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5.1 Preoperative care.

      Optimization of Nutritional Status

Cancer‐related malnutrition is multifactorial, including anorexia, nausea, vomiting, and metabolic disorders. It is not uncommon in patients undergoing major abdominal surgery. Although there is a lack of a standardized definition, it is well known that malnutrition is a significant risk factor of postoperative complications. Nutritional status can be measured using several tools. The gold standard for the American Society for Parenteral and Enteral Nutrition (ASPEN) is the Subjective Global Assessment (SGA), based on performance status and physical examination. It is widely used, but the main disadvantage is the high interobserver variability [19]. In 2003, the European Society of Parenteral and Enteral Nutrition (ESPEN) adopted Nutritional Risk Screening 2002 (NRS‐2002) to screen patients for malnutrition in the hospital. NRS‐2002 is based on oral food intake, weight loss, patient’s age, body mass index (BMI), and severity of underlying disease (Table 5.1) [4].

According to the ESPEN guidelines, a minimum of seven days of preoperative nutritional support that provides at least 10 kcal/kg/day is considered adequate for patients who are nutritionally at risk (NRS score at least 3) [4]. Oral nutrition support with a standard whole protein formula enriched with immune modulating substrates (arginine, ɷ‐3 fatty acids, and nucleotides) is strongly recommended [20]. Whenever feasible, enteral feeding should be preferred to parenteral nutrition [21]. Combination with parenteral nutrition may be considered in patients in whom 60% of caloric requirement cannot be achieved with the enteral route.

Table 5.1 Nutritional Risk Screening (based on NRS‐2002) [4].

	Impaired nutritional status	Severity of disease
Absent – Score 0	Normal nutritional status	Absent – Score 0	Normal nutritional requirements
Mild – Score 1	Weight loss > 5% in three months or food intake below 50–75% of normal requirement in preceding week	Mild – Score 1	Chronic patients, in particular with acute complications: cirrhosis, chronic obstructive pulmonary disease (COPD), chronic hemodialysis, diabetes, oncology
Moderate – Score 2	Weight loss > 5% in two months or BMI 18.5–20.5 plus impaired general condition or food intake 25–60% of normal requirement in preceding week	Moderate – Score 2	Major abdominal surgery, severe pneumonia, hematologic malignancy
Severe – Score 3	Weight loss > 5% in one month (> 15% in three months) or BMI < 18.5 plus impaired general condition or food intake 0–25% of normal requirement in preceding week	Severe – Score 3	Intensive care patients (APACHE > 10)
Age	If ≥ 70 years: add 1 to total score above	= Age‐adjusted total score
Score ≥ 3: the patient is nutritionally at‐risk and a nutritional care plan is initiated
Score < 3: weekly rescreening of the patient. If the patient, for instance, is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status

Mechanical Bowel Preparation and Oral Antibiotic Prophylaxis

      Mechanical bowel preparation (MBP) with concurrent oral antibiotics has recently been the subject of many trials. In North America this has been integrated into patient pathways [22]. A recent survey (2017) by the European Society of Coloproctology observed that only 16.8% of the European surgeons used oral antibiotics with MBP prior to rectal resection [23]. This was largely attributable to the fact that most enhanced recovery protocols recommend avoiding MBP [24].

However, a French Research Group of Rectal Cancer Surgery (GRECCAR) multicenter trial noted that patients undergoing elective rectal cancer surgery without MBP (retrograde enema and oral laxatives) had a higher risk of infectious complications (34% vs. 16%, p = 0.005) [25]. A meta‐analysis of 38 randomized clinical trials including 8458 patients compared four preoperative management strategies (MBP with oral antibiotics, oral antibiotics only, MBP only, or no preparation). The cohort of patients receiving only oral antibiotics had the lowest rate of surgical site infection [26]. Several other studies have reported conflicting results [23, 27], and there remains several further prospective trials in progress.

Thromboprophylaxis

      Cancer patients undergoing a surgical procedure have twice the risk of postoperative venous thromboembolism (VTE) and threefold risk of pulmonary embolism (PE) [28]. Therefore the use of prophylaxis is vital in reducing VTE events. Among pharmacological methods, low molecular weight heparin (LMWH) has some advantages to unfractionated heparin (UFH), including the ease of administration and a lower risk of hemorrhage. For these reasons, LMWH is considered the first choice [28, 29]. In addition, the use of mechanical thromboprophylactic modalities such as compression stockings or intermittent pneumatic compression devices is advocated [28].

      The enoxaparin and cancer (ENOXACAN) II multicenter trial observed a 60% reduction of VTE in cancer patients who received LMWH for extended duration (four weeks) compared to those only getting it for one week, without increased risk of bleeding [29]. The cancer, bemiparin, and surgery evaluation (CANBESURE) trial also demonstrated a considerable relative risk reduction (82.4%) of major VTE in having extended prophylaxis [30]. As a result, the use of extended prophylaxis is becoming protocolized in many institutions.

Stoma Education

      Preoperative education helps reduce stoma‐related complications including peristomal skin irritation and pouch leakage, and overall improves quality of life [31]. Ultimately, it provides an opportunity to prepare patients for a stoma, helping acceptance of new body image and promoting self‐care [31–36]. Person et al. evaluated the impact of preoperative stoma site marking on patients’ quality of life, independence, and complication rates in a series of 105 patients (60 permanent and 45 temporary stomas). The quality of life of patients whose stoma sites were educated preoperatively was significantly better [32]. Several trials and systematic reviews have demonstrated the positive impact of a structured stoma education program regarding length of hospital stay, psychosocial health, and overall healthcare expenditure [34–36].

      Summary Box

       A patient’s general physical condition is the most important determinant of postoperative complications.

       CPET is a reliable preoperative indicator, highlighting those at risk of surgical stress.

       Preoperative optimization involves a multidisciplinary team of surgeons, anesthesiologists, physiotherapists, stoma therapists, and dieticians.

       A minimum of seven days of preoperative nutritional support providing at least 10 kcal/kg/day is considered adequate for patients who are nutritionally at risk.

       Preoperative stoma education, correction of anemia, and psychological support have a positive impact on postoperative quality of life.

       Patients undergoing pelvic exenteration should receive extended VTE prophylaxis.

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