Challenges and Triumphs in Enterocutaneous Fistula Management: A Case Report of Complex Surgical Intervention and Multidisciplinary Care.

Enterocutaneous fistulas (ECF) present complex challenges following abdominal surgery, involving abnormal communication between the gastrointestinal system and skin. We report an intriguing case of a 50-year-old female with a history of appendiceal perforation, primarily managed by right hemicolectomy with ileotransverse anastomosis, which led to an anastomotic leak and eventually an ECF. Failed conservative management, prompting re-exploratory laparotomy revealing extensive adhesions and iatrogenic enterotomies secondary to attempted adhesiolysis, led to multiple fistulae, further complicated by failed abdominal closure leading to a large abdominal wound to be managed along with the numerous enteroatmospheric fistulae. Our comprehensive, structured approach included surgical care, nutritional support, and meticulous wound management, emphasizing patient comfort and recovery. If there were a graphical representation of the patient's smile and hope during the hospital stay, there would be a remarkable upward trend, symbolizing recovery and resilience. This case underscores the critical decisions and multidisciplinary teamwork required for the successful management of severe ECF, emphasizing holistic, patient-centered care. ECF is one such field that has been well researched in the medical literature, but what makes this case report special is the multifaceted management of a case complicated at all three phases of surgical management, that is, preoperative, intraoperative, and postoperative.

Protocolized Gastrointestinal Fistula Management is Superior to Historic Data and National Averages: A Retrospective Review of an Enterocutaneous Fistula Registry.

Background: Enterocutaneous fistula (ECF) management remains a complex clinical problem. Prehabilitation (prehab) protocols are becoming more popular. The prehabilitation protocol used in this paper was adopted in 2017 at the University of Florida. The Fistula Registry at University of Florida has captured the efforts of the UFAIR (University of Florida Abdominal Wall Reconstruction and Intestinal Rehab) service. We analyzed if the prehabilitation program is successful in reducing deaths, length of stay, recurrence of fistula, and readmissions to the hospital in our database.Methods: Charts were queried for patients with ECF/EAF from the UFAIR database from January 1, 2017, until present day. Several factors were recorded including: cause of fistula, recurrence of fistula, wound infection, postoperative sepsis, hospital length of stay, postoperative ICU length of stay, postoperative length of stay, death, discharge disposition, and if taken back to surgery.Results: 31 patients underwent prehabilitation while 30 patients underwent standard nutritional therapy. No deaths were reported in the prehab group, compared to 7 deaths in the standard group (P = .006). The prehab population had an average hospital stay of 15.19 days while the standard group had an average stay of 21.16 days (P = .045). 2/31 in the prehab protocol had a recurrence of ECF while 10/30 in the standard protocol recurred (P = .01). Conclusions: Our study showed promising data for the effects of prehabilitation protocol for patients with ECF. The outcomes of those in the prehab protocol surpassed historical outcomes. Our patients had no deaths, shorter hospital stays, and lower rates of recurrence.

A review of perioperative immune-modulating and metabolic-modulating nutrition strategies for bowel resection surgery.

Focused perioperative nutrition strategies have proven benefits on the outcomes for patients undergoing major abdominal surgery. In this brief article, we will review these strategies and the evidence to support them with a focus on gastrointestinal anastomotic healing. We will elaborate the risks and benefits of enteral feeds, immune- and metabolic-modulating formulas, prebiotics and probiotics, and prehabilitation in preparation for surgery. Additionally, we will discuss the role of fish oils (eicosapentaenoic acid and docosahexaenoic acid) in the surgical patient and new data on specialized proresolving mediators in inflammation resolution. Finally, this article will consider the harmful impact surgical trauma has on the microbiome and the potential for perioperative dietary modulation to attenuate these negative effects.

A Standardized Post-gastrostomy Feeding Protocol for Pediatric Patients Reduces Time to Postoperative Goal Feeding Volume.

