A retrospective study of preoperative malnutrition based on the Controlling Nutritional Status score as a predictive marker for short-term outcomes after open and minimally invasive esophagectomy for esophageal cancer

Abstract

Purpose

Preoperative malnutrition is a significant risk factor for post-esophagectomy morbidity. The Controlling Nutritional Status (CONUT) is an index used to assess the nutritional status, and it has been suggested to predict post-esophagectomy morbidity. However, the difference in the predictive value of CONUT in estimating morbidities between open esophagectomy (OE) and minimally invasive esophagectomy (MIE) has not yet been elucidated.

Methods

This study included 674 patients(OE, 295; MIE, 378) who underwent three-incision esophagectomy for esophageal cancer between April 2005 and August 2021. The patients were further divided into two groups according to their preoperative CONUT: normal and light malnutrition and moderate and severe malnutrition. Short-term outcomes between these groups were retrospectively compared in the OE and MIE groups.

Results

Moderate and severe malnutrition was significantly associated with a low body mass index, a poor performance status and American Society of Anesthesiologists physical status, advanced cancer stage, and frequent preoperative treatment. These patients also experienced significantly more frequent severe (p=0.016), respiratory (p=0.0013) and cardiovascular morbidities (p=0.013) after OE. Moreover, malnutrition in CONUT was an independent risk factor for severe (hazard ratio [HR]=3.38; 95%confidence interval [CI], 1.225-9.332; p=0.019), respiratory (HR=3.00; 95%CI, 1.161-7.736; p=0.023), and cardiovascular morbidities (HR=3.66; 95%CI, 1.068-12.55; p=0.039) after OE. However, it was not associated with the incidence of morbidities after MIE.

Conclusion

Preoperative malnutrition in CONUT reflects various disadvantageous clinical factors and could be a predictor of worse short-term outcomes after OE. Meanwhile, the low invasiveness of MIE might reduce the effect of preoperative malnutrition on worse short-term outcomes.

Introduction

Esophagectomy for esophageal cancer is a highly invasive surgery, and compared to other gastrointestinal cancer surgeries, it is associated with more postoperative morbidities [1]. Recently, minimally invasive esophagectomy (MIE) has become more widespread because compared to open esophagectomy (OE), MIE is less invasive and has fewer postoperative morbidities [2]. Several studies have suggested that MIE could alleviate the effect of disadvantageous clinical factors on the incidence of postoperative morbidities and could improve the short-term outcomes after esophagectomy [3, 4].

The nutritional status is an important factor that affects the short-term outcomes after esophagectomy. Several nutritional markers may be useful for estimating the incidence of post-esophagectomy morbidity [5, 6]. The Controlling Nutritional Status (CONUT) score is one such nutritional marker [7]. Malnutrition in CONUT has been suggested to be related to poor short-term outcomes after esophagectomy [8]. However, these studies did not analyze the use of OE versus MIE. Thus, the significance of MIE in reducing post-esophagectomy morbidity in patients with malnutrition in CONUT has not yet been established.

Therefore, this study aimed to elucidate the association between preoperative malnutrition based on the CONUT score and short-term outcomes in OE and MIE, separately, as it may clarify whether the low invasiveness of MIE could contribute to alleviating the effect of preoperative malnutrition on the incidence of postoperative morbidities.

Methods

Patients

A total of 853 Japanese patients underwent three-incision esophagectomy for esophageal cancer at Kumamoto University Hospital between April 2005 and August 2021. Among them, 179 patients with missing data were excluded. Finally, 674 patients were included in this retrospective survey. OE was performed in 296 patients, and MIE was performed in 378 patients (Figure 1). In addition, the OE and MIE groups were further divided into two groups according to the preoperative CONUT scores: normal and light malnutrition, and moderate and severe malnutrition. The short-term outcomes between the groups were retrospectively compared between the OE and MIE groups by using an institutional database. This study was conducted in accordance with the ethical standards of the Declaration of Helsinki 1975. The institutional ethics committee approved all the research procedures (Registration No. 1909) and waived the requirement for written informed consent owing to the retrospective nature of the study.

