Nutritional Consequences of Surgical Resection of the Gastrointestinal Tract for Cancer'
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(CANCER RESEARCH 37, 2379-2386, July 1977] Nutritional Consequences of Surgical Resection of the Gastrointestinal Tract for Cancer' Walter Lawrence, Jr.2 Division of Surgical Oncology and Cancer Center, Medical College of Virginia (Virginia Commonwealth University), Richmond, Virginia 23298 Summary the preoperative deficiency if nutritional intake has been hampered by these intake problems. The nutritional sequelae of major resection of the “hollow Since the nutritional sequelae of the resection of anatom organs―of the gastrointestinal tract for cancer are re ical structures in the head and neck are on a mechanical viewed. Radical surgery of the head and neck region may rather than a metabolic basis, the clinical solutions are lead to significant nutritional problems due to the mechani likewise mechanical ones. For short-term nutritional main cal effects of surgery that limit normal methods for nutri tenance, both before and after operation, the patient can be tional intake, but these problems can be overcome by tube fed by a nasopharyngeal or nasogastric tube. A frequent feeding. Resection of the thoracic esophagus or stomach lack of emphasis on preoperative nutritional support is cer for cancer may produce varied forms of malabsorption, tainly a partial explanation for the postoperative wound particularly of ingested fat, but the reduction of caloric problems that often plague the postoperative period. Ade intake that often will accompany these procedures plays the quate alimentation can be accomplished for both the re primary role in each instance where malnutrition is pro placement of preexisting nutritional defects, and postoper duced by the operation. These nutritional difficulties are ative maintenance, by using appropriately prepared high corrected by assuring adequate caloric intake and reducing calorie liquid diets. For patients requiring long-term tube the symptoms that inhibit this. Small bowel resection rarely feeding due to permanent intake disability or protracted produces nutritional problems unless the resection is mas reconstructive procedures in the post-resection interval, a sive, a situation wherein malabsorption becomes a major cervical tube esophagostomy is often preferable to the na problem in nutritional management. Fortunately, massive sal tube. This procedure is easily accomplished either at the small bowel resection is rarely indicated for the treatment of completion of the resection or at a later time. cancer. Radical colon surgery of any extent is well tolerated from the nutritional standpoint. An understanding of the Resection of Cancer of the Thoracic Esophagus causes of malnutrition in patients undergoing surgical re section of the gastrointestinal tract for cancer should lead Careful appraisal of patients undergoing total or partial resection of the thoracic esophagus for cancer led to the to effective management of any problems that do occur. observation that patients had varying degrees of clinical steatorrhea and diarrhea following these procedures. De The most common form of cancer in the United States is tailed metabolic studies of a series of patients by Shils and cancer of the gastrointestinal tract, and surgical resection Gilat (66) led to clear-cut evidence of laboratory steatorrhea is, currently, the primary approach to patient management. in all patients when quantitative stool fat excretion meas Since the gastrointestinal tube is our major source of nutri urements were made (Table 2) but carbohydrate, nitrogen, ents under normal circumstances, a nutritional impact re vitamin B12,and electrolyte absorption measurements were suIting from these operative manipulations is not unex virtually normal. These and other studies (52, 54, 64) dem pected. This report is not meant to be an exhaustive review onstrated data similar to those obtained in patients sub of the literature on this subject, but an attempt will be made jected to truncal vagotomy and a gastric drainage proce to summarize observations that have been made from a dure, although the effect on fat absorption was generally clinical perspective. These nutritional sequelae of resection greater in patients undergoing thoracic esophageal resec are summarized in Table 1. tion. These reports are convincing in regard to the major Resectionof Head and Neck Cancer role played by vagotomy in the production of the observed malabsorption and the diarrhea, but the mechanisms are not completely clear. Radical resection of cancer arising from the oral cavity Attempts to correct both this mild diarrhea and malab and pharynx is often required in subjects who present with sorption after esophagectomy by feeding pancreatic and preexisting nutritional