Nutrition Support or Weight Loss in our Surgical Patients: Why and When…

Update in General Surgery, 2013

Dr. Rupert Abdalian, MD.CM. FRCP(C)

Department of Medicine, Division of Gastroenterology

North York General Hospital, Toronto, Ontario

Disclosures

¤  I have no financial disclosures to declare

Overview

¤  To review the prevalence of malnutrition and obesity in our surgical patients

¤  To appreciate the impact of one’s nutritional status on surgical outcomes

¤  To develop a strategy for effective evaluation of one’s perioperative nutritional risk

¤  To discuss nutritional therapeutics aimed at improving surgical outcomes

Prevalence of Malnutrition Touchpoud Question 1

¤  In your opinion or experience, what proportion of patients presenting for surgery are “malnourished”?

A.  0-20%

B.  20-40%

C.  40-60%

D.  60-80%

E.  80-100%

Malnutrition in Our Patients

¤  15%: Community-dwelling elderly

¤  5-44% : Homebound patients

¤  20-65%: Hospitalized patients

¤  23-85%: Nursing home residents

¤  40%: Surgical patients

Sullivan et al. Ann Long Term Care 2000 Cederholm et al. Gerontology 1992 Bienia et al. J AM Geriatr Soc 1982 Costans et al. J Am Geriatr Soc 1992 Bristrian et al. JAMA 1976

Malnutrition Before Surgery: Causes/Contributors

¤  Decreased oral food intake

¤  Preexisting chronic disease

¤  Tumour cachexia

¤  Impaired absorption due to obstruction

¤  Previous bowel resections

¤  Low socioeconomic status

Maung A. et al. Surg Clin N Am 92

Malnutrition: Impact On Surgical Outcomes

¤  Increased susceptibility to local and systemic infections ¤  Poor wound healing ¤  Increased frequency of decubitus ulcers ¤  Functional and cognitive decline ¤  Higher risk of in-hospital delirium ¤  Delayed recovery from acute illness ¤  Higher morbidity/mortality ¤  Higher hospital readmission rates ¤  Increased health care costs

Studley et al. JAMA 1936 Elwyn et al. Ann Surg 1975 Kinney et al. Clin Chest Med 1986 Santos et al. Inf Dis Clin North Am 1994 Manous et al. Surg Clin North Am 1994

Consequences of Malnutrition

DISEASE SEVERITY

NUTRITIONAL PARAMETERS

MALNUTRITION

Reduction Intake Hypercatabolism Losses

Complication eg. infections

Physiology of Malnutrition

Decreased Intake or Absorption

How fast is fuel going in? Increased

Utilisation

How fast is fuel being used?

Protein-Calorie Malnutrition

How much fuel is in the tank?

Stroke Depression Dementia Decreased Concentration Poor self-esteem

Ischemic heart disease Hyperlipidemia Hypertension Diabetes Mellitus Obesity Hypoventilation Obstructive Sleep Apnea

Osteoarthritis Stress fractures Chronic pain Gout

Peripheral Vascular Disease Deep vein thrombosis

Gallstones Fatty liver Liver cirrhosis Gastrointestinal Cancers Pancreatitis

Pregnancy complications Menstrual irregularities Hirsuitism PCOS Gestational Diabetes

Obesity: Clinical Impact and Surgical Risk

Obesity: a North American Epidemic? Prevalence of BMI >25 in Canada 2009-10

Data Source: Diabetes in Canada, 2011, University of Ottawa

Obesity and Surgical Risk

¤  Obese patients undergoing colorectal surgery: ¤  Higher risk of wound infection and dehiscence ¤  Higher risk of incisional hernias ¤  Higher risk of stoma complications ¤  In IBD surgery, higher blood loss, OR time, conversion rates

¤  Patients with metabolic syndrome undergoing CABG: ¤  2.4% mortality (vs. 0.9%, p<0.001) ¤  Higher risk of vein graft occlusion within 5 years ¤  Higher all-cause and cardiovascular mortality at 10 years

¤  Obese patients undergoing percutaneous nephrolithotomy: ¤  Higher complications and need for re-interventions

¤  Obesity and Lumbar/Thoracic spine surgery ¤  High BMI is independent predictor of adverse outcomes

Yilmaz MB et al. Coron Artery Dis 2006 Kasai T et al. Circ J 2006 Kajimoto K et al. Circ J 2008 Tefekli A t al. J Endourol 2008 Patel N. t al. Neurosurg Spine 2007 Krane et al. J Am Coll Surg, 2013

