Gastric_Cancer.pdf

Dr.sh.khalooeifard.gastric cancer
1
Nutritional Support in Gastirc Cancer
Surgery
Sh. Khalooeifard
PhD of Clinical Nutrition
Assistant Professor
Tehran University of Medical Sciences
Sina Hospital
Board member of Iranian ERAS.
22/Sep/2022
10/7/2022

Nutrition in GCS
• The stomach is not a vital organ.
• However, loss of the stomach and alteration of small bowel anatomy poses a risk for nutritional
and metabolic derangements that may result in malnutrition and a poor quality of life,
particularly early after surgery.
• Gastric resections can be divided into two categories:partial or subtotal gastrectomy (PG) and total
gastrectomy (TG).
• Similar nutritional complications may result from either surgery. Timely and appropriate
nutritional intervention can minimize diet intolerances, weight loss and micronutrient deficiencies
that often follow.
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NUTRITIONAL PRESENTATION
• Studies investigating weight loss after gastric resection have found no significant difference between TG and PG
patients
• It is clear that weight loss usually follows gastric resection with reported loss ranging from 10%–30% of
preoperative weight.
• This loss has been attributed to inadequate oral intake, malabsorption, rapid intestinal transit time and
bacterial overgrowth. More likely, it is a combination of all these factors.
• Nevertheless, weight gain after surgery is possible.
• Frequent nutrition follow-up in the early postoperative period is the key to preventing a decline in nutritional status.
Indeed, several reports confirm that in the absence of nutrition follow-up, patients become progressively
malnourished.
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What is ERAS?
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What is ERAS?
• The Enhanced Recovery After Surgery (ERAS) Society was formed in
2010 for the purpose of developing best-practice protocols and an
implementation model to decrease variability in care and improve
patient outcomes.
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What is ERAS?
• ERAS programs are multimodal, evidence-based care improvement
processes that bundle >20 care elements throughout the perioperative
period and consistently demonstrate improved postoperative outcomes
in a variety of surgical settings.
• The goals are to manage the stress response to surgery, maintain
body stores, and improve physiological function for early
recovery.

Guidlines of ERAS (21)
• Gastrectomy / orthopaedic
• Bariatric/ gastrointestinal / pancreatic
• Breast/ gynaecology/ thoracic
• Cardiac/ liver/ urology
• Colorectal/ lumbar-spinal-fusion/ vascular
• Cytoreductive/ neonatal
• emergency-laparotomy/ obstetrics
• head-neck/ oesophagectomy

ERAS implementation is complex and requires a
collaborative team approach.
ERAS
Anesthetist
Nurse
Anesthesia
Technologist
Dietitian
Physiotherapist
Surgeon
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ERAS and nutrition
•Nutritional support came to be regarded as a
Panacea for all surgical.

Elements of Nutrition in GCS
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Nutritional support preoperative
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Avoid fasting??????
10/7/2022

Avoid fasting with oral carbohydrate loading
• Why?
• The purpose of preoperative carbohydrate loading is threefold:
• (1) change pre-surgical metabolism from a fasted to a fed state,
• (2) attenuate postoperative insulin resistance,
• (3) keep the patient hydrated.
• The ERAS protocol for GI surgery recommends a perioperative oral carbohydrate load using a 50-
g, 12.5% maltodextrin solution 2 h before induction of anesthesia.

• Nutritional support preoperative not only aims to improve nutrition
status during the perioperative period but also help patients establish
lifelong healthier lifestyle changes that last well beyond the recovery
period. The “teachable moment” is thus used to motivate lifestyle
modifications and improved nutrition intake for years to come.

• Pre-operative nutrition therapy is increasingly recognised as an essential
component of surgical care.
• In the peri-operative period, the primary nutrition goals are to evaluate the
patient for pre-existing malnutrition, treat malnutrition to optimise surgical
readiness, minimise starvation, prevent postoperative malnutrition, and support
anabolism for recovery.
• An understanding of the surgical stress response is essential to understanding
the role nutrition plays in promoting optimal surgical recovery.

