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Schineis CHW, Pozios I, Boubaris K, Weixler B, Kamphues C, Margonis GA, Kreis ME, Strobel RM, Beyer K, Seifarth C, Luitjens J, Kaufmann D, Lauscher JC. Role of visceral fat on postoperative complications and relapse in patients with Crohn's disease after ileocecal resection: Is it overrated? Int J Colorectal Dis 2024; 39:20. [PMID: 38240842 PMCID: PMC10798911 DOI: 10.1007/s00384-023-04586-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/22/2024]
Abstract
INTRODUCTION The role of visceral fat in disease development, particularly in Crohn´s disease (CD), is significant. However, its preoperative prognostic value for postoperative complications and CD relapse after ileocecal resection (ICR) remains unknown. This study aims to assess the predictive potential of preoperatively measured visceral and subcutaneous fat in postoperative complications and CD recurrence using magnetic resonance imaging (MRI). The primary endpoint was postoperative anastomotic leakage of the ileocolonic anastomosis, with secondary endpoints evaluating postoperative complications according to the Clavien Dindo classification and CD recurrence at the anastomosis. METHODS We conducted a retrospective analysis of 347 CD patients who underwent ICR at our tertiary referral center between 2010 and 2020. We included 223 patients with high-quality preoperative MRI scans, recording demographics, postoperative outcomes, and CD recurrence rates at the anastomosis. To assess adipose tissue distribution, we measured total fat area (TFA), visceral fat area (VFA), subcutaneous fat area (SFA), and abdominal circumference (AC) at the lumbar 3 (L3) level using MRI cross-sectional images. Ratios of these values were calculated. RESULTS None of the radiological variables showed an association with anastomotic leakage (TFA p = 0.932, VFA p = 0.982, SFA p = 0.951, SFA/TFA p = 0.422, VFA/TFA p = 0.422), postoperative complications, or CD recurrence (TFA p = 0.264, VFA p = 0.916, SFA p = 0.103, SFA/TFA p = 0.059, VFA/TFA p = 0.059). CONCLUSIONS Radiological visceral obesity variables were associated with postoperative outcomes or clinical recurrence in CD patients undergoing ICR. Preoperative measurement of visceral fat measurement is not specific for predicting postoperative complications or CD relapse.
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Affiliation(s)
- Christian Hans Wolfgang Schineis
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203, Berlin, Germany.
| | - Ioannis Pozios
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203, Berlin, Germany
| | - Katharina Boubaris
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203, Berlin, Germany
| | - Benjamin Weixler
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203, Berlin, Germany
| | - Carsten Kamphues
- Department of General- and Visceral Surgery, Schloßparkklinik, Berlin, Germany
| | | | - Martin Ernst Kreis
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203, Berlin, Germany
| | - Rahel Maria Strobel
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203, Berlin, Germany
| | - Katharina Beyer
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203, Berlin, Germany
| | - Claudia Seifarth
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203, Berlin, Germany
| | - Jan Luitjens
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - David Kaufmann
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Johannes Christian Lauscher
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203, Berlin, Germany
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Kato H, Seishima R, Nakamura K, Matsui S, Shigeta K, Okabayashi K, Kitagawa Y. The Prognostic Nutritional Index is a Predictive Marker for Postoperative Complications in Patients with Late-Onset Ulcerative Colitis. World J Surg 2023; 47:2867-2875. [PMID: 37470793 DOI: 10.1007/s00268-023-07118-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE The number of patients with late-onset ulcerative colitis (UC) requiring surgery has increased in recent years. The risk of postoperative complications is higher in the elderly, so preoperative assessment is important. We aimed to explore the performance of preoperative assessment of nutritional markers for predicting postoperative complications in patients with late-onset UC. METHODS We retrospectively analysed 140 medically refractory UC patients who underwent surgery. The association between age at UC onset and risk of postoperative complications was explored using a fractional polynomial model. Uni- and multi-variate logistic regression analyses were performed to identify nutritional markers associated with postoperative complications. RESULTS The polynomial model showed patients with UC onset after 50 years of age had an increased risk of postoperative complications. Late-onset (LO) UC, an onset occurring after 50 years old, was associated with a higher risk of incisional surgical site infection (SSI) and intra-abdominal abscess than early-onset (EO) UC. Compared with the EO group, the LO group had fewer nutritional markers that were significantly associated with postoperative complications. The prognostic nutritional index (PNI) was calculated using the albumin level and the total lymphocyte count, and it was the only index that was significant in the LO group (odds ratio 0.872 95% CI 0.77-0.99, P = 0.03). CONCLUSIONS It was more difficult to use nutritional status to predict the risk of postoperative complications in patients with late-onset UC than in patients with early-onset ulcerative colitis. PNI may be a useful nutritional marker for patients with both late- and early-onset UC.
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Affiliation(s)
- Hirochika Kato
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi , Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Ryo Seishima
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi , Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Kimihiko Nakamura
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi , Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shimpei Matsui
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi , Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kohei Shigeta
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi , Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Koji Okabayashi
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi , Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi , Shinjuku-ku, Tokyo, 160-8582, Japan
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Alves Martins BA, Filho ODM, Lopes ACB, de Faria RJ, Silva C, Lemos GDO, Silveira DB, de Sousa JB. Nutritional status in perianal Crohn's disease: are we underestimating the impact? Front Nutr 2023; 10:1271825. [PMID: 37743921 PMCID: PMC10512412 DOI: 10.3389/fnut.2023.1271825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Symptomatic perianal disease is common in patients with Crohn's disease (CD), and perianal fistulas represent the primary form of anal involvement. This type of involvement is associated with a poor prognosis and a disabling course. The treatment is challenging and involves both surgical and medical approaches. Despite combined therapy, a significant portion of patients may still require proctectomy to control the symptoms. Consequently, investigating factors that may influence the outcome of perianal disease remains a priority area of research in CD. Nutritional deficiencies are well documented among CD patients with luminal forms of involvement and are closely related to poor clinical outcomes, therapy response, and postoperative complications. As a result, leading guidelines recommend regular nutritional assessment and correction of nutritional deficiencies in patients requiring a surgical approach. Despite these recommendations and the high rate of surgeries among CD patients with perianal disease, there is a shortage of studies addressing the real impact of nutritional status on the course and outcomes of perianal disease. This knowledge gap underscores the importance of further research to understand better and improve the management of perianal CD. This narrative review aims to provide an overview of nutritional status assessment and the influence of nutritional status on the outcomes of patients with perianal CD.
