Arved Weimann

ESPEN Guidelines on Parenteral Nutrition: Surgery

In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.

ESPEN guideline: Clinical nutrition in surgery

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: • integration of nutrition into the overall management of the patient • avoidance of long periods of preoperative fasting • re-establishment of oral feeding as early as possible after surgery • start of nutritional therapy early, as soon as a nutritional risk becomes apparent • metabolic control e.g. of blood glucose • reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function • minimized time on paralytic agents for ventilator management in the postoperative period • early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice.

ESPEN expert group recommendations for action against cancer-related malnutrition

Patients with cancer are at particularly high risk for malnutrition because both the disease and its treatments threaten their nutritional status. Yet cancer-related nutritional risk is sometimes overlooked or under-treated by clinicians, patients, and their families. The European Society for Clinical Nutrition and Metabolism (ESPEN) recently published evidence-based guidelines for nutritional care in patients with cancer. In further support of these guidelines, an ESPEN oncology expert group met for a Cancer and Nutrition Workshop in Berlin on October 24 and 25, 2016. The group examined the causes and consequences of cancer-related malnutrition, reviewed treatment approaches currently available, and built the rationale and impetus for clinicians involved with care of patients with cancer to take actions that facilitate nutrition support in practice. The content of this position paper is based on presentations and discussions at the Berlin meeting. The expert group emphasized 3 key steps to update nutritional care for people with cancer: (1) screen all patients with cancer for nutritional risk early in the course of their care, regardless of body mass index and weight history; (2) expand nutrition-related assessment practices to include measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure, and physical function; (3) use multimodal nutritional interventions with individualized plans, including care focused on increasing nutritional intake, lessening inflammation and hypermetabolic stress, and increasing physical activity.

Central Venous Catheter Complications during Home Parenteral Nutrition: A Prospective Pilot Study of 481 Patients with More than 30,000 Catheter Days

Background: Home parenteral nutrition (HPN) has been shown to delay deterioration in cancer patients with malnutrition. Its risk-benefit ratio, however, is determined by the threat of central venous catheter (CVC) complications. Only few prospective studies on this subject exist, most of them based on small samples. The objective of this study was to provide reliable estimates of incidence rates of CVC complications in everyday HPN patient care in Germany. Patients and Methods: Aiming for a large prospective cohort study, we cooperated with a service provider caring for HPN patients nationwide. Between July 1 and November 30, 2006, all consecutive adult patients with more than 10 infusion days and no previous history of HPN were recruited. Follow-up ended on January 31, 2007. Data were collected in a standardised way by the provider’s staff. To prevent underreporting, we used computer-assisted telephone interviews with medical caregivers as a provider-independent data source. Results: 481 patients met the inclusion criteria, contributing a total of 31,337 catheter days. 52 patients experienced a total of 63 CVC complications, resulting in an incidence rate of 2.01 CVC complications per 1,000 catheter days including 1.02 CVC infections per 1,000 catheter days. Conclusion: HPN administration can be safely performed with a relatively low rate of CVC complications.

Klinische Ernährung in der Chirurgie

BACKGROUND While enhanced recovery after surgery (ERAS) programs are the standard for perioperative management, special nutritional care has to be administered to malnourished patients and those at metabolic risk with special regard to patients with postoperative complications. METHODS Existing guidelines of the German and European societies of nutritional medicine (DGEM and ESPEN) on enteral and parenteral nutrition in surgery were merged and in accordance with the principles of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, German Association of the Scientific Medical Societies) and Ärztliches Zentrum für Qualität in der Medizin (AeZQ, German Agency for Quality in Medicine) revised and extended. RESULTS AND DISCUSSION The working group developed 41 consensus-based recommendations for perioperative nutrition. The recommendation strength is: 9x A (recommendation based on significant good quality literature containing at least one randomized controlled trial), 12x B (recommendation based on well-designed trial without randomization), 13x C (recommendation based on expert opinions and/or clinical experience of respected authorities) and 7x CCP (clinical consensus point). CONCLUSION Even in patients without obvious malnutrition perioperative nutritional support is indicated when oral food intake is not feasible or inadequate for a longer period of time.

