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Slide 1 - Nutrition assessment & support in esophageal cancer 實習生:林廷駿 指導老師:陳燕慈營養師 報告日期:2012/12/25 1
Slide 2 - Introduction 2
Slide 3 - Treatment & Esophageal cancer Stahl et al., 2005 Schneider et al., 2007 Bedenne et al., 2007 radiotherapy chemotherapy surgery Only 30% to 40% of patients 3
Slide 4 - Malnutrition & Esophageal cancer Malnutrition (60~85%) Immune functions Performance status Muscle function Quality of life Response to chemotherapy Survival Van Cutsem et al., 2005 Mariette et al., 2012 4
Slide 5 - Postoperative complications Malnutrition enhances the chance of postoperative complications in patients with esophageal cancer. Kelsen et al., 1998 Senesse et al., 2008 Garth et al., 2010 Mariette et al., 2012 Postoperative complications delay postoperative recovery and impair quality of life. Viklund et al., 2005 Nutritional support can improve postoperative outcome in patients with gastrointestinal cancer. 5
Slide 6 - Preoperative nutritional condition The preoperative physiological status of the patient is known to influence postoperative mobidity and mortality. Lund et al., 1990 Law et al., 1994 Pretreatment nutritional support to maintain body weight throughout treatment could possibly decrease postoperative complications. 6
Slide 7 - Nutritional Status as a Risk Factor in Esophageal Surgery I.J.M. Han-Geurts, W.C. Hop, T.C.K. Tran, H.W. Tilanus Dig Surg 2006; 23: 159-163 7
Slide 8 - Purpose Preoperative nutritional condition Body mass index(BMI) Prognostic nutritional index(PNI) Nutritional risk index(NRI) Weight loss Postoperative morbidity 8
Slide 9 - Patients In total, 400 patients with an esophageal malignancy undergoing esophageal resection and gastric tube reconstruction between 1996 and 2003. 9
Slide 10 - Methods   PNI   NRI Borderline mild: > 97.5 Moderate: 83.5-97.5 Severe: < 83.5 None, < 5%, 5-10%, > 10% Weight loss < 18.5, 18.5-24.9, 25-29.9, > 30 BMI 10
Slide 11 - Methods Data were obtained on postoperative infectious complications, length of hospital stay and postoperative mortality. Data analysis: Chi-square test Mann-Whitney’s test Logistic regression 11
Slide 12 - Results 12
Slide 13 - Results P value for trend = 0.01 13
Slide 14 - Results 14
Slide 15 - Results 15
Slide 16 - Results 16
Slide 17 - Discussion The ROC curve shows that PNI and NRI do not make sensitive tests for predicting infectious complications. No correlation was found between the degree of preoperative weight loss and BMI and the incidence of postoperative infectious complication rate. 17
Slide 18 - Discussion Takagi et al. evaluated the relationship between preoperative immunosuppression and morbidity and demonstrated a higher BMI in patients with postoperative complications. They concluded that not the nutritional state but depression of cell-mediated immunity was related to the complication rate in patients who received preoperative nutritional support. 18
Slide 19 - Conculsion Preoperative nutritional status established by PNI, NRI, BMI and weight loss has no predictive value on postoperative infectious complications in patients with an esophageal malignancy. 19
Slide 20 - Baseline nutritional status is prognostic factor after definitive radiochemotherapy for esophageal cancer J.-B. Clavier, D. Antoni, D. Atlani, M. Ben Abdelghani, C. Schumacher, P. Dufour, J.-E. Kurtz, G. Noel Dis Esophagus 2012 Oct 26 doi: 10.1111/j.1442-2050.2012.01441.x 20
Slide 21 - Purpose 21
Slide 22 - Materials and Methods Study population: between 2003 and 2006 143 esophageal cancer patients Treated by definitive Concurrent radiochemotherapy Surgery Raditherapy without chemotherapy Distant metastasis Excluded 22
Slide 23 - Materials and Methods Pretreatment evaluation: Medical history Clinical examination Routine blood tests Cancer staging system: 2002 Union for International Cancer Control (UICC) TNM classification 23
Slide 24 - Materials and Methods Nutritional factors: Weight loss BMI Serum albumin level Nutritional Risk Index (NRI) Treatment: Three-dimensional conformal radiotherapy Concurrent cisplatin and 5-fluorouracil (5-FU) chemotherapy 24
Slide 25 - Materials and Methods Follow-up: Every 3 months for the first year, every 6 months for the second year, and yearly thereafter. Statistical analysis: Kaplan-Meier method and Log-rank test Cox regression Hazards ratios (HR), and within 95% confidence interval (CI) Log-minus-log plots and Schoenfeld residuals IBM SPSS Statistics v20 (IBM Inc., Armonk, NY, USA) 25
