Immunonutrition in gastrointestinal surgery

Perioperative Immunosuppressive Factors during Cancer Surgery: An Updated Review

Surgical excision of the primary tumor represents the most frequent and curative procedure for solid malignancies. Compelling evidence suggests that, despite its beneficial effects, surgery may impair immunosurveillance by triggering an immunosuppressive inflammatory stress response and favor recurrence by stimulating minimal residual disease. In addition, many factors interfere with the immune effectors before and after cancer procedures, such as malnutrition, anemia, or subsequent transfusion. Thus, the perioperative period plays a key role in determining oncological outcomes and represents a short phase to circumvent anesthetic and surgical deleterious factors by supporting the immune system through the use of synergistic pharmacological and non-pharmacological approaches. In line with this, accumulating studies indicate that anesthetic agents could drive both protumor or antitumor signaling pathways during or after cancer surgery. While preclinical investigations focusing on anesthetics' impact on the behavior of cancer cells are quite convincing, limited clinical trials studying the consequences on survival and recurrences remain inconclusive. Herein, we highlight the main factors occurring during the perioperative period of cancer surgery and their potential impact on immunomodulation and cancer progression. We also discuss patient management prior to and during surgery, taking into consideration the latest advances in the literature.

Synergistic effects of Ω-3 polyunsaturated fatty acid supplementation and programmed cell death protein 1 blockade on tumor growth and immune modulation in a xenograft model of esophageal cancer

BACKGROUND

Esophageal cancer, especially esophageal squamous cell carcinoma (ESCC), remains a significant global health challenge with limited survival rates. This study aimed to elucidate the combined effects of immune-modulating nutrition (IMN) with Ω-3 polyunsaturated fatty acid (PUFA) supplementation and anti-programmed cell death protein 1 (PD-1) treatment on tumor growth and immune responses in a xenograft model of ESCC.

METHODS

A total of 36 C57BL/6 mice were used to construct a xenograft model using the mouse esophageal cancer cell line AKR. Mice were subjected to treatment with anti- PD-1 antibody combined with either Ω-3 PUFA-rich or Ω-3 PUFA-deficient nutrition. Tumor growth, immune markers, cytokine profiles, and metabolic changes were evaluated.

RESULTS

The combination of anti-PD-1 and Ω-3 PUFA supplementation significantly inhibited tumor growth more effectively than anti-PD-1 treatment alone. Enhanced expression of immune markers PD-L1 and CD3 was observed in Ω-3 PUFA-fed mice. Additionally, compared with anti-PD-1 therapy and anti-PD-1 plus Ω-3 PUFA-deficient nutrition, Ω-3 PUFAs intensified alterations in key chemokines and cytokines, including elevated IL-12, IFN-γ, and GM-CSF levels, and reduced CXCL12 levels. However, Ω-3 PUFAs did not significantly alter the glycolysis and tryptophan metabolic program induced by anti-PD-1.

CONCLUSION

Our findings indicated the potential synergetic therapeutic benefits of combining anti-PD-1 treatment with Ω-3 PUFA supplementation in ESCC, which offered promising avenue for further research.

Efficacy of a new immunonutrition formula with extra virgin olive oil in the reduction of complications in surgeries of upper digestive tract tumors

Background

To demonstrate whether a nutritional supplement enriched with arginine, nucleotides, omega-3 fatty acids, and extra virgin olive oil reduces postoperative complications in patients with tumors in the upper digestive tract.

Methods

A randomized, controlled, double-blind, multicenter clinical trial, in which a new immunomodulatory formula with extra virgin olive oil was compared with a standard isoprotein and isoenergetic formula. Patients with gastric, esophageal or biliopancreatic tumors were recruited to receive two units of immunomodulatory formula or control, 5 days before the surgical intervention.

Results

A total of 119 patients were recruited. There was a significant reduction in the number of reinterventions (7.7 vs. 20.4%; p = 0.044) in the intervention group. There was a significant reduction in the development of fistulas in patients with phase angles >5.7°. Also, there were fewer readmissions after biliopancreatic surgeries (0.0 vs. 100%; p = 0.014). The length of hospital stay was similar between groups; however, with the immunomodulatory formula, the patients exhibited greater phase angle at the end of follow-up.

Conclusion

The immunomodulatory formula with extra virgin olive oil administered 5 days before surgery for stomach, esophageal and biliopancreatic tumors improved cellular health and reduced postoperative complications.Clinical trial registration: [https://clinicaltrials.gov/], identifier [NCT04027088].

Pharmaconutrition: Which substrates?

With the term "pharmaconutrition" or "immunonutrition" is intended the use of specific nutritional substrates having the ability of modulating specific mechanisms involved in several immune and inflammatory pathways. To achieve these goals, these substrates have to be administered with over physiologic dose. Glutamine and omega-3 polyunsaturated fatty acids, used as single substrate, did not show clear clinical advantages on solid endpoints such as postoperative complications. Despite several multiple substrate enteral feeds are available on the market, very few of them have been tested in randomized clinical trial to prove efficacy. The most extensive investigated formulation is a combination of arginine, omega-3 fatty acids, ribonucleic acid with or without glutamine. Several meta-analyses of randomized clinical trials have been conducted to compare the effects of enteral immunonutrition with control diets on post-surgical morbidity. The results consistently showed that the use of enteral multiple substrate formulas significantly reduced infectious complications and duration of hospitalization. In a more contemporary view, pharmaconutrition should be tested more accurately in the contest of enhanced recovery programs, during neoadjuvant chemotherapy, and in the prehabilitation setting.

Effect of preoperative immunonutrition on postoperative short-term clinical outcomes in patients with gastric cancer cachexia: a prospective randomized controlled trial

BACKGROUND

Although current guidelines(ESPEN guideline: Clinical nutrition in surgery and other guidelines) recommend preoperative immunonutrition for cachectic gastric cancer patients, the strength of the recommendation is weak, and the level of evidence is low. The benefits of preoperative immunonutrition still remain controversial.

PATIENTS AND METHODS

112 patients with gastric cancer cachexia were enrolled in the study and randomly assigned in a 1:1 ratio to receive either preoperative enteral immunonutrition support (IN, n = 56) or standard enteral nutrition support (SEN, n = 56). The primary endpoint was the incidence of infectious complications, and the secondary endpoints included the nutritional indicators, inflammatory markers, immune parameters, postoperative recovery and complications and gastrointestinal intolerance reactions.

RESULTS

The incidence of postoperative infectious complications(P = 0.040) and overall complications (P = 0.049)was significantly lower in the IN group compared to the SEN group. In terms of laboratory inflammatory indexes, patients in the IN group demonstrated significantly lower levels of white blood cells (WBC), C-reactive protein (CRP), and interleukin-6 (IL-6), as well as higher levels of lymphocytes (LYMPH) and immunoglobulin A (IgA), compared to patients in the SEN group, with statistically significant differences. In terms of clinical outcomes, the IN group had a shorter duration of antibiotic use (P = 0.048), shorter hospital stay (P = 0.018), and lower total hospital costs (P = 0.034) compared to the SEN group. The IN group also experienced significantly less weight loss after surgery (P = 0.043).

CONCLUSION

Preoperative administration of immunonutrition formula has a positive impact on the incidence of infectious complications in patients with gastric cancer cachexia after surgery. It improves patients' inflammatory and immune status, shortens hospital stays, and reduces healthcare costs. Preoperative use of immunonutrition may contribute to the improvement of prognosis in this high-risk population.

