Complexity of surgery and treatment burden in patients with peritoneal malignancy is not determined by addition of hyperthermic intraperitoneal chemotherapy.

BACKGROUND: This study describes surgical and quality of life outcomes in patients with peritoneal malignancy treated by cytoreductive surgery (CRS) alone compared with a subgroup treated with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Peritoneal malignancy patients undergoing surgery between 2017 and 2023 were included. The cohort was divided into patients treated by CRS and HIPEC and those treated by CRS without HIPEC (including CRS only or maximal tumour debulking (MTB)). Main outcomes included surgical outcomes, survival, and quality of life. Groups were compared using non-parametric tests and log-rank test was used to compare survival curves. RESULTS: 403 had CRS and HIPEC, 25 CRS only and 15 MTB. CRS and HIPEC patients had a lower peritoneal carcinomatosis index (12.0 vs. 17.0 vs. 35.0; P < 0.001) and longer surgical operative time (9.3 vs. 8.3 vs. 5.2 h; P < 0.001), when compared to CRS only and MTB, respectively. No other significant difference between groups was observed. CONCLUSIONS: The optimal management of selected patients with resectable peritoneal malignancy incorporates a combined strategy of CRS and HIPEC. When HIPEC is not utilized, due to significant residual disease or comorbidity precluding safe delivery, CRS alone is associated with good outcomes. Hospital stay and complications are acceptable but not significantly different to the CRS and HIPEC group. CRS alone is a complex intervention requiring comparable resources with good outcomes. In view of our findings 'intention to treat' with CRS and HIPEC should be the basis for resource allocation and funding.

Research Priorities in Prehabilitation for Patients Undergoing Cancer Surgery: An International Delphi Study.

BACKGROUND: Recently, the number of prehabilitation trials has increased significantly. The identification of key research priorities is vital in guiding future research directions. Thus, the aim of this collaborative study was to define key research priorities in prehabilitation for patients undergoing cancer surgery. METHODS: The Delphi methodology was implemented over three rounds of surveys distributed to prehabilitation experts from across multiple specialties, tumour streams and countries via a secure online platform. In the first round, participants were asked to provide baseline demographics and to identify five top prehabilitation research priorities. In successive rounds, participants were asked to rank research priorities on a 5-point Likert scale. Consensus was considered if > 70% of participants indicated agreement on each research priority. RESULTS: A total of 165 prehabilitation experts participated, including medical doctors, physiotherapists, dieticians, nurses, and academics across four continents. The first round identified 446 research priorities, collated within 75 unique research questions. Over two successive rounds, a list of 10 research priorities reached international consensus of importance. These included the efficacy of prehabilitation on varied postoperative outcomes, benefit to specific patient groups, ideal programme composition, cost efficacy, enhancing compliance and adherence, effect during neoadjuvant therapies, and modes of delivery. CONCLUSIONS: This collaborative international study identified the top 10 research priorities in prehabilitation for patients undergoing cancer surgery. The identified priorities inform research strategies, provide future directions for prehabilitation research, support resource allocation and enhance the prehabilitation evidence base in cancer patients undergoing surgery.

Preoperative nutritional status impacts clinical outcome and hospital length of stay in pelvic exenteration patients - a retrospective study.

BACKGROUND: Preoperative malnutrition is common in surgical oncology patients and can have negative effects on postoperative outcomes. Pelvic exenteration is major surgery associated with high morbidity rates. Associations between preoperative malnutrition, determined using the patient-generated subjective global assessment, and postoperative outcomes in this patient cohort has not yet been investigated. AIM: To determine if preoperative nutritional status is associated with postoperative surgical and quality of life (QoL) outcomes after pelvic exenteration surgery. METHODS: A retrospective cohort study was conducted at a quaternary hospital investigating 123 patients who had pelvic exenteration surgery from January 2017 to August 2019. Preoperative nutritional status and postoperative surgical and QoL outcomes were collected and analysed to determine any associations. RESULTS: Overall, 49.6% of patients were female with a median age of 59 years. Forty patients (32.5%) were malnourished and 83 (67.5%) were well nourished before surgery. Well-nourished patients had a shorter length of hospital stay (p = 0.034) and at 6 months post-surgery, presented with a significantly better physical and mental QoL score (p = 0.038 and p = 0.001 respectively). The regression analyses showed that intensive care unit (ICU) readmission rates were 7.19 times more likely to occur in malnourished patients (p = 0.022). CONCLUSIONS: Preoperative malnutrition is associated with increased length of stay, ICU readmissions and poorer QoL following pelvic exenteration. Nutrition screening, assessment and optimisation of management are essential in this patient cohort to improve patient outcomes. Future studies are needed to measure the effect of interventions and identify the most beneficial model of care for this complex patient group.

