101
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Hegazi RA, Hustead DS, Evans DC. Preoperative Standard Oral Nutrition Supplements vs Immunonutrition: Results of a Systematic Review and Meta-Analysis. J Am Coll Surg 2014; 219:1078-87. [DOI: 10.1016/j.jamcollsurg.2014.06.016] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 06/20/2014] [Accepted: 06/20/2014] [Indexed: 12/16/2022]
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102
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Tsukahara K, Motohashi R, Sato H, Endo M, Ueda Y, Nakamura K. Prospective Randomized Trial on Postoperative Administration of Diet Containing Eicosapentaenoic Acid, Docosahexaenoic Acid, Gamma-linolenic Acid, and Antioxidants in Head and Neck Cancer Surgery Patients with Free-flap Reconstruction. JAPANESE CLINICAL MEDICINE 2014; 5:47-54. [PMID: 25368541 PMCID: PMC4213189 DOI: 10.4137/jcm.s18125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/03/2014] [Accepted: 09/06/2014] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The purpose of this prospective, randomized study was to evaluate the effects of a diet containing eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), gamma-linolenic acid (GLA), and antioxidants in head and neck cancer surgery patients with free-flap reconstruction. METHODS In this randomized, prospective study, 62 patients with head and neck cancers were assigned to receive a general control diet (Ensure® H; Abbott Japan, Tokyo, Japan) or the study diet (Oxepa®; Abbott Japan) containing EPA, DHA, GLA, and antioxidants (eg vitamins A, E, and C). The primary assessment item was the degree of postoperative inflammation, as assessed by measuring maximum body temperature and levels of C-reactive protein (CRP) and procalcitonin from the day of surgery to postoperative day 8. Secondary assessment items were lengths of stays in the intensive care unit (ICU) and hospital. RESULTS The control diet group (n = 32) and study diet group (n = 30) showed no significant difference in energy administered through diet. No significant differences in the parameters of the primary assessment item were noted. Length of stay in the ICU was significantly shorter for the control diet group than for the study diet group (P = 0.011). No significant difference in duration of hospitalization was seen between groups. CONCLUSION No usefulness of a diet containing EPA, DHA, GLA, and antioxidants was demonstrated.
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Affiliation(s)
- Kiyoaki Tsukahara
- Department of Otolaryngology/Head and Neck Surgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Ray Motohashi
- Department of Otolaryngology/Head and Neck Surgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Hiroki Sato
- Department of Otolaryngology/Head and Neck Surgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Minoru Endo
- Department of Otolaryngology/Head and Neck Surgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Yuri Ueda
- Department of Otolaryngology/Head and Neck Surgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Kazuhiro Nakamura
- Department of Otolaryngology/Head and Neck Surgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
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Roca-Rodríguez MDM, García-Almeida JM, Ruiz-Nava J, Alcaide J, Lupiañez-Pérez Y, Rico-Pérez JM, Toledo-Serrano MD, Cardona F, Medina-Carmona JA, Tinahones FJ. Long-term effects of varying consumption of ω3 fatty acids in ear, nose and throat cancer patients: assessment 1 year after radiotherapy. Int J Food Sci Nutr 2014; 66:108-13. [PMID: 25265206 DOI: 10.3109/09637486.2014.953453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A prospective 1-year follow-up study in ear, nose, and throat (ENT) cancer patients was carried out one year after radiotherapy to assess the effect of varying consumption of ω3 fatty acid according to whether they consumed more or less than the 50th percentile of ω3 fatty acids. Clinical, analytical, inflammatory (CRP and IL-6), and oxidative variables (TAC, GPx, GST, and SOD) were evaluated. The study comprised 31 patients (87.1% men), with a mean age of 61.3 ± 9.1 years. Hematological variables showed significant differences in the patients with a lower consumption of ω3 fatty acids. A lower mortality and longer survival were found in the group with ω3 fatty acid consumption ≥50th percentile but the differences were not significant. No significant difference was reached in toxicity, inflammation, and oxidative stress markers. The group with ω3 fatty acid consumption <50th percentile significantly experienced more hematological and immune changes.
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Affiliation(s)
- María Del Mar Roca-Rodríguez
- Biomedical Research Institute of Malaga (IBIMA), Virgen de la Victoria Hospital, University of Malaga , Málaga , Spain
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Mortensen K, Nilsson M, Slim K, Schäfer M, Mariette C, Braga M, Carli F, Demartines N, Griffin SM, Lassen K, Fearon KCF, Ljungqvist O, Lobo DN, Revhaug A. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Br J Surg 2014; 101:1209-29. [PMID: 25047143 DOI: 10.1002/bjs.9582] [Citation(s) in RCA: 460] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/20/2014] [Accepted: 05/08/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy. METHODS An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'. RESULTS The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSION The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.
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Affiliation(s)
- K Mortensen
- Department of Gastrointestinal and Hepatobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | | | | | | | | | | | | | | | | | | | | | - K C F Fearon
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, UK
| | - O Ljungqvist
- Department of Surgery, Örebro University Hospital, Örebro and Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - D N Lobo
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research, Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - A Revhaug
- Department of Gastrointestinal and Hepatopancreaticobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
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105
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Impact of Preoperative Risk Factors on Morbidity after Esophagectomy: Is There Room for Improvement? World J Surg 2014; 38:2882-90. [DOI: 10.1007/s00268-014-2686-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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106
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Preoperative immunonutrition in liver resection-a propensity score matched case-control analysis. Eur J Clin Nutr 2014; 68:964-9. [PMID: 24961546 DOI: 10.1038/ejcn.2014.113] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 03/29/2014] [Accepted: 05/09/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES The value of preoperative nutritional support in liver resection remains questionable. The aim of the present study was to compare the incidence of postoperative complications after liver resection between those patients that received preoperative immunonutrition versus those patients without preoperative nutritional support. SUBJECTS/METHODS Patients undergoing elective liver resection between 9 November 2007 and 14 May 2013 were considered for the study: 84 with preoperative immunonutrition (Oral-Impact, Nestle, 3 × 237 ml per day for seven days at home) and 63 control patients without preoperative nutritional support. To reduce selection bias, propensity score matching was performed. Primary endpoint was the overall complication rate. Secondary endpoints were infectious and major complications. RESULTS Ninety-eight patients could be matched (49 in each group). Seventy-seven patients (78.6%) had a minor and 21 patients (21.4%) a major liver resection. The two groups were balanced for age, gender distribution, American Society of Anesthesiology score ⩾3, NRS 2002 score, weight loss>10%, cirrhosis, steathosis, preoperative chemotherapy, pathology, major liver resection and extrahepatic procedures. No significant differences were observed in the overall complication rate (53.0% versus 51.0%), infectious complications (38.7% versus 28.5%) and major complications (12.2% versus 10.2%) for the immunonutrition and control group, respectively. CONCLUSIONS The present study did not permit to demonstrate an impact of preoperative immunonutrition with Oral-Impact on postoperative complications after minor liver resection.
