Surgical Patient Optimization Summit May 18, 2018 BMI/Malnutrition As Markers For Post-surgical Morbidity Martin Luchtefeld, MD

Surgical Patient Optimization Summit May 18, 2018 I have no financial disclosures

BMI As A Risk Factor At what BMI do we quit offering elective surgery?

BMI As A Risk Factor Bmi of 31 so he is obese 6’ 234 lbs

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Obesity and Colorectal Surgery Thirty studies 23,649 patients including 17,895 non-obese and 5754 obese No significant differences: intra-operative blood loss, overall postoperative morbidity, anastomotic leakage, reoperation rate, mortality and the number of retrieved lymph nodes in patients operated on for malignancy. Colorectal Disease ª 2016 The Association of Coloproctology of Great Britain and Ireland. 18, O337–O366 The influence of obesity and body mass index on the outcome of laparoscopic colorectal surgery: a systematic literature review A. Hotouras*†, Y. Ribas‡, S. A. Zakeri†, Q. M. Nunes§, J. Murphy¶, C. Bhan† and S. D. Wexner**

Pooled analysis of 43 studies BMI as a Predictor for Perioperative Outcome of Laparoscopic Colorectal Surgery Pooled analysis of 43 studies Higher BMI was found to be significantly associated with increased risk of SSI (OW vs NO: OR,1.56) More accurate conclusions, with more precise cutoff values, can be achieved by future well-designed prospective investigations.

Int J Colorectal Dis (2017) 32:1447–1451 BMI Obese BMI>30 N=604 Morbidly Obese BMI>40 N=257 Super Obese BMI>50 N=62 SSI/Anastomotic leak 4.1/1.8% 7.8/3.1% 24.2/4.8% Overall Morbidity 12% 16% 35% OR Time 163 208

Int J Colorectal Dis (2017) 32:1447–1451 BMI Obese BMI>30 N=604 Morbidly Obese BMI>40 N=257 Super Obese BMI>50 N=62 SSI/Anastomotic leak 4.1/1.8% 7.8/3.1% 24.2/4.8% Overall Morbidity 12% 16% 35% OR Time 163 208

Int J Colorectal Dis (2017) 32:1447–1451 BMI Obese BMI>30 N=604 Morbidly Obese BMI>40 N=257 Super Obese BMI>50 N=62 SSI/Anastomotic leak 4.1/1.8% 7.8/3.1% 24.2/4.8% Overall Morbidity 12% 16% 35% OR Time 163 208

BMI and SSI in Colorectal Surgery at Spectrum 3651 colorectal procedures 1/1/2014 – 12/31/2017 BMI and rate of SSI: BMI 29.9 and Below: 143/1943 (7.36%) Obese ( BMI 30 – 39.9): 83/794 (10.45%) Morbidly Obese (BMI 40-49.9): 31/224 = 13.84 % Super Morbidly Obese (BMI>50) : 8/30 = 26.7 %

BMI and Colorectal Cancer Surgery

BMI and Colorectal Cancer Surgery

BMI and Colorectal Cancer Surgery For patients with BMI ≥35 the odds ratio (OR) for surgical complications was 1.71 (95% CI 1.03-2.85). Increased BMI was associated with anastomotic leakage (OR 1.06), superficial wound dehiscence (OR 1.16), deep wound dehiscence (OR 1.17) and wound infection (OR 1.07). Patients with a BMI≥30kg/m2 were more likely to be offered open surgery and less likely to be offered laparoscopic surgery compared with patients with BMI <30kg/m2 (Chi-sq p-value 0.002). Conversion to open surgery was more likely for BMI≥30kg/m2 (OR 2.30,), for rectal cancer (OR 2.85)

BMI and Ileoanal Pouch 178 patients (103 non-obese and 75 obese (BMI>30)) patients were identified who underwent IPAA. Obese patients had an increased rate of overall complications (80 % vs. 64%, p = 0.03) Obese patients had more anastomotic/pouch strictures (27% vs. 6%, p < 0.01), inflammatory pouch complications (17 % vs. 4%, p < 0.01) and pouch fistulas (12% vs. 3%, p = 0.03). In a regression model, obesity remained a significant risk factor (odds ratio [OR] = 2.86, p = 0.01) for pouch-related complications. J Gastrointest Surg. 2014 Mar;18(3):573-9. doi: 10.1007/s11605-013-2353-8

Assessing Malnutrition

Assessing Malnutrition BMI<18.5 Albumin <3.5, prealbumin <11-15 Prognostic nutritional index (PNI)<40 Neutrophil/lymphocyte ratio (NLR) >4 Controlling nutritional status(CONUT)>2 Weight loss >10% of body weight Sarcopenia

Assessing Malnutrition The European Society for Clinical Nutrition and Metabolism: nutritional risk situations body weight loss of 10% to 15% within 6 months BMI less than 18.5 kg/m2 subjective global assessment grade C Nutritional Risk Screening >5 Serum albumin less than 30 mg/dL (without evidence of hepatic and renal dysfunction). Lookis at randomized trials of immunonutrition in GI malignancies

Assessing Malnutrition NSQIP study of 42,483 patients with Colorectal cancer Studied three measures of malnutrition: albumin (<3.5), body weight loss >10%, BMI <18.5 Hu et al. Nutrition Journal (2015) 14:91 DOI 10.1186/s12937-015-0081-5