Improving geriatric outcomes through nutritional and immunonutritional strategies: Focus on surgical setting by a comprehensive evidence review

The aging population worldwide has led to an increased request for surgical interventions in older, geriatric, and frail patients. However, all the physiological changes related to aging are associated with many challenges in the perioperative period, strongly impacting surgical outcomes. Nutritional status plays a pivotal role in determining the resilience of older adults to surgical stress and their ability to recover postoperatively. It is well known that malnutrition, a prevalent concern in geriatrics, is linked to increased adverse outcomes, including morbidity and mortality. Recognizing the significance of preoperative nutritional screening, assessment, diagnosis, intervention, and monitoring is essential for optimizing surgical outcomes. In this context, immunonutrition, which involves the supplementation of specific nutrients to modulate immune responses, emerges as a promising strategy to mitigate the increased inflammatory response observed in geriatric surgical patients. This study reviews current literature on the impact of nutrition and immunonutrition on surgical outcomes in geriatrics, highlighting the potential benefits in terms of reduced complications, enhanced wound healing, and shortened hospital stays. Recognizing and addressing the specific nutritional needs of older persons undergoing surgery is essential for promoting successful surgical outcomes and improving overall quality of life in this vulnerable population.

Gut Microbiota and Critically Ill Patients: Immunity and Its Modulation via Probiotics and Immunonutrition

Critically ill patients have a hyper-inflammatory response against various offending injuries that can result in tissue damage, organ failure, and fatal prognosis. The origin of this detrimental, uncontrolled inflammatory cascade can be found also within our gut. In detail, one of the main actors is our gut microbiota with its imbalance, namely gut dysbiosis: learning about the microbiota's dysfunction and pathophysiology in the frame of critical patients is of crucial and emerging importance in the management of the systemic inflammatory response syndrome (SIRS) and the multiple organ dysfunction syndrome (MODS). Multiple pieces of evidence indicate that the bacteria that populate our gut efficiently modulate the immune response. Treatment and pretreatment with probiotics have shown promising preliminary results to attenuate systemic inflammation, especially in postoperative infections and ventilation performance. Finally, it is emerging how immunonutrition may exert a possible impact on the health status of patients in intensive care. Thus, this manuscript reviews evidence from the literature on gut microbiota composition, its derangement in critically ill patients, its pathophysiological role, and the described and emerging opportunities arising from its modulation.

Relevance of Dietary Supplement Use in Gastrointestinal-Cancer-Associated Cachexia

Cancer cachexia is a multi-organ syndrome with unintentional weight loss, sarcopenia, and systemic inflammation. Gastrointestinal (GI) cancer patients are more susceptible to cachexia development due to impaired nutrient absorption and digestion. Given the widespread availability and relatively low cost of dietary supplements, we examined the evidence and effects of fish oil (omega-3 fatty acids), melatonin, probiotics, and green tea for managing symptoms of GI cancer cachexia. A literature review of four specific supplements was conducted using PubMed, Google Scholar, and CINAHL without a date restriction. Of 4621 available literature references, 26 articles were eligible for review. Fish oil decreased C-reactive protein and maintained CD4+ cell count, while melatonin indicated inconsistent findings on managing cachexia, but was well-tolerated. Probiotics decreased serum pro-inflammatory biomarkers and increased the tolerability of chemotherapy by reducing side effects. Green tea preparations and extracts showed a decreased risk of developing various cancers and did not impact tumor growth, survival, or adverse effects. Among these four supplements, probiotics are most promising for further research in preventing systemic inflammation and maintaining adequate absorption of nutrients to prevent the progression of cancer cachexia. Supplements may benefit treatment outcomes in cancer cachexia without side effects while supporting nutritional and therapeutic needs.

Is preoperative hypoalbuminemia or hypoproteinemia a reliable marker for anastomotic leakage risk in patients undergoing elective colorectal surgery in an enhanced recovery after surgery (ERAS) program?

PURPOSE

Preoperative hypoalbuminemia has traditionally been used as a marker of nutritional status and is considered a significant risk factor for anastomotic leak (AL).

METHODS

The Westmead Enhanced Recovery After Surgery (WERAS) prospectively collected database, consisting of 361 patients who underwent colorectal surgery with primary anastomosis, was interrogated. Preoperative serum albumin and protein levels (measured within 1 week of surgery) were plotted on receiver operating characteristic curves (ROC curves) and statistically analyzed for cutoff values, sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV).

RESULTS

The incidence of AL was 4.4% (16/361). Overall mortality was 1.4% (5/361), 6.3% (1/16) in the AL group, and 1.2% (4/345) in the no AL group. The median preoperative albumin and protein level in the AL group were 39 g/L and 75 g/L, respectively. The median preoperative albumin and protein level in the no AL group were 38 g/L and 74 g/L, respectively. The Mann-Whitney U test showed no statistically significant difference in albumin levels (p = 0.4457) nor protein levels (p = 0.6245) in the AL and no AL groups. ROC curves demonstrated that preoperative albumin and protein levels were not good predictors of anastomotic leak. Cutoff values for albumin (38 g/L) and protein (75 g/L) both had poor PPV for AL (4.8% and 3.8% respectively).

CONCLUSION

In patients undergoing elective colorectal surgery as part of an ERAS program, preoperative serum albumin and protein levels are not reliable in predicting AL. This may be because of nutritional supplementation provided as part of an ERAS program may correct nutritional deficits to protect against AL or that low albumin/protein is not as robust a marker of AL as previously reported.

Contemporary association of preoperative malnutrition and outcomes of hiatal hernia repairs in the United States

BACKGROUND

Hypoalbuminemia has been used as a surrogate for malnutrition and is associated with worse postoperative outcomes across major operations. Because patients with hiatal hernia often have inadequate caloric intake, we examined the association of serum albumin levels with outcomes after hiatal hernia repair.

METHODS

Adults undergoing elective and non-elective hiatal hernia repair via any approach were tabulated from the 2012 to 2019 National Surgical Quality Improvement Program. Patients were stratified into the Hypoalbuminemia cohort if serum albumin <3.5 mg/dL using restricted cubic spline analysis. Major adverse events were defined as a composite of all-cause mortality and major complications per the American College of Surgeons National Surgical Quality Improvement Program risk calculator. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were then constructed to assess the association of preoperative albumin with major adverse events, postoperative length of stay, and 30-day readmission.

RESULTS

Of 23,103 patients, 11.7% comprised the Hypoalbuminemia cohort. The Hypoalbuminemia group was older, less commonly of White race, and less likely to have an independent functional status than others. They were also more likely to undergo inpatient, non-elective surgery via laparotomy. After entropy balancing and adjustment, hypoalbuminemia remained associated with increased odds of major adverse events and multiple complications and longer adjusted postoperative length of stay. There was no significant difference in adjusted odds of readmission.

CONCLUSION

We used a quantitative methodology to establish a serum albumin threshold of 3.5 mg/dL associated with increased adjusted odds of major adverse events, increased postoperative length of stay, and postoperative complications after hiatal hernia repair. These results may guide preoperative nutrition supplementation.

Perioperative nutrition for gastrointestinal surgery: On the cutting edge

Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.

The Impact of Peri-operative Enteral Immunonutrition on Post-operative Complications in Gastrointestinal Cancer Surgery: A Meta-Analysis

BACKGROUND

Immunonutrition (IMN) in gastrointestinal (GI) cancer surgery remains under-utilised and contentious. Despite previous meta-analysis reporting benefit, most recent randomised control trials (RCTs) have failed to demonstrate this and have recommended against its routine use. A contemporary meta-analysis may contribute to the recommendations for immunonutrition use and help select which patients may benefit. The objective of this study was to review IMN and its impact on post-operative outcomes in GI cancer surgery, exploring its role in both malnourished and non-malnourished populations, the optimal dose to use, cancer type of patients using IMN and the timing of IMN relative to the peri-operative period.

