57 ± 2.07 points. A total of 69 patients presented a low SPPB score (23.3%). Hand grip strength showed a mean value of 33.1 ± 8.5 kg/m2 for men and 20.7 ± 4.3 kg/m2 for women. A total of 58 patients presented low HGS (19.6%). SGA found 40.2% (119) of patients with normal nourishment, 32.4% (96) with moderate malnutrition, and 27.4% (81) with severe malnutrition. Postoperative complications were more frequent in patients with a low SPPB score (60.3% vs. 38.6%; p = 0.002) and low HGS (64.9% vs. 39.3%, p = 0.001). A low SPPB test score (OR 2.57, 95% CI 1.37−4.79, p = 0.003) and low HGS (OR 2.69, 95% CI 1.37−5.29, p = 0.004) were associated with a higher risk of postoperative complications after adjusting for tumor stage and age. Patients with a low SPPB score presented an increase in in-hospital mortality (8.7% vs. 0.9%; p = 0.021), at 1 month (8.7% vs. 1.3%; p = 0.002) and at 6 months (13.1% vs. 2.2%, p < 0.001). Patients with low HGS presented an increase in mortality at 6 months (10.5% vs. 3.3%; p = 0.022). Conclusions: The decrease in physical performance, evaluated by the SPPB test or hand grip strength, was elevated in patients with colorectal cancer prior to surgery and was related to an increase in postoperative complications and mortality.

Early identification of cancer-related malnutrition in patients with colorectal cancer before and after surgery: a literature review

PURPOSE

The aim of this literature review is to provide a comprehensive overview of methods for early identification of cancer-related malnutrition and/or risk of malnutrition in patients with colorectal cancer. The focus is also on applicability and feasibility of the use of nutritional tools in oncology clinical practice.

METHODS

The literature search was conducted from November to December 2020 in the health science databases by two independent persons. Inclusion criteria were English and German language and articles from 2010 to 2020. Data analysis was carried out through a structured procedure. The research questions guided the literature review.

RESULTS

After removing duplicates and screening titles and abstracts, a total of 35 studies were identified as suitable publications and further analyzed. Eventually, nine original studies, with a total of 926 patients with colorectal cancer before or before and after surgery, addressed assessment measures for early identification of the risk or presence of malnutrition. The following types of nutritional assessment have been described: nutritional anthropometric measurements, laboratory chemistry diagnostics for malnutrition, and several validated nutritional screening and assessment tools. The nutritional tools demonstrate differences in terms of application and content. None of the reviewed studies was a randomized trial. There is little scientific evidence to underpin their specific application in identifying early cancer-related malnutrition in patients with colorectal cancer.

CONCLUSION

The early assessment of nutritional status in this patient group seems to lack evidence-based standardization in oncology clinical practice. Different groups of health professionals are involved; however, studies do not describe standardized roles. Physical activity as part of nutritional screening is not yet included in the analyzed screening tools.

Preoperative malnutrition in patients with colorectal cancer

Preoperative malnutrition in patients with colorectal cancer is associated with several postoperative consequences and poorer prognosis. Currently, there is a lack of a universal screening tool to assess nutritional status, and intervention to treat preoperative malnutrition is often neglected. This review summarizes and compares preoperative screening and interventional tools to help providers optimize malnourished patients with colorectal cancer for surgery. We found that nutritional screenings, such as the Subjectibe Global Assessment, Patient-Generated Subjective Global Assessment, Prognostic Nutritional Index, Nutrition Risk Index, Malnutrition Universal Screening Tool, Nutrition Risk Screening 2002, Nutrition Risk Score, serum albumin, and prealbumin, have all effectively predicted postoperative outcome. Physicians should consider which of these tools best fits their needs based on the their mode of assessment, efficiency, and specified parameters. Additionally, preoperative nutritional support, such as trimodal prehabilitation, modified peripheral parenteral nutrition, and N-3 fatty acid and arginine supplementation, which have also benefited patients postoperatively, ought to be implemented appropriately according to their ease of execution. Given the high prevalence of preoperative malnutrition in patients undergoing surgery for colorectal cancer, it is essential that health care providers assess and treat this malnutrition to reduce postoperative complications and length of hospital stay, and to improve prognosis to augment a patient’s quality of care.