Early enteral feeding is beneficial for patients after pelvic exenteration surgery: A randomized controlled trial.

BACKGROUND: Postoperative feeding practices vary after pelvic exenteration surgery because of the lack of nutrition research in this specific surgical area. Postoperative ileus (POI) is common after pelvic exenteration surgery, and early enteral feeding is often avoided because of the lack of evidence and the belief that this may induce POI in this patient cohort. The aim of this study was to determine the effects of early enteral feeding after pelvic exenteration surgery on return of bowel movement and POI. METHODS: A randomized controlled trial was conducted with patients undergoing pelvic exenteration surgery from November 2018 to June 2020. Forty participants received standard nutrition care (parenteral nutrition) and 47 participants received trophic enteral feeding (20 ml/h) via a nasogastric tube, in addition to standard care, until participants were upgraded to free fluids. Time to first bowel movement and rates of POI were the main outcome measures. RESULTS: There was no significant difference between arms for time to first bowel movement; however, POI rates were significantly less in participants who were enterally fed (P = .036) in the per-protocol analysis. Regressions showed that the longer patients were restricted from an oral diet after surgery, the greater the time was to first bowel movement and the greater the postoperative complication rates (P < .0005). CONCLUSIONS: Early enteral feeding can be commenced safely to improve gastrointestinal function after pelvic exenteration surgery.

Failure in Systems and Culture: Barriers That Prevent Implementation of Evidence-Based Fasting Times for Patients in the Acute Care Setting.

BACKGROUND: There is strong evidence supporting fasting guidelines of 6 hours' fast from solids and 2 hours' fast from fluids prior to surgery. Despite this, patients spend prolonged periods of time fasting for surgery with a lack of research to support translating this evidence into practice, particularly for emergency surgical theater lists. This study aims to explore barriers and enablers to reduce prolonged fasting for patients on emergency surgical lists in the acute care setting. METHODS: Qualitative interviews were undertaken with 22 health professionals on acute surgical wards within a quaternary referral hospital in Sydney, Australia. Semistructured interviews explored barriers and enablers to implementing evidence-based fasting practices for patients on emergency surgical lists, using a theoretical domains framework. Interviews were transcribed verbatim and analyzed using an inductive thematic approach. RESULTS: Key barriers to implementing reduced fasting included unpredictable, inflexible systems; cultural concerns; and gaps in knowledge. Major enablers to reducing fasting times are the recognition of patient distress caused by excessive fasting and desire by all 22 interviewees to address the problem. CONCLUSIONS: This research is the first to explore barriers and enablers to implementing interventions to address excessive fasting. This research highlights the complexity of the issue and the need for a multifaceted translational intervention addressing limitations in systems and cultural barriers.

Interventions Aimed at Reducing Fasting Times in Acute Hospital Patients: A Systematic Literature Review.

Despite current guidelines recommending fasting from solids for ≤6 hours and clear fluids for ≤2 hours prior to surgery, outdated practices endure; patients fast for unnecessarily prolonged periods because of beliefs regarding aspiration risk upon anaesthesia induction. This literature review aimed to identify and evaluate current interventions aiming to reduce preoperative fasting times for acutely ill hospital patients, summarizing effective interventional strategies and associated outcomes. EMBASE, MEDLINE, PreMEDLINE, and CINAHL were systematically searched. Quality of evidence was assessed using Cochrane risk-of-bias tools. Studies, of any type, reporting fasting times as a primary or secondary outcome were included. A total of 1918 potential studies were identified; of these, 16 studies were included. Seven studies investigated the effect of changing fasting protocol on gastric fluid volume/residual gastric volume (GFV/RGV) and gastric pH as surrogate measures for aspiration risk. No significant differences in GFV/RGV and gastric pH due to reduced preoperative fasting were reported, thus no change in aspiration risk. Eight studies documented improvements in patient-reported outcomes with shorter fasting times. However, this review identified a paucity of studies that trialled interventions to reduce fasting times as the primary aim. These interventions were multimodal and multidisciplinary in nature, incorporating principles of implementation science to successfully achieve significant reductions in fasting times. This review highlights that reducing the preoperative fasting period is safe while improving patient's physical and psychological well-being. Further high-quality studies that investigate multimodal interventions, and that utilize implementation science principles, are required in this area.

