| BackgroundThe impact of malnutrition on clinical outcomes has always been the focus of research attention. However, the results of different studies differed greatly due to absence of standardized definition of malnutrition, variable populations or types of institutions and as most of the studies have been conducted in western cultures. Patients with gastrointestinal cancer may develop malnutrition in more than one way:mechanical obstructions in the gastrointestinal tract, response to tumor factors, normal food intake interrupted by digestive tract reconstruction. As a result, malnutrition is frequently seen in these patients. Few studies have involved the nutritional status and practice of nutrition support and the subsequent impact on clinical outcomes and hospital costs among these patients in China.Objectives1. To discribe the prevalence of malnutrition and nutrition support practice in gastrointestinal cancer surgical patients, and to analyze the relationship between nutritional status and nutrition support.2. To compare the incidence of complications and length of hospital stay between malnourished and well nourished gastrointestinal cancer surgical patients, and to evaluate the impact of malnutrition on related clinical indices.3. To compare the hospital costs between malnourished and well nourished gastrointestinal cancer surgical patients, and to evaluate the impact of malnutrition on hospital costs.MethodsIn this prospective cohort study, a consecutive series of 336 gastrointestinal cancer patients undergoing elective surgery in Peking Union Medical College Hospital were enrolled from April to December 2009. Nutritional status was evaluated by Subjective Global Assessment within 48h of admission and 7 days post surgery. Nutrition support practice, complications, length of hospital stay and hospital costs were collected during hospitalization. Patients were followed until discharge, hospital death, or transfer to Results1. Malnutrition was present in 28.6% and 53.6% on admission and 7 days post surgery, respectively.83.3%(280/336) of patients experienced mean weight loss of 2.73±1.64Kg. There were significant differences in the change of nutritional status and weight loss between admission and 7 days post surgery (P<0.05).2.24 patients were given nutritional support before surgery and the majority of them were given enteral nutrition. For the patients with nutritional status SGA A, SGA B and SGA C,2.9%(7/240),12.9%(9/70), and 30.8%(8/26) of them were given nutritional support, respectively. There was significant difference in the prescription rate of nutritional support among the three groups (P<0.05).3. All the patients were given nutritional support after surgery and parenteral nutrition was applied to most of them. Only 5.7%(19/336) were given combined parenteral-enteral nutrition. There was no relationship between the prescription of nutritional support and nutritional status, while patients with worse nutritional status were given longer duration of nutrition support and higher energy intake (P<0.05).4. Infectious complications occurred in 16.3% versus 17.7% and noninfectious complications occurred 1.7% versus 3.1% of the nourished patients versus malnourished patients according to the nutritional assessment within 48h on admission. Infectious complications occurred in 15.4% versus 17.8% and noninfectious complications occurred 0.6% versus 3.3% of the nourished patients versus malnourished patients according to the nutritional assessment 7 days post surgery. There were no significant differences between the two groups (P>0.05). Logistic regression analysis showed nutrition status was not the predictive parameter for the occurrence of postoperative complications when adjusted for confounders.5. Mean length of hospital stay were 18.07±6.74 days versus 18.45±5.73 days and postoperative hospital stay were 11.15±5.63 days versus 10.99±3.99 days of the nourished patients versus malnourished patients according to the nutritional assessment within 48h on admission. Mean length of hospital stay were 17.71±6.38 days versus 18.58±6.52 days and postoperative hospital stay were 10.85±5.19 days versus 11.33±5.22 days of the nourished patients versus malnourished patients according to the nutritional assessment 7 days post surgery. There were no significant differences between the two groups (P>0.05). Multiple stepwise regression analysis showed nutrition status was not the predictive parameter for the length of hospital stay when adjusted for confounders. 6. ICU transfer rate was 13.3%(32/240) of nourished patients versus 21.9%(21/96) of the malnourished patients according to the nutritional assessment within 48h on admission, but there was no significant difference between the two groups (P>0.05). Logistic regression analysis showed nutrition status was not the predictive parameter for ICU transfer when adjusted for confounders.7. The cost of postoperative nutrition solution accounted for 3%-39% of total hospital cost (mean 13.2%),13%-69% of drug cost (mean 36.8%). Mean total hospital cost was (?) 33230.77±11941.87 versus (?) 33720.60±10448.05, nutrition solution cost was (?) 4447.87±2039.26 versus Y 4334.66±1938.25, and median cost of treating complications was Y 1190.21 versus Y 642.93 of the nourished patients versus malnourished patients according to the nutritional assessment within 48h on admission. Mean total hospital cost was Y34120.96±11409.02 versus (?)32505.06±11627.53, nutrition solution cost was (?)4485.17±1994.66 versus Y4355.17±2024.39, and median cost of treating complications was Y977.74 versus Y886.77 of the nourished patients versus malnourished patients according to the nutritional assessment 7 days post surgery. There were no significant differences between the two groups (P>0.05). Multiple regression analysis showed nutrition status was not the predictive parameter for the total hospital cost when adjusted for confounders.Conclusions1. One patient in every three admitted to hospital was malnourished and malnutrition rates increased 7 days post surgery.2. With the decline in nutritional status before surgery, there was a significant increase in the prescription rate of nutritional support. Nutrition support was suboptimal in patients with nutritional status SGA C according to the guidelines on nutritional support.3. All the patients were given nutritional support after surgery and parenteral nutrition was applied to most of them. There was no relationship between the prescription of nutritional support and nutritional status, while patients with worse nutritional status were given longer duration of nutrition support and higher energy intake.4. Malnutrition was not the predictive parameter for the postoperative complications, length of hospital stay in gastrointestinal cancer undergoing elective surgery.5. Nutrition solution costs accounted for considerable proportion of total hospital cost and drug cost. Malnutrition was not the predictive parameter for the hospital cost in gastrointestinal cancer undergoing elective surgery.
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