BACKGROUND: Postoperative outcomes were studied in relation to adverse nutritional risk (body mass index (BMI) below 20 kg/m(2)), advanced age (80 years or more) and co-morbidity (American Society of Anesthesiologists (ASA) grade III-IV) in patients undergoing colorectal resection within an enhanced recovery after surgery programme. METHODS: Outcomes were audited prospectively in 1035 patients. Morbidity and mortality were compared with those predicted using the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, and a multivariable model was used to determine independent predictors of outcome. RESULTS: Postoperative morbidity was lower than predicted (observed to expected 0.68; P < 0.001). Independent predictors of delayed mobilization were ASA III-IV (P < 0.001) and advanced age (P = 0.025). Prolonged hospital stay was related to advanced age (P = 0.002), ASA III-IV (P < 0.001), male sex (P = 0.037) and rectal surgery (P < 0.001). Morbidity was related to ASA III-IV (P = 0.004), male sex (P = 0.023) and rectal surgery (P = 0.002). None of the factors predicted 30-day mortality. CONCLUSION: Age and nutritional status were not independent determinants of morbidity or mortality. Pre-existing co-morbidity was an independent predictor of several outcomes.

Determinants of outcome after colorectal resection within an enhanced recovery programme.

Patients undergoing neoadjuvant therapy for esophageal cancer are at a high risk for malnutrition due to the effects of chemoradiation, dysphagia, and malignancy induced cachexia. Preparation for esophagectomy requires careful assessment of nutritional risk and adequate supplementation as indicated. Supplementation via the enteral route is preferred to the parenteral route but requires feeding tube placement. Endoscopically placed silicone stents have also shown promise as a means to alleviate malnutrition and avoid invasive feeding tubes.

Nutritional management during neoadjuvant therapy for esophageal cancer.

Esophageal cancer has traditionally been a disease with poor long term outcomes in terms of both survival and quality of life In combination with surgical and pharmacologic therapy, nutrition support has been demonstrated to improve patient tolerance of treatment, quality of life, and longterm outcomes An aggressive multi-disciplinary approach is warranted with nutrition support remaining a cornerstone in management Historically, nutrition support has focused on adequate caloric provision to prevent weight loss and allow for tolerance of treatment regimens Alterations in metabolism occur in these patients making their use of available calories inefficient and the future of nutritional support may lie in the ability to alter this deranged metabolism The purpose of this article is to review the current literature surrounding the etiology, treatment, and role of nutrition support in improving outcomes in esophageal cancer

Nutrition Therapy Issues in Esophageal Cancer

Background: Each year approximately 3000 patients in the United Kingdom undergo surgery for esophagogastric cancer. Jejunostomy feeding tubes, placed at the time of surgery for early postoperative nutrition, have been shown to have a positive impact on clinical outcomes in the short term. Whether feeding out of hospital is of benefit is unknown. Local experience has identified that between 15 and 20% of patients required ‘rescue’ jejunostomy feeding for nutritional problems and weight loss while at home. This weight loss and poor nutrition may contribute to the detrimental effect on the overall quality of life (QoL) reported in these patients. Methods/Design: This randomized pilot and feasibility study will provide preliminary information on the routine use of jejunostomy feeding after hospital discharge in terms of clinical benefits and QoL. Sixty participants undergoing esophagectomy or total gastrectomy will be randomized to receive either a planned program of six weeks of home jejunostomy feeding after discharge from hospital (intervention) or treatment-as-usual (control). The intention of this study is to inform a multi-centre randomized controlled trial. The primary outcome measures will be recruitment and retention rates at six weeks and six months. Secondary outcome measures will include disease specific and general QoL measures, nutritional parameters, total and oral nutritional intake, hospital readmission rates, and estimates of healthcare costs. Up to 20 participants will also be enrolled in a qualitative sub-study that will explore participants’ and carers’ experiences of home tube feeding. The results will be disseminated by presentation at surgical, gastroenterological and dietetic meetings and publication in appropriate peer review journals. A patient-friendly lay summary will be made available on the University of Leicester and the University Hospitals of Leicester NHS Trust websites. The study has full ethical and institutional approval and started recruitment in July 2012.