difficulties. Prior to resection, there biliary supplements or the use of a gluten-free diet were are varying degrees of disability from restrictions in both unsuccessful. The substitution of medium-chain triglycer mastication and deglutition. Surgical resection of these ides for the longer-chain fatty acids did reduce fecal fat cancers often produces the same disabilities or increases excretion in patients with malabsorption (64). Another po tential solution to this metabolic defect observed in some I Presented at the Conference on Nutrition and Cancer Therapy, Novem bar 29 to December 1, 1976, Key Biscayne, Fla. patients after partial or total resection of the thoracic 2 American Cancer Society Professor of Clinical Oncology. esophagus might well be preservation of the vagus innerva JULY 1977 2379 Downloaded from cancerres.aacrjournals.org on October 1, 2021. © 1977 American Association for Cancer Research. w.Lawrence,Jr. Table 1 extent of resection is usually greater than that performed for resectionOrgansNutritionalconsequences of ‘‘radical'‘ benign disease, and the nutritional problems observed after sequeliaeOralresectedNutritional gastric resection generally increase proportionately with feedingsThoraciccavity and pharynxDependency on tube the extent of the resection that is performed. Malabsorption.There is an extensiveliterature docu esophagusGastric stasis (secondary to vagot menting absorptive defects following gastrectomy, particu omy) larly total gastrectomy. Absorption of one of the major Fat malabsorption Gastrostomy feedings in patients with nutrients, carbohydrate, is not quantitatively impaired by reconstructionStomachDumping out gastrectomy, and an increase in fecal excretion of the nitro gen, as a measure of protein malabsorption, is responsible syndrome for little if any nutritional impairment in the gastrectomized Fat absorption patient (17, 45, 61 , 74). The primary defect in absorption anemiaSmall intestineDuodenumPancreatobiliary that may play some role in chronic difficulties with weight deficiency with fat maintenance and nutrition in the postgastrectomy patient is malabsorptionJejunumDecrease impairment of fat absorption (8, 38, 45, 50, 56, 62, 67, 70, in efficiency of absorption 74). Associated problems in absorption of iron and vitamins (general)ileumVitamin may occur also. B2 and bile salt malabsorp tionMassive Fat Absorption(Chart 1). There are 2 aspectsof the (>75%)Fat malabsorption and diarrhea; vi steatorrhea problem that must be kept in mind from a prac tamin B12malabsorption; gastric hy tical clinical standpoint. The 1st is the relatively poor corre persecretionColon lation noted between the ability of the patient to maintain body weight after gastrectomy and the degree of steator (total or subtotal)Water and electrolyte loss rhea that has been observed on metabolic balance studies (38, 45, 58). Although these quantitative laboratory studies Table 2 demonstrate minor degrees of steatorrhea after partial gas Fat malabsorption after esophagectomy (distal or near total) trectomy, many patients,afterpartialresection,have fat Metabolic study of 7(66)].Range patients [from Shils and Gilat excretion levels in the normal range (73). Mean values for of fat absorp fat absorption after total gastrectomy (approximately 80% of (%)Before tion (%) Mean ingested fat) are well below the normal range (92 to 100%), 92-98 96 but there is much variation between individual patients, and After 65-84 74 these data bear little relationship to weight maintenance (38, 45) (Chart 2). The 2nd factor that should be appreciated tion, if this were feasible. When the resection is for cancer, is that the degree of steatorrhea noted in these gastrointes however, this approach is untenable, as the resection must tinal patients is mild, compared with that noted after mas include the vagus nerves, for obvious anatomical reasons. sive small bowel resection, and that of patients with sprue To put the nutritional problem of esophagectomy in per like syndromes or who are subjected to major pancreatic spective, it should be stressed that the degree of postopera resection. Although the steatorrhea observed after total tive nutritional disability observed is quite limited and is of gastrectomy is of great interest from both the etiological greater physiological interest than of practical importance. and physiological standpoints, the role of this steatorrhea in The fecal fat losses that may occur can be easily compen nutritional disability after gastrectomy appears to be a rela sated for by a modest increase in caloric intake and/or the tively minor one. exchange of medium-chain triglycerides for long-chain fatty acids inthe diet. .. 32- / GastrectomyforCancer . I 7 28- ... 7/ Nutritional disability is more frequently observed after S • 7 either partial or total gastrectomy for cancer than