Effectiveness of Intensive Perioperative Nutrition Therapy Among Adults Undergoing Gastrointestinal & Oncology Surgery

Malnutrition is well reported and common in surgery patients. Surgery itself leads to inflammation corresponding with the extent of the surgical trauma, and leads to a metabolic stress response. The existing research suggests that patients undergoing surgery for upper gastrointestinal or colorectal cancer are particularly at risk of malnutrition. Recent research from Malaysia shows almost similar findings from previous studies which is about 29.1% of surgical patients were malnourished and shows increase length of hospital stay, higher rate of surgical site infection and mortality.

Nutrition requirement for surgery is higher if compared with normal requirement in order to support speedy recovery. However, most of the patients especially cancer patients do unable to achieve even 50% energy requirement before operation. This will cause further depletion of nutritional status of patient. In conjunction with this, patients with suboptimal nutritional status pre-operatively will have a higher risk of postoperative complications. Interestingly, one of Malaysian study shows significant number of post-surgery complications compared to pre-surgery which was associated to the poor level of nutrition. The success of surgery does not depend exclusively on technical surgical skills but also on metabolic intervention therapy, taking into account the ability of patient to carry a metabolic load and to provide appropriate nutrition support. In fact, in patient with cancer, management during perioperative period may be crucial for long term outcome.

Nutrition therapy is the provision of nutrition or nutrients either orally (regular diet, therapeutic diet, e.g. fortified food, oral nutritional supplements) or via enteral nutrition (EN) or parenteral nutrition (PN) to prevent or treat malnutrition. Dietary advice or nutrition counselling is part of a nutrition therapy. In the surgical patient, the indications for nutritional therapy are prevention and treatment of catabolism and malnutrition. This affects mainly the perioperative maintenance of nutritional state in order to prevent postoperative complications. It is strongly recommended not to wait until severe disease-related malnutrition has developed, but to start nutrition therapy early, as soon as a nutritional risk becomes apparent.

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery e.g. for cancer. In addition, appropriate perioperative nutrition therapy has been shown on improvement of perioperative outcomes especially in gastrointestinal and oncologic surgical patients.

Early nutrition intervention or perioperative EN is optimising patient's nutritional status so that their bodies can receive optimal effects during surgical. The general indications for nutritional support therapy in patients undergoing surgery are the prevention and treatment of undernutrition, i.e. the correction of undernutrition before surgery and the maintenance of nutritional status after surgery, when periods of prolonged fasting and/or severe catabolism are expected. Morbidity, length of hospital stay, and mortality are considered principal outcome parameters when evaluating the benefits of nutritional support.

According to The European Society for Clinical Nutrition and Metabolism (ESPEN) Guidelines 2017, perioperative EN support will be indicated, when patient is unable to eat for more than 7 days preoperatively and in patient who cannot maintain oral intake more than 60-75% of recommended intake for more than 10 days. In addition, to most gastrointestinal surgeons, pre-operative nutritional support refers to a period of administration of supplementary calories, by enteral or parenteral route, prior to performing surgery in order to correct malnutrition and reduce the incidence of post-operative complications.

Maintenance or improvement in nutrition status is the key goal of medical nutrition therapy for individuals undergoing surgery. Although many patients tolerate therapy well and experience few or no post-operative complication, malnutrition is still a common condition, which affects quality of life and survival for many patients. To maintain or improve nutritional status, all barriers associated with oral intake should be aggressively addressed unless aggressive intervention is not warranted. Nutrition intervention are purposely-planned actions designed with the intent of changing behaviour, risk factor, environmental condition, or the aspect of health status for an individual, a target group, or the general population. The intervention involves dietetic strategies and strategies to meet the needs of surgical patients, which concentrate on helping patients to maintain and/or improve nutritional intake in the presence of symptoms, regain body weight or minimise weight loss and reduce post-operative complications.

Normally, the personalised dietetic intervention consists of strategies to modify the amount of food taken, either through advice or by provision of additional foods as snacks, fortification of foods to increase the energy and nutrient content; and the prescription of oral nutritional supplements. Ravasco and colleagues (2005) suggested that this type of intervention should be promptly carried out as early as possible as soon as any risk is identified and in close collaboration with the patient, along with monitoring of compliance to the diet.

Patients undergoing major surgery showed a consistently high prevalence of pre-operative malnutrition (50 -80%) and it is associated with higher post-operative mortality, morbidity, cost and longer hospital stay. Patients with severe nutritional risk in surgical patients with oral feeding, some improvements were shown in shortened duration of hospital stay and flatus, and some of wound and infectious complications. Particularly decreased hospital stay in patients is significant for prevention of increasing further complications and reduction in burden of hospital stay costs.

Studies show high prevalence of malnutrition or high nutritional risk during hospital admission but this is rarely assessed in the clinical setting especially patients who will undergone elective surgery. Surprisingly, a study in Latin American countries showed that nutrition information was included in the medical records of only 23% of patients and that 9% of patients received nutrition therapy, whereas up to 50% of patients were malnourished. Globally, hospital malnutrition is under-recognised, under-diagnosed and under-treated by health care professional, which may potentially of omission of nutritional assessments in routine patient assessment on admission. The use of nutrition screening tools i.e. Malnutrition Screening Tool (MST) or Nutritional Risk Screening (NRS) to identify surgical patient at risk of malnutrition are still low in Malaysian hospital setting. Currently, patient who has been scheduled to go for surgery will be admitted to the ward only two to three days prior to the operation date. Some of them are not screened and referred to dietitian for nutritional status assessment and intervene malnutrition before operation. Even these patients at risk of malnutrition or malnourished prior to the surgery. Two to three days admission prior to operation date is not enough to optimise their nutritional status when patient is having poor oral intake. And most of the time, surgery treatment needs to be delayed due to the nutritional status of these patients are not optimised prior surgery.

The use of oral nutritional supplementation (ONS), together with voluntary food intake, as a means of providing nutritional support to surgical patients is more straightforward; these products are easy to administer, comparatively cheap, free from complication and, with the range of flavours now available, palatable. Importantly, postoperative ONS has been shown to have a beneficial effect on outcome after surgery. Most studies have investigated the effect of nutrition therapy to look into the post-operative complication which ONS were prescribed during the pre-operative but not after the surgery. Conversely, there are limited data on the effects of perioperative nutrition therapy before and after surgery especially in Malaysia. Therefore, further research on the process of nutrition management, from screening/assessment on admission to nutritional support and monitoring needs to be conducted in this area in order to find good practices and should be mandated in routine patient care regardless of disease type.