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Matsui R, Sagawa M, Sano A, Sakai M, Hiraoka SI, Tabei I, Imai T, Matsumoto H, Onogawa S, Sonoi N, Nagata S, Ogawa R, Wakiyama S, Miyazaki Y, Kumagai K, Tsutsumi R, Okabayashi T, Uneno Y, Higashibeppu N, Kotani J. Impact of Perioperative Immunonutrition on Postoperative Outcomes for Patients Undergoing Head and Neck or Gastrointestinal Cancer Surgeries: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2024; 279:419-428. [PMID: 37882375 PMCID: PMC10829905 DOI: 10.1097/sla.0000000000006116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To clarify whether perioperative immunonutrition is effective in adult patients with or without malnutrition undergoing elective surgery for head and neck (HAN) or gastrointestinal (GI) cancers. BACKGROUND It is important to avoid postoperative complications in patients with cancer as they can compromise clinical outcomes. There is no consensus on the efficacy of perioperative immunonutrition in patients with or without malnutrition undergoing HAN or GI cancer surgery. MATERIALS AND METHODS We searched MEDLINE (PubMed), MEDLINE (OVID), EMBASE, Cochrane Central Register of Controlled Trials, Web of Science Core Selection, and Emcare from 1981 to 2022 using search terms related to immunonutrition and HAN or GI cancer. We included randomized controlled trials. Intervention was defined as immunonutritional therapy including arginine, n-3 omega fatty acids, or glutamine during the perioperative period. The control was defined as standard nutritional therapy. The primary outcomes were total postoperative and infectious complications, defined as events with a Clavien-Dindo classification grade ≥ II that occurred within 30 days after surgery. RESULTS Of the 4825 patients from 48 included studies, 19 had upper GI cancer, 9 had lower, and 8 had mixed cancer, whereas 12 had HAN cancers. Immunonutrition reduced the total postoperative complications (relative risk ratio: 0.78; 95% CI, 0.66-0.93; certainty of evidence: high) and infectious complications (relative risk ratio: 0.71; 95% CI, 0.61-0.82; certainty of evidence: high) compared with standard nutritional therapy. CONCLUSIONS Nutritional intervention with perioperative immunonutrition in patients with HAN and GI cancers significantly reduced total postoperative complications and infectious complications.
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Affiliation(s)
- Ryota Matsui
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Ariake, Koto, Tokyo, Japan
| | - Masano Sagawa
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, Tokyo Women’s Medical University Adachi Medical Center, Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Akihiko Sano
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of General Surgical Science, Division of Gastroenterological Surgery, Gunma University, Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Makoto Sakai
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of General Surgical Science, Division of Gastroenterological Surgery, Gunma University, Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Shin-ichiro Hiraoka
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- 1st Department of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Osaka University, Suita, Osaka, Japan
| | - Isao Tabei
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, The Jikei University School of Medicine, Daisan Hospital, Minato-ku, Tokyo, Japan
| | - Takayuki Imai
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Hideo Matsumoto
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, Public Mitsugi General Hospital, Onomichi, Hiroshima, Japan
| | - Seiji Onogawa
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Hiroshima, Japan
| | - Norihiro Sonoi
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Center for Education in Medicine and Health Sciences, Okayama University Kita Ward, Okayama, Japan
| | - Shigeyuki Nagata
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Naka Ward, Hiroshima, Japan
| | - Ryo Ogawa
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku Nagoya, Japan
| | - Shigeki Wakiyama
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, Machida Municipal Hospital, Nagoya-shi, Aichi, Japan
| | - Yasuhiro Miyazaki
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Osaka General Medical Center, Sumiyoshi Ward, Osaka, Japan
| | - Koshi Kumagai
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Ariake, Koto, Tokyo, Japan
| | - Rie Tsutsumi
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Nutrition and Metabolism, Institute of Health Biosciences, Tokushima University Graduate School, Kuramoto-cho, Tokushima, Japan
| | - Takehiro Okabayashi
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kohasu, Oko-cho, Nankoku-shi, Kochi, Japan
| | - Yu Uneno
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, Japan
| | - Naoki Higashibeppu
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Minatojima Minamimachi, Chuo-ku, Kobe City, Japan
| | - Joji Kotani
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery Related, Division of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Chuo-ward, Kobe, Japan
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Costantino A, Sampieri C, Pace GM, Festa BM, Cerri L, Giordano GG, Dalè M, Spriano G, Peretti G, De Virgilio A. Development of machine learning models for the prediction of long-term feeding tube dependence after oral and oropharyngeal cancer surgery. Oral Oncol 2024; 148:106643. [PMID: 38006688 DOI: 10.1016/j.oraloncology.2023.106643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/11/2023] [Accepted: 11/16/2023] [Indexed: 11/27/2023]
Abstract
PURPOSE To predict the necessity of enteral nutrition at 28 days after surgery in patients undergoing major head and neck oncologic procedures for oral and oropharyngeal cancers. MATERIAL AND METHODS Data from 193 patients with oral cavity and oropharyngeal squamous cell carcinoma were retrospectively collected at two tertiary referral centers to train (n = 135) and validate (n = 58) six supervised machine learning (ML) models for binary prediction employing 29 clinical variables available pre-operatively. RESULTS The accuracy of the six ML models ranged between 0.74 and 0.88, while the measured area under the curve (AUC) between 0.75 and 0.87. The ML algorithms showed high specificity (range 0.87-0.96) and moderate sensitivity (range: 0.31-0.77) in detecting patients with ≥28 days feeding tube dependence. Negative predictive value was higher (range: 0.81-0.93) compared to positive predictive value (range: 0.40-0.71). Finally, the F1 score ranged between 0.35 and 0.74. CONCLUSIONS Classification performance of the ML algorithms showed optimistic accuracy in the prediction of enteral nutrition at 28 days after surgery. Prospective studies are mandatory to define the clinical benefit of a ML-based pre-operative prediction of a personalized nutrition protocol.
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Affiliation(s)
- Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele (MI), Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano (MI), Italy
| | - Claudio Sampieri
- Department of Medical Science (DIMES), University of Genoa, Genoa, Italy; Functional Unit of Head and Neck Tumors, Hospital Clínic, Barcelona, Spain; Otorhinolaryngology Department, Hospital Clínic, Barcelona, Spain.
| | - Gian Marco Pace
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele (MI), Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano (MI), Italy
| | - Bianca Maria Festa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele (MI), Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano (MI), Italy
| | - Luca Cerri
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele (MI), Italy
| | - Giorgio Gregory Giordano
- Unit of Otorhinolaryngology-Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Michael Dalè
- Unit of Otorhinolaryngology-Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele (MI), Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano (MI), Italy
| | - Giorgio Peretti
- Unit of Otorhinolaryngology-Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele (MI), Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano (MI), Italy
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Tay VXP, Mohamed Noor NA, Tan LB. Effects of fibre-supplemented enteral feeds on bowel function of non-critically ill tube-fed adults: a meta-analysis of randomised controlled trials. Br J Nutr 2023; 130:2076-2087. [PMID: 37272621 DOI: 10.1017/s0007114523001289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Diarrhoea is common in enterally fed patients and can impact their nutritional and overall outcomes. This meta-analysis evaluates the potential benefits of fibre-supplemented (FS) feeds on incidence of diarrhoea and stool frequency in non-critically ill tube-fed adults. Databases including PubMed, Embase and CINAHL with full text were searched for randomised controlled trials (RCT) with adults on exclusive tube feeding, published until August 2022. The Cochrane Collaboration's tool was used for quality assessment. Studies with published results on incidence of diarrhoea and stool frequency were analysed using RevMan 5. Thirteen RCT with 847 non-critically ill patients between 20 and 90 years old without diarrhoea at the onset of enteral feeding were included. Study duration ranged from 3 to 35 d. Nine papers investigated the incidence of diarrhoea where intervention group was given FS and control was given non-fibre-supplemented (NFS) enteral feeds. Those receiving FS feeds were significantly less likely to experience diarrhoea as compared with those using NFS feeds (OR 0·44; 95 % CI 0·20, 0·95; P = 0·04; I2 = 71 %). Combined analysis showed no differences in stool frequency in those receiving NFS feeds (SMD 0·32; 95 % CI -0·53, 1·16; P = 0·47; I2 = 90 %). Results should be interpreted with caution due to considerable heterogeneity between study population, assessment tool for diarrhoea, potential conflict of interest and short duration of studies. This meta-analysis shows that FS feeds can reduce the incidence of diarrhoea in non-critically ill adults; however, the effects of stool frequency remain debatable.
