CASE STUDY:
GI Surgery
Cristel Moubarak – Dietetic Intern – 2014 Candidate
Elena Tejedor – GI/ENT Surgery RD – Preceptor
March 2014
OUTLINE
 Introduction
 Patient Case
 Initial Screening
 Nutrition Diagnosis
 Nutrition Needs
 Interventions
 Complications
 Follow-ups
Ms. C
 66 year old female
 Admitted with Peritoneal
Mesothelioma on Dec 10
 PMHx: Hypercholesterolemia and
depression
 Baseline Diet: Good appetite and
intake
 No recent significant weight loss
 ETOH Hx (2-3 glasses of wine/day)
INITIAL NUTRITION ASSESSMENT
 Usual Weight = 61.4 kg
Height = 165 cm
Current Weight = 60 kg
BMI = 22 kg/m2
 Nutritional Status Risk Factors: Nausea, NPO x4 days,
hypercatabolism, substance abuse (ETOH Hx), fatigue,
decreased mobility
 SGA: Mildly malnourished, at moderate risk
PROCEDURES
 Lysis of Adhesions
 Right Hemicolectomy
 Omentectomy
 Cholecystectomy
 Partial Vaginectomy
 Bilateral Salpingo-oophorectomy
 HIPEC
BASIC DEFINITIONS
 Peritoneal Mesothelioma: Rare cancer
that develops in the mesothelium cells
(usually due to exposure to asbestos) in
the peritoneum (abdomen cavity lining).
 Cytoreductive Surgery: Removing all
visible tumors that can be removed
throughout the peritoneal cavity.
 Hyperthermic Intraperitoneal
Chemotherapy (HIPEC): It is designed to
kill any remaining cancer cells by
circulating a sterile solution--containing a
chemotherapeutic agent--throughout the
peritoneal cavity, for a maximum of two
hours.
NUTRITION DIAGNOSIS
 P: Malnutrition
 E: related to altered GI function/predicted ileus and
increased needs with stress of OR
 S: as evidenced by cytoreductive surgery and HIPEC
treatment (x5d), post-operative nausea, ETOH Hx (23 glasses/d), and NPO x 5d to date and expected to
be NPO for ≥ 5d.
NUTRITION NEEDS
Goal of Nutrition Care:
PREVENT REFEEDING SYNDROME
 HBE = 1218 kcal
 REE x 1.2 – 1.4 = 1460 kcal – 1705 kcal [24-28 kcal/kg]
 Protein [1.2 – 1.5 g/kg/day] = 72 – 90 g/d
 CHO [ 2 – 3 g/kg/day] = 120 – 180 g/d
INTERVENTION #1: Day 2 Post-Op
TPN ORDER
Calculated
Requirements
1st: Dec 12 – Refeeding
Total Calories
1460 kcal – 1705 kcal 1290 kcal (20 kcal/kg)
Protein
72 – 90 g/d
70 g/d (22% - 1.2 g/kg)
CHO
120 – 180 g/d
(refeeding)
150 g/d (39% - 2.5 g/kg)
Fat
U/L 90 g/d
50 g/d (39% - 0.8g/kg)
Phosphate
30 mmol
30 mmol
Potassium
60 mmol
55.2 mmol
Magnesium
5 mmol
7.5 mmol
Folic Acid
5 mg
Zinc
2.5 mg
Vitamin C
200 mg
Thiamine
100 mg
COMPLICATIONS
 Ileus
 Nausea
 Abdominal Fluid and high NG drainage
 Magnesium, potassium and phosphate depletion
Day 2
Day 3
Magnesium (0.8 – 1.45)
0.63
0.60
Potassium
(3.5 – 5)
3.5
3.4
Phosphate
(0.7 – 1.10)
0.71
0.65
INTERVENTION #2: Day 4 Post-Op
 Continue to replete Mg (5g via IV), PO4 (15 mmol x 3)
and K-lyte (40 mEq)
TPN ORDER
Calculated
Requirements
1st: Refeeding
Total
Calories
1460 kcal – 1705
kcal
1290 kcal (20 kcal/kg) 1565 (26 kcal/kg)
Protein
72 – 90 g/d
70 g/d
(22% - 1.2 g/kg)
75 g/d
(19% - 1.25 g/kg)
CHO
120 – 180 g/d
(refeeding)
150 g/d
(39% - 2.5 g/kg)
225 g/d
(49% - 3.75 g/kg)
50 g/d
(39% - 0.8g/kg)
50 g/d
(32% - 0.83 g/kg)
Fat
Ranitidine
2nd: Goal
150 mg
INTERVENTION #3: Day 8 Post-Op
TPN ORDER
Calculated
Requirements
2nd: Goal
3rd: Goal
Total
Calories
1460 kcal –
1705 kcal
1565 (26 kcal/kg)
1565 (26 kcal/kg)
Protein
72 – 90 g/d
75 g/d (19%)
75 g/d (19%)
CHO
120 – 180 g/d
(refeeding)
225 g/d (49%)
225 g/d (49%)
50 g/d (32%)
50 g/d (32%)
Fat
Magnesium
10 mmol
Sodium
40 mmol
PROGRESSION
Diet progression:
Day 8 Post-Op: advance to CF
Day 14: advance to FF
Day 15: provide low residue diet education
Day 16: dental soft; hold TPN
Day 20: D/C on dental soft; low residue diet education
Dec 8
Day 16
Magnesium (0.8 – 1.45)
0.60
0.56
Potassium
(3.5 – 5)
3.6
3.6
Phosphate
(0.7 – 1.10)
1.08
1.2
FOLLOW-UP: Day 36 Post Op
Re-Admission
 Ms C was readmitted on January 16 for a Partial
Obstruction
 Weight loss of 10% over 2 months
 Loss of appetite, suboptimal intake
 Unresolved nausea and increased vomiting prior
re-admission and during
 Hypomagnesemia, Hypophosphatemia.
FOLLOW-UP: Day 78 Post-Op
Post-Discharge
 Controlled nausea with medications
 Regular bowel movements with medications
 Following a low residue diet
 Appetite is back! Eating 3 meals a day and 2 snacks
 Gaining lost weight (Currently at 124 lbs, aiming to get
back to 132 lbs)
REFERENCES

