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Assessment of Nutritional Status and Nutrition Impact Symptoms in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study.
Deftereos, I, Yeung, JMC, Arslan, J, Carter, VM, Isenring, E, Kiss, N, On Behalf Of The Nourish Point Prevalence Study Group,
Nutrients. 2021;(10)
Abstract
BACKGROUND Identification and treatment of malnutrition are essential in upper gastrointestinal (UGI) cancer. However, there is limited understanding of the nutritional status of UGI cancer patients at the time of curative surgery. This prospective point prevalence study involving 27 Australian tertiary hospitals investigated nutritional status at the time of curative UGI cancer resection, as well as presence of preoperative nutrition impact symptoms, and associations with length of stay (LOS) and surgical complications. METHODS Subjective global assessment, hand grip strength (HGS) and weight were performed within 7 days of admission. Data on preoperative weight changes, nutrition impact symptoms, and dietary intake were collected using a purpose-built data collection tool. Surgical LOS and complications were also recorded. Multivariate regression models were developed for nutritional status, unintentional weight loss, LOS and complications. RESULTS This study included 200 patients undergoing oesophageal, gastric and pancreatic surgery. Malnutrition prevalence was 42% (95% confidence interval (CI) 35%, 49%), 49% lost ≥5% weight in 6 months, and 47% of those who completed HGS assessment had low muscle strength with no differences between surgical procedures (p = 0.864, p = 0.943, p = 0.075, respectively). The overall prevalence of reporting at least one preoperative nutrition impact symptom was 55%, with poor appetite (37%) and early satiety (23%) the most frequently reported. Age (odds ratio (OR) 4.1, 95% CI 1.5, 11.5, p = 0.008), unintentional weight loss of ≥5% in 6 months (OR 28.7, 95% CI 10.5, 78.6, p < 0.001), vomiting (OR 17.1, 95% CI 1.4, 207.8, 0.025), reduced food intake lasting 2-4 weeks (OR 7.4, 95% CI 1.3, 43.5, p = 0.026) and ≥1 month (OR 7.7, 95% CI 2.7, 22.0, p < 0.001) were independently associated with preoperative malnutrition. Factors independently associated with unintentional weight loss were poor appetite (OR 3.7, 95% CI 1.6, 8.4, p = 0.002) and degree of solid food reduction of <75% (OR 3.3, 95% CI 1.2, 9.2, p = 0.02) and <50% (OR 4.9, 95% CI 1.5, 15.6, p = 0.008) of usual intake. Malnutrition (regression coefficient 3.6, 95% CI 0.1, 7.2, p = 0.048) and unintentional weight loss (regression coefficient 4.1, 95% CI 0.5, 7.6, p = 0.026) were independently associated with LOS, but no associations were found for complications. CONCLUSIONS Despite increasing recognition of the importance of preoperative nutritional intervention, a high proportion of patients present with malnutrition or clinically significant weight loss, which are associated with increased LOS. Factors associated with malnutrition and weight loss should be incorporated into routine preoperative screening. Further investigation is required of current practice for dietetics interventions received prior to UGI surgery and if this mitigates the impact on clinical outcomes.
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Efficacy and Safety of Low-Molecular-Weight Heparin on Prevention of Venous Thromboembolism after Laparoscopic Operation for Gastrointestinal Malignancy in Japanese Patients: A Multicenter, Open-Label, Prospective, Randomized Controlled Trial.
