Arved Weimann, MD, MA: Hello, I am Arved Weimann, general surgeon and head of the department of general and visceral surgery at St George Hospital, which is an affiliated hospital of the University of Leipzig in Germany. Welcome to this program entitled "Optimizing Nutritional Support in Critically Ill and Surgical Cancer Patients."

I’m joined in this program by Dr Daren Heyland, professor in the department of medicine, director of the Clinical Evaluation Research Unit in Kingston General Hospital at Queen's University in Kingston, Ontario, Canada; by Dr Alessandro Laviano, associate professor in the department of clinical medicine, Sapienza University in Rome, Italy; by Jean-Charles Preiser, professor in the department of Intensive care at the Erasmus University Hospital, University of Brussels in Brussels, Belgium; and by Kenneth Fearon, professor of surgical oncology, department of clinical and surgical sciences at the School of Clinical Sciences and Community Health at the University of Edinburgh, Royal Infirmary, Edinburgh, Scotland, in the United Kingdom.

In this program we will discuss malnutrition as an independent risk factor of prognostic value and a therapeutic target in critically ill and surgical cancer patients, the role of malnutrition in the pathophysiology, metabolic response and alteration of prognosis in these patients, and the latest nutritional guidelines and clinical findings on enteral nutrition (EN) and parenteral nutrition (PN) in these patients.

In the first segment, I will discuss with Dr Preiser about what we have learned from recent nutrition trials in critically ill and surgical cancer patients. Dr Heyland will then discuss nutrition screening with the NUTRIC score and the risk of underfeeding in the ICU patient. This will be followed by a discussion with Dr Laviano and Dr Fearon about the pathophysiology, diagnosis, screening and nutrition management for critically ill and surgical cancer patients. In the final segment, I will review with Dr Fearon the guidelines, clinical practice, and next steps for the cancer patient in the perioperative period.

Let me start this program by giving a brief introduction. As a surgeon, I am interested in clinical nutrition and nutritional risk. I have to operate on my patients, who are increasing in age and being diagnosed with more cancer; both factors that I cannot influence myself. These factors are relevant to the rate of clinical complications in the postoperative course, which was shown in the multicenter study by Sorensen and colleagues. However, there is one factor that I can detect and influence myself, the nutritional score of my patients. That is also a significant factor for the rate of complications.

Therefore, there is an accumulation of risk that should be taken into consideration by every surgeon, and is based on whether your patient is elderly with impaired functional dependency and capacities, whether your patient has cancer, as well as his or her nutritional status, which can be detected prior to surgery.

Cancer cachexia, as defined by Fearon and colleagues, starts very early with a weight loss of ≤5%. Here, alternations in metabolism lead to catabolic changes in the muscle, which promote muscle wasting, etc. We have to be diligent about identifying and detecting these phenomena at a very early stage in our patients.

Why is this so important? Because risk factors, complications, and survival after upper-abdominal surgery are related to weight loss, which was shown in a prospective cohort study from Aahlin and colleagues. A preoperative weight loss of >5% and a preoperative serum albumin of <35 g/L are both independent factors for reduced overall survival (OS).

There is a vicious circle in surgical metabolism related to nutritional factors, including wound healing, muscle strength, and immune defense. We want to avoid any septic complications as well as any fatal outcome. Therefore, nutrition is a great intervention to introduce into this catabolic circle.

There is a new concept, the enhanced recovery after surgery (ERAS) program, which will be expanded upon by Ken Fearon later in the program. ERAS is a new way to bring patients quickly out of the bed and into an early oral feeding regimen. It made us aware that metabolic changes in the early post-operative course can be overcome by early mobilization, enforced early oral nutrition, and appropriate analgesia.

Last year, Gillissen and colleagues showed that ERAS is associated with a significant advantage regarding a shorter overall length of hospital stay.

But ERAS can fail. If ERAS fails, we need a goal-directed Plan B for nutritional therapy in surgical cancer patients with special regard to those who need the intensive care unit (ICU) for the treatment of complications.