Oral nutrition interventions in patients undergoing gastrointestinal surgery for cancer: A systematic literature review.

PURPOSE: Weight loss and poor food intake have been shown to affect several outcomes in patients undergoing surgery for gastrointestinal cancer. This review aims to examine the effect of pre-, post- or perioperative nutrition interventions focused on increasing oral energy or protein intake in patients undergoing surgery for gastrointestinal cancer. Interventions using standard oral nutrition supplements and/or dietary counselling were included. The primary outcome was weight change, and secondary outcomes were energy and protein intake. A secondary aim was to examine this effect in malnourished patients. METHODS: Embase, Medline, CINAHL and CENTRAL were searched from inception to September 2019 for relevant randomised controlled trials. Study quality was assessed using the revised Cochrane Collaboration risk of bias tool for randomised trials. The quality of evidence for each outcome was assessed using GRADE. RESULTS: Fourteen articles met the inclusion criteria. Studies assessed patients undergoing surgery for gastric, colorectal, oesophageal and pancreatic cancers. The interventions studied included oral nutrition supplements and/or dietary counselling. Five studies reported preoperative interventions; five studies reported post-operative interventions; six studies reported post-discharge interventions; and two studies reported perioperative interventions. Overall, low or very low quality evidence was found to support the use of oral nutrition supplements to positively influence weight and increase energy and protein intake in the preoperative period and immediate post-operative period. Very low quality evidence was found to support the use of oral nutrition interventions to influence weight, energy or protein intake in the post-discharge period. Very limited evidence with high risk of bias was found to support positive effects of nutrition intervention in malnourished patients. CONCLUSIONS: This review demonstrates limited evidence for the use of oral nutrition supplements to increase intake and positively influence weight in patients undergoing surgery for gastrointestinal cancer. Overall, results were heterogeneous leading to inconsistent results. Further research into optimal nutrition support interventions and timing of interventions is required.

The Impact of Preoperative Immunonutrition and Standard Polymeric Supplements on Patient Outcomes After Pelvic Exenteration Surgery, Taking Compliance Into Consideration: A Randomized Controlled Trial.

BACKGROUND: The effect of immunonutrition vs standard polymeric nutrition in the preoperative phase on patient outcomes is still unclear, which could be due to contributing factors such as poorly reported compliance and unequal provision of protein, energy, and volume. The aim of this study was to examine the effects of preoperative immunonutrition compared with standard polymeric supplements matched for energy, protein, volume, length of stay, and postoperative complications in pelvic exenteration surgery, taking into consideration compliance. METHODS: This was a single-blinded, randomized, controlled trial in patients undergoing pelvic exenteration surgery. Fifty-two participants were randomly assigned to consume 3 immunonutrition supplements/d for 5 days preoperatively, and 56 participants were randomly assigned to consume 3 standard polymeric supplements/d for 5 days preoperatively. Primary and secondary outcome measures were assessed. Compliance with each nutrition regime was recorded during the intervention, and subanalysis was conducted. RESULTS: There was no significant difference between immunonutrition and standard polymeric supplements on length of stay (P = 0.988) or postoperative complications (P = 0.179) after pelvic exenteration surgery. Compliance with nutrition supplements was significantly less in malnourished (n = 33) compared with well-nourished participants (n = 74) (P = 0.016). Compliance varied between study groups, although not significant. CONCLUSION: Preoperative immunonutrition did not significantly impact length of stay or postoperative complications compared with standard polymeric supplements after pelvic exenteration surgery, despite controlling for protein, energy, and volume. Compliance, protein, and energy may considerably impact the effect of immunonutrition, particularly in malnourished patients.

Bridging the gap between research and practice for nutrition support after pelvic exenteration surgery.