Precision of Lunar Dual-energy X-ray Absorptiometry (iDXA) in measuring body composition among colorectal cancer patients and healthy subjects

BACKGROUND & AIMS

High quality and precise methods are needed when monitoring changes in body composition among colorectal cancer (CRC) patients and healthy subjects. The aim of this study was to estimate precision of the Dual-energy X-ray absorptiometry (Lunar iDXA, GE Healthcare software enCORE version 16) in measuring body composition in CRC patients and healthy subjects.

METHODS

Precision error of iDXA in measuring body composition was investigated in the current study. Thirty CRC patients and 30 healthy subjects, including both men and women underwent two consecutive whole-body DXA scan with repositioning. Precision estimates of visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) in the abdominal region, and total fat mass (FM), fat-free mass (FFM), lean mass (LM), bone mineral density (BMD) and bone mineral content (BMC) were calculated.

RESULTS

Precision error expressed as coefficient of variation (% CV) of VAT and SAT were estimated to be 3.56% and 3.28% among CRC patients, and 5.30% and 3.46% among healthy subjects. Estimated precision errors for body masses in the total region ranged between 0.49-1.01% and 0.40-0.88% in CRC patients and healthy subjects, respectively. Least significant change (LSC) in VAT mass, SAT mass, FM and LM were 140.9 g, 121.4 g, 637.0 g and 701.0 g, respectively, among CRC patients. Among healthy subjects the LSC in VAT, SAT, FM and LM were 80.93 g, 98.90 g, 484.0 g and 618.0 g, respectively. Only minor and non-significant differences between the two consecutive measurements for each body compartment were observed within both populations, and we found no systematic bias in the distribution of the differences.

CONCLUSION

The Lunar iDXA demonstrated high precision in body composition measurements among both CRC patients and healthy subjects. Hence, iDXA is a useful tool in clinical following-up and interventions targeted towards changes in body composition.

Prognostic nutritional index and postoperative outcomes in patients with colon cancer after laparoscopic surgery

PURPOSE

The prognostic nutritional index (PNI) is calculated using the serum albumin and peripheral lymphocyte counts. We sought to assess the correlation between the preoperative PNI and postoperative outcomes in patients with colon cancer treated with laparoscopic surgery.

METHODS

We included 896 colon cancer patients who underwent curative laparoscopic colectomy between January 2013 and March 2016. To identify any predictors of the postoperative outcomes, we compared the clinical characteristics and immunonutritional parameters, including the PNI, between patients classified as the Clavien-Dindo grade 2 or higher (n = 99) with those classified as grade 0 or 1 (n = 797).

RESULTS

A longer surgical time and a preoperative low PNI (< 49.8) (odds ratio; 1.913, p = 0.002) were independent predictors of postoperative complications according to a multivariate analysis. A preoperative low PNI was significantly associated with an older age, a lower performance status, a lower BMI, higher CEA levels, an advanced T status, lymph node metastasis, a longer operative time, a higher blood loss, a larger tumor size, treatment with a combined resection, a longer time to bowel recovery, a longer postoperative hospital stay, and a poor overall survival.

CONCLUSIONS

A preoperative low PNI was found to be significantly associated with the incidence of postoperative complications, an advanced tumor status, and a poor prognosis. Further research is needed to understand how to best clinically utilize this promising parameter.

Nutritional status and its effect on complications in patients with colorectal cancer

BACKGROUND

Nutritional status is an important factor for predicting the risk of developing complications after a surgical procedure. Many nutritional assessments are used in clinical practice, but their role in predicting postoperative outcomes is unknown. Therefore, the aim of this study was to assess the utility of nutritional risk factors at the diagnosis of colorectal cancer (CRC) for predicting early postsurgical complications.