Nutritional Assessment

Clinical History Family History Social History

Chronic disease Diabetes Smoking

Recent hospitalizations IBD Illicit substances

Infections Celiac Alcholism

Prior surgeries Cardiovascular disease Socioeconomic status

History of Present Illness

Weight loss history GI disturbances Dentition

Oral intake history Use of supplements Food intolerances

Peripheral manifestations of various macro/micronutrient deficiencies

Additional Nutrition Screening Tools

¤  Instant Nutritional Assessment (INA)

¤  Subjective Global Assessment (SGA)

¤  The DETERMINE questionnaire

¤  The Malnutrition Risk Scale (SCALES)

¤  The Mini-Nutritional Assessment (MNA)

¤  Malnutrition Universal Screening Tool (MUST)

¤  The Nutritional Risk Score (NRS)

Cerantola et al. Gastro Research & Practice 2011

Subjective Global Assessment (SGA)

¤ History: ¤ Weight loss- amount and % of usual body weight ¤ Dietary intake: degree of and duration of change ¤ Gastrointestinal symptoms ¤  Functional status compared to usual for patient ¤ Metabolic demands of underlying illness

¤ Physical exam ¤  Loss of subcutaneous tissue ¤ Muscle wasting ¤  Edema and ascites

SGA: Reproducibility

¤  More reproducible than any other nutritional measure

¤  Good interobserver agreement (kappa=0.78)

¤  Valid when comparing nurses to physicians and residents

¤  High sensitivity and specificity (0.82 and 0.72 respectively)

Detsky AS et al. JPEN 1987

Nutritional Assessment: Key Labs

¤  Serum albumin ¤  T ½ is approximately 3 weeks ¤  Good indicator of baseline nutritional status ¤  Serum pre-albumin, transferrin, carotene levels more reliable ¤  Emerging role for leptin measurements ¤  Other useful labs

¤  Lytes, creatinine ¤  Calcium profile ¤  Lymphocyte count ¤  Lipid profile ¤  Micronutrient levels

Reilly et al. JPEN 1988

Perioperative Nutrition Support: Indications

¤  Weight loss of 10-15% within 6 months

¤  BMI <18.5 kg/m2

¤  Serum albumin <30 g/L

¤  SGA Class C

¤  NRS score ≥ 3

Weimann et al. Clinical Nutrition 2006

Perioperative Nutritional Support Indicated in Special Groups

¤  Critically ill patients

¤  Burn patients

¤  Patients undergoing gastrointestinal surgery

¤  Patients with gastrointestinal cancers

¤  Patients with Inflammatory Bowel Diseases

¤  Elderly

¤  All well-nourished individuals?

Gianotti et al. Gastroenterology 2002

Early Postoperative Feeding

¤ Significant reductions in postoperative ¤ Mortality (RR 0.42) ¤  LOS (mean reduction 2.2 days) ¤ Postoperative infection (RR 0.45) ¤ No effect on anastomotic leak rate ¤ No effect on pneumonia rates

¤ Significant increase in vomiting (RR 1.270)

Lewis et al. Journal of Gastrointestinal Surgery 2009 Andersen et al. Cochrane Database of Systematic Reviews 2006

¤  Parenteral Nutrition (PN)

¤  Klein S, Jeejeebhoy K, et al. Clin Nutr 1997

Nutritional Intervention Outcomes:

¤  Parenteral Nutrition (PN)

¤  Klein S, Jeejeebhoy K, et al. Clin Nutr 1997

Nutritional Intervention Outcomes

TPN given to “malnourished” patients with gastrointestinal cancer for 7-10 days before surgery decreases postoperative

complications by 10%

Routine use of early postoperative TPN in malnourished general surgical patients is not recommended and increases

complications by 10%

Nutritional Intervention Outcomes: PN

¤  Koretz et al. Gastroenterology 2001

Nutritional Intervention Outcomes: PN

¤  Koretz R. et al. Gastroenterology 2001

Parenteral nutrition had no effect on postoperative mortality

There was no significant effect on

postoperative complication rates, although trends for all evaluated outcomes favored

parenteral nutrition over no nutrition

Perioperative PN: who benefits most?

¤  Malnoursihed patients with upper GI tract malignancies seem to benefit the most

¤  Müller JM et al. Preoperative parenteral feeding in patients with gastrointestinal carcinoma. Lancet 1982; 1:68.

¤  Müller JM et al. Indications and effects of preoperative parenteral nutrition. World J Surg 1986; 10:53.

¤  Bozzetti et al. Perioperative total parenteral nutrition in malnourished, gastrointestinal cancer patients: a randomized, clinical trial. JPEN J Parenter Enteral Nutr 2000; 24:7.

¤  Fan ST et al. Perioperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma. N Engl J Med 1994; 331:1547.

¤  Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. N Engl J Med 1991; 325:525.

