Chapter 14: Nutrition Management of the Surgical Oncology Patient

Question 1

Ms. Smith is a 65 year old, 60”, 120#, had a surgical resection of her ileum which result in a permanent ileostomy. Initially, her output was 1L per day which has slowed down. Her labs are Na 153, K 5.0, Creat 0.9. She is now ready to discharge and you are to instruct her on her fluid intake? What is the best recommendation given her ostomy?

Answer 1

Consume at least 1L more fluid than ostomy output

Question 2

Surgical interventions for gastric cancer can result in reduced gastric acid production. What is a predicted issue from reduced gastric acid?

Answer 2

Bacterial and fungal overgrowth resulting in pain when eating - by achlorhydria

Constipation - by dysmotlity s/p resection

Megaloblastic anemia - caused by inability to activate B12

Question 3

40 yr old female recently had a significant small bowel resection d/t tumor invasion. She now presents to the hospital with metabolic acidosis as a result of undigested food in the colon. What are your recommendations?

Answer 3

Restrict refined CHO (lactose, fructose and alcohol sugars)

Could also add probiotics, several Lactobacillus strains and antibiotics

Question 4

PT on tube feedings for 2 months secondary to severe anorexia and post-op dysphagia. She has been undergoing SLP therapy 3 days/week and upgraded to mech soft with thin liquids. Appetite has also improved. RD is working on weaning feedings to improve hunger cues. When should nutrition support be discontinued?

Answer 4

Once pt’s oral intake meets 75% of needs and can drink 1000 ml of fluid for 3 days

Question 5

Reggie has cancer at the GE junction. Will undergo a partial gastrectomy with removal of the lower esophageal sphincter (LES) and resection of the vagus nerve. What side effects should the RD be prepared to discuss with the patient?

Answer 5

Esophageal Dysmotility
Regurgitation
Reflux
Potential need for enteral nutrition support

**Resection of vagus nerve would reduce pt’s ability to experience early satiety

Question 6

Patients with an ileostomy are at increased risk for dehydration an electrolyte abnormalities and should consume what?

Answer 6

Fluids at least one liter greater than ostomy output

Question 7

A pt is experiencing reflux of bile from the small bowel into the stomach s/p gastrojujunostomy. What drugs would our recommend to help neutralize the irritating effect of the bile?

Answer 7

Sadly none - there are no drugs that neutralize the irritating effect of the bile in the esophagus

Question 8

Bacterial overgrowth in the terminal ileum following ileocecal valve resection can reduce absorption of which vitamin and may require supplementation?

Answer 8

Vitamin B12

Question 9

A loss of intrinsic factor due to proximal gastric resection may result in Vit B12 malabsorption, which may lead to what condition?

Answer 9

Megaloblastic Anemia

Question 10

A decreased or cessation of the production of gastric acid that may allow bacterial and fungal overgrowth. This can lead to pain when eating and suboptimal intake. What is this condition?

Answer 10

Achlorhydria

Question 11

A patient presents to your 6 months s/p partial resection of ileum with recent takedown of ileostomy. 20# wt loss since resection. Currently getting FOLFOX. Has following symptoms:

• diarrhea ~20 after eating
• heartburn after consuming milk/fruit/tomato products
• N/some V, usually within 3 days of treatment and then improves
• sensitivity to cold foods
• occasional dizziness about 2 hours after eating
• fatigue

What symptoms above might be associated with her bowel surgery and have potential long term feeding issues once chemo is completed

Answer 11

Reflux Esophagitis

Dumping Syndrome

Question 12

What recommendations would you give a patient with a new ileostomy following a bowel resection 2 weeks ago?

Answer 12

eat small/frequent meals
chew foods well
8-10 cups of fluid daily to prevent dehydration
avoid high fiber foods (both insoluble and soluble)
low fat foods for ease of digestion
limited high sugar foods to prevent diarrhea

Question 13

What surgical areas have the most potential for major derangements in nutrition status?

Answer 13

Head and Neck
GI tract
Abd vasculature

These areas also have associated conditions/symptoms that directly cause or predispose to malnutrition

Question 14

In a malnourished surgical patient, EN for ____ days prior has been found to reduce morbidity and mortality and preserve bowel mucosa and modulating the immune response

Answer 14

10 days

Question 15

Studies show that preoperative education on expectations and pain management can reduce _______ and ________, and improve _______

Answer 15

reduce anxiety and pain

improve outcomes

Question 16

How long does it take for the small bowel to adapt after an intestinal resection?

Answer 16

weeks to months

Question 17

Early initiation of EN postoperatively promotes many physiologic benefits including _____________, _________ and ________, and reduces ________________.

