Parenteral nutrition after cytoreductive surgery for peritoneal malignancy: Should it be administered routinely?

PURPOSE/BACKGROUND: Cytoreductive surgery (CRS) is complex abdominal surgery that is used to treat peritoneal malignancy. CRS is associated with major morbidity and efforts to address this include optimisation of perioperative care. There is variation in international protocols on the nutritional management after CRS, in particular whether parenteral nutrition (PN) should be routinely or selectively administered. HYPOTHESIS/AIM: This study assessed parenteral nutrition use, factors associated with PN requirement and nutritional outcomes in a centre that selectively uses PN after CRS. METHODS/INTERVENTIONS: A retrospective analysis was undertaken on patients who underwent cytoreductive surgery ± hyperthermic intraperitoneal chemotherapy (HIPEC) at Peter MacCallum Cancer Centre between 1st January 2015 and 31st December 2020 using data entered into a prospectively maintained database. Patient characteristics, nutritional status, oncological parameters, operative details and postoperative outcome data were retrieved. Categorical variables were compared using the chi-squared test and continuous data was compared using a non-parametric Mann-Whitney U-test. A p-value <0.05 was considered statistically significant. Cox regression analysis was performed to identify independent predictors of requiring PN and postoperative weight change over admission. RESULTS: A total of 222 patients who had CRS between were included (mean age 56 years; female 61.3%). Preoperative nutritional characteristics of participants included a mean body mass index (BMI) of 27.6 kg/m2 and the majority (77.9%) were not at nutritional risk pre-operatively with a Patient Generated Subjective Global Assessment (PG-SGA) score of category A. A high proportion of patients had surgery for colonic adenocarcinoma (58.1%), received HIPEC (87.4%) and achieved complete cytoreduction (82%). Postoperative parenteral nutrition was required for 65 patients (29.3%). The most frequent indication for PN was postoperative ileus (63.1%) with the mean (SD) time to commencing PN being postoperative day 5. Factors associated with the requirement for postoperative PN included preoperative albumin (OR 0.89; p = 0.015), weight loss >5% of body weight in the 6 months prior to admission (OR 2.2; p = 0.05), higher PCI score (OR 1.048; p = 0.005), number of anastomoses completed (OR 1.766; p = 0.017) and development of any postoperative complication (OR 2.71; p = 0.009). PN use was not associated with postoperative weight change. CONCLUSION: Most patients undergoing CRS did not require post-operative PN. Nutritional and operative factors may identify patients who are likely to need PN after surgery. Selective use of PN did not impact on postoperative weight change.

Perioperative nutritional assessment and interventions in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): A systematic review.

BACKGROUND: Peritoneal carcinomatosis is a catabolic state and cytoreductive surgery (CRS) is a high morbidity operation. Optimising perioperative nutrition is crucial to improve outcomes. This systematic review sought to examine literature describing clinical outcomes related to preoperative nutrition status and nutrition interventions in patients undergoing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: A systematic review was registered with PROSPERO (300326). A search of eight electronic databases was undertaken on 8th May 2022 and reported according to the PRISMA statement. Studies reporting nutrition status through use of screening and assessment tools, nutrition interventions or nutrition-related clinical outcomes for patients undergoing CRS with HIPEC were included. RESULTS: Of 276 screened studies, 25 studies were included for review. Commonly used nutrition assessment tools for CRS-HIPEC patients included Subjective Global Assessment (SGA), sarcopenia assessment with computed tomography, preoperative albumin, and body mass index (BMI). Three retrospective studies compared SGA with postoperative outcomes. Malnourished patients were more likely to have postoperative infectious complications (p = 0.042 SGA-B, p = 0.025 SGA-C). Malnutrition was significantly associated with increased hospital length of stay (LOS) in two studies (p = 0.006, p = 0.02), and with overall survival in another study (p = 0.006). Eight studies analysing preoperative albumin levels reported conflicting associations with postoperative outcomes. BMI in five studies was not associated with morbidity. One study did not support routine nasogastric tube (NGT) feeding. CONCLUSIONS: Preoperative nutritional assessment tools, including SGA and objective sarcopaenia measures, have a role in predicting nutritional status for CRS-HIPEC patients. Optimisation of nutrition is important for preventing complications.

Peripheral parenteral nutrition in surgery - a systematic review and meta-analysis.