PATIENTS AND METHODS

The EMBASE and Medline databases were searched from 2000 to 2022 for RCTs evaluating IMN in adults undergoing GI cancer surgery.

RESULTS

Thirty-seven studies were included (22 pre-operative IMN studies, 11 peri-operative IMN trials and 9 post-operative IMN trials; 4 trials had multiple IMN protocols) that reported on 3793 patients. The main outcome of post-operative infectious complications was reduced with IMN [odds ratio (OR) 0.58, 95% confidence interval (CI) 0.47-0.72]. This association was significant in subgroup analysis only with pre-operative and peri-operative administration and in trials including upper GI cancers, colorectal cancer and 'mixed GI' cancer populations, and significance was independent of nutritional status. IMN in pooled analysis reduced surgical site infection (SSI) (OR 0.65, 95% CI 0.52-0.81), anastomotic leak (OR 0.67, 95% CI 0.47-0.93) and length of stay (LOS) by 1.94 days (95% CI - 3 to - 0.87).

CONCLUSION

Immunonutrition was associated with reduced post-operative complications. Peri-operative administration may be the preferred strategy in reducing infectious complications, anastomotic leak, SSI and LOS.

Impact of Preoperative Immunonutrition on Oxidative Stress and Gut Barrier Function in Surgical Patients with Crohn's Disease

Several international guidelines recommend a peri-operative immunonutrition (IN) support for patients care in elective colorectal surgery, to reduce postoperative complications, particularly infections. In Crohn's patients, is also used to mitigate the severity of the disease. We performed a pilot study on 16 Crohn's patients undergoing intestinal surgery for active disease, not responsive to pharmacological treatment; half of them received an oral nutritional supplement enriched with immunonutrients (IN patients) for 7 days prior to surgery, in addition to normal food intake. Markers of oxidative stress (Advanced Glycated End-products (AGEs) and Advanced Oxidation Protein Products (AOPPs) were measured both in plasma and tissue samples wherein the Receptor for Advanced Glycation End products (RAGE) and Tight Junction Protein 1 (TJP1) gene expression were also determined. Plasma AGEs were significantly and positively correlated with tissue levels of AGEs (p = 0.0354) and AOPPs (p = 0.0043) while they were negatively correlated with TJP1 expression (p = 0.0159). The expression of RAGE was also negatively correlated with that of TJP1 gene (p = 0.0146). IN patients exhibited significantly lower AGEs plasma levels (p = 0.0321) and a higher mucosal TJP1 expression (p = 0.0182). No patient had postoperative complications and the length of hospital stay was similar in the two groups, but IN patients, showed a significantly shorter time to resume fluid and solid diet. These preliminary data suggest that IN might support patient's recovery by improving intestinal mucosa barrier function through the regulation of AGEs/RAGE signaling.

Assessment of the Predictive Value of Preoperative Serum Albumin and Postoperative Albumin Drop (ΔAlb) for Complications after Pancreas Surgery: A Single-Center Cross-Sectional Study

BACKGROUND

Serum albumin has been shown to be predictive of complications after various gastrointestinal operations. The present study aimed to assess whether preoperative serum albumin and serum albumin drop on postoperative day 1 are associated with postoperative complications after pancreatic surgery.

METHODS

A single-center cross-sectional study was performed. All patients who underwent pancreatectomy between January 2010 and June 2019 and had preoperative serum albumin value and serum albumin value on postoperative day 1 were included. ΔAlb was defined as the difference between preoperative serum albumin and serum albumin on postoperative day 1. Binary logistic regressions were performed to determine independent predictors of postoperative complications.

RESULTS

A total of 185 patients were included. Pancreatoduodenectomies were performed in 133 cases, left pancreatectomies in 36, and other pancreas operations in 16. The preoperative serum albumin value was found to be an independent predictor of complications (OR 0.9, 95%CI 0.9-1.0, p = 0.041), whereas ΔAlb was not significantly associated with postoperative complications (OR 1.0, 95%CI 0.9-1.1, p = 0.787). The threshold of 44.5 g/L for preoperative albumin level was found to have the highest combined sensitivity and specificity based on the maximum Youden index. Patients with preoperative albumin < 44.5 g/L had a higher incidence of postoperative complications and higher median comprehensive complication index than patients with preoperative albumin ≥ 44.5 g/L.

CONCLUSIONS

This study highlighted that preoperative serum albumin is an independent predictor of postoperative complications after pancreas surgery.

Paving the Path for Immune Enhancing Nutrition in Colon Cancer: Modulation of Tumor Microenvironment and Optimization of Outcomes and Costs

INTRODUCTION

Published evidence suggests that immunonutrition has the potential to decrease postoperative complications and reduce length of stay in patients undergoing surgery for colorectal cancer. However, only a few studies have analyzed the effects of immunonutrition on tumor microenvironment and evaluated its prognostic impact.

MATERIAL AND METHODS

This is a single center retrospective study enrolling 50 patients undergoing elective surgery for colorectal cancer managed with immunonutrition and 50 patients managed with standard nutrition for comparison. Tumor microenvironment was analyzed before (on the biopsy at the time of diagnosis) and after (on the matched surgical specimen) administration of immunonutrition. Immune function related indicators, including cytotoxic T-lymphocytes, helper T-cells, antigen presenting cells, natural killer cells, T-exhausted lymphocytes, T-regulatory cells, M1 and M2 tumor associated macrophages and PD-L1 expression were assessed by immunohistochemistry. For both groups, clinicopathological data were collected and a 5-year follow-up was available.

RESULTS

We found that immunonutrition significantly activated the T-cell response against cancer, alter tumor microenvironment phenotype towards M2 polarization and inhibits the PD1/PD-L1 axis. A lower rate of postoperative complications and a shorter length of stay (p = 0.04) were observed in the immune nutrition group. Compared to standard nutrition group, patients managed wit immune nutrition showed a higher 5-year overall survival (p = 0.001). Finally, immune nutrition allowed to reduce the hospital care costs.

CONCLUSIONS

Immunonutrition modulates tumor microenvironment by improving immune function and could prolong survival in patients undergoing elective surgery for colorectal cancer. Further studies are needed to optimize IN protocols and confirm their prognostic impact.

Immunonutrition reduces complications rate and length of stay after laparoscopic total gastrectomy: a single unit retrospective study

BACKGROUND

Preoperative immunonutrition (IN) reduces the incidence of postoperative complications in malnourished patients undergoing upper gastrointestinal surgery. However, its effect in norm-nourished patients remains unclear. Furthermore, patients with gastric cancer undergoing laparoscopic total gastrectomy (LTG) are not routinely included in protocols of enhanced recovery after surgery (ERAS).

OBJECTIVE

The aim of this study was to investigate the effects of perioperative IN in patients undergoing laparoscopic total gastrectomy (LTG) within an established ERAS pathway.

METHODS

A comparative retrospective study of patients undergoing LTG, receiving an immune-enhancing feed plus maltodextrin load the day of surgery (Group A) versus patients who had the same operation but no IN nor fast track management (group B).

RESULTS

There were no significant differences in patient demographic characteristics between the two groups but the medium age of patients in group A was older. Thirty-days postoperative complications were respectively 8.7% in Group A and 33.3% in Group B (p 0.04). Mean and median LOS for Group A and B were also significantly different: 7.2 ± 4.4 vs 10.3 ± 5.4 and 7 vs 10 days respectively.

