Body composition assessment by artificial intelligence can be a predictive tool for short-term postoperative complications in Hartmann's reversals.

BACKGROUND: Hartmann's reversal, a complex elective surgery, reverses and closes the colostomy in individuals who previously underwent a Hartmann's procedure due to colonic pathology like cancer or diverticulitis. It demands careful planning and patient optimisation to help reduce postoperative complications. Preoperative evaluation of body composition has been useful in identifying patients at high risk of short-term postoperative outcomes following colorectal cancer surgery. We sought to explore the use of our in-house derived Artificial Intelligence (AI) algorithm to measure body composition within patients undergoing Hartmann's reversal procedure in the prediction of short-term postoperative complications. METHODS: A retrospective study of all patients who underwent Hartmann's reversal within a single tertiary referral centre (Western) in Melbourne, Australia and who had a preoperative Computerised Tomography (CT) scan performed. Body composition was measured using our previously validated AI algorithm for body segmentation developed by the Department of Surgery, Western Precinct, University of Melbourne. Sarcopenia in our study was defined as a skeletal muscle index (SMI), calculated as Skeletal Muscle Area (SMA) /height2 < 38.5 cm2/m2 in women and < 52.4 cm2/m2 in men. RESULTS: Between 2010 and 2020, 47 patients (mean age 63.1 ± 12.3 years; male, n = 28 (59.6%) underwent body composition analysis. Twenty-one patients (44.7%) were sarcopenic, and 12 (25.5%) had evidence of sarcopenic obesity. The most common postoperative complication was surgical site infection (SSI) (n = 8, 17%). Sarcopenia (n = 7, 87.5%, p = 0.02) and sarcopenic obesity (n = 5, 62.5%, p = 0.02) were significantly associated with SSIs. The risks of developing an SSI were 8.7 times greater when sarcopenia was present. CONCLUSION: Sarcopenia and sarcopenic obesity were related to postoperative complications following Hartmann's reversal. Body composition measured by a validated AI algorithm may be a beneficial tool for predicting short-term surgical outcomes for these patients.

Ostomy Information on the Internet-Is It Good Enough?

PURPOSE: The aim of this study was to determine which internet search engines and keywords patients with ostomies utilize, to identify the common websites using these terms, to determine what aspects of information they wanted, and to perform a quality and readability assessment for these websites. DESIGN: A cross-sectional survey of persons with ostomies to identify search engines and terms, followed by a structured assessment of the quality and readability of the identified web pages. SUBJECT AND SETTINGS: The sample comprised 20 hospitalized patients with ostomies cared for on a colorectal surgical ward of a tertiary care hospital located in Melbourne, Australia. There were 15 (75%) adult males and 5 (25%) adult females; their mean age was 52.2 years. Participants were surveyed between August and December 2020. METHODS: Patients with newly formed ostomies were surveyed about which search engines and keywords they would use to look for information and for which questions regarding ostomies they wanted answers. In addition, 2 researchers then performed independent searches using the search terms identified by patient participants. These searches were conducted in August 2021, with the geographical location set to Australia. The quality of the websites was graded using the DISCERN, Ensuring Quality Information for Patients, and Quality Evaluation Scoring Tool scoring assessments, and their readability was graded using the Flesch Reading Ease Score tool. RESULTS: Participants used Google as their primary search engine. Four keywords/phrases were identified: stoma for bowel surgery, ileostomy, colostomy, and caring for stoma. Multiple web pages were identified, 8 (21%) originated from Australia, 7 (18%) were from the United Kingdom, and 23 (61%) were from the United States. Most web pages lacked recent updates; only 18% had been undated within the last 12 months. The overall quality of the online information on ostomies was moderate with an average level of readability, deemed suitable for patient educational purposes. CONCLUSIONS: Information for persons living with an ostomy can be obtained from multiple web pages, and many sites have reasonable quality and are written at a suitable level. Unfortunately, these websites are rarely up-to-date and may contain advice that may not be applicable to individual patients.

Health service nutrition practices and associations with clinical outcomes in patients undergoing resection for upper gastrointestinal cancer: Results from the multi-centre NOURISH point prevalence study.

