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Preoperative Nutritional Status and Risk Factors Associated with Delayed Discharge in Geriatric Patients Undergoing Gastrectomy: A Single-Center Retrospective Study

Preoperative Nutritional Status and Risk Factors Associated with Delayed Discharge in Geriatric... Hindawi Applied Bionics and Biomechanics Volume 2022, Article ID 8263986, 7 pages https://doi.org/10.1155/2022/8263986 Research Article Preoperative Nutritional Status and Risk Factors Associated with Delayed Discharge in Geriatric Patients Undergoing Gastrectomy: A Single-Center Retrospective Study Xining Zhao , Jie Liu, Ying Wang, Yuying Yang, Yan Pan, and Shengjin Ge Department of Anesthesiology, Zhongshan Hospital Fudan University, Shanghai 200032, China Correspondence should be addressed to Shengjin Ge; ge.shengjin@zs-hospital.sh.cn Received 1 March 2022; Revised 8 May 2022; Accepted 12 May 2022; Published 3 June 2022 Academic Editor: Fahd Abd Algalil Copyright © 2022 Xining Zhao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. Preoperative malnutrition is an independent risk factor for postoperative complications and survival for gastric cancer patients. The study is aimed at investigating the prevalence of malnutrition, perioperative nutritional support, and the risk factors associated with delayed discharge of geriatric patients undergoing gastrectomy. Methods. A retrospective study of gastric cancer patients (age ≥ 65) who underwent gastrectomy at Zhongshan Hospital from January 2018 to May 2020 was conducted. Clinical data, including demographic information, medical history, surgery-related factors, and perioperative nutritional management, were collected and analyzed. Postoperative complications were assessed according to the Clavien-Dindo grading system, and the prognostic nutritional index (PNI) was calculated. The risk factors affecting the prolongation of postoperative hospital stay were analyzed. Results. A total of 783 patients were reviewed. The overall frequency of malnutrition was 31.3% (249/783). The albumin, prealbumin, and hemoglobin levels were lower in the malnutrition group than in the well-nourished group. The proportion of patients who received preoperative total parenteral nutritional support in the malnutrition group was significantly higher than in the well-nourished group (12.4% vs. 3.7%, P <0:001). All patients received postoperative parenteral nutrition (PN); the proportion of patients who received total nutrient admixture (TNA) in the malnutrition group was lower than in the well-nourished group (22.1% vs. 33.5%, P =0:001). No significant difference was found in the duration of postoperative nutrition between groups (P >0:05). The malnutrition group was associated with a higher rate of postoperative complications (P <0:001). Univariate and multivariate regressions revealed that age > 70 years (OR = 1:216, 95% CI 1.048- 1.411, P =0:010), operation time > 180 min (OR = 1:431, 95% CI 1.237-1.656, P <0:001), PNI < 44:5 (OR = 1:792, 95% CI 1.058-3.032, P =0:030), and postoperative complications (OR = 2:191, 95% CI 1.604-2.991, P <0:001) were significant risk factors associated with delayed discharge. Conclusion. Malnutrition is relatively common in elderly patients undergoing gastrectomy. Advanced age, duration of surgery, lower levels of PNI, and postoperative complications were risk factors associated with delay discharge. Elderly gastric cancer patients with risk factors urgently require specific attention for reducing hospital stay. 1. Introduction of postoperative complications shortly after surgical treat- ment [5] and lower 5-year overall survival as long-term out- th Gastric cancer (GC) remains the 5 most common cancer come [6]. worldwide [1] and had the second-highest mortality rate in In China, the prevalence of malnutrition in hospitalized China [2]. The population of elder patients with GC has patients is around 12.6% to 46.19% [7–10]. Malnutrition is been increasing because of the high prevalence of H. pylori one of the great risk factors of adverse clinical outcomes in elderly patients with GC [11]. The nutritional status at the infection and increasing life expectancy. Elderly GC patients face several challenges during treatment, such as comorbid- time of diagnosis was independently associated with postop- ities, organ dysfunction, immunosuppression, and delayed erative complications, overall survival, and disease-free sur- recovery [3, 4]. Advanced age is associated with a higher rate vival [12, 13]. The condition can be caused by mechanical 2 Applied Bionics and Biomechanics obstruction of the digestive tract or anorexia-cachexia syn- 3. Results drome, leading to insufficient protein or energy intake and 3.1. General Characteristics. A total of 783 adults were absorption disorder. Nutrition screening, assessment, and included in this study (Figure 1). The characteristics of the intervention are important steps in nutritional management. patients were shown in Table 1. The median age at diagnosis Previous studies mostly focused on hospitalized internal was 70 years (range: 65-86 years). The proportion of male medical patients [14]. Only a few studies focused on surgical individuals was 584 (74.6%). Among the 783 individuals, patients regardless of age [9]. Therefore, in this retrospective 76 (9.7%) suffered from 3 or more chronic diseases. There study, we investigated the nutritional status and periopera- were 132 (16.9%) patients received preoperative consultation tive nutritional support of geriatric surgical patients with because of comorbidities. GC and provide a basis for implementing an effective nutri- tional intervention. 