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Affiliation(s)
- Valerie Xin Pei Tay
- Department of Dietetics, Singapore General Hospital, Outram Road Singapore 169608, Singapore
| | | | - Lee Boo Tan
- Department of Dietetics, Singapore General Hospital, Outram Road Singapore 169608, Singapore
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Sampieri C, Costantino A, Giordano GG, Dalè M, Marchi F, Iandelli A, Filauro M, Parrinello G, Pace GM, Festa BM, Spriano G, De Virgilio A, Peretti G. Predicting the need for prophylactic gastrostomy in major head and neck cancer surgery: The PEG score. Head Neck 2023; 45:3042-3052. [PMID: 37789705 DOI: 10.1002/hed.27532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/03/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND To elaborate a preoperative score to predict the necessity of enteral nutrition at 28 days postoperatively in patients undergoing head and neck surgery. METHODS A total of 424 patients with oral cavity, oropharyngeal, laryngeal, and hypopharyngeal carcinoma were retrospectively enrolled and analyzed to identify preoperative predictors of prolonged postsurgical enteral feeding which were used to create a prediction model with an easy-to-use nomogram. RESULTS Five preoperative variables (body mass index, previous radiotherapy, preoperative dysphagia, type of surgery, flap reconstruction) were found to be independent predictive factors and were used to create a prediction model named PEG score together with the related nomogram. Accuracy, F1, and the area under the curve (AUC) were 0.74, 0.83, and 0.74. Different decision thresholds can be used to vary the sensitivity and specificity. CONCLUSIONS The PEG score showed high prediction performances for modeling the need for enteral nutrition at 28 days postoperatively. Prospective studies are needed to define a personalized nutrition protocol.
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Affiliation(s)
- Claudio Sampieri
- Department of Medical Science (DIMES), University of Genoa, Genoa, Italy
- Otorhinolaryngology Department, Hospital Clínic, Barcelona, Spain
- Functional Unit of Head and Neck Tumors, Hospital Clínic, Barcelona, Spain
| | - Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Giorgio Gregory Giordano
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Michael Dalè
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Filippo Marchi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Iandelli
- Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marta Filauro
- Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giampiero Parrinello
- Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gian Marco Pace
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Bianca Maria Festa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Giorgio Peretti
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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5
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Ascoli A, Missale F, Giordano GG, Vallin A, Gradaschi R, Guiddo E, Schenone G, Sukkar SG, Copello F, Parrinello G, Iandelli A, Peretti G, Marchi F. Immunonutrition in major oncologic head and neck surgery: Analysis of complications, plasmatic equilibrium, and costs. Head Neck 2023; 45:449-463. [PMID: 36490206 DOI: 10.1002/hed.27270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/27/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Malnutrition, in patients with solid tumors, is associated with a worse clinical outcome and about 40% of patients affected by head and neck cancers (HNC) are malnourished at the time of cancer diagnosis. We investigated the potential benefit of a standardized immunonutritional protocol (INP) to patients with HNC receiving major ablative surgery. METHODS An observational study was conducted enrolling 199 patients: 50 treated with the INP and 149 with standard enteral nutrition. Complication rates, need for medications, and costs were considered as outcomes. RESULTS INP played a protective role in development of major surgical complications (OR 0.23, p = 0.023), albumin administration (RR 0.38, p = 0.018), and antibiotic duration (p < 0.001) and is cost-effective in patients with moderate or severe malnutrition (-6083€ and -11 988€, p < 0.05). CONCLUSIONS Our study supports the utility of INP, and accurate nutritional screening can help to identify malnourished patients who would receive the most benefits from this protocol.
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Affiliation(s)
- Alessandro Ascoli
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Francesco Missale
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Department of Head & Neck Oncology & Surgery Otorhinolaryngology, Antoni Van Leeuwenhoek, Nederlands Kanker Instituut, Amsterdam, The Netherlands
| | - Giorgio-Gregory Giordano
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Alberto Vallin
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Raffaella Gradaschi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Dietetics and Clinical Nutrition Unit, University of Genova, Genoa, Italy
| | - Erica Guiddo
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Dietetics and Clinical Nutrition Unit, University of Genova, Genoa, Italy
| | | | - Samir Giuseppe Sukkar
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Dietetics and Clinical Nutrition Unit, University of Genova, Genoa, Italy
| | - Francesco Copello
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Occupational Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | - Giorgio Peretti
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Filippo Marchi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
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Dechaphunkul T, Arundon T, Raungkhajon P, Jiratrachu R, Geater SL, Dechaphunkul A. Benefits of immunonutrition in patients with head and neck cancer receiving chemoradiation: A phase II randomized, double-blind study. Clin Nutr 2021; 41:433-440. [PMID: 35007812 DOI: 10.1016/j.clnu.2021.12.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/07/2021] [Accepted: 12/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND & AIMS The benefits of immunonutrition in patients with head and neck cancer (HNC), especially for those undergoing definitive concurrent chemoradiation (CCRT), remain unclear. We evaluated the benefits of immunonutrition regarding the prevention of severe oral mucositis. Secondary objectives included assessments of other treatment-related toxicities, changes of nutritional and inflammatory marker levels, treatment tolerance, and survival. METHODS In total, 110 patients with HNC undergoing definitive CCRT including 3-week cycles of cisplatin were enrolled in our double-blind phase II study. Patients were randomly assigned to receive an immunonutrient formula containing omega-3-fatty acids, arginine, dietary nucleotides, and soluble fiber (n = 55) or an isocaloric isonitrogenous control (n = 55). All patients received the assigned product 5 consecutive days before each chemotherapy session. The proportion of patients with severe oral mucositis was compared between the immunonutrients and control groups. RESULTS The rates of nasopharyngeal cancer (NPC) were 67% and 51% in the immunonutrients and control groups, respectively. All patients had 100% compliance to the assigned product. There was no difference of the proportion of patients with grade 3-4 oral mucositis between the two groups (62% vs. 67%, p = 0.690). At the time of analyses, survival tended to be better in the immunonutrients group. The 3-year progression-free survival rates were 69% (95% confidence interval [CI] = 55%-80%) and 44% (95% CI = 30%-57%) in the immunonutrients and control groups, respectively (p = 0.056), whereas the 3-year overall survival rates in these groups were 69% (95% CI = 54%-80%) and 50% (95% CI = 36%-66%; p = 0.065), respectively. In subgroup analyses according to the primary tumor location, the survival benefits were apparently maintained in patients with NPC. CONCLUSIONS Although our study did not demonstrate a reduced risk of severe oral mucositis, we found that immunonutrition might improve survival. Larger studies are needed to determine the optimal dose and schedule of immunonutrition to prevent oral mucositis. In addition, randomized phase III trials evaluating the survival benefits of immunonutrition in patients with cancer are required, and NPC might be a primary malignancy of interest. TRIAL REGISTRATION ClinicalTrials.gov ID NCT05101889.
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Affiliation(s)
- Tanadech Dechaphunkul
- Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Tippawan Arundon
- Holistic Center for Cancer Study and Care (HOCC-PSU), Unit of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Ponpis Raungkhajon
- Nutrition Dietetics Division, Songklanagarind Hospital, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Rungarun Jiratrachu
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Sarayut Lucien Geater
- Division of Respiratory and Respiratory Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
| | - Arunee Dechaphunkul
- Holistic Center for Cancer Study and Care (HOCC-PSU), Unit of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Hatyai, Songkhla, 90110, Thailand.
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Effect of a perioperative immune-enhancing diet in clean-contaminated head and neck cancer surgery: A randomized controlled trial. Int J Surg 2021; 93:106051. [PMID: 34371175 DOI: 10.1016/j.ijsu.2021.106051] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 07/09/2021] [Accepted: 08/06/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Malnutrition is a common problem in head and neck cancer patients and is associated with an increased risk of postoperative complications and prolonged length of hospital stay (LOS). The purpose of this study was to evaluate the effect of an immune-enhancing diet with supplementary arginine, glutamine, and fish oil in clean-contaminated head and neck cancer surgery. MATERIALS AND METHODS A randomized controlled trial study in clean-contaminated head and neck cancer surgery patients was conducted. Patients undergoing surgery received either an immune-enhancing diet or hospital-prepared blenderized diet 7 days preoperatively and 14 days postoperatively. Clinical outcomes (mucocutaneous fistula, wound infection, general infection, LOS, and hospital costs) and nutritional parameters (body weight, prealbumin, transferrin, and albumin) were compared between the two groups. RESULTS 116 patients were included in the analysis, 60 in the immune-enhancing diet group and 56 in the blenderized diet group. There was a significant association between the immune-enhancing diet and the decrease in fistula rate (8.3 % vs. 23.2 %, p = 0.039), LOS (24 days vs. 29 days, p = 0.043), hospital costs (6312 US dollars vs. 7461 US dollars, p = 0.048), and higher prealbumin level on postoperative day 7 and 14 (p = 0.015 and 0.001, respectively) and transferrin level on postoperative day 14 (p = 0.047). In addition, the immune-enhancing diet also had a positive effect on body weight on postoperative day 14 (p = 0.028). However, there was no difference in nutrition-related adverse events between the two groups. CONCLUSION The administration of a perioperative diet containing arginine, glutamine, and fish oil in clean-contaminated head and neck cancer surgery patients led to a significant reduction in mucocutaneous fistula, LOS, and hospital costs. Results also indicated improved nutritional status, including body weight, prealbumin, and transferrin levels.