Slide 26 - Results 26
Slide 27 - Results 27
Slide 28 - Results P=0.0098 28
Slide 29 - Discussion In the study, NRI is described as an independent prognostic factor for both DFS and OS, which emphasizes the major impact of nutrition on the outcome of esophageal cancer patients. Several previous studies have shown that weight loss, serum albumin level, BMI, performance status (PS) were able to be identified as independent prognostic factors. 29
Slide 30 - Conclusion This study found a major impact of baseline nutritional status on the outcome of esophageal cancer patients treated by definitive radiochemotherapy. NRI was an independent prognostic factor of both DFS and OS. 30
Slide 31 - Dietician-delivered intensive nutritional support is associated with adecrease in severe postoperative complications after surgery in patientswith esophageal cancer G. C. Ligthart-Melis, P. J. M. Weijs, N. D. te Boveldt, S. Buskermolen, C. P. Earthman, H. M. W. Verheul, E. S. M. de Lange- de Klerk, S. J. B. van Weyenberg, D. L. van der Peet Dis Esophagus 2012 Dec 13 doi: 10.1111/dote.12008 31
Slide 32 - Purpose To evaluate the effect of an intensive nutritional support (INS) program under the guidance of a dietician on postoperative outcome in patients with esophageal cancer. 32
Slide 33 - Patients 65 patients with esophageal cancer 37 patients who underwent an esophagectomy between January 2006 and February 2009 were included in the control group. 28 patients who underwent an esophagectomy between March 2009 and April 2010 were included in the INS intervention group. 33
Slide 34 - Nutritional treatment INS group 34
Slide 35 - Nutritional treatment 35
Slide 36 - Results 36
Slide 37 - Results Preoperative weight change P=0.048 unadjusted Adjusted: non-significant With NAT P=0.002 unadjusted P=0.009 adjusted 37
Slide 38 - Results The adjusted odds ratio after surgery was 0.23 (95% CI: 0.05–0.97; P=0.045) The adjusted odds ratio undergoing NAT was 0.14 (95% CI: 0.23–0.89; P=0.037) 38
Slide 39 - Results Patients undergoing NAT ICU/MCU stay: P=0.049 Hospital stay: P=0.04 39
Slide 40 - Discussion Dietary intervention is especially beneficial in patients who received NAT. The longer time between diagnosis and surgery may have been to the advantage of the INS group. The prevention of preoperative weight loss may also be an explanation for the observed effect of INS on postoperative complications in patients receiving NAT. 40
Slide 41 - Discussion In the present study, patients in the INS group were intensively guided by a dietitian without the use of immune system modulating nutrients. This result suggests that a lot is to gain with plain improvement of energy and protein intake. 41
Slide 42 - Conclusion This study shows that INS by a dietician is associated with preoperative weight preservation and less severe short-term postoperative complications in patients with esophageal cancer. 42
Slide 43 - Summary Nutritional status such as NRI, weight loss, serum albumin, and performance status can be independent prognostic factors in patients with esophageal cancer and lead to an early specific nutritional support. 43
Slide 44 - Summary Patients with esophageal cancer should have dietary counseling once every two week, whether in preoperative stage or in postoperative stage. As well as the most important thing is that patients with NAT is a high risk group that is most likely to suffer from malnutrition, however, treating them with INS can evidently improve their nutritional condition, then it finally affect prognosis positively and rise survival rate. 44
Slide 45 - Reference I.J.M. Han-Geurts, W.C. Hop, T.C.K. Tran, H.W. Tilanus. Nutritional Status as a Risk Factor in Esophageal Surgery. Dig Surg 2006; 23: 159-163 J.-B. Clavier, D. Antoni, D. Atlani, M. Ben Abdelghani, C. Schumacher, P. Dufour, J.-E. Kurtz, G. Noel. Baseline nutritional status is prognostic factor after definitive radiochemotherapy for esophageal cancer. Dis Esophagus 2012 Oct 26 doi: 10.1111/j.1442-2050.2012.01441.x G. C. Ligthart-Melis, P. J. M. Weijs, N. D. te Boveldt, S. Buskermolen, C. P. Earthman, H. M. W. Verheul, E. S. M. de Lange- de Klerk, S. J. B. van Weyenberg, D. L. van der Peet. Dietician-delivered intensive nutritional support is associated with a decrease in severe postoperative complications after surgery in patients with esophageal cancer. Dis Esophagus 2012 Dec 13 doi: 10.1111/dote.12008 45