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Affiliation(s)
- Bruno Augusto Alves Martins
- Medical Sciences Postgraduate Program, School of Medicine, University of Brasilia, Brasília, Brazil
- Department of Colorectal Surgery, Hospital Universitário de Brasília, Brasília, Brazil
| | - Oswaldo de Moraes Filho
- Medical Sciences Postgraduate Program, School of Medicine, University of Brasilia, Brasília, Brazil
- Department of Colorectal Surgery, Hospital Universitário de Brasília, Brasília, Brazil
| | | | | | - Clíslian Silva
- Department of Nutrition and Dietetics, Hospital Universitário de Brasília, Brasília, Brazil
| | | | | | - João Batista de Sousa
- Medical Sciences Postgraduate Program, School of Medicine, University of Brasilia, Brasília, Brazil
- Department of Colorectal Surgery, Hospital Universitário de Brasília, Brasília, Brazil
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Bedard K, Taylor L, Rajabali N, Kroeker K, Halloran B, Meng G, Raman M, Tandon P, Abraldes JG, Peerani F. Handgrip strength and risk of malnutrition are associated with an increased risk of hospitalizations in inflammatory bowel disease patients. Therap Adv Gastroenterol 2023; 16:17562848231194395. [PMID: 37667803 PMCID: PMC10475242 DOI: 10.1177/17562848231194395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/26/2023] [Indexed: 09/06/2023] Open
Abstract
Background In patients with inflammatory bowel disease (IBD), frailty is independently associated with mortality and morbidity. Objectives This study aimed to extend this work to determine the association between the clinical frailty scale (CFS), handgrip strength (HGS), and malnutrition with IBD-related hospitalizations and surgeries. Design IBD patients ⩾18 years of age were prospectively enrolled from two ambulatory care clinics in Alberta, Canada. Methods Frailty was defined as a CFS score ⩾4, dynapenia as HGS < 16 kg for females and <27 kg for males, malnutrition using the subjective global assessment (SGA), and the risk of malnutrition using either the abridged patient-generated SGA (abPG-SGA), or the Saskatchewan Inflammatory Bowel Disease Nutrition Risk Tool (SaskIBD-NRT). Logarithm relative hazard graphs and multivariable logistic regression models adjusting for relevant confounders were constructed. Results One hundred sixty-one patients (35% ulcerative colitis, 65% Crohn's disease) with a mean age of 42.2 (±15.9) years were followed over a mean period of 43.9 (±10.1) months. Twenty-seven patients were hospitalized, and 13 patients underwent IBD-related surgeries following baseline. While the CFS (aHR 1.34; p = 0.61) and SGA (aHR 0.81; p = 0.69) did not independently predict IBD-related hospitalizations, decreased HGS (aHR 3.96; p = 0.03), increased abPG-SGA score (aHR 1.07; p = 0.03) and a SaskIBD-NRT ⩾ 5 (aHR 4.49; p = 0.02) did. No variable was independently associated with IBD-related surgeries. Conclusion HGS, the abPG-SGA, and the SaskIBD-NRT were independently associated with an increased risk of IBD-related hospitalizations. Future studies should aim to validate other frailty assessments in the IBD population in order to better tailor care for all IBD patients.
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Affiliation(s)
- Katherine Bedard
- Department of Medicine, Faculty of Graduate Studies and Research, University of Alberta, Edmonton, AB, Canada
| | - Lorian Taylor
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Naheed Rajabali
- Division of Geriatric Medicine, University of Alberta, Edmonton, AB, Canada
| | - Karen Kroeker
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Brendan Halloran
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Guanmin Meng
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Maitreyi Raman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Puneeta Tandon
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Juan G. Abraldes
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Farhad Peerani
- Division of Gastroenterology, University of Alberta, 1-59 Zeidler Ledcor Centre, 8540 – 112 Street NW, Edmonton AB T6G 2P8, Canada
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Bigagli E, D’Ambrosio M, Cinci L, Fiorindi C, Agostiniani S, Bruscoli E, Nannoni A, Lodovici M, Scaringi S, Giudici F, Luceri C. Impact of Preoperative Immunonutrition on Oxidative Stress and Gut Barrier Function in Surgical Patients with Crohn's Disease. Nutrients 2023; 15:nu15040882. [PMID: 36839239 PMCID: PMC9960923 DOI: 10.3390/nu15040882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/02/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
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.
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Affiliation(s)
- Elisabetta Bigagli
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze, 50134 Firenze, Italy
| | - Mario D’Ambrosio
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze, 50134 Firenze, Italy
| | - Lorenzo Cinci
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze, 50134 Firenze, Italy
| | - Camilla Fiorindi
- Department of Health Science, University of Firenze, 50134 Firenze, Italy
| | - Sara Agostiniani
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze, 50134 Firenze, Italy
| | - Elisa Bruscoli
- Department of Health Science, University of Firenze, 50134 Firenze, Italy
| | - Anita Nannoni
- Department of Health Science, University of Firenze, 50134 Firenze, Italy
| | - Maura Lodovici
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze, 50134 Firenze, Italy
| | - Stefano Scaringi
- Department of Experimental and Clinical Medicine, University of Firenze, 50134 Firenze, Italy
| | - Francesco Giudici
- Department of Experimental and Clinical Medicine, University of Firenze, 50134 Firenze, Italy
- Correspondence: (F.G.); (C.L.)
| | - Cristina Luceri
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze, 50134 Firenze, Italy
- Correspondence: (F.G.); (C.L.)
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Jiang K, Chen B, Lou D, Zhang M, Shi Y, Dai W, Shen J, Zhou B, Hu J. Systematic review and meta-analysis: association between obesity/overweight and surgical complications in IBD. Int J Colorectal Dis 2022; 37:1485-1496. [PMID: 35641579 PMCID: PMC9262757 DOI: 10.1007/s00384-022-04190-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE While the prevalence of obesity in inflammatory bowel disease (IBD) patients is rapidly increasing, it is unclear whether obesity affects surgical outcomes in this population. This meta-analysis aims to assess the impact of obesity/overweight on patients undergoing surgery for IBD. METHODS Databases (PubMed, Web of Science, Cochrane Library, and Springer) were searched through September 2021. The meta-analysis included patients with surgically treated IBD to investigate the impact of obesity/overweight on this population. Primary outcomes included overall complications, infectious complications, noninfectious complications, and conversion to laparotomy. RESULTS Fifteen studies totaling 12,622 IBD patients were enrolled. Compared with nonobese (including overweight) patients, obese IBD patients have increased the risk in terms of overall complications (OR = 1.45, p < 0.001), infectious complications (OR = 1.48, p = 0.003) (especially wound complications), as well as conversion to laparotomy (OR = 1.90, p < 0.001). Among the noninfectious complications, only the incidence of visceral injury (OR = 2.36, p = 0.05) had significantly increased. Compared with non-overweight patients, the risk of developing wound complications (OR = 1.65, p = 0.01) and sepsis (OR = 1.73, p = 0.007) were increased in overweight patients, but the rates of overall complications (OR = 1.04, p = 0.81), infectious complications (OR = 1.31, p = 0.07), and conversion to laparotomy (OR = 1.33, p = 0.08) associated with body mass index (BMI) were not significantly different. CONCLUSION Obesity is a risk factor for surgical complications in IBD patients, mainly reflected in infectious complications. Moreover, obese patients seem to have a more common chance of developing surgical complications than overweight patients.