BACKGROUND: The present study aimed to investigate health service nutrition practices of sites providing care to patients undergoing surgery for upper gastrointestinal cancer within Australia, including the provision of perioperative nutrition support services and outpatient clinics, as well as the use of evidence-based nutrition care pathways/protocols. Secondary aims were to investigate associations between the use of a nutrition care pathway/protocol and patient outcomes. METHODS: Principal investigator dietitians for the sites (n = 27) participating in the NOURISH point prevalence study participated in a purpose-built site-specific survey regarding perioperative nutrition practices and protocols. Data from the 200 patients who participated in the study (including malnutrition prevalence, preoperative weight loss and receipt of dietetics intervention, intraoperative feeding tube insertions, provision of nutrition support day 1 post surgery, length of stay, and complications) were investigated using multivariate analysis to determine associations with the sites' use of a nutrition care pathway/protocol. RESULTS: The majority of sites (>92%) reported having dietetics services available in chemotherapy/radiotherapy. Eighty-five percent of sites reported having some form of outpatient clinic service; however, a routine service was only available at 26% of sites preoperatively and 37% postoperatively. Most preoperative services were embedded into surgical/oncology clinics (70%); however, this was reported for only 44% of postoperative clinics. Only 44% had a nutrition care pathway/protocol in place. The use of a nutrition care pathway/protocol was associated with lower rates of malnutrition, as well as higher rates of preoperative dietetics intervention, intraoperative feeding tube insertions, and European Society of Clinical Nutrition and Metabolism (ESPEN) guideline compliant care day 1 post surgery. CONCLUSIONS: The results of the present study demonstrate varied perioperative outpatient nutrition services in this high-risk patient group. The use of nutrition care pathways and protocols was associated with improved patient outcomes.

A single institution's long-term follow-up of patients with pathological complete response in locally advanced rectal adenocarcinoma following neoadjuvant chemoradiotherapy.

PURPOSE: This paper aimed to study the long term follow-up of patients with primary rectal adenocarcinoma receiving neoadjuvant chemoradiotherapy who obtained a pathological complete response (pCR) and identify factors predicting complete response. METHODS: Retrospective review of notes, histology, pre-operative full blood count and imaging of patients with primary rectal adenocarcinoma diagnosed in our institute from 2000 to 2012 from a prospectively maintained database were used. SPSS version 22.0 was used for statistical analysis. RESULTS: Three hundred eighty patients diagnosed with primary rectal adenocarcinoma were identified, 277 received neoadjuvant chemoradiotherapy followed by curative resection. Forty-six patients obtained a pCR (ypT0N0) with no local recurrence and two metastatic recurrences on follow-up. Patients with a pCR have a significantly improved overall survival and disease-free survival compared to a non-pCR (150.0 and 136.1 vs 77.5 and 84.7 months, p = 0.001). On univariate analysis, increased tumour height above anal verge, low lymph node yield, high pre-operative haemoglobin and a low neutrophil-lymphocyte ratio are significant factors identifying a pCR. Multivariable analysis of the above factors confirmed tumour height above anal verge as significant in obtaining a pCR. CONCLUSION: Patients with rectal adenocarcinoma who develop a pCR following neoadjuvant chemoradiotherapy have improved overall and disease-free survival. We have identified distance from anal verge, low lymph node yield, high pre-operative haemoglobin and low neutrophil-lymphocyte ratio as significant predictors of developing a pCR.

Development, evaluation, and delivery of an innovative national undergraduate surgical workshop: recognition and management of the acutely unwell surgical patient.

