Elsevier

Clinical Nutrition

Volume 26, Issue 6, December 2007, Pages 698-709
Clinical Nutrition

Original article
Postoperative complications in gastrointestinal cancer patients: The joint role of the nutritional status and the nutritional support

https://doi.org/10.1016/j.clnu.2007.06.009Get rights and content

Summary

Background & aims

This study investigated the effects of nutritional support on postoperative complications, in relation with demographic and nutritional factors, intraoperative factors, type and routes of nutritional regimens.

Methods

A series of 1410 subjects underwent major abdominal surgery for gastrointestinal cancer and received various types of nutritional support: standard intravenous fluids (SIF; n=149), total parenteral nutrition (TPN; n=368), enteral nutrition (EN; n=393), and immune-enhancing enteral nutrition (IEEN; n=500).

Postoperative complications, considered as major (if lethal or requiring re-operation, or transfer to intensive care unit), or otherwise minor, were recorded.

Results

Major and minor complications occurred in 101 (7.2%) and 446 (31.6%) patients, respectively. Factors correlated with postoperative complications at multivariate analysis were pancreatic surgery, (p<0.001), advanced age (p=0.002), weight loss (p=0.019), low serum albumin (p=0.019) and nutritional support (p=0.001). Nutritional support reduced morbidity versus SIF with an increasing protective effect of TPN, EN, and IEEN. This effect remained valid regardless the severity of risk factors identified at the multivariate analysis and it was more evident by considering infectious complications only.

Conclusions

Pancreatic surgery, advanced age, weight loss and low serum albumin are independent risk factors for the onset of postoperative complications. Nutritional support, particularly IEEN, significantly reduced postoperative morbidity.

Introduction

In surgical patients, the traditional rationale behind the use of nutritional support was the attempt to correct malnutrition and, consequently, the malnutrition-associated adverse effects such as postoperative complications.

In the worldwide experience, weight loss (WL), alone or variously combined with other laboratory parameters, has been considered the main indicator of poor nutritional status. Therefore, its modification was the main target of the therapeutic efforts used to prevent postoperative complications through nutritional support.

Most recently, however, the above concepts evolved and the maintenance of a trophic gut mucosa through enteral nutrition,1 and the boost of the immune response through administration of specialized nutrients became the main aim of perioperative nutrition even in well-nourished patients.2, 3, 4, 5 Other strategies such as early postoperative oral intake and mobilization, and intravenous fluid restriction have been shown to be advantageous on outcome, particularly after colorectal surgery.6, 7

In the present study we reviewed a large series of cancer patients enrolled in previous randomized clinical trials (RCTs), who received different types of nutritional support such as total parenteral nutrition, enteral nutrition, immune enhancing enteral nutrition, or standard intravenous fluid, before and/or after abdominal surgery. The purpose was to investigate the potential joint prognostic role of baseline demographic and nutritional parameters, type of nutritional support, and intraoperative factors upon the occurrence of postoperative complications.

Section snippets

Materials and methods

The patient data used for the present analysis were extracted from electronic databases. All these databases were specifically created to archive charts of patients included in RCTs designed to test the effect of different nutritional approaches on clinical outcome.1, 2, 3, 8, 9, 10, 11 In these trials, patients were included if they had an histologically documented gastrointestinal malignancy and were candidate for major open elective surgery, or excluded if they had clinically relevant organ

Results

Clinical-demographic characteristics of the whole series of 1410 patients and of the four different treatment groups, defined by the type of nutritional support, are described in Table 2. Age was mostly distributed in the range between 55 and 75 years but it is noteworthy that 33.6% of patients were over 65% and 10.7% over 75. As regards the remaining characteristics, all the classes stratifying our series were well represented. However, it must be noted the relatively high frequency of missing

Univariate analysis of complications

At the univariate analysis of complications, categorized as absent, minor or major (Table 3) the following variables yielded significant results: among the preoperative ones, advanced patient age (p=0.001), pancreatic tumor site (p<0.001), low serum albumin (p=0.001), and WL (p=0.014); among the intraoperative factors, duration of the surgical procedure (p=0.001), operative blood loss (p=0.003), and blood transfusion (p=0.001). The trends for minor and major complications were generally similar.

Multivariate analysis of complications

Table 5 shows the results of the multivariate analysis on complications (pooled together regardless of their type). The exact percent of WL, available in 1240 patients, was analyzed as a continuous covariate. Similar results were obtained when WL was entered into the model as a categorical factor (1410 patients).

Among preoperative factors, significant results (ordered by increasing p-values) were obtained for all covariates entered into the logistic model, namely tumor site, patient age, WL and

Discussion

The purpose of this study was the attempt to elucidate the relationship between nutritional status, nutritional support and postoperative complications in cancer patients. We had the opportunity to utilize a large database from patients enrolled in previous RCTs (mainly from two major institutions in Milan) and to analyze data with a scope and a statistical power which are uncommon for clinical investigations of this type.

Notably, it was possible to perform multivariate analyses for the most

Acknowledgments

FB, LG, MB and VDC conceived and carried out the study and data analysis, and drafted the manuscript. LM participated in the design of the study, performed the statistical analysis and drafted the manuscript. All the authors read and approved the final manuscript.

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