Journal of eISSN: 2373-6437 JACCOA

Anesthesia & Critical Care: Open Access
Volume 4 Issue 3 - 2016
Onco-Surgery and Nutrition in Cancer Patients
Neha Kapoor1 and Rakesh Garg2*
1University of Westminster, UK
2Department of Onco-Anesthesiology and Palliative Medicine, India
Received:February 01, 2015 | Published: February 12, 2016
*Corresponding author: RRakesh Garg, Department of Onco-Anesthesiology and Palliative Medicine, Dr Brairch All India Institute of Medical Sciences, Ansari Nagar, NewDelhi -110029, India, Tel: +91-9868398335; +91-9810394950; Email:
Citation: Kapoor N, Garg R (2016) Onco-Surgery and Nutrition in Cancer Patients. J Anesth Crit Care Open Access 4(3): 00143. DOI: 10.15406/jaccoa.2016.04.00143


PHA: Phyto Hem Agglutinin; PNI: Prognostic Nutritional Index; PG-SGA: Patient Generated Subjective Global Assessment; MST: Malnutrition Screening Tool; MUST: Malnutrition Universal Screening Tool; MNA: Mini Nutritional Assessment; SGA: Subjective Global Assessment; BMI: Body Mass Index; MUAC: Mid Upper Arm Thickness


The prevalence of malnutrition in hospitalized patients is to the extent of 40% on a worldwide basis [1]. Among cancer patients, due to the multiple catabolic changes and treatment effect, patient’s nutritional status is progressively affected. Chemotherapy, radiotherapy and surgical treatments lead to side effects like nausea, vomiting, anorexia, esophagities, dysphagia, diarrhoea and lethargy. This further deteriorates their nutritional status and the body enters the state of malnutrition [2,3]. During the phase of malnutrition the body is deficient of energy, protein and other important nutrients necessary to support bodily functions [4]. Malnutrition leads to weight loss, muscle wasting, extracellular fluid volume expansion, sensitivity to fluid and salt overload, which further leads to delayed wound healing, morbidity, mortality, and increased cost of medical care [5]. Malnutrition results in lower immunity and therefore the stress response to trauma, injury and surgery is deranged [6,7]. According to literature, due to immune dysfunction lymphocyte response sensitivity to phyto hem agglutinin stimulation and macrophage passage inhibitory factor activity is declined in malnourished cancer patients. This further leads to slow cell regeneration, decline in protein synthesis and thymic atrophy [8-10]. In totality, the recommendation proposed for these cancer patients is to employ nutritional supplementation (in the form of oral, enteral, parentral, total parentral) -along with immune nutrition support in preoperative period [11].

Prognostic nutritional index (PNI), patient generated subjective global assessment (PG-SGA), malnutrition screening tool (MST), malnutrition universal screening tool (MUST), mini nutritional assessment (MNA) are valid nutrition assessment tools used to assess cancer patients nutritional status [12-14]. PG-SGA is an adaptation of subjective global assessment (SGA), which, as well as incorporating three global ratings of nutritional status (well nourished, moderately or suspected of being malnourished and severely malnourished), includes a numerical score (0-35) and additional nutrition impact symptoms [15].