PROBLEM: Recognition and management of acutely unwell surgical patients is an important skill to which medical students have little exposure. INTERVENTION: We present the evaluation of a novel national surgical workshop that consisted of high-fidelity simulations, lectures, case demonstrations, case discussions, and a basic surgical skills tutorial. The high-fidelity simulations re-created genuine patient encounters and were used to facilitate the acquisition of knowledge and skill in the early recognition and management of acutely unwell surgical patients. CONTEXT: The optional workshop was designed for senior medical students and delivered by surgical trainees. Students were asked to complete a 12-item evaluation questionnaire and a 26-item multiple-choice question (MCQ) quiz, which assessed their confidence; self-perceived competence; and knowledge prior to, immediately following, and 8 weeks after the workshop. Pre- and postdata were compared using student's two-tailed t test. OUTCOME: A total of 66 medical students from 6 UK universities attended, the majority of whom enjoyed the workshop (98.3%, n = 59). Participants' confidence rating (scale = 1-5) in assessing an unwell surgical patient improved from a mean of 2.5 (n = 47) to 4.4 (n = 60). Confidence in commencing initial management improved from a mean of 2.7 (n = 47) to 4.1 (n = 59). Confidence and self-perceived competence across 12 domains improved significantly following the workshop, two-tailed unpaired t test, t(22) = 8.64, p <.0001, d = 3.68. MCQ scores immediately following the workshop were a statistically significant improvement on the preworkshop MCQ scores (n = 44), paired two-tailed t test, t(43) = 7.76, p <.0001, d = 2.37, and the improvement was sustained 8 weeks following the workshop (n = 18), paired two-tailed t test, t(17) = 3.34, p =.0039, d = 1.62. LESSONS LEARNED: Feedback from students was very positive and clearly demonstrated that a workshop taught by surgical trainees improved medical students' confidence, self-perceived competence, and knowledge in the assessment and management of acutely unwell surgical patients.

Robots down-under: the current climate of robotic-assisted surgery education in Australia.

Australia has seen a significant rise in the use of Robotic-Assisted Surgery (RAS), with general surgery being the fastest-growing field in this technology. The proportion of general surgical RAS has grown from 1% to 17% of all RAS between 2008 and 2023 in Australasia. As of May 2023, there were 162 robotic platforms in Australasia, with 26 of them in the public sector. As the cost of establishing RAS decreases over time, public hospital robotics systems are expected to become more accessible. Despite the increasing demand, many specialties, including general surgery, do not have an agreed RAS curriculum for trainees. It is imperative for Australia to develop its own curriculum akin to our overseas colleagues to match this growth.

Two cases of atraumatic adrenal hemorrhage: A review of active management, conservative management, and challenges faced.

Adrenal hemorrhage (AH) is an uncommon and potentially disastrous affliction that carries an accepted mortality risk of 15%. Variable symptomatology can cause a diagnostic dilemma and may be missed. We present 2 cases of right-sided AH; both cases were initially presumed to be renal colic. Case 1 was an 86-year-old gentleman, presenting with right flank pain found to have a right-sided atraumatic AH. He presented with hemorrhagic shock, requiring angioembolization of the bleeding vessel. Case 2 was a 62-year-old gentleman who presented with right flank pain and was found to have a right-sided atraumatic AH. He was hemodynamically stable and successfully managed conservatively. Adrenal hemorrhage is a potentially fatal affliction that may be missed. CT scans are the recommended imaging modality during an acute presentation due to wider availability and fast assessment. We demonstrate a hemodynamically stable patient managed with a 'watch and wait' approach and an unstable patient managed with resuscitation followed by urgent angioembolization.

Digital health and medical technology for perioperative sarcopenia optimisation and prehabilitation - Where to go from here?

Sarcopenia has been shown to cause poorer outcomes in surgical oncology. With the advancement of artificial intelligence technology, body composition analysis can be obtained with ease. Given the lead time between cancer diagnosis and surgery, selected patients at risk of complications secondary to sarcopenia may be amenable to prehabilitation. The COVID-19 pandemic has led to the rapid adaptation of digital health and medical technology. Our perspective piece will review the current available evidence and propose innovative ways to incorporate technology into physical and nutritional prehabilitation.

The association of body composition on chemotherapy toxicities in non-metastatic colorectal cancer patients: a systematic review.