Does malnutrition just mean that?
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Malnutrition???????
• There is no universally accepted definition for malnutrition;
however, commonalities among definitions include an
‘unbalanced nutritional state’ that leads to ‘alterations in
body composition’ and ‘diminished function’. An unbalanced
nutritional state refers to both over- and undernutrition.

Screen for nutrition risk before surgery
• Why?
• It has been estimated that 24%–65%patients in developed countries
present for elective surgeries in a state of malnutrition risk.
• Unfortunately, perioperative malnutrition is poorly screened for and
remains largely unrecognized and undertreated—a true “silent
epidemic” in surgical care.

Screen for nutrition risk before surgery
• Why?
• >1 in every 3 hospitalized patients is malnourished at hospital
admission.
• only 3% are being recognized and diagnosed, and fewer are
treated.
• lack of malnutrition recognition is tragic, because mortality is 5
times greater in patients diagnosed with malnutrition.

Evaluation by biochemical factors
• Albumin, rapid-turnover proteins (prealbumin, transferrin, and retinal- binding protein),
C-reactive protein, total cholesterol, cholinesterase, glucose, hemoglobin, neutrophils, and
total lymphocytes are among the well-known nutritional indicators monitored before GC
surgery.
• Numerous studies have sought to develop more reliable, combined scoring systems that
can identify patients with a poor nutritional status, such as the Prognostic Nutritional
Index, Glasgow Prognostic Score, and Controlling Nutritional Status score. These
systems have been used successfully to predict postoperative complications and survival.
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Controlling nutritional status (COUNT)
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Evaluation by physical factors
• Body weight (BW) loss before surgery, which is a simple nutritional
Index
• Body mass index (BMI) is also a simple indicator of the physical
condition, but it is paradoxical.
• Measured the visceral fat area (VFA) and evaluated the impact of
obesity on postoperative complications as compared with the BMI.
They found that VFA was an independent risk factor for postoperative
complications and showed that VFA was superior to BMI in accurately
and effectively predicting the impact of obesity on short-term
outcomes.
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• There is increasing evidence that as patients age, a relationship exists between sarcopenia and
surgical outcomes.
• Sarcopenia is characterized by a loss of skeletal muscle mass and strength and is a major
contributor to overall frailty. Sarcopenia is present in a large proportion of patients with advanced
GC and significantly influences tolerance.
• Therefore, an appropriate assessment of the preoperative nutritional status through various
biochemical and physiological tests and subsequent nutritional intervention before
gastrectomy is essential for malnourished patients with GC.
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• The duration of preoperative support needed varies in
published guidelines from 7 to 14 days.
• However, even 5–7 days of preoperative nutrition therapy
can lead to a 50% reduction in postoperative morbidity in
malnourished patients.

• The ERAS protocol suggests 7–10 days, whereas ESPEN guidelines for clinical
nutrition in surgery recommend that in cases of “severe metabolic risk” (detected
with the NRS-2002, as per the guideline), 10–14 days of nutrition therapy may be
beneficial preoperatively.
• However, the length of time required to restore nutrition status in a malnourished
patient is patient dependent.
• Monitoring the effectiveness of a given nutrition intervention to improve or
resolve the nutrition diagnosis is essential.

• Interestingly, Recent consensus recommendations from the North American
Surgical Nutrition Summit emphasize that nutrition care should be established
preoperatively for both malnourished and well-nourished patients to promote
optimal nutrition status throughout the perioperative period and, to maintain their
nutrition status perioperatively.
• One-third of patients not malnourished at the time of admission become
malnourished during their stay at the hospital.
• In an open label RCT, Kabata et al found that cancer patients with no clinical
signs of malnutrition who received two bottles of a hypercaloric formula (1.5
kcal/ml: providing a total of 600 kcal and 40 g of protein for 14 days before
surgery) had fewer wound infections and anastomotic leakages compared with
the control group, who did not receive a supplement.