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Six weeks of home enteral nutrition versus standard care after esophagectomy or total gastrectomy for cancer: study protocol for a randomized controlled trial

..............................................................................................xx Introduction......................................................................................... 1 1.0 Literature Review..........................................................................4 1.1 Upper Gastrointestinal Cancers....................................................................4 1.1.0 Introduction................................................................................................. 4 1.1.1 Oesophageal Cancer................................................................................. 5 1.1.2 Stomach Cancer.......................................................................................10 1.1.3 Pancreatic Cancer....................................................................................12 1.1.4 The Management of Upper Gastrointestinal Cancers............................14 1.1.5 Summary of Section..................................................................................15 1.2. Malnutrition: Incidence and Causes......................................................... 16 1.2.0 Introduction................................................................................................16 1.2.1 The Extent of Malnutrition........................................................................ 16 1.2.2 Causes of Malnutrition in the Surgical Patient........................................ 19 1.2.3 Summary of Section................................................................................ 25 1.3 Nutritional Assessment................................................................................26 1.3.0 Introduction................................................................................................26 1.3.1 Weight........................................................................................................ 26 1.3.2 Determination of Body Stores................................................................. 27 1.3.3 Skeletal Muscle Function......................................................................... 29 1.3.4 Biochemical Assessment......................................................................... 30 1.3.5 Nitrogen Balance...................................................................................... 32 1.3.6 Dietary Assessment..................................................................................32 1.3.7 Nutritional Assessment Indexes.............................................................. 33 1.3.8 Summary of Section..................................................................................34 1.4 The Consequences of Malnutrition............................................................ 35 1.4.0 Introduction................................................................................................35 1.4.1 Body Composition.....................................................................................35 1.4.2 Organ Function......................................................................................... 37 1.4.3 Psychological Function............................................................................ 41 1.4.4 Health Related Quality of L ife ..................................................................42 1.4.5 Wound Healing......................................................................................... 42 1.4.6 Malnutrition and Surgical Risk..................................................................43 1.4.7 The Economic Impact of Malnutrition......................................................46 1.4.8 Summary of Section..................................................................................47 1.5 Nutritional Support........................................................................................ 48 1.5.0 Introduction................................................................................................48 1.5.1 Nutritional Support: Impact on Nutritional Outcome...............................50 1.5.2 Nutritional Support and Physiological Function...................................... 52 1.5.3 Nutritional Support and Health Related Quality of Life............................65 1.5.4 Summary of Section..................................................................................66 1.6 Nutritional Support and Clinical Outcome in Surgical Patients............67 1.6.0 Introduction................................................................................................67 1.6.1 Current Use of Nutritional Support in the United Kingdom......................67 1.6.2 Literature Search Strategy.......................................................................68 1.6.3 Pre-operative Nutritional Support versus Post-operative Nutritional Support................................................................................................................69 1.6.4 Enteral Nutrition versus Parenteral Nutrition.......................................... 69 1.6.5 Peri-operative Parenteral Nutrition versus Standard Hospital care 70 1.6.6 Post-operative Parenteral Nutrition versus Standard Hospital Management....................................................................................................... 77 1.6.7 Peri-operative Enteral Nutrition versus Parenteral Nutrition....................81 1.6.8 Early Enteral Nutrition versus Standard hospital management.............. 89 1.6.9 Immuno-enhanced Enteral Nutrition..................................................... 111 1.6.10 Pre-operative Enteral Nutrition.............................................................113 1.6.11 Limitations with Clinical Trials in Nutritional Support in Surgical Patients..............................................................................................................114 1.6.12 Consensus of Clinical Trials and Meta-analysis to date......................116 1.6.13 Summary of Section..............................................................................116 1.7 The Design of Clinical Trials.....................................................................117 1.7.0 Introduction..............................................................................................117 1.7.1 Contrasting Explanatory with Pragmatic Randomised Clinical Trials. 120 1.7.2 Choice of intervention and Control Groups...........................................121 1.7.3 Sample Size and Power Calculation..................................................... 121 1.7.4 Randomisation.........................................................................................122 1.7.5 Blinding.................................................................................................... 124 1.7.6 Ethical Issues...........................................................................................124 1.7.7 Frameworks for Conducting Clinical Trials............................................125 1.7.8 Summary of Section................................................................................ 127 2. Original Work: A Randomised Controlled Trial of Early Enteral Nutrition versus Standard Management in patients undergoing Major Upper Gastrointestinal Resection for Malignancy........................................................................................128 2.1 Methods of the Main Study.........................................................................129 2.1.0 Introduction..............................................................................................129 2.1.1 Aim of the Trial.........................................................................................129 2.1.2 Primary (null) Hypothesis........................................................................129 2.1.3 Primary Objective.................................................................................... 129 2.1.4 Secondary Objectives.............................................................................130 2.1.5 Conceptual Map.......................................................................................131 2.1.7 Reliability and Validity of the Study....................................................... 153 2.1.8 Summary.................................................................................................. 154 2.2 Study Procedures for the Randomised Controlled Trial.......................155 2.2.0 Introduction..............................................................................................155 2.2.1 Sample Population.................................................................................. 155 2.2.2 Registration and initiation of the Clinical T ria l...................................... 156 2.2.3 Recruitment of Patients into the Trial.................................................... 158 2.2.4 Non-Interventional phase....................................................................... 160 2.2.5 Interventional Phase...............................................................................161 2.2.6 Post Operative Stage Data Collection................................................... 163 2.2.7 Summary of Methods..............................................................................166 2.3 Data Management.........................................................................................167 2.3.0 Introduction..............................................................................................167 2.3.1 Quality Control.........................................................................................167 2.3.2 Data Analysis...........................................................................................169 2.3.3 Summary.................................................................................................. 172 3. Results..........................................................................................173 3.0 Introduction............

