CASE STUDY: GI Surgery Cristel Moubarak – Dietetic Intern – 2014 Candidate Elena Tejedor – GI/ENT Surgery RD – Preceptor March 2014

OUTLINE Introduction Patient Case Initial Screening Nutrition Diagnosis Nutrition Needs Interventions Complications Follow-ups

Ms. C 66 year old female Admitted with Peritoneal Mesothelioma on Dec 10 PMHx: Hypercholesterolemia and depression Baseline Diet: Good appetite and intake No recent significant weight loss ETOH Hx (2-3 glasses of wine/day) Mesothelioma is pretty rare… prevalence is 1-2 cases per million WORLDWIDE (200-400 new cases annually) – and out of those cases, 20-30% is in the peritoneum. Usually, median survival time is between 6-12 months. Since its symptoms are so non-specific, it’s hard to detect – so by the time we find out, it’s in its advanced stage

INITIAL NUTRITION ASSESSMENT Usual Weight = 61.4 kg Current Weight = 60 kg Height = 165 cm BMI = 22 kg/m2 Nutritional Status Risk Factors: Nausea, NPO x4 days, hypercatabolism, substance abuse (ETOH Hx), fatigue, decreased mobility SGA: Mildly malnourished, at moderate risk At risk for more severe malnutrition due to her risk factors, GI alteration and chemo/surgeries Dr. Yarrow McConnell is the surgical oncologist – MSC in Cancer Biology She was brought in to VGH from Alberta specifically for these operations. Once she had a diagnostic laparoscopy (abdmn scope) which showed limited extent of disease – pt was brought in for curative intent surgery

PROCEDURES Lysis of Adhesions Right Hemicolectomy Omentectomy Cholecystectomy Partial Vaginectomy Bilateral Salpingo-oophorectomy HIPEC Right hemicolectomy – resection of the right (ascending) colon and stapling the small bowel with the remaining colon Scattered nodules in the distal part of the small bowel and a few on anterior and a little on posterior surface of the stomach which were destroyed by a high electric current (fulguration)  preserved the small bowel Fulguration, also called electrofulguration, is a procedure to destroy and remove tissue (such as a malignant tumor) using a high-frequency electric current applied with a needlelike electrode. Total time of procedure (cytoreduction and HIPEC was 8 hours – 9 am to 5 pm ) By touching the bowel a lot when removing other organs, it increases the risk of developing an ileus

BASIC DEFINITIONS Peritoneal Mesothelioma: Rare cancer that develops in the mesothelium cells (usually due to exposure to asbestos) in the peritoneum (abdomen cavity lining). Cytoreductive Surgery: Removing all visible tumors that can be removed throughout the peritoneal cavity. Hyperthermic Intraperitoneal Chemotherapy (HIPEC): It is designed to kill any remaining cancer cells by circulating a sterile solution--containing a chemotherapeutic agent--throughout the peritoneal cavity, for a maximum of two hours. Either explain the procedure, or show video: http://www.hipectreatment.com/videos/hipec_animation.ogv Peritoneal Mesothelioma: 10-20% of all malignant mesotheliomas. Causes weight loss, abdominal pain and swelling due to build-up of fluid in the abdomen; also bowel obstruction, blood clotting, anemia and fever. In 60-70% of mesothelioma cases the person has been exposed to asbestos. If non-asbestos related, it could be due to exposure to radiation, genetic factors, dietary factors, chemical exposure and viruses. HIPEC: It improves drug absorption and most side effects of normal intravenous chemo are avoided. Surgery separates adhesions and debulks tumor. Use a high dose of chemo because the barrier function of the abdominal wall limits the amount of drug that enters the bloodstream  better tumor killing effect especially of those tumor cells that could remain after surgery. It’s hyperthermic fluid used  heated to above 40 deg C. Heat is toxic for cancer cells but not so much for normal cells. The solution needs to be consistently heated to prevent temp drop with blood perfusion in the abdo. This is done by having in and out flow of tubes, a roller pump and heat exchanger (30-90 minutes) The aim of this procedure is to prolong one’s life expectancy and overall quality of life  often survive >10 years without signs of recurrence

NUTRITION DIAGNOSIS P: Malnutrition E: related to altered GI function/predicted ileus and increased needs with stress of OR S: as evidenced by cytoreductive surgery and HIPEC treatment (x5d), post-operative nausea, ETOH Hx (2- 3 glasses/d), and NPO x 5d to date and expected to be NPO for ≥ 5d.