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Affiliation(s)
- Ke Jiang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Bangsheng Chen
- Emergency Medical Center, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China
| | - Dandi Lou
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Mengting Zhang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yetan Shi
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Wei Dai
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jingyi Shen
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Bin Zhou
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Jinxing Hu
- Department of Endocrinology, HwaMei Hospital, University of Chinese Academy of Sciences, Haishu District, Northwest Street 41, Ningbo, 315010, Zhejiang, China.
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Simple Clinical Screening Underestimates Malnutrition in Surgical Patients with Inflammatory Bowel Disease-An ACS NSQIP Analysis. Nutrients 2022; 14:nu14050932. [PMID: 35267906 PMCID: PMC8912602 DOI: 10.3390/nu14050932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/12/2022] [Accepted: 02/20/2022] [Indexed: 12/16/2022] Open
Abstract
The present large scale study aimed to assess the prevalence and consequences of malnutrition, based on clinical assessment (body mass index and preoperative weight loss) and severe hypoalbuminemia (<3.1 g/L), in a representative US cohort undergoing IBD surgery. The American College of Surgeons National Quality improvement program (ACS-NSQIP) Public User Files (PUF) between 2005 and 2018 were assessed. A total of 25,431 patients were identified. Of those, 6560 (25.8%) patients had severe hypoalbuminemia, 380 (1.5%) patients met ESPEN 2 criteria (≥10% weight loss over 6 months PLUS BMI < 20 kg/m2 in patients <70 years OR BMI < 22 kg/m2 in patients ≥70 years), and 671 (2.6%) patients met both criteria (severe hypoalbuminemia and ESPEN 2). Patients who presented with malnutrition according to any of the three definitions had higher rates of overall, minor, major, surgical, and medical complications, longer LOS, higher mortality and higher rates of readmission and reoperation. The simple clinical assessment of malnutrition based on BMI and weight loss only, considerably underestimates its true prevalence of up to 50% in surgical IBD patients and calls for dedicated nutritional assessment.
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Clinical and Nutritional Impact of a Semi-Elemental Hydrolyzed Whey Protein Diet in Patients with Active Crohn's Disease: A Prospective Observational Study. Nutrients 2021; 13:nu13103623. [PMID: 34684624 PMCID: PMC8538212 DOI: 10.3390/nu13103623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Malnourishment is a common complication in patients with Crohn’s disease. Methods: An observational, prospective study was conducted to assess the nutritional status, disease activity, and stool frequency at baseline and after 12 weeks of treatment with a semi-elemental diet in patients with active Crohn’s disease. Results: A total of 144 patients with Crohn’s disease were included. The nutritional status improved after treatment, resulting in 76.1% of patients at low risk of malnourishment, 20.4% moderately malnourished, and 8.5% severely malnourished after 12 weeks of treatment. Nutritional status improvement was associated with the number of nutritional supplements. Mean albumin levels and body mass index (BMI) improved after 12 weeks of nutritional treatment (from 3.0 g/dL to 3.7 g/dL and from 20.2 kg/m2 to 21.1 kg/m2, respectively). A significant decrease in HBI was found after 12 weeks of nutritional treatment (from 10.2 to 3.7). The mean number of stools per day decreased with the 12 week semi-elemental diet (from 4.6 stools/day to 1.7 stools/day). Conclusion: In this observational study, the semi-elemental diet seemed effective in improving the nutritional status, disease activity, and stool frequency in patients with active Crohn’s disease.
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Abstract
The purpose of this article is to provide an updated review of the definition, prevalence, causes, and clinical management of malnutrition in inflammatory bowel disease (IBD). Prevalence of malnutrition in IBD is estimated to be between 6.1% and 69.7% depending on the definition used, the type of IBD, the clinical setting, and whether the IBD is active or in remission. Whereas older definitions of malnutrition have been found to be correlated with mortality and length of hospital stay, the more recent European Society for Clinical Nutrition and Metabolism (ESPEN) 2015 and the Global Leadership Initiative on Malnutrition (GLIM) definitions provide significantly different prevalence estimates of malnutrition when applied to the same patient population, and further work is needed to validate these two definitions against clinical outcomes. In patients with IBD with identified malnutrition, oral nutrition supplementation, enteral nutrition, or parenteral nutrition should be started. In malnourished patients with Crohn's disease undergoing surgery, preoperative enteral nutrition has been demonstrated to reduce the rate of postoperative complications. Overall, patients with IBD are at significant risk for malnutrition and should be screened for malnutrition by using a validated screening tool. The management of malnutrition in IBD is complex, and studies are often limited in their size or their ability to demonstrate an improvement in clinical outcomes based on specific nutrition-related interventions. Future studies particularly regarding the validation of new screening tools and perioperative management of malnutrition may provide insight into the standardization of diagnosis and management of malnutrition in IBD.
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Affiliation(s)
- Austin Lin
- Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, Illinois, USA
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GLIM Criteria for Malnutrition in Surgical IBD Patients: A Pilot Study. Nutrients 2020; 12:nu12082222. [PMID: 32722435 PMCID: PMC7469012 DOI: 10.3390/nu12082222] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/19/2020] [Accepted: 07/22/2020] [Indexed: 12/17/2022] Open
Abstract
Background: A gold standard method for malnutrition diagnosis is still lacking in Inflammatory Bowel Disease (IBD). Objective: The aims of this study are to determine the prevalence of malnutrition in IBD patients according with recently published Global Leadership Initiative on Malnutrition (GLIM) criteria, to detect the factors contributing to the onset of malnutrition, and to evaluate the most accurate predictor of malnutrition risk within the available nutritional screening tools. Methods: Fifty-three consecutive adult IBD patients [38 Crohn’s disease (CD) and 15 ulcerative colitis (UC)] had been assessed preoperatively by a multidisciplinary IBD team before undergoing elective surgery. Several malnutrition risk tools were tested, such as NRS-2002, MUST, MST, MIRT, and SaskIBD-NR. The statistical association of independent GLIM variables with baseline characteristics of patients was explored as well as the concordance with the European Society for Clinical Nutrition and Metabolism (ESPEN 2015) and the screening tools. Results: Twenty-two IBD patients (42%) were malnourished according to GLIM criteria, of which 13 were CD (34%) and 9 UC (60%). The etiological criteria of inflammation and reduction of food intake were present in 51% and 19% of our patients, respectively. The prevalence of GLIM phenotypic criteria was 28%, 28% and 34% for BMI, Free Fat Mass Index (FFMI) and unintended weight loss (UWL), respectively. The presence of ileostomy was statistically associated with a higher prevalence of BMI (p = 0.030), FFMI (p = 0.030) and UWL (p = 0.002) values lower than the GLIM criteria cut-offs, while secondary surgery is associated with a decrease in FFMI (p = 0.017) and UWL (p = 0.041). The sensitivity of the tested nutritional screening tools, compared with the GLIM prevalence of malnutrition, was not satisfactory (between 50 and 82%). Conclusions: GLIM has a higher rate of malnutrition detection than ESPEN 2015, as malnutrition in IBD seems linked to inflammation and secondary malabsorption even without a reduction of food intake. The sensitivity of the screening tools is lower than the specificity when compared with GLIM criteria for malnutrition diagnosis.
