Adverse perioperative outcomes among patients undergoing gastrointestinal cancer surgery: Quantifying attributable risk from malnutrition.

BACKGROUND: Preoperative malnutrition adversely impacts perioperative outcomes among patients with gastrointestinal (GI) cancer. The attributable risk (AR) that nutrition status contributes towards negative outcomes is poorly understood. METHODS: Adults undergoing GI cancer surgeries were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2017). Emergency surgeries, outpatients, and cases with an American Society of Anesthesiologists status above III were excluded. Adjusted multivariable models were constructed to determine the associations between markers of nutrition status (body mass index, >10% weight loss in last 6 months, functional status, and serum albumin level) and adverse perioperative outcomes (presence and number of complications, death, 30-day readmission, and length of stay). Predictive accuracy statistics and population AR (PAR) were determined. RESULTS: The final sample included 78,662 cases. Patients with >10% weight loss 6 months preceding surgery (compared with those who did not), had a significantly increased risk of complications (Relative Risk = 1.28; 95% CI, 1.20-1.37) and odds of death (odds ratio [OR] = 1.37; 95% CI, 1.18-1.59). A totally dependent functional status (compared with independent status) was associated with a 3.3-times higher odds of death (OR = 3.30; 95% CI, 1.53-7.15). Multivariable models were not predictive of adverse outcomes; PAR from the markers ranged 1%-2%. CONCLUSION: Ten percent weight loss in preceding 6 months was associated with increased risk of adverse perioperative outcomes among adults undergoing GI cancer surgery. The contribution of nutrition status markers to surgical outcomes as assessed by PAR was small (1%-2%), a finding not previously reported. Future intervention studies should include validated nutrition risk markers, control for effects of perioperative variables, and evaluate PAR within the immediate/long-term postoperative periods.

Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer.

BACKGROUND: Unintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer-associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients. METHODS: We retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017-August 2019) were compared with patients who underwent resection before protocol implementation (January 2015-July 2017). Patients undergoing surgery during the month of protocol initiation were excluded. RESULTS: Of the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30-day readmission, or mortality rates between groups. CONCLUSIONS: Results of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.

Structured Review of the Value Added by the Registered Dietitian to the Care of Gastrointestinal Cancer Patients.

BACKGROUND: Malnutrition is common among patients with gastrointestinal (GI) cancer and contributes to their morbidity and mortality. Nutrition interventions provided by a registered dietitian (RD) or dietitian may improve nutrition status and patient outcomes; however, there are few studies that attempt to define the contribution of the dietitian to these outcomes. OBJECTIVE: Our objective was to identify the value added by the dietitian to the care of patients with GI malignancies. METHODS: A structured review was conducted using PubMed, CINAHL, Scopus, Medline, and ClinicalKey (all dates up to December 2019). Patients included those with GI malignancies undergoing cancer treatment and receiving intervention provided by an dietitian. Intervention included provision of medical nutrition therapy by an dietitian in the form of counseling, diet advice, oral nutritional supplementation, and enteral and/or parenteral nutrition-directed recommendations. RESULTS: Ten relevant studies were identified and included for analysis. Studies suggest that nutrition counseling by a dietitian during cancer treatment results in improved weight maintenance and energy intake. Preoperative nutrition counseling and inpatient dietitian intervention seem to decrease length of stay after major surgery. CONCLUSIONS: We conclude that the dietitian, especially when providing nutrition counseling, improves the nutrition-related outcomes of patients with GI malignancies. The small number of existent studies highlights the need for further research to define the impact of dietitian interventions and to determine which particular interventions best improve patient outcomes.

Child witnesses to domestic violence: a meta-analytic review.

This meta-analysis examined 118 studies of the psychosocial outcomes of children exposed to interparental violence. Correlational studies showed a significant association between exposure and child problems (d = -0.29). Group comparison studies showed that witnesses had significantly worse outcomes relative to nonwitnesses (d = -0.40) and children from verbally aggressive homes (d = -0.28). but witnesses' outcomes were not significantly different from those of physically abused children (d = 0.15) or physically abused witnesses (d = 0.13). Several methodological variables moderated these results. Similar effects were found across a range of outcomes, with slight evidence for greater risk among preschoolers. Recommendations for future research are made, taking into account practical and theoretical issues in this area.