BACKGROUND: In recent years, certain body composition measures, assessed by computed tomography (CT), have been found to be associated with chemotherapy toxicities. This review aims to explore available data on the relationship between skeletal muscle and adiposity, including visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), intramuscular and intermuscular adipose tissue and their association with chemotherapy toxicity in non-metastatic colorectal cancer (CRC) patients. METHODS: A systematic literature search following PRISMA guidelines was conducted in Medline, Embase, Cochrane and Web of Science, for papers published between 2011 and 2023. The search strategy combined keywords and MESH terms relevant to 'body composition', 'chemotherapy toxicities', and 'non-metastatic colorectal cancer'. RESULTS: Out of 3868 studies identified, six retrospective studies fulfilled the inclusion criteria with 1024 eligible patients. Low skeletal muscle mass was strongly associated with increased incidence of both chemotherapy toxicities and dose-limiting toxicity (DLT). The association of VAT, intramuscular and intermuscular adiposity was heterogeneous and inconclusive. There was no association between SAT and chemotherapy intolerance. No universal definitions or cut-offs for sarcopenia and obesity were noted. All studies utilized 2-dimensional (2D) CT slices for CT body composition assessment with varied selection on the vertebral landmark and inconsistent reporting of tissue-defining Hounsfield unit (HU) measurements. CONCLUSION: Low skeletal muscle is associated with chemotherapy toxicities in non-metastatic CRC. However, quality evidence on the role of adiposity is limited and heterogeneous. More studies are needed to confirm these associations with an emphasis on a more coherent body composition definition and an approach to its assessment, especially regarding sarcopenia.

Using a new artificial intelligence-aided method to assess body composition CT segmentation in colorectal cancer patients.

INTRODUCTION: This study aimed to evaluate the accuracy of our own artificial intelligence (AI)-generated model to assess automated segmentation and quantification of body composition-derived computed tomography (CT) slices from the lumber (L3) region in colorectal cancer (CRC) patients. METHODS: A total of 541 axial CT slices at the L3 vertebra were retrospectively collected from 319 patients with CRC diagnosed during 2012-2019 at a single Australian tertiary institution, Western Health in Melbourne. A two-dimensional U-Net convolutional network was trained on 338 slices to segment muscle, visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). Manual reading of these same slices of muscle, VAT and SAT was created to serve as ground truth data. The Dice similarity coefficient was used to assess the U-Net-based segmentation performance on both a validation dataset (68 slices) and a test dataset (203 slices). The measurement of cross-sectional area and Hounsfield unit (HU) density of muscle, VAT and SAT were compared between two methods. RESULTS: The segmentation for muscle, VAT and SAT demonstrated excellent performance for both the validation (Dice similarity coefficients >0.98, respectively) and test (Dice similarity coefficients >0.97, respectively) datasets. There was a strong positive correlation between manual and AI segmentation measurements of body composition for both datasets (Spearman's correlation coefficients: 0.944-0.999, P < 0.001). CONCLUSIONS: Compared to the gold standard, this fully automated segmentation system exhibited a high accuracy for assessing segmentation and quantification of abdominal muscle and adipose tissues of CT slices at the L3 in CRC patients.

Colorectal cancer treatment outcomes during the pandemic: Our experience of COVID-19 at a tertiary referral center.

BACKGROUNDS: The coronavirus disease 2019 (COVID-19) has led to major shifts in the management of colorectal cancer (CRC). This study aims to identify the impact and early outcomes of COVID-19 following CRC management at a tertiary referral center in Victoria, Australia. METHODS: This was a retrospective study, utilizing the Australian Comprehensive Cancer Outcomes and Research Database and inpatient records. Patients presenting for CRC management at our institution were identified coinciding with the first Victorian outbreak of COVID-19 (March 26 to September 26, 2020) (COVID). Management decisions including chemoradiotherapy utilization and surgical outcomes were analyzed within 6 months and compared with the corresponding period in 2019 (pre-COVID). RESULTS: A total of 276 patients were included in this study (147 pre-COVID period, 129 COVID period). During the COVID period, more patients (47.6% vs. 60.5%; p = 0.033) presented symptomatically and less for surveillance (10.9% vs. 2.3%; p < 0.01). Eighty-four pre-COVID and 69 COVID period patients proceeded to surgery. The average time from diagnosis date to surgery was 15.6 days less during the COVID period. There were no significant differences in postoperative utilization of higher care (p = 0.74), complications (p = 0.93), median hospital length of stay (p = 0.67), 30-day readmission (p = 0.50), or 30-day reoperation (p = 0.74). In 1.6% of cases, pandemic impacts resulted in a change in management. CONCLUSION: Presentation of patients with CRC varied, with a significant increase in symptomatic presentations and decreased numbers for surveillance. Through flexibility and change in practice, our institution helped improve access to surgical intervention and oncological therapies. Further prospective work is required to identify long-term outcomes and characterize the effects of ongoing disruptions.