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Palchaudhuri S, Albenberg L, Lewis JD. Diet Recommendations for Hospitalized Patients With Inflammatory Bowel Disease: Better Options Than Nil Per Os. CROHN'S & COLITIS 360 2020; 2:otaa059. [PMID: 33954288 PMCID: PMC8096188 DOI: 10.1093/crocol/otaa059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hospitalizations are a time when providers often have uncertainty about what to feed patients with inflammatory bowel disease (IBD). While there are many trials evaluating the role of diet in the management of IBD, the role of diet for the hospitalized patient is less clear. The hospitalization may serve as an opportunity to educate patients about the role of diet, try different diets, and develop dietary recommendations for after discharge. Here, we review the literature for dietary considerations during hospitalizations and acute settings, as well as upon discharge. Patients with IBD benefit from screening and nutritional support for malnutrition and nutritional deficiencies. Enteral nutrition and exclusion diets are promising as induction and maintenance therapies, but no specific recommendations during hospitalization for adult patients are available currently. There are very few reasons to enforce bowel rest or clear liquids other than bowel obstruction, uncontrolled sepsis, or need for urgent or emergent surgery; most patients - including many with penetrating or stricturing disease - benefit from feeding in whichever capacity is tolerated, with enteral and parenteral nutrition used as needed to reach nutritional goals. Future studies are needed to define how the use of different diets can influence the outcomes of patients hospitalized for IBD.
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Affiliation(s)
- Sonali Palchaudhuri
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA,Address correspondence to: Sonali Palchaudhuri, MD, Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104 ()
| | - Lindsey Albenberg
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Pulley J, Todd A, Flatley C, Begun J. Malnutrition and quality of life among adult inflammatory bowel disease patients. JGH OPEN 2019; 4:454-460. [PMID: 32514453 PMCID: PMC7273715 DOI: 10.1002/jgh3.12278] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/28/2019] [Indexed: 12/30/2022]
Abstract
Background and Aim Inflammatory bowel diseases (IBD) are chronic inflammatory conditions of the gut resulting in a significant risk for malnutrition. The reported prevalence of malnutrition in inflammatory disease patients varies from 5.7 to 82.8%. The aim of this study was to measure the prevalence of malnutrition and its association with quality of life (QOL) in a cohort of Australian IBD outpatients. Methods A total of 107 consecutive patients (68 Crohn's disease, 35 ulcerative colitis, 4 indeterminate colitis) were enrolled in this cross‐sectional study. Demographic data were collected, and patients underwent a malnutrition assessment using the patient‐generated subjective global assessment. The RAND 36‐item health survey was used to measure QOL. Results Mild to moderate malnutrition was detected in 17 patients (16%). Malnourished patients were more likely to be underweight (P ≤ 0.01), have active disease (P ≤ 0.01), and have been admitted to hospital in the preceding 12 months (P ≤ 0.05). Malnourished patients had a significantly lower QOL in physical (P ≤ 0.01) and mental (P ≤ 0.01) health components. Patients with active or recently active disease had reduced QOL compared to patients in remission. Malnutrition factors predictive of poor physical health‐related QOL were pain (odds ratio [OR] = 12.8, 95% confidence interval [CI] 2.0–80.4) and unintentional weight loss (OR = 3.1 per kg lost, 95% CI 1.2–7.9). The predictor of poor mental health‐related QOL was early satiety (OR = 7.7, 95% CI 1.7–33.9). Conclusions The malnutrition prevalence for this population was 16%. Malnutrition was associated with being underweight, active disease, and increased number of hospital admissions. Disease activity and malnutrition were associated with poorer QOL.
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Affiliation(s)
- Jessica Pulley
- Department of Nutrition and Dietetics Mater Health Services Brisbane Queensland Australia
| | - Alwyn Todd
- Department of Nutrition and Dietetics Mater Health Services Brisbane Queensland Australia.,Menzies Health Institute Griffith University Gold Coast Queensland Australia.,Mater Research Institute The University of Queensland Brisbane Queensland Australia
| | - Christopher Flatley
- Mater Research Institute The University of Queensland Brisbane Queensland Australia
| | - Jakob Begun
- Mater Research Institute The University of Queensland Brisbane Queensland Australia.,Department of Gastroenterology Mater Health Services Brisbane Queensland Australia.,Translational Research Institute Brisbane Queensland Australia
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Stoner PL, Kamel A, Ayoub F, Tan S, Iqbal A, Glover SC, Zimmermann EM. Perioperative Care of Patients with Inflammatory Bowel Disease: Focus on Nutritional Support. Gastroenterol Res Pract 2018; 2018:7890161. [PMID: 30344603 PMCID: PMC6174741 DOI: 10.1155/2018/7890161] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/28/2018] [Indexed: 12/16/2022] Open
Abstract
Patients with inflammatory bowel disease (IBD) commonly require surgery despite the availability of an increasingly large repertoire of powerful immunosuppressive medications for the treatment of IBD. Optimizing patients' care preoperatively is crucial to obtaining good surgical outcomes. This review discusses preoperative assessment and management principles including assessing disease location and activity with cross-sectional or endoscopic imaging, addressing modifiable risk factors (i.e., stopping smoking, weaning steroids, and correcting anemia), and properly managing medications. The major focus of our literature review is the evaluation for malnutrition, a common finding that affects up to 70% of patients with IBD and a well-known, independent risk factor for adverse postoperative outcomes. Our review confirms that whenever feasible, oral or enteral nutrition (EN) is the preferred method of nutritional support; parenteral nutrition (PN) should be reserved for nutritionally deficient IBD patients unable to tolerate EN. In selected patients, recent data demonstrated that the use of preoperative PN resulted in improved nutritional status, fewer postoperative complications, and reduced disease severity. Our review highlights the need for well-designed, prospective trials investigating perioperative nutritional support in patients with IBD. Future studies should perform modern nutritional assessment, standardize for diet, and include patients with UC since this subset of patients is underrepresented in existing studies. In addition, relevant outcome of interest specific to Crohn's disease (CD) patients such as length of small bowel resected, number of anastomoses, and need for an ostomy should be included as these patients may require repeated small bowel resections.