3.2. Malnutrition. The frequency of malnutrition is shown in Table 1. The overall frequency of malnutrition was 31.8%. The age in the malnourished group (M group) was sig- 2. Methods nificantly higher than that in the well-nourished group (W group) (72 vs. 69, P <0:001). Significant differences were 2.1. Study Design and Participants. The research project was found in albumin, prealbumin, hemoglobin, and PNI a retrospective, observational study approved by the Ethics between the M group and W group (P <0:05). The number Committee of Zhongshan Hospital (B2021-392) and was conducted in accordance with the Declaration of Helsinki. of patients with 3 or more preoperative comorbidities, gender ratio, surgery type, surgery time, anesthetic method, The records of elderly patients with GC who underwent preoperative consultation, and preoperative neoadjuvant open gastrectomy and were 65 or older between May 2018 therapy was of no significance between the two groups and May 2021 at Zhongshan Hospital affiliated to Fudan (P >0:05). University were retrospectively identified. Patients with other malignancies, previous gastrointestinal surgery, emer- 3.3. Preoperative Nutritional Support. As shown in Table 2, gency surgery, or incomplete medical record were excluded. of the 783 elderly individuals, 424 (54.1%) received nutri- Clinical data, including demographic information, med- tional support. Of the 249 elderly patients with malnutrition, ical history, laboratory tests, postoperative complications, 77 (30.8%) received a single nutritional transfusion and 31 lengths of hospital stay (LOS), and cost were collected and (12.4%) received total parenteral nutrition (TPN). Of the analyzed. Postoperative complications (PPC) were graded 534 individuals without malnutrition, 296 (55.4%) received according to the Clavien-Dindo (CD) classification [15], a single transfusion and 20 (3.7%) received TPN. The com- and grade II or higher were regarded as complications [16]. position of nutritional support was mainly carbohydrates based on diet. The rate of TPN was higher in the M group 2.2. Definition and Assessment of Malnourished Patients. than in the W group (P <0:001). Malnutrition was defined, according to the European Society for Clinical Nutrition and Metabolism (ESPEN) diagnostic 3.4. Postoperative Nutritional Support. All patients received criteria [17], as a weight loss of more than 10% (indefinite parenteral nutrition after surgery. Of the 249 malnutrition of time) or more than 5% over the last 3 months and a patients, 194 (77.9%) patients were given a single transfusion 2 2 body mass index ðBMIÞ <20 kg/m or <22 kg/m in patients of carbohydrates with or without composite amino acid, and under or above the age of 70, respectively. Nutritional assess- 55 (22.1%) received total nutrient admixture (TNA). In ment was performed based on a prognostic nutritional index patients with normal nutrition, 355 (66.5%) received single (PNI), which is an easily available index widely employed for transfusion and 179 (33.5%) received TNA. The proportion evaluating the nutritional status of patients with gastric of patients in the M group who received TNA was signifi- cancer [18]. The PNI was calculated based on the equation: cantly lower than that in the W group (P =0:001). No signif- ½ð10 × serum albumin ðg/dLÞÞ + ð0:005 × total lymphocyte icant differences were found in rates or duration of postoperative nutrition between the two groups (P >0:05) count ð/mm ÞÞ. The composition and duration of nutri- tional management were recorded and analyzed. (Table 2). 3.5. Postoperative Complications. Comparing the two groups, 2.3. Statistical Analysis. All statistical analyses were per- the incidence of PPC in group M was significantly higher formed using SPSS ver. 22.0 (IBM SPSS, Chicago, USA). than that in group W (grade I-II: 10.8% vs. 6.9%; grade Normal distribution measurement data were expressed as III-V: 11.6% vs. 3.9%; P <0:001). There was no significant mean ± SD, and t-test was used to compare the differences difference in hospital mortality, unplanned readmission rate between the groups. The measurement data of skewed distri- within 30 days, LOS, and cost between the two groups bution were expressed as median (interquartile range), and (P >0:05) (Table 2). the categorical variables were expressed as counts and per- centages and compared using the χ test. Univariate and 3.6. Risk Factors Associated with Prolonged LOS. The median multivariate analyses were carried out using logistic regres- LOS was 8 d (Table 2); therefore, a LOS of 9 d or more was sion. The P value was considered to be statistically signifi- defined as prolonged LOS. Factors such as patient age, gen- der, nutritional status, operation time, anesthesia method, cant at 0.05 level. Applied Bionics and Biomechanics 3 Geriatric patients undergoing D2 gastrectomy for gastric cancer (n = 896) Exclusion criteria With other malignancy (n = 41) With previous gastrointestinal surgery (n = 52) Incomplete clinical or pathological n = 783 record (n = 20) e remaining 783 patients were enrolled in present study Figure 1: Flowchart of patients’ selection. Table 1: Clinical and nutritional characteristics of malnourished and well-nourished elderly patients. Malnourished Well-nourished Item Group All (n = 783) t/χ /F P (n = 249, 31.8%) (n = 534, 