CONCLUSION

Preoperative IN associated with ERAS protocol in normo-nourished patient undergoing LTG seems to reduce postoperative complications. Reduction in LOS is possibly associated to the ERAS protocol. Clinical trial registration Clinical trials.gov: NCT05259488.

Prognostic Factors Affecting Short- and Long-Term Outcomes of Gastrectomy for Gastric Cancer in Older Patients

INTRODUCTION

The benefits of surgery in older patients with gastric cancer are controversial. This single-institution retrospective study in Japan aimed to evaluate the impact of gastrectomy in older patients with gastric cancer.

METHODS

A series of 234 patients aged ≥80 years with histologically confirmed gastric cancer had indications for surgical treatment at the Gastroenterological Center, Yokohama City University Medical Center, between April 2002 and December 2018. Patients who were lost to follow-up (n = 27), had tumors not eligible for surgery (n = 14), and could not achieve R0 resection (n = 7) were excluded from this retrospective study. The remaining 186 patients were included. Patient characteristics, intraoperative outcomes, postoperative complications, and long-term survival were evaluated.

RESULTS

The incidence of postoperative complications with Clavien-Dindo grade ≥ II was observed in 61 patients (32.8%). The 5-year relapse-free survival and overall survival (OS) rates were 84.2% and 63.4%, respectively. Multivariate analysis showed that geriatric nutritional risk index (<98) (odds ratio, 1.97; p = 0.047), neutrophil/lymphocyte ratio (>2.36) (odds ratio, 1.94; 95% confidence interval, 1.02-3.67; p = 0.043), and total gastrectomy (TG) (odds ratio, 1.97; p = 0.042) significantly predicted postoperative complications. Moreover, TG (hazard ratio, 1.91; p = 0.036) was an independent prognostic factor of OS.

CONCLUSIONS

Poor immunonutritional status and TG led to worse short-term outcomes. Moreover, TG was an independent prognostic factor of OS in older patients with gastric cancer. It is necessary to provide effective perioperative care, including nutritional support, to clarify whether short-term outcomes would be improved.

Perioperative Nutritional Support: A Review of Current Literature

Since the beginning of the practice of surgery, the reduction of postoperative complications and early recovery have been two of the fundamental pillars that have driven the improvement of surgical techniques and perioperative management. Despite great advances in these fields, the rationalization of antibiotic prophylaxis, and other important innovations, postoperative recovery (especially in elderly patients, oncological pathology or digestive or head and neck surgery) is tortuous. This can be explained by several reasons, among which, malnutrition has a major role. Perioperative nutritional support, included within the ERAS (Enhanced Recovery After Surgery) protocol, has proven to be a main element and a critical step to achieve better surgical results. Starting with the preoperative nutritional assessment and treatment in elective surgery, we can improve nutritional status using oral supplements and immunomodulatory formulas. If we add early nutritional support in the postoperative scenario, we are able to significantly reduce infectious complications, need for intensive care unit (ICU) and hospital stay, costs, and mortality. Throughout this review, we will review the latest developments and the available literature.

Preoperative Nutritional Optimization of the Oncology Patient: A Scoping Review

BACKGROUND

Malnutrition is common among patients with cancer and is a known risk factor for poor postoperative outcomes; however, preoperative nutritional optimization guidelines are lacking in this high-risk population. The objective of this study was to review the evidence regarding preoperative nutritional optimization of patients undergoing general surgical operations for the treatment of cancer.

METHODS

A literature search was performed across the Ovid (MEDLINE), Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCOhost), and Web of Science (Clarivate) databases. Eligible studies included randomized clinical trials, observational studies, reviews, and meta-analyses published between 2010 and 2020. Included studies evaluated clinical outcomes after preoperative nutritional interventions among adult patients undergoing surgery for gastrointestinal cancer. Data extraction was performed using a template developed and tested by the study team.

RESULTS

A total of 5,505 publications were identified, of which 69 studies were included for data synthesis after screening and full text review. These studies evaluated preoperative nutritional counseling, protein-calorie supplementation, immunonutrition supplementation, and probiotic or symbiotic supplementation.

CONCLUSIONS

Preoperative nutritional counseling and immunonutrition supplementation should be considered for patients undergoing surgical treatment of gastrointestinal malignancy. For malnourished patients, protein-calorie supplementation should be considered, and for patients undergoing colorectal cancer surgery, probiotics or symbiotic supplementation should be considered.

Impact of Preoperative Immunonutritional Support in Patients Undergoing Elective Thoracic Surgery

Introduction:

Several immunonutritional supplements have recently been developed. However, improvements in preoperative immunonutritional conditions using these supplements have not been analyzed in patients undergoing thoracic surgery.

Methods:

This prospective, single-arm, single-institution pilot study involved patients planning to undergo thoracic surgery. Forty adults with a poor preoperative immunonutritional status were enrolled. The patients freely selected one of three oral immunonutritional supplements (IMPACT^Ⓡ, MEIN^Ⓡ, or Abound^Ⓡ) and started taking it on an outpatient basis from 7 to 14 days before thoracic surgery. The primary endpoint was the rate of improvement in three immunonutritional parameters on the hospitalization day: body mass index (BMI), prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI). These improvement rates were compared with those of a matched historical control group.

Results:

The PNI and GNRI improvement rates were significantly higher in the immunonutritional support group than in the control group (PNI: 103.1% ± 0.6% vs. 98.9% ± 1.3%, p = 0.0391; GNRI: 101.7% ± 0.8% vs. 99.3% ± 0.8%, p = 0.0266), although there was no significant difference in the BMI improvement rate (101.0% ± 0.6% vs. 100.2% ± 0.7%, p = 0.3626). The PNI and GNRI improvement rates were significantly higher in the IMPACT^Ⓡ support group than in the control group (PNI: 104.5% ± 2.4% vs. 98.9% ± 1.3%, p = 0.0212; GNRI: 101.6% ± 1.1% vs. 99.3% ± 0.8%, p = 0.0415).

Conclusions:

The present study revealed that short-term preoperative immunonutritional support can actually improve immunonutritional parameters immediately before surgery. In particular, preoperative immunonutritional support using IMPACT^Ⓡ supplementation might be the most promising agent in patients with a poor immunonutritional condition undergoing elective thoracic surgery.

Trial registration:

University Hospital Medical Information Network 000035851

ESPEN practical guideline: Clinical nutrition in surgery

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Clinical, randomized, double blind clinical trial to study the effect of parenteral supplementation with fish oil emulsion in the nutritional support in esophagectomized patients

INTRODUCTION

Esophagectomy is a major surgery with a high degree of catabolic and post-surgical inflammatory response accompanied by high morbidity and significant mortality. Post-surgical nutritional support via enteral administration of ω-3 fatty acids has been seen to be effective although its bad tolerance. There are few clinical trials with parenteral ω-3 fatty acids in these patients. We propose to investigate the effect of combining a parenteral fish oil lipid emulsion with the standard enteral nutrition (EN) support.