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Digestion-Specific Acupuncture Effect on Feeding Intolerance in Critically Ill Post-Operative Oral and Hypopharyngeal Cancer Patients: A Single-Blind Randomized Control Trial. Nutrients 2021; 13:nu13062110. [PMID: 34205461 PMCID: PMC8234819 DOI: 10.3390/nu13062110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 12/13/2022] Open
Abstract
Malnourishment is prevalent in patients suffering from head and neck cancer. The postoperative period is crucial in terms of nutritional support, especially after composite resection and reconstruction surgery. These patients present with a number of risk factors that aggravate feeding intolerance, including postoperative status, prolonged immobility, decreased head elevation, mechanical ventilation, and applied sedative agents. Routine management protocols for feeding intolerance include prokinetic drug use and post-pyloric tube insertion, which could be both limited and accompanied by detrimental adverse events. This single-blind clinical trial aimed to investigate the effects of acupuncture in postoperative feeding intolerance in critically ill oral and hypopharyngeal cancer patients. Twenty-eight patients were randomized into two groups: Intervention group and Control group. Interventions were administered daily over three consecutive postoperative days. The primary outcome revealed that the intervention group reached 70% and 80% of target energy expenditure (EE) significantly earlier than the control group (4.00 ± 1.22 versus 6.69 ± 3.50 days, p = 0.012), accompanied by higher total calorie intake within the first postoperative week (10263.62 ± 1086.11 kcals versus 8384.69 ± 2120.05 kcals, p = 0.004). Furthermore, the intervention group also needed less of the prokinetic drug (Metoclopramide, 20.77 ± 48.73 mg versus 68.46 ± 66.56 mg, p = 0.010). In conclusion, digestion-specific acupuncture facilitated reduced postoperative feeding intolerance in oral and hypopharyngeal cancer patients.
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Ralph N, Brown L, McKillop KL, Duff J, Osborne S, Terry VR, Edward KL, King R, Barui E. Oral nutritional supplements for preventing surgical site infections: protocol for a systematic review and meta-analysis. Syst Rev 2020; 9:37. [PMID: 32079543 PMCID: PMC7031994 DOI: 10.1186/s13643-020-01293-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 02/09/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are among the most common healthcare-associated infections. Under-nutrition is an important risk factor for SSIs and can lead to delayed wound healing and longer hospital stays. Oral nutritional supplements are prescribed to reduce the risk of infection and improve health status, but data from randomised controlled trials (RCTs) have shown mixed results. Thus, the objective of our planned systematic review is to evaluate oral nutritional supplements on preventing SSIs in adult surgical patients METHODS: RCTs conducted in adult surgical patients who receive oral nutritional support will be included. The primary outcome will be the incidence of SSIs (within 30 days of surgery or within 90 days for joint replacement surgery). Secondary outcomes will be changes in nutritional status, mortality, health-related quality of life and costs. Literature searches will be conducted in several electronic databases (from inception onwards): MEDLINE, Embase, CINAHL and The Cochrane Central Register of Controlled Trials (CENTRAL). Grey literature will be identified through searching clinical trial registers and dissertation databases. Two reviewers will independently screen all citations, full-text articles and abstract data. The study methodological quality (or bias) will be appraised using the Cochrane risk of bias tool. If feasible, we will conduct random effects meta-analysis where appropriate. DISCUSSION This systematic review will evaluate the evidence for pre- and post-surgical intervention with oral nutritional supplements in adults. Findings from this planned review may inform subsequent nutritional interventions for hospitalised patients who undergo surgery. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020140954.
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Affiliation(s)
- Nicholas Ralph
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
- Division of Research and Innovation, University of Southern Queensland, Toowoomba, Australia
- Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Lindsay Brown
- School of Health and Wellbeing, University of Southern Queensland, Toowoomba, Australia
| | | | - Jed Duff
- School of Nursing and Midwifery, The University of Newcastle, Callaghan, Australia
| | - Sonya Osborne
- School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Victoria R. Terry
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
| | | | - Rachel King
- School of Sciences, University of Southern Queensland, Toowoomba, Australia
| | - Edward Barui
- St Vincent’s Private Hospital, Toowoomba, Australia
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Chitapanarux I, Traisathit P, Chitapanarux T, Jiratrachu R, Chottaweesak P, Chakrabandhu S, Rasio W, Pisprasert V, Sripan P. Arginine, glutamine, and fish oil supplementation in cancer patients treated with concurrent chemoradiotherapy: A randomized control study. Curr Probl Cancer 2020; 44:100482. [DOI: 10.1016/j.currproblcancer.2019.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/15/2019] [Indexed: 11/17/2022]
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Mueller SA, Mayer C, Bojaxhiu B, Aeberhard C, Schuetz P, Stanga Z, Giger R. Effect of preoperative immunonutrition on complications after salvage surgery in head and neck cancer. J Otolaryngol Head Neck Surg 2019; 48:25. [PMID: 31151486 PMCID: PMC6544965 DOI: 10.1186/s40463-019-0345-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 05/16/2019] [Indexed: 11/17/2022] Open
Abstract
Background Patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma are at high risk of postoperative complications due to the adverse effects of radiotherapy on wound healing. Malnutrition is an additional risk factor and we tested the hypothesis that preoperative administration of immunonutrition would decrease complications in this high risk population. Methods This single armed study with historical control included consecutive patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma. We compared outcomes before and after implementation of preoperative immunonutrition and adjusted the regression analysis for gender, age, body mass index, Nutritional Risk Screening (NRS 2002), tobacco and alcohol consumption, tumor localization, tumor stage, and type of surgery. The primary endpoint was overall complications from surgery within a follow-up of 30 days. Results Ninety-six patients were included (intervention group: 51, control group: 45). Use of preoperative immunonutrition was associated with a significant reduction in overall complications (35% vs. 58%, fully-adjusted odds ratio 0.30 (95%CI 0.10–0.91, p = 0.034). Length of hospital stay was also significantly reduced (17 days vs. 6 days, p = < 0.001). No differences in mortality and hospital readmission were found. These results remained robust in multivariate analysis. Conclusions In patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma, preoperative immunonutrition exhibited favorable effects on the complication rate and consequently reduced the length of hospital stay. By improving both tissue regeneration and immune response, immunonutrition may help to improve surgical outcomes in this high-risk population.