Treatment strategy

Patients diagnosed as not having lymph node metastasis underwent esophagectomy without preoperative treatment. Patients with non-T4 lymph node-positive tumors received either adjuvant chemotherapy (from April 2005 to July 2008) or neoadjuvant chemotherapy (from August 2008 to August 2021). For T4 tumors, neoadjuvant chemoradiotherapy (CRT) was commonly administered. If patients preferred nonsurgical treatment, definitive CRT was considered regardless of the tumor stage. If definitive CRT was performed and recurrence occurred, salvage esophagectomy was performed according to the patient’s requirement. The Union for International Cancer Control TNM staging version 8 was used to classify the pretreatment clinical staging [9].

Surgery

Esophagectomy was defined as an esophagectomy requiring the placement of three incisions (on the neck, chest, and abdomen) with lymphadenectomy. The extent of lymphadenectomy was determined based on the 11th Japanese Esophageal Cancer Classification [10]. For upper or middle thoracic esophageal cancers, lymphadenectomy was performed in three regions. Cervical lymphadenectomy was not performed for clinical T1 tumors in lower thoracic esophageal cancers. MIE was defined as esophagectomy performed via thoracoscopy, regardless of the use of laparoscopy. MIE for clinical T1 and T2 tumors began in May 2011 and has been performed for clinical T3 and T4 tumors since September 2011.

Perioperative management

The details of perioperative management have been described previously [11]. Before the start of esophagectomy, a 24-h continuous intravenous infusion of a neutrophil elastase inhibitor and a bolus of methylprednisolone were administered. Antibiotics were administered intraoperatively every 4 h. Extubation was performed in the operating room immediately after esophagectomy. The patient was observed in the intensive care unit on postoperative day 1. Postoperative enteral nutrition was also commonly started on postoperative day 1.

Definitions of morbidities

The details of morbidities have been described previously [8]. A morbidity was defined as a complication ≥ grade II according to the Clavien–Dindo classification (CDc) [12]. Severe morbidity was defined as a complication ≥ grade IIIb requiring endoscopic, radiological, or surgical intervention under general anesthesia.

Statistical methods

All statistical analyses were performed using JMP® version 14.2 (SAS Institute, Cary, NC, USA). Statistical significance was set at p < 0.05. A chi-square test was used for comparisons between groups. The Mann-Whitney U test was used to analyze unpaired samples. A logistic regression analysis was performed to determine the hazard ratio (HR) in the 95% confidence interval (CI) of morbidities. The following data were used to analyze independent risk factors for severe, respiratory, and cardiovascular morbidities: age at esophagectomy (the cutoff value was calculated via receiver operating characteristic [ROC] analysis), sex (male vs. female), body mass index (BMI) (≥18.5 vs.<18.5 kg/m²), Brinkman index (≥800 vs.<800), CONUT (moderate and severe malnutrition vs. normal and light malnutrition), diabetes mellitus (yes vs. no), respiratory comorbidity (yes vs. no), cardiovascular comorbidity (yes vs. no), American Society of Anesthesiologists physical status (ASA-PS) (2 and 3 vs. 1), performance status (PS) (1 and 2 vs. 0), clinical stage (III and IV vs. 0, I, and II), preoperative treatment (yes vs. no), preoperative radiotherapy (yes vs. no), operative time (the cutoff values were calculated via ROC analysis), and bleeding (the cutoff values were calculated via ROC analysis). A subsequent multivariate analysis selected factors with p ≤ 0.1 and recognized variables with p < 0.05 as independent risk factors.

Results

Clinical features of all patients who underwent esophagectomy

Table 1 shows the characteristics of all patients who underwent esophagectomy according to the CONUT scores. Of all patients, 48 (7%) were classified as having moderate and severe malnutrition. Compared to normal and light malnutrition, moderate and severe malnutrition significantly correlated with a low BMI (p < 0.001), worse PS (p < 0.001) and ASA-PS (p < 0.001), frequent respiratory comorbidities (p = 0.0023), advanced cancer stage (p < 0.001), and more frequent preoperative treatment (p < 0.001).