BACKGROUND: Gastrostomy creation is a common pediatric surgical procedure, but the time to initiation of feeds and to goal feeding volumes postoperatively varies greatly. Delays in reaching goal feeding volumes promote malnutrition and may prolong hospital length of stay. We hypothesized that implementing an accelerated, standardized post-gastrostomy feeding protocol would allow patients to reach goal feeding volumes sooner, without increasing postoperative complications. METHODS: We conducted a retrospective cohort study of children who underwent gastrostomy tube placement between 1/1/2022 and 11/30/2023. The feeding protocol was implemented on 11/16/2022, with patients separated into pre- and post-protocol cohorts. Abstracted data included comorbidities, time to initiation of enteral feeds, time to goal feeding volume, and postoperative complications. RESULTS: 322 patients were included: 166 pre-protocol and 156 post-protocol. The post-protocol cohort had a greater proportion of patients with gastrointestinal and/or cardiac comorbidities (P < .001). Through the protocol, postoperative enteral feeds were initiated significantly faster (5.4 hrs [IQR 43-7.7] vs 7.0 hrs [IQR 5.6-14.3]; P < .001). The post-protocol cohort also achieved goal feeding volumes sooner (12.8 hrs [IQR 9.1-25.3] vs 26.3 hrs [IQR 21.6-38.9]; P < .001). Postoperative complication rates did not differ between cohorts. Sub-analysis of children with complex cardiac conditions also demonstrated faster time to goal nutrition without an associated increase in postoperative events. DISCUSSION: These findings demonstrate that our accelerated post-gastrostomy feeding protocol was effective in achieving goal enteral nutrition earlier without increasing postoperative adverse outcomes. This protocol may be used by other centers to safely expedite time to goal enteral feeds in children postoperatively.

A survey of preoperative surgical nutrition practices, opinions, and barriers across Canada.

Malnutrition is prevalent among surgical candidates and associated with adverse outcomes. Despite being potentially modifiable, malnutrition risk screening is not a standard preoperative practice. We conducted a cross-sectional survey to understand healthcare professionals' (HCPs) opinions and barriers regarding screening and treatment of malnutrition. HCPs working with adult surgical patients in Canada were invited to complete an online survey. Barriers to preoperative malnutrition screening were assessed using the Capability Opportunity Motivation-Behaviour model. Quantitative data were analyzed using descriptive statistics and qualitative data were analyzed using summative content analysis. Of the 225 HCPs surveyed (n = 111 dietitians, n = 72 physicians, n = 42 allied HCPs), 96%-100% agreed that preoperative malnutrition is a modifiable risk factor associated with worse surgical outcomes and is a treatment priority. Yet, 65% (n = 142/220; dietitians: 88% vs. physicians: 40%) reported screening for malnutrition, which mostly occured in the postoperative period (n = 117) by dietitians (n = 94). Just 42% (48/113) of non-dietitian respondents referred positively screened patients to a dietitian for further assessment and treatment. The most prevalent barriers for malnutrition screening were related to opportunity, including availability of resources (57%, n = 121/212), time (40%, n = 84/212) and support from others (38%, n = 80/212). In conclusion, there is a gap between opinion and practice among surgical HCPs pertaining to malnutrition. Although HCPs agreed malnutrition is a surgical priority, the opportunity to screen for nutrition risk was a great barrier.

The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury.

INTRODUCTION: Severe traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. METHODS: We queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. RESULTS: We identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). CONCLUSIONS: PN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.

Optimizing Nutritional Status of Patients Prior to Major Surgical Intervention.

In patients undergoing elective cardiovascular and thoracic surgery, malnutrition and the deterioration of nutritional status are associated with negative outcomes. Recognition of the contributory factors and the complications stemming from surgical stress is important for the prevention and management of these patients. We have reviewed the literature available and focused on the nutritional and metabolic aspects affecting surgical patients, with emphasis on the recommendations of enhanced recovery protocols. The implementation of enhanced recovery protocols and nutritional support guidelines focusing on the surgical patient as part of a multidisciplinary approach would improve the nutritional status of surgical patients at risk for negative outcomes.

Clinical characteristics, prognosis, and surgical outcomes of patients with non-HBV and non-HCV related hepatocellular carcinoma: three-decade observational study.