Reversal of Hartmann's procedure: timelines, preoperative investigations and early outcomes. A single Australian institution's ten-year experience.

BACKGROUND: Real-world data on outcomes following Hartmann's reversal is necessary to help optimize the patient experience. We have explored the timing between the index operation and its reversal; what investigations were carried out prior to this, and the associated short-term outcomes. METHODS: A retrospective study of all patients who underwent Hartmann's reversal from 2010 to 2020 within a tertiary referral centre in Melbourne, Australia. One hundred from a total of 406 (25%) who underwent an emergency Hartmann's procedure had a subsequent reversal. Complete patient data was available for 83 of these patients. RESULTS: The average patient age was 60 years, and the median time for reversal was 14.0 (IQR 10-23) months. Seventy-nine of 83 (95%) reversals had a preoperative endoscopic evaluation of both their rectal stump and a complete colonoscopy. Stoma stenosis (n = 2), patient refusal (n = 1) and emergency reversal (n = 1) were cited reasons for not undergoing preoperative endoscopic evaluation. A third (n = 28, 34%) had a computed tomography prior to reversal; the majority was due to their underlying cancer surveillance (n = 21, 75%). Reversal was associated with a morbidity rate of 47% (n = 39). Surgical site infections (SSIs) (n = 21, 25%) were the most common type of complications encountered, with the majority being superficial (n = 15, 71%). SSIs were associated with steroid use (5/21 versus 4/62, p = 0.03) and greater hospital length of stay (6 versus 10 days, p = 0.03). CONCLUSION: Only a quarter of emergency Hartmann's procedures within our institution were reversed. A significant proportion developed postoperative complications. Surgical site infection was the most common morbidity.

Can AI-based body composition assessment outperform body surface area in predicting dose-limiting toxicities for colonic cancer patients on chemotherapy?

PURPOSE: Gold standard chemotherapy dosage is based on body surface area (BSA); however many patients experience dose-limiting toxicities (DLT). We aimed to evaluate the effectiveness of BSA, two-dimensional (2D) and three-dimensional (3D) body composition (BC) measurements derived from Lumbar 3 vertebra (L3) computed tomography (CT) slices, in predicting DLT in colon cancer patients. METHODS: 203 patients (60.87 ± 12.42 years; 97 males, 47.8%) receiving adjuvant chemotherapy (Oxaliplatin and/or 5-Fluorouracil) were retrospectively evaluated. An artificial intelligence segmentation model was used to extract 2D and 3D body composition measurements from each patients' single mid-L3 CT slice as well as multiple-L3 CT scans to produce a 3D BC report. DLT was defined as any incidence of dose reduction or discontinuation due to chemotherapy toxicities. A receiver operating characteristic (ROC) analysis was performed on BSA and individual body composition measurements to demonstrate their predictive performance. RESULTS: A total of 120 (59.1%) patients experienced DLT. Age and BSA did not vary significantly between DLT and non-DLT group. Females were significantly more likely to experience DLT (p = 4.9 × 10-3). In all patients, the predictive effectiveness of 2D body composition measurements (females: AUC = 0.50-0.54; males: AUC = 0.50-0.61) was equivalent to that of BSA (females: AUC = 0.49; males: AUC = 0.58). The L3 3D skeletal muscle volume was the most predictive indicator of DLT (AUC of 0.66 in females and 0.64 in males). CONCLUSION: Compared to BSA and 2D body composition measurements, 3D L3 body composition measurements had greater potential to predict DLT in CRC patients receiving chemotherapy and this was sex dependent.

Identification of Differences in Body Composition Measures Using 3D-Derived Artificial Intelligence from Multiple CT Scans across the L3 Vertebra Compared to a Single Mid-Point L3 CT Scan.

