Prof. Arved Weimann 

Presentation Roadmap/ Summary

Preoperative impairment of nutritional status, and sarcopenia have shown significant impact on surgical outcome in patients undergoing surgery for cancer (1, 2). Sarcopenia is also a predictor for long-term survival after gastrectomy for gastric cancer (3). 

 “Severe” nutritional risk for surgical patients has been defined according to the ESPEN working group as the presence of at least one of the following criteria (4):

• Weight loss >10-15% within 6 months
• BMI <18.5 kg/m²
• NRS >5
• Serum albumin <30g/l (with no evidence of hepatic or renal dysfunction)

The ESPEN guidelines from 2017 (4) state: “Patients with severe nutritional risk shall receive nutritional therapy prior to major surgery (A) even if operations including those for cancer have to be delayed (BM). A period of 7 to 14 days may be appropriate (0).”

In patients undergoing neoadjuvant (radio-)/chemotherapy for gastrointestinal cancer usually a time period of 4-6 weeks precedes surgery. With special regard to those patients the new “prehabilitation” program including physical exercise, psychological support and nutrition therapy in an outpatient setting for 4-6 weeks may be very beneficial and attenuate post-surgical loss in lean body mass (5, 6). In a recent randomized controlled study a significant decrease in the number of patients with complications and the number of complications per patient had been observed (7). Nutritional management 7-14 days before surgery includes immunonutrition (8) and even parenteral supplementation, the day and the morning before surgery carbohydrate drink (4). 

After surgery early oral food intake is feasible, however, it should be kept in mind that many patients after major upper gastrointestinal surgery will not cover their energy requirements for a longer period. Therefore, it is recommended to consider jejunal tube placement e.g. needle catheter jejunostomy for postoperative enteral supplementation. In case it is anticipated that oral/enteral nutrition will be not more than 50% of the recommended intake for more than seven days parenteral supplementation should be started. In patients with perioperative nutritional therapy follow-up of nutritional status is recommended after discharge.    

At the conclusion of the presentation, the participant will be able to learn:

1. Indication for the delay of surgery in order to condition the patient - prehabilitation
2. Immunologic and metabolic conditioning 
3. Perioperative nutritional strategy

Key Takeaways/ Fast Facts

The preoperative period should be used for appropriate conditioning of the patient in a multimodality approach – so called “prehabilitation”

Key references

1. Scarborough JE, Bennett KM, Englum BR, Pappas TN, Lagoo-Deenadayalan SA The impact of functional dependency on outcomes after complex general and vascular surgery. Ann Surg 2015; 261: 432 – 437
2. Simonsen C, de Heer P, Bjerre ED, Suetta C, Hojman P, Pedersen BK, Svendsen LB, Christensen JF Sarcopenia and postoperative complication risk in gastrointestinal surgical oncology. Ann Surg 2018; 228; 58-69
3. Zhuang CL, Huang DD, Rang WY, Zhou CJ, Wang SL, Lou N, MaLL, Yu Z, Shen X Sarcopenia is an independent predictor of severe postoperative complications and long-term survival after radical gastrectomy for gastric cancer: analysis from a large-scale cohort. Medicine (Balt) 2016; 95: e3164
4. Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Lobo DN, Ljungqvist O,  Martindale R, Waitzberg D, Bischoff SC, Singer P  ESPEN Guideline Clinical Nutrition in Surgery, Clin Nutr 2017; 6: 623-650
5. Gillis C, Buhler K, Bresee L, Carli F, Gramlich L, Culos-Reed N, Sajobi TT, Fenton TR Effects of Nutritional Prehabilitation, With and Without Exercise, on Outcomes of Patients Who Undergo Colorectal Surgery: A Systematic Review and Meta-analysis. Gastroenterology. 2018; 155:391-410.e4
6. Barberan-Garcia A, Ubré M, Roca J, Lacy AM, Burgos F, Risco R, Momblán D, Balust J, Blanco I, Martinez-Palli G Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomized blinded controlled trial. Ann Surg 2018; 267: 50-56
7. Gillis C, Fenton TR, Sajobi TT, Minnella EM, Awasthi R, Loiselle SE, Liberman AS, Stein B, Charlebois P Carli F Trimodal prehabilitation for colorectal surgery attenuates post-surgicval losses in lean body mass: a pooled nalysis of randomized controlled trials. Clin Nutr 2018 epub ahead of print 
8. Adiamah A, Skorepa P, Weimann A, Lobo DN The impact of preoperative immune modulating nutrition on outcomes in patients undergoing surgery for gastrointestinal cancer: A systematic review and meta-analysis. Ann Surg 2019  epub ahead of print