BACKGROUND: The incidence of non-hepatitis B virus, non-hepatitis C virus hepatocellular carcinoma (non-B non-C-HCC) is increasing worldwide. We assessed the clinical characteristics and surgical outcomes of non-B non-C-HCC, versus hepatitis B (HBV-HCC) and hepatitis C (HCV-HCC). METHODS: Etiologies, fibrosis stages, and survival outcomes were analyzed of 789 consecutive patients who underwent surgery from 1990 to 2020 (HBV-HCC, n = 149; HCV-HCC, n = 424; non-B non-C-HCC, n = 216). RESULTS: The incidence of hypertension and diabetes mellitus was significantly higher in patients with NON-B NON-C-HCC than in those with HBV-HCC and HCV-HCC. Significantly more advanced tumor stages were observed in patients with non-B non-C-HCC; however, better liver function and lower fibrosis stages were observed. Patients with non-B non-C-HCC had significantly worse 5-year overall survival than patients with HBV-HCC; overall survival was comparable between patients with non-B non-C-HCC and HCV-HCC. Patients with HCV-HCC had significantly worse 5-year recurrence-free survival than patients with HBV-HCC and non-B non-C-HCC. In patients with non-B non-C-HCC, overall survival was comparable among three periods (1990-2000, 2001-2010, and 2011-2020) despite significant improvement in patients with HBV-HCC and HCV-HCC. CONCLUSION: The prognosis of non-B non-C-HCC was similar to that of HBV-HCC and HCV-HCC regardless of tumor progression at surgery. Patients with hypertension, diabetes mellitus, and dyslipidemia require careful systematic follow-up and treatment.

Hypothyroidism Complicated by Vitamin C and Thiamin Deficiency in Surgical Patients.

Multiple vitamin deficiencies together with endocrinopathy may be encountered in individuals presenting with critical illness. Following the surprise postmortem diagnosis of concomitant scurvy, Wernicke, and hypothyroidism in an elderly woman presenting with a mix of atypical symptoms, patients considered at risk were tested for TSH, vitamin C, and thiamin levels. Between September 1, 2018, and December 31, 2022, 801 vitamin C levels in 679 patients were measured in our rural hospital and 309 (39%) were found <0.4 mg/dL. In this population, 39% of 626 thiamin levels were found to be low. Twenty-two patients with vitamin C and/or thiamin deficiency and elevated TSH levels were identified. Two patients died from scurvy; one also had myxedema. The incidence of vitamin C and thiamin deficiency in our patient population was higher than expected. Further studies should determine if this is unique to our rural setting or part of a bigger trend associated with poor dietary choices.

Improving Post-procedure Outcomes With Clinical Care Pathway for Enteral Access.

Our health system introduced an enteral access clinical pathway (EACP) hoping to increase nutritionist consults and decrease presentation to the Emergency Department, readmission to the hospital, and overall hospital length of stay. We followed patients with short-term access (STA), longterm access (LTA), and short-long-term conversions (SLT) seen in the six months prior to the EACP launch (baseline group) and the six months after (performance group). The baseline cohort consisted of 2,553 patients and the performance cohort of 2,419 patients. Those in the performance group were more likely to receive a nutrition consult (52.4% vs 48.0%, P < .01), less likely to re-present to the ED (31.9% vs 42.6%, P < .001), and less likely to be readmitted to the hospital (31.0% vs 41.6%, P < .001. These findings suggest that the EACP may increase the likelihood of both expert-driven nutritional support and effective discharge planning for hospitalized patients.

Percutaneous Endoscopic Gastrostomy Placement in Trauma Patients: Early vs Delayed Initiation of Enteral Feeding.

In critically ill trauma patients, adequate nutrition is essential for the body's healing process. Currently, there is no clinical standard for initiating feeds after percutaneous endoscopic gastrostomy (PEG) tube placement. We aimed to demonstrate that early enteral nutrition (EN) is as safe as delayed EN in patients who have undergone PEG tube insertion. We conducted a multi-center, retrospective cohort study of 384 patients from the Prisma Health Trauma Registries who received PEGs. Feeding intolerance was defined as high gastric residuals, nausea, emesis, sustained diarrhea, or ileus. The probability that a patient would experience intolerance was 11.7% in those fed within 6 hours, 5.1% among patients fed between 6 and 12 hours, 6.0% among patients fed between 12 and 24 hours, and 7.6% among patients fed after 24 hours, for which no statistically significant difference was detected. These findings support that early EN after PEG placement is safe in critically ill, trauma patients.