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107
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Mariette C, Chambrier C. Response to the authors of the article "Enhanced recovery after scheduled colo-rectal surgery" published in the Journal de Chirurgie. J Visc Surg 2014; 152:79-80. [PMID: 24928384 DOI: 10.1016/j.jviscsurg.2014.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- C Mariette
- Service de chirurgie digestive et générale, hôpital Claude-Huriez, CHRU, place de Verdun, 59037 Lille cedex, France.
| | - C Chambrier
- Unité de nutrition clinique intensive, groupement hospitalier Nord, 103, Grande-Rue-de-la-Croix-Rousse, Lyon, France
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108
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Xu YJ, Cheng JCH, Lee JM, Chen CCH. Management of Malnutrition in Esophageal Cancer Patients. JOURNAL OF CANCER RESEARCH AND PRACTICE 2014. [DOI: 10.1016/s2311-3006(16)30019-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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109
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Morán López JM, Piedra León M, García Unzueta MT, Ortiz Espejo M, Hernández González M, Morán López R, Amado Señaris JA. Soporte nutricional perioperatorio. Cir Esp 2014; 92:379-86. [DOI: 10.1016/j.ciresp.2013.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 12/04/2013] [Accepted: 12/18/2013] [Indexed: 12/15/2022]
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110
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Braga M, Wischmeyer PE, Drover J, Heyland DK. Clinical evidence for pharmaconutrition in major elective surgery. JPEN J Parenter Enteral Nutr 2014; 37:66S-72S. [PMID: 24009251 DOI: 10.1177/0148607113494406] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In recent years, standard nutrition preparations have been modified by adding specific nutrients, such as arginine, ω-3 fatty acids, glutamine, and others, which have been shown to upregulate host immune response, modulate inflammatory response, and improve protein synthesis after surgery. Most randomized trials and several meta-analyses have shown that perioperative administration of enteral arginine, ω-3 fatty acids, and nucleotides (immunonutrition) reduced infection rate and length of hospital stay in patients with upper and lower gastrointestinal (GI) cancer. The most pronounced benefits of immunonutrition were found in subgroups of high-risk and malnourished patients. Promising but not conclusive results have been found in non-GI surgery, especially in head and neck surgery and in cardiac surgery, but larger trials are required before recommending immunonutrition as a routine practice. Conflicting results on the real benefit of parenteral glutamine supplementation in patients undergoing elective major surgery have been published. In conclusion, enteral diets supplemented with specific nutrients significantly improved short-term outcome in patients with cancer undergoing elective GI surgery. Future research should investigate a molecular signaling pathway and identify specific mechanisms of action of immune-enhancing substrates.
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111
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Ruiz Tovar J, Badia JM. Prevention of Surgical Site Infection in Abdominal Surgery. A Critical Review of the Evidence. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.cireng.2013.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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112
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Munbauhal G, Drouin SJ, Mozer P, Colin P, Phé V, Cussenot O, Rouprêt M. Malnourishment in bladder cancer and the role of immunonutrition at the time of cystectomy: an overview for urologists. BJU Int 2014; 114:177-84. [DOI: 10.1111/bju.12529] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Gavish Munbauhal
- Department of Urology Pitié Hospital; Assistance Publique Hopitaux de Paris; University Paris-6; Paris France
| | - Sarah J. Drouin
- Department of Urology Pitié Hospital; Assistance Publique Hopitaux de Paris; University Paris-6; Paris France
| | - Pierre Mozer
- Department of Urology Pitié Hospital; Assistance Publique Hopitaux de Paris; University Paris-6; Paris France
| | - Pierre Colin
- Academic Department of Urology; CHU Lille; Lille Nord University; Lille France
| | - Véronique Phé
- Department of Urology Pitié Hospital; Assistance Publique Hopitaux de Paris; University Paris-6; Paris France
| | - Olivier Cussenot
- Department of Urology Pitié Hospital; Assistance Publique Hopitaux de Paris; University Paris-6; Paris France
- GRC-05, Institut Universitaire de Cancerologie (IUC); University Paris-6; Paris France
| | - Morgan Rouprêt
- Department of Urology Pitié Hospital; Assistance Publique Hopitaux de Paris; University Paris-6; Paris France
- GRC-05, Institut Universitaire de Cancerologie (IUC); University Paris-6; Paris France
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113
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[Prevention of surgical site infection in abdominal surgery. A critical review of the evidence]. Cir Esp 2014; 92:223-31. [PMID: 24411561 DOI: 10.1016/j.ciresp.2013.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 07/19/2013] [Accepted: 08/01/2013] [Indexed: 11/22/2022]
Abstract
Surgical site infection (SSI) is associated with prolonged hospital stay, increased morbidity, mortality and sanitary costs, and reduced patients quality of life. Many hospitals have adopted guidelines of scientifically-validated processes for prevention of surgical site and central-line catheter infections and sepsis. Most of these guidelines have resulted in an improvement in postoperative results. A review of the best available evidence on these measures in abdominal surgery is presented. The best measures are: avoidance of hair removal from the surgical field, skin decontamination with alcoholic antiseptic, correct use of antibiotic prophylaxis (administration within 30-60 min before incision, use of 1(st) or 2(nd) generation cephalosporins, single preoperative dosis, dosage adjustments based on body weight and renal function, intraoperative re-dosing if the duration of the procedure exceeds 2 half-lives of the drug or there is excessive blood loss), prevention of hypothermia, control of perioperative glucose levels, avoid blood transfusion and restrict intraoperative liquid infusion.
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114
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Osland E, Hossain MB, Khan S, Memon MA. Effect of Timing of Pharmaconutrition (Immunonutrition) Administration on Outcomes of Elective Surgery for Gastrointestinal Malignancies. JPEN J Parenter Enteral Nutr 2014; 38:53-69. [DOI: 10.1177/0148607112474825] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Emma Osland
- Department of Nutrition, Royal Brisbane and Womens Hospital, Brisbane, Queensland, Australia
| | - Md Belal Hossain
- Department of Mathematics and Computing, Australian Centre for Sustainable Catchments, University of Southern Queensland, Toowoomba, Queensland, Australia
- Department of Statistics, Biostatistics and Informatics, University of Dhaka, Bangladesh
| | - Shahjahan Khan
- Department of Mathematics and Computing, Australian Centre for Sustainable Catchments, University of Southern Queensland, Toowoomba, Queensland, Australia
| | - Muhammed Ashraf Memon
- Sunnybank Obesity Centre, Sunnybank, Queensland, Australia
- Mayne Medical School, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- Faculty of Health and Social Science, Bolton University, Bolton, Lancashire, UK
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115
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Evans DC, Martindale RG, Kiraly LN, Jones CM. Nutrition optimization prior to surgery. Nutr Clin Pract 2013; 29:10-21. [PMID: 24347529 DOI: 10.1177/0884533613517006] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Optimization of metabolic state prior to major surgery leads to improved surgical outcomes. Nutrition screening protocols should be implemented in the preoperative evaluation, possibly as part of a bundle. Strategies to minimize hyperglycemia and insulin resistance by aggressive preoperative nutrition and carbohydrate loading may promote maintenance of a perioperative anabolic state, improving healing, reducing complications, and shortening the time to recovery of bowel function and hospital discharge. Short courses of preoperative immune-modulating formulas, using combinations of arginine, ω-3 fatty acids, and other nutrients, have been associated with improved surgical outcomes. These immune-modulating nutrients are key elements of metabolic pathways that promote attenuation of the metabolic response to stress and improve both wound healing and immune function. Patients with severe malnutrition and gastrointestinal dysfunction may benefit from preoperative parenteral nutrition. Continuation of feeding through the intraoperative period for severely stressed hypermetabolic patients undergoing nongastrointestinal surgery is another strategy to optimize metabolic state and reduce prolonged nutrition deficits. In this paper, we review the importance of preoperative nutrition and strategies for effective preoperative nutrition optimization.
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Affiliation(s)
- David C Evans
- Christopher M. Jones, University of Louisville, Hiram C. Polk Jr MD Department of Surgery, Ambulatory Care Building, 2nd Floor, Louisville, KY 40292, USA.
