The Hidden Value for Peri-Operative Nutritional Support in Surgical GIT Cancer

Wafaa Taha Vise Dean of National Cancer Institute and Prof of Anesthesia

The efficacy of perioperative nutrition support to reduce surgical complications and mortality significantly

has been an area of active clinical investigation over the past three decades. From multiple prospective, randomized trials, significant benefit from perioperative nutritional support has been demonstrated in severely malnourished patients undergoing major surgery. Routine preoperative TPN may not proper for all types of cancer. To appreciate the value of nutritional assessment and support for surgical cancer patients, we need to know the consequences of malnutrition: These are:

1. Slow wound healing which results to complications and longer hospital stay

2. Reduced muscle strength which also leads to longer hospitalization

3. Decrease in respiratory muscle strength with slower recovery due to poor tissue oxygenation

4. Impaired cardiac function which leads to hypoperfusion, weakness and slow recovery

5. Immune hypofunction and dysfunction leading to increased infection and complications

6. Higher morbidity and mortality which is the result of the above conditions

7. Poor quality of life which is the ultimate complaint of the patient Thus knowing that a patient has a poor nutritional status will guide us in avoiding the above complications of malnutrition.

Following major surgery in cancer patients, Nutritional Support should be started if malnutrition is already present, If inadequate food intake is anticipated for more than 5-7 days and It should substitute the difference between actual intake & calculated requirements. Patients with severe malnutrition benefit from Nutritional Support 10-14 days prior to major surgery, even if surgery has to be delayed. Treatment-related (chemotherapy and radiation,) side effects are extremely common in people with cancer. These side effects can significantly impact both nutritional intake and weight status, and may result from the cancer and/or its treatment. Common side effects include, weight loss, fatigue , nausea and vomiting , oral mucositis, taste alterations. Constipation, a common side effect, especially for people taking Opioid analgesics, with a 40%–50% occurrence in individuals with advanced cancer. In these patients malnutrition increased morbidity and mortality, reduction of treatment efficacy, increased risk of therapy-associated side-effects, increased length of hospital stay, and reduced quality of life. Proposing an adaptive nutritional support at each step of a multidisciplinary treatment approach for cancer patient is essential. Nutritional counseling is essential for patients with cancer, especially GIT cancer. Early, intensive and individualized nutritional counseling has shown to be effective in preserving body weight and physical function in cancer patients. The efficacy of nutritional counseling relies on the presence of a well-trained and specialized nutrition support team. In pancreatic cancer, malnutrition and cachexia is encountered in up to 80% of patients and significantly contributes to the related morbidity and mortality. Since many factors lead to cachexia in these patients, a multimodal treatment approach is needed, including nutritional support and pharmacological intervention as well as the treatment of symptoms exacerbating weight loss such as chronic pain, gastrointestinal disorders, fatigue and depression Furthermore, interventions should be implemented in a stepwise manner, starting with oral nutritional support and dietary counseling from the time of diagnosis. Screening and monitoring of cachexia and malnutrition should be performed regularly. The Nutritional Support for cancer patients can be by oral, enteral route using Nasogastric tube , Gastrostomy tube or Jejunostomy. Parenteral route using peripheral venous access or Central venous access (catheter tip in SVC) Oral Supplementation of Diet, appropriate for patients who are unable to meet their caloric needs through food choices. Nasogastric Feeding Tubes appropriate for patients who are unable to ingest sufficient calories despite supplementation and who will need enteral nutrition for less than 30 days. Gastrostomy Feeding Tubes appropriate for patients who will need longer-term enteral feeds (at least 2 weeks). Jejunostomy Feeding Tubes Indicated for patients who need prolonged enteral feeds and who have had previous gastric surgery, gastric outlet obstruction. Parenteral Nutrition Appropriate for patients who are severely malnourished or have contraindications to enteral feeding—”If the gut works, use it” Immunonutrients are Specific nutrients found to have effects on immune system, metabolism, and GIT structure and function, as they enhance immune system, preserve gut integrity, improve wound healing, decrease infection complications, lower ICU stay and reduce hospital stay. These groups of nutrients include Glutamine, Arginine and Omega-3 fatty acids. Recent research found that enteral nutrition supplemented with arginine and omega 3-fatty acids and nutritional support with glutamine had beneficial effects on the patients with cancers. In Esophageal cancer patients, preoperative TPN + amino acids+ certain fatty acids and Immunonutrients decrease postoperative infections. Also in postoperative when given combined Enteral & TPN , and Early as soon as possible this enhance recovery and healing, decrease morbidity and mortality. All patients undergoing major abdominal surgery, nutritional support (with immune-modulating substrates) is recommended for 5-7 days independent of nutritional status (Braga et al. 2009) The Immunonutrients can modulation of dysfunctional inflammation witch after major surgery. An initial insult such as sepsis, trauma and major operation induces early systemic inflammatory response syndrome. The amplitude and duration depends on the magnitude of insult and inherent factors. Severe systemic inflammatory response syndrome can precipitate early MOF. On the other hand, to counter-regulate the severe inflammatory response, systemic Immunosuppression may occur. In addition, malnutrition induced by surgical stress will add to the Immunosuppression. The severe Immunosuppression may contribute to the occurrence of infection. The resulting infection triggers late MOF. Therefore, both severe inflammatory response and severe Immunosuppression are needed to be moderated. Immunonutrition can modulate these dysfunctional responses to well-regulated inflammatory responses. The effect of Omega-3-fatty acids in Parenteral Nutritionis is very immportant as it dampen acute leukocyte responses , facilitate the resolution of inflammation and decreased production of TNF- , IL-1 , and IL-6. Nutrition is a low coast, non toxic and scientifically helpful component in the comprehensive treatment of cancer. The main goals of nutrition therapy for cancer Patients Prevent & treat malnutrition, enhance anti-tumour treatment effects , improve recovery and healing, reduce Side effects of cancer treatment, modulate Immune system, improve Patient's strength and energy and finally , improve the subjective quality of life (QoL)