Two Current Perspectives on the Importance of (Par)enteral Nutrition in Cancer Patients
Adequate (par)enteral nutrition is crucial for cancer patients in terms of prognosis and quality of life. The following recent studies examined parenteral nutrition as an alternative to ileostomy in patients with colorectal anastomosis and muscle mass loss in patients with metastatic cancer.
Parenteral Nutrition as an Alternative to Ileostomy in Patients with Colorectal Anastomosis?
Anastomotic leak is a feared complication in patients with colorectal anastomosis. The solution is ileostomy, which, however, can be associated with a number of complications, worsen the quality of life, and subsequently require additional surgery.
In April 2022, a case series of 6 patients with a high risk of anastomotic leak (≤ 10 cm from the anal opening and/or presence of severe comorbidity) were administered parenteral nutrition only for 7 days after elective left-sided colorectal anastomosis with good tolerance. From the 8th postoperative day, they were allowed liquid food. During the recovery period, no serious complications, including anastomotic leak, were reported. Two patients had elevated CRP levels, with one developing fever and another a seroma in the wound requiring drainage (both cases effectively treated with intravenous antibiotic therapy).
Muscle Mass Loss and Inadequate Nutritional Counseling in Patients with Metastatic Cancer?
Muscle mass loss in cancer patients negatively affects overall survival, quality of life, and tolerance to cancer treatment, and notably increases the risk of postoperative complications.
The cross-sectional multicenter French SCAN study, conducted in September and October 2017, involved 29 healthcare facilities and included 766 patients (49.9% men; average age 65 years) with metastatic colorectal cancer (37.1%), lung cancer (25.5%), breast cancer (22.6%), kidney cancer (7.8%), or prostate cancer (7.0%). All had undergone 1 month or 1 cycle of systemic therapy (most commonly chemotherapy − 69.2%), with an average time from diagnosis of 46.9 months. The amount of muscle mass was estimated using the muscle mass index at the L3 vertebra level determined by CT. Exclusion criteria included exclusive radiotherapy, surgery within the last 30 days, neurological comorbidity, and non-metastatic brain involvement.
Low muscle mass volume (in men < 55 cm2/m2; in women < 39 cm2/m2) was found in 69.1% (n = 529) patients. Women (55.2% vs. 83.0% men; odds ratio [OR] 0.22; p < 0.01) and relatively younger patients were at lower risk. Significantly more frequent low muscle mass volume was diagnosed in patients with prostate cancer (94.4%) compared to breast cancer patients (54.3%) and in patients with metastatic brain involvement (12.7%) compared to those without brain metastases (5.9%; p < 0.01). Only one-third of them received nutritional counseling (p < 0.01) and only 28.4% received nutritional treatment (supplementation, enteral, or parenteral nutrition). Oncologists underdiagnosed cachexia in 74.3% of obese and 44.9% of non-obese patients (p < 0.01). Good performance status (PS 0) was observed in 40.1% of patients without muscle mass loss compared to 29.7% with muscle mass loss (p < 0.01), while poor performance status (PS 2) was more frequently observed in patients with muscle mass loss (17.2% vs. 10.5%; p = 0.02). In addition, cachectic patients had to frequently delay cancer treatment due to its toxicity (11.9% vs. 6.8%; p = 0.04).
Conclusion
Total 7-day parenteral nutrition post left-sided colorectal anastomosis appears to be a suitable alternative to ileostomy to prevent anastomotic leaks. However, further clinical studies are needed to verify this hypothesis.
In patients with metastatic cancer, muscle mass loss is very common − and often underdiagnosed. Unfortunately, even today, they still do not receive adequate nutritional counseling and treatment.
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Sources:
1. Kryzauskas M., Jakubauskas M., Gendvilaite N. et al. Bowel rest with total parenteral nutrition as an alternative to diverting ileostomy in high-risk colorectal anastomosis: a pilot study. Medicina (Kaunas) 2022; 58 (4): 540, doi: 10.3390/medicina58040510.
2. Raynard B., Pigneur F., Di Palma M. et al. The prevalence of CT-defined low skeletal muscle mass in patients with metastatic cancer: a cross-sectional multicenter French study (the SCAN study). Support Care Cancer 2022; 30 (4): 3119–3129, doi: 10.1007/s00520-021-06603-0.
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