Perioperative Nutrition Optimization and Support in Next Stage of Enhanced Recovery After Surgery
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AbstractWe wish to highlight the need for better preoperative screening, assessment and management of protein-energy malnutrition in future ERAS endeavours.
Malnutrition is common in the ageing population but is usually unrecognized and untreated (1), exposing patients at higher risks of postoperative complications and discharge to a facility (2). The perioperative use of accurate nutritional screening tools and timely referrals to dieticians are crucial steps towards determining the best nutritional approach for patients. Based upon the widely used Malnutrition Universal Screening Tool, the Perioperative Nutrition Screen (PONS) tool includes any one of the following criteria: (1) Body Mass Index (BMI)<18.5 in patients aged <=65 years or BMI<20 in patients aged>65 years, (2) unintentional weight loss>10% in last 6 months, (3) <50% of normal oral diet intake in last week, and (4) serum albumin concentration <3 g/L (2). However, the diagnostic accuracy of PONS against the Subjective Global Assessment (SGA) performed by a dietician is currently unknown. Using the recent Global Leadership Initiative on Malnutrition (GLIM) consensus-based framework that includes three phenotypic (weight loss, low BMI, reduced muscle mass) and two etiologic (reduced food intake and inflammation) criteria for malnutrition diagnosis and severity grading (3), four GLIM criteria combinations are available for PONS malnutrition classification risk. These are (a) weight loss/reduced food intake, (b) low BMI/reduced food intake, (c) weight loss/albumin, and (d) low BMI/albumin. Which GLIM criteria combination has the highest diagnostic test performance against the SGA remains to be evaluated but is necessary to estimate the true extent of perioperative malnutrition in ERAS patients.
Opportunities and challenges for nutrition optimization and support during prehabilitation are emerging (1) and will require timely coordination and communication between multidisciplinary team members. A systematic review of nine studies (n=914) showed that nutritional prehabilitation with and without exercise was associated with a reduction in hospital length of stay (-2.2 days, 95%CI: -3.5 to -0.9) but patient-centred outcomes (eg. quality of recovery, disability-free survival and quality of life) were not reported (4). Determining the best approach for nutrition optimization and support for improving patient-centred outcomes will first require the application and validation of the GLIM criteria for PONS in the next stage of ERAS.
References
1. Williams DGA, Villalta E, Aronson S, et al. Tutorial: Development and implementation of a multidisciplinary preoperative nutrition optimization clinic. JPEN.2020;44:1185-96.
2. Sathianathen NJ, Kwaan M, Lawrentschuk N, et al. Adverse impact of malnutrition markers on major abdominopelvic cancer surgery. ANZ J Surg.2019;89:509-14.
3. de van der Schueren MAE, Keller H; GLIM Consortium, et al. Global Leadership Initiative on Malnutrition (GLIM): Guidance on validation of the operational criteria for the diagnosis of protein-energy malnutrition in adults. Clin Nutr. 2020;39:2872-80.
4. Gill C, Buhler K, Bresee L, et al. Effects of nutritional prehabilitation, 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
Helen Hoi Ting CHEUNG, MS, RD
Man Kin Henry WONG, MBChB FHKCA
Anna LEE, MPH, PhD
Malnutrition is common in the ageing population but is usually unrecognized and untreated (1), exposing patients at higher risks of postoperative complications and discharge to a facility (2). The perioperative use of accurate nutritional screening tools and timely referrals to dieticians are crucial steps towards determining the best nutritional approach for patients. Based upon the widely used Malnutrition Universal Screening Tool, the Perioperative Nutrition Screen (PONS) tool includes any one of the following criteria: (1) Body Mass Index (BMI)<18.5 in patients aged <=65 years or BMI<20 in patients aged>65 years, (2) unintentional weight loss>10% in last 6 months, (3) <50% of normal oral diet intake in last week, and (4) serum albumin concentration <3 g/L (2). However, the diagnostic accuracy of PONS against the Subjective Global Assessment (SGA) performed by a dietician is currently unknown. Using the recent Global Leadership Initiative on Malnutrition (GLIM) consensus-based framework that includes three phenotypic (weight loss, low BMI, reduced muscle mass) and two etiologic (reduced food intake and inflammation) criteria for malnutrition diagnosis and severity grading (3), four GLIM criteria combinations are available for PONS malnutrition classification risk. These are (a) weight loss/reduced food intake, (b) low BMI/reduced food intake, (c) weight loss/albumin, and (d) low BMI/albumin. Which GLIM criteria combination has the highest diagnostic test performance against the SGA remains to be evaluated but is necessary to estimate the true extent of perioperative malnutrition in ERAS patients.
Opportunities and challenges for nutrition optimization and support during prehabilitation are emerging (1) and will require timely coordination and communication between multidisciplinary team members. A systematic review of nine studies (n=914) showed that nutritional prehabilitation with and without exercise was associated with a reduction in hospital length of stay (-2.2 days, 95%CI: -3.5 to -0.9) but patient-centred outcomes (eg. quality of recovery, disability-free survival and quality of life) were not reported (4). Determining the best approach for nutrition optimization and support for improving patient-centred outcomes will first require the application and validation of the GLIM criteria for PONS in the next stage of ERAS.
References
1. Williams DGA, Villalta E, Aronson S, et al. Tutorial: Development and implementation of a multidisciplinary preoperative nutrition optimization clinic. JPEN.2020;44:1185-96.
2. Sathianathen NJ, Kwaan M, Lawrentschuk N, et al. Adverse impact of malnutrition markers on major abdominopelvic cancer surgery. ANZ J Surg.2019;89:509-14.
3. de van der Schueren MAE, Keller H; GLIM Consortium, et al. Global Leadership Initiative on Malnutrition (GLIM): Guidance on validation of the operational criteria for the diagnosis of protein-energy malnutrition in adults. Clin Nutr. 2020;39:2872-80.
4. Gill C, Buhler K, Bresee L, et al. Effects of nutritional prehabilitation, 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
Helen Hoi Ting CHEUNG, MS, RD
Man Kin Henry WONG, MBChB FHKCA
Anna LEE, MPH, PhD
Acceptance Date18/05/2021
All Author(s) ListHelen Hoi Ting CHEUNG, Man Kin Henry WONG, Anna LEE
Title of PublicationPerioperative Nutrition Optimization and Support in Next Stage of Enhanced Recovery After Surgery, online comment to Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review
Year2021
Month5
Day18
PublisherAmerican Medical Association
Place of PublicationUSA
LanguagesEnglish-United States
KeywordsEarly Recovery After Surgery, prehabilitation