METHODS

This was a prospective observational study including 127 patients with CRC at diagnosis. Their preoperative nutritional status was analyzed by body mass index (BMI), triceps and subscapular skinfolds and two nutritional scales: the Patient-Generated Subjective Global Assessment (PG-SGA) and the Malnutrition Universal Screening Tool (MUST). The outcome variables, including postoperative complications, length of hospital stay and mortality, were analyzed.

RESULTS

Patients identified as malnourished by PG-SGA score had prolonged hospital stays (p = 0.01). The risk of infection was increased in older patients (hazard ratio, HR 1.12; 95% confidence interval, CI 1.04-1.21) but was not associated with nutritional status. Early wound dehiscence was increased in patients with higher BMI (HR 1.15; 95% CI 1.01-1.29), with higher subscapular skinfold thickness and increased age (HR 1.05; 95% CI 1.05-1.10). Postoperative mortality was not significantly associated with nutritional status.

CONCLUSION

Malnourished patients, as identified by the PG-SGA score, stayed longer in hospital than patients who were not malnourished, while increased BMI was recognized as a risk factor for wound dehiscence.

Nutritional Assistance by Software Improves Surgical Outcomes of Elective Colorectal Surgery

Objective

The present study analyzes nutrition support in a group of patients undergoing colorectal surgery managed by nutritional requirement software compared to a group of consecutive patients undergoing colorectal surgery with conventional nutrition

Materials and Methods

A total of 485 patients were treated between January 2000 and January 2013 with colorectal resection. Outcomes (mortality, morbidity according to Clavien classification, length of hospital stay, type of colorectal disease) in a group of patients who received nutrition support through software (SG) were compared to those in a previous series, control group (CG) with conventional nutrition support

Results

Of the patients, 59.6% were men and the median age of the population was 68.2 years (range, 19–95 years), with no difference between the 2 groups. There were significantly more malnourished patients in the SG group (SG 63.8% versus 45.2% CG; P &lt; 0.0001). The overall mortality was 2.1% lower in the SG group, but without a significant difference (SG 0.7% versus 2.7% CG). There were more severe stage III to IV complications according to Clavien classification in the SG group (SG 10.7 GC versus 17% NS), with significantly greater collections (SG 8% versus 16.9% CG; P = 0.015) and greater anastomotic leaks (SG 4% versus 13.9% CG; P &lt; 0.001). The median hospital stay was lower in the SG group (SG 12 days versus 15 days CG; P = 0.049).

Conclusion

The proposed software could contribute to optimizing the strategy of nutritional support in hospitalized patients.

Nutritional, immunological and antioxidant defense status of outpatients diagnosed with colorectal cancer - a case-control study of the little-studied population

This cross-sectional study was conducted to investigate nutritional and immunological status of colorectal cancer (CRC) patients in a little-studied population from developing country, Pakistan. Data on 81 CRC patients and 37 healthy controls (HCs) were collected on nutritional status, nutrient intake, percent body fat (%BF), selected immunological parameters, phytochemical index (PI), healthy eating index (HEI), and prognostic nutrition index (PNI). Blood samples were used for immunological and antiradical defense potential (expressed as 50% hemolysis time; HT₅₀). Results show 40/81 (49.4%) patients reported weight loss in past 3-6 mo, Significant differences were found in HEI values between patients vs. HCs, and between patients in low vs. high PNI groups (P, for all trends <0.05). Patients in the higher PNI group were heavier, had higher % BF, higher energy intake, and higher PI score as compared to patients in the low PNI group (P < 0.05). Low PNI was positively associated with non-significantly lower CD4:CD8 ratios, higher B-cells and NK cells (P, for all trends >0.05), but with significantly higher hs-CRP levels, and lower HT₅₀ values (P, for all trends <0.001). In conclusion, CRC patients in a little-studied population have compromised nutritional and immunological health with lower HEI and PNI scores.

Association Between Standardized Phase Angle, Nutrition Status, and Clinical Outcomes in Surgical Cancer Patients

BACKGROUND

Different nutrition assessment tools in surgical cancer patients are used in clinical practice, which results in different prevalence rates of malnutrition. This may impact the interpretation of the association between nutrition status and clinical outcomes. Reduced standardized phase angle (SPA) values are associated with adverse outcomes in patients with cancer. Thus, it is important to assess the association of SPA with nutrition status and relate it to postoperative clinical outcomes.