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Affiliation(s)
- Simon Andreas Mueller
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Catherine Mayer
- Department of Diabetes, Endocrinology, Clinical Nutrition and Metabolism Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Beat Bojaxhiu
- Department of Radiation Oncology Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Carla Aeberhard
- Department of Diabetes, Endocrinology, Clinical Nutrition and Metabolism Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Philipp Schuetz
- Department of Endocrinology, Diabetes and Clinical Nutrition University Department of Internal Medicine, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Clinical Nutrition and Metabolism Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Roland Giger
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
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Howes N, Atkinson C, Thomas S, Lewis SJ. Immunonutrition for patients undergoing surgery for head and neck cancer. Cochrane Database Syst Rev 2018; 8:CD010954. [PMID: 30160300 PMCID: PMC6513580 DOI: 10.1002/14651858.cd010954.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
| | - Charlotte Atkinson
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreUpper Maudlin StreetBristolAvonUKBS2 8AE
| | - Steven Thomas
- University Hospitals Bristol NHS TrustHead & Neck SurgeryMarlborough StreetBristolUKBS1 3NU
| | - Stephen J Lewis
- Derriford HospitalDepartment of GastroenterologyDerriford RoadPlymouthDevonUKPL6 8DH
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Abstract
BACKGROUND Randomized controlled trials demonstrate the efficacy of arginine-enriched nutritional supplements (immunonutrition) in reducing complications after surgery. The effectiveness of preoperative immunonutrition has not been evaluated in a community setting. OBJECTIVE This study aims to determine whether immunonutrition before elective colorectal surgery improves outcomes in the community at large. DESIGN This is a prospective cohort study with a propensity score-matched comparative effectiveness evaluation. SETTINGS This study was conducted in Washington State hospitals in the Surgical Care Outcomes Assessment Program from 2012 to 2015. PATIENTS Adults undergoing elective colorectal surgery were selected. INTERVENTIONS Surgeons used a preoperative checklist that recommended that patients take oral immunonutrition (237 mL, 3 times daily) for 5 days before elective colorectal resection. MAIN OUTCOME MEASURES Serious adverse events (infection, anastomotic leak, reoperation, and death) and prolonged length of stay were the primary outcomes measured. RESULTS Three thousand three hundred seventy-five patients (mean age 59.9 ± 15.2 years, 56% female) underwent elective colorectal surgery. Patients receiving immunonutrition more commonly were in a higher ASA class (III-V, 44% vs 38%; p = 0.01) or required an ostomy (18% vs 14%; p = 0.02). The rate of serious adverse events was 6.8% vs 8.3% (p = 0.25) and the rate of prolonged length of stay was 13.8% vs 17.3% (p = 0.04) in those who did and did not receive immunonutrition. After propensity score matching, covariates were similar among 960 patients. Although differences in serious adverse events were nonsignificant (relative risk, 0.76; 95% CI, 0.49-1.16), prolonged length of stay (relative risk, 0.77; 95% CI, 0.58-1.01 p = 0.05) was lower in those receiving immunonutrition. LIMITATIONS Patient compliance with the intervention was not measured. Residual confounding, including surgeon-level heterogeneity, may influence estimates of the effect of immunonutrition. CONCLUSIONS Reductions in prolonged length of stay, likely related to fewer complications, support the use of immunonutrition in quality improvement initiatives related to elective colorectal surgery. This population-based study supports previous trials of immunonutrition, but shows a lower magnitude of benefit, perhaps related to compliance or a lower rate of adverse events, highlighting the value of community-based assessments of comparative effectiveness.
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New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. THE LANCET. INFECTIOUS DISEASES 2016; 16:e276-e287. [PMID: 27816413 DOI: 10.1016/s1473-3099(16)30398-x] [Citation(s) in RCA: 453] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/27/2016] [Accepted: 09/13/2016] [Indexed: 12/13/2022]
Abstract
Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.
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Kim JM, Sung MK. The Efficacy of Oral Nutritional Intervention in Malnourished Cancer Patients: a Systemic Review. Clin Nutr Res 2016; 5:219-236. [PMID: 27812512 PMCID: PMC5093220 DOI: 10.7762/cnr.2016.5.4.219] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 10/15/2016] [Accepted: 10/26/2016] [Indexed: 12/18/2022] Open
Abstract
Cancer is currently a leading cause of deaths worldwide and the number of new cases is growing rapidly in both, developed and developing countries. Nutritional management during and after cancer treatment affects treatment efficacy and patient quality of life (QOL). This review systemically examined the effect of oral nutritional interventions on nutritional and clinical outcomes in cancer patients. We especially focused on outcomes such as nutritional status indices, immune-associated biochemical markers, and QOL assessments to provide insights on the applicability of different outcomes. A total of 28 papers were selected for systematic review. The nutritional composition of oral nutritional supplements (ONS), outcome measures, and efficacy of the oral nutritional interventions were summarized and discussed. Most ONS contain 1 or more functional components in addition to basic nutrients. Each study used various outcome measures and significant efficacy was observed for a limited number of measures. Nutritional status indices, QOL measures, and the duration of hospital stay improved in about 40% of the studies. One or more markers of immune function and inflammatory responses were improved by ONS in 65% of the selected studies. These results suggest that appropriate use of ONS may be an ideal way to improve treatment efficacy; however, additional intervention trials are required to confirm these findings.
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Affiliation(s)
- Jin-Min Kim
- Department of Food and Nutrition, Sookmyung Women's University, Seoul 04310, Korea
| | - Mi-Kyung Sung
- Department of Food and Nutrition, Sookmyung Women's University, Seoul 04310, Korea
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Garg RK, Wieland AM, Hartig GK, Poore SO. Risk factors for unplanned readmission following head and neck microvascular reconstruction: Results from the National Surgical Quality Improvement Program, 2011-2014. Microsurgery 2016; 37:502-508. [DOI: 10.1002/micr.30116] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/01/2016] [Accepted: 09/09/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Ravi K. Garg
- Division of Plastic and Reconstructive Surgery, Department of Surgery; University of Wisconsin; Madison Wisconsin
| | - Aaron M. Wieland
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery; University of Wisconsin; Madison Wisconsin
| | - Gregory K. Hartig
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery; University of Wisconsin; Madison Wisconsin
| | - Samuel O. Poore
- Division of Plastic and Reconstructive Surgery, Department of Surgery; University of Wisconsin; Madison Wisconsin
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Bharadwaj S, Trivax B, Tandon P, Alkam B, Hanouneh I, Steiger E. Should perioperative immunonutrition for elective surgery be the current standard of care? Gastroenterol Rep (Oxf) 2016; 4:87-95. [PMID: 27081153 PMCID: PMC4863194 DOI: 10.1093/gastro/gow008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 02/23/2016] [Indexed: 12/22/2022] Open
Abstract
Postoperative infectious complications are independently associated with increased hospital length of stay (LOS) and cost and contribute to significant inpatient morbidity. Many strategies such as avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, metabolic control and early mobilization have been used to either prevent or reduce the incidence of postoperative infections. Despite these efforts, it remains a big challenge to our current healthcare system to mitigate the cost of postoperative morbidity. Furthermore, preoperative nutritional status has also been implicated as an independent risk factor for postoperative morbidity. Perioperative nutritional support using enteral and parenteral routes has been shown to decrease postoperative morbidity, especially in high-risk patients. Recently, the role of immunonutrition (IMN) in postoperative infectious complications has been studied extensively. These substrates have been found to positively modulate postsurgical immunosuppression and inflammatory responses. They have also been shown to be cost-effective by decreasing both tpostoperative infectious complications and hospital LOS. In this review, we discuss the postoperative positive outcomes associated with the use of perioperative IMN, their cost-effectiveness, current guidelines and future clinical implications.
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Affiliation(s)
- Shishira Bharadwaj
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Brandon Trivax
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Parul Tandon
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Bilal Alkam
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ibrahim Hanouneh
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ezra Steiger
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
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Rowan NR, Johnson JT, Fratangelo CE, Smith BK, Kemerer PA, Ferris RL. Utility of a perioperative nutritional intervention on postoperative outcomes in high-risk head & neck cancer patients. Oral Oncol 2016; 54:42-6. [PMID: 26803343 DOI: 10.1016/j.oraloncology.2016.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Investigate both the utility and feasibility of perioperative nutritional supplementation with an arginine-enriched immunonutrition formula to high-risk head and neck cancer surgical patients and examine its effects on acute post-operative clinical outcomes. MATERIALS & METHODS This prospective, non-randomized, interventional cohort study compared high-risk head and neck cancer surgical patients who consumed a pre- and post-operative arginine-based nutritional supplement to those that did not. Outcome measures included post-operative complications, length of hospitalization, readmission rates and measurement of nutritional biomarkers. RESULTS 195 high-risk head and neck cancer surgical patients were enrolled. 59% of the patients used the nutritional supplement, 41% did not. Of the 80 patients who did not receive the immunonutrition formula, 38 (47.5%) experienced post-operative complications of all types as compared to 29 of the 115 (25.2%) patients who did consume the product (p=0.0021). Pharyngeal leaks or fistulas were the most common post-operative complications in both groups and more common in patients who did not receive supplementation (p=0.007). Length of stay was on average 2.8 days longer in patients who did not have enhanced nutrition (p=0.02), while readmission rates between the two groups were similar (p=0.91). Measurements of nutritional biomarkers were not reported secondary to low collection rates. CONCLUSION Enhanced perioperative nutrition may result in significant reductions of post-operative fistula formations and decreased length of stay in a high-risk head and neck cancer population, even in the setting of poor compliance. The potential quality improvement in both patient care and healthcare cost is both real and significant.