Clinical nutrition in surgery. Guidelines of the German Society for Nutritional Medicine

BACKGROUND While enhanced recovery after surgery (ERAS) programs are the standard for perioperative management, special nutritional care has to be administered to malnourished patients and those at metabolic risk with special regard to patients with postoperative complications. METHODS Existing guidelines of the German and European societies of nutritional medicine (DGEM and ESPEN) on enteral and parenteral nutrition in surgery were merged and in accordance with the principles of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, German Association of the Scientific Medical Societies) and Ärztliches Zentrum für Qualität in der Medizin (AeZQ, German Agency for Quality in Medicine) revised and extended. RESULTS AND DISCUSSION The working group developed 41 consensus-based recommendations for perioperative nutrition. The recommendation strength is: 9x A (recommendation based on significant good quality literature containing at least one randomized controlled trial), 12x B (recommendation based on well-designed trial without randomization), 13x C (recommendation based on expert opinions and/or clinical experience of respected authorities) and 7x CCP (clinical consensus point). CONCLUSION Even in patients without obvious malnutrition perioperative nutritional support is indicated when oral food intake is not feasible or inadequate for a longer period of time.

Organotypic slice cultures of human gastric and esophagogastric junction cancer

Gastric and esophagogastric junction cancers are heterogeneous and aggressive tumors with an unpredictable response to cytotoxic treatment. New methods allowing for the analysis of drug resistance are needed. Here, we describe a novel technique by which human tumor specimens can be cultured ex vivo, preserving parts of the natural cancer microenvironment. Using a tissue chopper, fresh surgical tissue samples were cut in 400 μm slices and cultivated in 6‐well plates for up to 6 days. The slices were processed for routine histopathology and immunohistochemistry. Cytokeratin stains (CK8, AE1/3) were applied for determining tumor cellularity, Ki‐67 for proliferation, and cleaved caspase‐3 staining for apoptosis. The slices were analyzed under naive conditions and following 2–4 days in vitro exposure to 5‐FU and cisplatin. The slice culture technology allowed for a good preservation of tissue morphology and tumor cell integrity during the culture period. After chemotherapy exposure, a loss of tumor cellularity and an increase in apoptosis were observed. Drug sensitivity of the tumors could be assessed. Organotypic slice cultures of gastric and esophagogastric junction cancers were successfully established. Cytotoxic drug effects could be monitored. They may be used to examine mechanisms of drug resistance in human tissue and may provide a unique and powerful ex vivo platform for the prediction of treatment response.

Avoiding underfeeding in severely ill patients

www.thelancet.com Vol 381 May 25, 2013 1811 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ Authors’ reply We thank Arved Weimann and Pierre Singer for their letter which gives us the opportunity to explain further the rationale behind our suggested strategy. The early parenteral nutrition approach suggested by Weimann and Singer is mainly based on the association between the magnitude of the so-called caloric debt and the complication rate. By contrast, we based our algorithm on recent progress in the understanding of the metabolic response to critical illness, supported by the results of prospective trials. From an evolutionary perspective, the metabolic response to stress is highly preserved among species, and is largely expressed as insulin resistance, which is now understood to be an adaptive mechanism developed to survive injury. Insulin resistance results in an unavoidable increase in endogenous glucose production, up to 1 500 kcal per day, at least for the fi rst 3 days after injury. Hence, the caloric debt during the acute phase of critical illness should no longer be calculated as the Avoiding underfeeding in severely ill patients

Quality of Life of Colorectal Cancer Patients in Certified Centers versus Non-Certified Hospitals

Background: Since 2006, in Germany colorectal cancer patients can be treated in certified colorectal cancer centers. The aim of this explorative study was to investigate whether there are differences in the quality of life (QoL) of colorectal cancer patients who were treated in certified versus noncertified centers. Patients and Methods: A total of 284 colorectal cancer patients participated in the study: 184 patients from certified colorectal cancer centers and 100 patients from noncertified centers. Data on QoL (using the Quality of Life Questionnaire of the European Organization for Research and Treatment of Cancer (EORTC-QLQ C30)), patient satisfaction, mental distress and sociodemographic data were assessed with a questionnaire in a written survey after the hospital stay. The moderating influence of patientrelated characteristics (e.g. age, sex, patient satisfaction, and psychological distress) and cancerrelated factors (Union internationale contre le cancer (UICC) stage) were tested. Results: On a descriptive level, patients from noncertified centers had a higher QoL in 5 subdimensions (higher physical and role functioning and less insomnia, appetite loss and financial difficulties). After adjustment, only 2 differences remained significant: physical functioning (p < 0.01) and role functioning (p = 0.02). Conclusion: Structural improvements in the oncological care are not necessarily reflected in a better QoL of the patients treated in certified colorectal cancer centers. The findings are discussed in the context of the applied study design.