Obitsu, T, Tanaka, N, Oyama, A, Ueno, T, Saito, M, Yamaguchi, T, Takagi, A, Rikiyama, T, Unno, M, Naitoh, T, et al
Journal of the American College of Surgeons. 2020;(5):501-509.e2
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) after surgery for malignancy in Japanese patients is unclear; therefore, standard prevention protocols have not been established, especially for minimally invasive procedures. We aimed to investigate the additional effect of low molecular weight heparin (LMWH) on prevention of VTE after laparoscopic surgery for gastrointestinal malignancy. STUDY DESIGN From February 2013 to January 2017, 400 patients scheduled for laparoscopic surgery were included. Cases were randomly allocated to the physical therapy group (Control group; 201 patients) or to the combination-therapy group (LMWH group; 199 patients), in which enoxaparin sodium (20 mg [= 2000 IU] twice a day) was administered for 1 week postoperatively in addition to the physical therapy. A diagnosis of VTE was made by contrast-enhanced CT or ultrasonography when symptomatic or D-dimer was ≥10 μg/mL. RESULTS VTE was observed in 1.2% and 4.0% of patients in the LMWH and Control groups, respectively (odds ratio [OR] 0.3, 95% confidence interval [CI] 0.03-1.53). Pulmonary embolism was confirmed only in the Control group (1.7%). No major bleeding occurred in either group. Logistic multiple regression analysis revealed that surgical time extension (OR 1.02, 95% CI 1.00-1.04) was a risk factor of VTE, while administration of LMWH (OR 0.21, 95% CI 0.03-0.99), male sex (OR 0.12, 95% CI 0.01-0.60), and early cancer (OR 0.17, 95% CI 0.02-0.82) reduced the risk of VTE. CONCLUSIONS Postoperative LMWH administration is safe. The additional effect of LMWH administration on the physical therapy was not statistically proven in this study. However, it could be useful for the patients with risk factors such as female sex, long operation time, and higher cancer stage.
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Effect of oral nutritional supplementation on the post-discharge nutritional status and quality of life of gastrointestinal cancer patients after surgery: a multi-center study.
Zhu, MW, Yang, X, Xiu, DR, Yang, Y, Li, GX, Hu, WG, Wang, ZG, Cui, HY, Wei, JM
Asia Pacific journal of clinical nutrition. 2019;(3):450-456
Abstract
BACKGROUND AND OBJECTIVES To evaluate the effect of oral nutritional supplementation (ONS) on the postdischarge nutritional status and quality of life (QoL) of gastrointestinal cancer patients after surgery. METHODS AND STUDY DESIGN A multi-center study was conducted on gastrointestinal cancer patients who received surgical treatment from 2013-2015. All patients were screened using the Nutrition Risk Screening 2002 (NRS 2002) to assess nutritional risk. Patients with nutritional risk were randomized into two groups: patients in the study group (n=55) were given dietary guidance and ONS, control group (n=59) received only dietary guidance. Anthropometric measurements, nutrition-related laboratory tests, and gastrointestinal function scores were also collected and analyzed using Student's t test and analysis of variance (ANOVA). In addition, the EQ-5D was used to evaluate patients' QoL. RESULTS Compared with baseline measurements, the body weight of patients in the study group increased by 1.35±0.53 kg and 1.35±0.73 kg at 60 and 90 days, which were significantly higher than those in the control group (-1.01±0.54 kg, and -1.60±0.81 kg at 60 and 90 days). The results from ANOVA showed that only weight and BMI differed significantly between the study and control groups and also between different measurement times (p<0.01). No differences were found for the other indicators or QoL between the study groups. CONCLUSIONS ONS may improve the weight and BMI of surgically treated gastrointestinal cancer patients postdischarge. However, these effects had little impact on patients' QoL.
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[Efficacy of Weitan Waifu patch on the postsurgical gastroparesis syndrome of gastrointestinal cancer: a multi-center trial].
