Effect of Enteral Immunonutrition on Immune, Inflammatory Markers and Nutritional Status in Gastric Cancer Patients Undergoing Gastrectomy: A Randomized Double-Blinded Controlled Trial

Preoperative nutrition therapy in people undergoing gastrointestinal surgery

BACKGROUND

Poor preoperative nutritional status has been consistently linked to an increase in postoperative complications and worse surgical outcomes. We updated a review first published in 2012.

OBJECTIVES

To assess the effects of preoperative nutritional therapy compared to usual care in people undergoing gastrointestinal surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, three other databases and two trial registries on 28 March 2023. We searched reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of people undergoing gastrointestinal surgery and receiving preoperative nutritional therapy, including parenteral nutrition, enteral nutrition or oral nutrition supplements, compared to usual care. We only included nutritional therapy that contained macronutrients (protein, carbohydrate and fat) and micronutrients, and excluded studies that evaluated single nutrients. We included studies regardless of the nutritional status of participants, that is, well-nourished participants, participants at risk of malnutrition, or mixed populations. We excluded studies in people undergoing pancreatic and liver surgery. Our primary outcomes were non-infectious complications, infectious complications and length of hospital stay. Our secondary outcomes were nutritional aspects, quality of life, change in macronutrient intake, biochemical parameters, 30-day perioperative mortality and adverse effects.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. We assessed risk of bias using the RoB 1 tool and applied the GRADE criteria to assess the certainty of evidence.

MAIN RESULTS

We included 16 RCTs reporting 19 comparisons (2164 participants). Seven studies were new for this update. Participants' ages ranged from 21 to 79 years, and 62% were men. Three RCTs used parenteral nutrition, two used enteral nutrition, eight used immune-enhancing nutrition and six used standard oral nutrition supplements. All studies included mixed groups of well-nourished and malnourished participants; they used different methods to identify malnutrition and reported this in different ways. Not all the included studies were conducted within an Enhanced Recovery After Surgery (ERAS) programme, which is now current clinical practice in most hospitals undertaking GI surgery. We were concerned about risk of bias in all the studies and 14 studies were at high risk of bias due to lack of blinding. We are uncertain if parenteral nutrition has any effect on the number of participants who had a non-infectious complication (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.36 to 1.02; 3 RCTs, 260 participants; very low-certainty evidence); infectious complication (RR 0.98, 95% CI 0.53 to 1.80; 3 RCTs, 260 participants; very low-certainty evidence) or length of hospital stay (mean difference (MD) 5.49 days, 95% CI 0.02 to 10.96; 2 RCTs, 135 participants; very low-certainty evidence). None of the enteral nutrition studies reported non-infectious complications as an outcome. The evidence is very uncertain about the effect of enteral nutrition on the number of participants with infectious complications after surgery (RR 0.90, 95% CI 0.59 to 1.38; 2 RCTs, 126 participants; very low-certainty evidence) or length of hospital stay (MD 5.10 days, 95% CI -1.03 to 11.23; 2 RCTs, 126 participants; very low-certainty evidence). Immune-enhancing nutrition compared to controls may result in little to no effect on the number of participants experiencing a non-infectious complication (RR 0.79, 95% CI 0.62 to 1.00; 8 RCTs, 1020 participants; low-certainty evidence), infectious complications (RR 0.74, 95% CI 0.53 to 1.04; 7 RCTs, 925 participants; low-certainty evidence) or length of hospital stay (MD -1.22 days, 95% CI -2.80 to 0.35; 6 RCTs, 688 participants; low-certainty evidence). Standard oral nutrition supplements may result in little to no effect on number of participants with a non-infectious complication (RR 0.90, 95% CI 0.67 to 1.20; 5 RCTs, 473 participants; low-certainty evidence) or the length of hospital stay (MD -0.65 days, 95% CI -2.33 to 1.03; 3 RCTs, 299 participants; low-certainty evidence). The evidence is very uncertain about the effect of oral nutrition supplements on the number of participants with an infectious complication (RR 0.88, 95% CI 0.60 to 1.27; 5 RCTs, 473 participants; very low-certainty evidence). Sensitivity analysis based on malnourished and weight-losing participants found oral nutrition supplements may result in a slight reduction in infections (RR 0.58, 95% CI 0.40 to 0.85; 2 RCTs, 184 participants). Studies reported some secondary outcomes, but not consistently. Complications associated with central venous catheters occurred in RCTs involving parenteral nutrition. Adverse events in the enteral nutrition, immune-enhancing nutrition and standard oral nutrition supplements RCTs included nausea, vomiting, diarrhoea and abdominal pain.