• In this regard, it is important to understand and weigh the risk of
delaying surgery in a malnourished patient against the imperative
to proceed with surgery.
• This process of perioperative optimization of malnutrition requires
close collaboration with surgeons.

What Is the Role of Achieving Protein Delivery
Goals in the Perioperative Period?

Protein requirements are elevated in states of stress, such as surgery, to account for the
added demands of hepatic acute phase proteins synthesis (2.6 g of muscle protein would
need to be catabolised to synthesise 1 g of the positive acute phase reactant fibrinogen),
the synthesis of proteins involved in immune function, and wound healing. Although
optimal protein intakes for surgery are currently not clearly defined, surgical nutrition
guidelines suggest that stressed patients should consume at least 1.2–2.0 g of protein/kg/d.

Several studies have identified that consuming 25–35 g of protein in a
single meal maximally stimulates muscle protein synthesis.
Whey protein and casein are among the best quality proteins overall
for muscle synthesis and to stimulate anabolism in patients.

Nutritional support postoperative
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• Early initiation of ON or EN after gastrectomy has recently been recommended.
• This may be due to the “no fasting” element of ERAS. The ERAS consensus guidelines
recommend offering patients drink and food at will from 1 day after TG.
• There is no report that has stated that early ON increased any adverse events, including
anastomotic leakage. Conversely, a Japanese multicenter RCT in 2018 showed that early ON did
not shorten the postoperative hospital stay after distal gastrectomy.
EN?ON?PN?
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Begin oral nutrition early postoperatively
• Why?
• Traditionally, institutions exercised slow resumption of regular oral food
intake (ie, began with fluids, then soft foods) upon the return of bowel
function.
• The rationale behind this traditional approach was to “rest” the bowel;
however, physiological studies have identified that the bowel continues to
be active, producing large amounts of digestive fluids, even in the fasted
state.
• Moreover, clinical and physiologic studies of gastrointestinalmotility after
surgery have found that small-bowel motility resumes within hours of the
operation, and over 90% of digestion and absorption occurs in the small
intestine.

• Early feeding refers to providing food and oral nutrition supplements to patients
within hours after their operation. Several meta-analyses have demonstrated the
safety and efficacy of oral intake within 24 h after abdominal surgery.
• After GI surgery, early feeding is associated with positive clinical outcomes such
as reduced mortality, anastomotic dehiscence, and length of hospital stay.
Additionally, early feeding may stimulate gut hormones and propulsive activity,
which encourages normal resumption of bowel activity and tolerance of oral
intake.
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Early Oral Feeding
• EOF after laparoscopic radical total gastrectomy promotes recovery
of intestinal function, improves postoperative nutritional status,
reduces the length of postoperative hospital stay and
hospitalization costs and does not increase the incidence of related
complications, which indicates its safety, feasibility and short-term
potential benefits for GC patients.
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jejunostomy feeding
• Placement of a tube should be considered if ON is likely to be
impaired, such as in advanced-age patients undergoing TG, patients
with severe preoperative malnutrition, patients who are expected to
lose BW after surgery, and patients at high risk for postoperative
complications.
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TIME?
• After surgical treatment, appetite and diet intake decline during recovery and
nutritional status can take up to 1 year to recover.
• Small intestinal functions resume between 6 and 12 h after surgery, indicating that
EN support could be started at that time.
• EN can be safely initiated 6 h after surgery via a percutaneous jejunostomy tube .
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Protein
• Insufficient protein intake is a particularly relevant problem for
patients with gastrointestinal cancers who often experience anorexia
and malnutrition because of disease progression and side effects of
medical treatment.
• Metabolically healthy patients lose between 40 and 80 g of nitrogen
after open abdominal operations, which is equivalent to 1.2 to 2.4 kg
of wet skeletal muscle.
• Patients with insulin resistance can experience a 50% greater protein
loss.
• The loss of lean muscle can delay wound healing, impair organ
function, and compromise immune function.

