Background The preoperative period likely provides an important opportunity to improve postoperative recovery, as suggested by the finding that low nutrition status is a predictor of increased postoperative complications and longer length of stay (LOS). It was investigated whether a home‐delivered, protein‐rich meal service improves protein intake relative to requirements within 3 weeks prior to surgery compared to usual care (UC). Methods This randomized controlled trial included adults (n = 126) with planned surgery performed at the orthopedics, urology, gynecology, or general surgery departments. The intervention group received 6 protein‐rich dishes per day for 3 weeks, and the control group sustained their usual diet. Dietary intake, nutrition status, hand grip strength, physical performance, and quality of life were assessed at baseline and after 3 weeks. Patient satisfaction was reported after 3 weeks, and data on complications and LOS were reported 30 days after surgery. Results Protein intake relative to requirements significantly improved by 16%, and energy intake relative to requirements increased by 19% for the meal service, as compared with UC. The intervention group experienced significantly less stress with preparing meals and were more satisfied with the presentation of the meals than the control group. No significant effects of the intervention were detected on other secondary outcomes. Conclusion The home‐delivered, protein‐rich meal service was successfully implemented before surgery and improved protein and energy intake relative to requirements within 3 weeks while patient satisfaction maintained. The preoperative period serves as a window of opportunity to prepare patients before hospitalization.

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BACKGROUND: A more extensive resection is often required in locally advanced rectal cancer, depending on preoperative neoadjuvant treatment response. OBJECTIVE: Circumferential margin involvement and postoperative outcomes after total mesorectal excision and multivisceral resection were assessed in patients with clinical locally advanced (cT4) rectal cancer at a national level. DESIGN: This is a population-based study. SETTINGS: Data were retrieved from the Dutch Colorectal Audit. PATIENTS: A total of 2242 of 2881 patients with cT4 rectal cancer between January 2009 and December 2017 were selected. MAIN OUTCOME MEASURES: Main outcomes were resection margins, postoperative complications, and mortality. RESULTS: Multivisceral resection was performed in 936 of 2242 patients, of whom 629 underwent extended multivisceral resection. Positive circumferential margin rate was higher after multivisceral resection than after total mesorectal excision: 21.2% vs 13.9% (p < 0.001). More postoperative complications occurred after limited and extended multivisceral resections than after total mesorectal excision (44.1% and 53.8% vs 37.6%, p < 0.001). Incidence of 30-day mortality was similarly low in both groups (1.5% vs 2.2%, p = 0.20). Independent predictors of postoperative complications were age ≥70 years (OR, 1.28 [95% CI, 1.04–1.56]; p = 0.02), male sex (OR, 1.68 [95% CI, 1.38–2.04]; p< 0.001), mucinous tumors (OR, 1.55 [95% CI, 1.06–2.27]; p = 0.02), extended multivisceral resection (OR, 1.98 [95% CI, 1.56–2.52]; p< 0.001), Hartmann procedure (OR, 1.42 [95% CI, 1.07–1.90]; p = 0.02), and abdominoperineal resection (OR, 1.56 [95% CI, 1.25–1.96]; p < 0.001). LIMITATIONS: Data specifying the extent of multivisceral resections and Clavien Dindo I to II complications were not available. CONCLUSIONS: This population-based study revealed relatively high circumferential margin positivity and postoperative complication rates in patients with cT4 rectal cancer, especially after multivisceral resections, but low mortality rates. See Video Abstract at http://links.lww.com/DCR/B457. ALTA TASA PERSISTENTE DE MÁRGENES POSITIVOS Y COMPLICACIONES POSTOPERATORIAS DESPUÉS DE LA CIRUGÍA DE CÁNCER RECTAL CT4A NIVEL NACIONAL ANTECEDENTES: A menudo se requiere una resección más extensa en el cáncer de recto localmente avanzado, según la respuesta al tratamiento neoadyuvante preoperatorio. OBJETIVO: Se evaluó la afectación del margen circunferencial y los resultados postoperatorios después de la escisión mesorrectal total y la resección multivisceral en pacientes con cáncer rectal clínico localmente avanzado (cT4) a nivel nacional. DISEÑO: Este es un estudio poblacional. ENTORNO CLINICO: Los datos se recuperaron de la Auditoría colorrectal holandesa. PACIENTES: Se seleccionaron un total de 2242 de 2881 pacientes con cáncer de recto cT4 entre enero de 2009 y diciembre de 2017. PRINCIPALES MEDIDAS DE VALORACION: Los principales resultados fueron los márgenes de resección, las complicaciones postoperatorias y la mortalidad. RESULTADOS: Se realizó resección multivisceral en 936 de 2242 pacientes, de los cuales 629 fueron sometidos a resección multivisceral extendida. La tasa de margen circunferencial positivo fue mayor después de la resección multivisceral que después de la escisión mesorrectal total: 21,2% versus a 13,9% (p <0,001). Se produjeron más complicaciones postoperatorias después de resecciones multiviscerales limitadas y extendidas en comparación con la escisión mesorrectal total (44,1% y 53,8% versus a 37,6%, p <0,001). La incidencia de mortalidad a 30 días fue igualmente baja en ambos grupos (1,5% versus a 2,2%, p = 0,20). Los predictores independientes de complicaciones posoperatorias fueron la edad ≥70 años (OR = 1,28, IC del 95% [1,04 a 1,56], p = 0,02), hombres (OR = 1,68, IC del 95% [1,38 a 2,04], p <0,001), tumores mucinosos (OR = 1,55, IC del 95% [1,06 a 2,27], p = 0,02), resección multivisceral extendida (OR = 1,98, IC del 95% [1,56 a 2,52], p <0,001), Hartmann (OR = 1,42, 95% Cl [1,07 a 1,90], p = 0,02) y resección abdominoperineal (OR 1,56, Cl 95% [1,25 a 1,96], p <0,001). LIMITACIONES: No se disponía de datos que especificaran el alcance de las resecciones multiviscerales y las complicaciones de Clavien Dindo I-II. CONCLUSIONES: Este estudio poblacional reveló tasas de complicaciones postoperatorias y positividad del margen circunferencial relativamente altas en pacientes con cáncer de recto cT4, especialmente después de resecciones multiviscerales, pero tasas de mortalidad bajas. Consulte Video Resumen en http://links.lww.com/DCR/B457.

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