MATERIALS AND METHODS

Prospective, single-center, randomized, double-blind study in esophagectomized patients, and treated after surgery with parenteral lipid emulsions of ω-3 fatty acids or a mixture of ω-6 long-chain triglycerides/short-chain triglycerides 50%. These emulsions will be added to the standard nutritional support in continuous infusion until 5 days of treatment have been completed. Patients will be randomized 1:1:1 in Group A receiving 0.4 g/kg/d of fish-oil lipid emulsion and 0.4 g/kg/d of a lipid emulsion mixture of ω-6 long-chain fatty acids (LCT) plus medium-chain fatty acids (MCT) (total dose of 0.8 g/kg/d of lipid emulsion); Group B receiving 0.8 g/kg/d of fish oil lipid emulsion and Group C receiving 0.8 g/kg/d of LCT/MCT emulsion.The main objective is to determine whether 5 days administration of intravenous ω-3 fatty acid lipid emulsion is effective in normalizing interleukin-6 levels compared with LCT/MCT emulsions, and whether a 0.8 g/kg/d dose is more effective than 0.4 g/kg/d. Secondary outcomes include other inflammatory markers such as C-reactive protein, tumor necrosis factor alpha and interleukin-10, and parameters of morbidity, safety, nutrition and mortality.Samples will be collected at the time when surgery is indicated and on days 0, 1, 3, 5 and 21 to determine inflammatory, nutritional, hepatic and safety parameters. In addition, clinical follow-up will be continued throughout the hospital admision and up to 1 year after surgery.

DISCUSSION

Studies of ω-3 fatty acids administered parenterally in esophagectomized patients are scarce. This study proposes to investigate the effect of combining fish-oil lipid emulsions administered parenterally with EN support. Potential benefits include fast incorporation of lipids to the cellular membranes and to the inflammatory cascade, and the use of only 1 pharmaconutrient.

TRIAL REGISTRATION

FAR-NP-2017-01 EudraCT number: 2016-004978-17.https://reec.aemps.es/reec/public/detail.html searching the EudraCT number.

VERSION IDENTIFIER

Version 2, 08/06/2017.

Perioperative immunonutrition in hepatectomy: A systematic review and meta-analysis

Backgrounds/Aims

The role of immunonutrition (IMN) after liver resections or hepatectomies remains unclear and controversial. We undertook a systematic review to evaluate the effects of IMN on clinical outcomes of patients undergoing hepatectomy.

Methods

Main electronic databases were searched for randomised trials reported clinical outcomes or effects of IMN. The systematic review was conducted in accordance with the PRISMA guideline and meta-analysis was analysed using fixed or random-effects models.

Results

Eleven RCTs were identified. A total of 1084 patients (529 IMN and 555 Control) were included in the final pooled analysis. Of these patients, 43% (440/1016) underwent major hepatectomies and the majority are for hepatocellular carcinoma (90%, 956/1055) with Child-Pugh A disease (89%, 793/894). IMN significantly reduced post-operative wound infection (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.43 to 0.96; p=0.03). IMN also had a shorter hospital stay (MD -4.97 days, 95% CI -8.23 to -1.72; p=0.003). There was no statistically significant in other post-operative morbidities and mortality.

Conclusions

Wound infection rate was not significantly different between oral and parenteral IMN group. The length of hospital stay was significantly lower in parenteral IMN group than in oral IMN group. The mortality rates were not affected. Immunonutrition should be recommended routinely as part of the nutritional support in the Enhanced Recovery after Surgery (ERAS) protocol for hepatectomy.

Evidence-Based Perioperative Nutrition Recommendations: Optimizing Results and Minimizing Risks

Plastic surgery patients span the nutritional spectrum from generally healthy, nutritionally competent patients to inherently catabolic, nutritionally deficient, and chronic wound patients. Therefore, plastic and reconstructive surgery affords the opportunity to investigate the impact of nutrition across a heterogeneous patient population following a wide variety of procedures. Although patients may be nutritionally deficient in certain vitamins warranting perioperative repletion, other supplements have the potential to benefit all patients, regardless of nutritional status. Despite these putative benefits, there is a dearth of information regarding nutritional optimization, with the limited, available literature focusing mostly on herbal supplements and their potential side effects. A significant barrier to supplement use is the lack of education and available supporting information regarding the indications, contraindications, and physiology of these adjuncts. The goal of this article is to provide a comprehensive, evidence-based review of available nutritional supplements that can be considered for the plastic surgery patient in the perioperative period to optimize surgical outcomes while minimizing risk. Prospective, well-designed studies using validated, high-quality supplements will be critical in determining the significance that perioperative supplementation can have for surgical outcomes. Until well-done prospective studies are performed, the supplement, dose, and duration should be determined on an individual, patient-per-patient basis at the discretion of the operating surgeon.

Long-term outcomes after perioperative treatment with omega-3 fatty acid supplements in colorectal cancer

Background

This study aimed to evaluate the effect of perioperative supplementation with omega‐3 fatty acids (n‐3 FA) on perioperative outcomes and survival in patients undergoing colorectal cancer surgery.

Methods

Patients scheduled for elective resection of colorectal cancer between 2007 and 2010 were randomized to either an n‐3 FA‐enriched oral nutrition supplement (ONS) twice daily or a standard ONS (control) for 7 days before and after surgery. Outcome measures, including postoperative complications, 3‐year cumulative incidence of local or metastatic colorectal cancer recurrence and 5‐year overall survival, were compared between the groups.

Results

Of 148 patients enrolled in the study, 125 (65 patients receiving n‐3 FA‐enriched ONS and 60 receiving standard ONS) were analysed. There were no differences in postoperative complications after surgery (P = 0·544). The risk of disease recurrence at 3 years was similar (relative risk 1·66, 95 per cent c.i. 0·65 to 4·26).The 5‐year survival rate of patients treated with n‐3 FA was 69·2 (95 per cent c.i. 56·5 to 78·9) per cent, compared with 81·7 (69·3 to 89·4) per cent in the control group (P = 0·193). After adjustment for age, stage of disease and adjuvant chemotherapy, n‐3 FA was associated with higher mortality compared with controls (hazard ratio 1·73, 95 per cent c.i. 1·06 to 2·83; P = 0·029). The interaction between n‐3 FA and adjuvant chemotherapy was not statistically significant.

Conclusion

Perioperative supplementation with n‐3 FA did not confer a survival benefit in patients undergoing colorectal cancer surgery. n‐3 FA did not benefit the subgroup of patients treated with adjuvant chemotherapy or decrease the risk of disease recurrence.

Risk factors for postoperative pneumonia after general and digestive surgery: a retrospective single-center study

PURPOSE

Pneumonia is the second-most common complication in postoperative patients and is associated with significant morbidity and high costs of care. We aimed to determine the risk factors for pneumonia after general and digestive surgery.

METHODS

The medical records of 1,016 patients who underwent general and digestive surgery between January 2016 and March 2019 in our hospital were reviewed.

RESULTS

Of the 1,016 patients, 67 (6.6%) developed postoperative pneumonia. The multivariate analysis showed that significant predictors of postoperative pneumonia were a poor Eastern Cooperative Oncology Group performance status (ECOG-PS), low forced vital capacity and low forced expiratory volume in one second in the spirometry test, malnutrition (low serum albumin levels and low controlling nutritional status scores and prognostic nutritional index [PNI] values), esophagectomy, upper gastrointestinal surgery, and nonlaparoscopic surgery. Of these factors, the combination of PNI and ECOG-PS clearly stratified patients into low-, intermediate-, and high-risk groups with respect to developing postoperative pneumonia (area under the curve: 0.709).

CONCLUSIONS

Although postoperative pneumonia is associated with many clinical variables, active medical intervention for the prevention of pneumonia in patients with multiple risk factors can improve the postoperative course. In particular, perioperative nutritional care may prevent postoperative pneumonia in patients with malnutrition and a poor PS.

Effect of Preoperative Administration of Oral Arginine and Glutamine in Patients with Enterocutaneous Fistula Submitted to Definitive Surgery: a Prospective Randomized Trial

BACKGROUND

The use of glutamine and arginine has shown several advantages in postoperative outcomes in patients after gastrointestinal surgery. We determined the effects of its use in patients with enterocutaneous fistula after operative treatment.