NUTRIENT DEFICIENCIES
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Anemia
• Nutritional anemias resulting from a vitamin B12, folate or iron
deficiency are common in gastrectomized patients.
• Consequences of anemia can be severe, therefore baseline and
periodic monitoring are important.
• Anemia often presents as a late complication of gastric resection.
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Megaloblastic and Pernicious Anemia
• Megaloblastic anemia may be the result of either vitamin B12 or folate deficiency.
• Either vitamin will clear the anemia but folate supplementation alone can provide a
deceptive cure, leaving a serious B12 deficiency untreated.
• B12 deficiency may result in PG and TG patients for numerous reasons.
• Normally, intrinsic factor is complexed to B12 and facilitates its absorption by the
terminal ileum. Reduction in intrinsic factor and reduced gastric acidity in
gastrectomized patients impairs cleavage of protein bound B12, Bacterial overgrowth and
reduced intake.
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VB12
• VB12 plays an important role in DNA synthesis and neurologic function.
VB12 deficiency is associated with hematologic, neurologic, and
psychiatric manifestations. In addition, VB12 deficiency may exert indirect
cardiovascular effects since it is associated with hyperhomocysteinemia,
which is an independent risk factor for atherosclerotic disease.
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B12 deficiency
• A wide range of B12 deficiency has been reported in PG (10%–43%) and TG (100%)
• Deficiencies have been found as early as one year post-operatively and are more
common in late post-operative states.
• Lassitude, fatigability, chills, numbness in extremities, dizziness and neurological
symptoms may be symptoms of B12 deficiency.
• Clinical features are useful in the diagnosis of megaloblastic anemia but can be non-
specific or absent in some patients.
• Therefore, periodic serum monitoring and supplementation of B12 is warranted.
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• Normally, between 2-3mg vitamin B12 are stored in human body. Because
of this, vitamin B12 deficiency would not be occured.
• Most gastric cancer patients are complicated with atrophic gastritis. A
severe lack of intrinsic factor due to gastric atrophy. Vitamin B12 storage
before TG would be decreased in gastric cancer patients with gastric
atrophy. If this hypothesis is correct, it can be inferred that the median time
to vitamin B12 deficiency after TG is shortened.
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IM or EN?
• Intramuscular supplementation of VB12 has been considered the standard treatment, although it is associated with
high costs and patient discomfort.
• A recent study investigated the effects on TG patients supplemented with either oral or intramuscular
supplementation.
• Interestingly, enteral B12 treatment increased serum concentration rapidly. Symptom resolution was comparable
in patients who received enteral and parenteral supplementation.
• It is possible that the body adapts after TG and may produce intrinsic factor
in the duodenum and jejunum.
• 1000 IM/M-300-500 PO OR EN/DAILY
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Folate
• Folate deficiency may develop after gastric surgery but is not well studied.
• Causes of folate deficiency are likely multifactorial including malabsorption (the first
site of absorption is the duodenum) and impaired digestion.
• Red blood cell (RBC) folate should be used when diagnosing a folate deficiency. RBC
folate is a better indicator of body folate stores than serum folate, which is affected by
recent folate intake.
• A daily dose of 5 mg folate is recommended in deficiency states but 100 mcg as
supplied in a daily multivitamin is probably sufficient.
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Microcytic Anemia
• Iron deficiency is the most common anemia following gastric resection.
• The duodenum, the primary site for iron absorption, is bypassed (except with BI) and reduced gastric acidity
impairs the conversion of ferric iron to the more absorbable ferrous form. Reduced iron intake may also play
a role.
• Iron supplementation, in the form of oral therapy, is effective in deficiency states.Oral iron may be given as
oral ferrous sulphate, gluconate or fumarate. Optimal response occurs with approximately 200 mg elemental