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Affiliation(s)
- Patrick L. Stoner
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Amir Kamel
- Department of Pharmacotherapy, College of Pharmacy, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Fares Ayoub
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Sanda Tan
- Department of Surgery, Division of Colorectal Surgery, College of Medicine, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Atif Iqbal
- Department of Surgery, Division of Colorectal Surgery, College of Medicine, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Sarah C. Glover
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Ellen M. Zimmermann
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
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Aydinli HH, Aytac E, Remzi FH, Bernstein M, Grucela AL. Factors Associated with Short-Term Morbidity in Patients Undergoing Colon Resection for Crohn's Disease. J Gastrointest Surg 2018; 22:1434-1441. [PMID: 29663305 DOI: 10.1007/s11605-018-3763-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 03/24/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients undergoing colon resection for Crohn's disease are at risk of developing postoperative complications. The aim of this study is to identify factors associated with short-term (30-day) morbidity in patients undergoing colon resection for Crohn's disease from a national database. METHODS Patients who underwent colon resection for Crohn's disease in 2015 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The groups were classified based on presence of postoperative 30-day complications. The overall morbidity was calculated by including patients who had at least one postoperative complication. Demographics, preoperative, and operative factors were assessed and compared between the two groups. Further multivariate logistic regression analysis was conducted. RESULTS A total of 1643 patients met the inclusion criteria [mean age of 41.2 (± 15.5) years, 871 (53%) female]. Sixty percent (n = 993) of the procedures were performed laparoscopically and 128 (12.8%) cases were converted to open. Ninety-five patients (5%) underwent emergent resections. Thirty percent (n = 507) of patients had at least one postoperative complication within 30 days of surgery. Ileus (16%), transfusion (7%), and organ-space surgical site infection (6%) were the most common morbidities. Independent risk factors for postoperative morbidity were male gender (p = 0.01), open surgery (p = 0.002), preoperative severe anemia (p = 0.001), and preoperative weight loss (p = 0.04). CONCLUSION Approximately one third of the patients who undergo colon resection for Crohn's disease experience postoperative complications. Preoperative optimization of nutrition and anemia may improve outcomes. Laparoscopic technique appears to be the preferred surgical treatment option for resection when feasible.
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Affiliation(s)
- H Hande Aydinli
- Department of Surgery, Division of Colon and Rectal Surgery, Department of Colorectal Surgery, New York University Langone Medical Center, 530 First Ave Suite 7V, New York, NY, 10016, USA
| | - Erman Aytac
- Department of Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Feza H Remzi
- Department of Surgery, Division of Colon and Rectal Surgery, Department of Colorectal Surgery, New York University Langone Medical Center, 530 First Ave Suite 7V, New York, NY, 10016, USA
| | - Mitchell Bernstein
- Department of Surgery, Division of Colon and Rectal Surgery, Department of Colorectal Surgery, New York University Langone Medical Center, 530 First Ave Suite 7V, New York, NY, 10016, USA
| | - Alexis L Grucela
- Department of Surgery, Division of Colon and Rectal Surgery, Department of Colorectal Surgery, New York University Langone Medical Center, 530 First Ave Suite 7V, New York, NY, 10016, USA.
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Zangenberg MS, Horesh N, Kopylov U, El-Hussuna A. Preoperative optimization of patients with inflammatory bowel disease undergoing gastrointestinal surgery: a systematic review. Int J Colorectal Dis 2017; 32:1663-1676. [PMID: 29051981 DOI: 10.1007/s00384-017-2915-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical management of inflammatory bowel disease (IBD) is a challenging task. The aim of preoperative optimization (PO) is to decrease the risk of complications and reduce the length of postoperative stay. The aim of this study was to review and grade the available evidence, attain clear recommendations, and point out potential future research. METHODS Studies were identified from electronic databases (PubMed, Embase, and Cochrane Library) and scanning reference lists in relevant papers. English-written studies examining PO in adult patients with IBD were included. Eight PO factors were investigated. RESULTS Management of IBD is a multidisciplinary task. Steroid withdrawal is recommended while steroid stress dose is not recommended. Thiopurines appear to be safe, but it may be prudent to plan the procedure remotely from the last dose of an anti-TNF agent. Nutritional risk screening is recommended to unveil and correct any malnutrition. Thrombosis prophylaxis prior to surgery is well supported by evidence while extended 4-week prophylaxis needs further research. Percutaneous ultrasound or CT-guided drainage for intra-abdominal abscesses is recommended, but it is unclear for how long supplementary antibiotics (ABs) should be used. Oral AB 24 h prior to open surgery might improve outcome if given as complementary to IV perioperative AB. Mechanical bowel preparation is not supported by evidence. Comorbidities must be treated accordingly prior to surgical intervention. Smoking cessation can be beneficial for wound healing. CONCLUSION Multimodel PO intervention in IBD patients is recommended.
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Affiliation(s)
| | - Nir Horesh
- Department of Surgery, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.
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Dreznik Y, Horesh N, Gutman M, Gravetz A, Amiel I, Jacobi H, Zmora O, Rosin D. Preoperative Nutritional Optimization for Crohn's Disease Patients Can Improve Surgical Outcome. Dig Surg 2017; 35:442-447. [PMID: 29130989 DOI: 10.1159/000481408] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 09/10/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative preparation of patients with Crohn's disease is challenging and there are no specific guidelines regarding nutritional support. The aim of this study was to assess whether preoperative nutritional support influenced the postoperative outcome. METHODS A retrospective, cohort study including all Crohn's disease patients who underwent abdominal surgery between 2008 and 2014 was conducted. Patients' characteristics and clinical and surgical data were recorded and analyzed. RESULTS Eighty-seven patients were included in the study. Thirty-seven patients (42.5%) received preoperative nutritional support (mean albumin level 3.14 vs. 3.5 mg/dL in the non-optimized group; p < 0.02) to optimize their nutritional status prior to surgery. Preoperative albumin level, after adequate nutritional preparation, was similar between the 2 groups. The 2 groups differ neither in demographic and surgical data, overall post-op complication (p = 0.85), Clavien-Dindo score (p = 0.42), and length of stay (p = 0.1). Readmission rate was higher in the non-optimized group (p = 0.047). CONCLUSION Nutritional support can minimize postoperative complications in patients with low albumin levels. Nutritional status should be optimized in order to avoid hazardous complications.
