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

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

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

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

6. Please note – there is nothing active on this page/ Lynn

7. 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**

8. 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.

9. 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

10. 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

11. 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

12. 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 ): 31/224 = %
Super Morbidly Obese (BMI>50) : 8/30 = 26.7 %

13. BMI and Colorectal Cancer Surgery

14. BMI and Colorectal Cancer Surgery

15. BMI and Colorectal Cancer Surgery
For patients with BMI ≥35 the odds ratio (OR) for surgical complications was 1.71 (95% CI ). 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)

16. 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 Mar;18(3): doi: /s

20. Assessing Malnutrition

21. 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

22. 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

23. 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 /s

24. Malnutrition and Surgical Complications
Hu et al. Nutrition Journal (2015) 14:91 DOI /s

25. 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)

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

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

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

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

30. 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

31. 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

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

33. 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

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

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

36. 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 < ) 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.

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

38. 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

40. BMI/Malnutrition As Markers For Post-surgical Morbidity
Conclusions

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

42. 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)

43. 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

44. 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

45. 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

47. Sarcopenia “the loss of skeletal muscle mass and quality”
Mei et al. Perioperative Medicine (2016) 5:30
DOI /s

48. 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 /s