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Affiliation(s)
- Nicholas R Rowan
- University of Pittsburgh Medical Center, Department of Otolaryngology Head & Neck Surgery, Eye & Ear Institute, Suite 500, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Jonas T Johnson
- University of Pittsburgh Medical Center, Department of Otolaryngology Head & Neck Surgery, Eye & Ear Institute, Suite 500, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Christina E Fratangelo
- University of Pittsburgh Medical Center, Department of Otolaryngology Head & Neck Surgery, Eye & Ear Institute, Suite 500, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Brenda K Smith
- UPMC Montefiore Hospital, Same Day Surgery Services, 3459 Fifth Avenue, Pittsburgh, PA 15213, United States.
| | - Patricia A Kemerer
- University of Pittsburgh Medical Center, Department of Otolaryngology Head & Neck Surgery, Eye & Ear Institute, Suite 500, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Robert L Ferris
- University of Pittsburgh Medical Center, Department of Otolaryngology Head & Neck Surgery, Eye & Ear Institute, Suite 500, 200 Lothrop St., Pittsburgh, PA 15213, United States.
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Papanikolopoulou A, Syrigos KN, Drakoulis N. The role of glutamine supplementation in thoracic and upper aerodigestive malignancies. Nutr Cancer 2015; 67:231-7. [PMID: 25629996 DOI: 10.1080/01635581.2015.990572] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In cancer patients, marked glutamine (gln) depletion develops over time. Host tissues (epithelial cells and lymphocytes) that depend upon adequate stores of gln for optimal functioning can be negatively influenced. In addition, radiation and/or chemotherapy cause normal tissues damage that might be enhanced by this depletion effect. The present review evaluates in vivo clinical data about the potential beneficial role of gln administration in the prevention of host tissue toxicity, in a patient group with thoracic and upper aerodigestive malignancies (T&UAM) during cancer treatment. Publications were identified in a systematic review of MEDLINE Database from the last 2 decades (1994-2014) using key search terms and through manual searches. Overall, 13 clinical studies (9 oral/4 parenteral) evaluated the safety and tolerance of gln supply, showing a beneficial effect in the grade, duration of mucositis and esophagitis, decreased gut permeability, and weight loss. Only 1 Phase 1 clinical trial had negative results because the chemo-radiotherapy combined treatment was not feasible. The use of oral gln may especially have an important role in the prevention of acute radiation toxicities, the weight loss and the need for analgesics in patients with T&UAM, especially if the treatment plan includes combined modality therapy with chemo-radiation.
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Ellinger S. Micronutrients, Arginine, and Glutamine: Does Supplementation Provide an Efficient Tool for Prevention and Treatment of Different Kinds of Wounds? Adv Wound Care (New Rochelle) 2014; 3:691-707. [PMID: 25371852 DOI: 10.1089/wound.2013.0482] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Indexed: 11/12/2022] Open
Abstract
Significance: Wound-healing complications are a clinical problem with a considerable socioeconomic burden. Since several nutrients play a physiological role in wound healing, supplementation of these nutrients may improve wound healing. Recent Advances: Oral nutritional supplements and enteral formulas providing arginine, glutamine, and micronutrients such as ascorbic acid and zinc should improve the healing of pressure ulcers (PU) and the healing of surgical, traumatic, and burned wounds. Is their efficacy proved from clinical intervention trials? Critical Issues: Formulas that are rich in energy, protein, arginine, vitamin C, and zinc can improve PU healing, whereas their efficacy for PU prevention is less clear. High-dose supplementation of vitamin C, zinc, and pantothenic acid may improve the healing of surgical wounds in healthy subjects. Arginine lowers the risk of fistulas in patients undergoing elective surgery due to gastrointestinal cancer. However, formulations also enriched with n-3-fatty acids and ribonucleic acids lower the risk of several wound complications, thus being more effective than isolated arginine. Glutamine and antioxidant micronutrients (vitamin C and E, zinc, selenium, and copper) can improve the healing of surgical, traumatic, and burned wounds. Future Directions: Considerable evidence suggests that formulations, indicated especially for critically ill patients, support the healing of PU and the healing of surgical and burned wounds. However, their optimal composition with regard to the dose of individual components has to be determined in future studies. Further well-designed trials should investigate the impact of certain nutrients for the prevention of PU and for the healing of surgical wounds in healthy subjects.
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Affiliation(s)
- Sabine Ellinger
- Faculty of Food, Nutrition and Hospitality Sciences, Hochschule Niederrhein, University of Applied Sciences, Mönchengladbach, Germany
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Reduced infections with perioperative immunonutrition in head and neck cancer: Exploratory results of a multicenter, prospective, randomized, double-blind study. Clin Nutr 2014; 33:776-84. [DOI: 10.1016/j.clnu.2013.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 10/03/2013] [Accepted: 10/09/2013] [Indexed: 01/21/2023]
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Vidal-Casariego A, Calleja-Fernández A, Villar-Taibo R, Kyriakos G, Ballesteros-Pomar MD. Efficacy of arginine-enriched enteral formulas in the reduction of surgical complications in head and neck cancer: a systematic review and meta-analysis. Clin Nutr 2014; 33:951-7. [PMID: 24844870 DOI: 10.1016/j.clnu.2014.04.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/07/2014] [Accepted: 04/28/2014] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Arginine improves healing and modulates inflammation and the immune response. A systematic review and meta-analysis were conducted to assess whether arginine-enriched enteral formulas reduce complications (fistulas, wound infections, other infections) and hospital length of stay (LoS) in patients undergoing surgery for head and neck cancer. METHODS Medline, CENTRAL, and Trip Database were searched using the search strategy "Head and Neck Neoplasms" AND "Enteral Nutrition" AND "Arginine" OR "Immunonutrition". Inclusion criteria comprised: type of study (RCT), language (English, Spanish), outcomes (complications of surgery, LoS), and methodological quality (Jadad scale). The odds ratio (OR) and confidence intervals (95% CI) were calculated using the Mantel-Haenszel method, and the mean difference (MD) with the random effects method. Heterogeneity was assessed using Cochran's Q. RESULTS Six studies were included, with 397 patients receiving peri/postoperative enteral nutrition with different doses of arginine (6.25-18.7 g/L). Enteral formulas containing arginine were associated with a reduction in fistulas [OR = 0.36 (95% CI 0.14-0.95), p = 0.039; Q = 3.93, p = 0.269], and LoS [MD = -6.8 (95% CI -12.6 to -0.9) days, p = 0.023; Q = 2.44, p = 0.486]. There were no reductions in wound infections [OR = 1.04 (95% CI 0.49-2.17), p = 0.925; Q = 1.60, p = 0.809] or other infections [OR = 0.79 (95% CI 0.48-1.31); p = 0.369; Q = 7.94, p = 0.094]. Arginine administration did not increase the occurrence of diarrhoea [OR = 1.80 (95% CI 0.50-6.52), p = 0.375; Q = 0.16, p = 0.691]. CONCLUSIONS The administration of arginine-enriched enteral nutrition led to a significant reduction in fistulas and hospital stay in patients undergoing surgery for head and neck cancer.
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Affiliation(s)
- Alfonso Vidal-Casariego
- Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, Altos de Nava SN, 24008 León, Spain.
| | - Alicia Calleja-Fernández
- Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, Altos de Nava SN, 24008 León, Spain
| | - Rocío Villar-Taibo
- Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, Altos de Nava SN, 24008 León, Spain
| | - Georgios Kyriakos
- Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, Altos de Nava SN, 24008 León, Spain
| | - María D Ballesteros-Pomar
- Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, Altos de Nava SN, 24008 León, Spain
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Chaukar DA, Deshmukh AD, Majeed T, Chaturvedi P, Pai P, D'cruz AK. Factors affecting wound complications in head and neck surgery: A prospective study. Indian J Med Paediatr Oncol 2014; 34:247-51. [PMID: 24604952 PMCID: PMC3932590 DOI: 10.4103/0971-5851.125236] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Context: Head and neck surgeries are complex. Wound complications are associated with considerable morbidity and can result in delay in the adjuvant treatment. Identification of factors will help in formulating preventive guidelines. Aims: The aim of this study is to identify perioperative factors responsible for wound complications. Settings and Design: Prospective study of 186 head and neck patients. Subjects and Methods: Pre-operative, intraoperative and post-operative factors were recorded. Each patient was evaluated for minor and major wound complications twice daily during the hospital stay. Statistical Analysis: Chi-square test was used for univariate and log regression test was used for multivariate analysis. Results: The overall wound complication rate was 29% with 7% major and 22% minor complications. On univariate analysis, laryngeal and hypopharyngeal location, advanced T stage, poor oral hygiene, clean-contaminated surgery, low Karnofsky performance status (KPS), flap reconstruction, blood loss more than 1000 ml, perioperative blood transfusion, duration of surgery greater than 4.3 h and post-operative hemoglobin lesser than 11 g%, post-operative tracheostomy and resection of mandible were statistical significant factors. On multivariate analysis, post-operative tracheostomy, low KPS, post-operative serum albumin less than 3.7 g/dl and duration of surgery greater than 4.3 h were significant factors. Conclusion: Apart from unavoidable factors, it is essential to take care of certain factors viz nutrition, haemoglobin, oral hygiene, asepsis and repeating antibiotics in prolonged surgery.