Preoperative body mass index (BMI), percentage weight loss and hypoalbuminemia are important components of several malnutrition screening indices among cancer patients. Among malnourished colorectal cancer patients also these screening indices have shown increased association to length of hospital stay. While hypoalbuminemia (serum albumin <3.5g/L) was more accurate in predicting post operative morbidities [16]. Studies suggested that low hemoglobin levels were related to poor survival in patients with ovarian cancer. An inverse correlation between serum albumin and length of hospital stay among patients with gynecological cancer has been shown [17]. Serum creatinine has shown significant correlation with body weight and with lean (fat-free) mass [18]. Level of muscle mass affects serum creatinine concentration, therefore it can be an indicators for muscle wasting in malnourished cancer patients [18]. Malnutrition status assessed using SGA tool has displayed close correlation with skin fold thickness, mid upper arm thickness (MUAC), and serum albumin in advanced cancer patients [19]. Gastrointestinal postoperative cancer patients with significant preoperative weight loss have reported lengthier hospital stay than their counter parts with no weight loss [1]. They also documented significant positive correlation between length of hospital stay and reinforcement of adequate post-operative adequate nutrition postoperatively [1]. Longer hospital stay was also associated to increased risk of post operative complications. Compared to well-nourished preoperative patients, malnourished showed a trend to experience more postoperative complications [1]. Another study on gastrointestinal cancer patients concluded that severely malnourished cancer patients (classified using SGA tool) had a longer length of hospital stay leading to an overall higher expenditure. This study in addition, revealed a close relationship between patient nutritional status and clinical outcomes [20]. A study on gynecological cancer patients assessing patient nutritional status and its relation with length of hospitalization showed more severely malnourished the patient was, the lower the levels of BMI, total skin fold thickness and serum albumin. They suggested that addressing malnutrition and poor quality of life may decrease patient length of hospitalization [21].

Since surgery is associated with morbidity like infections and wound complications, which can increase length of hospital stay, it may be prudent to provide nutrition support during the perioperative period in these individuals. A sensible approach would be to implement protocols for oncology patients, which show nutritional screening, assessment, and intervention as appropriate [22]. It is recommended to delay surgery and imparting 10-14 days of pre-operative nutritional supplementation in hospitalized malnourished patients [23,24]. Correcting malnutrition may decrease the length of hospital stay and even lower the rate of hospital readmissions in undernourished cancer patients. A recent meta-analysis on intervention studies focusing on malnourished preoperative surgical patients highlighted the importance of nutritional supplementation prior to surgery. Patients on nutrition support had improved prognosis to reduce postoperative infectious complication, non-infection complications and length of hospital stay than on standard treatment [11]. It has been earlier reported that colon cancer patients with more than 5% preoperative weight loss have experienced significantly higher incidence of anastomotic leakage [25] and over 15 % weight loss (in surgical oncological patients) experience severe postoperative complications [26]. Recently a randomized intervention control trial on surgical oncology patients with no symptoms of malnutrition was concluded. The patients consuming an isocaloric nutritional drink two weeks prior to surgery had less severe postoperative complication than the control group patients on daily diets [27]. Therefore, it is recommended to initiate nutritional supplementation in all surgical patients with treatment related weight loss history.

We conclude malnutrition remains a major issue for onco-surgical patients it requires appropriate assessment and optimization prior to a major onco-surgery. This requires a multi-disciplinary approach including clinical nutrition experts, peri-operative physician and surgeon.


