Nutritional Prehabilitation in Patients Undergoing Abdominal Surgery-A Narrative Review.

Malnutrition plays a crucial role as a risk factor in patients undergoing major abdominal surgery. To mitigate the risk of complications, nutritional prehabilitation has been recommended for malnourished patients and those at severe metabolic risk. Various approaches have been devised, ranging from traditional short-term conditioning lasting 7-14 days to longer periods integrated into a comprehensive multimodal prehabilitation program. However, a significant challenge is the considerable heterogeneity of nutritional interventions, leading to a lack of clear, synthesizable evidence for specific dietary recommendations. This narrative review aims to outline the concept of nutritional prehabilitation, offers practical recommendations for clinical implementation, and also highlights the barriers and facilitators involved.

Malnutrition screening with Nutritional Risk Screening 2002 prior to assessment as part of GLIM criteria in patients undergoing major abdominal surgery for gastrointestinal cancer.

INTRODUCTION: For diagnosing malnutrition as an important modifiable risk factor in surgical cancer patients, GLIM criteria offer a standardised diagnostic pathway. Before assessing malnutrition it is suggested to screen for malnutrition with an implemented screening tool, i.e. the NRS-2002. Validated data regarding the applied screening tool and its relevance for predicting outcome parameters in surgical patients is sparse. METHODS: 260 patients undergoing major abdominal surgery for cancer were retrospectively analysed. Between January 2017 and December 2019, patients were prospectively screened for malnutrition with the Nutritional Risk Score 2002 (NRS). Irrespective of their screening result malnutrition was assessed with GLIM criteria using CT scan at lumbar level 3 for measuring skeletal muscle mass (GLIM MMCT). Patients with negative screening results (NRS ≤ 2) were analysed regarding their malnutrition assessment and outcome parameters. RESULTS: 34 of 67 patients with NRS ≤ 2, posing no risk for malnutrition, were diagnosed malnourished according to GLIM MMCT (n=34, 50.7%). 19 patients (55.9%) with NRS ≤ 2 and malnutrition according to GLIM had at least one complication, 12 patients (35.3%) had a severe complication (Clavien-Dindo Grade ≥ 3a), in 26.5% re-laparotomy was necessary, re-admission within one month in 20.6% of patients, and length of hospital stay was 18.76 ± 12.66, which was in total worse in outcome compared to the whole study group (n=260). Patients with NRS ≤ 2 but diagnosed malnourished by GLIM were at significant higher risk to develop a severe complication (OR 2.256, 95% CI 1.038 - 4.9095, p=0.036) compared to patients with NRS ≤ 2 but not being diagnosed malnourished. The risk for overall complications was significantly increased in patients with malnutrition diagnosed by the GLIM criteria using MMCT (OR 2.028, 95% CI 1.188-3.463, p= 0,009). Patients screened at risk with NRS ≥ 3 and diagnosed malnourished by GLIM were also at significant higher risk for developing complications (OR 1.728, 95% CI 1.054 - 2.832, p=0.029). CONCLUSION: GLIM MMCT is suitable for diagnosing malnutrition and estimating postoperative risk in gastrointestinal cancer patients. Nutritional assessment only in patients with NRS > 2 may bear the risk to miss malnourished patients with high risk for poor clinical outcome. In every patient undergoing major cancer surgery regular assessment of nutritional status regardless of screening result should be performed exploiting CT body composition analysis.

ESPEN Guidelines on Clinical nutrition in surgery - Special issues to be revisited.

The ESPEN Guidelines on Clinical nutrition in Surgery from 2017 has been also available as practical guideline with algorithms since 2021 (www.espen.org). An update will be perfomed in the near future. This review focuses on recent data with regard to special issues and topics to be revisited in the guidelines: These are nutritional assessment, sarcopenic obesity, prehabilitation, oral/enteral immunonutrition, postoperative oral supplementation in hospital and after discharge.

Evaluation of malnutrition in patients undergoing major abdominal surgery using GLIM criteria and comparing CT and BIA for muscle mass measurement.

BACKGROUND & AIMS: GLIM criteria have become a worldwide standard for diagnosing malnutrition. They emphasize the measurement of muscle mass but do not provide clear recommendations for the use of different diagnostic tools and cut-offs. Measurements of body composition by using computerized tomography (CT) and bioelectrical impedance analysis (BIA) are both easily accessible in hospitalized patients. However, there is sparse data regarding the comparison for GLIM diagnosis of malnutrition and its prognostic impact for postoperative outcome in patients undergoing major abdominal surgery for cancer. METHODS: We retrospectively analysed 260 patients undergoing major abdominal surgery between January 2017 and December 2019. Patients were prospectively screened and assessed for malnutrition with Nutritional Risk Score (NRS) and Subjective Global assessment (SGA). Body composition was analysed with CT scan and BIA within 30 days before surgery. GLIM criteria were retrospectively determined referring to the Fat free Mass from BIA (FFMBIA) and Muscle Mass from axial CT scan at lumbar level 3 (MMCT). The prevalence of GLIM - malnutrition according to BIA and CT was evaluated. Multivariate logistic regression analysis was used to determine association between malnutrition and outcome parameters. ROC-curves specified sensitivity and specificity of the different tools and areas under the curve were calculated. RESULTS: From 260 patients in total, 179 patients (68.8%) had a confirmed malnutrition according to MMCT, 178 patients (68.5%) were malnourished according to SGA (grade B or C), whereas 66 patients (25.4%) were diagnosed with malnutrition using FFMBIA. The risk for developing a complication was significant associated with both methods, FFMBIA (OR 2.116, 95% CI 1.185-3.778, p = 0.01) and MMCT (OR 2.028, 95% CI 1..188-3.463, p = 0.009). Sensitivity for the prediction of overall complications was: MMCT 76.3%, FFMBIA 31.9%, and SGA 73.3%; specificity: MMCT 40.0%, FFMBIA 81.6%, and SGA 36.8%. CONCLUSION: When using GLIM criteria, the method for measuring muscle mass is pivotal resulting in considerable differences in prevalence, sensitivity, and specificity. GLIM criteria are predictive for the risk of developing complications in patients undergoing major abdominal surgery. With the pre-existing cut-offs, BIA seems to diagnose patients at an more advanced stage of malnutrition and indicates an advanced deterioration of nutritional status.

