Body weight loss is an inevitable and serious problem after gastrectomy. Recent reports documented that weight loss of 15 per cent or more, and loss of lean body mass of at least 5 per cent at 1 month after surgery were independent risk factors for the discontinuation of adjuvant chemotherapy with S-1 after gastrectomy. Therefore, weight loss, which is the most reliable indicator of malnutrition, leads to not only a decline in postoperative quality of life, but also a worse survival. Based on such backgrounds described above, Japanese gastric surgeons have paid attention to nutritional counseling and oral nutritional supplements （ONS）. Four interventional studies using （ONS）, 2 randomized controlled trials （RCTs） and 2 single arm studies, were reported in major articles. One RCT showed the efficacy of an oral elemental diet （Elental™） in reducing postoperative weight loss. Meanwhile, another RCT using eicosapentaenoic acid （EPA）-rich nutrition as perioperative oral immunonutrition did not demonstrate any preventive effect of EPA immunonutrition on body weight loss after gastrectomy. Thus, there have been no consolidated nutritional intervention with ONS after gastrectomy. Now, we designed the large-sized RCT （500 patients as control vs. 500 patients with n-3 rich ONS （Racol™） after gastrectomy） and finished the all patients enrollment. In this joint session, we’d like to present the Japanese evidence with regard to ONS for patients with gastrectomy, including our preliminary data of our trials and to discuss how to deal with body weight loss after gastrectomy.
The history of medicine is to lessen morbidity and mortality and improve wellness of the patients. The nutritional management has been tremendously helped reduce morbidity and mortality in surgical patients. This has improved postoperative outcomes in malnourished or undernourished patients, old patients and critically ill patients.
HBP surgery field is special field, in which operative procedure is usually extensive and complicated. Most challenging surgeries in HBP field are pancreaticoduodenectomy （PD）, major liver resection, and liver transplantation. The patients are already under nutrition due to cancer, chronic liver disease or cirrhosis. And operations are associated with high rates of postoperative morbidity. Therefore, nutritional therapy on HBP surgery is important, and the benefits of nutritional support are well shown in many studies. Recently ERAS program was introduced in many fields of surgery. ERAS program was also introduced in HBP surgery. Adoption of ERAS program reduces the stressful effect of the surgery and facilitates recovery as well. In addition to ERAS, NST（nutritional support team） activity improves the patient’s outcomes. This multi-disciplinary approach finds the optimal treatment for the individual patient. Another way to improve patient care is to screen highly susceptible group and take care of the patients before the surgery.
Recently minimal invasive surgery become popular due to its advantages of early recovery and reduced morbidity. Therefore it will be good for the patients if we can combine ERAS with minimal invasive surgery.
As the inflammation including postoperative complications is associated poor survival of the patients, any efforts should be made to decrease postoperative complications including infectious complications. One way is to perform precise and meticulous operations. We believe that there will be new approach for improving patient’s health conditions.
The new way for optimal patient care combining ERAS with precise minimal invasive surgery （ERAS plus PMIS） will prevail in the future.
PURPOSE：Entity of surgical diabetes associated with operation is surgical stress induced hyperglycemia which is trigger of postoperative infection（POI）. This study aimed to evaluate the effects of surgical diabetes treatment using an artificial pancreas（AP）.
METHODS：From 2006 to 2018 on April, more than 700 surgical patients underwent perioperative glycemic control using an AP with closed-loop system（Nikkiso, Tokyo）. Among them, almost patients performed tight glycemic control（TGC）including intensive insulin therapy（IIT）targeting blood glucose range of 80-110 mg/dL.
RESULTS：All patients undergoing TGC had no hypoglycemia less than 70 mg/dl. Consecutive 305 patients undergoing IIT had not only no hypoglycemia but also high achievement rate of targeting blood glucose range, approximately 90%. Of note, this novel glycemic control revealed more stable continuous blood glucose monitoring with less variability of blood concentrations compared with conventional glycemic control. In addition, we would like to introduce several prospective randomized controlled trials of TGC using an AP leading to better surgical outcomes after major surgery.
CONCLUSION：Perioperative TGC using an AP is an effective and a safe surgical diabetes treatment to avoid not only hyperglycemia and hypoglycemia but also variability of blood glucose levels. In particular, this novel glycemic control method is compatible with perioperative nutrition support easily.
Nutritional treatment（NT）such as EN or PN is essential for the malnourished or long term fasting patients. As NT is usually delivered to complicated, fragile, or acute ill patients, many events can occur during NT. Recently, we conducted one single center and one multi-center clinical studies focusing on NT-related complications.
Firstly, 4,527 cases of NST consultation for adult patients（> 18 years）at SNUH from Jan to Dec 2016 were reviewed. We analyzed the reasons of NST re-consultation according to the type of current nutritional support. NST re-consultation rate was 46.8%（n=2,117). The reasons of NST re-consultations included（1）changes of nutritional provision method（n=1,014, 47.9%),（2）complication related to artificial nutrition（n=700, 33.1%),（3）routine follow-up（n=303, 14.3%),（4）home nutritional therapy（n=80, 3.8%), and（5）others（n=20, 0.9%). Re-consultation rate of enteral nutrition（EN）was 55.7%（988/1,773）and that of parenteral nutrition（PN）was 41.0%（1,129/2,754）.
Secondly, we conducted a multicenter trial（supported by KSPEN）regarding NT-related complications in adult, in-hospital patients. We collected 14,600 NT-related complications from 12,453 patients from 28 hospitals. Regarding type of complication according to the type of NT, calorie deficiency（31.3%, n=1,332), diarrhea（22.0%, n=935), and GI trouble except diarrhea（11.9%, n=508）were most common in EN. Similarly, calorie deficiency（55.4%, n=4,236), GI trouble except diarrhea（9.8%, n=750), and electrolyte imbalance（8.2%, n=626）were most common in PN. Regarding clinical outcomes, 18.7%（n=2,158）was finally expired, and 58.1%（n=7,027）was admitted to ICU. Volume overload（OR=3.48）and catheter infection（OR=2.54）were closely associated with hospital death. Hyperammonemia（OR=3.09）and renal insufficiency（OR=2.77）were closely associated with ICU admission.
In summary, NT may induce or be associated with several complications, and some of them may affect patient’s outcome seriously. NST personnel in each hospital should be aware of each problem during nutritional support.