BACKGROUND: Peripheral parenteral nutrition (PPN) refers to the delivery of artificial nutrition via a peripheral intravenous cannula. As a nutritional intervention it remains under-utilised in peri-operative care. This is despite purported advantages which includes avoiding the risks associated with central venous lines and preventing potential delays to the initiation of nutrition support. This systematic review and meta-analysis will detail the available evidence for PPN use in surgery. METHODS: A comprehensive search of the EMBASE and Medline databases was undertaken to identify randomised control trials (RCTs) involving PPN use in surgical patients published until July 30th 2022. Three domains of PPN use were reviewed including: PPN compared to crystalloid intravenous fluids on nutritional and clinical outcomes; PPN compared to Central PN (CPN) on nutritional outcomes and complications; and strategies to prevent thrombophlebitis associated with PPN. RESULTS: The meta-analysis included 8 studies which included 698 patients. Use of PPN led to reduced post-operative weight loss (% body weight change) with a mean difference of -1.45% (95% CI -2.9 to -0.01, p = 0.05). There was no statistically significant difference in terms of length of stay, infectious/non-infectious complications, surgical site infections or phlebitis. 42 RCTs were included in the systematic review. 14 RCTs compared PPN to crystalloid infusion. There was significant heterogeneity in the trial populations, interventions and measured outcomes. Most trials found that PPN may improve nitrogen balance and positively impact nutritional markers. Quality of life and post-operative complications were either improved or no difference found in trials assessing these outcomes. Four RCTs showed that PPN is a safe and feasible alternative to CPN. 22 RCTs reported on measures that may impact on thrombophlebitis rates associated with PPN. These included lower osmolality of PPN solution, cyclical PPN delivery, use of a small gauge polyurethane cannula in an upper limb vein, addition of heparin/hydrocortisone to PPN solutions and placement of a GTN patch over infusion sites. CONCLUSION: PPN is a safe and effective mode of delivery of peri-operative nutrition. It is a feasible short-term alternative to central-line delivered PN. There are a number of strategies to reduce thrombophlebitis associated with PPN use. Further high-quality RCTs are required to assess the use of PPN in contemporary surgical practice.

The Impact of Peri-operative Enteral Immunonutrition on Post-operative Complications in Gastrointestinal Cancer Surgery: A Meta-Analysis.

BACKGROUND: Immunonutrition (IMN) in gastrointestinal (GI) cancer surgery remains under-utilised and contentious. Despite previous meta-analysis reporting benefit, most recent randomised control trials (RCTs) have failed to demonstrate this and have recommended against its routine use. A contemporary meta-analysis may contribute to the recommendations for immunonutrition use and help select which patients may benefit. The objective of this study was to review IMN and its impact on post-operative outcomes in GI cancer surgery, exploring its role in both malnourished and non-malnourished populations, the optimal dose to use, cancer type of patients using IMN and the timing of IMN relative to the peri-operative period. PATIENTS AND METHODS: The EMBASE and Medline databases were searched from 2000 to 2022 for RCTs evaluating IMN in adults undergoing GI cancer surgery. RESULTS: Thirty-seven studies were included (22 pre-operative IMN studies, 11 peri-operative IMN trials and 9 post-operative IMN trials; 4 trials had multiple IMN protocols) that reported on 3793 patients. The main outcome of post-operative infectious complications was reduced with IMN [odds ratio (OR) 0.58, 95% confidence interval (CI) 0.47-0.72]. This association was significant in subgroup analysis only with pre-operative and peri-operative administration and in trials including upper GI cancers, colorectal cancer and 'mixed GI' cancer populations, and significance was independent of nutritional status. IMN in pooled analysis reduced surgical site infection (SSI) (OR 0.65, 95% CI 0.52-0.81), anastomotic leak (OR 0.67, 95% CI 0.47-0.93) and length of stay (LOS) by 1.94 days (95% CI - 3 to - 0.87). CONCLUSION: Immunonutrition was associated with reduced post-operative complications. Peri-operative administration may be the preferred strategy in reducing infectious complications, anastomotic leak, SSI and LOS.

Implementation of a Multidisciplinary Allied Health Optimisation Clinic for Cancer Patients with Complex Needs.

This study examined the feasibility of implementing a multidisciplinary allied health model of care (MOC) for cancer patients with complex needs. The MOC in this retrospective study provided up to eight weeks of nutritional counselling, exercise prescription, fatigue management and psychological support. Implementation outcomes (acceptability, adoption, fidelity and appropriateness) were evaluated using nine patient interviews, and operational data and medical records of 185 patients referred between August 2017 and December 2018. Adoption, including intention to try and uptake, were acceptable: 88% of referred patients agreed to screening and 71% of eligible patients agreed to clinic participation. Fidelity was mixed, secondary to inpatient admissions and disease progression interrupting patient participation. Clinician compliance with outcome assessment was variable at program commencement (dietetic, 95%; physiotherapy, 91%; occupational therapy, 33%; quality of life, 23%) and low at program completion (dietetic, 32%; physiotherapy, 13%; occupational therapy, 10%; quality of life, 11%) mainly due to non-attendance. Patient interviews revealed high satisfaction and perceived appropriateness. Adoption of the optimisation clinic was acceptable. Interview responses suggest patients feel the clinic is both acceptable and appropriate. This indicates a multidisciplinary model is an important aspect of comprehensive, timely and effective care. However, fidelity was low, secondary to the complexities of the patient cohort.

An extreme presentation of pancreatic pseudocyst.

Pancreatitis is a serious and common presentation to general surgery departments. There are many complications associated with pancreatitis and we present an undescribed presentation of a pancreatic pseudocyst and include its management strategy.