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116
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Are Patients at Nutritional Risk More Prone to Complications after Major Urological Surgery? J Urol 2013; 190:2126-32. [DOI: 10.1016/j.juro.2013.06.111] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2013] [Indexed: 01/04/2023]
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117
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Sorensen LS, Thorlacius-Ussing O, Schmidt EB, Rasmussen HH, Lundbye-Christensen S, Calder PC, Lindorff-Larsen K. Randomized clinical trial of perioperative omega-3 fatty acid supplements in elective colorectal cancer surgery. Br J Surg 2013; 101:33-42. [PMID: 24281905 DOI: 10.1002/bjs.9361] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Omega-3 fatty acids (n-3 FAs) may have beneficial clinical effects, and n-3 FA supplements may improve outcome after surgery. METHODS In a randomized double-blind placebo-controlled trial in single centre, patients referred for elective colorectal cancer surgery received either an n-3 FA-enriched oral nutritional supplement (ONS) (Supportan, 200 ml twice daily) providing 2.0 g eicosapentaenoic acid (EPA) and 1.0 g docosahexaenoic acid (DHA) per day, or a standard isocaloric and isonitrogenous ONS, for 7 days before and 7 days after surgery. The primary endpoint was infectious and non-infectious complications within 30 days of surgery. Secondary endpoints were length of hospital stay, intensive care unit admission, readmissions, and concentrations of marine n-3 FAs and arachidonic acid in granulocyte membranes. RESULTS Some 148 consecutive patients (68 women, 80 men; mean age 71 (range 41-89) years) were randomized. There was no significant difference between groups in infectious or non-infectious postoperative complications (P = 1.000). Granulocyte levels of EPA, DHA and docosapentaenoic acid (DPA) were significantly higher in the n-3 FA-enriched supplement group compared with the control group (P < 0.001). The arachidonic acid level in granulocytes was significantly lower in the enriched group than in the control group (P < 0.001). CONCLUSION EPA, DHA and DPA were incorporated into granulocytes in patients receiving n-3 FAs, but this was not associated with improved postoperative outcomes. REGISTRATION NUMBER NCT00488904 (http://www.clinicaltrials.gov).
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Affiliation(s)
- L S Sorensen
- Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
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118
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Rasmussen HH, Irtun &O, Olesen SS, Drewes AM, Holst M. Nutrition in chronic pancreatitis. World J Gastroenterol 2013; 19:7267-7275. [PMID: 24259957 PMCID: PMC3831208 DOI: 10.3748/wjg.v19.i42.7267] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 09/24/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023] Open
Abstract
The pancreas is a major player in nutrient digestion. In chronic pancreatitis both exocrine and endocrine insufficiency may develop leading to malnutrition over time. Maldigestion is often a late complication of chronic pancreatic and depends on the severity of the underlying disease. The severity of malnutrition is correlated with two major factors: (1) malabsorption and depletion of nutrients (e.g., alcoholism and pain) causes impaired nutritional status; and (2) increased metabolic activity due to the severity of the disease. Nutritional deficiencies negatively affect outcome if they are not treated. Nutritional assessment and the clinical severity of the disease are important for planning any nutritional intervention. Good nutritional practice includes screening to identify patients at risk, followed by a thoroughly nutritional assessment and nutrition plan for risk patients. Treatment should be multidisciplinary and the mainstay of treatment is abstinence from alcohol, pain treatment, dietary modifications and pancreatic enzyme supplementation. To achieve energy-end protein requirements, oral supplementation might be beneficial. Enteral nutrition may be used when patients do not have sufficient calorie intake as in pylero-duodenal-stenosis, inflammation or prior to surgery and can be necessary if weight loss continues. Parenteral nutrition is very seldom used in patients with chronic pancreatitis and should only be used in case of GI-tract obstruction or as a supplement to enteral nutrition.
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119
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Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M, Kassouf W, Muller S, Baldini G, Carli F, Naesheimh T, Ytrebo L, Revhaug A, Lassen K, Knutsen T, Aarsether E, Wiklund P, Patel HRH. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS(®)) society recommendations. Clin Nutr 2013; 32:879-87. [PMID: 24189391 DOI: 10.1016/j.clnu.2013.09.014] [Citation(s) in RCA: 457] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/26/2013] [Accepted: 09/26/2013] [Indexed: 12/17/2022]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) pathways have significantly reduced complications and length of hospital stay after colorectal procedures. This multimodal concept could probably be partially applied to major urological surgery. OBJECTIVES The primary objective was to systematically assess the evidence of ERAS single items and protocols applied to cystectomy patients. The secondary objective was to address a grade of recommendation to each item, based on the evidence and, if lacking, on consensus opinion from our ERAS Society working group. EVIDENCE ACQUISITION A systematic literature review was performed on ERAS for cystectomy by searching EMBASE and Medline. Relevant articles were selected and quality-assessed by two independent reviewers using the GRADE approach. If no study specific to cystectomy was available for any of the 22 given items, the authors evaluated whether colorectal guidelines could be extrapolated. EVIDENCE SYNTHESIS Overall, 804 articles were retrieved from electronic databases. Fifteen articles were included in the present systematic review and 7 of 22 ERAS items were studied. Bowel preparation did not improve outcomes. Early nasogastric tube removal reduced morbidity, bowel recovery time and length of hospital stay. Doppler-guided fluid administration allowed for reduced morbidity. A quicker bowel recovery was observed with a multimodal prevention of ileus, including gum chewing, prevention of PONV and minimally invasive surgery. CONCLUSIONS ERAS has not yet been widely implemented in urology and evidence for individual interventions is limited or unavailable. The experience in other surgical disciplines encourages the development of an ERAS protocol for cystectomy.
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120
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The nutritional impact of diverting stoma-related complications in elderly rectal cancer patients. Int J Colorectal Dis 2013; 28:1393-400. [PMID: 23702819 DOI: 10.1007/s00384-013-1699-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Diverting stomas following rectal cancer surgery can affect patients' quality of life, and their complications may negatively affect patients' long-term outcomes and quality of life. The purpose of this study is to investigate the relationship between diverting stoma-related complications and nutritional status. METHODS In a retrospective study of 114 patients aged 65 years and older who underwent diverting loop ileostomy following rectal cancer surgery between June 2004 and March 2011, we analyzed retrospectively diverting stoma-related complications and nutrition status for the following time periods: before stoma construction, before stoma closure, and after stoma closure. RESULTS Complications related to the diverting stoma developed in 24 (21.1%) patients and complications related to stoma closure in 11 (9.6%) patients. Nutritional screening performed prior to stoma closure showed that patients who experienced stoma formation-related complications had lower albumin levels (P = 0.016) and lower total lymphocytes (P = <0.0001). Body weight loss was more severe in patients with stoma-related complication (P = 0.036). CONCLUSIONS Diverting stoma-related complications may affect patient's nutritional status. Stoma closure operation and proper nutritional support may be important for avoiding complications and improving patients' long-term outcomes and quality of life.
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121
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Chevrou-Séverac H, Pinget C, Cerantola Y, Demartines N, Wasserfallen JB, Schäfer M. Cost-effectiveness analysis of immune-modulating nutritional support for gastrointestinal cancer patients. Clin Nutr 2013; 33:649-54. [PMID: 24074548 DOI: 10.1016/j.clnu.2013.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 07/19/2013] [Accepted: 09/05/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIM Immune-modulating nutritional formula containing arginine, omega-3 fatty acids and nucleotides has been demonstrated to decrease complications and length of stay in surgical patients. This study aims at assessing the impact of immune-modulating formula on hospital costs in gastrointestinal cancer surgical patients in Switzerland. METHOD Based on a previously published meta-analysis, the relative risks of overall and infectious complications with immune-modulating versus standard nutrition formula were computed. Swiss hospital costs of patients undergoing gastrointestinal cancer surgery were retrieved. A method was developed to compute the patients' severity level, not taking into account the complications from the surgery. Incremental costs of complications were computed for both treatment groups, and sensitivity analyses were carried out. RESULTS Relative risk of complications with pre-, peri- and post-operative use of immune-modulating formula was 0.69 (95%CI 0.58-0.83), 0.62 (95%CI 0.53-0.73) and 0.73 (95%CI 0.35-0.96) respectively. The estimated average contribution of complications to the cost of stay was CHF 14,949 (€10,901) per patient (95%CI 10,712-19,186), independently of case's severity. Based on this cost, immune-modulating nutritional support decreased costs of hospital stay by CHF 1638 to CHF 2488 per patient (€1195-€1814). Net hospital savings were present for baseline complications rates as low as 5%. CONCLUSION Immune-modulating nutritional solution is a cost-saving intervention in gastrointestinal cancer patients. The additional cost of immune-modulating formula are more than offset by savings associated with decreased treatment of complications.
