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

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

3. 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 ( 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

4. 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

5. 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

6. 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:
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

7. 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.

8. 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

9. 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% g/kg)
CHO
120 – 180 g/d (refeeding)
150 g/d (39% 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

10. 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

11. 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% g/kg)
75 g/d
(19% g/kg)
CHO
120 – 180 g/d (refeeding)
150 g/d
(39% g/kg)
225 g/d
(49% g/kg)
Fat
50 g/d
(39% - 0.8g/kg)
(32% 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

12. 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.

13. 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
140 80
Ileum
3000
104
Colon –
Pancreas
60 / 140
30 / 5
40 / 70
/ 115
Bile
50-800
145
100 35
Salivary and gastric secretions amount to 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

14. 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

15. 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)

16. 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

17. REFERENCES
HIPEC Treatment. (2014). The hipec procedure; what is hipec and how does it work?. Retrieved from
BC Cancer Agency. (2013, October). Mesothelioma. Retrieved from
BC Cancer Agency. (2013, March). Hyperthermic intraperitoneal chemotherapy (hipec). Retrieved from appendix/13.5+Hyperthermic+Intraperitoneal+Chemotherapy+(HIPEC).htm
Mulier, S. (n.d.). Hipec for peritoneal cancer; patient information. Retrieved from en pat info hipec.html
Ceelen, W. P. (2013). Treatment of peritoneal carcinomatosis using surgery combined with hyperthermic intraperitoneal chemotherapy (hipec). Retrieved from
Ceelen, W. P., & Flessner, M. F. (2010). Intraperitoneal therapy for peritoneal tumors: Biophysics and clinical evidence. Nat. Rev. Clin. Oncol., 7, doi: /nrclinonc
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), Retrieved from