iron daily. Doses are typically administered three times daily, preferably six hours apart. The addition of
vitamin C will enhance iron absorption.
• Although vitamin C deficiency is rare, iron deficiency is exacerbated by vitamin C deficiency, and
supplemental vitamin C, regardless of its level, can increase iron absorption.
• Of note, solubilization of iron tablets may not be adequate in gastrectomized patients. Chewable or liquid
iron will ensure dissolution. Dr.sh.khalooeifard.gastric cancer
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Metabolic Bone Disease
• Bone disease, as osteoporosis, osteopenia and osteomalacia, is commonly reported
in gastrectomy Patients.
• The etiology of bone disease in gastrectomized patients is uncertain but appears to
be a combination of decreased intake of calcium, vitamin D and lactose-
containing foods, coupled with altered absorption and metabolism.
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calcium and vitamin D
• Currently, there are no accepted supplementation guidelines for calcium and vitamin D
in post-gastrectomy states.
• For patients with bone disease, 1500 mg calcium and 800 IU vitamin D daily is
recommended.
• For maximum absorption, calcium should be administered in single doses no greater
than 500 mg.
• Patients should be encouraged to include calcium rich foods in their diet as tolerated.
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• Dual energy x-ray absorptiometry (DEXA) provides an inexpensive,
reproducible method to determine BMD.
• Given the frequency with which bone disease affects gastrectomized
patients, it is reasonable to monitor BMD, even in the setting of
normal laboratory values, at baseline and then every one to two
years.
• Prompt initiation of anti-resorptive agents (calcium, vitamin D,
calcitonin and bisphosphonates) and bone-formation agents
(recombinant hormone PTH) may need to be considered in severe
cases.
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TEST
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POSTGASTRECTOMY SYNDROME
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Dumping Syndrome
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• Early dumping syndrome (DS) occurs about 15–30 minutes after ingesting
a meal and is evidenced by diarrhea, fullness, abdominal cramps and
vomiting. Postprandial weakness, flushing, dizziness and sweating may also
accompany early DS.
• The symptoms of DS are attributed to loss of the gastric reservoir and
accelerated gastric emptying of hyperosmolar contents into the proximal
small bowel.
• Late DS presents two to three hours after eating and results in weakness,
sweating, nausea, hunger and anxiety. Late dumping is thought to be the
result of reactive hypoglycemia.
• Foods and liquids with high sugar content may exacerbate symptoms of
both early and late DS.
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• Late dumping syndrome is characterized predominantly by vasomotor symptoms that occur post-
prandial, 1–3 h after eating. Symptoms include flushing, weakness, perspiration, shakiness, and
change in mentation.
• This is due to reactive hypoglycemia from excessive insulin release in response to rapid transit of
carbohydrate to the distal small bowel. The large carbohydrate load results in release of GLP-1
from L cells in the distal ileum, not normally exposed to high glucose loads. GLP-1 then stimulates
insulin release from the pancreas.
• The diagnosis of late dumping syndrome is made based on symptoms and evidence of
hypoglycemia in a patient with gastrectomy.
• An oral glucose tolerance test using 50–75 g of glucose solution after an overnight fast
confirms the diagnosis.
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Medications for Dumping Syndrome
• Octreotide, a somatostatin analog, decreases small bowel transit time
and post-prandial vasodilation and inhibits GI hormones, including
GLP-1, and insulin secretion.
• Subcutaneous octreotide injections ranging from 25 to 100 (mcg)
three times a day given 15–30 min before meals improved
symptoms.
• The use of long-acting octreotide (octreotide LAR 10–20 (mg)
intramuscular injection every 4 weeks) improved symptoms, weight
gain, and quality of life.
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• Acarbose, an a-glycosidase hydrolase inhibitor, delays conversion of
polysaccharides to monosaccharides in the intestine hence decreasing
insulin release. It has been shown to decrease symptoms of late