Nutritional Intervention Outcomes Enteral Nutrition Support

¤  Koretz R. et al. AM J Gastro 2007

Nutritional Intervention Outcomes Enteral Nutrition (EN) Support

¤  Koretz R. et al. AM J Gastro 2007

EN associated with fewer infections (non wound-related) No significant impact on duration of hospitalization

What About Immunonutrition?

¤  Arginine

¤  Glutamine

¤  RNA nucleotides

¤  Omega-3 fatty acids

•  Lower infectious complications •  Shorter hospital stays •  Shorter ICU days •  Shorter “Ventilator” days •  No survival benefit •  Possible increased mortality in

septic patients!

Senkal M et al. Crit Care Med 1997 Senkal M et al. Arch Surg 1999 Gianotti L et al. Gastro 2002 Braga M et al. Arch Surg 2002 Okabayashi T et al. Dig Dis Sci 2007 Morlion BJ et al. Ann Surg 1998 Powell-Tuck J et al. Gut 1999

What about Probiotics?

¤  Reduction in severity and duration of infectious diarrhea

¤  Prevention of antibiotic-associated diarrhea

¤  Reduction in mortality in necrotizing enterocolitis

¤  Possible prevention of Clostridium difficile infection

¤  Reduction in bacterial infection rates in surgical, trauma and acute pancreatitis patients

¤  Still many questions remain unanswered Chen CC et al. Pediatr Infect Dis J 2010 Pedone CA et al. Int J Clin Pract 1999 Szajewska Het al. J Pediatr 2006 Alfaleh K et al. Neonatology 2009 Rayes N et al. Ann Nutr Metab 2010 Besselink MG et al. Lancet 2008

Lassen K et al. Archives of Surgery 2009 Cerantola et al. Gastro Research & Practice 2011

Preoperative Perioperative Postoperative

Counseling Prebiotics/probiotics Oral CHO load Fasting < 3 hours No bowel prep Omission of NG

NG removal Transverse incision Specialized nutrients

Prompt NG removal Minimize drains Immediate postop fluid and diet initiation Epidural analgesia Aggressive mobilization

Obesity: Minimizing Perioperative and Postoperative Risks

¤  Consider pre-surgical weight loss

¤  Weight loss should not be achieved at the expense of lean body mass

¤  Aggressive weight loss may not be appropriate in patients with a BMI <35

¤  Role of perioperative immunonutrition in obesity is not well known

Mullen JT, t al. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg 2009

Question No. 2: Practice Survey

¤  Do you routinely recommend or implement a supervised pre-surgical weight loss/meal replacement plan for obese patients prior to elective surgery?

A. Yes

B. No

Preoperative weight loss: Benefits of Very-Low Calorie Diets…

¤  Reduced risk for complications during surgery

¤  Shorter hospital stays

¤  Increased weight loss first year following surgery

¤  Improvement in fatty liver

¤  Decrease of intra abdominal fat mass

¤  Reduced operative time

¤  Improves protein levels for better healing

¤  Easier recovery and improved respiratory function

Colles SL. et al. Am J Clin Nutri 2006

Very-low Calorie Diets

¤  Optifast ® is an example:

¤  3 shakes/d provides 1906 kJ (456 kcal) 52 g protein, 7 g fat, and 45 g carbohydrate

¤  RDI of vitamins, minerals, and trace elements added as supplements

¤  250 g (up to 2 cups) of low- starch vegetables allowed

¤  Should be started at least 2 weeks and preferably 12 weeks preoperatively

¤  Average weight loss of 26 lbs (1.5-2% of body weight/week)

Colles SL. et al. Am J Clin Nutri 2006

Very-low Calorie Diets

¤  Adverse effects: ¤  Dry mouth, cold intolerance, constipation or diarrhea,

headache, dizziness, nausea, cramps, fatigue, hunger, menstrual changes and hair thinning

¤  Serious adverse events: ¤  acute gout, cholelithiasis, steatohepatitis, osteoporosis and

acute psychosis

Delbridge E et al. State of the science: VLED (Very Low Energy Diet) for obesity. Asia Pac J Clin Nutr. 2006;15 Suppl:49-54.

Summary

¤  Malnutrition is a common problem in surgery. Obesity is becoming prevalent as well

¤  Both are important risk factors for postoperative complications

¤  Validated malnutrition screening tools exist (NRS, SGA)

¤  Depending on the degree of malnutrition and the type of surgery, nutritional support should start within 14–7 days preoperatively

¤  If insufficient postoperative food intake is anticipated, early enteral tube feeding should be considered

¤  In obesity, pre-operative weight loss may be of value and VLCDs such as Optifast seem promising