Applied nutritional investigationNutriCatt protocol in the Enhanced Recovery After Surgery (ERAS) program for colorectal surgery: The nutritional support improves clinical and cost-effectiveness outcomes
Introduction
Postoperative complications (POC) and length of hospital stay (LOS) are emerging problems in major surgery [1], [2]. Accurate preoperative screenings and advances in mini-invasive surgical approaches have reduced mortality risk on the operating table [3]. However, more general factors such as comorbidities, nutritional status, advanced age, and pathophysiological response to surgery may still hamper the postoperative course, leading to drawbacks and increased hospitalization [4], [5], [6]. Therefore, many physicians are gathering in multidisciplinary networks adopting a new integrated and evidence-based method to enhance patients' recovery after surgery. The Enhanced Recovery After Surgery (ERAS) protocol is an integrated program based on several evidence-based items, approaching the surgical patient in the perioperative period. It may involve surgeons, clinicians, anesthesiologists, dietitians, physiotherapists, and nurses. Its aim is to give the patient an early and better recovery after a surgical intervention, therefore lowering complications and LOS [7]. The first idea of applying evidence-based principles in colorectal surgery was launched in the early 1990s by Henrik Kehlet [8], [9]. He reported that length of hospital stay might be decreased 2 to 3 d in this way; ERAS programs have now been adopted in several surgical areas, and they have gained a high level of standardization. ERAS recommendations are collected in international guidelines in different surgical areas. Dietetic items were introduced into ERAS protocols to minimize both preoperative and postoperative fasting. These items recommends avoiding fasting in the preoperative phase, allowing clear fluids up to 2 h and solid food up to 6 h before the induction of anesthesia; a preoperative carbohydrate loading (12.5% weight/volume of maltodextrins in water) up to 2 h before surgery; and an early refeeding with common hospital food. These items lead to a better management of postoperative hyperglycemia, insulin resistance, and catabolic response to stress [7]. Other ERAS items focus on surgical and anesthetic procedures, such as no drains, no bowel preparation, use of short-acting anesthetic agent and avoidance of salt and fluid overload [7], [10], [11], [12]. For a complete understanding of all ERAS items, we invite the reader to visit the website of the ERAS Society (www.erassociety.org).
Many reports have indicated that the adoption of ERAS protocols leads to better outcomes in terms of earlier recovery and discharge, postoperative morbidity, and hospital readmissions [13], [14], [15], [16], [17], [18].
Recently, an oral or enteral nutritional support with ω-3 fatty acids, nucleotides, and arginine in the perioperative period has been reported to reduce POC and LOS in gastrointestinal surgery [10], [11], [12]. This support is now endorsed by international guidelines on nutrition in surgical and critically ill patients [19], [20], [21].
Worthy evidence suggests a role for nutrition in reducing surgically induced stress response, embedded into a multimodal program called “prehabilitation phase” [22]. Current guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) [21] on nutrition in surgery similarly state that patients at malnutrition risk should receive nutritional therapy before major surgery, preferably 10 to 14 d before. However, no dietary plans are to date proposed in the preadmission phase, nor in the perioperative or in the postoperative periods.
We propose an implementation of the ERAS nutritional protocol in colorectal surgery, introducing a nutritional evaluation and intervention before, during, and after hospital admission, in our center, Fondazione Policlinico Universitario Agostino Gemelli, in Rome.
Aims of this work are as follows:
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To describe an integrated nutritional approach within an ERAS program in colorectal cancer surgery
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To verify if a nutritional support, starting in preadmission, is able to improve recovery after surgery and reduce complications, LOS, readmission at 30 d, and late complications.
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To translate, in terms of cost effectiveness for the hospital and health care system, the clinical outcomes reached through this novel and multidisciplinary approach
Section snippets
Methods
We consecutively enrolled all cancer patients suitable for colorectal surgery in the general surgery division at our center from February to September 2016. These patients were treated according to ERAS program [6], implemented with a nutritional protocol that we called NutriCatt. It consists of several phases:
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Preadmission (3 wk before admission): Nutritional Risk Screening (NRS) 2002, anthropometric measures, and bioelectrical impedance analysis (BIA) are carried out for each patient (BIA 101,
Results
A total of 105 patients were treated according to ERAS + NutriCatt protocol, compared with 114 patients of the previous ERAS cohort. Baseline characteristics of patients were similar in the two cohorts, except for the American Society of Anesthesiologists (ASA) score. In the ERAS + NutriCatt cohort, in fact, the rate of patients with an ASA score of III was significantly higher. According to NRS 2002 [22], 22 patients (21%) were at risk of malnutrition (NRS 2002 ≥ 3); mean phase angle (±SD) was
Discussion
Compared with traditional management, the ERAS protocol represents a fundamental shift in colorectal surgery perioperative care, resulting in reduced rates of morbidity, faster recovery, and shorter LOS [13], [14], [15], [16], [17], [18], so that ERAS protocols are highly recommended for elective colonic surgery.
This standard ERAS protocol was followed by our institution from April 2015 to January 2016, until the clinical nutrition unit introduced a modification, which we refer to as the
Conclusions
In a multidisciplinary context of excellence adopting the ERAS protocol, we found that a specific nutritional support, starting 2 to 3 wk before admission and continuing during and after hospitalization, may reduce length of hospital stay, postoperative complications, drug-associated costs for complications, and late (90-d) complications in colorectal surgery, even in patients with severe systemic diseases. This program could represent an advantage not only for the patients but also for the
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The authors have no conflicts of interest to declare.