dumping syndrome by lessening post-prandial hypoglycemia. Side
effects include gas/bloating and diarrhea.
• More recently, Exendin-9, a GLP-1 receptor antagonist, has been
studied in post-gastrectomy patients. In one small double-blinded,
placebo-controlled cross-over study, Exendin-9 blunted insulin release
in response to an oral glucose tolerance test and improved nadir blood
sugars
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Fat Maldigestion
• Studies looking at fat malabsorption after PG and TG have demonstrated abnormal fecal fat
excretion.
• The etiology of fat malabsorption appears to be multifactorial.
• First, increased transit time prevents sufficient mixing of food with digestive enzymes and bile
salts, especially in TG or BII patients.
• Second, decreased enzyme production reduces the ratio of enzymes to food.
• Finally, due to loss of the antrum, and hence its sieving function, larger than normal food particles
empty into the jejunum, making enzyme attack more difficult.
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• Qualitative or quantitative fecal fat may be useful in the diagnosis of fat
maldigestion. For these tests to be accurate, clinicians must ensure patients
consume at least 100 grams fat/day.
• Enzyme replacement may be necessary in those patients with clinically
significant fat maldigestion.
• Prolonged steatorrhea may necessitate monitoring and replacement of fat-soluble
vitamins.
• The use of a low-fat diet with the addition of medium-chain triglycerides
(MCT) to treat steatorrhea has been suggested.
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Gastric Stasis
• Three to five percent of patients with truncal vagotomy are reported to
experience problems with gastric stasis.
• Use of gastroscopy is essential to distinguish patients with mechanical obstruction
from those with gastric atony.
• Symptoms of poor emptying may manifest as post-prandial bloating, discomfort
or fullness lasting many hours. Emesis of undigested food ingested hours to days
before may also be present.
• These patients are at a higher risk for bezoar formation, bacterial overgrowth
and intolerance to solid food; liquids may be processed normally or rapidly.
• Diet manipulation and/or prokinetic drugs are variably effective.
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Lactose Intolerance
• Lactase, the enzyme required for lactose absorption, is found primarily on villi in
the jejunum.
• Patients complaining of Most gastrectomized patients have an intact jejunum,
therefore lactose intolerance, in these patients, is deemed “functional.”
• abdominal cramping or pain, bloating, diarrhea, flatulence and distention after
consumption of lactose may do well to decrease or avoid it.
• Tolerance to lactose is typically dosedependent and may improve over time.
Many patients may be able to tolerate smaller amounts of lactose containing foods
throughout the day.
• Lactase enzymes are available for patients who wish to continue consuming dairy
products.
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Perioperative hyperglycemia
• Even patients without diabetes may develop hyperglycemia after surgery, and postoperative hyperglycemia
increases the occurrence of a multitude of adverse clinical outcomes including surgical site infection (SSI),
pneumonia, sepsis, cardiovascular complications, and acute kidney injury.
• Surgical stress activates the sympathetic nervous system and causes increased secretion of catecholamines,
cortisol, growth hormone, glucagon, and other factors.
• These counter-regulatory hormones increase hepatic glucose production, promote gluconeogenesis, and
interfere with peripheral glucose uptake to create a state of relative insulin resistance, resulting in
hyperglycemia.
• In ERAS, blood glucose management was not initially a recommended item, but it was added as a
recommended item in the guidelines published in 2012.
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• The American College of Surgeons and Surgical Infection Society also
published a consensus report indicating that better short-term
perioperative glucose control (110-150 mg/dL) is important for all
patients to lower the SSI risk.
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Thanks for your attention
Insta: @drkhalooeifard
76
E-mail: shkhalooei1367@gmail.com
rkhalooeifard@sina.tums.ac.ir
10/7/2022

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