Letter to the Editor: Practical considerations for continuity and precision in perioperative nutritional management

Abstract

It is our assertion that the combination of the PIPOST framework and early enteral nutrition (EEN) provides a strong basis for the nutritional management of perioperative patients. There are some practical tweaks, though, which could enhance its clinical impact. The clinical utility and scalability of the framework may be further enhanced through integrating biologically informed and data driven support throughout the entire perioperative period as well as tailoring interventions to the characteristics of different patient subgroups. Based on the latest work of Chang et al in the World Journal of Gastrointestinal Oncology, who show that PIPOST-EEN is useful in colorectal cancer surgery. We present these thoughts as constructive considerations to further develop this model and to ensure more widespread application of the model.

Key Words: Perioperative nutritional management; Early enteral nutrition; Colorectal cancer; Nutritional prehabilitation; Clinical decision support

Core Tip: The integrated PIPOST framework and early enteral nutrition framework will be enhanced as per this letter. This model may evolve from a static protocol into a more adaptive and personalized clinical decision-support system for perioperative nutritional management by incorporating dynamic biomarkers, extending care across the entire perioperative continuum, and prioritizing validation in vulnerable patient subgroups.

TO THE EDITOR

We were alerted by an important article by Chang et al[1] entitled “Integration of the PIPOST model with early enteral nutrition to enhance postoperative rehabilitation in colorectal cancer patients” on the association of PIPOST framework and early enteral nutrition (EEN) in colorectal cancer surgery patients. The study presented an important clinical question regarding how to translate structures and evidence-based assessments into personalized and actionable perioperative nutritional choices.

The early commencement of enteral nutrition through continuous perioperative management should be a global recommendation of enhanced recovery protocols. This is according to the latest accreditation standard[2]. As per the latest national recommendations of Polish Society of Gastroenterology regarding enteral nutrition in gastrointestinal diseases detailed nutritional screening, endoscopic access and perioperative nutrition are to be used[3]. Chang et al’s findings[1] present credible clinical evidence regarding the efficacy of this implementation technique for this application.

The results from Chang et al[1] are promising, however, a single-center study may limit their generalizability. Moreover, the results may also be influenced by selection bias or certain perioperative management effects at the researcher’s institution. Using the model in other health settings and with different patient groups will reinforce the text and make it more valid.

The PIPOST–EEN model can evolve from a perioperative nutritional protocol to a decision-support model for clinical use, at a wider decision-making level. The authors’ comments, as well as those of the cohort reviewers, are general of nature and we are in agreement with them on all comments.

The current PIPOST model allows for the integration of clinical and functional indicators but may predict better. The results of several meta-analyses showed that enteral feeding started within 24-48 hours after surgery has a positive impact on recovery, length of hospital stay, immuno-nutritional status, as well as surgical complications in the surgical population[4]. The inclusion of biologically relevant parameters such as metabolomic profile or gut microbiota related parameters, alongside machine-learning-based analytic techniques and perioperative risk prediction models can take the PIPOST framework towards an adaptive and individualized nutritional decision-making process[5].

Using new data-driven approaches developed in a wider clinical context can bring helpful methodological insights for perioperative nutritional assessments, notes the author. The usage of body composition and inflammatory nutritional indices of multisite trial predicts early recurrence after colorectal cancer surgery[6]. In addition, prehabilitation strategies based on structured nutrition will become part of perioperative optimization[7]. A smart nutrition management system that continuously monitored gastric residuals, automatically detected reflux, and administered compensatory feeding was associated with noticeably less feeding deviation (10.5% vs 34.3%) and shorter intensive care unit stay (3.3 days) in critically ill patients according to a recently randomized controlled trial[8]. Based on this result, advanced monitoring and decision support technologies might enhance the delivery systems for perioperative nutrition in the future.

The diagnosis of malnutrition itself may be improved with machine learning. A recent multicenter study indeed indicates that a random forest model using routine clinical data predicted malnutrition (as regulated by GLIM with NRS-2002) in colorectal cancer patients with an area under the receiver operating characteristics curve of 0.830 while also offering an online tool that supports timely nutrition[9]. The clinical translation of these technologies must be stepwise, however, involving multicenter validation and developing simplified decision-support tools that can be easily accommodated in the daily perioperative workflow.

Currently, PIPOST-EEN strategy is mainly employed in the hospital perioperative period. However, more evidence suggests that preoperative nutritional optimization has an important role in surgical outcomes. A systematic review and meta-analysis in gastrointestinal surgery showed that there is an improvement of nutritional status as well as a lowering of infectious complications after surgery with the use of perioperative immunonutrition and preoperative enteral or oral nutritional supplementation[10]. Additionally, malnutrition is now acknowledged as a modifiable perioperative risk factor. Also, nutritional prehabilitation is associated with improved postoperative recovery in abdominal surgery[11]. A systematic review and meta-analysis of 23 randomized controlled trials revealed that preoperative nutritional supplementation decreased the risk of postoperative infectious complications by 35%, and the hospital stay decreased by one day in patients with colorectal cancer undergoing surgery[12]. The PIPOST–EEN framework could be extended to include a preoperative nutritional prehabilitation structured postoperative follow-up standardized transitions to home-based nutritional support in order to make it more clinically relevant across the continuum of care. A relevant prospective study reported that structured stoma education as part of the ERAS program decreased length of hospital stay after colorectal operation without an increase in readmission[13]. A high-impact near-term improvement that is practical is to extend the framework to cover the entire perioperative pathway.

In the end, it is important to assess the effectiveness and appropriateness of the PIPOST–EEN regimen in specific patient subgroups, such as older patients as well as obese, diabetic, and renal impaired ones. Various studies’ data infer that nutrition-based interventions, including the prehabilitation and perioperative nutritional interventions such as immunonutrition, can enhance postoperative clinical outcomes and reduce hospital stay of patients undergoing surgery for gastrointestinal malignancies[14]. Elderly frequently suffer from malabsorption and nutrient deficiency (e.g., vitamin B12), according to a recent European consensus document on malabsorption and, therefore, comprehensive nutritional assessment and individualized supplementation are necessary[15]. In a validation focusing on specific subgroups, it will be concerned to ensure that personalized nutritional approaches are safe, affordable, and clinically realistic in frail elderly and other patients with multiple metabolic disorders[16]. A further immediately actionable option to strengthen the robustness and clinical value of the PIPOST-EEN model is validation in these at-risk groups.

In short, the Chang et al’s proposed PIPOST–EEN model may serve a useful purpose for perioperative nutrition in patients undergoing surgery for colorectal cancer[1]. Owing to the extensive clinical validation, addition across the whole perioperative continuum and constant implementation of a new generation of data-based clinical decision-support technologies, outcomes will become more favorable.