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Turkot M, Sobocki J. Results of home parenteral nutrition in patients with severe inflammatory bowel disease - an alternative for surgery of malnourished patients. POLISH JOURNAL OF SURGERY 2017; 89:23-28. [PMID: 29154237 DOI: 10.5604/01.3001.0010.5408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION In the world, the inflammatory bowel disease affects an increasing number of younger and younger patients, and in some of them parenteral nutrition is an alternative to high-risk surgical intervention due to advancement of the disease and malnutrition. AIM The aim of the study was to assess the results of home parenteral nutrition in patients with severe bowel inflammatory disease, in whom surgical treatment is associated with high risk of complications. MATERIALS AND METHODS A retrospective analysis was conducted on 46 patients, who received home parenteral nutrition instead of another surgical intervention. The inclusion criteria included home parenteral nutrition and diagnosis of Crohn's disease or ulcerative colitis. RESULTS Mean number of complications requiring hospital admission per patient was 1.76, the BMI increased by 4.3 on average [kg/m2]. During parenteral nutrition, the percentage of patients, in whom anti-inflammatory or immunosuppressant drugs were completely discontinued, was 17.4%. In the whole group, at least one immunosuppressive drug was discontinued in onefifth of patients. Mean albumin level increased by 2.4 g/L, lymphocyte count dropped by 474 lymphocytes/mm3, and leukocyte count increased by 747.6/mm3. The patients described their condition as good in 87%, and 7.4% of patients were able to work. CONCLUSIONS Home parenteral nutrition positively affects patient's general condition by increasing BMI and normalizing biochemical test results. The results indicate the need to consider this method as an alternative to surgical intervention in severe bowel inflammatory disease with high perioperative risk, which could reduce the complication rate.
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Affiliation(s)
- Maryla Turkot
- Department of General Surgery and Clinical Nutrition, Warsaw Medical University; Head: dr hab. n. med. Jacek Sobocki
| | - Jacek Sobocki
- Department of General Surgery and Clinical Nutrition, Warsaw Medical University; Head: dr hab. n. med. Jacek Sobocki
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Preoperative Nutritional Conditioning of Crohn’s Patients—Systematic Review of Current Evidence and Practice. Nutrients 2017. [DOI: 10.3390/nu9060661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Grass F, Pache B, Martin D, Hahnloser D, Demartines N, Hübner M. Preoperative Nutritional Conditioning of Crohn's Patients-Systematic Review of Current Evidence and Practice. Nutrients 2017; 9:nu9060562. [PMID: 28587182 PMCID: PMC5490541 DOI: 10.3390/nu9060562] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/23/2017] [Accepted: 05/30/2017] [Indexed: 12/11/2022] Open
Abstract
Crohn’s disease is an incurable and frequently progressive entity with major impact on affected patients. Up to half of patients require surgery in the first 10 years after diagnosis and over 75% of operated patients require at least one further surgery within lifetime. In order to minimize surgical risk, modifiable risk factors such as nutritional status need to be optimized. This systematic review on preoperative nutritional support in adult Crohn’s patients between 1997 and 2017 aimed to provide an overview on target populations, screening modalities, routes of administration, and expected benefits. Pertinent study characteristics (prospective vs. retrospective, sample size, control group, limitations) were defined a priori. Twenty-nine studies were retained, of which 14 original studies (9 retrospective, 4 prospective, and 1 randomized controlled trial) and 15 reviews. Study heterogeneity was high regarding nutritional regimens and outcome, and meta-analysis could not be performed. Most studies were conducted without matched control group and thus provide modest level of evidence. Consistently, malnutrition was found to be a major risk factor for postoperative complications, and both enteral and parenteral routes were efficient in decreasing postoperative morbidity. Current guidelines for nutrition in general surgery apply also to Crohn’s patients. The route of administration should be chosen according to disease presentation and patients’ condition. Further studies are needed to strengthen the evidence.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Basile Pache
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - David Martin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
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El-Hussuna A, Iesalnieks I, Horesh N, Hadi S, Dreznik Y, Zmora O. The effect of pre-operative optimization on post-operative outcome in Crohn's disease resections. Int J Colorectal Dis 2017; 32:49-56. [PMID: 27785551 DOI: 10.1007/s00384-016-2655-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The timing of surgical intervention in Crohn's disease (CD) may depend on pre-operative optimization (PO) which includes different interventions to decrease the risk for unfavourable post-operative outcome. The objective of this study was to investigate the effect of multi-model PO on the post-operative outcome in CD. METHOD This is a multicentre retrospective cohort study. The primary outcome was 30-day post-operative complications. Secondary outcomes were intra-abdominal septic complications, surgical site infection (SSI), re-operation, length of post-operative stay in a hospital and re-admission. PO included nutritional support, discontinuation of medications, pre-operative antibiotic course and thrombosis prophylaxis. RESULTS Two hundred and thirty-seven CD elective bowel resections were included. Mean age was 39.9 years SD 14.25, 144 (60.8 %) were female and 129 (54.4 %) had one or more types of medical treatment pre-operatively. Seventy-seven patients (32.5 %) optimized by at least nutritional support or change in pre-operative medications. PO patients were more likely to have penetrating disease phenotype (p = 0.034), lower albumin (p = 0.015) and haemoglobin (p = 0.021) compared to the non-optimized. Multivariate analyses showed that treatment with anti-TNF alpha agents OR 2.058 CI [1.043-4.4.064] and low haemoglobin OR 0.741 CI [0.572-0.0.961] increased the risk of overall post-operative complications. Co-morbidity increased the risk of SSI OR 2.567 CI [1.182-5.576] while low haemoglobin was a risk factor for re-admission OR 0.613 CI [0.405-0.926]. Low pre-operative albumin correlated with longer stay in hospital. CONCLUSIONS PO did not change post-operative outcome most likely due to selection bias. Anti-TNF alpha agents, low haemoglobin, low albumin and co-morbidity were associated with unfavourable outcome.