A multi-centre randomised controlled trial of early enteral nutrition versus standard management in patients undergoing major resection for gastrointestinal cancer

INTRODUCTION Patients with oesophageal carcinoma are at high risk of malnutrition. The aim of this study was to assess current practice for the nutritional management of patients following surgery for oesophageal carcinoma. PATIENTS AND METHODS A postal questionnaire was sent to 82 dietetic departments of those hospitals in England identified as major centres for upper gastrointestinal surgery. RESULTS Of the 66 (80%) responses received, 22 (33%) centres routinely perform pre-operative nutritional screening/assessment on oesophageal carcinoma patients. Centres with dietetic support dedicated to these patients are more likely to perform a pre-operative nutritional assessment (n = 17; 55%) than those without (n = 5; 14%; P < 0.001; χ 2 = 12.17). Pre-operative nutritional support is routinely provided in only 11 (17%) centres with the majority of centres (n = 50; 75%), providing it if patients are considered malnourished only. A total of 47 (70%) centres routinely provide postoperative nutritional support with jejunal feeding being the most commonly chosen route. Dedicated dietetic support is provided at 31 (47%) centres. Those centres with a dedicated dietitian are more likely to provide early postoperative nutritional support (n = 27; 87%) than those without (n = 20; 57%; P = 0.007; χ 2 = 7.195) and more likely to review patients routinely following discharge from hospital (n = 25 [81%] with a dietitian versus n = 17 [49%] without; P = 0.007; χ 2 = 7.2). CONCLUSIONS The nutritional management of patients following surgery for upper gastrointestinal carcinoma is not uniform with practice varying considerably between centres. Those centres with a dedicated dietitian are more likely to assess patients’ nutritional status and provide nutritional support.

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Papers

An investigation into the current peri-operative nutritional management of oesophageal carcinoma patients in major carcinoma centres in England.