68.2%) Age, years Median (IQR) 70 (67, 74) 72 (69, 76) 69 (67, 73) 36.700 <0.001 Male 584 (74.6) 184 (74.9) 400 (73.9) 0.092 0.762 Gender, n (%) Female 199 (25.4) 65 (25.1) 134 (26.1) 22:9±3:419:4±1:824:5±2:6 BMI (kg/m ) -31.949 <0.001 0 ~ 2 707 (90.3) 221 (88.8) 486 (91.0) 0.986 0.321 Number of chronic diseases, n (%) ≥3 76 (9.7) 28 (11.2) 48 (9.0) PNI 48:1±5:648:8±5:346:7±5:7 -5.108 <0.001 40:2±4:339:1±4:640:7±4:0 Albumin (g/L) -4.680 <0.001 Prealbumin (mg/L) 207:8±49:6 193:2±50:6 214:6±47:7 -5.709 <0.001 121:0±23:6 117:0±24:1 122:8±23:1 Hemoglobin (g/L) -3.205 0.001 TLC (×10 /L) 1:59 ± 0:54 1:57 ± 0:55 1:60 ± 0:54 0.719 0.472 Total gastrectomy 359 (45.8) 112 (45.0) 247 (46.3) 0.653 0.721 Type of surgery, n (%) Distal gastrectomy 397 (50.7) 130 (52.2) 267 (50.0) Proximal gastrectomy 27 (3.4) 7 (2.8) 20 (3.7) Operation time (min) Median (IQR) 160 (123, 189.5) 160 (126, 189) 160 (129, 191) 3.025 0.082 GA 87 (11.1) 35 (14.1) 52 (9.7) 3.206 0.073 Type of anesthesia, n (%) TEA 696 (88.9) 214 (85.9) 482 (90.3) Yes 132 (16.9) 47 (18.9) 85 (15.9) 1.060 0.303 Preoperative consultation, n (%) No 651 (83.1) 202 (81.1) 449 (84.1) Yes 25 (3.2) 9 (3.6) 16 (3.0) 0.210 0.647 Preoperative neoadjuvant chemotherapy, n (%) No 758 (96.8) 240 (96.4) 518 (97.0) I 126 (16.1) 32 (13.0) 87 (16.2) 7.452 0.059 II 150 (19.2) 53 (21.3) 133 (24.9) Tumor stage, n (%) III 402 (51.3) 128 (51.3) 267 (50.0) IV 105 (13.4) 36 (14.4) 47 (8.9) Abbreviations: BMI: body mass index; PNI: prognostic nutritional index; TLC: total lymphocyte count; GA: general anesthesia; TEA: general anesthesia combined with thoracic epidural block. chronic comorbidities, postoperative nutritional support, LOS was used as the dependent variable. The multivariate and PPC were included in the univariate analysis. Age ≥ 70 logistic regression showed that age ≥ 70 years (OR = 1:216, years, operation time ≥ 180 min, PNI < 44:5, and CD ≥ 3 95% CI 1.048-1.411, P =0:010), operation time ≥ 180 min were related factors of prolonged LOS (P <0:05). The fac- (OR = 1:431, 95% CI 1.237-1.656, P <0:001), PNI < 44:5 tors with P >0:1 in the univariate analysis were used as (OR = 1:792, 95% CI 1.058-3.032, P =0:030), and CD grade independent variables, and the occurrence of prolonged I-II (OR = 2:191, 95% CI 1.604-2.991, P <0:001) (Table 3). 4 Applied Bionics and Biomechanics Table 2: Preoperative and postoperative nutritional supports among elderly gastric cancer patients with or without malnutrition. Malnourished Well-nourished All (n = 783) Z/χ /F P (n = 249, 31.8%) (n = 534, 68.2%) Diet 359 (45.9) 141 (56.6) 218 (40.8) 14.75 <0.001 Preoperative nutrition, n (%) Diet+single transfusion 373 (47.6) 77 (30.8) 296 (55.4) TPN 51 (6.5) 31 (12.4) 20 (3.7) Single transfusion 549 (70.1) 194 (77.9) 355 (66.5) 10.592 0.001 Postoperative nutrition, n (%) TNA 234 (29.9) 55 (22.1) 179 (33.5) PN period Median (IQR), day 5 (4, 6) 5 (4, 6) 5 (4, 6) 0.004 0.951 EN period Median (IQR), day 2 (1, 2) 2 (1, 3) 2 (1, 2) 1.201 0.273 No, n (%) 669 (85.4) 193 (77.5) 476 (89.1) 21.696 <0.001 Clavien-Dindo grade I-II, n (%) 64 (8.2) 27 (10.8) 37 (6.9) III or higher, n (%) 50 (6.4) 29 (11.6) 21 (3.9) In-hospital mortality n 2 2 1 0.535 Readmission within 30 d n 15 11 4 0.79 Length of hospital stay Median (IQR), day 8 (7, 10) 8 (7, 9) 8 (7, 10) -1.504 0.133 Cost of hospitalization Median (IQR), K¥ 54.8 (47.7, 64.7) 55.3 (47.4, 66.6) 54.7 (47.8, 63.2) -1.051 0.293 Abbreviations: EN: enteral nutrition; PN: parenteral nutrition; TPN: total parenteral nutrition; TNA: total nutrient admixture; IQR: interquartile range. The “¥” refers to RMB, and “K¥” refers to "per 1000 RMB". Table 3: Univariate and multivariate analyses of clinical factors associated with prolonged length of stay. Univariate LOS Multivariate analysis analysis Clinical factors Group N = 783 (days) χ P OR 95% CI P Male 584 8 (7, 10) Sex Female 199 7 (7, 9) 3.142 0.076 0.962 (0.817, 1.132) 0.637 65~70 349 7 (7, 9) Age (years) ≥70 434 8 (7, 10) 9.730 0.002 1.216 (1.048, 1.411) 0.010 Well-nourished 534 8 (7, 9) Nutritional status Malnourished 249 8 (7, 10) 2.245 0.134 0.990 (0.842, 1.163) 0.899 <180 438 7 (7, 8) Surgery time (min) ≥180 345 8 (7, 11) 44.218 <0.001 1.431 (1.237, 1.656) <0.001 GA 87 8 (7, 11) Anesthesia TEA 696 8 (7, 9) 2.714 0.099 0.921 (0.734, 1.154) 0.474 <3 707 8 (7, 9) Comorbidity ≥3 76 8 (7, 11) 3.915 0.048 1.067 (0.839, 1.357) 0.595 ≥90 675 8 (7, 9) Hemoglobin (g/L) <90 108 8 (7, 11) 1.893 0.169 >30 772 8 (7, 9) Albumin (g/L) ≤30 11 10 (7, 11) 1.789 0.181 ≥180 523 8 (7, 9) Prealbumin (mg/L) <180 260 8 (7, 10) 7.389 0.007 0.797 (0.514, 1.237) 0.312 Single transfusion 549 8 (7, 10) Postoperative PN TNA 234 8 (7, 9) 0.317 0.573 ≥44.5 718 8 (7, 11) PNI <44.5 65 9 (8, 13) 7.856 0.005 1.792 (1.058, 3.032) 0.030 0 669 8 (7, 9) Clavien-Dindo grade 1 ~ 2 64 10 (7, 12) 2.191 (1.604, 2.991) <0.001 ≥3 50 10 (7, 17) 40.624 <0.001 1.163 (1.163, 1.701) 0.435 Abbreviations: LOS: length of stay; GA: general anesthesia; TEA: general anesthesia combined with thoracic epidural block; PN: parenteral nutrition; TNA: total nutrient admixture; PNI: prognostic nutritional index. Applied Bionics and Biomechanics 5 while, 54.8% of old patients received only carbohydrates 4. Discussion with or without composite amino acids postoperatively. No In the present study, the prevalence of preoperative malnu- significant difference was found in duration between mal- nourished and well-nourished patients. It might take some trition in elderly patients undergoing gastrectomy was 31.3%, which was