RF5 - Multidisciplinary Preoperative Immunonutrition Initiative in Colon and Rectal Surgery

Purpose/Background: Preoperative malnutrition is associated with increased morbidity and mortality in patients undergoing gastrointestinal surgical procedures. Immunonutrition enhances host defenses via supplementation of depleted nutrition. Its use in the preoperative period has been shown to improve postsurgical infectious and noninfectious complications. Our study aimed to determine the impact of a preoperative nutrition initiative in patients undergoing elective colectomy and proctectomy.

Methods/Interventions: All consecutive elective colectomy and proctectomy patients from March 2022 to April 2023 were eligible to receive nutrition supplements. Patients were prescribed a 7-day regimen of twice daily Ensure® Surgery Immunonutrition Shakes prior to surgery. Concurrently, patients underwent comprehensive nutritional assessment and educational reinforcement with registered dietitians (RDs). This was a multidisciplinary effort involving physicians, RDs, nursing, advanced practice providers and coordinators to ensure that eligible patients received treatment. There were no other changes in our longstanding ERAS program. The treatment cohort was compared to historical controls from the prior year. The primary aim of the study was patient compliance with the nutrition shakes. Secondary outcomes included post-operative complications and outcomes.

Results/Outcomes: Of the 313 eligible patients, 216 patients received nutrition supplements. Of the patients who received supplements, the median compliance with respect to completion of the immunonutrition regimen was 85.9%. Compliance data was missing on 34% of patients. The majority of patients (84%) in the treatment cohort completed a RD consultation prior to surgery. The control cohort included data on 253 patients undergoing colectomy or proctectomy in 2021. Baseline characteristics of the two cohorts, including indications for surgery, were largely similar, with the exception of BMI (treatment, mean 29.6 kg/m2 vs. control, mean 28.1 kg/m2, p=0.018).
Preoperative albumin levels were similar between the cohorts (treatment, mean 4.02 g/dL vs. control, mean 3.71 g/dL). In the treatment cohort, the Malnutrition Screening Tool (MST) identified malnutrition in 3.2% of patients, and 8.4% were at risk. There were 15 surgical site infections (SSIs) in the treatment cohort and 16 SSIs in the control group. A trend towards decreased organ space SSI was noted with 8 in the treatment cohort and 13 in the control group (p=0.45). Length of stay (LOS) was significantly decreased from 6.2 days to 4.6 days in the treatment cohort (p= < 0.001). Our initiative was limited by inability to reliably capture data related to supplement intake, representing an opportunity to develop and implement a more reliable preoperative workflow.

Conclusion/Discussion: Following initiation of a multidisciplinary program to administer oral immunonutrition supplements to patients undergoing elective colorectal resection, we identified process challenges and patient compliance limitations. Despite these issues, immunonutrition supplementation resulted in a significant decrease in postoperative hospital length of stay, regardless of baseline nutritional status. Further refinement of the program may expand utilization and improve compliance to further identify and minimize the risks associated with colorectal surgery.