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Affiliation(s)
| | - Christophe Pinget
- University Hospital of Lausanne (CHUV), Medical Direction, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Yannick Cerantola
- University Hospital of Lausanne (CHUV), Department of Visceral Surgery, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Nicolas Demartines
- University Hospital of Lausanne (CHUV), Department of Visceral Surgery, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Jean-Blaise Wasserfallen
- University Hospital of Lausanne (CHUV), Medical Direction, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Markus Schäfer
- University Hospital of Lausanne (CHUV), Department of Visceral Surgery, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
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Ligthart-Melis GC, Weijs PJM, te Boveldt ND, Buskermolen S, Earthman CP, Verheul HMW, de Lange-de Klerk ESM, van Weyenberg SJB, van der Peet DL. Dietician-delivered intensive nutritional support is associated with a decrease in severe postoperative complications after surgery in patients with esophageal cancer. Dis Esophagus 2013; 26:587-93. [PMID: 23237356 DOI: 10.1111/dote.12008] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to evaluate the effect of dietician-delivered intensive nutritional support (INS) on postoperative outcome in patients with esophageal cancer. Approximately 50-80% of patients with esophageal cancer are malnourished at the time of diagnosis. Malnutrition enhances the risk of postoperative complications, resulting in delay of postoperative recovery and impairment of quality of life. Sixty-five patients with esophageal cancer were included. All patients who received surgery (n = 28) in the time frame between March 2009 and April 2010, the first year after the start of INS, were included in the INS intervention group. The control group (n = 37) consisted of patients who received surgery during the 3 years before the start of INS. Logistic regression analysis was used to compare differences in severity of postoperative complications using the Dindo classification. Linear regression was applied to evaluate differences in preoperative weight change. The adjusted odds ratio for developing serious complications after surgery of INS compared with the control group was 0.23 (95% confidence interval: 0.053-0.97; P = 0.045). Benefit was mainly observed in patients who received neoadjuvant therapy before esophagectomy (n = 35). The INS program furthermore resulted in a relative preoperative weight gain in comparison with the control group of +4.8% (P = 0.009, adjusted) in these neoadjuvant-treated patients. This study shows that dietician-delivered INS preserves preoperative weight and decreases severe postoperative complications in patients with esophageal cancer.
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Affiliation(s)
- G C Ligthart-Melis
- Nutrition & Dietetics, Department of Internal Medicine, VU University Medical Center (VUmc), Amsterdam, The Netherlands.
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Marano L, Porfidia R, Pezzella M, Grassia M, Petrillo M, Esposito G, Braccio B, Gallo P, Boccardi V, Cosenza A, Izzo G, Di Martino N. Clinical and immunological impact of early postoperative enteral immunonutrition after total gastrectomy in gastric cancer patients: a prospective randomized study. Ann Surg Oncol 2013; 20:3912-8. [PMID: 23838912 DOI: 10.1245/s10434-013-3088-1] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enteral immunodiet has been gaining increasing attention, but experimental data of its clinical effects in patients with gastric cancer are inconsistent, contradictory, and poorly investigated. The aim of this study was to assess the impact of early postoperative enteral immunonutrition on clinical and immunological outcomes in a homogeneous group of gastric cancer patients submitted to total gastrectomy. METHODS A total of 109 patients with gastric cancer were randomized to receive early postoperative enteral immunonutrition (formula supplemented with arginine, omega-3 fatty acids and ribonucleic acid [RNA]), or an isocaloric-isonitrogenous control. The postoperative outcome was evaluated based on clinical variables, including postoperative infectious complications, anastomotic leak rate, and length of hospitalization. In addition, state of cellular immunity was evaluated and compared between the 2 groups. RESULTS The incidence of postoperative infectious complications in the immunodiet group (7.4%) was significantly (p < .05) lower than that of the control group (20%), as well as the anastomotic leak rate (3.7% in immunodiet group vs 7.3% in standard nutrition group, p < .05). Mortality rate did not show any significant differences; patients of the immunodiet group were found to have a significantly reduced length of hospitalization (12.7 ± 2.3 days) when compared with standard diet group (15.9 ± 3.4 days, p = .029). The data on cellular immunity showed that the postoperative CD4(+) T-cell counts decreased in both groups, but the reduction in the IED group was significantly higher (p = .032) compared with the SND group. CONCLUSIONS Early postoperative enteral immunonutrition significantly improves clinical and immunological outcomes in patients undergoing gastrectomy for gastric cancer.
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Affiliation(s)
- Luigi Marano
- 8th General and Gastrointestinal Surgery-Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Naples, Italy,
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Barker LA, Gray C, Wilson L, Thomson BNJ, Shedda S, Crowe TC. Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial. Eur J Clin Nutr 2013; 67:802-7. [PMID: 23801093 DOI: 10.1038/ejcn.2013.117] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 04/28/2013] [Accepted: 05/17/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND/OBJECTIVES Invasive procedures such as surgery cause immunosuppression, leading to increased risk of complications, infections and extended hospital stay. Emerging research around immune-enhancing nutrition supplements and their ability to reduce postoperative complications and reduce treatment costs is promising. This randomised controlled trial aims to examine the effect of preoperative immunonutrition supplementation on length of hospital stay (LOS), complications and treatment costs in both well-nourished and malnourished gastrointestinal surgery patients. SUBJECTS/METHODS Ninety-five patients undergoing elective upper and lower gastrointestinal surgery were recruited. The treatment group (n=46) received a commercial immuno-enhancing supplement 5 days preoperatively. The control group (n=49) received no supplements. The primary outcome measure was LOS, and secondary outcome measures included complications and cost. RESULTS A nonsignificant trend towards a shorter LOS within the treatment group was observed (7.1 ± 4.1 compared with 8.8 ± 6.5 days; P=0.11). For malnourished patients, this trend was greater with hospital stay reduced by 4 days (8.3 ± 3.5 vs 12.3 ± 9.5 days; P=0.21). Complications and unplanned intensive care admission rates were very low in both the groups. The average admission cost was reduced by AUD1576 in the treatment group compared with the control group (P=0.37). CONCLUSIONS Preoperative immunonutrition therapy in gastrointestinal surgery has the potential to reduce the LOS and cost, with greater treatment benefit seen in malnourished patients; however, there is a need for additional research with greater patient numbers.
