ICU Management & Practice, ICU Volume 12 - Issue 3 - Autumn 2012
Malnutrition is frequently observed in upper
gastrointestinal cancer surgical patients; it is an independent predictor of
postoperative morbidity and mortality and leads to both increased length of
hospital stay and hospital costs. Consequently, every effort should be made to
apply nutritional support, including both standard enteral nutrition (EN) and
immunonutrition, as a complementary therapeutic limb in current oncological
treatment protocols.
Epidemiology and Consequences of Malnutrition
Gastric and oesophageal cancers are among the leading causes of cancer-related death worldwide due to late presentation and poor prognosis. In curable disease, a therapeutic strategy encompassing surgery, chemotherapy and/or chemoradiation is thus mandatory (Mariette et al. 2012). Malnutrition is frequently observed in 60–85% of surgical patients with an upper gastrointestinal cancer (Stratton et al. 2003) and is an independent predictor of postoperative morbidity and mortality, leading to increased length of hospital stay and hospital costs (Stratton et al. 2006). Many factors can affect nutritional status, particularly disease stage and the choice of treatment used (surgery, chemotherapy and/or radiotherapy) (Van Cutsem 2005). Nutritional support should therefore be used as a strong therapeutic weapon, which may be complementary to standard active oncological therapy.
Nutritional Interventions in Digestive Cancer Surgery
Nutritional support in oncology patients aims to prevent early death, decrease postoperative complications and improve quality of life. It should begin early and be a routine part of the treatment of cancer patients. Depending on patients’ individual needs, these goals may be achieved by giving patients nutritional recommendations and dietary advice, as well as by providing artificial nutrition using oral supplements, EN via a feeding tube, or parenteral nutrition (PN).
Dietary advice may be sufficient
when the patient is capable of consuming at least 75% of his or her nutritional
requirements to maintain good health and there is no radiotherapy, chemotherapy
or surgery scheduled. However, when these requirements are not met and dietary
advice is insufficient, a higher level of nutritional support must be
initiated. Oral supplementation should be used in cases of malnutrition or when
the patient is unable to consume at least 50–75% of his or her requirements by
means of conventional feeding for a period longer than five consecutive days.
In
moderate or severe malnutrition, or when patients are unable to consume at
least 50% of their requirements through conventional feeding for more than five
consecutive days (Lipman 1998; Braunschweig et al. 2001), enteral feeding is
required. The implementation of EN is recommended when the patient’s
gastrointestinal tract is functional as it appears to have better efficacy,
lower cost and cause less iatrogenic complications than PN (Mariette et al.
2005). In cases where swallowing is affected, for example in oesophageal
cancer, or if serious mucositis is expected, EN should be administered through
a nasogastric or nasoenteric tube for a duration of two to three weeks.
Alternatively, gastrostomy (in oesophageal cancer) and jejunostomy (in
oesogastric cancer) feeding may be administered for a duration of more than two
to three weeks (Mariette et al. 2005, Conference de consensus 1995). Figures 1
and 2 propose an algorithm for deciding upon the route of EN administration in
oesophageal and gastric cancers, respectively. In a recent review of our
experience with percutaneaous radiological gastrostomy (PRG) before surgery for
oesophageal cancer, we found a PRG complication rate of 3.4%, without any
incidence of metastatic inoculation and without any injury of the gastric
vascular arcade, thus not compromising subsequent gastric pull-up. Due to early
enteral feeding, outcomes of malnourished patients were similar to those of
non-malnourished patients (Tessier et al. 2012).
As other scientific societies
have done, the French Society of Digestive Surgery established guidelines,
graded from A to C, on perioperative nutritional support in GI cancer surgery
(Mariette et al. 2005), including the following suggestions:
• During the perioperative period, EN is not required in well-nourished patients, those with weight loss of <10% or in patients who can sustain an oral diet providing at least 60% of their needs within the week following surgery (Grade A).