  1. Garth AK, Newsome CM, Simmance N, Crowe TC (2010) Nutritional status, nutrition practices and post‐operative complications in patients with gastrointestinal cancer. J Hum Nutr Diet 23(4): 393-401.
  2. Kyle UG, Genton L, Pichard C (2005) Hospital length of stay and nutritional status. Curr Opin Clin Nutr Metab Care 8(4): 397-402.
  3. Odelli C, Burgess D, Bateman L, Hughes A, Ackland S, et al. (2005) Nutrition support improves patient outcomes, treatment tolerance and admission characteristics in oesophageal cancer. Clin Oncol 17(8): 639-645.
  4. Allison SP (2000) Malnutrition, disease, and outcome. Nutrition 16(7-8): 590-593.
  5. Hill GL (1987) Malnutrition and surgical risk: guidelines for nutritional therapy. Ann R Coll Surg Eng 69(6): 263-265.
  6. Sungurtekin H, Sungurtekin U, Balci C, Zencir M, Erdem E (2004) The influence of nutritional status on complications after major intraabdominal surgery. J Am Coll Nutr 23(3): 227-232.
  7. Cano NJ, Heng AE, Pison C (2011) Multimodal approach to malnutrition in malnourished maintenance hemodialysis patients. J Ren Nutr 21(1): 23-26.
  8. Villa ML, Ferrario E, Bergamasco E, Bozzetti F, Cozzaglio L, et al. (1991) Reduced natural killer cell activity and IL-2 product ion in malnourished cancer patients. Br J Cancer 63(6): 1010-1014.
  9. Savino W (2002) The thymus gland is a target in malnutrition. Eur J Clin Nutr 56(3): S46-S49.
  10. Briet F, Twomey C, Jeejeebhoy KN (2003) Effect of malnutrition and short-term refeeding on peripheral blood mononuclear cell mitochondrial complex I activity in humans. Am J Clin Nutr 77(5): 1304-1311.
  11. Zhong JX, Kang K, Shu XL (2015) Effect of nutritional support on clinical outcomes in perioperative malnourished patients: a meta-analysis. Asia Pac J Clin Nutr 24(3): 367-378.
  12. Mohri Y, Inoue Y, Tanaka K, Hiro J, Uchida K, et al. (2013) Prognostic nutritional index predicts postoperative outcome in colorectal cancer. World Journal of Surgery 37(11): 2688-2692.
  13. Roulston F, McDermott R (2009) Comparison of three validated nutritional screening tools in the oncology setting, Clinical Oncology 15: 443-450.
  14. Shirodkar M, Mohandas KM (2005) Subjective global assessment: a simple and reliable screening tool for malnutrition among Indians. Indian J Gastroenterol 24(6): 246-250.
  15. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, et al. (1987) What is subjective global assessment of nutritional status?. JPEN J Parenter Enteral Nutr 11(1): 8-13.
  16. Hu WH, Cajas-Monson LC, Eisenstein S, Parry L, Cosman B, et al. (2015) Preoperative malnutrition assessments as predictors of postoperative mortality and morbidity in colorectal cancer: an analysis of ACS-NSQIP. Nutr J 14: 91.
  17. Laky B, Janda M, Kondalsamy-Chennakesavan S, Cleghorn G, Obermair A (2010) Pretreatment malnutrition and quality of life - association with prolonged length of hospital stay among patients with gynecological cancer: a cohort study. BMC Cancer 10: 232.
  18. Baxmann AC, Ahmed MS, Marques NC, Menon VB, Pereira AB, et al. (2008) Influence of muscle mass and physical activity on serum and urinary creatinine and serum cystatin C. Clin J Am Soc Nephrol 3(2): 348-354.
  19. Thoresen L, Fjeldstad I, Krogstad K, Kaasa S, Falkmer UG (2002) Nutritional status of patients with advanced cancer: the value of using the subjective global assessment of nutritional status as a screening tool. Palliat Med 16(1): 33-42.
  20. Wu B, Yin TT, Cao W, Gu ZD, Wang X, et al. (2010) Validation of the Chinese version of the Subjective Global Assessment scale of nutritional status in a sample of patients with gastrointestinal cancer. Int J Nurs Stud 47(3): 323-331.
  21. Wu BW, Yin T, Cao WX, Gu ZD, Wang XJ, et al. (2009) Clinical application of subjective global assessment in Chinese patients with gastrointestinal cancer. World J Gastroenterol 15(28): 3542-3549.
  22. Huhmann MB, August DA (2008) Review of American society for parenteral and enteral nutrition (ASPEN) clinical guidelines for nutrition support in cancer patients: Nutrition screening and assessment. Nutr Clin Pract 23(2): 182-188.
  23. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, et al. (2006) ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 25(2): 224-244.
  24. Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, et al. (2009) ESPEN guidelines on parenteral nutrition: surgery. Clin Nutr 28(4): 378-386.
  25. Makela JT, Kiviniemi H, Laitinen S (2003) Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis. Dis Colon Rectum 46(5): 653-660.
  26. Antoun S, Rey A, Beal J, Montagne F, Pressoir M, et al. (2009) Nutritional risk factors in planned oncologic surgery: what clinical and biological parameters should be routinely used? World J Surg 33(8): 1633-1640.
  27. Kabata P, Jastrzębski T, Kąkol M, Król K, Bobowicz M, et al. (2014) Preoperative nutritional support in cancer patients with no clinical signs of malnutrition-prospective randomized controlled trial. Supportive Care in Cancer 23(2): 365-370.
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