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Affiliation(s)
- L A Barker
- Nutrition Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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125
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Advanced tumor stage is an independent risk factor of postoperative infectious complications after colorectal surgery: arguments from a case-matched series. Dis Colon Rectum 2013; 56:568-76. [PMID: 23575395 DOI: 10.1097/dcr.0b013e318282e790] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patient and technical factors influencing postoperative infectious complications after elective colorectal resections for cancer are well described. Tumor related factors, however, have not been extensively evaluated. OBJECTIVE This study aimed to measure the effect of tumor stage on postoperative surgical site and extra surgical site infections after elective colorectal cancer resection. DESIGN This was a retrospective matched-cohort analysis of prospectively gathered data. SETTINGS The study was conducted in a tertiary referral center and a private hospital specializing in colorectal surgery. PATIENTS Between 2004 and 2011, 740 consecutive patients underwent elective resection for colorectal cancer in 2 centers. Patients undergoing resection for advanced tumors (group A, ≥ stage IIB, n = 177) were matched to randomly selected patients with localized disease (group L, <stage IIB, n = 354). Matching variables were age, sex, American Society of Anesthesiologists score, malnutrition, and surgical approach. MAIN OUTCOME MEASURES We compared 30-day infectious complications rates between patients with advanced (group A) and localized (group L) tumors. Multivariable logistic regression analysis was performed to identify risk factors for infectious complications. RESULTS Group A had a higher overall rate of IC (44.6 vs 25.4 %, p < 0.001), with a higher risk of infectious complications at both the resection site (p < 0.001) and distant to the resection site (p = 0.015). Independent risk factors for infectious complications were advanced tumors (OR = 2.70; p < 0.001), obesity (OR = 1.89; p = 0.018), malnutrition (OR = 2.22; p = 0.008), and open rather than laparoscopic procedure (OR = 5.11; p < 0.001). LIMITATIONS This study is limited by its retrospective methodology. CONCLUSION Advanced tumors increase the risk of infectious complications after colorectal resection, with other risk factors including malnutrition, obesity, and resection by laparotomy. Optimization of modifiable risk factors through nutritional repletion and the choice of a minimally invasive operation should be considered.
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Turnock A, Calder PC, West AL, Izzard M, Morton RP, Plank LD. Perioperative immunonutrition in well-nourished patients undergoing surgery for head and neck cancer: evaluation of inflammatory and immunologic outcomes. Nutrients 2013; 5:1186-99. [PMID: 23571650 PMCID: PMC3705342 DOI: 10.3390/nu5041186] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 03/21/2013] [Accepted: 03/26/2013] [Indexed: 12/16/2022] Open
Abstract
Limited work is available on the benefits of nutritional support enriched with arginine and n-3 fatty acids in surgical patients with head and neck cancer, particularly if well-nourished. We conducted a pilot study in these patients to examine effects on inflammatory markers and clinical outcome. Patients scheduled for radical resection of the oral cavity were randomised to 5 day preoperative and 5 day postoperative Impact® (IMN, n = 4), or no preoperative supplementary nutrition and Isosource® postoperatively (STD, n = 4). Plasma fatty acids, C-reactive protein (CRP), tumour necrosis factor (TNF)-α, interleukin (IL)-6 and IL-10 were measured at baseline, day of surgery and on postoperative days (POD) 2, 4 and 10. Postoperative complications were recorded. The (eicosapentaenoic acid plus docosahexaenoic acid) to arachidonic acid ratio was significantly higher in IMN patients on POD 2, 4 and 10 (P < 0.01). While not statistically significant, CRP, TNF-α, and IL-6 concentrations were higher in the STD group on POD2 while IL-10 was lower. Median length of stay was 10 (range 10–43) days in the IMN group and 21.5 (7–24) days in the STD group. Five complications were seen in the STD group and two in the IMN group. The results support the need for a larger trial focusing on clinical outcome.
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Affiliation(s)
- Amy Turnock
- Department of Surgery, University of Auckland, Auckland 1142, New Zealand; E-Mail:
| | - Philip C. Calder
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; E-Mails: (P.C.C.); (A.L.W.)
| | - Annette L. West
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; E-Mails: (P.C.C.); (A.L.W.)
| | - Mark Izzard
- Department of Otorhinolaryngology, Auckland City Hospital, Auckland 1142, New Zealand; E-Mail:
| | - Randall P. Morton
- Department of Otolaryngology, Counties-Manukau District Health Board, Auckland 1640, New Zealand; E-Mail:
| | - Lindsay D. Plank
- Department of Surgery, University of Auckland, Auckland 1142, New Zealand; E-Mail:
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +64-9-923-6949; Fax: +64-9-377-9656
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Disease-specific nutrition therapy: one size does not fit all. Eur J Trauma Emerg Surg 2013; 39:215-33. [PMID: 26815228 DOI: 10.1007/s00068-013-0264-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 02/04/2013] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The delivery of adequate nutrition is an integral part of the care of the critically ill surgical patient, and the provision of nutrition may have a greater impact on outcome than many other therapies commonly employed in the treatment of certain disease states. METHODS A review of the existing literature was performed to summarize the evidence for utilizing disease-specific nutrition in critically ill surgical patients. RESULTS Enteral nutrition, unless specifically contraindicated, is always preferable to parenteral nutrition. Methodological heterogeneity and conflicting results plague research in immunonutrition, and routine use is not currently recommended in critically ill patients. CONCLUSION There is currently insufficient evidence to recommend the routine initial use of most disease-specific formulas, as most patients with the disease in question will tolerate standard enteral formulas. However, the clinician should closely monitor for signs of intolerance and utilize disease-specific formulas when appropriate.
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Slim K. Oral sweet liquids 2 hours before surgery, chewing-gum and coffee after surgery... What else! J Visc Surg 2013; 150:1-2. [PMID: 23391662 DOI: 10.1016/j.jviscsurg.2013.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kuppinger D, Hartl WH, Bertok M, Hoffmann JM, Cederbaum J, Bender A, Küchenhoff H, Rittler P. Nutritional screening for risk prediction in patients scheduled for extra-abdominal surgery. Nutrition 2013; 29:399-404. [DOI: 10.1016/j.nut.2012.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/31/2012] [Accepted: 06/26/2012] [Indexed: 02/04/2023]
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130
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Weimann A. [Immunonutrition in intensive care medicine]. Med Klin Intensivmed Notfmed 2013; 108:85-94; quiz 95. [PMID: 23354409 DOI: 10.1007/s00063-012-0211-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 12/11/2012] [Indexed: 10/27/2022]
Abstract
The review presents the concept of immunonutrition in enteral and parenteral nutrition of the critically ill. The present indications for supplementing immune enhancing and anti-inflammatory substances are summarized and discussed in accordance with the recent literature and guidelines.
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Affiliation(s)
- A Weimann
- Klinik für Allgemein- und Visceralchirurgie, Klinikum St. Georg Leipzig, Delitzscher Strasse 141, Leipzig, Germany.