PATIENTS AND METHODS

Forty patients with enterocutaneous fistula were randomly assigned to one of two groups. The control group received the standard medical care while the patients of the experimental group were supplemented with enteral administration of 4.5 g of arginine and 10 g of glutamine per day for 7 days prior to the surgery. The primary outcome variable was the recurrence of the fistula and the secondary outcomes were preoperative and postoperative serum concentrations of interleukin 6 and C-reactive protein and postoperative infectious complications.

RESULTS

Twenty patients were assigned to each group. The fistula recurred in two patients (10%) of the experimental group and in nine patients (45%) of the control group (P < 0.001). We found a total of 13 infectious complications in six patients of the control group (all with fistula recurrence) and none in the experimental group. Mean preoperative serum concentrations of interleukin 6 and C-reactive protein were lower in patients from the experimental group. In addition, these levels were lower in patients who had recurrence if compared to patients that did not recur.

CONCLUSION

Preoperative administration of oral arginine and glutamine could be valuable in the postoperative recovery of patients with enterocutaneous fistulas submitted to definitive surgery.

Preoperative immunonutrition in frail patients with colorectal cancer: an intervention to improve postoperative outcomes

PURPOSE

The aim of this study is to evaluate whether preoperative immunonutrition can shorten length of stay and improve postoperative outcomes in frail patients who are candidates for major oncologic colorectal surgery.

METHODS

A single center retrospective analysis of a prospectively collected database of frail patients, who underwent surgery with curative intent for colorectal cancer between January 2014 and December 2017, was performed. From March 2016, frail oncological patients undergoing major surgery were recommended to receive preoperative immunonutrition; their postoperative outcomes were compared to those of patients not treated with any preoperative nutritional support. Propensity score matching in a 1:1 ratio was used to balance patient characteristics.

RESULTS

Overall, 175 patients were included in the study. Of 74 patients receiving immunonutrition, 65 were matched with the group not treated with immunonutrition (n = 101). Baseline characteristics were comparable after matching. Although differences in postoperative length of stay were nonsignificant (p = 0.38), patients who received immunonutrition showed a shorter gastrointestinal (GI) recovery time (3.00 [2.00-4.00] versus 4.00 [2.00-5.00], p = 0.04), a lower rate of situs site infections complications (0.31 [0.10, 0.94], p = 0.04) and less need of antibiotic treatment (0.19 [0.06, 0.64], p = 0.01).

CONCLUSION

Preoperative immunonutrition was found to reduce both postoperative situs site infections and need of antibiotic treatment during the postoperative course. This study encourages the use of preoperative immune-enhancing nutrition as a part of multimodal prehabilitation programs in the management of frail colorectal cancer patients.

Preoperative lymphocyte-to-monocyte ratio predicts postoperative infectious complications after laparoscopic colorectal cancer surgery

BACKGROUND AND AIM

Postoperative infectious complications (POI), which can increase length of hospital stay, medical cost, and worsen overall survival, are a concern in minimally invasive colorectal cancer (CRC) surgeries. Recent reports showed that relatively new inflammation-based score, lymphocyte-to-monocyte ratio (LMR) is an independent predictor of long-term outcomes after CRC surgeries. In this study, LMR was evaluated as a predictor of short-term postoperative outcomes.

PATIENTS AND METHODS

This was a single-institutional retrospective study of 211 consecutive patients who had undergone laparoscopic CRC surgery with primary tumor resection from January 2014 to August 2015 at Nippon Medical School Chiba Hokusoh Hospital. The patients were divided into two groups (no POI; n = 176 and POI; n = 35). The associations between inflammation-based scores, namely neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and LMR, and the occurrence of POI were investigated. Receiving operator characteristic curve analysis was used to determine the cutoff point of preoperative LMR.

RESULTS

Low LMR (cut-off 3.46), long operative time, and smoking were found to be independent predictors of POI in a multivariate analysis (LMR: Odds ratio 5.61, 95% confidence interval 1.98-15.9, P = 0.001). Patients with low LMR also appeared to have more advanced and aggressive tumours.

CONCLUSION

This is the first study to report that the lower LMR is a predictive factor of POI after laparoscopic CRC surgery, and it may provide additional information for treatment decisions to prevent POI.

The Role of Malnutrition in Ninety-Day Outcomes After Total Joint Arthroplasty

BACKGROUND

Research has linked malnutrition to more complications in total joint arthroplasty (TJA) patients. The role of preoperative albumin in predicting length of stay (LOS) and 90-day outcomes remains understudied. Often, an albumin cut-off ≤3.5 g/dL is used as proxy for malnutrition, although this value remains understudied. This preoperative level may be missing some patients at risk for adverse events post TJA.

METHODS

TJA patients at a single institution from 2013 to 2018 were reviewed for preoperative albumin level. In total, 4047 cases (total knee arthroplasty: 2058; total hip arthroplasty: 1989) had available data, including 90-day readmissions, 90-day emergency department (ED) visits, and postoperative LOS.

RESULTS

About 5.6% experienced a readmission and 9.6% had at least one ED visit within 90 days. Overall prevalence of malnutrition was 3.6%, and this cohort experienced a longer average LOS (3.5 vs 2.2 days, P < .0001) and was more likely to experience a readmission (16% vs 5%, P < .0001) or ED visit (18% vs 9%, P = .0005). Additionally, albumin ≤3.5 g/dL was correlated with more frequent discharge to skilled nursing facility/rehab (30.8% vs 14.7%, P < .0001), increased risk for 90-day readmission with univariable (odds ratio [OR] 1.79, P < .0001) and multivariable logistic regression (OR 1.55, P < .0001), and increased risk for 90-day ED visits with univariable (OR 1.62, P < .0001) and multivariable regression (OR 1.35, P < .0001). The optimal albumin cut-off was 3.94 g/dL in a univariable model for 90-day readmission.

CONCLUSION

Screening for malnutrition may serve a role in preoperative evaluation. An albumin cutoff value of 3.5 g/dL may miss some at-risk patients.

The Impact of Preoperative Immunonutrition and Standard Polymeric Supplements on Patient Outcomes After Pelvic Exenteration Surgery, Taking Compliance Into Consideration: A Randomized Controlled Trial

BACKGROUND

The effect of immunonutrition vs standard polymeric nutrition in the preoperative phase on patient outcomes is still unclear, which could be due to contributing factors such as poorly reported compliance and unequal provision of protein, energy, and volume. The aim of this study was to examine the effects of preoperative immunonutrition compared with standard polymeric supplements matched for energy, protein, volume, length of stay, and postoperative complications in pelvic exenteration surgery, taking into consideration compliance.

METHODS

This was a single-blinded, randomized, controlled trial in patients undergoing pelvic exenteration surgery. Fifty-two participants were randomly assigned to consume 3 immunonutrition supplements/d for 5 days preoperatively, and 56 participants were randomly assigned to consume 3 standard polymeric supplements/d for 5 days preoperatively. Primary and secondary outcome measures were assessed. Compliance with each nutrition regime was recorded during the intervention, and subanalysis was conducted.

RESULTS

There was no significant difference between immunonutrition and standard polymeric supplements on length of stay (P = 0.988) or postoperative complications (P = 0.179) after pelvic exenteration surgery. Compliance with nutrition supplements was significantly less in malnourished (n = 33) compared with well-nourished participants (n = 74) (P = 0.016). Compliance varied between study groups, although not significant.