AUTHORS' CONCLUSIONS

We were unable to determine if parenteral nutrition, enteral nutrition, immune-enhancing nutrition or standard oral nutrition supplements have any effect on the clinical outcomes due to very low-certainty evidence. There is some evidence that standard oral nutrition supplements may have no effect on complications. Sensitivity analysis showed standard oral nutrition supplements probably reduced infections in weight-losing or malnourished participants. Further high-quality multicentre research considering the ERAS programme is required and further research in low- and middle-income countries is needed.

Factors associated with variability in skeletal muscle radiodensity in patients with metastatic cancer

OBJECTIVES

This study aimed to explore factors associated with skeletal muscle radiodensity (SMD) variability in patients with metastatic cancer.

METHODS

This study included 393 patients (median age 61 y, 70% women) who had computed tomography (CT) scans within 30 days of inclusion in the study. SMD was evaluated from CT by averaging the Hounsfield unit value of the total muscle area. Skeletal muscle index (SMI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and total adipose tissue index (TATI) were also assessed by CT. Additionally, age, sex, race/skin color, disease characteristics, comorbidities, inflammatory markers, handgrip strength (HGS), and body mass index (BMI) were recorded and evaluated in the linear regression analysis to identify factors associated with SMD variability.

RESULTS

Multivariate explanatory models having SMD as an independent variable were performed and included BMI (model 1, r2 = 0.699), TATI (model 2, r2 = 0.712) or VATI and SATI (model 3, r2 = 0.706) in addition to age, race/skin color, tumor site, kidney disease, serum albumin, HGS, and SMI as dependent variables. For all models, lower SMD was associated with higher age, BMI, and adiposity measurements, kidney disease, White race/skin color, and lower serum albumin, HGS, and SMI. The primary tumor site also contributed to changes in SMD in all models, specifically those located in the gastrointestinal tract, gynecologic, and bone and connective tissue.

CONCLUSION

In this group of patients with metastatic cancer, lower SMD was associated with older age, White race/skin color, and an overall worse clinical condition.

Comparison of enteral immunonutrition and enteral nutrition in patients undergoing gastric cancer surgery: a systematic review and meta-analysis of randomized, controlled trials

OBJECTIVE

Enteral immunonutrition is a nutritional intervention that has been studied in postoperative patients with gastric cancer, but its effectiveness is controversial. This study aimed to investigate the effects of enteral immunonutrition and enteral nutrition on immune function in patients who undergo gastric cancer surgery.

METHODS

We performed a systematic review and meta-analysis. A comprehensive search was conducted in PubMed, Embase, Cochrane, Web of Knowledge, and ClinicalTrials.gov from the inception of the review until 10 March 2023. Twelve studies were included for qualitative and quantitative analyses.

RESULTS

We studied 1124 patients, including 565 patients in the enteral immunonutrition group and 559 in the enteral nutrition (controls) group. All included randomized, controlled trials were high quality. CD4+ levels, lymphocytes, transferrin concentrations, and systemic inflammatory response syndrome were not significantly different between the enteral immunonutrition and enteral nutrition groups. However, CD8+, immunoglobulins G and M, and proalbumin concentrations, CD4+/CD8+, and infectious complications were significantly higher in the enteral immunonutrition group than in the enteral nutrition group. A sensitivity analysis showed consistent results after excluding each study. Begg's test showed no publication bias.