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131
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Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:817-30. [DOI: 10.1016/j.clnu.2012.08.011] [Citation(s) in RCA: 357] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 08/19/2012] [Indexed: 02/06/2023]
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Burden S, Todd C, Hill J, Lal S. Pre-operative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev 2012; 11:CD008879. [PMID: 23152265 DOI: 10.1002/14651858.cd008879.pub2] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post-operative management in gastrointestinal (GI) surgery is becoming well established with 'Enhanced Recovery After Surgery' protocols starting 24 hours prior to surgery with carbohydrate loading and early oral or enteral feeding given to patients the first day following surgery. However, whether or not nutritional intervention should be initiated earlier in the preoperative period remains unclear. Poor pre-operative nutritional status has been linked consistently to an increase in post-operative complications and poorer surgical outcome. OBJECTIVES To review the literature on preoperative nutritional support in patients undergoing gastrointestinal surgery (GI). SEARCH METHODS The searches were initially run in March 2011 and subsequently updated in February 2012. Databases including all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA and NHSEED) MEDLINE, EMBASE, AMED, British Nursing Index Archive using OvidSP were included and a search was run on each database separately after which duplicates were excluded. SELECTION CRITERIA The inclusion criteria were randomised controlled trials that evaluated pre-operative nutritional support in GI surgical participants using a nutritional formula delivered by a parenteral, enteral or oral route. The primary outcomes included post-operative complications and length of hospital stay. DATA COLLECTION AND ANALYSIS Two observers screened the abstracts for inclusion in the review and performed data extraction. Bias was assessed for each of the included studies using the bias assessment tables in the Cochrane Software Review Manager (version 5.1, Cochrane Collaboration). The trials were analysed using risk ratios with Mantel-Haenszel in fixed effects methods displayed with heterogeneity. Meta-analyses were undertaken on trials evaluating immune enhancing (IE) nutrition, standard oral supplements, enteral and parenteral nutrition (PN) which were administered pre-operatively.Study characteristics were summarised in tables. Dichotomous and ratio data were entered into meta-analyses for the primary outcomes. These were then summarised in tables with assumed and corresponding risk with relative effect giving 95% confidence intervals. MAIN RESULTS The searches identified 9900 titles and, after excluding duplicates, 6433 titles were initially screened. After the initial title screen, 6266 were excluded. Abstracts were screened for 167 studies and 33 articles were identified as meeting the inclusion criteria, of which 13 were included in the review after an assessment of the complete manuscripts.Seven trials evaluating IE nutrition were included in the review, of which 6 were combined in a meta-analysis. These studies showed a low to moderate level of heterogeneity and significantly reduced total post-operative complications (risk ratio (RR) 0.67 CI 0.53 to 0.84). Three trials evaluating PN were included in a meta-analysis and a significant reduction in post-operative complications was demonstrated (RR 0.64 95% CI 0.46 to 0.87) with low heterogeneity, in predominantly malnourished participants. Two trials evaluating enteral nutrition (RR 0.79, 95% CI 0.56 to 1.10) and 3 trials evaluating standard oral supplements (RR 1.01 95% CI 0.56 to 1.10) were included, neither of which showed any difference in the primary outcomes. AUTHORS' CONCLUSIONS There have been significant benefits demonstrated with pre-operative administration of IE nutrition in some high quality trials. However, bias was identified which may limit the generalizability of these results to all GI surgical candidates and the data needs to be placed in context with other recent innovations in surgical management (eg-ERAS). Some unwanted effects have also been reported with components of IE nutrition in critical care patients and it is unknown whether there would be detrimental effects by administering IE nutrition to patients who could require critical care support after their surgery. The studies evaluating PN demonstrated that the provision of PN to predominantly malnourished surgical candidates reduced post-operative complications; however, these data may not be applicable to current clinical practice, not least because they have involved a high degree of 'hyperalimentation'. Trials evaluating enteral or oral nutrition were inconclusive and further studies are required to select GI surgical patients for these nutritional interventions.
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Affiliation(s)
- Sorrel Burden
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
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133
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Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KCH, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CHC. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2012; 37:240-58. [DOI: 10.1007/s00268-012-1771-1] [Citation(s) in RCA: 276] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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The role of the enteral route and the composition of feeds in the nutritional support of malnourished surgical patients. Nutrients 2012; 4:1230-6. [PMID: 23112911 PMCID: PMC3475233 DOI: 10.3390/nu4091230] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 08/21/2012] [Accepted: 08/27/2012] [Indexed: 12/22/2022] Open
Abstract
In surgical patients, malnutrition is an important risk factor for post-operative complications. In undernourished patients undergoing major gastrointestinal procedures, preoperative enteral nutrition (EN) should be preferred whenever feasible. It may be given either orally or by feeding tubes, depending on patient compliance. Early oral intake after surgery should be encouraged, but if an insufficient postoperative oral intake is anticipated, tube feeding should be initiated as soon as possible. The use of immunomodulating formulas offers significant advantages when compared to standard feeds and the positive results on postoperative complications seem independent from the baseline nutritional status. In malnourished patients, the optimal timing and dose of immunonutrition is unclear, but consistent data suggest that they should be treated peri-operatively for at least two weeks.
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Abstract
PURPOSE OF REVIEW In the last year, several meta-analyses focused on the potential clinical benefits of perioperative immunonutrition in surgical patients. Purpose of this review is to summarize their results and to draw recommendations about the current indication of immunonutrition in surgery. RECENT FINDINGS Standard enteral preparations have been modified by adding specific nutrients, such as arginine, omega-3 fatty acids and others, which have been shown to upregulate immune response, to control inflammatory response, and to improve gut function after surgery. The majority of the randomized trials found that perioperative immunonutrition improved short-term outcome in patients, who underwent elective major gastrointestinal (GI) surgery. Four meta-analyses including a large number of randomized clinical trials reported that perioperative immunonutrition is associated with a substantial reduction in both infection rate and length of hospital stay. These results have been found in both upper and lower GI patients, regardless of their baseline nutritional status. Promising results have been found also in head and neck surgery. SUMMARY In the light of these findings the use of perioperative immunonutrition should be implemented in patients undergoing elective major GI surgery. This should result in a considerable reduction in both postoperative morbidity and costs for healthcare systems.Larger trials are required before recommending immunonutrition as a routine practice in head and neck surgery.
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Affiliation(s)
- Marco Braga
- Professor of Surgery, San Raffaele University, Milan, Italy.
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136
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Abstract
Malnutrition and weight loss negatively affect outcomes in surgical cancer patients. Decades of research have sought to identify the most appropriate use of nutrition support in these patients. National and international guidelines help to direct clinicians' use of nutrition support in surgical patients, but a number of specific issues concerning the use of nutrition support continue to evolve. This review focuses on 5 key issues related to perioperative nutrition support in cancer patients: (1) Which perioperative cancer patients should receive nutrition support? (2) How can the nutrition status and requirements of these patients be optimally assessed? (3) What is the optimal route of administration (parenteral nutrition vs enteral nutrition) and composition of nutrition support in this setting? (4) When should feedings be initiated? (5) What is the role of glycemic control in these patients?
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Affiliation(s)
- Maureen B Huhmann
- Department of Nutritional Science, University of Medicine and Dentistry of New Jersey, Newark, NJ 07107, USA.
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137
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Mauskopf JA, Candrilli SD, Chevrou-Séverac H, Ochoa JB. Immunonutrition for patients undergoing elective surgery for gastrointestinal cancer: impact on hospital costs. World J Surg Oncol 2012; 10:136. [PMID: 22770421 PMCID: PMC3506456 DOI: 10.1186/1477-7819-10-136] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 06/18/2012] [Indexed: 11/27/2022] Open
Abstract
Background Oral or enteral dietary supplementation with arginine, omega 3 fatty acids and nucleotides (known as immunonutrition) significantly improve outcomes in patients undergoing elective surgery. The objective of the study was to determine the impact on hospital costs of immunonutrition formulas used in patients undergoing elective surgery for gastrointestinal cancer. Methods US hospital costs of stay with and without surgical infectious complications, and average cost per day in the hospital for patients undergoing elective surgery for gastrointestinal cancer were estimated using data from the Healthcare Cost and Utilization Project’s 2008 Nationwide Inpatient Sample. These costs were then used to estimate the impact of perioperative immunonutrition on hospital costs using estimates of reduction in infectious complications or length of stay from a meta-analysis of clinical trials in patients undergoing elective surgery for gastrointestinal cancer. Sensitivity of the results to changes in baseline complication rates or length of stay was tested. Results From the meta-analysis estimates, use of immunonutrition resulted in savings per patient of $3,300 with costs based on reduction in infectious complication rates or $6,000 with costs based on length of hospital stay. Cost savings per patient were present for baseline complication rates above 3.5% or when baseline length of stay and infectious complication rates were reduced to reflect recent US data for those with upper and lower GI elective cancer surgery (range, $1,200 to $6,300). Conclusions Use of immunonutrition for patients undergoing elective surgery for gastrointestinal cancer is an effective and cost-saving intervention.
