术后营养支持是上消化道(UGI)癌症切除术管理的重要组成部分,然而,目前的临床实践知识有限。这项研究旨在描述接受UGI癌症切除术的患者接受的术后营养支持。评估ESPEN手术指南建议的依从性,为了研究食道之间的差异,胃和胰腺手术。次要目的是探索坚持使用ESPEN指南和提供营养支持之间的关联。手术并发症和住院时间(LOS)。
NOURISH点患病率研究于2019年9月至2020年6月在澳大利亚27个三级中心进行。使用主观全局评估诊断营养不良。关于术后饮食代码的数据,营养支持处方(口服(ONS),肠内(EN),在入院的前10天,营养师收集了肠胃外(PN)和营养充足性。Fisher精确检验用于确定手术类型之间营养管理和遵守ESPEN指南的差异。多变量回归分析与手术结果的关联。
纳入了两百名参与者(42%是胰腺,33%食道,25%的胃手术)。总的来说,只有34.9%(n=53)符合适用于他们的指南建议.早期口服液体或固体(术后24小时内)开始23.5%(n=47),而ONS/EN/PN启动率为49.5%(n=99)。只有25%的胰腺手术在术后第一天开始营养支持,而食管手术为86.4%,胃手术为42.0%(p<0.001)。在那些“嘴巴没有”的人中,EN/PN在24小时内开始,51.0%(n=78),胰腺和胃手术的比例分别为18.5%和45.2%,而食管手术的比例为86.0%(p<0.001)。在营养不良的患者中,35.7%(n=30)在24小时内开始EN,胰腺和胃的比例分别为11.1%和31.8%,而食管手术的比例为73.1%(p<0.001)。对于满足≥7天的能量/蛋白质需求<60%的患者,只有14.8%(n=9)接受了EN/PN,胰腺和胃的比例分别为2.5%和16.7%,而食管手术的比例为75.0%(p<0.001)。在没有EN/PN的情况下,通过口\'nil\'或\'清除液体\'所花费的天数,估计需求满足<60%的天数与LOS增加和并发症独立相关.
总的来说,对大多数评估的ESPEN指南的依从性较差,对接受胰腺和胃手术的患者的护理依从性低于食管切除术。营养不良与LOS和并发症增加有关。显然需要进行知识翻译和实施研究,以增加对澳大利亚环境中基于证据的建议的依从性,并通过对障碍和促进因素的理解来支持最佳的术后营养管理。
Postoperative nutrition support is an essential component of management in upper gastrointestinal (UGI) cancer resection, however there is limited knowledge of current clinical practice. This study aimed to describe the postoperative nutrition support received by patients undergoing UGI cancer resections, assess adherence with ESPEN surgical
guideline recommendations, and to investigate differences between oesophageal, gastric and pancreatic surgeries. The secondary aim was to explore the association of adherence with ESPEN
guidelines and provision of nutrition support, with surgical complications and length of stay (LOS).
The NOURISH point prevalence study was conducted between September 2019-June 2020 across 27 Australian tertiary centres. Malnutrition was diagnosed using subjective global assessment. Data on postoperative diet codes, prescription of nutrition support (oral (ONS), enteral (EN), parenteral (PN)) and nutritional adequacy were collected by dietitians for the first 10 days of admission. Fisher\'s exact test was used to determine differences in nutritional management and adherence to ESPEN
guidelines between surgery types. Multivariate regression analysed associations with surgical outcomes.
Two-hundred participants were included (42% pancreatic, 33% oesophageal, 25% gastric surgery). Overall, only 34.9% (n = 53) met the
guideline recommendations that were applicable to them. Early oral intake of fluids or solids (within 24 h post surgery) was initiated for 23.5% (n = 47), whilst ONS/EN/PN was initiated for 49.5% (n = 99). Only 25% of pancreatic surgeries had nutrition support initiated on the first postoperative day compared to 86.4% of oesophageal and 42.0% of gastric surgeries (p < 0.001). In those who were \'nil by mouth\', EN/PN were commenced within 24 h for 51.0% (n = 78), with 18.5% and 45.2% for pancreatic and gastric surgeries compared to 86.0% in oesophageal surgeries (p < 0.001). In malnourished patients, 35.7% (n = 30) commenced EN within 24 h, with 11.1% and 31.8% for pancreatic and gastric compared to 73.1% in oesophageal surgeries (p < 0.001). For patients meeting <60% energy/protein requirements for ≥7 days, only 14.8% (n = 9) received EN/PN, with 2.5% and 16.7% of pancreatic and gastric compared to 75.0% of oesophageal surgeries (p < 0.001). The number of days spent \'nil by mouth\' or \'clear fluids\' without EN/PN, as well as number of days with <60% estimated requirements met were independently associated with increased LOS and complications.
Overall, there was poor adherence to the majority of assessed ESPEN
guidelines, and care for patients undergoing pancreatic and gastric surgeries was less compliant than oesophagectomy. Poor nutritional adequacy was associated with increased LOS and complications. There is a clear need for knowledge translation and implementation studies to increase adherence to evidence-based recommendations in the Australian setting supported by an understanding of barriers and enablers to optimal postoperative nutrition management.