Successful Use of an Exclusion Diet with Partial Enteral Nutrition in a Patient After Total Gastrectomy: A Case Report

Background

Gastric cancer is the 5th most common malignancy worldwide and the annual incidence is estimated at about one million cases [1,2]. Surgery is the only radical treatment for advanced cancer, often in combination with chemotherapy or radiotherapy. The operation consists of excision of the entire stomach with as many lymph nodes as possible from the direct and distant vicinity of the tumor [3]. The gastrectomy procedure carries the risk of complications, of which the problem of malnutrition is very important from the point of view of further treatment and prognosis. Appropriate planning and monitoring of nutritional treatment is therefore a necessary element of holistic patient care.

Malnutrition is a common feature of patients diagnosed with gastric cancer, but cancer-related malnutrition is underestimated and often untreated worldwide [6]. Malnutrition has a negative impact on the course of treatment and the quality of life of patients. It is estimated that 10–20% of cancer patients die as a result of malnutrition, not the tumor itself [4]. Total gastrectomy increases the risk of malnutrition due to early satiety and changes in dietary tolerance, among other post-gastrectomy symptoms, resulting in unintentional weight loss as well as high risk of micronutrient deficiencies. Gastrectomy disrupts reservoir capacity, mechanical digestion, and gastric emptying [5]. Proper nutritional status plays a key role in the care of cancer patients and in postoperative recovery, so nutrition intervention to optimize nutrition status should be prior-itized at the time of diagnosis and conducted in parallel with anti-cancer treatment.

Case Report

DIAGNOSTIC AND THERAPEUTIC PROCEDURES:

On the day of admission to the Department of Surgery, the general condition of the patient was good (height 180 cm, weight 66 kg, BMI: 20.4, 2 points on the NRS 2002 scale [Nutritional risk score]). He had been on home parenteral nutrition for 2.5 years, which provided 1100 calories and 65 g of protein per day. He reported that if he remained without parenteral nutrition, he lost weight.

Due to increasing abdominal pain after oral intake, a decision was made to perform X-ray examination with the small bowel follow-through while the patient was fasting. The examination showed no features of contrast agent leaking and the esophageal stump was described as having ‘smooth wall outline and normal peristalsis’. There was no mechanical obstruction in the small intestine or in the large intestine. The consulting psychiatrist ruled out psychogenic causes of the symptoms. Angiology and gastroenterology consultation were requested. In the ultrasound examination, the venous and arterial flows in the visceral circulation were normal and the consulting angiologist excluded a vascular cause of the abdominal pain. In the gastroenterological consultation, a gradual reduction of parenteral nutrition was recommended, while an attempt was made to load the gastrointestinal tract with oral nutrition.

Nutritional treatment was started based on the recommendations of a dietitian. In the nutritional interview, the dietitian determined that the patient ate about 7 meals a day, with a volume of up to 150 g each, and he was in pain after eating these meals. During the analysis of a sample food diary, it was calculated that the patient consumed about 1700 kcal/ day orally. He reported symptoms of intolerance to dairy products, constipation, and abdominal pain. During the examination, 2 weeks after admission to the hospital, his weight was 64 kg and his BMI was 19.75. The calculations established a daily energy requirement of approximately 2400 calories. At the time, he was on a hospital diet that was light, dairy-free, and low-residue. Due to the proposed attempt to abandon parenteral nutrition, abdominal pain after consuming a standard diet, and the need to ensure proper caloric content of the diet, a decision was made to include Modulen IBD (Nestle Health Science) in the patient’s diet, in the amount of 2 portions a day with a volume of 6 scoops dissolved in 210 ml of water. This amount provided the patient with 500 kcal and 17.5 g of protein. He was instructed to take Modulen IBD in small sips and to drink it between the main meals as a second breakfast and afternoon snack. In addition, an easily digestible, dairy-free, low-residue diet was recommended, and due to constipation reported by the patient, probiotic therapy was proposed (Vivomix 450 1–2 sachets/day). Modulen IBD was introduced in the absence of specific nutritional recommendations to test the patient’s tolerance of the preparation before possible treatment modification.

Two days later, another dietary consultation was held, during which the patient was found to have very good tolerance of Modulen IBD. In addition, he reported improved rhythm of bowel movements and reduction in abdominal pain after eating. He was offered implementation of the principles of the ModuLife nutritional program, based on the CDED diet (Crohn Disease Exclusion Diet), and he received brochures about the program and access to the ModuLife mobile application. The nutritional plan was based on food products recommended during phase I of the ModuLife program, with a daily energy supply of 2000–2100 calories and supplementation with 6 scoops of Modulen IBD twice a day, which increased the energy supply by about 500 kcal. The recommended calorie goal was 2400–2500 calories per day. In addition, it was decided to maintain probiotic therapy with Vivomix 450 in the scheme of 20 days of taking 1–2 sachets a day of the probiotic, with 10 days off, for a total of 3 months.