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138
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Donnellan CF, Lal S. The future developments in nutrition. Frontline Gastroenterol 2012; 3:i28-i32. [PMID: 28839689 PMCID: PMC5551954 DOI: 10.1136/flgastro-2012-100137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 02/28/2012] [Indexed: 02/04/2023] Open
Abstract
Malnutrition is both a cause and consequence of disease. It is imperative that evidence-based approaches to detect and treat malnutrition are embedded into routine practice; these can range from routine malnutrition screening, the safe and appropriate use of enteral feeding and managing more complex patients with intestinal failure. This article outlines service developments over the next 5 years that may enable all hospitals to achieve optimal standards of care for a malnourished patient and examines the role of developments in clinical nutrition over the next 5-10 years.
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Affiliation(s)
- C F Donnellan
- Department of Gastroenterology, St James's University Hospital, Leeds, UK
| | - S Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
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A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery. Ann Surg 2012; 255:1060-8. [PMID: 22549749 DOI: 10.1097/sla.0b013e318252edf8] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Immune modulating nutrition (IMN) has been shown to reduce complications after major surgery, but strong evidence to recommend its routine use is still lacking. OBJECTIVE The aim of this meta-analysis was to evaluate the impact of IMN combinations on postoperative infectious and noninfectious complications, length of hospital stay, and mortality in patients undergoing major open gastrointestinal surgery. METHODS Randomized controlled trials published between January 1980 and February 2011 comparing isocaloric and isonitrogenous enteral IMN combinations with standard diet in patients undergoing major open gastrointestinal surgery were included. The quality of evidence and strength of recommendation for each postoperative outcome were assessed using the GRADE approach and the outcome measures were analyzed with RevMan 5.1 software (Cochrane Collaboration, Copenhagen, Denmark). RESULTS Twenty-six randomized controlled trials enrolling 2496 patients (1252 IMN and 1244 control) were included. The meta-analysis suggests strong evidence in support of decrease in the incidence of postoperative infectious [risk ratio (RR) (95% confidence interval [CI]): 0.64 (0.55, 0.74)] and length of hospital stay [mean difference (95% CI): -1.88 (-2.91, -0.84 days)] in those receiving IMN. Even though significant benefit was observed for noninfectious complications [RR (95% CI): 0.82 (0.71, 0.95)], the quality of evidence was low. There was no statistically significant benefit on mortality [RR (95% CI): 0.83 (0.49, 1.41)]. CONCLUSIONS IMN is beneficial in reducing postoperative infectious and noninfectious complications and shortening hospital stay in patients undergoing major open gastrointestinal surgery.
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140
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Hübner M, Cerantola Y, Grass F, Bertrand PC, Schäfer M, Demartines N. Preoperative immunonutrition in patients at nutritional risk: results of a double-blinded randomized clinical trial. Eur J Clin Nutr 2012; 66:850-5. [DOI: 10.1038/ejcn.2012.53] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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141
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Melchior JC, Jean-Claude M, Préaud E, Emmanuelle P, Carles J, Juliette H, Brami M, Michèle B, Duru G, Gérard D, Fontaine E, Eric F, Hébuterne X, Xavier H, Lukacs B, Bertrand L, Zazzo JF, Jean-Fabien Z, Panis Y, Yves P, Nitenberg G, Gérard N. Clinical and economic impact of malnutrition per se on the postoperative course of colorectal cancer patients. Clin Nutr 2012; 31:896-902. [PMID: 22608918 DOI: 10.1016/j.clnu.2012.03.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 03/19/2012] [Accepted: 03/24/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS To assess the medico-economic impact of malnutrition in patients who underwent surgery for colorectal cancer. METHODS We performed post-hoc analyses of data from the Alves et al. prospective study. Using standard criteria of malnutrition, 2 groups were created a posteriori: Well-nourished (WN) and Mal-nourished (MN) patients. The 2 groups were statistically adjusted for age, cancer status, and scheduled surgery. Individual costs were valued using the French National Cost Study. Postoperative morbidity, mortality, hospital length-of-stay (LOS), and discharge setting were compared. We defined 3 scenarios, the most accurate estimate and its upper and lower limits, to assess the economic impact of malnutrition. RESULTS 453 patients were included in the analyses. Complication and mortality rates were not significantly different between the 2 groups. MN patients had a mean LOS 3.41 days significantly longer than WN patients (p = 0.017). In MN patients, the cost of hospital stay was increased by around 3360 €, creating an annual impact of 10,159,436 € for French non-profit hospitals. CONCLUSIONS Malnutrition in colorectal cancer surgical patients is associated with an increased LOS resulting in significant budget impact. Further studies are needed to investigate this impact and the related cost-benefit of perioperative specialized nutritional support and implementation of the ERAS protocol in this homogeneous category of patients.
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Affiliation(s)
| | - Melchior Jean-Claude
- Acute Medicine Department, R. Poincaré Hospital, APHP, Garches, Versailles Saint-Quentin-en-Yvelines University, Medical School, EA 4497, France.
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142
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Worthington ML, Cresci G. Immune-modulating formulas: who wins the meta-analysis race? Nutr Clin Pract 2012; 26:650-5. [PMID: 22205552 DOI: 10.1177/0884533611425799] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Most agree that enteral nutrition is the ideal way to feed critically ill patients who have a functional gastrointestinal tract, but selecting the appropriate enteral formula can be difficult. Specifically, the use of immune-modulating diets has brought much excitement as well as debate. Literature to date presents both positive and potential adverse effects. To aid the clinician in the decision-making process, this article reviews the current research and recommendations regarding the use of immune-modulating diets.
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143
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Wehner S, Vilz TO, Stoffels B, Kalff JC. Immune mediators of postoperative ileus. Langenbecks Arch Surg 2012; 397:591-601. [PMID: 22382699 DOI: 10.1007/s00423-012-0915-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 01/24/2012] [Indexed: 02/08/2023]
Abstract
UNLABELLED CLINICAL BACKGROUND: In all patients undergoing abdominal surgery, a transient phase of interruption of bowel motility, named postoperative ileus (POI) occurs. POI is often accepted as an unavoidable "physiological" response and a self-limiting complication after surgery although it has a significant impact on patient morbidity with prolonged hospitalization and increased costs. Annual economic burden has been estimated as much as US $1.47 billion in the USA (Iyer et al. in J Manag Care Pharm 15(6):485-494, 2009). PATHOPHYSIOLOGY The pathophysiology has been elucidated within the last decades, demonstrating that both, neurogenic and inflammatory mechanisms are involved in response to the surgical trauma. It is now generally accepted that POI pathogenesis processes in two phases: a first neurogenic phase is accountable for the immediate postoperative impairment of bowel motility. This is followed by a second immunological phase that can last for days and mainly affects strength and length of POI. More recent findings demonstrate a bidirectional interaction between the nervous and the immune system, and this interaction significantly contributed to our present understanding of POI pathophysiology. Although nerval mechanisms have a significant impact in the early phase of POI, the contribution of the immune system and subsequently its manipulation has risen as the most promising strategy in prevention or treatment of the clinically relevant prolonged form of POI. AIMS The present manuscript will give an update on the inflammatory responses, the involved cell types, and participating immune mediators in POI.