relatively high compared with that in previ- time before patients with malnutrition are properly taken ous studies [9]. Many factors are contributed to observed in charge. This study also supported the findings of previous differences in malnutrition prevalence include instruments, studies that patients with malnutrition have a higher rate of age distribution, hospital location, and characteristics of the overall postoperative complications [19, 28]. This indicated that old patients with malnutrition should be paid more patients. Patients with preoperative malnutrition were associ- ated with low levels of albumin, prealbumin, and hemoglobin attention during the postoperative period, and nutritional than well-nourished patients. Furthermore, malnourished support should be individualized for these vulnerable elderly patients were found to be associated with higher post- patients. operative complications and prolonged length of hospital stay At multivariate analysis, we found that longer duration of surgery was significantly related with delayed discharge, than well-nourished elderly. There was no significant differ- ence in composition and timing of postoperative nutritional which was in accordance with previous study [29]. This management between malnourished and well-nourished suggested that the length of surgery could be regarded as patients. a convenient marker of surgical stress burden, and patients Malnutrition is one of the risk factors for PPC [19]. In going through a long period of surgery need special care postoperatively. old patients with GC, malnutrition is often caused by frailty, absorption disorder, and a decrease in food intake [20]. The novelty of this study was the assessment of nutri- These patients often develop anemia, hypoproteinemia, tional status and risk factors associated with delayed dis- and electrolyte abnormalities before surgery. Therefore, charge among geriatric GC patients with a large sample screening and assessing for malnutrition is an important size in China. As a single-center retrospective study, this study had several limitations. We did not follow up for step for all patients scheduled for major gastrointestinal sur- gery. The preoperative PNI is an independent prognostic long-term outcomes, and we could not investigate the rela- factor for disease-free along with age and TNM stage in tionship between perioperative nutritional support and clin- GC patients after surgery [21]. A recent study found that ical outcomes among malnourished patients. Therefore, preoperative PNI is a sensitive and specific prognostic large multicenter prospective RCTs should be conducted to further investigation. predictor among elderly patients undergoing gastric cancer surgery [22]. The result in our study showed that low PNI is an independent risk factor associated with prolonged 5. Conclusion LOS, suggesting that PNI is a predictor for both short-term and long-term outcomes for elderly patients. Meantime, In conclusion, malnutrition is relatively common in elderly the measurement of PNI (albumin and lymphocyte count) patients undergoing gastrectomy. Age, length of surgery, is simple and convenient to achieve. PNI, and postoperative complications were risk factors asso- The guidelines of both the American Society for Paren- ciated with delay discharge. Elderly gastric cancer patients teral and Enteral Nutrition (ASPEN) and the ESPEN recom- with risk factors urgently require specific attention for reduc- mend oral or enteral feeding whenever possible [23, 24]. ing hospital stay. Enteral nutrition is preferred over parenteral nutrition because of a lower incidence of surgical site infection [25]. But in patients with a pyloric obstruction or inadequate Data Availability energy supply by enteral nutrition, peripheral parenteral The data used to support the findings of this study are avail- nutrition or TPN is often performed [23]. In our study, the able from the corresponding author upon request. rate of preoperative TPN in patients with malnutrition was significantly higher than in well-nourished patients. How- ever, the total rate of preoperative parenteral nutrition sup- Disclosure port was still low (43.5%) in patients with malnutrition. Optimal preoperative management for elder patients with This manuscript has been preprinted (doi:10.21203/rs.3.rs- malnutrition is essential to improve surgical outcomes. 1008430/v1) [30]. Although early initiation of oral or enteral feeding has been recommended to improve clinical outcomes and to Conflicts of Interest reduce surgical complications in GC patients following gas- trectomy [23, 26], the postoperative nutritional support for The authors declare that they have no competing interests. patients is quite variable between different surgical teams. And in the statement of the Japanese Gastric Cancer Treatment Guideline, the drink should be offered after post- Authors’ Contributions operative day 1 and a solid diet should begin from postoper- ative day 2 to 4 regardless of surgery type [27]. In this study, Xining Zhao, Jie Liu, and Ying Wang contributed equally to the median period of parenteral nutrition is 5 days. 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Ge, Preoper- ative nutritional status and risk factors associated with delayed discharge in geriatric patients undergoing gastrectomy: a single- center retrospective study, PREPRINT (Version 1), 2021. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Applied Bionics and Biomechanics Hindawi Publishing Corporation