Zhou, Q, Zuo, MH, Li, QW, Tian, YT, Xie, YB, Wang, YB, Yang, GY, Ye, YJ, Guo, P, Liu, JP, et al
Zhonghua zhong liu za zhi [Chinese journal of oncology]. 2017;(12):919-925
Abstract
Objective: To investigate the safety and efficacy of the Weitan Waifu patch on the postsurgical gastroparesis syndrome (PGS) of gastrointestinal cancer. Methods: The multi-center, double-blind, randomized controlled trial was conducted with superiority design. Patients with PGS of gastrointestinal cancer diagnosed in 4 AAA hospitals and the abdominal symptom manifested as cold syndrome by Chinese local syndrome differentiation were recruited. These patients were randomly divided into two groups according to 1∶1 proportion. Placebo or Weitan Waifu patch was applied in control group or intervention group, respectively, based on the basic treatments, including nutrition support, gastrointestinal decompression, promoting gastric dynamics medicine.Two acupuncture points (Zhongwan and Shenque) were stuck with placebo in control group or patch in treatment group. The intervention course was 14 days or reached the effective standard. Results: From July 15, 2013 to Jun 3, 2015, 128 participants were recruited and 120 eligible cases were included in the full analysis set (FAS), and 60 cases in each group. 88 cases were included in the per-protocol set (PPS), including 45 cases in the treatment group and 43 cases in the control group. In the FAS, the clinical effective rate in the treatment group was 68.3%, significantly superior than 41.7% of the control group (P=0.003). The medium time of effective therapy in the treatment group was 8 days, significantly shorter than 10 days in the control group (P=0.017). In the FAS, 3 adverse events occurred in the treatment group, including mild to moderate decrustation, pruritus and nausea. The incidence rate of adverse events was 5.0% (3/60) and these symptoms were spontaneously remitted after drug withdrawal. No severe adverse events were observed in the control group. There was no significant difference between these two groups (P=0.244). Conclusion: Weitan Waifu patch is a safely and effectively therapeutic method for patients with PGS (cold syndrome) of gastroenterological cancer. Trial registration: International Standard Randomized Controlled Trial Number Register, ISRCTN18291857.
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Enteral nutrition improves clinical outcome and shortens hospital stay after cancer surgery.
Wang, X, Pan, L, Zhang, P, Liu, X, Wu, G, Wang, Y, Liu, Y, Li, N, Li, J
Journal of investigative surgery : the official journal of the Academy of Surgical Research. 2010;(6):309-13
Abstract
BACKGROUND AND AIMS The aim of our study was to investigate whether medium-chain triglyceride (MCT) and protein-enriched enteral nutrition (EN) could improve protein level and clinical outcomes in postoperative patients with gastrointestinal cancer. MATERIAL AND METHODS A randomized clinical trial was performed. A population of 229 patients with gastrointestinal cancer was enrolled and allocated to two groups: (a) 114 patients received MCT and protein-enriched EN (Group I) and (b) 115 patients received an isocaloric EN (Group II). The total calorie was 25 kcal/kg/day and the time period of full dose of EN must be at least five days. RESULTS The three plasma proteins were improved after the EN support in both groups (p < .05). But, the increase of prealbumin in Group I was higher than that in Group II (p < .05). Episodes of diarrhea rate were equal and the postoperative infectious complications were not different between both groups. The length of hospital stay was shorter in Group I (18.4 ± 12 vs. 24.5 ± 15 d; p < .05). CONCLUSIONS MCT and protein-enriched EN improves the prealbumin level and shortens the length of hospital stay in patients with gastrointestinal cancer without a high rate of adverse reaction, which may be due to high content of MCT and protein in EN.
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Perioperative intravenous glutamine supplemetation in major abdominal surgery for cancer: a randomized multicenter trial.
Gianotti, L, Braga, M, Biffi, R, Bozzetti, F, Mariani, L, ,
Annals of surgery. 2009;(5):684-90
Abstract
OBJECTIVE To investigate whether perioperative intravenous glutamine supplementation may affect surgical morbidity. SUMMARY BACKGROUND DATA Small-sized randomized trials showed a trend toward a reduction of postoperative infections in surgical patients receiving glutamine. METHODS : A randomized, multicentre trial was carried out in 428 subjects who were candidates for elective major gastrointestinal surgery. Inclusion criteria were: documented gastrointestinal cancer, weight loss <10% in previous 6 months, and age >18 years. Patients received either intravenous infusion of L-alanine-L-glutamine dipeptide (0.40 g/kg/d; equal to 0.25 g of free glutamine) (Ala-Glu group, n = 212), or no supplementation (control group, n = 216). Glutamine infusion began the day before operation and continued postoperatively for at least 5 days. No postoperative artificial nutrition was allowed unless patients could not adequately eat by day 7. Postoperative morbidity was assessed by independent observers according to a priori definition. RESULTS Patients were homogenous for baseline and surgical characteristics. Mean percent of weight loss was 1.4 (2.7) in controls and 1.4 (2.4) in Ala-Glu group. Overall postoperative complication rate was 34.9% (74/212) in Ala-Glu and 32.9% (71/216) in control group (P = 0.65). Infectious morbidity was 19.3% (41/212) in Ala-Glu group and 17.1% (37/216) in controls (P = 0.55). The rate of major complications was 7.5% (16/212) in Ala-Glu group and 7.9% (17/216) in controls (P = 0.90). Mean length of hospitalization was 10.2 days (4.8) in Ala-Glu group versus 9.9 days (3.9) in controls (P = 0.90). The rate of patients requiring postoperative artificial nutrition was 13.2% (28/212) in Ala-Glu group and 12.0% (26/216) in controls (P = 0.71). CONCLUSIONS Perioperative glutamine does not affect outcome in well-nourished GI cancer patients.