METHODS

This prospective observational study included 121 surgical cancer patients. Bioelectrical impedance analysis, subjective global assessment (SGA), anthropometric measurements, and assessment of muscle strength were used to provide nutrition diagnosis 1 day before surgery. The patients were followed for infectious and noninfectious postoperative complications from the first day after the operation until discharge or death.

RESULTS

The prevalence of malnutrition was higher according to SGA (63.6%). Patients with an SPA < -1.65 had a greater chance of being diagnosed as malnourished according to the SGA (3.66 [1.35-9.90]), midarm circumference (OR 4.24; CI95%; 1.72-10.43), midarm muscle area (OR 4.38; CI95%; 1.68-11.42), and low handgrip strength (3.84 [1.31-11.25]). Patients with an SPA < -1.65 presented with more infectious complications (OR 4.19; CI95%; 1.52-11.53), but there was no association between SPA and other outcomes or death. SPA was the only significant predictor of infectious complications (AUC, 0.61; 95% CI, 0.51-0.71).

CONCLUSION

SPA was associated with different nutrition status parameters, and it was able to predict postoperative infectious complications.

Different nutritional assessment tools as predictors of postoperative complications in patients undergoing colorectal cancer resection

BACKGROUND & AIMS

Malnutrition in patients with colorectal cancer contributes to increased postoperative complications. The aim of the study was to evaluate the prognostic value of several nutritional assessment parameters: body mass index versus percentage of weight loss grading system (BMI/%WL); Patient-Generated Subjective Global Assessment (PG-SGA); standardized phase angle (SPA) by BIA; muscle strength by handgrip strength; muscle mass by computerized tomography; and the combination of muscle mass and strength in patients undergoing resection surgery.

METHODS

Patients diagnosed with cancer of the colon or rectum, who were over 18 years old and were scheduled to undergo surgical treatment were invited to participate. Postoperative complications were assessed from the first day post-surgery until discharge. Complications classified as Grade II or above according to the Clavien-Dindo classification were considered. Chi-square test or Fisher's exact test, bivariate analysis, Poisson regression and receiver operator characteristic (ROC) curve were utilized and p < 0.05 was considered significant.

RESULTS

84 patients were evaluated, with 28 (33.3%) presenting with Grade II postoperative complications. SPA showed no association with postoperative complications (p = 0.199). In multivariate analysis, low skeletal muscle mass showed a relative risk (RR) of 1.80 (CI: 1.02-3.17), BMI/%WL equal or higher than grade 3 had a RR of 1.90 (95% CI: 1.22-3.39). PG-SGA classified as malnutrition showed a RR of 2.08 (95% CI: 1.06-4.06); and low muscle mass plus low muscle strength showed a RR 2.13 (95% CI: 1.23-3.69). Low strength alone was not associated with postoperative complications after controlling for confounding factors (p = 0.16; 95% CI: 0.83-2.77). Low muscle mass in combination with low strength showed the highest predictive power for postoperative complications (AUC: 0.68; CI: 0.56-0.80).

CONCLUSIONS

BMI/%WL > grade 3, PG-SGA defined malnutrition, low muscle mass and low muscle mass plus low strength were independent risk factors for complications controlling for confounding factors. However, low muscle mass in combination with low muscle strength were the strongest variables associated with complications.

CLINICAL TRIALS IDENTIFICATION NUMBER

NCT02901132 (www.clinicaltrials.gov).

Attitudes of Surgeons toward Elderly Cancer Patients: A Survey from the SIOG Surgical Task Force

Cancer care in elderly patients is complex. A recent survey showed that among mostly academic surgeons, practice patterns varied in the care of elderly patients. The authors suggested three areas of intervention in improving care of this population: frailty assessment, nutritional assessment, and assessment of quality of life.