Preoperative Nutritional Status and Risk Factors Associated with Delayed Discharge in Geriatric Patients Undergoing Gastrectomy: A Single-Center Retrospective Study

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Copyright © 2022 Xining Zhao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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1754-2103
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10.1155/2022/8263986
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Hindawi Applied Bionics and Biomechanics Volume 2022, Article ID 8263986, 7 pages https://doi.org/10.1155/2022/8263986 Research Article Preoperative Nutritional Status and Risk Factors Associated with Delayed Discharge in Geriatric Patients Undergoing Gastrectomy: A Single-Center Retrospective Study Xining Zhao , Jie Liu, Ying Wang, Yuying Yang, Yan Pan, and Shengjin Ge Department of Anesthesiology, Zhongshan Hospital Fudan University, Shanghai 200032, China Correspondence should be addressed to Shengjin Ge; ge.shengjin@zs-hospital.sh.cn Received 1 March 2022; Revised 8 May 2022; Accepted 12 May 2022; Published 3 June 2022 Academic Editor: Fahd Abd Algalil Copyright © 2022 Xining Zhao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. Preoperative malnutrition is an independent risk factor for postoperative complications and survival for gastric cancer patients. The study is aimed at investigating the prevalence of malnutrition, perioperative nutritional support, and the risk factors associated with delayed discharge of geriatric patients undergoing gastrectomy. Methods. A retrospective study of gastric cancer patients (age ≥ 65) who underwent gastrectomy at Zhongshan Hospital from January 2018 to May 2020 was conducted. Clinical data, including demographic information, medical history, surgery-related factors, and perioperative nutritional management, were collected and analyzed. Postoperative complications were assessed according to the Clavien-Dindo grading system, and the prognostic nutritional index (PNI) was calculated. The risk factors affecting the prolongation of postoperative hospital stay were analyzed. Results. A total of 783 patients were reviewed. The overall frequency of malnutrition was 31.3% (249/783). The albumin, prealbumin, and hemoglobin levels were lower in the malnutrition group than in the well-nourished group. The proportion of patients who received preoperative total parenteral nutritional support in the malnutrition group was significantly higher than in the well-nourished group (12.4% vs. 3.7%, P <0:001). All patients received postoperative parenteral nutrition (PN); the proportion of patients who received total nutrient admixture (TNA) in the malnutrition group was lower than in the well-nourished group (22.1% vs. 33.5%, P =0:001). No significant difference was found in the duration of postoperative nutrition between groups (P >0:05). The malnutrition group was associated with a higher rate of postoperative complications (P <0:001). Univariate and multivariate regressions revealed that age > 70 years (OR = 1:216, 95% CI 1.048- 1.411, P =0:010), operation time > 180 min (OR = 1:431, 95% CI 1.237-1.656, P <0:001), PNI < 44:5 (OR = 1:792, 95% CI 1.058-3.032, P =0:030), and postoperative complications (OR = 2:191, 95% CI 1.604-2.991, P <0:001) were significant risk factors associated with delayed discharge. Conclusion. Malnutrition is relatively common in elderly patients undergoing gastrectomy. Advanced age, duration of surgery, lower levels of PNI, and postoperative complications were risk factors associated with delay discharge. Elderly gastric cancer patients with risk factors urgently require specific attention for reducing hospital stay. 1. Introduction of postoperative complications shortly after surgical treat- ment [5] and lower 5-year overall survival as long-term out- th Gastric cancer (GC) remains the 5 most common cancer come [6]. worldwide [1] and had the second-highest mortality rate in In China, the prevalence of malnutrition in hospitalized China [2]. The population of elder patients with GC has patients is around 12.6% to 46.19% [7–10]. Malnutrition is been increasing because of the high prevalence of H. pylori one of the great risk factors of adverse clinical outcomes in elderly patients with GC [11]. The nutritional status at the infection and increasing life expectancy. Elderly GC patients face several challenges during treatment, such as comorbid- time of diagnosis was independently associated with postop- ities, organ dysfunction, immunosuppression, and delayed erative complications, overall survival, and disease-free sur- recovery [3, 4]. Advanced age is associated with a higher rate vival [12, 13]. The condition can be caused by mechanical 2 Applied Bionics and Biomechanics obstruction of the digestive tract or anorexia-cachexia syn- 3. Results drome, leading to insufficient protein or energy intake and 3.1. General Characteristics. A total of 783 adults were absorption disorder. Nutrition screening, assessment, and included in this study (Figure 1). The characteristics of the intervention are important steps in nutritional management. patients were shown in Table 1. The median age at diagnosis Previous studies mostly focused on hospitalized internal was 70 years (range: 65-86 years). The proportion of male medical patients [14]. Only a few studies focused on surgical individuals was 584 (74.6%). Among the 783 individuals, patients regardless of age [9]. Therefore, in this retrospective 76 (9.7%) suffered from 3 or more chronic diseases. There study, we investigated the nutritional status and periopera- were 132 (16.9%) patients received preoperative consultation tive nutritional support of geriatric surgical patients with because of comorbidities. GC and provide a basis for implementing an effective nutri- tional intervention. 