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Affiliation(s)
- Devendra A Chaukar
- Department of Head & Neck Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Anuja D Deshmukh
- Department of Head & Neck Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | | | - Pankaj Chaturvedi
- Department of Head & Neck Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Prathamesh Pai
- Department of Head & Neck Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Anil K D'cruz
- Department of Head & Neck Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
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Turnock A, Calder PC, West AL, Izzard M, Morton RP, Plank LD. Perioperative immunonutrition in well-nourished patients undergoing surgery for head and neck cancer: evaluation of inflammatory and immunologic outcomes. Nutrients 2013; 5:1186-99. [PMID: 23571650 PMCID: PMC3705342 DOI: 10.3390/nu5041186] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 03/21/2013] [Accepted: 03/26/2013] [Indexed: 12/16/2022] Open
Abstract
Limited work is available on the benefits of nutritional support enriched with arginine and n-3 fatty acids in surgical patients with head and neck cancer, particularly if well-nourished. We conducted a pilot study in these patients to examine effects on inflammatory markers and clinical outcome. Patients scheduled for radical resection of the oral cavity were randomised to 5 day preoperative and 5 day postoperative Impact® (IMN, n = 4), or no preoperative supplementary nutrition and Isosource® postoperatively (STD, n = 4). Plasma fatty acids, C-reactive protein (CRP), tumour necrosis factor (TNF)-α, interleukin (IL)-6 and IL-10 were measured at baseline, day of surgery and on postoperative days (POD) 2, 4 and 10. Postoperative complications were recorded. The (eicosapentaenoic acid plus docosahexaenoic acid) to arachidonic acid ratio was significantly higher in IMN patients on POD 2, 4 and 10 (P < 0.01). While not statistically significant, CRP, TNF-α, and IL-6 concentrations were higher in the STD group on POD2 while IL-10 was lower. Median length of stay was 10 (range 10–43) days in the IMN group and 21.5 (7–24) days in the STD group. Five complications were seen in the STD group and two in the IMN group. The results support the need for a larger trial focusing on clinical outcome.
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Affiliation(s)
- Amy Turnock
- Department of Surgery, University of Auckland, Auckland 1142, New Zealand; E-Mail:
| | - Philip C. Calder
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; E-Mails: (P.C.C.); (A.L.W.)
| | - Annette L. West
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; E-Mails: (P.C.C.); (A.L.W.)
| | - Mark Izzard
- Department of Otorhinolaryngology, Auckland City Hospital, Auckland 1142, New Zealand; E-Mail:
| | - Randall P. Morton
- Department of Otolaryngology, Counties-Manukau District Health Board, Auckland 1640, New Zealand; E-Mail:
| | - Lindsay D. Plank
- Department of Surgery, University of Auckland, Auckland 1142, New Zealand; E-Mail:
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +64-9-923-6949; Fax: +64-9-377-9656
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Mesquita da Silveira GR, Coutinho ES. Effectiveness of immunonutrient-enriched diets in the decrease of infections and mortality in the critically ill. Nutrition 2013; 29:485-90. [DOI: 10.1016/j.nut.2012.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 07/04/2012] [Accepted: 07/13/2012] [Indexed: 10/27/2022]
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Ghosh S, Dempsey G, Skelly R, Shaw RJ, Rogers SN, Lowe D, Jones TM. A double blind, randomised, placebo controlled, feasibility phase III clinical trial of peri-operative immune-enhancing enteral nutrition in patients undergoing surgery for advanced head and neck cancer. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.clnme.2011.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Intravenous arginine and human skin graft donor site healing: A randomized controlled trial. Burns 2011; 37:420-6. [DOI: 10.1016/j.burns.2010.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 06/18/2010] [Accepted: 06/24/2010] [Indexed: 11/21/2022]
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O'Neill JP, Shaha AR. Nutrition management of patients with malignancies of the head and neck. Surg Clin North Am 2011; 91:631-9. [PMID: 21621700 DOI: 10.1016/j.suc.2011.02.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The importance of nutrition and the prognostic impact of malnutrition in patients with head and neck cancer are not fully appreciated in the surgical world where a pervasive attitude exists that weight loss during treatment is inevitable and nutritional expertise or intervention may be dismissed out of ignorance. In this article, the authors explore the nutritional requirements of these patients and the impact of a multidisciplinary therapeutic approach to head, neck, and skull base cancer care.
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Affiliation(s)
- James Paul O'Neill
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Marik PE, Zaloga GP. Immunonutrition in high-risk surgical patients: a systematic review and analysis of the literature. JPEN J Parenter Enteral Nutr 2011; 34:378-86. [PMID: 20631383 DOI: 10.1177/0148607110362692] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunomodulating diets (IMDs) have been demonstrated to improve immune function and modulate inflammation. However, the clinical benefit of these diets in patients undergoing elective surgery is controversial. The goal of this meta-analysis was to determine the impact of IMDs on the clinical outcomes of high-risk patients undergoing elective surgery. METHODS The review included prospective, controlled, clinical trials that compared the clinical outcome of elective surgical patients who were randomized to receive an IMD or a control enteral diet. Studies were stratified according to the type of IMD and the timing of the initiation of the IMD. Data were abstracted on study design, study size, patient population, and IMD used. The outcomes of interest were the acquisition of new infections, wound complications, length of hospital stay (LOS), and mortality. Meta-analytic techniques were used to analyze the data. RESULTS Twenty-one relevant studies were identified, which included a total of 1918 patients. Immunonutrition significantly reduced the risk of acquired infections, wound complications, and LOS. The mortality rate was 1% in both groups. The treatment effect was similar regardless of the timing of the commencement of the IMD. The benefits of immunonutrition required both arginine and fish oil. CONCLUSIONS An immunomodulating enteral diet containing increased amounts of both arginine and fish oil should be considered in all high-risk patients undergoing major surgery. Although the optimal timing cannot be determined from this study, it is suggested that immunonutrition be initiated preoperatively when feasible.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Stableforth W, Thomas S, Lewis S. A systematic review of the role of immunonutrition in patients undergoing surgery for head and neck cancer. Int J Oral Maxillofac Surg 2009; 38:103-10. [DOI: 10.1016/j.ijom.2008.12.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 07/24/2008] [Accepted: 12/09/2008] [Indexed: 10/21/2022]
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Efecto de una fórmula enteral enriquecida en arginina sobre los marcadores inflamatorios en pacientes con tumores de cabeza y cuello. Med Clin (Barc) 2009; 132:49-52. [DOI: 10.1016/j.medcli.2008.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 03/26/2008] [Indexed: 11/20/2022]
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Soporte con nutrición enteral en tumores de cabeza y cuello. Med Clin (Barc) 2009; 132:59-61. [DOI: 10.1016/j.medcli.2008.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 09/18/2008] [Indexed: 11/23/2022]
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de Luis DA, Sagrado MG, Vallejo LA, Carcedo LMG, Izaola O, Cuellar L, Terroba MC, Aller R. Influence of G308A polymorphism of tumor necrosis factor-α gene on inflammatory markers in postsurgical head and neck cancer patients with early enteral nutrition. Nutrition 2007; 23:529-32. [PMID: 17560079 DOI: 10.1016/j.nut.2007.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 04/23/2007] [Accepted: 04/23/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Although immune dysfunction in patients with cancer could be multifactorial, the immune system may be modulated by nutritional substrates and genetic background. Our study evaluated the effect of G308A polymorphism of the tumor necrosis factor-alpha (TNF-alpha) gene on inflammatory markers in patients after surgery for head and neck cancer who received early enteral nutrition. METHODS A population of 60 patients with oral and laryngeal cancer was enrolled. At surgery patients were treated with a hyperproteic enteral diet. Perioperatively and on postoperative day 6 the following parameters were evaluated: serum values of prealbumin, transferrin, total number of lymphocytes, interleukin-6, TNF-alpha, and C-reactive protein. In addition, genotyping of G308A gene polymorphism was assessed. RESULTS Patients' mean age was 61.1 +/- 14.6 y (four women, 56 men) with a body mass index of 25.4 +/- 5.2 kg/m(2) and a previous weight loss of 0.35 +/- 0.2 kg. Forty patients (37 men, 3 women; 66.6%) had the genotype G308/G308 (wild group) and 20 patients (19 men, 1 woman; 23.4%) had the genotype G308/A308 (mutant group). A significant increase in prealbumin and transferrin levels was detected in both groups. C-reactive protein decreased in both groups (wild group: 105.1 +/- 60 versus 53.8 +/- 62.3 mg/dL, P < 0.05; mutant group: 99.5 +/- 46 versus 43.9 +/- 51.9 mg/dL, P < 0.05). Interleukin-6 decreased in both groups (wild group: 20.1 +/- 22 versus 6.2 +/- 4.1 pg/mL, P < 0.05; mutant group: 22.3 +/- 38 versus 9.2 +/- 7.4 pg/mL, P = NS). Lymphocytes increased in both groups (wild group: 1102 +/- 468 versus 1600 +/- 537 10(3)/mL, P = NS; mutant group: 1441 +/- 739 10(3)/mL versus 1669 +/- 614 10(6)/mL, P = NS). TNF-alpha showed no changes. CONCLUSION The G308A polymorphism of the TNF-alpha gene did not affect levels of inflammatory markers in patients after surgery for head and neck cancer who were treated with early enteral nutrition.