CONCLUSION

Preoperative immunonutrition did not significantly impact length of stay or postoperative complications compared with standard polymeric supplements after pelvic exenteration surgery, despite controlling for protein, energy, and volume. Compliance, protein, and energy may considerably impact the effect of immunonutrition, particularly in malnourished patients.

The Impact of Preoperative Immune Modulating Nutrition on Outcomes in Patients Undergoing Surgery for Gastrointestinal Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

To define the influence of preoperative immune modulating nutrition (IMN) on postoperative outcomes in patients undergoing surgery for gastrointestinal cancer.

BACKGROUND

Although studies have shown that perioperative IMN may reduce postoperative infectious complications, many of these have included patients with benign and malignant disease, and the optimal timing of such an intervention is not clear.

METHODS

The Embase, Medline, and Cochrane databases were searched from 2000 to 2018, for prospective randomized controlled trials evaluating preoperative oral or enteral IMN in patients undergoing surgery for gastrointestinal cancer. The primary endpoint was the development of postoperative infectious complications. Secondary endpoints included postoperative noninfectious complications, length of stay, and up to 30-day mortality. The analysis was performed using RevMan v5.3 software.

RESULTS

Sixteen studies reporting on 1387 patients (715 IMN group, 672 control group) were included. Six of the included studies reported on a mixed population of patients undergoing all gastrointestinal cancer surgery. Of the remaining, 4 investigated IMN in colorectal cancer surgery, 2 in pancreatic surgery, and another 2 in patients undergoing surgery for gastric cancer. There was 1 study each on liver and esophageal cancer. The formulation of nutrition used in all studies in the treated patients was Impact (Novartis/Nestlé), which contains ω-3 fatty acids, arginine, and nucleotides. Preoperative IMN in patients undergoing surgery for gastrointestinal cancer reduced infectious complications [odds ratio (OR) 0.52, 95% confidence interval (CI) 0.38-0.71, P < 0.0001, I = 16%, n = 1387] and length of hospital stay (weighted mean difference -1.57 days, 95% CI -2.48 to -0.66, P = 0.0007, I = 34%, n = 995) when compared with control (isocaloric isonitrogeneous feed or normal diet). It, however, did not affect noninfectious complications (OR 0.98, 95% CI 0.73-1.33, P = 0.91, I = 0%, n = 1303) or mortality (OR 0.55, 95% CI 0.18-1.68, P = 0.29, I = 0%, n = 955).

CONCLUSION

Given the significant impact on infectious complications and a tendency to shorten length of stay, preoperative IMN should be encouraged in routine practice in patients undergoing surgery for gastrointestinal cancer.

Preoperative immunonutrition in patients undergoing liver resection: A prospective randomized trial

BACKGROUND

Preoperative supplementation with immunonutrients, including arginine and n-3 fatty acids, has been shown in a number of systematic reviews to reduce infectious complications in patients who have undergone gastrointestinal surgery. Limited information, however, is available on the benefits of nutritional supplementation enriched with arginine and n-3 fatty acids in patients undergoing liver resection.

AIM

To evaluate the effects of preoperative nutritional supplementation enriched with arginine and n-3 fatty acids on inflammatory and immunologic markers and clinical outcome in patients undergoing liver resection.

METHODS

Thirty-four patients undergoing liver resection were randomized to either five days of preoperative Impact^® [1020 kcal/d, immunonutrition (IMN) group], or standard care [no supplementation, standard care (STD) group]. Nutritional status was measured at study entry by subjective global assessment (SGA). Functional assessments (grip strength, fatigue and performance status) were carried out at study entry, on the day prior to surgery, and on postoperative day (POD) 7 and 30. Inflammatory and immune markers were measured at study entry, on the day prior to surgery, and POD 1, 3, 5, 7, 10 and 30. Postoperative complications were recorded prospectively until POD30.

RESULTS

A total of 32 patients (17 IMN and 15 STD) were analysed. All except four patients were SGA class A. The plasma ratio of (eicosapentaenoic acid plus docosahexaenoic acid) to arachidonic acid was higher in IMN patients on the day prior to surgery and POD 1, 3, 5 and 7 (P < 0.05). Plasma interleukin (IL)-6 concentrations were elevated in the IMN group (P = 0.017 for POD7). No treatment effect was detected for functional measures, immune response (white cell count and total lymphocytes) or markers of inflammation (C-reactive protein, tumour necrosis factor-α, IL-8, IL-10). There were 10 patients with infectious complications in the IMN group and 4 in the STD group (P = 0.087). Median hospital stay was 9 (range 4–49) d in the IMN group and 8 (3-34) d in the STD group (P = 0.476).

CONCLUSION

In well-nourished patients undergoing elective liver resection, this study failed to show any benefit of preoperative immunonutrition.

The serum albumin threshold for increased perioperative complications after total hip arthroplasty is 3.0 g/dL

INTRODUCTION:

Low serum albumin is associated with higher perioperative complications following total hip arthroplasty (THA). The distinct threshold for a significant rise in perioperative complications has not been defined for THA. The purpose of this study was to define the threshold at which perioperative complications rise after THA.

METHODS:

We analysed the American College of Surgeons NSQIP database from 2006 to 2013. Our study cohort included unilateral primary THA with reported preoperative albumin levels. Patients were stratified by albumin level. We analysed mortality and 6 composite complication variables (any complication, any complication without transfusion, wound infection, systemic infection, cardiac/pulmonary complications, and any major complication). All data analysis was executed in STATA statistical software. Multivariable logistic regression analysis was used to adjust for odds ratios.

RESULTS:

The final cohort included 24,586 patients who were stratified based upon serum albumin levels. Odds ratios after multivariable regression adjustment for age, gender, race, body mass index, ASA classification, and Charlson Comorbidity Index indicated a trend to elevated odds of complication for all composite complications (3 of which were statistically significant) when serum albumin level was <3.0 g/dL.

CONCLUSION:

Low serum albumin is associated with increased perioperative complications following THA. The threshold associated with an increase in major perioperative complications appears to be an albumin level of <3.0 g/dL. With attempts to correct modifiable risk factors prior to surgery, the threshold value at which perioperative complications increase is important to define.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Pre-Operative vs. Peri-Operative Nutrition Supplementation in Hepatic Resection for Cancer: A Systematic Review

Despite improvements in safety of hepatic resection post-operative complications occur in up to a half of patients. A systematic review was undertaken to compare the effect of pre-operative and peri-operative nutritional supplementation on post-operative outcomes in patients undergoing hepatic resection for malignancy. Included studies were identified through a search of PubMed (1966 to November 2016), Embase (1947 to November 2016) and the Cochrane Library (1993 to November 2016). Eleven studies involving a total of 725 patients were included in this systematic review. BCAA supplementation in the pre-operative and peri-operative period was reported to reduce the overall complication rate by 26.9% (P = 0.01) in one cohort study while pre-operative immunonutrition was shown to reduce post-operative ascites by 25.4% (P =0.012) in another cohort study without affecting the overall complication rate. Four further studies on enteral supplementation failed to show a benefit with regards to post-operative complications. Post-operative mortality was unaffected by pre-operative and peri-operative BCAA. Both pre-operative and peri-operative nutritional supplementation have shown promising results regarding the post-operative course of patients undergoing hepatic resection for malignancy. No randomized controlled study exists directly comparing pre-operative and peri-operative nutrition and this needs to be focused on in future research.

Impact of Enteral Nutrition with an Immunomodulating Diet Enriched with Hydrolyzed Whey Peptide on Infection After Liver Transplantation

BACKGROUND

Infection is a leading cause of death after liver transplantation (LT). Therefore, prevention of infection is crucial for improving outcomes after LT. We examined the impact of early enteral nutrition with an immunomodulating diet (IMD) enriched with hydrolyzed whey peptide (HWP) formulation on infection after living donor LT (LDLT), focusing on sarcopenia.