3.2. Malnutrition. The frequency of malnutrition is shown in Table 1. The overall frequency of malnutrition was 31.8%. The age in the malnourished group (M group) was sig- 2. Methods nificantly higher than that in the well-nourished group (W group) (72 vs. 69, P <0:001). Significant differences were 2.1. Study Design and Participants. The research project was found in albumin, prealbumin, hemoglobin, and PNI a retrospective, observational study approved by the Ethics between the M group and W group (P <0:05). The number Committee of Zhongshan Hospital (B2021-392) and was conducted in accordance with the Declaration of Helsinki. of patients with 3 or more preoperative comorbidities, gender ratio, surgery type, surgery time, anesthetic method, The records of elderly patients with GC who underwent preoperative consultation, and preoperative neoadjuvant open gastrectomy and were 65 or older between May 2018 therapy was of no significance between the two groups and May 2021 at Zhongshan Hospital affiliated to Fudan (P >0:05). University were retrospectively identified. Patients with other malignancies, previous gastrointestinal surgery, emer- 3.3. Preoperative Nutritional Support. As shown in Table 2, gency surgery, or incomplete medical record were excluded. of the 783 elderly individuals, 424 (54.1%) received nutri- Clinical data, including demographic information, med- tional support. Of the 249 elderly patients with malnutrition, ical history, laboratory tests, postoperative complications, 77 (30.8%) received a single nutritional transfusion and 31 lengths of hospital stay (LOS), and cost were collected and (12.4%) received total parenteral nutrition (TPN). Of the analyzed. Postoperative complications (PPC) were graded 534 individuals without malnutrition, 296 (55.4%) received according to the Clavien-Dindo (CD) classification [15], a single transfusion and 20 (3.7%) received TPN. The com- and grade II or higher were regarded as complications [16]. position of nutritional support was mainly carbohydrates based on diet. The rate of TPN was higher in the M group 2.2. Definition and Assessment of Malnourished Patients. than in the W group (P <0:001). Malnutrition was defined, according to the European Society for Clinical Nutrition and Metabolism (ESPEN) diagnostic 3.4. Postoperative Nutritional Support. All patients received criteria [17], as a weight loss of more than 10% (indefinite parenteral nutrition after surgery. Of the 249 malnutrition of time) or more than 5% over the last 3 months and a patients, 194 (77.9%) patients were given a single transfusion 2 2 body mass index ðBMIÞ <20 kg/m or <22 kg/m in patients of carbohydrates with or without composite amino acid, and under or above the age of 70, respectively. Nutritional assess- 55 (22.1%) received total nutrient admixture (TNA). In ment was performed based on a prognostic nutritional index patients with normal nutrition, 355 (66.5%) received single (PNI), which is an easily available index widely employed for transfusion and 179 (33.5%) received TNA. The proportion evaluating the nutritional status of patients with gastric of patients in the M group who received TNA was signifi- cancer [18]. The PNI was calculated based on the equation: cantly lower than that in the W group (P =0:001). No signif- ½ð10 × serum albumin ðg/dLÞÞ + ð0:005 × total lymphocyte icant differences were found in rates or duration of postoperative nutrition between the two groups (P >0:05) count ð/mm ÞÞ. The composition and duration of nutri- tional management were recorded and analyzed. (Table 2). 3.5. Postoperative Complications. Comparing the two groups, 2.3. Statistical Analysis. All statistical analyses were per- the incidence of PPC in group M was significantly higher formed using SPSS ver. 22.0 (IBM SPSS, Chicago, USA). than that in group W (grade I-II: 10.8% vs. 6.9%; grade Normal distribution measurement data were expressed as III-V: 11.6% vs. 3.9%; P <0:001). There was no significant mean ± SD, and t-test was used to compare the differences difference in hospital mortality, unplanned readmission rate between the groups. The measurement data of skewed distri- within 30 days, LOS, and cost between the two groups bution were expressed as median (interquartile range), and (P >0:05) (Table 2). the categorical variables were expressed as counts and per- centages and compared using the χ test. Univariate and 3.6. Risk Factors Associated with Prolonged LOS. The median multivariate analyses were carried out using logistic regres- LOS was 8 d (Table 2); therefore, a LOS of 9 d or more was sion. The P value was considered to be statistically signifi- defined as prolonged LOS. Factors such as patient age, gen- der, nutritional status, operation time, anesthesia method, cant at 0.05 level. Applied Bionics and Biomechanics 3 Geriatric patients undergoing D2 gastrectomy for gastric cancer (n = 896) Exclusion criteria With other malignancy (n = 41) With previous gastrointestinal surgery (n = 52) Incomplete clinical or pathological n = 783 record (n = 20) e remaining 783 patients were enrolled in present study Figure 1: Flowchart of patients’ selection. Table 1: Clinical and