Goal of Nutrition Care: PREVENT REFEEDING SYNDROME NUTRITION NEEDS Goal of Nutrition Care: PREVENT REFEEDING SYNDROME HBE = 1218 kcal REE x 1.2 – 1.4 = 1460 kcal – 1705 kcal [24-28 kcal/kg] Protein [1.2 – 1.5 g/kg/day] = 72 – 90 g/d CHO [ 2 – 3 g/kg/day] = 120 – 180 g/d Refeeding syndrome d/t ETOH hx

INTERVENTION #1: Day 2 Post-Op TPN ORDER Calculated Requirements 1st: Dec 12 – Refeeding Total Calories 1460 kcal – 1705 kcal 1290 kcal (20 kcal/kg) Protein 72 – 90 g/d 70 g/d (22% - 1.2 g/kg) CHO 120 – 180 g/d (refeeding) 150 g/d (39% - 2.5 g/kg) Fat U/L 90 g/d 50 g/d (39% - 0.8g/kg) Phosphate 30 mmol Potassium 60 mmol 55.2 mmol Magnesium 5 mmol 7.5 mmol Folic Acid 5 mg Zinc 2.5 mg Vitamin C 200 mg Thiamine 100 mg NOTE why you were giving numbers of each micronutrient (like ETOH) Phosphate, 700 ml of AA electrolytes soln is 21 and added 9 mmol Potassium, 42 mmol AA electrolytes soln and 13.2 mmol added through Potassium Acid Phosphate Magnesium, 3.5 mmol AA electrolytes soln and added 4 mmol Magnesium Sulfate Folic Acid : 200 mcg provided by 5 ml of multivitamin, and additional 5 mg d/t ETOH abuse Zinc: 2.5 mg through trace elements solution and additional 2.5 mg through Zinc Sulfate Vitamin C: additional 200 mg as per ASPEN recommendations on PN patients who are stable and acute (b/c MVI is cut in half) Thiamine: 100 mg d/t ETOH She had chronically low Mg

COMPLICATIONS Ileus Nausea Abdominal Fluid and high NG drainage Magnesium, potassium and phosphate depletion AS RESEARCH SHOWS: Ileus post-op (1-2 weeks)  indication to TPN  is expected to develop due to hyperthermia  alteration of GI function as a result of chemotherapy The adverse effects associated with hyper­thermia itself consists mainly of prolonged post-operative ileus and temperature­ dependent edema of the small bowel Nausea: This is a common side effect of anesthetic, some pain medications, and chemotherapy. Nausea controlled with Ondansetron (and maxeran works on gastric motility  on emptying stomach – if there’s an obstruction, maxeran is contraindicated) Nausea is indicated w/ chemo; it is psychological and very difficult to control (there’s a connection between the brain and the nausea resulting, so meds are less likely to have a strong impact) Ondansetron is the best med to use as it works on the brain  very strong antiemetic Irritation of the GI mucosa by chemotherapy, radiation, distention, or acute infectious gastroenteritis activates the 5-HT3 receptors of these inputs.[4] It is now widely known that cytotoxic chemotherapeutic agents cause a detectable increase in blood levels of serotonin (5-HT) and its major metabolite, 5-Hydroxyindoleacetic acid (5-HIAA).[5] The presence of these chemicals in the blood activate 5-HT3 receptors in the chemoreceptor trigger zone, in turn releasing substance P, which activates NK1 receptors to cause an emetic response (vomiting). (NG LOSSESS GREATER THAN A LITRE) Day 2 Day 3 Magnesium (0.8 – 1.45) 0.63 0.60 Potassium (3.5 – 5) 3.5 3.4 Phosphate (0.7 – 1.10) 0.71 0.65

INTERVENTION #2: Day 4 Post-Op Continue to replete Mg (5g via IV), PO4 (15 mmol x 3) and K-lyte (40 mEq) TPN ORDER Calculated Requirements 1st: Refeeding 2nd: Goal Total Calories 1460 kcal – 1705 kcal 1290 kcal (20 kcal/kg) 1565 (26 kcal/kg) Protein 72 – 90 g/d 70 g/d (22% - 1.2 g/kg) 75 g/d (19% - 1.25 g/kg) CHO 120 – 180 g/d (refeeding) 150 g/d (39% - 2.5 g/kg) 225 g/d (49% - 3.75 g/kg) Fat 50 g/d (39% - 0.8g/kg) (32% - 0.83 g/kg) Ranitidine 150 mg Mg takes a few days to regulate blood levels post repletion. Significant doses of repletion for all 3. Up by 6 kcal/kg Ranitidine = anti-GERD. Ranitidine used to be given through IV Ranitidine (Zantac) histamine H2-receptor antagonist that inhibits stomach acid production

INTERVENTION #3: Day 8 Post-Op TPN ORDER Calculated Requirements 2nd: Goal 3rd: Goal Total Calories 1460 kcal – 1705 kcal 1565 (26 kcal/kg) Protein 72 – 90 g/d 75 g/d (19%) CHO 120 – 180 g/d (refeeding) 225 g/d (49%) Fat 50 g/d (32%) Magnesium 10 mmol Sodium 40 mmol Up by 6 kcal/kg Ranitidine = anti-GERD Hypomagnesemic Hyponatremia  NG losses (d/t ileus) not fluid overload  where are the NG losses from (GI secretions  Cl and Na)  list what Ringers Lactate contains of electrolytes. True sodium depletion and not a free water deficit. Doctors decided to use Ringers Lactate and Pharmacy accounted for the losses.