METHODS

This study enrolled 279 consecutive patients who underwent primary LDLT at our institute between January 2008 and April 2015. Early enteral nutrition with the IMD enriched with HWP formulation and a conventional elemental diet were started within the first 24 h after surgery for 164 (IMD-HWP) and 115 (conventional) patients. Sequential changes in nutritional parameters, and the incidences of acute cellular rejection (ACR) and bacteremia were compared between the IMD-HWP and control groups. The comparison was made between those members of each group that did or did not exhibit sarcopenia. Risk factors for post-transplant bacteremia were also assessed.

RESULTS

Postoperative nutritional parameters and the incidence of ACR were comparable between the groups, except for the prealbumin level. The incidence of bacteremia was significantly lower in the IMD-HWP group, and among patients without sarcopenia in the IMD-HWP group compared with the conventional group (24.4 vs. 41.7%; P = 0.002 and 20.8 vs. 39.0%; P = 0.040, respectively). Independent risk factor for bacteremia comprised bleeding ≥10,000 mL (P = 0.025). In contrast, enteral nutrition without HWP formulation was not significantly associated with bacteremia. However, enteral nutrition without HWP formulation (P = 0.080), MELD scores (P = 0.097), and ABO incompatibility (P = 0.088) showed a trend toward increased incidence of bacteremia, although they did not reach statistical significance in the multivariate analysis.

CONCLUSION

Postoperative immunonutrition with an IMD enriched with HWP formulation was closely involved with post-transplant bacteremia.

Immunonutrition for patients undergoing surgery for head and neck cancer

BACKGROUND

Patients with head and neck cancer are often malnourished. Surgery for such cancers is complex and may be undertaken after a course of radiotherapy. As a result, patients may have postoperative complications such as fistulae and wound infections, as well as more generalised infections such as pneumonia. One possible way to enhance recovery, and reduce the incidence of these complications, is by improving nutrition. Nutritional formulas that deliver basic nutrients as well as amino acids (arginine and glutamine), ribonucleic acid (RNA) and/or lipids (omega-3 fatty acids) are known as immunonutrition.

OBJECTIVES

To assess the effects of immunonutrition treatment, compared to standard feeding, on postoperative recovery in adult patients undergoing elective (non-emergency) surgery for head and neck cancer.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 February 2018.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing immunonutrition given either preoperatively, postoperatively or perioperatively to adult patients (18 years of age or older) undergoing an elective surgical procedure for head and neck cancer, compared with a control group receiving either standard polymeric nutritional supplements or no supplements.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were: length of hospital stay (days), wound infection, fistula formation and adverse events/tolerance of feeds, as defined by trial authors. Secondary outcomes were: all-cause mortality and postoperative complications (as defined by trial authors). We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included 19 RCTs (1099 participants). The mean age of participants ranged from 47 to 66 years. Most studies (12/19) had fewer than 25 patients in each treatment group. Most studies (16/19) used immunonutrition formulas containing arginine, but there was variation in the actual products and amounts used, and in the length of intervention postoperatively. Follow-up time for outcome measurement varied considerably across studies, ranging from five days to greater than or equal to 16 months.Primary outcomesWe found no evidence of a difference in the length of hospital stay (mean difference -2.5 days, 95% confidence interval (CI) -5.11 to 0.12; 10 studies, 757 participants; low-quality evidence). Similarly, we found no evidence of an effect of immunonutrition on wound infection (risk ratio (RR) 0.94, 95% CI 0.70 to 1.26; 12 studies, 812 participants; very low-quality evidence). Fistula formation may be reduced with immunonutrition; the absolute risks were 11.3% and 5.4% in the standard care and immunonutrition groups, with a RR of 0.48 (95% CI 0.27 to 0.85; 10 studies, 747 participants; low-quality evidence). We found no evidence of a difference in terms of tolerance of feeds ('adverse events') between treatments (RR 1.33, 95% CI 0.86 to 2.06; 9 studies, 719 participants; very low-quality evidence).Secondary outcomesWe found no evidence of a difference between treatments in all-cause mortality (RR 1.33, 95% CI 0.48 to 3.66; 14 studies, 776 participants; low-quality evidence). Other postoperative complications such as pneumonia and urinary tract infections were not commonly reported.

AUTHORS' CONCLUSIONS

The risk of postoperative fistula formation may be reduced with immunonutrition, but we found no evidence of an effect of immunonutrition on any of the other outcomes that we assessed. The studies included in this review were generally small or at high risk of bias (or both). We judged the overall quality of the evidence to be low for the outcomes length of hospital stay and all-cause mortality, and very low for wound infection and adverse events. Further research should include larger, better quality studies.

Pharmaconutrition administration on outcomes of elective oncological surgery for gastrointestinal malignancies: is timing everything?-a review of published meta-analyses until the end of 2016

The last 25 years have seen an increasing number of publications attesting the benefits of pharmaconutrition in the management of patients undergoing elective oncological gastrointestinal surgery. A number of randomized controlled trials and meta-analyses suggest the use of pharmaconutrition in this group of patients produces superior outcomes to standard nutritional formulations in terms of postoperative infective complications, anastomotic breakdown and length of hospital stay. The use of pharmaconutrition products, therefore, has gained increasing acceptance for use in elective gastrointestinal oncological surgical populations and been incorporated into practice guidelines. However, there remains doubts as to the robustness of such data supporting these recommendation. This is because studies reporting improved outcomes with pharmaconutrition (I) frequently compare this intervention with non-equivalent control groups; (II) do not report on the actual nutritional provision received by study participants; (III) overlook the potential impact of industry funding on research conducted and (IV) do not adopt a multi-disciplinary approach to the research undertaken. For these reasons, a critical re-appraisal of the use and recommendations of pharmaconutrition in this group of patients is urgently warranted to resolve some of the above mentioned issues. The aim of this review was to analyse meta-analyses published until the end of 2016 in this area to highlight the strengths and weakness of the present research and prioritize certain areas which will benefit from future research.

Gastric cancer: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO)

INTRODUCTION

This document is a summary of the French Intergroup guidelines regarding the management of gastric cancer published in October 2016, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org), updated in October 2017.

METHODS

This collaborative work was realized under the auspices of several French medical societies involved in management of gastric cancer. Recommendations are graded in three categories (A-C), according to the amount of evidence found in the literature until July 2017.

RESULTS

There are several known risk factors for gastric cancer, including Helicobacter pylori and genetic predispositions, both requiring a specific screening for patients and their relatives. The diagnosis and staging evaluation are essentially based on gastroscopy plus biopsies and computed tomography scan. The endoscopic ultrasonography can be used for superficial tumors in case of discussion for endoscopic resection (T1N0). For local disease (N+ and/or T > T1), the strategic therapy is based on surgery associated with perioperative chemotherapy. In the absence of preoperative treatment (for any raison), the postoperative chemoradiotherapy (or chemotherapy) should be discussed for patients with stage II or III tumor. For metastatic disease, the treatment is based on "palliative" chemotherapy consisting in a doublet or triplet regimens depending of age, performance status and HER2 tumor status. For patients with limited metastatic disease, surgical resection could be discussed in multidisciplinary meeting in case of stable disease after chemotherapy.

CONCLUSION

These guidelines in gastric cancer are done to help decision for daily clinical practice. These recommendations are permanently being reviewed. Each individual case must be discussed within a multidisciplinary team.