Answer 17

wound healing, gut function and immunity

hospital length of stay

Question 18

What are the major implications for nutrition regarding surgery to:

Head and Neck

Answer 18

Compromise the ability to chew/swallow
Possible dependence of EN for life
Side effects from treatment like mucositis

Question 19

What are the major implications for nutrition regarding surgery to:

Peritoneal

Answer 19

Initial present with abd bloating/cramping, N/D/C, anorexia

Due to proximity, its common for GI resections to occur during the debulking surgery, causing disruption to normal GI function

Peritonitis can cause an ileus or impair gut absorption

Question 20

What are the major implications for nutrition regarding surgery to:

Esophageal

Answer 20

Preop present with swallowing issues/dysphagia

Dumping is common after surgery, as is reflux, dysmotility of the remaining esophagus and gastric dysmotility (secondary to resection of vagus nerve). Damage to this nerve can cause satiety issues, leading to overfeeding and possibly regurgitation.

30% experience stricture(s) after esophagectomy

Question 21

What are the major implications for nutrition regarding surgery to:

Stomach

Answer 21

Depends on site…

Removal of LES (lower esophageal sphincter) results in acid reflux.

Disruption of the Pyloric function (lower) causes reflux of bile from small bowel into stomach, dumping syndrome

A decrease in gastric acid can lead to uncontrolled bacterial/fungal growth, causing pain. It also impacts intrinsic factor/B12 absorption

Dysmotility causes early satiety, heartburn, dysphagia, aspiration, and pneumonia

Question 22

What are the major implications for nutrition regarding surgery to:

Small Bowel

Answer 22

Loss of portions of the jejunum can result in inapprorpiate secretion of digestive enzyimes and accelerate gastric emptying.

Significant resection to lower jejunum and ileum reduces absorption, may result in short bowel syndrome (having less than 30% (200 cm)).

If there is high gastric acid, this won’t get neutralized properly, resulting int deactivating enzymes and deconjugates bile acids, leading to maldigestion/malabsorption

Undigested food in colon can cause metabolic acidosis, bacteria overgrowth, sepsis

Question 23

What are the major implications for nutrition regarding surgery to:

Colon

Answer 23

It may take 2 years or longer for a colon to restructure/adapt after a surgery

resections to the terminal ileum and colon (ileostomy and/or colostomy) have permanent effects.

Bacteria overgrowth can be a concern, causing several problems

decreased transit time is common

Question 24

What are the major implications for nutrition regarding surgery to:

Pancreatic

Answer 24

impacts to both exocrine and endocrine functions

exocrine - pancreatic enzymes, bicarbonate production

Question 25

What are the major implications for nutrition regarding surgery to:

Liver

Answer 25

hypoalbuminemia, hyperglucagonaemia, increased energy expenditure, depleted skeletal muscle mass and anorexia

Question 26

Effects and nutrition interventions for Insulinomas

Answer 26

fasting hypoglycemia - consume complex carbs every 2-3 hrs

Question 27

Effects and nutrition interventions for Gastrinomas

Answer 27

recurrent ulcer/diarrhea/reflux - treat with meds

Question 28

Effects and nutrition interventions for Glucagonomas

Answer 28

Erythema/diabetes - carb counting plan

Question 29

Effects and nutrition interventions for VIPomas

Answer 29

increased secretion of vasoactive intestinal peptide, Verner-Morrison syndrome, pancreatic cholera or WHDA - meds and fluids to manage losses and limit output, EN/PN replacement of electrolytes may be needed

Question 30

Explain Dumping Syndrome and the Nutrition Intervention

Answer 30

Early: D/N/Bloating, tachycardia immediately - 30 min after a meal

Late: hypoglycemic symptoms, dizziness - 90-180 min after a meal

small/frequent meals
separate solids/fluids at meals
reduce simple carbs/concentrated fats
increase soluble fiber intake

Question 31

Explain Reflux Esophagitis and the Nutrition Intervention

Answer 31

Regurgitation of food/digestive juices causing heartburn, N/V

small/frequent meals
Diet mod (lower fat, avoid alcohol, consume smaller volumes/meal or snack)
antacids/sucralfate

Question 32

Explain Delayed Gastric Emptying/gastric stasis and the Nutrition Intervention

Answer 32

Early satiety, postprandial fullness, heartburn, dysphagia, aspiration

small/frequent meals
Diet mod (5-6 meals/day, chew food well, avoid fried/greasy foods, mod fiber intake)
Prokinetic agents

Question 33

Explain Pancreaticocibal Asynchrony and the Nutrition Intervention

Answer 33

Steatorrhea, frequent light greasy stools

pancreatic enzyme supplements
supplement of micronutrients as needed (fat soluble vit, Ca, Vit D)

Question 34

Explain Reduced intake/impaired absorption/increased losses and the Nutrition Intervention

Answer 34

micronutrient deficiencies

enteral/panenteral replacement
pancreatic enzyme supplementation

Question 35

Explain stricture/gastric outlet obstruction and the Nutrition Intervention

Answer 35

vomiting/constipation

enteral/panenteral depending on extent
endoscopic balloon dilation or surgical stenting
promotility agetn

Question 36

Explain Pancreatic Enzyme insufficiency and the Nutrition Intervention

Answer 36

steatorrhea, bloating

pancreatic enzyme replacement