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Chapter 9
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Nutritional Care inGastrointestinal
Surgery
MariaWobith andArvedWeimann
Abbreviations
BIA Bioelectrical impedance analysis
BMI Body mass index
CT Computertomography
DXA Dual-X-absorptiometry
ERAS Enhanced Recovery after Surgery
ESPEN European Society for Clinical Nutrition and Metabolism
GCP Good clinical practice
GLIM Global Leadership Initiative on Malnutrition
MRI Magnitude resonance imaging
NRS Nutritional risk score
ONS Oral nutrition supplement
PG-SGA Patient-Generated Subjective Global Assessment
SGA Subjective Global Assessment
SMI Skeletal muscle index
6 MWD 6-Minute Walking Distance
CCI Comprehensive Complication Index
95% CI 95% Condence interval
OR Odds ratio
NCJ Needle catheter jejunostomy
NJ Nasojejunal tube
ICU Intensive care unit
M. Wobith · A. Weimann (*)
Department for General, Visceral and Oncological Surgery, St. George Hospital,
Leipzig, Germany
e-mail: Maria.Wobith@sanktgeorg.de; Arved.Weimann@sanktgeorg.de
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_9
145© The Author(s), under exclusive license to Springer Nature
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M. Wobith and A. Weimann
Introduction
In an overweight population, the “metabolic risk” is often underestimated, with special
regard to sarcopenic obesity [1–5]. The impact of malnutrition and sarcopenia for the
risk of postoperative complications and the length of hospital stay has been shown very
often [2–5]. Nutritional conditioning or “prehabilitation” should be considered for those
exhibiting signicant metabolic risk, in accordance with ERAS protocols [6–10].
Malnutrition, Sarcopenia, Sarcopenic Obesity
Malnutrition often goes along with sarcopenia. While sarcopenia means a decrease
in muscle mass and function, malnutrition is characterized by a global decrease of
body cell mass. Especially in geriatric patients, sarcopenia can be present without
malnutrition [11, 12]. Diagnosing sarcopenia is not easy in obese patients [13], and
in seriously ill older populations, up to 83% can be affected [14].
Prognostic Implications
Preoperatively impaired functionality along with impaired nutritional status is crucial
for postoperative mobilization and pulmonary function [15, 16]. In gastric cancer,
preoperative sarcopenia has been shown to be associated with overall survival [17].
Sarcopenic obesity is a separate risk factor, where an increased amount of fat
may hide a decrease in muscle mass [13, 18, 19].
Metabolic Risk
A well validated tool is the Nutritional Risk Score (NRS-2002) [20]. NRS≥3 indicates a risk for malnutrition, and assessment should then be initiated. Parameters of
the NRS are body mass index (BMI), unintended weight loss, reduced food intake,
and severity of disease. Furthermore, serum albumin can be used as preoperative
predictor for the underlying risk for postoperative complications [5] in line with the
Joint Consensus Statement on Nutritional Screening and Therapy within a Surgical
Enhanced Recovery Pathway of the American Society for Enhanced Recovery and
Perioperative Quality Initiative [21]. A high metabolic risk is dened by the ESPEN
guidelines if one of the following criteria is fullled: [5]:
• BMI less than 18.5kg/m
• Involuntary weight loss of more than 10–15% within 6 months
• SGA grade C, NRS≥5
• Serum albumin <30g/L (no liver/renal disease, no trauma/surgery)
2
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Malnutrition According toGLIM Criteria
Muscle mass measurement has been incorporated into the Global Leadership
Initiative on Malnutrition (GLIM) criteria with (1) phenotypic criteria (low body
mass index (BMI), reduced muscle mass, non-volitional weight loss and (2) etiological criteria (reduced food intake or assimilation, disease burden/inammatory condition) [12]. One variable from each category conrms the suspicion of malnutrition.
Measurement ofMuscle Mass
As patients undergoing surgery for gastrointestinal cancer always undergo computer tomography/CT for cancer staging, CT can also be exploited to determine
muscle quantity and quality. Skeletal muscle index (SMI) is highly regarded as a
marker of muscle mass by GLIM criteria. In the axial scan at lumbar level 3 skeletal
muscle area and density can be calculated [16, 22–25].
So far, no specic GLIM cut-off values have been anticipated, however proposals should soon emerge. GLIM criteria could be also appropriate to predict postoperative complications, in many cancer and non-cancer settings [26–30].