A Novel Nomogram for Early Identification and Intervention in Colorectal Cancer Patients at Risk for Malnutrition.

BACKGROUND: Malnutrition is under-recognized in cancer patients and can lead to poor treatment outcomes. We aim to develop an outpatient-focused score based on the Malnutrition Screening Tool (MST) to help identify colorectal cancer (CRC) profiles at high risk for malnutrition. METHODS: 506 CRC patients during initial outpatient oncology consultation at our tertiary referral outpatient oncology clinic completed the MST. Objective and subjective data were collected through chart review. Data gathered are as follows: demographics, anthropometrics, laboratory values, patient-reported symptoms, MST score, cancer history, performance status, socioeconomic status, and Charlson Comorbidity. Predictors of malnutrition were identified by logistic regression. Receiver operating curve (ROC), area under the curve (AUC), and our model's predictability were determined. RESULTS: Significant predictors of malnutrition are as follows: younger age (20-39 vs >40 years) (P = .007), normal-to-low body mass index at presentation (P = .019), Eastern Cooperative Oncology Group classification 2-3 (P = .012), metastatic disease (P = .046), albumin <3.0 g/dL (P = .033), fatigue (P < .001), and change in stool/bowel habits (P = .002). In our derived malnutrition score, risk of malnutrition increased from 11% for score 0, to 100% for scores 9-10. Receiver operating curve showed AUC .745 (95% CI, .697-.793). DISCUSSION: An outpatient clinic-derived malnutrition score obtained from objective and patient-reported variables may facilitate identification of CRC patients at highest risk for malnutrition. Rapid identification and intervention in high-risk patients may improve treatment recovery, therapy tolerance, and quality of life. Our tool requires external validation before application in clinical practice.

Nutrition for the high-risk surgical patient, when they need it most: Question and answer session.

Patients requiring complex or extensive surgery are often at high risk for perioperative and postoperative nutrition risk. Despite published guidelines, providing adequate nutrition to these patients continues to remain a clinical challenge. Using the case of a patient with preoperative nutrition risk who will need to undergo timely cancer resectional surgery, speakers presenting at the American Society for Parenteral and Enteral Nutrition 2022 Preconference discussed novel strategies to assess for nutrition risk, enhanced recovery after surgery, and preoperative and postoperative nutrition management in these often complex surgical patients.

Nutrition education: Optimising preparation and recovery for benign oesophageal surgery.

BACKGROUND: Patients requiring upper gastrointestinal surgery for benign oesophageal conditions are at nutrition risk before and after surgery. There is a dearth of published evidence guiding clinicians on effective collaboration with patients to mitigate perioperative nutritional challenges. We conducted a qualitative study aiming to explore patients' perioperative food, nutrition, and educational experiences to guide future care. METHODS: Adult patients who had undergone elective, benign oesophageal surgery were invited to participate in semi-structured interviews within 3 weeks of hospital discharge. Interviews were transcribed and analysed with a reflexive form of inductive thematic analysis in addition to synthesised member checking. RESULTS: Interviews with 12 patients identified three major themes. First, nutrition education fosters a better surgical recovery experience: patients expressed a desire to be prepared for their upcoming surgery and engage in the recovery process with informed food choices. Most patients preferred preoperative education given limited capacity for learning during hospital admission. Second, patients have priorities for nutrition information: patients expressed that educational material should be printed, comprehensive, practical, include familiar foods and focus on managing postoperative physical symptoms. Third, food impacts social and emotional experiences of surgery: resumption of a normal diet was a sign of recovery that enabled social reintegration. Identified themes resonated with Knowles' six-core principles of andragogy. CONCLUSIONS: Patients with benign oesophageal conditions perceived nutrition education to be a vital aspect of surgical preparation and recovery. Re-designing perioperative education with patient input has the potential to improve outcomes and experiences.

Nutrition Care Process Model Approach to Surgical Prehabilitation in Oncology.

The nutrition care process is a standardized and systematic method used by nutrition professionals to assess, diagnose, treat, and monitor patients. Using the nutrition care process model, we demonstrate how nutrition prehabilitation can be applied to the pre-surgical oncology patient.

Current Landscape of Nutrition Within Prehabilitation Oncology Research: A Scoping Review.