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Affiliation(s)
- Sven Wehner
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany
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144
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Kuppinger D, Hartl WH, Bertok M, Hoffmann JM, Cederbaum J, Küchenhoff H, Jauch KW, Rittler P. Nutritional screening for risk prediction in patients scheduled for abdominal operations. Br J Surg 2012; 99:728-37. [PMID: 22362084 DOI: 10.1002/bjs.8710] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Increased risks related to surgery might reflect the nutritional status of some patients. Such a group might benefit from perioperative nutritional support. The purpose of this study was to identify the relative importance of nutritional risk screening along with established medical, anaesthetic and surgical predictors of postoperative morbidity and mortality. METHODS This prospective observational study enrolled consecutive eligible patients scheduled for elective abdominal operations. Data were collected on nutritional variables (body mass index, weight loss, food intake), age, sex, type and extent of operation, underlying disease, American Society of Anesthesiologists grade and co-morbidities. A modified composite nutritional screening tool (Nutritional Risk Screening, NRS 2002) currently recommended by European guidelines was used. Relative complication rates were calculated with multiple logistic regression and cumulative proportional odds models. RESULTS Some 653 patients were enrolled of whom 132 (20.2 per cent) sustained one or more postoperative complications. The frequency of this event increased significantly with a lower food intake before hospital admission. No other individual or composite nutritional variable provided comparable or better risk prediction (including NRS 2002). Other factors significantly associated with severe postoperative complications were ASA grade, male sex, underlying disease, extent of surgical procedure and volume of transfused red cell concentrates. CONCLUSION In abdominal surgery, preoperative investigation of feeding habits may be sufficient to identify patients at increased risk of complications. Nutritional risk alone, however, is not sufficient to predict individual risk of complications reliably.
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Affiliation(s)
- D Kuppinger
- Department of Surgery, University School of Medicine, Grosshadern Campus, Munich, Germany
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145
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Sultan J, Griffin SM, Di Franco F, Kirby JA, Shenton BK, Seal CJ, Davis P, Viswanath YKS, Preston SR, Hayes N. Randomized clinical trial of omega-3 fatty acid-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing oesophagogastric cancer surgery. Br J Surg 2012; 99:346-55. [PMID: 22237467 PMCID: PMC3625735 DOI: 10.1002/bjs.7799] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2011] [Indexed: 12/31/2022]
Abstract
Background Oesophagogastric cancer surgery is immunosuppressive. This may be modulated by omega-3 fatty acids (O-3FAs). The aim of this study was to assess the effect of perioperative O-3FAs on clinical outcome and immune function after oesophagogastric cancer surgery. Methods Patients undergoing subtotal oesophagectomy and total gastrectomy were recruited and allocated randomly to an O-3FA enteral immunoenhancing diet (IED) or standard enteral nutrition (SEN) for 7 days before and after surgery, or to postoperative supplementation alone (control group). Clinical outcome, fatty acid concentrations, and HLA-DR expression on monocytes and activated T lymphocytes were determined before and after operation. Results Of 221 patients recruited, 26 were excluded. Groups (IED, 66; SEN, 63; control, 66) were matched for age, malnutrition and co-morbidity. There were no differences in morbidity (P = 0·646), mortality (P = 1·000) or hospital stay (P = 0·701) between the groups. O-3FA concentrations were higher in the IED group after supplementation (P < 0·001). The ratio of omega-6 fatty acid to O-3FA was 1·9:1, 4·1:1 and 4·8:1 on the day before surgery in the IED, SEN and control groups (P < 0·001). There were no differences between the groups in HLA-DR expression in either monocytes (P = 0·538) or activated T lymphocytes (P = 0·204). Conclusion Despite a significant increase in plasma concentrations of O-3FA, immunonutrition with O-3FA did not affect overall HLA-DR expression on leucocytes or clinical outcome following oesophagogastric cancer surgery. Registration number: ISRCTN43730758 (http://www.controlled-trials.com). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- J Sultan
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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The Importance of Enteral Nutrition. Dysphagia 2012. [DOI: 10.1007/174_2012_578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Prins A, Visser J. Immunonutrition: a South African perspective. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2012. [DOI: 10.1080/16070658.2012.11734414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
PURPOSE OF REVIEW Postoperative sepsis is a major cause of surgical associated morbidity and mortality. Our goal is to describe its incidence, pathophysiology, and contributing factors. In addition, we will review preventive measures and treatment options that may possibly reduce its healthcare burden. RECENT FINDINGS We review epidemiologic data and clinical tools presented in multiple current studies, which may help lower incidence and improve outcome of postoperative sepsis. SUMMARY The incidence of postoperative sepsis has not declined over the past years, although mortality is trending downwards. Several biochemical and genetic markers may allow early diagnosis. Prevention and prompt treatment may lower mortality.
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Koo EGY, Lai LML, Choi GYS, Chan MTV. Systemic inflammation in the elderly. Best Pract Res Clin Anaesthesiol 2011; 25:413-25. [PMID: 21925406 DOI: 10.1016/j.bpa.2011.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 06/16/2011] [Indexed: 01/11/2023]
Abstract
Inflammation is an adaptive response to surgery. When the pro-inflammatory responses are unregulated and become over reactive, systemic inflammatory response syndrome may occur. Postoperative systemic inflammation is more common than is generally acknowledged and is observed in about 10-15% of elderly patients undergoing major surgery. Although the vast majority of systemic inflammation is related to infections, other important predisposing risk factors, such as extent of trauma and haemorrhage, should not be overlooked. Increased awareness, modification of risk factors and early recognition are the key elements in the management of systemic inflammation. Prompt resuscitation aiming to correct hypotension, hypovolaemia and tissue hypoxia may improve outcome. Future large prospective observational studies are needed to define the incidence, risk factors and impact of systemic inflammatory syndrome in the elderly surgical patients. A better understanding of the molecular events during the systemic inflammatory response syndrome is required for future development of specific immunotherapy.
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Affiliation(s)
- Emily G Y Koo
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region.
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150
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van der Meij BS, van Bokhorst-de van der Schueren MAE, Langius JAE, Brouwer IA, van Leeuwen PAM. n-3 PUFAs in cancer, surgery, and critical care: a systematic review on clinical effects, incorporation, and washout of oral or enteral compared with parenteral supplementation. Am J Clin Nutr 2011; 94:1248-65. [PMID: 21940600 DOI: 10.3945/ajcn.110.007377] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND n-3 (omega-3) Fatty acids (FAs) may have beneficial effects in patients with cancer or in patients who undergo surgery or critical care. OBJECTIVE Our aim was to systematically review the effects of oral or enteral and parenteral n-3 FA supplementation on clinical outcomes and to describe the incorporation of n-3 FAs into phospholipids of plasma, blood cells, and mucosal tissue and the subsequent washout in these patients. DESIGN We investigated the supplementation of n-3 FAs in these patients by using a systematic literature review. RESULTS In cancer, the oral or enteral supplementation of n-3 FAs contributed to the maintenance of body weight and quality of life but not to survival. We did not find any studies on parenteral supplementation of n-3 FAs in cancer. In surgical oncology, we did not find any studies on enteral supplementation of n-3 FAs. However, postoperative parenteral supplementation in surgical oncology may reduce the length of a hospital stay. For general surgery, we did not find any studies on enteral supplementation of n-3 FAs, and evidence on parenteral supplementation was insufficient. In critical care, enteral supplementation of n-3 FAs had beneficial effects on clinical outcomes; evidence on parenteral supplementation in critical care was inconsistent. The incorporation of n-3 FAs in plasma and blood cells was slower with enteral supplementation (4-7 d) than with parenteral supplementation (1-3 d). The washout was 5-7 d. CONCLUSIONS This review shows the beneficial effects of n-3 FA supplementation in cancer, surgical oncology, and critical care patients. Supplementation in these specific patient populations could be considered with the route of administration taken into account.
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Affiliation(s)
- Barbara S van der Meij
- Department of Nutrition and Dietetics, VU University Medical Center Amsterdam, Netherlands
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