HIPEC Treatment. (2014). The hipec procedure; what is hipec and how does it work?. Retrieved
from http://www.hipectreatment.com/about-the-hipec-procedure/

BC Cancer Agency. (2013, October). Mesothelioma. Retrieved from
http://www.bccancer.bc.ca/PPI/TypesofCancer/Mesothelioma/default.htm

BC Cancer Agency. (2013, March). Hyperthermic intraperitoneal chemotherapy (hipec). Retrieved
from http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Gastrointestinal/13appendix/13.5+Hyperthermic+Intraperitoneal+Chemotherapy+(HIPEC).htm

Mulier, S. (n.d.). Hipec for peritoneal cancer; patient information. Retrieved from
http://www.drmulier.com/3 en pat info hipec.html

Ceelen, W. P. (2013). Treatment of peritoneal carcinomatosis using surgery combined with
hyperthermic intraperitoneal chemotherapy (hipec). Retrieved from
http://www.surgery.ugent.be/pages/hipec_eng.htm

Ceelen, W. P., & Flessner, M. F. (2010). Intraperitoneal therapy for peritoneal tumors: Biophysics and
clinical evidence. Nat. Rev. Clin. Oncol., 7, 108-115. doi: 10.1038/nrclinonc.2009.217

Tan, G. H., Cheung , M., Chanyaputhipong, J., Soo , K. C., & Teo , M. C. (2013). Cytoreductive
surgery (crs) and hyperthermic intraperitoneal chemotherapy (hipec) for peritoneal mesothelioma.
Ann Acad Med Singapore, 42(6), 291-6. Retrieved from
http://www.annals.edu.sg/pdf/42VolNo6Jun2013/V42N6p291.pdf