Purpose: Body composition analysis in colorectal cancer (CRC) typically utilises a single 2D-abdominal axial CT slice taken at the mid-L3 level. The use of artificial intelligence (AI) allows for analysis of the entire L3 vertebra (non-mid-L3 and mid-L3). The goal of this study was to determine if the use of an AI approach offered any additional information on capturing body composition measures. Methods: A total of 2203 axial CT slices of the entire L3 level (4-46 slices were available per patient) were retrospectively collected from 203 CRC patients treated at Western Health, Melbourne (97 males; 47.8%). A pretrained artificial intelligence (AI) model was used to segment muscle, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) on these slices. The difference in body composition measures between mid-L3 and non-mid-L3 scans was compared for each patient, and for males and females separately. Results: Body composition measures derived from non-mid-L3 scans exhibited a median range of 0.85% to 6.28% (average percent difference) when compared to the use of a single mid-L3 scan. Significant variation in the VAT surface area (p = 0.02) was observed in females compared to males, whereas male patients exhibited a greater variation in SAT surface area (p < 0.001) and radiodensity (p = 0.007). Conclusion: Significant differences in various body composition measures were observed when comparing non-mid-L3 slices to only the mid-L3 slice. Researchers should be aware that considering only the use of a single midpoint L3 CT scan slice will impact the estimate of body composition measurements.

Outcomes of perineal reconstruction with inferior gluteal artery myocutaneous flaps and primary closure following abdominoperineal resection.

BACKGROUND: Perineal wound morbidity following abdominoperineal resection (APR) is a significant challenge. Myocutaneous flap-based techniques have been developed to overcome morbidity associated with perineal reconstruction. We reviewed outcomes for patients undergoing APR in a hospital that performs inferior gluteal artery myocutaneous (IGAM) island transposition flaps and primary closure (PC) for perineal reconstruction. METHODS: A retrospective study of patients who underwent APR for malignancy between January 2012 and March 2020 was performed and outcomes between IGAM reconstruction and PC compared. Primary outcomes were wound infection and dehiscence. Secondary outcomes included return to theatre, operative time, length of stay, flap loss and perineal hernia incidence. RESULTS: One-hundred and two patients underwent APR, with 50 (49%) who had PC and 52 (51%) had IGAM flap reconstructions. There were no differences between each group with regards to wound infection (23 vs. 22%, P = 0.55) or wound dehiscence (25 vs. 24%, P = 0.92). Thirteen (25%) IGAM patients required a return to theatre compared to three PC patients (6%) (P = 0.008). IGAM procedures required twice the overall operative time (506 vs. 240 min, P = 0.001) with no differences between groups when comparing the APR component (250 vs. 240 min, P = 0.225). The IGAM group had a longer length of stay (median 13 days vs. 9 days, P = 0.001). Only one IGAM flap was lost and no symptomatic hernias were identified. CONCLUSION: Perineal closure technique did not affect the incidence of wound infection or dehiscence. Closure technique should be tailored to underlying patient characteristics and surgical pathology.

Chronic rectal anastomosis complications prior to ileostomy reversal: development of a pilot classification system and associated outcomes.

BACKGROUNDS: A loop ileostomy may reduce the severity of acute anastomotic complications after low rectal resection, but some patients have persistent rectal anastomotic problems. No consensus exists for the management of patients with a chronic low rectal anastomosis complication and a loop ileostomy. There is need for a standard description of these anastomotic complications and to determine whether it is safe to reverse the ileostomy. This study proposes a classification of chronic rectal anastomotic complications and to report the correlation with successful restoration of rectal continuity. METHODS: This was a retrospective project from a prospectively maintained database at a single colorectal unit in a large tertiary hospital in Metropolitan Melbourne. Patients with rectal anastomotic complications following rectal cancer resections between March 2012 and October 2019 were included. A classification of chronic rectal anastomotic complication was developed by reviewing the interval assessments of the rectal anastomosis. The classification categories were correlated with outcomes after stoma closure. RESULTS: Of the 149 patients, 20 patients had an anastomotic complication identified during work up prior to loop ileostomy reversal. Eleven patients had an anastomotic stenosis and nine had an anastomotic defect. Eighteen patients were eligible for stomal closure. The majority (11/12) of patients with a Type 1 stenosis or defect had no rectal complications after stoma closure. CONCLUSION: The classification system helps to describe chronic rectal anastomotic abnormalities and guide management. Although these patients may be a challenge, many can undergo successful ileostomy reversal.