nutritional characteristics of malnourished and well-nourished elderly patients. Malnourished Well-nourished Item Group All (n = 783) t/χ /F P (n = 249, 31.8%) (n = 534, 68.2%) Age, years Median (IQR) 70 (67, 74) 72 (69, 76) 69 (67, 73) 36.700 <0.001 Male 584 (74.6) 184 (74.9) 400 (73.9) 0.092 0.762 Gender, n (%) Female 199 (25.4) 65 (25.1) 134 (26.1) 22:9±3:419:4±1:824:5±2:6 BMI (kg/m ) -31.949 <0.001 0 ~ 2 707 (90.3) 221 (88.8) 486 (91.0) 0.986 0.321 Number of chronic diseases, n (%) ≥3 76 (9.7) 28 (11.2) 48 (9.0) PNI 48:1±5:648:8±5:346:7±5:7 -5.108 <0.001 40:2±4:339:1±4:640:7±4:0 Albumin (g/L) -4.680 <0.001 Prealbumin (mg/L) 207:8±49:6 193:2±50:6 214:6±47:7 -5.709 <0.001 121:0±23:6 117:0±24:1 122:8±23:1 Hemoglobin (g/L) -3.205 0.001 TLC (×10 /L) 1:59 ± 0:54 1:57 ± 0:55 1:60 ± 0:54 0.719 0.472 Total gastrectomy 359 (45.8) 112 (45.0) 247 (46.3) 0.653 0.721 Type of surgery, n (%) Distal gastrectomy 397 (50.7) 130 (52.2) 267 (50.0) Proximal gastrectomy 27 (3.4) 7 (2.8) 20 (3.7) Operation time (min) Median (IQR) 160 (123, 189.5) 160 (126, 189) 160 (129, 191) 3.025 0.082 GA 87 (11.1) 35 (14.1) 52 (9.7) 3.206 0.073 Type of anesthesia, n (%) TEA 696 (88.9) 214 (85.9) 482 (90.3) Yes 132 (16.9) 47 (18.9) 85 (15.9) 1.060 0.303 Preoperative consultation, n (%) No 651 (83.1) 202 (81.1) 449 (84.1) Yes 25 (3.2) 9 (3.6) 16 (3.0) 0.210 0.647 Preoperative neoadjuvant chemotherapy, n (%) No 758 (96.8) 240 (96.4) 518 (97.0) I 126 (16.1) 32 (13.0) 87 (16.2) 7.452 0.059 II 150 (19.2) 53 (21.3) 133 (24.9) Tumor stage, n (%) III 402 (51.3) 128 (51.3) 267 (50.0) IV 105 (13.4) 36 (14.4) 47 (8.9) Abbreviations: BMI: body mass index; PNI: prognostic nutritional index; TLC: total lymphocyte count; GA: general anesthesia; TEA: general anesthesia combined with thoracic epidural block. chronic comorbidities, postoperative nutritional support, LOS was used as the dependent variable. The multivariate and PPC were included in the univariate analysis. Age ≥ 70 logistic regression showed that age ≥ 70 years (OR = 1:216, years, operation time ≥ 180 min, PNI < 44:5, and CD ≥ 3 95% CI 1.048-1.411, P =0:010), operation time ≥ 180 min were related factors of prolonged LOS (P <0:05). The fac- (OR = 1:431, 95% CI 1.237-1.656, P <0:001), PNI < 44:5 tors with P >0:1 in the univariate analysis were used as (OR = 1:792, 95% CI 1.058-3.032, P =0:030), and CD grade independent variables, and the occurrence of prolonged I-II (OR = 2:191, 95% CI 1.604-2.991, P <0:001) (Table 3). 4 Applied Bionics and Biomechanics Table 2: Preoperative and postoperative nutritional supports among elderly gastric cancer patients with or without malnutrition. Malnourished Well-nourished All (n = 783) Z/χ /F P (n = 249, 31.8%) (n = 534, 68.2%) Diet 359 (45.9) 141 (56.6) 218 (40.8) 14.75 <0.001 Preoperative nutrition, n (%) Diet+single transfusion 373 (47.6) 77 (30.8) 296 (55.4) TPN 51 (6.5) 31 (12.4) 20 (3.7) Single transfusion 549 (70.1) 194 (77.9) 355 (66.5) 10.592 0.001 Postoperative nutrition, n (%) TNA 234 (29.9) 55 (22.1) 179 (33.5) PN period Median (IQR), day 5 (4, 6) 5 (4, 6) 5 (4, 6) 0.004 0.951 EN period Median (IQR), day 2 (1, 2) 2 (1, 3) 2 (1, 2) 1.201 0.273 No, n (%) 669 (85.4) 193 (77.5) 476 (89.1) 21.696 <0.001 Clavien-Dindo grade I-II, n (%) 64 (8.2) 27 (10.8) 37 (6.9) III or higher, n (%) 50 (6.4) 29 (11.6) 21 (3.9) In-hospital mortality n 2 2 1 0.535 Readmission within 30 d n 15 11 4 0.79 Length of hospital stay Median (IQR), day 8 (7, 10) 8 (7, 9) 8 (7, 10) -1.504 0.133 Cost of hospitalization Median (IQR), K¥ 54.8 (47.7, 64.7) 55.3 (47.4, 66.6) 54.7 (47.8, 63.2) -1.051 0.293 Abbreviations: EN: enteral nutrition; PN: parenteral nutrition; TPN: total parenteral nutrition; TNA: total nutrient admixture; IQR: interquartile range. The “¥” refers to RMB, and “K¥” refers to "per 1000 RMB". Table 3: Univariate and multivariate analyses of clinical factors associated with prolonged length of stay. Univariate LOS Multivariate analysis analysis Clinical factors Group N = 783 (days) χ P OR 95% CI P Male 584 8 (7, 10) Sex Female 199 7 (7, 9) 3.142 0.076 0.962 (0.817, 1.132) 0.637 65~70 349 7 (7, 9) Age (years) ≥70 434 8 (7, 10) 9.730 0.002 1.216 (1.048, 1.411) 0.010 Well-nourished 534 8 (7, 9) Nutritional status Malnourished 249 8 (7, 10) 2.245 0.134 0.990 (0.842, 1.163) 0.899 <180 438 7 (7, 8) Surgery time (min) ≥180 345 8 (7, 11) 44.218 <0.001 1.431 (1.237, 1.656) <0.001 GA 87 8 (7, 11) Anesthesia TEA 696 8 (7, 9) 2.714 0.099 0.921 (0.734, 1.154) 0.474 <3 707 8 (7, 9) Comorbidity ≥3 76 8 (7, 11) 3.915 0.048 1.067 (0.839, 1.357) 0.595 ≥90 675 8 (7, 9) Hemoglobin (g/L) <90 108 8 (7, 11) 1.893 0.169 >30 772 8 (7, 9) Albumin (g/L) ≤30 11 10 (7, 11) 1.789 0.181 ≥180 523 8 (7, 9) Prealbumin (mg/L) <180 260 8 (7, 10) 7.389 0.007 0.797 (0.514, 1.237) 0.312 Single transfusion 549 8 (7, 10) Postoperative PN TNA 234 8 (7, 9) 0.317 0.573 ≥44.5 718 8 (7, 11) PNI <44.5 65 9 (8, 13) 7.856 0.005 1.792 (1.058, 3.032) 0.030 0 669 8 (7, 9) Clavien-Dindo grade 1 ~ 2 64 10 (7, 12) 2.191 (1.604, 2.991) <0.001 ≥3 50 10 (7, 17) 40.624 <0.001 1.163 (1.163, 1.701) 0.435 Abbreviations: LOS: length of stay; GA: general anesthesia; TEA: general anesthesia combined with thoracic epidural block; PN: parenteral nutrition; TNA: total nutrient admixture; PNI: prognostic nutritional index. Applied Bionics and Biomechanics 5 while, 54.8% of old patients received only carbohydrates 4. Discussion with or without composite amino acids postoperatively. No In the present study, the prevalence of preoperative malnu- significant difference