• Preoperative nutrition is recommended in severely malnourished patients with weight loss ≥20% who will undergo major surgery (Grade A). The same approach seems to be beneficial for patients with moderate malnutrition (weight loss of 10–19%) (Grade B).
• Postoperative nutrition is recommended:
i. In all patients who benefited from preoperative nutrition (Grade A);
ii. In all malnourished patients who did not benefit from preoperative nutrition (Grade A);
iii. In patients who cannot resume an oral diet in the postoperative course due to surgical complications (Grade A), or in patients consuming <60% of the required diet within the week following surgery (Grade A); and
iv. In other patients for whom no unequivocal recommendation could be drawn (Grade B).
Immuno Nutrition
Major surgery leads to a decline in immune status, and an increase in postoperative mortality and rates of infectious morbidity. Enhancing immune function could help decrease such complications. In recent years, standard EN has been enhanced with nutrients whose specific purpose is to upregulate the host immune response, control the inflammatory response and improve nitrogen balance and protein synthesis following surgery. The immunonutrients used are glutamine, arginine, poly-unsaturated fatty acids (omega- 3), nucleotides, taurine, vitamins A, E, and C, beta-carotene and trace elements.
The use of immunonutrition in the surgical setting has been well
studied with over 28 randomised controlled trials showing that immunonutrition
is more efficient than standard isocaloric and isoenergetic nutrition in
significantly decreasing postoperative infectious morbidity, length of hospital
stay and healthcare costs (Gianotti et al. 2002, Beale et al. 1999).
However, there is a great degree
of heterogeneity in terms of nutritional status and the type of control used,
and in some studies samples were quite small. Despite this, the effect of
immunonutrition has generally been found to be beneficial, especially in
malnourished patients.
Numerous meta-analyses have assessed the evidence relating to the use
of immunonutrition in the surgical setting (Cerantola et al. 2011; Marimuthu et
al. 2012). The overall conclusion is that in surgical patients, a lower rate of
infectious complications and shorter hospital stay were associated with perioperative
immunonutrition, relative to standard EN.
Enteral immunonutrition lasting
five to seven days is recommended in the preoperative setting in all patients
who will benefit from oncological GI surgery (Grade A). In the postoperative
period, immunonutrition should be continued in all patients who were
malnourished in the preoperative period:
• For five to seven days, provided that there are no postoperative complications; or
• Until patients can consume an oral diet meeting at least 60% of their requirements (Grade A).
Putting the Perspective into Practice
It is known that:
(i) Immunonutrition is efficient in the perioperative period in oesophago-gastric cancers;
(ii) Both oesophageal and gastric cancer patients are frequently malnourished; and
(iii) Most patients with oesophago-gastric cancer will receive neoadjuvant chemo(radio)therapy that may compromise both nutritional and immune status.
Hence, routine immunonutrition may help to support immune and nutritional status during the neoadjuvant and perioperative treatment periods. To test this hypothesis, an ongoing European randomised controlled trial sponsorised by Nestle Health Science, with myself Prof. Mariette as Principal Investigator, is assessing the role of long-term administration of immunonutrition during the neoadjuvant and the surgical phases to improve quality of life, to reduce postoperative morbidity and to reduce neoadjuvant treatment toxicities (NCT01423799).
Conclusion
Knowledge of the nutritional status of patients with oesophago-gastric cancer is essential, not only in identifying malnourished and non-malnourished patients, but also in allowing treatment adaptations along each step of the multimodal oncological treatment path. Whether or not the treatment procedure is surgical, all patientscould benefit from nutritional support duringoncologic treatments. Preoperative immunonutritionlasting five to seven days isproposed for both malnourished and nonmalnourishedpatients with oesophago-gastriccancer, along with artificial nutritionfor at least seven days after surgery for malnourishedpatients. Dietary counsellingshould be provided to all patients receivingchemotherapy and/or radiotherapy.Surgeons play a key role in including andapplying nutritional support as a strongtherapeutic weapon in the oncological therapeuticstrategy for GI cancer patients.