Cancer patients are particularly susceptible to nutritional depletion due to the combined effects of the malignant disease and its treatment. CRS followed by HIPEC is a major surgical procedure that can further accentuate the risk of nutritional depletion in patients with peritoneal carcinomatosis [10, 11, 33]. As a result, timely nutritional assessment and intervention in this patient population might be critical to achieving optimal clinical outcomes including LOS, cost, quality of life, survival and ability to tolerate treatment. In this retrospective study of the first 60 patients at our institution who had CRS and HIPEC for peritoneal carcinomatosis, we investigated the relationship between baseline nutritional status and clinical outcomes. We also conducted a preliminary analysis of clinical outcomes as a function of parenteral nutrition.
There are 2 key findings of our study. Baseline nutritional status, as evaluated using SGA, was predictive of patient LOS. This finding is consistent with the existing literature in this area. A recently published systematic review (based on a total of 21 studies ) on the role of nutritional status in predicting LOS in cancer concluded that validated nutritional tools such as SGA are good predictors of LOS in gastrointestinal cancers requiring surgery . Since CRS and HIPEC are associated with significant morbidity which can potentially increase the LOS, it is prudent to provide nutrition support during the perioperative period in these individuals. It makes sense to implement the ASPEN guidelines  for these patients, which include nutritional screening, assessment, and intervention as appropriate. Correcting malnutrition may decrease the LOS and perhaps even reduce the rate of hospital readmissions in this population. Consistent with the vast body of existing literature in this area [14, 15], we also found that baseline nutritional status, as evaluated using SGA, was a significant predictor of survival in this patient population.
The LOS in patients who received PN was longer than in patients who did not receive PN. Similarly, the survival in the PN + group was shorter than in the PN- group. This was expected considering the patients who did not receive PN had regained gastrointestinal functions within 7 days of surgery and were better nourished than patients who received PN. Given the lack of comparability between the PN + and PN- groups, no conclusions related to causation can be drawn from these findings.
The peritoneal malignancy program at our institution was started by a dedicated team of physicians, nurses and surgical staff and led by a surgical oncologist with special training in CRS and HIPEC. Our experience with the first 60 patient in this study has helped us develop processes for nutritional evaluation and interventions with oral, parenteral or enteral nutrition in the pre- and post-operative periods. Guidelines established by ASPEN for nutritional support in surgical patients were used for all patients . Although the role of nutritional support has not been studied in patients undergoing CRS and HIPEC, the benefits of perioperative nutrition have been well-established for other planned major abdominal surgeries . As part of future research in this area, the role of additional pre-operative enteral nutrition to enhance nutritional status in eligible cohorts could be examined.
Some limitations of this study need to be acknowledged. Our study, because of its retrospective nature, relies on data not collected to test a specific hypothesis. A majority of our patients had advanced stage disease at presentation and had failed primary treatment elsewhere before coming to our hospital. As a result, we acknowledge that our findings may not be applicable to newly-diagnosed patients with peritoneal carcinomatosis, an issue that needs to be tested in suitable patient populations. Our retrospective study was not designed to investigate a causative relationship between PN and clinical outcomes. This is evident by the fact that our PN + and PN- groups were substantially different from each other with regard to the baseline clinical and demographic characteristics. As compared to the PN- group, the PN + group had a greater proportion of male patients as well as a greater proportion of patients with previously treated disease, gynecologic cancers and malnourished status prior to surgery. As a result, no definitive conclusions can be made regarding the role of parenteral nutrition in improving clinical outcomes in this patient population. Prospective randomized clinical trials are needed to this effect. Our study had a relatively small sample size of 60 patients. Finally, an overall complication rate of 26.7% could be an underestimate owing to the retrospective nature of this study and the lack of complication grading criteria. Despite these limitations, to the best of our knowledge, this is the first study to evaluate the prognostic significance of nutritional assessment in peritoneal carcinomatosis patients undergoing CRS and HIPEC.