Preoperative Nutrition Intervention in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study

Abstract

Background: Preoperative nutrition intervention is recommended prior to upper gastrointestinal (UGI) cancer resection; however, there is limited understanding of interventions received in current clinical practice. This study investigated type and frequency of preoperative dietetics intervention and nutrition support received and clinical and demographic factors associated with receipt of intervention. Associations between intervention and preoperative weight loss, surgical length of stay (LOS), and complications were also investigated. Methods: The NOURISH Point Prevalence Study was conducted between September 2019 and May 2020 across 27 Australian tertiary centres. Subjective global assessment and weight were performed within 7 days of admission. Patients reported on preoperative dietetics and nutrition intervention, and surgical LOS and complications were recorded. Results: Two-hundred patients participated (59% male, mean (standard deviation) age 67 (10)). Sixty percent had seen a dietitian preoperatively, whilst 50% were receiving nutrition support (92% oral nutrition support (ONS)). Patients undergoing pancreatic surgery were less likely to receive dietetics intervention and nutrition support than oesophageal or gastric surgeries (p < 0.001 and p = 0.029, respectively). Neoadjuvant therapy (p = 0.003) and malnutrition (p = 0.046) remained independently associated with receiving dietetics intervention; however, 31.3% of malnourished patients had not seen a dietitian. Patients who received ≥3 dietetics appointments had lower mean (SD) percentage weight loss at the 1-month preoperative timeframe compared with patients who received 0–2 appointments (1.2 (2.0) vs. 3.1 (3.3), p = 0.001). Patients who received ONS for >2 weeks had lower mean (SD) percentage weight loss than those who did not (1.2 (1.8) vs. 2.9 (3.4), p = 0.001). In malnourished patients, total dietetics appointments ≥3 was independently associated with reduced surgical complications (odds ratio 0.2, 95% confidence interval (CI) 0.1, 0.9, p = 0.04), and ONS >2 weeks was associated with reduced LOS (regression coefficient −7.3, 95% CI −14.3, −0.3, p = 0.04). Conclusions: Despite recommendations, there are low rates of preoperative dietetics consultation and nutrition support in this population, which are associated with increased preoperative weight loss and risk of increased LOS and complications in malnourished patients. The results of this study provide insights into evidence–practice gaps for improvement and data to support further research regarding optimal methods of preoperative nutrition support.

Health service nutrition practices and associations with clinical outcomes in patients undergoing resection for upper gastrointestinal cancer: Results from the multi‐centre NOURISH point prevalence study

“…However overall, the results of the present study are more positive compared to the results of previously conducted surveys of Australian UGI dietitians over 7-10 years ago, which estimated significantly lower outpatient service provision to this population. 4,20 We have previously demonstrated that receiving neoadjuvant therapy was associated with greater likelihood of receiving preoperative dietetics intervention, 3 which is supported by the results of this study demonstrating that the vast majority of sites had dietetics services available in the chemo/radiotherapy settings. However, only 23% and 39% of sites reported having a routine service for the preoperative chemotherapy and radiotherapy settings, respectively, with 31% and 43% for the postoperative chemotherapy and radiotherapy settings.…”

“…This is not surprising given that we have previously reported that receiving ≥ 3 preoperative dietetics appointments was associated with lower percentage weight loss because a nutrition care pathway can create a structured approach to nutrition reviews enabling ongoing monitoring and adjustment of intervention. 3 Previous studies have also demonstrated a reduction in malnutrition rates and weight loss when a nutrition care pathway was implemented in an oncology population. 27,28 Receiving care under a pathway/protocol was not associated with receiving preoperative nutrition support, and this could be a result of other health care professionals administering nutrition support such as oral nutrition supplements without the involvement of a dietitian, 3 particularly at sites with limited dietetics services.…”

“…However, significant inadequacies and variations in perioperative nutrition care were demonstrated in patients participating in NOURISH, with only 60% reporting seeing a dietitian prior to surgery, and only 50% reporting being prescribed nutrition support prior to surgery. 3 The results of the NOURISH point prevalence study demonstrate a clear need for improved identification and treatment of malnutrition in this high-risk patient group. Strategies to improve perioperative care include the funding of dedicated outpatient clinics to enable early access to nutrition assessment, intervention and regular monitoring.…”

Nutrition practices with a focus on parenteral nutrition in the context of enhanced recovery programs: An exploratory survey of gastrointestinal surgeons

“…Studies in other major GI surgery settings are needed to further inform the impact of providing MNT in accordance with ERAS guidance on patient outcomes. Nevertheless, studies to date point to a need for greater awareness and practical guidance on how to identify patients at nutritional risk, and provide nutritional prehabilitation and perioperative nutritional support, to address malnutrition as a modifiable risk factor for poor postoperative outcomes [35,36].…”

Interrelationships between Dietary Outcomes, Readmission Rates and Length of Stay in Hospitalised Oncology Patients: A Scoping Review

“…Achieving nutritional sufficiency reduces malnutrition risk and results in improved clinical outcomes, including shortened LOS and fewer non-elective hospital readmissions. However, structural and institutional barriers to meeting inpatient nutritional requirements and low adherence to ESPEN guidelines occur worldwide [ 23 , 24 , 25 ]. The purpose of this scoping review was to assess the evidence for interrelationships between dietary (energy and protein) intake and clinical outcomes, LOS and hospital readmissions, among adult hospitalised oncology patients.…”