was found in duration between mal- nourished and well-nourished patients. It might take some trition in elderly patients undergoing gastrectomy was 31.3%, which was relatively high compared with that in previ- time before patients with malnutrition are properly taken ous studies [9]. Many factors are contributed to observed in charge. This study also supported the findings of previous differences in malnutrition prevalence include instruments, studies that patients with malnutrition have a higher rate of age distribution, hospital location, and characteristics of the overall postoperative complications [19, 28]. This indicated that old patients with malnutrition should be paid more patients. Patients with preoperative malnutrition were associ- ated with low levels of albumin, prealbumin, and hemoglobin attention during the postoperative period, and nutritional than well-nourished patients. Furthermore, malnourished support should be individualized for these vulnerable elderly patients were found to be associated with higher post- patients. operative complications and prolonged length of hospital stay At multivariate analysis, we found that longer duration of surgery was significantly related with delayed discharge, than well-nourished elderly. There was no significant differ- ence in composition and timing of postoperative nutritional which was in accordance with previous study [29]. This management between malnourished and well-nourished suggested that the length of surgery could be regarded as patients. a convenient marker of surgical stress burden, and patients Malnutrition is one of the risk factors for PPC [19]. In going through a long period of surgery need special care postoperatively. old patients with GC, malnutrition is often caused by frailty, absorption disorder, and a decrease in food intake [20]. The novelty of this study was the assessment of nutri- These patients often develop anemia, hypoproteinemia, tional status and risk factors associated with delayed dis- and electrolyte abnormalities before surgery. Therefore, charge among geriatric GC patients with a large sample screening and assessing for malnutrition is an important size in China. As a single-center retrospective study, this study had several limitations. We did not follow up for step for all patients scheduled for major gastrointestinal sur- gery. The preoperative PNI is an independent prognostic long-term outcomes, and we could not investigate the rela- factor for disease-free along with age and TNM stage in tionship between perioperative nutritional support and clin- GC patients after surgery [21]. A recent study found that ical outcomes among malnourished patients. Therefore, preoperative PNI is a sensitive and specific prognostic large multicenter prospective RCTs should be conducted to further investigation. predictor among elderly patients undergoing gastric cancer surgery [22]. The result in our study showed that low PNI is an independent risk factor associated with prolonged 5. Conclusion LOS, suggesting that PNI is a predictor for both short-term and long-term outcomes for elderly patients. Meantime, In conclusion, malnutrition is relatively common in elderly the measurement of PNI (albumin and lymphocyte count) patients undergoing gastrectomy. Age, length of surgery, is simple and convenient to achieve. PNI, and postoperative complications were risk factors asso- The guidelines of both the American Society for Paren- ciated with delay discharge. Elderly gastric cancer patients teral and Enteral Nutrition (ASPEN) and the ESPEN recom- with risk factors urgently require specific attention for reduc- mend oral or enteral feeding whenever possible [23, 24]. ing hospital stay. Enteral nutrition is preferred over parenteral nutrition because of a lower incidence of surgical site infection [25]. But in patients with a pyloric obstruction or inadequate Data Availability energy supply by enteral nutrition, peripheral parenteral The data used to support the findings of this study are avail- nutrition or TPN is often performed [23]. In our study, the able from the corresponding author upon request. rate of preoperative TPN in patients with malnutrition was significantly higher than in well-nourished patients. How- ever, the total rate of preoperative parenteral nutrition sup- Disclosure port was still low (43.5%) in patients with malnutrition. Optimal preoperative management for elder patients with This manuscript has been preprinted (doi:10.21203/rs.3.rs- malnutrition is essential to improve surgical outcomes. 1008430/v1) [30]. Although early initiation of oral or enteral feeding has been recommended to improve clinical outcomes and to Conflicts of Interest reduce surgical complications in GC patients following gas- trectomy [23, 26], the postoperative nutritional support for The authors declare that they have no competing interests. patients is quite variable between different surgical teams. And in the statement of the Japanese Gastric Cancer Treatment Guideline, the drink should be offered after post- Authors’ Contributions operative day 1 and a solid diet should begin from postoper- ative day 2 to 4 regardless of surgery type [27]. In this study, Xining Zhao, Jie Liu, and Ying Wang contributed equally to the median period of parenteral nutrition is 5 days. 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Applied Bionics and BiomechanicsHindawi Publishing Corporation

Published: Jun 3, 2022

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