Ability of malnutrition screening and assessment tools to identify computed tomography defined low muscle mass in colorectal cancer surgery.

BACKGROUND: Malnutrition and low muscle mass are independently associated with poor outcomes in colorectal cancer (CRC). However, tools to identify low muscle mass are limited in the clinical setting. We investigated the ability of existing malnutrition screening and assessment tools to identify low muscle mass assessed by computed tomography (CT). Secondary aims were to determine the feasibility of CT analysis and handgrip strength (HGS). METHODS AND ANALYSIS: An exploratory study of patients who underwent curative surgery for CRC between February and September 2019. Nutrition tools used included body mass index (BMI), Malnutrition Screening Tool (MST), and Patient-Generated Subjective Global Assessment (PG-SGA). Muscle mass was determined by preoperative CT image at the third lumbar vertebral level (L3), and muscle strength was determined by HGS dynamometry. Fisher's exact and Mann-Whitney U tests were used to compare results of nutrition tools with CT muscle assessment. RESULTS: In total, 57 patients were included. MST classified 18 patients (32%) as at risk of malnutrition, and PG-SGA classified 10 patients (17%) as malnourished. Fifty-one (90%) CT scans were analysable and 21 (47%) had low muscle mass. Of those with low muscle mass, PG-SGA classified 22 patients (92%) as well nourished and MST classified 17 patients (71%) as not being at nutrition risk. No tool was able to identify CT-diagnosed low muscle mass. Inability to complete HGS was associated with malnutrition (P = .001). CONCLUSION: In this cohort, nutrition screening and assessment tools did not identify CT-diagnosed low muscle mass. Feasible tools to identify low muscle mass in the clinical setting are required.

Assessment of Nutritional Status and Nutrition Impact Symptoms in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study.

BACKGROUND: Identification and treatment of malnutrition are essential in upper gastrointestinal (UGI) cancer. However, there is limited understanding of the nutritional status of UGI cancer patients at the time of curative surgery. This prospective point prevalence study involving 27 Australian tertiary hospitals investigated nutritional status at the time of curative UGI cancer resection, as well as presence of preoperative nutrition impact symptoms, and associations with length of stay (LOS) and surgical complications. METHODS: Subjective global assessment, hand grip strength (HGS) and weight were performed within 7 days of admission. Data on preoperative weight changes, nutrition impact symptoms, and dietary intake were collected using a purpose-built data collection tool. Surgical LOS and complications were also recorded. Multivariate regression models were developed for nutritional status, unintentional weight loss, LOS and complications. RESULTS: This study included 200 patients undergoing oesophageal, gastric and pancreatic surgery. Malnutrition prevalence was 42% (95% confidence interval (CI) 35%, 49%), 49% lost ≥5% weight in 6 months, and 47% of those who completed HGS assessment had low muscle strength with no differences between surgical procedures (p = 0.864, p = 0.943, p = 0.075, respectively). The overall prevalence of reporting at least one preoperative nutrition impact symptom was 55%, with poor appetite (37%) and early satiety (23%) the most frequently reported. Age (odds ratio (OR) 4.1, 95% CI 1.5, 11.5, p = 0.008), unintentional weight loss of ≥5% in 6 months (OR 28.7, 95% CI 10.5, 78.6, p < 0.001), vomiting (OR 17.1, 95% CI 1.4, 207.8, 0.025), reduced food intake lasting 2-4 weeks (OR 7.4, 95% CI 1.3, 43.5, p = 0.026) and ≥1 month (OR 7.7, 95% CI 2.7, 22.0, p < 0.001) were independently associated with preoperative malnutrition. Factors independently associated with unintentional weight loss were poor appetite (OR 3.7, 95% CI 1.6, 8.4, p = 0.002) and degree of solid food reduction of <75% (OR 3.3, 95% CI 1.2, 9.2, p = 0.02) and <50% (OR 4.9, 95% CI 1.5, 15.6, p = 0.008) of usual intake. Malnutrition (regression coefficient 3.6, 95% CI 0.1, 7.2, p = 0.048) and unintentional weight loss (regression coefficient 4.1, 95% CI 0.5, 7.6, p = 0.026) were independently associated with LOS, but no associations were found for complications. CONCLUSIONS: Despite increasing recognition of the importance of preoperative nutritional intervention, a high proportion of patients present with malnutrition or clinically significant weight loss, which are associated with increased LOS. Factors associated with malnutrition and weight loss should be incorporated into routine preoperative screening. Further investigation is required of current practice for dietetics interventions received prior to UGI surgery and if this mitigates the impact on clinical outcomes.