GI SECRETIONS Type Volume (ml/24h) Na (mEq/L) K (mEq/L) Cl (mEq/L) HCO3 (mEq/L) Salivary 1500 10 26 30 Stomach 60 130 Duodenum 100-2000 140 80 Ileum 3000 104 Colon – Pancreas 100-800 60 / 140 30 / 5 40 / 70 / 115 Bile 50-800 145 100 35 Salivary and gastric secretions amount to 2500-4000 ml/day. Ms. C was getting 3000 ml of RL (125ml/hr) which account for most of the GI losses and electrolytes. These secretions are essentially recycled in the GI tract and contribute to the overall hydration status of the individual, but are lost via NG drainage. Hyponatremia  NG losses (d/t ileus) not fluid overload  where are the NG losses from (GI secretions  Cl and Na)  list what Ringers Lactate contains of electrolytes Ringers Lactate is isotonic, used for fluid resuscitation after blood loss of surgery. ?induce urine output  fluid stays intervascularly rather than going into your tissues (albumin has a huge impact on that, because it keeps fluids intervascularly). used because the by-products of lactate metabolism in the liver counteract acidosis, which is a chemical imbalance that occurs with acute fluid loss or renal failure. Over long hours, it maintains a more stable blood pH

PROGRESSION Diet progression: Day 8 Post-Op: advance to CF Day 14: advance to FF Day 15: provide low residue diet education Day 16: dental soft; hold TPN Day 20: D/C on dental soft; low residue diet education She was eating well prior to d/c ( >75% of needs ) Follow low residue diet for 6 weeks post d/c ==> b/c of edema of the bowel expected to narrow the bowel and increase risk of obstruction Dec 8 Day 16 Magnesium (0.8 – 1.45) 0.60 0.56 Potassium (3.5 – 5) 3.6 Phosphate (0.7 – 1.10) 1.08 1.2

FOLLOW-UP: Day 36 Post Op Re-Admission Ms C was readmitted on January 16 for a Partial Obstruction Weight loss of 10% over 2 months Loss of appetite, suboptimal intake Unresolved nausea and increased vomiting prior re-admission and during Hypomagnesemia, Hypophosphatemia. (loss of 7 kg all throughout tx and readmit)

FOLLOW-UP: Day 78 Post-Op Post-Discharge Controlled nausea with medications Regular bowel movements with medications Following a low residue diet Appetite is back! Eating 3 meals a day and 2 snacks Gaining lost weight (Currently at 124 lbs, aiming to get back to 132 lbs) Current reports have shown that with CRS and HIPEC, the median survival of patients with peritoneal mesothelioma can be increased to 92 months, with a 3-year overall survival of 59%. Docusate and sennokot for BM Dislike mushy veggies As per oncology surgeon and studies done, takes 3 months to start feeling good and 6 months to get back to normal/baseline

REFERENCES HIPEC Treatment. (2014). The hipec procedure; what is hipec and how does it work?. Retrieved from http://www.hipectreatment.com/about-the-hipec-procedure/ BC Cancer Agency. (2013, October). Mesothelioma. Retrieved from http://www.bccancer.bc.ca/PPI/TypesofCancer/Mesothelioma/default.htm BC Cancer Agency. (2013, March). Hyperthermic intraperitoneal chemotherapy (hipec). Retrieved from http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Gastrointestinal/13- appendix/13.5+Hyperthermic+Intraperitoneal+Chemotherapy+(HIPEC).htm Mulier, S. (n.d.). Hipec for peritoneal cancer; patient information. Retrieved from http://www.drmulier.com/3 en pat info hipec.html Ceelen, W. P. (2013). Treatment of peritoneal carcinomatosis using surgery combined with hyperthermic intraperitoneal chemotherapy (hipec). Retrieved from http://www.surgery.ugent.be/pages/hipec_eng.htm Ceelen, W. P., & Flessner, M. F. (2010). Intraperitoneal therapy for peritoneal tumors: Biophysics and clinical evidence. Nat. Rev. Clin. Oncol., 7, 108-115. doi: 10.1038/nrclinonc.2009.217 Tan, G. H., Cheung , M., Chanyaputhipong, J., Soo , K. C., & Teo , M. C. (2013). Cytoreductive surgery (crs) and hyperthermic intraperitoneal chemotherapy (hipec) for peritoneal mesothelioma. Ann Acad Med Singapore, 42(6), 291-6. Retrieved from http://www.annals.edu.sg/pdf/42VolNo6Jun2013/V42N6p291.pdf