Postoperative Nutrition Management: Who Needs What?

Background: Early oral feeding after major abdominal surgery has been clearly shown to be safe and not a risk factor for anastomotic dehiscence. Within the Enhanced Recovery after Surgery protocol, it is the nutritional plan A. Nonetheless, one must consider that postoperative protein and energy requirements will often be not covered by oral food intake alone. Because nutritional status has been shown to be a prognostic factor in patients undergoing major abdominal surgery, the preoperative identification of patients at risk may be mandatory. Malnutrition may be underestimated in an overweight society. With special regard to patients with cancer and those with preexisting malnutrition, an accumulating caloric gap may be harmful in the early and late postoperative periods. Furthermore, complications requiring reoperation and intensive care treatment may occur. Summary: Therefore, a plan B for postoperative nutrition therapy is needed, using preferentially the enteral route. The European Society for Clinical Nutrition and Metabolism recently addressed perioperative nutritional management and the indications for enteral and even parenteral supplementation to achieve caloric requirements in the postoperative course. In the first months after surgery, persisting weight loss is common in patients with upper gastrointestinal resections, even in those with an uncomplicated course. This may delay the initiation of adjuvant chemotherapy, increase toxicity, and worsen long-term outcomes.

Oral Nutritional Supplements and Enteral Nutrition in Patients with Gastrointestinal Surgery.

Nowadays, patients undergoing gastrointestinal surgery are following perioperative treatment in enhanced recovery after surgery (ERAS) protocols. Although oral feeding is supposed not to be stopped perioperatively with respect to ERAS, malnourished patients and inadequate calorie intake are common. Malnutrition, even in overweight or obese patients, is often underestimated. Patients at metabolic risk have to be identified early to confirm the indication for nutritional therapy. The monitoring of nutritional status postoperatively has to be considered in the hospital and after discharge, especially after surgery in the upper gastrointestinal tract, as normal oral food intake is decreased for several months. The article gives an overview of the current concepts of perioperative enteral nutrition in patients undergoing gastrointestinal surgery.

Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period.

The metabolic risk for patients undergoing abdominal cancer resection increases in the perioperative period and malnutrition may be observed. In order to prevent further weight loss, the guidelines recommend for high-risk patients the placement of a needle catheter jejunostomy (NCJ) for supplementing enteral feeding in the early and late postoperative period. Our aim was to evaluate the safety of NCJ placement and its potential benefits regarding the nutritional status in the postoperative course. We retrospectively analyzed patients undergoing surgery for upper gastrointestinal cancer, such as esophageal, gastric, and pancreato-biliary cancer, and NCJ placement during the operation. The nutritional parameters body mass index (BMI), perioperative weight loss, phase angle measured by bioelectrical impedance analysis (BIA) and the clinical outcome were assessed perioperatively and during follow-up visits 1 to 3 months and 4 to 6 months after surgery. In 102 patients a NCJ was placed between January 2006 and December 2016. Follow-up visits 1 to 3 months and 4 to 6 months after surgery were performed in 90 patients and 88 patients, respectively. No severe complications were seen after the NCJ placement. The supplementing enteral nutrition via NCJ did not improve the nutritional status of the patients postoperatively. There was a significant postoperative decline of weight and phase angle, especially in the first to third month after surgery, which could be stabilized until 4-6 months after surgery. Placement of NCJ is safe. In patients with upper gastrointestinal and pancreato-biliary cancer, supplementing enteral nutrition during the postoperative course and continued after discharge may attenuate unavoidable weight loss and a reduction of body cell mass within the first six months.

Predictors of New Cerebral Microbleeds in Patients with Antiplatelet Drug Therapy.

BACKGROUND: Cerebral microbleeds (CMB) are associated with an increased risk for ischemic and especially hemorrhagic stroke. The aim of the present study is to identify patients at high risk for the development of new CMB after initiation of an antiplatelet drug therapy. METHODS: Patients received magnetic resonance imaging (MRI) within 1 week after initiation of an antiplatelet drug treatment due to a first ischemic stroke (n = 58) and after a follow-up period of 6 months (n = 40). We documented the presence and the number of CMB at baseline and follow-up and analyzed the influence of possible risk factors including vascular risk factors, stroke etiology, and number of CMB at baseline using stepwise logistic regression and Spearman's correlation coefficient. We compared progression rates of CMB in relation to each risk factor using the Mann-Whitney U-test. RESULTS: The logistic regression model could correctly predict the presence of CMB in 70.7% of patients at baseline and 80% at follow-up. The model correctly identified 85% of patients with new CMB. We observed progression of CMB in 40% of the patients. The overall progression rate was .8 CMB per patient. The progression rate was significantly influenced by age more than 70 years and atherothrombotic stroke. The number of new CMB correlated significantly with the number of CMB at baseline. CONCLUSIONS: We found several predictors of CMB after initiation of antiplatelet drug therapy. The results help to identify patients who need closer monitoring and thorough control of risk factors in order to lower the risk of new CMB and associated complications.