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Affiliation(s)
- Daniel Antonio de Luis
- Institute of Endocrinology and Nutrition, Medicine School and Hospital Rio Hortega, University of Valladolid, Valladolid, Spain.
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Foster JM, Filocamo P, Nava H, Schiff M, Hicks W, Rigual N, Smith J, Loree T, Gibbs JF. The introducer technique is the optimal method for placing percutaneous endoscopic gastrostomy tubes in head and neck cancer patients. Surg Endosc 2006; 21:897-901. [PMID: 17180272 DOI: 10.1007/s00464-006-9068-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Revised: 06/21/2006] [Accepted: 07/31/2006] [Indexed: 01/25/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) tubes are often placed in head and neck cancer patients to provide nutritional support, but studies have found the complication rates to be higher than other subsets of patients who undergo PEG placement. Complication rates as high as 50% have been reported, with the bulk of these complications being PEG site issues (i.e., cellulitis, abscess, fascitis, and tumor implantation). Because the pull technique has been the primary technique used, the theory is that the transoral tube passage is the source of the complications in these patients. Alternatively, the introducer technique uses a transabdominal approach to place the device, avoiding any tube contamination by upper aerodigestive organisms or tumor cells. At our institution, this technique has been used exclusively for head and neck cancer patients and this article reports our experience. METHODS One hundred forty-nine head and neck cancer patients who had a prophylactic PEG tube placed were reviewed from January 1, 1999 to December 31, 2003. The rates of placement success, morbidity, and complications were determined. RESULTS Successful placement was achieved in 148 (99%) patients without any PEG-related deaths. Overall, 17 complications (11%) occurred, with only one major complication (0.7%) identified. PEG site infections were uncommon with only five cases (3.4%) and all were mild cellulitis. CONCLUSIONS The introducer technique is the safest method for PEG tube placement in head and neck cancer patients. The overall rate of complications is low and PEG site infectious complications are rare. The introducer technique should be the method of choice for PEG tubes in head and neck cancer patients.
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Affiliation(s)
- Jason M Foster
- Department of Surgery, Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY, USA
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de Luis DA, Izaola O, Cuellar L, Terroba MC, Martin T, Aller R. Clinical and biochemical outcomes after a randomized trial with a high dose of enteral arginine formula in postsurgical head and neck cancer patients. Eur J Clin Nutr 2006; 61:200-4. [PMID: 16929239 DOI: 10.1038/sj.ejcn.1602515] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients, using a higher dose of arginine-enhanced diet (17 g/day) than previous studies, could improve nutritional variables as well as clinical outcomes, when compared with a control enteral diet. DESIGN Randomized clinical trial. SETTING Tertiary care. SUBJECTS A population of 72 patients with oral and laryngeal cancer was enrolled. INTERVENTIONS At surgery, patients were randomly allocated to two groups: (a) 35 patients receiving an arginine-enhanced formula with arginine (group I) and (b) 37 patients receiving an isocaloric, isonitrogenous enteral formula (group II). RESULTS No significant intergroup differences in the trend of the three plasma proteins (albumin, transferrin, prealbumin) and lymphocytes were detected. Episodes of diarrhea rate were equal in both groups (22.8% group I and 21.6% group II: NS). The postoperative infections complications were equal in both groups (5.7% group I and 5.4% group II: NS). Fistula (wound complication) was less frequent in enriched nutrition group (2.8% group I and 18.9% group II: P<0.05), whereas wound infection was similar in both groups. The length of postoperative stay was similar in both (27.9+/-21 vs 28.2+/-12 days; NS). CONCLUSIONS At this dose, arginine-enhanced formula improves fistula rates in postoperative head and neck cancer patients without a high rate of diarrhea.
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Affiliation(s)
- D A de Luis
- Medicine School and Unit of Investigation, Institute of Endocrinology and Nutrition, Hospital Rio Hortega, University of Valladolid, Valladolid, Spain.
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de Luis D, Aller R, Culebras J. Recomendaciones para el soporte nutricional artificial del paciente crítico. Med Clin (Barc) 2006; 127:232-6. [PMID: 16938246 DOI: 10.1157/13091411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The development of artificial nutritional support has been increased in the last years. Access routes and composition of formulas have been improved. Critic patients is a group of great controversy in this topic area. Enteral nutrition is better than parenteral nutrition in patients with inflammatory bowel disease, acute pancreatitis, burn and septic with a A level of evidence. Enteral nutrition is better than parenteral nutrition in patients with short bowel disease, chronic hepatopathy, surgery ot digestive tract in patients with cancer disease, patients with HIV infection and patients with politraumatism. Parenteral nutrition is better than enteral nutrition in patients with haematopoyetic transplantation with a B level of evidence. Some nutrients have been shown a beneficial effect in artificial nutritional support such as (diets low in fat and high in complex carbohydrates) (level A), diets with inmunonutrients in patients with surgery of digestive tract cancer (level B), diet enhanced with w3 fatty acids in patients with acute respiratory distress syndrome (level C), and patients with HIV infection (level B), diets enriched with glutamin in patients with politraumatism and haematopoyetic transplantation (level B). Specific diets have not been shown beneficial effects in some pathologies (short bowel syndrome, acute pancreatitis, renal insufficiency treated with dialysis, and respiratory insufficiency). Diets with arginine are contraindicated in septic critically ill patients (level A). In conclusion, artificial nutritional support in critic patients is a controversy topic area with a high level of change in knowledgments with new improvements in access route, diets and designs of interventional trials.
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Affiliation(s)
- Daniel de Luis
- Instituto de Endocrinología y Nutrición Clínica, Facultad de Medicina de Valladolid, Valladolid, España
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García-Peris P, Lozano MA, Velasco C, de La Cuerda C, Iriondo T, Bretón I, Camblor M, Navarro C. Prospective study of resting energy expenditure changes in head and neck cancer patients treated with chemoradiotherapy measured by indirect calorimetry. Nutrition 2005; 21:1107-12. [PMID: 16308133 DOI: 10.1016/j.nut.2005.03.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2005] [Accepted: 03/30/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The prevalence of malnutrition is high in patients with head and neck cancer due to tumor location and coadjuvant treatment. We studied changes in resting energy expenditure (REE) during treatment with chemoradiotherapy and compared the measured REE by indirect calorimetry (IC) with the value estimated by the Harris-Benedict (HB) formula. METHODS Eighteen patients with head and neck cancer (15 men and 3 women, mean age 57 +/- 10.7 y, age range 30-71 y) entered the study. All patients were treated with radiotherapy (70.8 +/- 1 Gy, range 70-72) and received 37.4 +/- 3.5 fractions (range 32-42) and concurrent chemotherapy with cisplatinum (absolute doses of 400 to 1000 mg). Nutrition assessment included anthropometry (body mass index, triceps skinfold thickness, subscapular skinfold thickness, midarm circumference, and midarm muscle circumference) and tetrapolar bioimpedance (Holtain BC). The IC (kcal/24 h; Deltatrac II MBM-200) was performed after an overnight fast. Measurements were done before treatment, at weeks 2, 4, and 6 of treatment, at the end of treatment, and 2 wk after treatment. RESULTS Body mass index decreased during treatment from 24.7 +/- 4.4 kg/m(2) (range 16.9-31.4) to 22.3 +/- 4.2 kg/m(2) (range 15.1-29.6). REE (kcal/24 h) changed significantly during treatment (IC P < 0.05, HB formula P < 0.001). REE measured by IC appeared as a U-shaped curve, but REE estimated by the HB formula decreased during treatment. The HB underestimated REE measurements compared with IC. These differences were statistically significant before treatment, at the end of treatment, and 2 wk after treatment (P < 0.05) and showed a limited clinical agreement with the Bland-Altman method. CONCLUSIONS REE measured by IC significantly changed during chemoradiotherapy. It was higher before treatment, at the end of treatment, and 2 wk after treatment. The HB formula underestimated REE in these patients. IC is a suitable method for measuring REE in this cohort of patients.