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Prevention of irinotecan associated diarrhea by intestinal alkalization. A pilot study in gastrointestinal cancer patients.
Valentí Moreno, V, Brunet Vidal, J, Manzano Alemany, H, Salud Salvia, A, Llobera Serentill, M, Cabezas Montero, I, Servitja Tormo, S, Sopena Bert, E, Gumà Padró, J
Clinical & translational oncology : official publication of the Federation of Spanish Oncology Societies and of the National Cancer Institute of Mexico. 2006;(3):208-12
Abstract
AIM AND BACKGROUND Intestinal alkalization could prevent irinotecan associated diarrhea modulating some chemical equilibria between irinotecan metabolites. The aim of this study was to evaluate the efficacy of this procedure in advanced gastrointestinal cancer patients (GICP). MATERIALS AND METHOD In this prospective study advanced GICP, receiving irinotecan based chemotherapy regimens, were well trained to add sodium bicarbonate to the water intake in order to accomplish intestinal alkalization. RESULTS A total of twenty four advanced GICP were enrolled. Grade III-IV diarrhea has been observed in four patients (16%), some of whom had several risk factors for diarrhea. Only one out of seventeen colorectal cancer patients, receiving the irinotecan combination as first line therapy, had grade III-IV diarrhea. No side effects of the procedure have been appreciated. CONCLUSIONS Intestinal alkalization may be effective as a preventive treatment for irinotecan associated diarrhea in chemotherapy regimens used in GICP. This procedure deserves further investigation.
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Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area.
Isenring, EA, Capra, S, Bauer, JD
British journal of cancer. 2004;(3):447-52
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Abstract
Malnutrition occurs frequently in patients with cancer of the gastrointestinal (GI) or head and neck area and can lead to negative outcomes. The aim of this study is to determine the impact of early and intensive nutrition intervention (NI) on body weight, body composition, nutritional status, global quality of life (QoL) and physical function compared to usual practice in oncology outpatients receiving radiotherapy to the GI or head and neck area. Outpatients commencing at least 20 fractions of radiotherapy to the GI or head and neck area were randomised to receive intensive, individualised nutrition counselling by a dietitian using a standard protocol and oral supplements if required, or the usual practice of the centre (general advice and nutrition booklet). Outcome parameters were measured at baseline and 4, 8 and 12 weeks after commencing radiotherapy using valid and reliable tools. A total of 60 patients (51 M : 9 F; mean age 61.9+/-14.0 years) were randomised to receive either NI (n=29) or usual care (UC) (n=31). The NI group had statistically smaller deteriorations in weight (P<0.001), nutritional status (P=0.020) and global QoL (P=0.009) compared with those receiving UC. Clinically, but not statistically significant differences in fat-free mass were observed between the groups (P=0.195). Early and intensive NI appears beneficial in terms of minimising weight loss, deterioration in nutritional status, global QoL and physical function in oncology outpatients receiving radiotherapy to the GI or head and neck area. Weight maintenance in this population leads to beneficial outcomes and suggests that this, rather than weight gain, may be a more appropriate aim of NI.
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Protracted infusional 5-fluorouracil plus high-dose folinic acid combined with bolus mitomycin C in patients with gastrointestinal cancer: a phase I/II dose escalation study.