For patients undergoing colorectal cancer surgery, it has been suggested that low
risk or no need for intensive nutritional therapy would correspond to high SMI,
excluding patients with BMI≥35kg/m2. High-risk subjects would be in the opposite category: low SMI plus those with BMI≥35kg/m2 [31].
Sarcopenic Obesity
This condition features high body fat and reduced muscle mass. Clinical, functional,
and imaging diagnostic methods are available and are strongly recommended for
surgical services, as postoperative complications and slow recovery are likely. Stage
I is not associated with comorbidities, stage II displaying metabolic, functional, or
cardiopulmonary dysfunction [32].
Nutritional Assessment inthePreoperative Period
Evaluation of CT scan (preferably utilizing existing images, without new expenses
and X-ray exposure), bioelectrical impedance analysis (BIA), and handgrip strength
can be performed very easily, and cut-off points have been dened for such variables. In case body composition from CT or BIA is not available, severe metabolic
risk may be dened according to the ESPEN guideline [5].
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M. Wobith and A. Weimann
Indication forNutrition Therapy
Nutritional counseling should be offered to patients undergoing gastrointestinal
cancer surgery. Ideally, the perioperative trajectory will be accompanied by an
experienced dietician, or by the Nutrition Support Team if available [33]. It
should not be waited until overt malnutrition is present. A risk for malnutrition
or an underlying metabolic derangement could underlie the start of nutrition
therapy.
ESPEN guidelines [5] advise nutritional support in case of malnutrition or
nutritional risk, when dietary intake is likely for more than 5 days before operation, or when <50% of the necessary requirements will be consumed more
than 7 days.
For severe nutritional risk 7–14days assistance is indicated, if necessary
postponing surgical intervention [5, 7]. Parenteral nutrition is nowadays an
exception, reserved for intolerance of the gastrointestinal tract [5] (Table9.1).
Immune Enhancement
Benets regarding infectious complications have been established [35–37]. Rather
similar outcomes were documented within an ERAS protocol [38]. According to
ESPEN, ONS is recommended for 5–7 days before surgery when risky interventions are programmed, and immunomodulating supplements are suggested [5].
Prehabilitation
This technique is increasingly used in many parts of the world, notably for elderly,
unt, and inadequately nourished individuals. ERAS directives endorse nutritional
therapy combined with exercise (physical training) and psychological support for
4–6weeks [8, 9, 39, 40]. If severe malnutrition is diagnosed there must be an interdisciplinary decision, if and for how long the surgical procedure may be delayed for
sufcient conditioning of the patient [40].
Table 9.1 Postoperative enteral and parenteral supplementation related to anticipated oral
intake [34]
Oral intake (% caloric requirement) >5days Feeding
None Enteral
<30–50% Enteral (possible combination with parenteral)
>50% Monitoring of oral intake
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In a recently published multicentric trial targeting non-metastasized colorectal
cancer patients who underwent a 4 weeks hospital based trimodal prehabilitation
versus standard care, the nutritional intervention was dietary advice aiming a protein intake of 1.5g/kg body weight. Furthermore, patients were encouraged to take
a whey protein supplement (30g) 1 h after in-hospital training and 1 h before sleeping daily. A multivitamine supplement including vitamin D was also provided. In
the intervention group the rate of severe and medical complications was signicantly reduced, a result that coincides with other reports, however divergent results
have been published as well [41, 42].
Specic evidence-based recommendations concerning nutritional therapy are lacking [8, 9, 43–45]. Most randomized studies have been performed for a duration of
7–14days, and there is no data for a period of 4–6weeks. Preoperative immunonutrition
and synbiotics may be discussed and are supported in some circumstances [35, 46].
Perioperative Nutrition Therapy
In general, even after upper gastrointestinal resections, oral intake can be started on
the rst day after surgery [5]. NRS≥3 tends to be a predictor for low compliance to
ERAS protocol and for longer stay in hospital [47]. Compliance to ERAS of less
than 70% signals a higher rate of postoperative complications. Nevertheless, outcomes concerning recovery time or complications are heterogeneous [48, 49]. A
scheme for clinical practice is shown in Fig.9.1 [34].