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Affiliation(s)
| | | | - Nir Horesh
- Sheba Medical Center, Tel Hashomer, Israel
| | - Sabah Hadi
- Bispiberg Hospital, 2400, Copenhagen, Denmark
| | | | - Oded Zmora
- Sheba Medical Center, Tel Hashomer, Israel
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Oliveira MAP, Pereira TRD, Gilbert A, Tulandi T, de Oliveira HC, De Wilde RL. Bowel complications in endometriosis surgery. Best Pract Res Clin Obstet Gynaecol 2016; 35:51-62. [DOI: 10.1016/j.bpobgyn.2015.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/05/2015] [Indexed: 12/17/2022]
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Chen L, Sun L, Lang Y, Wu J, Yao L, Ning J, Zhang J, Xu S. Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer. BMC Cancer 2016; 16:449. [PMID: 27401305 PMCID: PMC4940721 DOI: 10.1186/s12885-016-2506-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 07/05/2016] [Indexed: 12/21/2022] Open
Abstract
Background Our aim was to investigate the influence of FTS on human cellular and humoral immunity using a randomized controlled clinical study in esophageal cancer patients. Methods Between October 2013 and December 2014, 276 patients with esophageal cancer in our department were enrolled in the study. The patients were randomized into two groups: FTS pathway group and conventional pathway group. The postoperative hospital stay, hospitalization expenditure, and postoperative complications were recorded. The markers of inflammatory and immune function were measured before operation as well as on the 1st, 3rd, and 7th postoperative days (POD), including serum level of interleukin-6 (IL-6), C-reactive protein (CRP), serum globulin, immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA) and lymphocyte subpopulations (CD3 lymphocytes, CD4 lymphocytes, CD8 lymphocytes and the CD4/CD8 ratio) in the patients between the two groups. Results In all, 260 patients completed the study: 128 in the FTS group and 132 in the conventional group. We found implementation of FTS pathway decreases postoperative length of stay and hospital charges (P < 0.05). In addition, inflammatory reactions, based on IL-6 and CRP levels, were less intense following FTS pathway compared to conventional pathway on POD1 and POD3 (P < 0.05). On POD1 and POD3, the levels of IgG, IgA, CD3 lymphocytes, CD4 lymphocytes and the CD4/CD8 ratio in FTS group were significantly higher than those in control group (All P < 0.05). However, there were no differences in the level of IgM and CD8 lymphocytes between the two groups. Conclusions FTS improves postoperative clinical recovery and effectively inhibited release of inflammatory factors via the immune system after esophagectomy for esophageal cancer. Trial registration ChiCTR-TRC-13003562, the date of registration: August 29, 2013.
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Affiliation(s)
- Lantao Chen
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Lixin Sun
- Department of Thoracic Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yaoguo Lang
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Jun Wu
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China.,Department of Thoracic Surgery, Hainan Cancer Hospital, Haikou, Hainan Province, China
| | - Lei Yao
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Jinfeng Ning
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Jinfeng Zhang
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Shidong Xu
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China.
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Nickerson TP, Merchea A. Perioperative Considerations in Crohn Disease and Ulcerative Colitis. Clin Colon Rectal Surg 2016; 29:80-4. [PMID: 27247531 DOI: 10.1055/s-0036-1580633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The management of inflammatory bowel disease (IBD) is medically and surgically complex. Numerous patient- and disease-oriented factors must be considered in treating patients with IBD, including nutritional replenishment/support, effect of immunosuppressive medications, extent of resection, and use of proximal diversion. Perioperative planning and optimization of the patient is imperative to ensuring favorable outcomes and limiting morbidity. These perioperative considerations in Crohn disease and ulcerative colitis are reviewed here.
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Affiliation(s)
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida
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Wędrychowicz A, Zając A, Tomasik P. Advances in nutritional therapy in inflammatory bowel diseases: Review. World J Gastroenterol 2016; 22:1045-66. [PMID: 26811646 PMCID: PMC4716019 DOI: 10.3748/wjg.v22.i3.1045] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/22/2015] [Accepted: 09/13/2015] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn's disease are chronic, life-long, and relapsing diseases of the gastrointestinal tract. Currently, there are no complete cure possibilities, but combined pharmacological and nutritional therapy may induce remission of the disease. Malnutrition and specific nutritional deficiencies are frequent among IBD patients, so the majority of them need nutritional treatment, which not only improves the state of nutrition of the patients but has strong anti-inflammatory activity as well. Moreover, some nutrients, from early stages of life are suspected as triggering factors in the etiopathogenesis of IBD. Both parenteral and enteral nutrition is used in IBD therapy, but their practical utility in different populations and in different countries is not clearly established, and there are sometimes conflicting theories concerning the role of nutrition in IBD. This review presents the actual data from research studies on the influence of nutrition on the etiopathogenesis of IBD and the latest findings regarding its mechanisms of action. The use of both parenteral and enteral nutrition as therapeutic methods in induction and maintenance therapy in IBD treatment is also extensively discussed. Comparison of the latest research data, scientific theories concerning the role of nutrition in IBD, and different opinions about them are also presented and discussed. Additionally, some potential future perspectives for nutritional therapy are highlighted.
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25
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Schwartz E. Perioperative Parenteral Nutrition in Adults With Inflammatory Bowel Disease. Nutr Clin Pract 2015; 31:159-70. [DOI: 10.1177/0884533615594011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Connelly TM, Messaris E. Predictors of recurrence of Crohn’s disease after ileocolectomy: A review. World J Gastroenterol 2014; 20:14393-14406. [PMID: 25339826 PMCID: PMC4202368 DOI: 10.3748/wjg.v20.i39.14393] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 05/08/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
Recurrence after ileocolectomy for Crohn’s disease (CD) is common and occurs in up to 80% of patients. Such recurrence can result in repeated surgical interventions, an increased need for medical treatment and, frequently, an impaired quality of life. The aim of this overview is to provide a summary of the factors associated with disease recurrence after ileocolectomy for CD. Recurrence can be measured clinically or endoscopically using established scoring systems. Radiology and serologic tests can also be used, oftentimes in conjunction with endoscopy and/or clinical findings. Many patient and operative factors as well as pharmacologic treatments have been studied as potential predictors of recurrence. Of these, only smoking and immunomodulatory or biologic medical treatment have repeatedly been shown to effect recurrence. Genetic predictors have been studied and suggested but further evaluation in larger cohorts is necessary. This paper highlights validated, reproducible scoring systems for recurrence and the key findings of studies including patient demographics, operative techniques, various pharmacological treatments and histological findings as predictors of recurrence post ileocolectomy in CD.