Preoperative Nutrition Intervention in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study.

BACKGROUND: Preoperative nutrition intervention is recommended prior to upper gastrointestinal (UGI) cancer resection; however, there is limited understanding of interventions received in current clinical practice. This study investigated type and frequency of preoperative dietetics intervention and nutrition support received and clinical and demographic factors associated with receipt of intervention. Associations between intervention and preoperative weight loss, surgical length of stay (LOS), and complications were also investigated. METHODS: The NOURISH Point Prevalence Study was conducted between September 2019 and May 2020 across 27 Australian tertiary centres. Subjective global assessment and weight were performed within 7 days of admission. Patients reported on preoperative dietetics and nutrition intervention, and surgical LOS and complications were recorded. RESULTS: Two-hundred patients participated (59% male, mean (standard deviation) age 67 (10)). Sixty percent had seen a dietitian preoperatively, whilst 50% were receiving nutrition support (92% oral nutrition support (ONS)). Patients undergoing pancreatic surgery were less likely to receive dietetics intervention and nutrition support than oesophageal or gastric surgeries (p < 0.001 and p = 0.029, respectively). Neoadjuvant therapy (p = 0.003) and malnutrition (p = 0.046) remained independently associated with receiving dietetics intervention; however, 31.3% of malnourished patients had not seen a dietitian. Patients who received ≥3 dietetics appointments had lower mean (SD) percentage weight loss at the 1-month preoperative timeframe compared with patients who received 0-2 appointments (1.2 (2.0) vs. 3.1 (3.3), p = 0.001). Patients who received ONS for >2 weeks had lower mean (SD) percentage weight loss than those who did not (1.2 (1.8) vs. 2.9 (3.4), p = 0.001). In malnourished patients, total dietetics appointments ≥3 was independently associated with reduced surgical complications (odds ratio 0.2, 95% confidence interval (CI) 0.1, 0.9, p = 0.04), and ONS >2 weeks was associated with reduced LOS (regression coefficient -7.3, 95% CI -14.3, -0.3, p = 0.04). CONCLUSIONS: Despite recommendations, there are low rates of preoperative dietetics consultation and nutrition support in this population, which are associated with increased preoperative weight loss and risk of increased LOS and complications in malnourished patients. The results of this study provide insights into evidence-practice gaps for improvement and data to support further research regarding optimal methods of preoperative nutrition support.

Nutritional Outcomes of patients Undergoing Resection for upper gastroIntestinal cancer in AuStralian Hospitals (NOURISH): protocol for a multicentre point prevalence study.

INTRODUCTION: Nutritional intervention and prevention of malnutrition is significantly important for patients with upper gastrointestinal oesophageal, pancreatic and gastric cancer. However, there is limited information regarding nutritional status, and perioperative nutritional interventions that patients receive when undergoing curative surgery. METHODS AND ANALYSIS: Patients diagnosed with upper gastrointestinal cancer, planned for curative intent resection across 27 Australian hospitals will be eligible to participate in this point prevalence study. The primary aim is to determine the prevalence of malnutrition in patients with upper gastrointestinal cancer at the time of surgery using subjective global assessment. Secondary aims are to determine the type and frequency of perioperative nutritional intervention received, the prevalence of clinically important weight loss and low muscle strength, and to investigate associations between the use of an evidence-based nutrition care pathway or protocol for the nutritional management of upper gastrointestinal surgical oncology patients and malnutrition prevalence. Data collection will be completed using a purpose-built data collection tool. ETHICS AND DISSEMINATION: Ethical approval was granted in May 2019 (LNR/51107/PMCC-2019). The design and reporting of this study comply with the Strengthening the Reporting of Observational Studies in Epidemiology checklist for reporting of observational cohort studies. Findings will be published in peer-reviewed scholarly journals and presented at relevant conferences. Results will assist in defining priority areas for research to improve patient outcomes.