Prediction Model for Screening Patients at Risk of Malnutrition After Gastric Cancer Surgery

BACKGROUND

Malnutrition after gastrectomy is associated with a poor prognosis; however, no accurate model for predicting post-gastrectomy malnutrition exists. Hence, we conducted a retrospective study to develop a prediction model identifying gastric cancer patients at high risk of malnutrition after gastrectomy.

METHOD

Gastric cancer patients who underwent curative gastrectomy with more than one weight measurement during a 3-year follow-up period were included. Malnutrition was defined as body mass index (BMI) < 18.5 kg/m² according to the European Society of Clinical Nutrition and Metabolism diagnostic criteria. BMI-loss pattern was analyzed using a group-based trajectory model. A prediction model for malnutrition 6 months after gastrectomy was developed based on significant risk factors, and then validated.

RESULTS

Overall, 1421 patients were examined. The BMI-loss trajectory model showed significant BMI loss at 6 months after gastrectomy. Severe BMI loss (mean 21.5%; n = 109) was significantly associated with the elderly, female sex, higher preoperative BMI, advanced cancer stage, open surgery, total gastrectomy, Roux-en-Y reconstruction, chemotherapy, and postoperative complications (all p < 0.05). Malnutrition 6 months after gastrectomy was observed in 152 (11.9%) of 1281 patients. Preoperative BMI, sex, and type of operation were included in the final prediction model as predictive factors (p < 0.05). The C-index of the developmental set and bootstrap validation of the prediction model was 0.91 (95% confidence interval 0.89-0.94) and 0.91, respectively.

CONCLUSION

The prediction model for the risk of malnutrition 6 months after gastrectomy was accurately developed, with three independent risk factors: low preoperative BMI, female sex, and total or proximal gastrectomy.

Nutrition Support Team Reconsultation During Nutrition Therapy in Korea

BACKGROUND

The aim of this study was to investigate the nutrition support team (NST) reconsultation practice and to evaluate reasons and describe risk factors for NST reconsultation during nutrition therapy (NT) in hospitalized patients.

METHODS

This study included 2505 patients aged >18 years who received NT through NST consultation between January 2016 and December 2016 at Seoul National University Hospital. NST reconsultation refers to consulting the NST more than twice during a single hospitalization period. Risk factors affecting NST reconsultation were included only when NST reconsultation occurred for specific reasons other than routine evaluations.

RESULTS

The NST reconsultation rate was 36.4% (913/2505) with 926 reasons, including 'changes in the nutrition provision method' (n = 474, 51.2%), 'NT-related complications' (n = 284, 30.7%), 'routine evaluations' (n = 137, 14.8%), and 'discharge planing including home NT' (n = 31, 3.3%). The reconsultation rate of enteral nutrition (EN) was 40.8% (n = 378) and that of parenteral nutrition (PN) was 59.2% (n = 548). Among the NT-related complications, diarrhea (n = 65, 49.2%) was the most common with EN, whereas electrolyte abnormality (n = 52, 34.2%) was the most common with PN. Performance of surgery (odds ratio [OR], 2.061; P < .001), low serum albumin levels (<3 mg/dL; OR, 1.672; P < .001), presence of comorbidities (OR, 1.556; P < .001), and low body mass index (kg/m² ) (<18.5; OR, 1.508; P < .001) were predictive risk factors for NST reconsultation.

CONCLUSIONS

Frequent evaluation of nutrition status through a multidisciplinary NST is important in patients with these risk factors.

Critical Care Nurses' Perceptions of Parenteral and Enteral Nutrition at the End-of-Life in South Korea

PURPOSE

The purpose of this study was to explore the perceptions of critical care nurses regarding the withdrawal or withholding of enteral nutrition (EN) and parenteral nutrition (PN) at the end-of-life, which is not allowed according to the current law in South Korea.

METHODS

This was a cross-sectional study utilizing a self-report survey. The participants in the study were 141 nurses working in the intensive care units of a tertiary university hospital. The critical care nurses' general attitudes about EN and PN at the end-of-life were measured using the questionnaires developed by Lubart, Leibovitz, and Habot. The nurses responded to additional questions on whether withdrawal or withholding of EN or PN at the end-of-life should be legally allowed.

RESULTS

The mean scores of the general attitude items on EN ranged between 3.03 and 3.35 on a 5-point Likert scale where a value of 1 represents "strongly disagree" and a value of 5 represents "strongly agree," while those for PN ranged between 2.89 and 3.65. Respecting attitudes toward EN and PN, critical care nurses had more negative attitudes about stopping PN than EN. Regarding attitudes about whether patients should be legally able to refuse EN, 34.3% agreed, while 25.7% disagreed. For PN, 40.0% agreed, while 24.3% disagreed.

CONCLUSION

Discussions about making the withdrawal and withholding of artificial nutrition legal should be initiated. Moreover, education regarding evidence about the outcomes of EN and PN during end-of-life care and up-to-date clinical guidelines about it should be provided.

Intensive Nutrition Management in a Patient with Short Bowel Syndrome Who Underwent Bariatric Surgery

Many individuals with short bowel syndrome (SBS) require long-term parenteral nutrition (PN) to maintain adequate nutritional status. Herein, we report a successful intestinal adaptation of a patient with SBS through 13 times intensive nutritional support team (NST) managements. A thirty-five-year-old woman who could not eat due to intestinal discontinuity visited Seoul National University Hospital for reconstruction of the bowel. She received laparoscopic Roux-en-Y gastric bypass (RYGB) due to morbid obesity in Jan 2013 at a certain hospital and successfully reduced her weight from 110 kg to 68 kg. However, after a delivery of the second baby by cesarean section in Jul 2016, most of small bowel was herniated through Peterson's defect, and emergent massive small bowel resection was performed. Thereafter, she visited our hospital for the purpose of intestinal reconstruction. In Sep 2016, she received side-to-side gastrogastrostomy and revision of double barrel enterostomy. The remaining small bowel included whole duodenum, 30 cm of proximal jejunum, and 10 cm of terminal ileum. Pylorus and ileocecal valves were intact. The patient given only PN after surgery was provided rice-based soft fluid diet after 10 day of operation. Through intensive nutritional management care, she could start solid meals, and finally stop the PN and eat only orally at 45 days postoperatively. Three nutritional interventions were conducted over 2 months after the patient was discharged. She did not require PN during this period, and maintained her weight within the normal weight range. Similar interventions could be used for other patients with malabsorption problems similar to SBS.