Improving Surgical Outcomes in Patients Undergoing Major Gastrointestinal and Gynecologic Surgery with Aggressive Perioperative Immunonutrition

Background: Early recognition of malnutrition and preoperative nutritional status is paramount in improving surgical outcomes. Poor nutrition can be an independent risk factor for postoperative morbidity. Perioperative immunonutrition can modulate favorable immune and inflammatory responses in patients undergoing oncologic surgery. Amino acids, dietary nucleotides, and lipids play a critical role in controlling immune function resulting in decreased surgical site infections, shorter hospital length of stay (LOS), and fewer overall complications.

Objective: Our purpose was to institutionalize these best practices using a standard protocol for at-risk malnourished gastrointestinal (GI)/gynecologic (GYN) cancer surgery patients using an immunonutrient blend product (IBP) to decrease their hospital LOS, postoperative complications, and readmission rates.

Methods: The population was limited to patients with a new diagnosis of upper/lower GI and GYN malignancies. To deliver a consistent nutritional formula, an IBP containing arginine, fish oil, nucleotides, and antioxidants was purchased through a hospital research grant. Patients were screened using a standard screen adapted from AND/ASPEN malnutrition guidelines. If patients met ≥2 criteria, they received IBP 500 to 1000 mL per day for 5 days before and 5 days after surgery. Outcome measures were hospital LOS, postoperative complications, and readmission rates.

Results: Fifty-one patients were screened for malnutrition based on parameters for ascites (moderate vs severe), edema (+2 vs ≥3), weight loss (>5% in 1 m vs ≥5%-10% in 1-3 m), oral intake (~50% vs <50%), facial fat loss/muscle wasting (moderate vs severe), and skin integrity (superficial breakdown vs skin loss). Sixty-eight percent (N = 35) met criteria with ≥2 parameters for receiving IBP, while 32% did not.

Per national benchmark data for GYN and GI cancer surgical patients, median LOS is 7 to 10 days, the average post-op complication rate is 27.12%, and readmission rate is 14.77%. In IBP study patients, the median hospital LOS was 5 days, post-op complication rate was 26%, and the readmission rate 8.5%. Of the 32% of patients who did not receive IBP but had surgery, the median LOS was 6 days, the post-op complication rate 40%, and the readmission rate 20% despite not at risk of malnutrition per screening. The LOS cost analysis based on NIS-HCUP data (2008) for GI surgery reflected an average cost saving of $100,136.48 after including the cost of IBP. The cost analysis was based on the decreased LOS of 1 day in 68% of patients (N = 35) with IBP versus the remaining 32% not on IBP (median of 5 days vs 6 days) per national average of per-day hospital cost of $2,948.

Conclusion: Recognizing and treating patients who meet criteria for malnutrition with an IBP blend product can result in reduced hospital LOS, postoperative complication rates, and readmission rates. Utilizing this approach resulted in better patient outcomes and significant cost savings and should serve as the standard of care in the GI/GYN malignancy pre- and postoperative setting.