Hartmann, JT, Oechsle, K, Quietzsch, D, Wein, A, Hofheinz, RD, Honecker, F, Nehls, O, Köhne, CH, Käfer, G, Kanz, L, et al
British journal of cancer. 2003;(11):2051-6
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Abstract
The aim of this study was to define the maximum tolerated dose (MTD) of bolus mitomycin C (MMC) in combination with 24 h-continuous infusion of 5-flourouracil (FU) plus folinic acid, and to assess the toxicity and activity in patients with previously treated colorectal and gastric cancer. Escalating doses of MMC starting from 6 mg m(-2) in 2 mg m(-2)-steps to a maximum of 10 mg m(-2) were applied on days 1 and 22, given to fixed doses of 5-FU (2.600 mg m(-2)) as 24 h infusion and folinic acid 500 mg m(-2) prior to 5-FU weekly for 6 weeks. At least three patients were treated at each dose level. A total of 16 patients have been included in the phase I study. At the highest dose level (MMC 10 mg m(-2)), grade III thrombocytopenia, dyspnoea, mucositis and diarrhoea were observed in one patient each (17 %). In the phase II study 45 patients, 33 with colorectal cancer and 12 with gastric cancer, 23 patients after failure of first- and 22 patients after at least second-line or subsequent chemotherapy have been treated. Seven partial responses (PR) were registered (16%), one (3%; CI(95%), 0-16) in colorectal and six (50%; CI(95%), 21-79%) in gastric cancer patients. In all, 17 (38%) achieved disease stabilisation, 15 colorectal (45%, CI(95%), 28-64%) and two gastric cancer patients (17%; CI(95%), 2-48%). The median progression-free survival was 3.1 months (range, 0.9-9.1) in colorectal and 4.6 months (range, 0.7-12.4) in gastric cancer. The median overall survival time was 6.6 months (range, 1.9-15.6) in colorectal and 7.1 months (range, 1.7-20.8) in patients with gastric cancer. This regimen was considered to be safe and well tolerated for pretreated patients with gastrointestinal adenocarcinoma. In gastric cancer,MMC plus infusional 5-FU/folinic acid may be a potential second-line regimen with promising antitumour activity.
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Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial.
Bozzetti, F, Braga, M, Gianotti, L, Gavazzi, C, Mariani, L
Lancet (London, England). 2001;(9292):1487-92
Abstract
BACKGROUND Although current opinion favours the use of enteral over parenteral nutrition, the clinical benefits of early postoperative nutrition in patients undergoing elective surgery have never been clearly shown. We aimed to test the hypothesis that postoperative enteral nutrition is better (fewer postoperative complications) than parenteral nutrition containing similar energy and nitrogen amounts (112 kJ kg(-1) day(-1) and 1.4 g aminoacid kg(-1) day(-1)). METHODS We did a randomised multicentre clinical trial in patients with gastrointestinal cancer who were malnourished and candidates for major elective surgery. 159 patients were assigned to enteral nutrition and 158 to parenteral nutrition. The primary endpoint was the occurrence of postoperative complications, and secondary endpoints were length of postoperative hospital stay, adverse effects, and treatment crossover. Analysis was by intention to treat. FINDINGS Postoperative complications occurred in 54 (34%) patients fed enterally versus 78 (49%) fed parenterally (relative risk 0.69, 95% CI 0.53-0.90, p=0.005). Length of postoperative stay was 13.4 days and 15.0 days in the enteral nutrition and parenteral nutrition groups, respectively (p=0.009). Adverse effects occurred in 56 (35%) patients fed enterally versus 22 (14%) patients fed parenterally (2.50, 1.61-3.86, p<0.0001). 14 (9%) patients on enteral nutrition had to switch to parenteral nutrition, whereas none of those fed parenterally crossed over to enteral feeding. INTERPRETATION We conclude that early enteral nutrition significantly reduces the complication rate and duration of postoperative stay compared with parenteral nutrition, although parenteral nutrition is better tolerated than enteral nutrition.