BACKGROUND AND OBJECTIVES: Current best practice for postoperative feeding in surgical patients is well established, however implementation of evidence-based practice comes with many challenges. A common barrier is surgeon adherence to guidelines and the reasons behind this are not well understood. Pelvic exenteration surgery is a complex surgery and postoperative feeding methods in this patient cohort vary significantly from patient to patient. The aim of this study was to identify barriers and enablers for surgeons to implement evidence based feeding methods after pelvic exenteration surgery and provide practical strategies for non-surgeon healthcare workers to improve compliance. METHODS AND STUDY DESIGN: A qualitative study was conducted by performing semi-structured interviews with 12 Consultant Surgeons at hospitals in Australia and New Zealand with dedicated pelvic exenteration services. Deductive and inductive thematic analysis was performed in line with the Theoretical Domains Framework and Behaviour Change Wheel model to identify relevant domains, themes and intervention functions. RESULTS: Culture was identified as an overarching theme that influenced postoperative feeding practices, surgeon behaviours and sub-themes. Identified sub-themes included motivation, relationships and expectations, environment and 'moving forward'. Motivations to use different types of feeding routes postoperatively varied across hospitals. Relationships, surgeons' expectations and the environment all influenced the way in which patients were fed postoperatively. Practical strategies were identified to assist non-surgeon healthcare workers achieve positive change moving forward with postoperative feeding. CONCLUSIONS: Practical strategies to promote enablers and reduce barriers are required to bring about positive change and align practice with the evidence.

The effect of diets delivered into the gastrointestinal tract on gut motility after colorectal surgery-a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND/OBJECTIVES: Despite best practice guidelines, feeding methods after colorectal surgery vary due to the difficulties translating evidence into practice. The aim was to determine the effectiveness of diets delivered into the gastrointestinal tract (GIT) on gut motility following colorectal surgery. SUBJECTS/METHODS: EMBASE, MEDLINE, CINAHL, Web of Science and PubMed were systematically searched. Randomised controlled trials investigating effectiveness of a diet on gut motility after colorectal surgeries were included. Outcomes included postoperative ileus, length of stay, mortality, nausea and vomiting. RESULTS: A total of 756 potential studies were identified; of these, 10 trials reporting on 1237 unique patients were included. There is evidence that early feeding reduces time (days) to first flatus (mean difference (MD):-0.64; 95% CI:-0.84 to -0.44) and bowel movements (MD:-0.64; 95% CI:-1.01 to -0.26), when compared to traditional postoperative fasting. Introducing solids versus the progression of fluids to solids had no effect on time (days) to first flatus (MD:0.13; 95% CI:-1.99 to 1.74) or bowel movement (MD:0.20; 95% CI:-0.50 to 0.98). Complete nutrition compared to hypocaloric nutrition had no effect on time to first flatus (MD:-0.60; 95% CI:-1.66 to 0.46) or bowel movement (MD:-0.20; 95% CI:-1.59 to 1.19), whereas coffee and diet compared to water and diet significantly decreased time (days) to first bowel movement (MD:-0.60; 95% CI:-0.97 to -0.19) but had no effect on time to first flatus (MD:-0.20; 95% CI:-0.57 to 0.09). CONCLUSIONS: Any form of early postoperative diet provided into the GIT early after colorectal surgery is likely to stimulate gut motility, resulting in earlier return of bowel function and shorter length of stay.

Exploring reasons behind patient compliance with nutrition supplements before pelvic exenteration surgery.

PURPOSE: Compliance with oral nutrition support (ONS) is poorly reported in the literature. Many factors influence compliance, which could mask the true benefits of preoperative ONS. Surgical oncology patients, including pelvic exenteration patients, are often requested by healthcare workers to consume nutrition supplements before surgery. Exploration of barriers and enablers to compliance with nutrition supplements is needed to improve patient compliance and understand the real impact of preoperative ONS. METHOD: A qualitative study using semi-structured interviews was performed to investigate enablers and barriers to preoperative nutrition supplement compliance. Twenty participants who had been asked to consume 15 nutrition supplements, either immunonutrition or standard polymeric supplements, were interviewed. Inductive thematic analysis was used to determine major themes associated with compliance. RESULTS: Twelve out of 20 participants were not compliant with recommended dosing. Well-nourished participants were more compliant than malnourished participants. Major themes associated with compliance were flavour, volume, texture, impact on dietary intake and motivation to consume supplements. Flavour differed between the two groups, negatively impacting compliance in the immunonutrition group. Volume, texture and impact on dietary intake also negatively impacted compliance whereas motivation positively impacted compliance. CONCLUSION: To overcome barriers and enforce enablers with nutrition supplement compliance, it is essential healthcare workers implement individualised interventions, taking into account nutritional status. A range of flavours, minimal volume and low viscosity supplements should be provided to address individual preference and minimise poor compliance. Better-targeted education and regular motivation are needed to improve compliance.