On March 21, 2022 he was discharged home with a diagnosis of impaired bowel function resulting from long-term discontinuation of oral nutrition. Dietary recommendations were maintained, including gradual reduction of parenteral nutrition.

About 3 months later, he was readmitted to the Department of Surgery to assess his nutritional status after implementing the recommendations. A dietary consultation was ordered. During the nutritional interview, he reported continued adherence to the ModuLife program. During the consultation, he was in the 12^th week of the diet (6th week of phase II). He expanded the diet in accordance with the program’s instructions. He maintained a consistent body weight of 64 kg. He reported having a very good mood, no abdominal pain, and regular bowel movements (once a day, stool with a formed consistency). Laboratory test results, including electrolytes, albumin, creatinine, glucose, lipid profile, and C-reactive protein, were within reference values.

Discussion

In the described case, the patient underwent a total gastrectomy due to gastric cancer. Despite effective treatment of the underlying disease, there were significant adverse effects of surgical treatment in the form of chronic malnutrition, which required years of parenteral nutrition. The need for long-term parenteral nutrition made it impossible for the patient to return to normal life activity. An attempt to extend the oral diet resulted in intensification of abdominal pain, and he also had chronic constipation.

After excluding mechanical, vascular and psychogenic causes of symptoms, it was decided to try to include Modulen IBD in the patient’s oral diet. The preparation was well tolerated, so he was offered to implement the principles of the CDED diet (Crohn’s Disease Exclusion Diet) – ModuLife Diet. The diet is effective in pediatric patients, and, according to the latest research, also in adult patients with Crohn’s disease in inducing remission of the disease [7–10]. In a typical nutritional regimen, which was also used in this case, the CDED diet supplemented with Modulen (providing 50% of caloric intake) is maintained for 6 weeks, followed by the recommendations of the CDED diet supplemented with Modulen, providing 25% of caloric needs. Modulen is a nutritionally complete diet, normocaloric and normoprotein, rich in medium-chain fatty acids, and containing the transforming growth factor TGF-β2. TGF-β2 plays a role in the processes of cell differentiation and proliferation, wound healing, as well as the functioning of the immune system. Its effect, even on the same cell lines, is varied and may vary depending on the clinical situation [11].

The goal of the CDED diet is to limit exposure to nutrients that have an adverse effect on the intestinal microbiota and permeability and functioning of the intestinal barrier. Another argument in favor of using the CDED diet in Crohn’s disease, but also in the case of impaired bowel function, as in the described case, is the avoidance of pro-inflammatory factors of the diet, such as food additives [7,8,12,13]. Recommended foods include chicken breast meat, eggs, potatoes, various fruits, and vegetables. Some products are prohibited, including processed foods, animal fat, gluten, and dairy, and the list of prohibited foods is shortened in the next phase of the nutritional program. The effectiveness of such management in children with Crohn’s disease was confirmed by Levin et al, including a prospective randomized study [7,8]. In children receiving CDED in combination with partial enteral nutrition, the acceptance of the nutritional program was definitely better than only enteral nutrition with an industrial preparation administered orally or, in the case of poor tolerance, through a gastric tube [14]. Achieving clinical remission was associated with a reduction in inflammation expressed by a decrease in the concentration of CRP in the blood serum and calprotectin in the feces. Beneficial changes in the composition of the intestinal microbiota were also observed, namely an increase in the amount of Firmicutes and a decrease in Proteobacteria in the feces [7,8]. The results of some clinical trials indicate improvement in the nutritional status of patients after use of the CDED diet by supplementing the deficiencies of nutrients, trace elements, and vitamins involved in the mechanism of tissue repair and immune defense [12,13]. The authors of studies in which CDED was used in combination with partial enteral nutrition with Modulen in patients with Crohn’s disease discussed its anti-inflammatory effect and improvement of nutritional status due to continuous contact of the preparation with the pathologically changed mucosa of the gastrointestinal tract. Such dietary management improves diet tolerance with the use of the gastrointestinal tract and allows for a gradual increase in meal portions [8,9].

Conclusions

In the described case, the patient did not have inflammatory bowel disease, but presented with symptoms of impaired bowel function resulting from long-term cessation of oral nutrition. We hypothesize that the nutritional and immunomodulating effect of Modulen, in combination with an anti-inflammatory elimination diet, results in better nutrition of intestinal epithelial cells and a gradual improvement in intestinal motility and absorption, which in turn enabled the patient to completely discontinue parenteral nutrition and return to normal life activity. It seems, therefore, that this type of nutritional management may also be considered in other cases of impaired bowel function.