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Affiliation(s)
- Pilar García-Peris
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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de Luis DA, Izaola O, Aller R, Cuellar L, Terroba MC. A Randomized Clinical Trial with Oral Immunonutrition (ω3-Enhanced Formula vs. Arginine-Enhanced Formula) in Ambulatory Head and Neck Cancer Patients. ANNALS OF NUTRITION AND METABOLISM 2005; 49:95-9. [PMID: 15802904 DOI: 10.1159/000084742] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Accepted: 11/09/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of our study was to investigate whether oral ambulatory nutrition of head and neck cancer patients, using an omega3 fatty acid-enhanced diet (low ratio omega6/omega3 fatty acids) versus an arginine-enhanced diet, could improve nutritional variables as well as clinical outcome, postoperative infectious and wound complications. RESEARCH METHODS A population of 73 ambulatory postsurgical patients with oral and laryngeal cancer were enrolled. At discharge from hospital the postsurgical head and neck cancer patients were asked to consume two units per day of either a specially designed omega3 fatty acid-enhanced supplement (group 1) or an arginine-enhanced supplement (group 2) for a 12-week period. RESULTS No significant intergroup differences in the trend of the three serum proteins and lymphocytes were detected. Differences were detected in weight (group 1: 65.5 +/- 11.5 kg vs. 70.4 +/- 11.1 kg; p < 0.05) with a significant increase in fat mass in group 1 (15.4 +/- 6.6 vs. 18.1 +/- 8.4 kg; p < 0.05) and in tricipital skinfold. The postoperative infectious complications were similar in both groups (0 in group 1 and 8.57% in group 2; nonsignificant). No local complications were detected in the surgical wound. Gastrointestinal tolerance (diarrhea and vomiting episodes) of both formulas was good. CONCLUSIONS At the dose taken, the omega3-enhanced formula improved fat mass and proteins in ambulatory postoperative head and neck cancer patients. The arginine-enhanced formula improved proteins. Further studies are required to examine the potential role of immune-enhanced supplements.
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Affiliation(s)
- D A de Luis
- Institute of Endocrinology and Nutrition, Medicine School and Unit of Investigation, Hospital Rio Hortega, Valladolid, Spain.
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de Luis DA, Izaola O, Aller R, González-Sagrado M, Cuéllar L, Terroba MC. [Utility of a omega 3 fatty acids oral enhanced formula in biochemical parameters of head and neck cancer patients]. Med Clin (Barc) 2004; 123:499-500. [PMID: 15511371 DOI: 10.1016/s0025-7753(04)74571-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVE To investigate the influence of a arginine and omega3 fatty acids enhanced supplement in nutritional variables in postsurgical ambulatory patients with head and neck tumors. PATIENTS AND METHOD A population of 18 ambulatory postsurgical patients with oral and laryngeal cancer was studied. At hospital discharge, postsurgical head and neck cancer patients were asked to consume two units per day of a specially designed omega3 fatty acid enhanced supplement for a twelve week period. RESULTS Eighteen patients were enrolled in the study. The mean age was 62.5 (11.4) years (1 females/17 males). Duration of supplementation was 90.5 (22) days. Significant increases of serum protein levels and lymphocites were detected. PCR levels decreased after supplementation (71.96 [21.7] md/dl vs 25.9 [11.1] mg/dl; p < 0.05). No differences were detected in weight and other anthropometric parameters. A positive correlation between omega3/omega6 ratio and kg of fat mass (r = 0.59; p < 0.05) and midarm circumference (r = 0.62; p < 0.05) were detected. When the population was divided in two groups, group I (ratio omega3/omega6 < 0.51) and group II (ratio omega3/omega6 > 0.51), group II showed higher fat mass than group I (17.32 [5.3] kg vs 13.8 [5.1] kg; p < 0.05). CONCLUSIONS This immuno-enhanced formula could improve serum protein levels and PCR in ambulatory postoperative head and neck cancer patients. An increase in fat mass was detected in patients with a high omega3/omega6 intake of polyunsaturated fatty acids.
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Affiliation(s)
- Daniel Antonio de Luis
- Instituto de Endocrinología y Nutrición, Facultad de Medicina, Universidad de Valladolid, Unidad de Investigación, Hospital Río Hortega, Valladolid, Spain
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de Luis DA, Arranz M, Aller R, Izaola O, Cuellar L, Terroba MC. Immunoenhanced enteral nutrition, effect on inflammatory markers in head and neck cancer patients. Eur J Clin Nutr 2004; 59:145-7. [PMID: 15266308 DOI: 10.1038/sj.ejcn.1602034] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The aim of our study was to evaluate the effect of enteral nutrition supplemented with arginine in inflammatory markers in surgical head and neck cancer patients. A population of 29 patients with oral and laryngeal cancer were enrolled in a randomized trial. At surgery patients were randomly allocated to two groups: (a) patients receiving an enteral diet supplements with arginine (group I, n=14); (b) patients receiving an isocaloric, isonitrogenous enteral formula (group II, n=15). The mean age was 61.1+/-10.8 y (five females/24 males). Characteristics of the patients on enrollment were similar for the two groups. Prealbumin and transferrin improved in both groups. c-reactive protein (CRP) levels decreased in both groups, (group I: 134.5+/-62.5 vs 75.3+/-51 mg/dl:P<0.05) and (group II: 103.6+/-62 vs 43.8+/-34.4 mg/dl:P<0.05). Interleukin-6 (IL-6) improved in both groups (group I: 20.35+/-11.2 vs 6.7+/-3.1 pg/ml:P<0.05) and (group II:22.8+/-40 vs 9.9+/-17.7 pg/ml:ns). Tumoral necrosis factor alpha and lymphocytes did not change. In conclusion, both formulas improved IL-6 and CRP levels. Further studies are needed to determine whether type of formula is the key in these patients or genetic background play a main role in inflammatory response.
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Affiliation(s)
- D A de Luis
- Institute of Endocrinology and Nutrition, Medicine School and Unit of Investigation Hospital Rio Hortega, Spain.
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de Luis DA, Izaola O, Cuellar L, Terroba MC, Aller R. Randomized clinical trial with an enteral arginine-enhanced formula in early postsurgical head and neck cancer patients. Eur J Clin Nutr 2004; 58:1505-8. [PMID: 15138461 DOI: 10.1038/sj.ejcn.1601999] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients using an arginine-enhanced formula could improve nutritional variables as well as clinical outcomes. DESIGN Randomized clinical trial. SETTING Tertiary care. SUBJECTS A population of 90 patients with oral and laryngeal cancer was enrolled. INTERVENTIONS At surgery, patients were randomly allocated to two groups: (a) patients receiving an arginine-enhanced formula with arginine and fiber (group I) and (b) patients receiving an isocaloric, isonitrogenous formula with fiber enteral formula (group II). RESULTS No significant intergroup differences in the trend of the three plasma proteins (albumin, transferrin, prealbumin) and lymphocytes were detected. Gastrointestinal tolerance (diarrhea) was better in group II than I (40% group I and 13% group II: P<0.05). The postoperative complications due to infections were similar in both groups (4% group I and 9% group II: ns). Fistula (wound complication) was less frequent in the enriched nutrition group (5% group I and 11% group II: P<0.05); wound infection was similar in both groups. The length of postoperative stay was better in group I than II (25.8+/-15 days vs 35+/-24.6 days; P<0.05). CONCLUSIONS In conclusion, arginine-enhanced formula improves fistula rates in postoperative head and neck cancer patients and decreases length of stay.
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Affiliation(s)
- D A de Luis
- Institute of Endocrinology and Nutrition, Medicine School and Unit of Investigation, Hospital Rio Hortega, University of Valladolid, Valladolid, Spain.
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