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Wilson MZ, Connelly TM, Hollenbeak CS, Messaris E. Organ space infection following ileocolectomy for Crohn's disease: a National Surgical Quality Improvement Project study. Am J Surg 2014; 208:749-755. [PMID: 25096262 DOI: 10.1016/j.amjsurg.2014.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 04/07/2014] [Accepted: 04/18/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Organ space infection (OSI) rates post ileocolectomy for Crohn's disease are relatively high. The aim of this study was to determine which factors predispose to OSI in this patient cohort. METHODS Data for 2,618 Crohn's patients undergoing ileocolectomy between 2005 and 2011 were obtained from the American College of Surgeons National Surgical Quality Improvement Project database. Primary outcome was an OSI within 30 days of discharge. Univariate analysis using chi-square and Student t tests and a logistic multivariate analysis were performed. RESULTS Preoperative weight loss (odds ratio [OR] 2.11, P = .002), extended operating time (OR 1.57, P = .016), open procedures (OR 1.47, P = .043), and contaminated/dirty wounds (OR 1.95, P = .008) conferred an increased risk for OSI on multivariate analysis. Rates of stoma creation and steroid use were not significantly different between the groups. CONCLUSIONS Weight loss is a preoperative, potentially modifiable variable associated with OSI in Crohn's patients undergoing ileocolectomy and OSI-associated operative factors which may be noted to identify high-risk patients include extended operating time and open procedures.
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Affiliation(s)
- Matthew Z Wilson
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - Tara M Connelly
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - Christopher S Hollenbeak
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA 17033, USA; Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - Evangelos Messaris
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
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Abstract
Crohn disease is a chronic disease that is treated with aminosalicylates, antibiotics, and immunosuppressant agents. Most patients ultimately require surgical intervention and many will require additional surgery for recurrent disease. Consequently, surgery is generally performed only when medical management fails; however, these patients are often malnourished and immunosuppressed. Preoperative optimization is necessary to minimize morbidity, including intra-abdominal septic complications and anastomotic leaks. In this article, the authors review some considerations to improve the surgical outcome in Crohn disease.
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Affiliation(s)
- Amit Sharma
- Division of Colon and Rectal Surgery, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Edison, New Jersey
| | - Bertram T Chinn
- Division of Colon and Rectal Surgery, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Edison, New Jersey
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Nguyen DL, Parekh N, Bechtold ML, Jamal MM. National Trends and In-Hospital Outcomes of Adult Patients With Inflammatory Bowel Disease Receiving Parenteral Nutrition Support. JPEN J Parenter Enteral Nutr 2014; 40:412-6. [PMID: 24687967 DOI: 10.1177/0148607114528715] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 02/27/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are susceptible to protein-calorie malnutrition secondary to decreased oral intake, malabsorption, and increased metabolic expenditure. In this study, we seek to assess the national frequencies of parenteral nutrition (PN) use among hospitalized patients with IBD and to determine their in-hospital outcomes. METHODS We analyzed the Nationwide Inpatient Sample from 1988-2006 to determine the frequency of PN usage among patients with UC or CD and to determine their in-hospital outcomes. A multivariate analysis was performed to identify factors predictive of increased inpatient mortality in this population. RESULTS From 1988-2006, the annual incidence of PN use among hospitalized patients with CD was 4.29 per 100,000 and among those with UC was 3.80 per 100,000, with trends being relatively stable through the indexed period. The mean length of hospitalization among patients with UC receiving PN was longer compared with patients with CD. Factors predictive of an increased risk for mortality include the following: age >50 years, acute kidney injury, hospital-acquired pneumonia, Clostridium difficile colitis, prolonged postoperative ileus requiring PN use, pulmonary embolism, malnutrition, and patients with UC relative to CD. CONCLUSION Traditionally, patients with CD are at a higher risk for developing malnutrition than patients with UC; however, there is a 2-fold higher risk for inpatient mortality and a longer length of hospitalization among patients with UC compared with those with CD. This pattern suggests that the use of PN, particularly among patients with UC, serves as a surrogate marker of higher disease acuity and severity.
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Affiliation(s)
- Douglas L Nguyen
- Division of Gastroenterology & Hepatology, University of California, Irvine, Orange, California Division of Gastroenterology & Hepatology, Veterans Affairs Long Beach Health Care Systems, Long Beach, California
| | - Nimisha Parekh
- Division of Gastroenterology & Hepatology, University of California, Irvine, Orange, California
| | - Matthew L Bechtold
- Division of Gastroenterology & Hepatology, University of Missouri-Columbia, Columbia, Missouri
| | - M Mazen Jamal
- Division of Gastroenterology & Hepatology, University of California, Irvine, Orange, California Division of Gastroenterology & Hepatology, Veterans Affairs Long Beach Health Care Systems, Long Beach, California
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Yu G, Chen G, Huang B, Shao W, Zeng G. Effect of early enteral nutrition on postoperative nutritional status and immune function in elderly patients with esophageal cancer or cardiac cancer. Chin J Cancer Res 2013; 25:299-305. [PMID: 23825906 DOI: 10.3978/j.issn.1000-9604.2013.06.01] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 05/25/2013] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To explore the effect of early enteral nutrition (EN) on postoperative nutritional status, intestinal permeability, and immune function in elderly patients with esophageal cancer or cardiac cancer. METHODS A total of 96 patients with esophageal cancer or cardiac cancer who underwent surgical treatment in our hospital from June 2007 to December 2010 were enrolled in this study. They were divided into EN group (n=50) and parenteral nutrition (PN) group (n=46) based on the nutrition support modes. The body weight, time to first flatus/defecation, average hospital stay, complications and mortality after the surgery as well as the liver function indicators were recorded and analyzed. Peripheral blood samples were collected on the days 1, 4 and 7 after surgery. The plasma diamine oxidase (DAO) activity and D-lactate level were determined to assess the intestinal permeability. The plasma endotoxin levels were determined using dynamic turbidimetric assay to assess the protective effect of EN on intestinal mucosal barrier. The postoperative blood levels of inflammatory cytokines and immunoglobulins were determined using enzyme-linked immunosorbent assay (ELISA). RESULTS After the surgery, the time to first flatus/defecation, average hospital stay, and complications were significantly less in the EN group than those in the PN group (P<0.05), whereas the EN group had significantly higher albumin levels than the PN group (P<0.05). On the 7th postoperative day, the DAO activity, D-lactate level and endotoxin contents were significantly lower in the EN group than those in the PN group (all P<0.05). In addition, the EN group had significantly higher IgA, IgG, IgM, and CD4 levels than the PN group (P<0.05) but significantly lower IL-2, IL-6, and TNF-α levels (P<0.05). CONCLUSIONS In elderly patients with esophageal cancer or cardiac cancer, early EN after surgery can effectively improve the nutritional status, protect intestinal mucosal barrier (by reducing plasma endoxins), and enhance the immune function.
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Affiliation(s)
- Guiping Yu
- Department of Cardiothoracic Surgery, The Affiliated Jiangyin Hospital, Southeast University Medical College, Jiangyin 214400, China
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