Malnutrition and Surgical Complications Hu et al. Nutrition Journal (2015) 14:91 DOI 10.1186/s12937-015-0081-5

Assessing Malnutrition Conclusions: There are no single, specific tools used to screen or assess the nutritional status of colorectal cancer patients. All tools showed varied diagnostic accuracies when compared to the reference standards SGA and PG-SGA. Hence clinical judgment combined with perhaps the SGA or PG-SGA should play a major role. (SGA: subjective global assessment; PG-SGA: Patient Generated Subjective Global Assessment) Diagnostic test accuracy of nutritional tools used to identify undernutrition in patients with colorectal cancer: a systematic review. JBI Database of Systematic Reviews & Implementation Reports 2015;13(4) 141 - 187

BMI/Malnutrition As Markers For Post-surgical Morbidity Conclusion:

BMI/Malnutrition As Markers For Post-surgical Morbidity Conclusion: Malnutrition is bad!

BMI/Malnutrition As Markers For Post-surgical Morbidity Conclusion: Malnutrition is bad! What now?

BMI/Malnutrition As Markers For Post-surgical Morbidity Immunonutrition Arginine Omega 3 fatty acids Nucleotides Glutamine

BMI/Malnutrition As Markers For Post-surgical Morbidity Immunonutrition Arginine: under stress, arginine is the primary fuel source for T cells; it helps maintain immune function and decreases the risk of infection Omega 3 fatty acids Nucleotides Glutamine

BMI/Malnutrition As Markers For Post-surgical Morbidity Immunonutrition Arginine Omega 3 fatty acids: play a role in the resolution of inflammation and enhance wound healing; enhance immune response by improving lymphocyte function Nucleotides Glutamine May also decrease arginase

Immunonutrition in GI Malignancy Lookis at randomized trials of immunonutrition in GI malignancies Medicine Volume 94, Number 29, July 2015

Immunonutrition in GI Malignancy Pre-operative Nutrition Support in Patients Undergoing Gastrointestinal Surgery. (Review) Cochrane Collaboration Lookis at randomized trials of immunonutrition in GI malignancies

Immunonutrition in GI Malignancy Lookis at randomized trials of immunonutrition in GI malignancies Gastroenterol Clin N Am 47 (2018) 231–242

Immunonutrition in GI Malignancy Lookis at randomized trials of immunonutrition in GI malignancies Gastroenterol Clin N Am 47 (2018) 231–242

Immunonutrition in Cystectomy Immunonutrition intervention was evaluated in a randomized controlled trial of 29 patients Compared calorie and nitrogen matched oral nutrition support before and after bladder surgery Rates of postoperative complications of decreased by 33% (p < 0.060) and infections were reduced by 39% (p ¼< 0.027). Hamilton-Reeves JM, Bechtel MD, Hand LKet al: Effects of immunonutrition for cystectomy on immune response and infection rates: a pilot randomized controlled clinical trial. Eur Urol 2016; 69: 389.

Malnutrition in Orthopedics “Literature is scant on nutritional intervention and its effects in orthopedic patients.”

Malnutrition in Orthopedics Authors' conclusions: There is low-quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality… The Cochrane Library Nutritional supplementation for hip fracture aftercare in older people;First published: 30 November 2016;Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

BMI/Malnutrition As Markers For Post-surgical Morbidity Conclusions

BMI/Malnutrition As Markers For Post-surgical Morbidity Conclusions BMI > 40 is a reasonable cut-off for elective abdominal colorectal surgery

BMI/Malnutrition As Markers For Post-surgical Morbidity Conclusions BMI > 40 is a reasonable cut-off for elective abdominal colorectal surgery (but is likely different for other surgeries)

BMI/Malnutrition As Markers For Post-surgical Morbidity Conclusions BMI > 40 is a reasonable cut-off for elective abdominal colorectal surgery Albumin > 3.5 is a reasonable measure of good nutrition in current state

BMI/Malnutrition As Markers For Post-surgical Morbidity Conclusions BMI > 40 is a reasonable cut-off for elective abdominal colorectal surgery Albumin > 3.5 is a reasonable measure of good nutrition in current state Immunonutrition should be a part of pre-operative preparation for intra-abdominal malignancies

BMI/Malnutrition As Markers For Post-surgical Morbidity Conclusions BMI > 40 is a reasonable cut-off for elective abdominal colorectal surgery Albumin > 3.5 is a reasonable measure of good nutrition in current state Immunonutrition should be a part of pre-operative preparation for intra-abdominal malignancies This field is ripe for research

Sarcopenia “the loss of skeletal muscle mass and quality” Mei et al. Perioperative Medicine (2016) 5:30 DOI 10.1186/s13741-016-0052-1

Sarcopenia - “the loss of skeletal muscle mass and quality” Colorectal cancer Increased infections Decreased Survival Colorectal cancer with liver mets Increased morbidity Long term outcomes? Hepatocellular CA and hepatectomy More predictive of long term adverse outcomes (short term results not as predictive) Pancreatic CA and resection Generally predicts greater complications Mei et al. Perioperative Medicine (2016) 5:30 DOI 10.1186/s13741-016-0052-1