• Screeningfor malnutrition
• Assessment of nutritional status
• Oral nutritionalsupplements 5 to 7 days before surgery
Preoperative
In-patients
After
discharge
Fig. 9.1 Nutrition therapy for gastrointestinal cancer patients during the trajectory (after discharge ***)
• Prehabilitation 4-6 weeks
• Earlyoralfeedingconsideringtolerance
• Consider supplementation if calorieand proteinintakeis insufficientfor > 5 days useONS,
enteral, or parental nutritioninastepwise approach
• Consider placement of feeding jejunostomy in high-risk patients undergoing upper
gastrointestinal cancer surgery
• Dietarycounsellingbeforedischarge
• Monitoringof nutritional status and nutrition intake
• ONSor tube feedingincase of inadequate calorieintakeor severe weight loss
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Enteral Feeding—Jejunostomy andNasojejunal Tube
A “bariatric effect” of upper GI operations for cancer including ghrelin deciency
has been advocated. Typically these patients lose 10% or more of their body weight
in the rst 6 months after the procedure, with parallel muscle wasting, a condition
that adversely affects tolerance and response to cancer adjuvant treatments.
Nasojejunal feeding, and needle catheter jejunostomy when a longer period is
considered, are classic recommendations in such circumstances. The tubes can be
placed during surgery, whenever oral alimentation is impaired or malabsorption is
anticipated, as a consequence of extensive anatomical changes induced by the operation [5, 50–59].
Gastrointestinal Complaints
Limited gastrointestinal tolerance should be always kept in mind [60, 61].
Diarrhea has been a serious problem during long term enteral alimentation in
the past. Currently with less risk of contamination of ready-to-use liquid diets,
and a variety of protein and calorie compositions to choose from, depending on
individual tolerance and absorptive function, this has become a much less troubling condition.
Vomiting, gastroesophageal reux and abdominal distension can still precipitate
aspiration pneumonitis, and are one of the reasons some prefer jejunostomy instead
of nasoenteral tube, in high-risk patients.
Parenteral Nutrition
The peripheral parenteral route is safe [60] and allows complementation of enteral
feeding, for those unable to achieve >50% of their caloric needs more than 7days
[5] via the oral/enteral route. Nevertheless, this may be a cumbersome but reasonable option in patients with inadequate oral/enteral intake on pod 3 [61].
Supplemented Parenteral Nutrition Mixtures
Glutamine and omega-3 fatty acids have been extensively used to enrich intravenous dietary mixtures. However, their use remains mostly optional, as long term
outcomes are not clearly improved [5, 62, 63]. Whenever possible, enteral feeding
should be adopted, even if only partially, as a more complete and affordable source
of a balanced diet.
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Complicated Course/Intensive Care Unit
Measured body weight (BMI≤30kg/m2), or corrected body weight (BMI>30kg/
m2) corresponding to BMI of 22kg/m2 only, have been advised to guide routine
dietary prescriptions. Indirect calorimetry is a reliable tool and should be employed
especially in critically ill cases [64, 65].
Late Postoperative Period, After Discharge
After undergoing extensive cancer surgery prolonged loss of 10% or 20% of previous body weight is frequently seen and can interfere not only with functional status,
but also with response to chemotherapy. This reinforces the importance enteral support in the subsequent months as prophylaxis, for those classied as high risk
[66, 67].
Therefore, dietary counseling and follow-up may be mandatory. If appropriate
additionally oral nutritional supplements (ONS) may be helpful [68].
With special regard to patients with upper gastrointestinal resections, several
studies have pointed out home enteral nutrition as superior to ONS.Counseling can
be employed as well, however home enteral nutrition is still endowed with more
predictable outcomes, generally including body mass index and skeletal muscle
mass index (SMI) [68–72]. Another more simple alternative to attenuate weight loss
during the rst year could be ONS providing up to 400kcal/day, but compliance of
the patients may be often limited [73].
The Bariatric Effect
Pharmacologic treatment may become more important in the future. In a recent
randomized trial ghrelin was postoperatively administered in patients undergoing
esophagectomy. A dosage dependent benecial effect of ghrelin infusion was
observed on erector spinae, a marker of muscle loss [74].
Based on the available positive data, a randomized nutritional trial may be debatable from an ethical point of view. Patient reported outcomes (PROMS) will provide
a measure for shared decision making regarding post-discharge enteral nutrition.
Overall, nutritional care may be considered an essential item of perioperative management in gastrointestinal cancer patients. While changes may often be “marginal”, underestimated cumulative effects will impact postoperative outcome [75].
Conict of Interest Arved Weimann: Lecture fees: Abbott, B. Braun, Fresenius Kabi, Falk
Foundation. Research grant: B. Braun, Mucos. Maria Wobith: Lecture fees: Fresenius Kabi.
Research grant: B Braun.
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