Short-term outcomes after OE

Table 2 shows the short-term outcomes after OE according to the CONUT scores. Compared to patients with normal and light malnutrition, those with moderate and severe malnutrition experienced significantly more frequent severe (p = 0.016), respiratory (p = 0.0013) and cardiovascular morbidities (p = 0.013).

Short-term outcomes after MIE

Table 3 shows the short-term outcomes after MIE according to the CONUT scores. Regarding short-term outcomes, malnutrition in CONUT did not increase post-MIE morbidities.

Risk factors for postoperative severe, respiratory, and cardiovascular morbidities after OE

Table 4 shows the results of the univariate and multivariate analyses of risk factors for severe, respiratory, and cardiovascular morbidities after OE. Moderate and severe malnutrition in CONUT was an independent risk factor for severe (HR = 3.38; 95% CI, 1.225-9.332; p = 0.019), respiratory (HR = 3.00; 95% CI, 1.161-7.736; p = 0.023), and cardiovascular morbidities (HR = 3.66%; 95% CI, 1.068-12.55; p = 0.039). Risk factor for severe morbidity included cardiovascular comorbidity (HR = 3.16; 95% CI, 1.305-7.633; p = 0.011), for respiratory morbidity included a Brinkman index ≥ 800 (HR = 2.29; 95% CI, 1.122-4.661; p = 0.023) and operation time ≥530 minutes (HR = 2.03; 95% CI, 1.006-4.098; p = 0.048), and for cardiovascular morbidity included cardiovascular comorbidity (HR = 3.38; 95% CI, 1.124-10.14; p = 0.030) and operation time ≥591 minutes (HR = 5.06; 95% CI, 1.804-14.18; p = 0.0021).

Discussion

This study yielded several interesting results on the association between preoperative malnutrition estimated using the CONUT scores and short-term outcomes after esophagectomy for esophageal cancer. First, moderate and severe malnutrition in CONUT was significantly associated with several disadvantageous patient characteristics, such as a low BMI, poor PS, poor ASA-PS, and frequent comorbidity. Second, it was also significantly associated with several disadvantageous cancer-related factors, such as advanced cancer stage and frequent preoperative treatment. Third, patients with moderate and severe malnutrition in CONUT who underwent OE had significantly more frequent postoperative severe, respiratory, and cardiovascular morbidities. Finally, malnutrition did not increase the incidence of postoperative morbidities after MIE.

Several studies have suggested that preoperative malnutrition could cause frequent post-esophagectomy morbidities [6, 13]. However, OE and MIE were not distinctly analyzed in these studies. Thus, the effect of MIE on the incidence of post-esophagectomy morbidities in patients with a poor nutritional status has not been well established. To the best of our knowledge, this is the first study to elucidate that preoperative malnutrition in CONUT was associated with worse short-term outcomes only after OE, but not after MIE.

CONUT was calculated using the serum albumin and total cholesterol levels and total lymphocyte count (TLC). Serum albumin levels reflect the nutritional status, inflammation, liver dysfunction, and kidney disease [14, 15]. Total cholesterol levels reflect the nutritional status related to lipid metabolism and inflammation [16, 17]. TLC is an indicator of nutrition and immunity [18]. Deterioration in these parameters can adversely affect tissue repair and resistance against infection, which may be a reason for the increased incidence of postoperative morbidities. Moreover, in this study, malnutrition estimated using the CONUT score was associated with disadvantageous patient characteristics and tumor-related factors for post-esophagectomy morbidity, which might result in frequent post-esophagectomy morbidity and surgery-related mortality [2]. These associations may explain why malnutrition estimated using the CONUT score could be a significant risk factor for postoperative morbidities after OE.