Pre-operative oral nutritional supplementation with dietary advice versus dietary advice alone in weight-losing patients with colorectal cancer: single-blind randomized controlled trial

BACKGROUND

Pre-operative weight loss has been consistently associated with increased post-operative morbidity. The study aims to determine if pre-operative oral nutritional supplements (ONSs) with dietary advice reduce post-operative complications.

METHODS

Single-blinded randomized controlled trial. People with colorectal cancer scheduled for surgery with pre-operative weight loss >1 kg/3-6 months were randomized by using stratified blocks (1:1 ratio) in six hospitals (1 November 2013-28 February 2015). Intervention group was given 250 mL/day ONS (10.1 KJ and 0.096 g protein per mL) and dietary advice. Control group received dietary advice alone. Oral nutritional supplements were administered from diagnosis to the day preceding surgery. Research team was masked to group allocation. Primary outcome was patients with one or more surgical site infection (SSI) or chest infection; secondary outcomes included percentage weight loss, total complications, and body composition measurements. Intention-to-treat analysis was performed with both unadjusted and adjusted analyses. A sample size of 88 was required.

RESULTS

Of 101 participants, (55 ONS, 46 controls) 97 had surgery. In intention-to-treat analysis, there were 21/45 (47%) patients with an infection-either an SSI or chest infection in the control group vs. 17/55 (30%) in the ONS group. The odds ratio of a patient incurring either an SSI or chest infection was 0.532 (P = 0.135 confidence interval 0.232 to 1.218) in the unadjusted analysis and when adjusted for random differences at baseline (age, gender, percentage weight loss, and cancer staging) was 0.341 (P = 0.031, confidence interval 0.128 to 0.909). Pre-operative percentage weight loss at the first time point after randomization was 4.1% [interquartile range (IQR) 1.7-7.0] in ONS group vs. 6.7% (IQR 2.6-10.8) in controls (Mann-Whitney U P = 0.021) and post-operatively was 7.4% (IQR 4.3-10.0) in ONS group vs. 10.2% (IQR 5.1-18.5) in controls (P = 0.016).

CONCLUSIONS

Compared with dietary advice alone, ONS resulted in patients having fewer infections and less weight loss following surgery for colorectal cancer. We have demonstrated that pre-operative oral nutritional supplementation can improve clinical outcome in weight losing patients with colorectal cancer.

Dietary Practices, Addictive Behavior and Bowel Habits and Risk of Early Onset Colorectal Cancer: a Case Control Study

BACKGROUND

The abrupt rise of colorectal cancer in developing countries is raising concern in healthcare settings. Studies on assessing relationships with modifiable and non-modifiable risk factors in the Pakistani population have been limited. The present investigation was designed to examine associations of dietary practices, addictive behavior and bowel habits in developing colorectal cancer (CRC) among patients in a low-resource setup.

MATERIALS AND METHODS

An age-gender matched case control study was conducted from October 2011 to July 2015 in Karachi, Pakistan. Cases were from the surgical oncology department of a public sector tertiary care hospital, while their two pair-matched controls were recruited from the general population. A structured questionnaire was used which included questions related to demographic characteristics, family history, dietary patterns, addictive behavior and bowel habits.

RESULTS

A family history of cancer was associated with a 2.2 fold higher chance of developing CRC. Weight loss reduced the likelihood 7.6 times. Refraining from a high fat diet and consuming more vegetables showed protective effects for CRC. The risk of CRC was more than twice among smokers and those who consumed Asian specific addictive products as compared to those who avoid using these addictions (ORsmoking: 2.12, 95% CI: 1.08 - 4.17, ORpan: 2.92, 95% CI: 1.6 - 5.33, ORgutka: 2.13, 95% CI: 1.14 - 3.97). Use of NSAID attenuated risk of CRC up to 86% (OR: 0.14, 95% CI: 0.07 - 0.31).

CONCLUSIONS

Most of the findings showed concordance with the literature elucidating protective effects of consuming vegetables and low fat diet while documenting adverse associations with family history, weight loss, constipation and hematochezia. Moreover, this study highlighted Asian specific indigenous addictive products as important factors. Further studies are needed to validate the findings produced by this research.