Ernährung bei Organdysfunktion

Die Ernährungstherapie – und dies ist inzwischen wohl allgemein anerkannt – ist ebenso wie beispielsweise die Beatmungstherapie oder das hämodynamische Management eine unverzichtbare Säule in der Therapie jedes Intensivpatienten. Nicht jeder Intensivpatient bedarf frühzeitig einer kalorienbedarfsdeckenden kombinierten enteralen-/parenteralen Ernährung. Es besteht jedoch Einigkeit, dass mangelernährte Patienten mit eingeschränkter enteraler Toleranz oder solche mit Organdysfunktion, bei denen ein längerer Intensivaufenthalt vorausgesehen werden muss, innerhalb von 3 bis 5 Tagen zusätzlich parenteral ernährt werden. Die Herausforderung ist es für den Intensivmediziner, mit seiner klinischen Erfahrung die geeigneten Risikopatienten zu erkennen. Zusätzliche metabolische Probleme der Substratutilisation sind beim Vorliegen einer Organinsuffizienz zu erwarten. Die Ernährung muss qualitativ optimal zusammengesetzt und vollständig sein und sollte quantitativ ausreichend verabreicht werden. In den letzten Jahren sind mehrere Studien erschienen, die verschiedene Aspekte der Ernährungstherapie von Intensivpatienten sehr kritisch beleuchtet haben und in der Fachpresse breit diskutiert wurden. Dies betraf aber nicht die grundsätzliche Notwendigkeit der Ernährung an sich sondern Fragen der optimalen Form der Ernährung, der Zusammensetzung, des Zufuhrwegs, der Geschwindigkeit des Ernährungsaufbaus bzw. auch der Wirkung besonderer Ernährungszusätze, wie spezifischer Substrate (sog. Pharmakonutrients). Die Frage, welchen Einfluss Organversagen auf die Ernährungstherapie ausüben, ist als ein Aspekt der Ernährungstherapie von Intensivpatienten in diesen Diskussionen der letzten Jahre weitgehend vernachlässigt worden. Wie wird der Stoffwechsel und Substratbedarf durch Organversagen modifiziert? Erfordern diese die Verwendung spezieller Nährstoffe? Ist die Ernährung dabei gänzlich unterschiedlich oder eher als eine Adaptierung einer Intensivernährung zu sehen? Wegen der großen Unsicherheiten zu diesem wichtigen Thema haben wir uns entschlossen, diesen Fragen ein Themenheft Ernährung bei Organinsuffizienz zu widmen. In den einzelnen Beiträgen wird von namhaften Experten der Einfluss von Organinsuffizienz auf Stoffwechsel und Ernährung abgehandelt, wobei die klassischen Organversagen von Lunge bzw. Niere oder Leber, das Darmversagen und die schwere akute Pankreatitis besprochen werden. Aus diesen Beiträgen geht hervor, dass sich die Ernährungstherapie von Intensivpatienten mit Organversagen nicht grundsätzlich von der bei anderen Patienten unterscheidet. Jedoch wird auch klar, dass verschiedene Organversagen bzw. im Fall des Nierenversagen auch die durchgeführten (extrakorporalen) Therapiemaßnahmen einen ausgeprägten Einfluss auf den Stoffwechsel und den Substratbedarf haben. Diese vielfältigen Änderungen müssen in der Planung und Durchführung der Ernährungstherapie berücksichtigt werden. Die Autoren dieser Ausgabe sind nicht nur anerkannte Experten auf ihrem Gebiet sondern sind auch federführend an den Leitlinien zur enteralen und parenteralen Ernährung, die derzeit von der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) erarbeitet werden, beteiligt. Damit ist gewährleistet, dass die Beiträge in diesem Themenheft dem aktuellsten Stand der Wissenschaft entsprechen.