Hello I'm Phillip Carrott, one of the thoracic surgeons at the University of Michigan, and I have an interest in peri-operative nutrition and support. And this lecture is for thoracic oncology and nutrition support in the pre-operative period. So our objectives today, who needs pre-operative supplemental nutrition? And in addition, strategies specific to thoracic surgery patients, mostly in the esophagectomy population or esophageal cancer population. And then when is it best to intervene? Our pre-lecture question, what patient factor best indicates active malnutrition? A low triceps skin fold, BMI 22, weight loss, like greater than 5% in one month, or albumin 3.5? In thoracic oncology there is certainly a measure of cancer cachexia, this is cytokine driven catabolic state, usually in the patients with widely or bulky cancer. It is a combination of anorexia and metabolic derangement from the tumor burden. And really cannot be reversed with increased nutrition. In our population, most operable patients will not have true cancer cachexia. This would be the operable lung cancer patients or usually as operable esophageal cancer. Specific to esophageal cancer, though, there is a component dysphagia from the cancer and then weight loss from this and may be in combination with some cancer-driven cachexia. When esophageal cancer is noticed, it is usually at a fairly advanced stage. Talk about two different ways to assess nutrition. The first, the subjective global assessment, is a very robust tool. However, it does have some disadvantages. But to introduce it, it has a both history and physical exam component. Weight loss in the last six months to two weeks, as well as dietary intake, GI symptoms, and then activity level, are all components of this. As far as weight loss, mild weight loss is 5% in six months, or 1% in one week. Moderate weight loss, 5 to 10% percent in six months, 1 to 2% in a week. And severe would be greater than 10% in six months and greater than 2% in a week. So in an acute patient with esophageal cancer, say, greater than 5% in one month is a severe weight loss. This is a well known picture of the first successful esophagectomy. The patient lived for, I think, five or ten years after this picture was taken. In terms of the physical exam findings, loss of subcutaneous fat is important as well as muscle wasting, and then the highlighted components at the bottom are more advanced malnourished patients that would probably not be something we would see routinely. In esophageal cancer, the SGA can identify patents easily with malnutrition. Physical exam findings and weight loss are significant if it's greater than 5%. In one to two months and do significantly predict malnutrition. 40 to 80% of all esophageal cancer patients are likely to be malnourished. So in a case example, a 65 year old male with esophageal cancer and severe dysphagia for three months may have reduced functional status and weight loss of 10% in the last two months, is severely malnourished by the SGA. And there's the website for this measure. In comparing with another tool, the SGA is really difficult to administer and requires payment for the screening tool that's not too expensive. The NRS-2002 is a different tool that has fewer questions and it's in public domain. It was very simple to administer. Initial screening of these four questions, is the BMI low, outside of normal range? Is there weight loss in the last three months? Does the patient have reduced dietary intake? And is the patient severely ill? So yes on any of these initial screen questions moves to a final screening score. And in this NRS-2002, the score greater than or equal to 3 indicates somebody that is nutritionally at risk, and should consult with a dietician or have supplementation strategy implemented. A score of 1 to 3 for weight loss or dietary intake, 1 to 3 for severity of disease. And add in a 1 for age over 70. This is from the original paper indicating the scoring system. We'll leave this up for a minute, but most esophageal cancer patients, as we'll see, would get a score greater than or equal to 3 in most cases. So in taking our example again, of a 65 year old male with esophageal cancer and dysphagia and weight loss of 10% in the last 2 months, this would again be severely malnourished. As he does have an impaired nutritional status, and at least a 2 on severity of disease so it would be picked up on the screening. So once we identify the patient is malnourished, they should be assessed by a dietician if possible. And then assessed for how much dysphagia they are having. Patients in the middle of chemotherapy and radiation will likely have some weight loss, but then may have their dysphagia improve as the cancer is treated. As well, we should be thinking of our surgical strategy, is this patient somebody that is going to go on to an esophagectomy, and would they benefit from a feeding access? In our population, oftentimes nasal tubes can be placed easily in the clinic. And avoid further surgery in somebody that's undergoing chemotherapy and radiation. As we've discussed, there's a high instance of dysphagia and that may also have components of anorexia or cachexia while undergoing treatment or as part of the disease process. In these patients, meal supplements can be a good strategy to halt or reduce any weight loss. It should be emphasized that any brand will work. Often times Carnation Instant Breakfast or any of the Ensure Boost type of drinks that can be picked up at any supermarket will work. The difficulty becomes patient adherence, if they do have components of anorexia that is part of the disease or treatment process. Feeding access, either the nasal tube, which is easy to place, or surgical tubes, G or J type of tube placed either with a PEG endoscopic approach or laparoscopic. Or even just a small incision for a open jejunostomy can halt the progress of the malnutrition. It should be emphasized that if a patient is undergoing a trimodality surgery, chemotherapy, radiation, approach, PEG tube should be avoided if possible. As this does, while not make it impossible, it does complicate the use of the stomach for esophageal replacement. In placing a feeding access, it should be emphasized that early identification and treatment are essential, and that just getting a nasal tube into the stomach in a clinic can be very easily done. The patient preference of having a tube can vary. So our post-lecture question, what patient factor best indicates active malnutrition? If it's skin fold, fat loss, low BMI, weight loss being 5% or more in a month or albumin, weight loss 5% in one month is the answer to this. And our take home points, malnutrition is prevalent in thoracic oncology, in both lung cancer and esophageal cancer. It often is unrecognized. Diagnosis and treatment is important in multi-disciplinary cancer care. And weight loss is a critical sign of malnutrition. Thank you.
