Perioperative Care — Preoperative Nutritional Optimisation in Colorectal Cancer
A 62-year-old woman is scheduled for elective right hemicolectomy for a non-obstructing caecal adenocarcinoma. She has lost 10% of her body weight over 4 months because of poor appetite. She eats and drinks without vomiting or difficulty swallowing, but the dietitian finds her protein and energy intake well below her estimated needs. Serum albumin is 32 g/L. What is the most appropriate next step?
- A.Proceed with surgery without nutritional intervention
- B.Oral high-protein nutritional supplements before surgeryCorrect
- C.Total parenteral nutrition before surgery
- D.Nasogastric tube feeding before surgery
Explanation
She is malnourished, with 10% weight loss in 4 months and inadequate intake, but her gastrointestinal tract works and she can swallow safely. The least invasive route that meets her needs is the right one, so oral high-protein nutritional supplements alongside dietary counselling come first. ESPEN guidance on clinical nutrition in surgery recommends nutritional therapy for 7 to 14 days before major surgery in patients at severe nutritional risk, even if this delays the operation, because preoperative malnutrition raises rates of infection, anastomotic leak and death. Proceeding without intervention ignores a modifiable risk factor. Nasogastric feeding is a step up, used when oral supplements cannot meet requirements or swallowing is unsafe, which is not the situation here. Parenteral nutrition is reserved for patients whose gut cannot be used, such as those with obstruction, intestinal failure or high-output fistula, and it carries catheter sepsis and metabolic risks without advantage when enteral feeding is possible. Watch for refeeding syndrome when feeding is started in a patient who has eaten little for some time: check phosphate, potassium and magnesium early.
Why each option
- A.
- Operating on a malnourished patient without nutritional support increases infection, anastomotic leak and mortality when a short delay could correct it.
- B.
- Correct. With a working gut and safe swallowing, oral high-protein supplements are the first-line way to correct preoperative malnutrition.
- C.
- Parenteral nutrition is reserved for a nonfunctioning or inaccessible gut and adds catheter and metabolic risks without benefit here.
- D.
- Tube feeding is used when oral supplements fail to meet needs or swallowing is unsafe, neither of which applies to her.
Reference: ESPEN practical guideline: Clinical nutrition in surgery (Weimann et al., Clin Nutr 2021); ERAS Society guidelines for elective colorectal surgery (Gustafsson et al., World J Surg 2019)
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