Nevertheless, malnutrition in CONUT did not affect the incidence of postoperative morbidities after MIE. Studies have reported that MIE is less invasive than OE is and is associated with fewer postoperative morbidities [19]. Several studies have suggested that the low invasiveness of MIE could alleviate the effect of preoperative disadvantageous clinical factors on the incidence of post-esophagectomy morbidities [3, 4]. High preoperative HbA1c levels can be a risk factor for anastomotic leakage, surgical site infection, and pneumonia after esophagectomy [20]. However, it might increase morbidities only after OE, but not after MIE [3]. Moreover, we have reported that a high pretreatment red blood cell distribution width, which is a surrogate marker of the nutritional status, might be an independent risk factor for severe morbidity and reoperation only after OE [4]. These previous studies may support the current result that malnutrition in CONUT could increase the incidence of morbidities only after OE, but not after MIE.

For patients assessed as being malnourished in CONUT, preoperative nutritional interventions may be effective in improving the short-term outcomes. A meta-analysis suggested that the administration of immunoenhancing enteral nutrition might reduce postoperative morbidities after gastrointestinal surgeries [21]. In contrast, a randomized controlled trial suggested that short-term nutritional intervention (7 days before esophagectomy) did not reduce post-esophagectomy morbidities. Thus, long-term nutritional intervention during preoperative treatment should be considered in malnourished patients scheduled to undergo esophagectomy [22]. Improvement in oral ingestion during preoperative treatment via stent insertion for patients with swallowing difficulty due to advanced esophageal cancer may also reduce post-esophagectomy mortality [23].

In this study, malnutrition in CONUT was an independent risk factor for respiratory morbidity after OE. Thus, when patients with malnutrition undergo OE, measures should be taken against respiratory morbidities. Smoking and impaired respiratory function could be risk factors for respiratory morbidities after esophagectomy [24, 25]. Thus, smoking cessation [25] and preoperative respiratory rehabilitation [26] are necessary. Moreover, oral hygiene [27], enforcement of the Enhanced Recovery after Surgery Program [28], and perioperative management by a multidisciplinary perioperative care team [29] are helpful in reducing post-esophagectomy respiratory morbidities. In addition, less invasive surgeries may further reduce post-esophagectomy morbidities in patients with malnutrition undergoing OE. A meta-analysis suggested that compared to MIE, robot-assisted esophagectomy may help reduce the incidence of pneumonia [30]. Transhiatal esophagectomy and mediastinoscopic esophagectomy are also effective candidates for further reducing postoperative respiratory morbidities [31, 32]. These procedures can be treatment options for patients assessed as being malnourished according to their CONUT scores.

This study had several limitations. Because this was a single-center retrospective study conducted over a long period, historical biases with regard to treatment strategy, surgery, and perioperative management existed. Notably, MIEs were more frequently performed in recent cases, and this strategy affected the current results, wherein malnutrition did not increase the incidence of morbidities after MIE. Moreover, the exclusion of patients owing to the lack of data could be a cause of a selection bias.

Nevertheless, our findings revealed that moderate and severe malnutrition assessed using the preoperative CONUT score can be a predictor of severe, respiratory, and cardiovascular morbidities after OE. Moreover, the low invasiveness of MIE might reduce the effect of preoperative malnutrition on worse short-term outcomes.

Declarations

Funding information

This manuscript did not receive sponsorship for publication.

Conflict of interest

All authors declare no conflict of interest for this article.

Authors’ contributions

Tomo Horinouchi described and designed the article. Naoya Yoshida edited the article. Hideo Baba supervised the editing of the manuscript. Material preparation, data collection and analysis were performed by Tomo Horinouchi, Naoya Yoshida, Kazuto Harada, Kojiro Eto, Masaaki Iwatsuki and Yoshifumi Baba. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

Ethics statements

This study was conducted in accordance with the ethical standards of the Declaration of Helsinki 1975. The institutional ethics committee approved all the research procedures (Registration No. 1909) and waived the requirement for written informed consent owing to the retrospective nature of the study.

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Tables

Table 1 Association between malnutrition according to the CONUT and patient characteristics.

Table 2 Short-term outcomes after open esophagectomy

Table 3 Short-term outcomes after minimally invasive esophagectomy.

Table 4 Logistic regression analysis of postoperative morbidities in patients who underwent open esophagectomy.