Background: Prehabilitation aims to improve functional capacity prior to cancer treatment to achieve better psychosocial and clinical outcomes. Prehabilitation interventions vary considerably in design and delivery. In order to identify gaps in knowledge and facilitate the design of future studies, we undertook a scoping review of prehabilitation studies to map the range of work on prehabilitation being carried out in any cancer type and with a particular focus on diet or nutrition interventions. Objectives: Firstly, to describe the type of prehabilitation programs currently being conducted. Secondly, to describe the extent to which prehabilitation studies involved aspects of nutrition, including assessment, interventions, implementation, and outcomes. Eligibility Criteria: Any study of quantitative or qualitative design that employed a formal prehabilitation program before cancer treatment ("prehabilitation" listed in keywords, title, or abstract). Sources of Evidence: Search was conducted in July 2020 using MEDLINE, PubMed, EMBASE, EMCARE, CINAHL, and AMED. Charting Methods: Quantitative data were reported as frequencies. Qualitative nutrition data were charted using a framework analysis that reflects the Nutrition Care Process Model: assessment, intervention, and monitoring/evaluation of the nutrition intervention. Results: Five hundred fifty unique articles were identified: 110 studies met inclusion criteria of a formal prehabilitation study in oncology. prehabilitation studies were mostly cohort studies (41%) or randomized-controlled trials (38%) of multimodal (49%), or exercise-only (44%) interventions that were applied before surgery (94%). Nutrition assessment was inconsistently applied across these studies, and often conducted without validated tools (46%). Of the 110 studies, 37 (34%) included a nutrition treatment component. Half of these studies provided the goal for the nutrition component of their prehabilitation program; of these goals, less than half referenced accepted nutrition guidelines in surgery or oncology. Nutrition interventions largely consisted of counseling with dietary supplementation. The nutrition intervention was indiscernible in 24% of studies. Two-thirds of studies did not monitor the nutrition intervention nor evaluate nutrition outcomes. Conclusion: Prehabilitation literature lacks standardized and validated nutritional assessment, is frequently conducted without evidence-based nutrition interventions, and is typically implemented without monitoring the nutrition intervention or evaluating the intervention's contribution to outcomes. We suggest that the development of a core outcome set could improve the quality of the studies, enable pooling of evidence, and address some of the research gaps identified.

The Critical Role of Nutrition in Facial Plastic Surgery.

Nutrition plays a key role in optimizing healing following surgery. The increased catabolic state postoperatively, coupled with a propensity for patients to be suffering from marginal nutritional deficiencies at baseline preoperatively, necessitates that the surgeon be attuned to the need for optimal perioperative nutritional support. This ensures the smoothest recovery and best possible outcomes in facial plastic surgery. Key nutrients include vitamin A, vitamin C, zinc, bromelain, arnica montana, arginine, glutamine, hydrolyzed collagen, vitamin B complex, and protein. The ability for patients to obtain this optimal supplementation in a single product is the ideal solution for both surgeon and patient.

Nutrition for the Surgical Infant with Gastroschisis.

Nutrition for the infant with gastroschisis is a complex topic and there is not a lot of uniformity in the literature to formulate evidence-based care. This article discusses more recent findings in the literature as we search for an effective method of feeding these infants. Issues with growth and development, illustrating the variety of outcomes, are also addressed.

Perioperative nutrition management as an important component of surgical capacity in low- and middle-income countries.

Needs for surgical care are growing in low- and middle-income countries. Existing surgical care capacity indicators, focusing on the availability of equipment, personnel, and operation and anaesthetic skills, are not intended to evaluate perioperative nutrition management, which influences surgical outcomes. In this narrative review, we describe the prevalence of malnutrition and its clinical consequences among surgical patients in low- and middle-income countries, suggest potential measures to improve nutrition management and discuss the necessity of considering nutrition management as a component of surgical care capacity.

The teaching process of surgical nutrition therapy / 肠外与肠内营养

Surgical nutrition therapy is a novel course for undergraduates who are major in food hygiene and nutrition.In this study,the purpose,content,model and specific teaching approaches of the course were discussed,and the essentials of clinical practice for surgical nutrition therapy were pointed out.We hope that our experience would be helpful for the development of the course.