CONCLUSIONS

Enteral immunonutrition is an effective nutritional intervention that improves immune function in patients who have undergone gastric cancer surgery.

A multifaceted comparative analysis of image and video technologies in gastrointestinal endoscope and their clinical applications

This paper presents a comprehensive exploration of endoscopic technologies in clinical applications across seven tables, each focusing on a unique facet of the medical field. The discourse begins with a detailed analysis of pediatric endoscopes, highlighting their diagnostic capabilities in various conditions. It then delves into the specifications and applications of globally recognized capsule endoscopy devices. Additionally, the paper incorporates an analysis of advanced imaging techniques, such as Narrow Band Imaging (NBI), Flexible Spectral Imaging Color Enhancement (FICE), and i-scan, which are increasingly being integrated into ultrathin gastrointestinal (GI) endoscopes. Factors like technological capabilities, light source, camera technology, and computational constraints are evaluated to understand their compatibility with these advanced imaging techniques, each offering unique advantages and challenges in clinical settings. NBI, for instance, is lauded for its user-friendly, real-time enhanced imaging capabilities, making it effective for early detection of conditions like colorectal cancer and Barrett's esophagus. Conversely, FICE and i-scan offer high customizability and are compatible with a broader range of endoscope models. The paper further delves into innovative advances in movement control for Nasojejunal (NJ) feeding tube endoscopy, elucidating the potential of AI and other novel strategies. A review of the technologies and methodologies enhancing endoscopic procedure control and diagnostic precision follows, emphasizing image and video technologies in pediatric endoscopy, capsule endoscopes, ultrathin endoscopes, and their clinical applications. Finally, a comparative analysis of leading real-time video monitoring endoscopes in clinical practices underscores the continuous advancements in the field of endoscopy, ensuring improved diagnostics and precision in surgical procedures. Collectively, the comparative analysis presented in this paper highlights the remarkable diversity and continuous evolution of endoscopic technologies, underlining their crucial role in diagnosing and treating an array of medical conditions, thereby fostering advancements in patient care and clinical outcomes.

Immune function, gastrointestinal hormone levels, and their clinical significance in patients with gastric ulcers complicated with depression

BACKGROUND

Gastric ulcer (GU) is a common digestive tract disease, and medical records of GU combined with depression are increasingly common. Currently, the risk factors and pathogenesis of GU complicated with depression remain unclear. Low immune function and gastrointestinal hormone levels may also be significant risk factors. Therefore, this study explored the immune function and gastrointestinal hormone levels in patients with GU combined with depression.

AIM

To explore the immune function, gastrointestinal hormone level, and clinical significance of patients with GU combined with depression.

METHODS

A retrospective analysis was conducted on 300 patients with GU combined with depression admitted to Guizhou Provincial People's Hospital from January 2021 to June 2022 as the study subjects. According to the Hamilton Depression Scale (HAMD) score, patients were divided into mild-to-moderate (n = 210) and heavy (n = 90) groups. Basic data, immune function indices [immunoglobulin A (IgA), IgM, IgG, serum CD4+ and CD8+ percentage, and CD4+/CD8+ ratio], and gastrointestinal hormone indices [serum gastrin (GAS), cholecystokinin (CCK), and motilin (MTL) levels] were collected. The basic data of the two groups were compared, and the immune function and gastrointestinal hormone indices were analyzed. Multivariate logistic regression was used to analyze the factors influencing the severity of GU complicated with depression. The receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) were used to analyze the value of the immune function index, gastrointestinal hormone index, and combined index in predicting the severity of GU complicated with depression.

RESULTS

There were no marked differences in sex, age, body mass index, abdominal distension, abdominal pain, belching, nausea, vomiting, or sleep disorders between the heavy and mild-to-moderate groups (P > 0.05). There was a marked difference in the family history of depression between the heavy and mild-to-moderate groups (P < 0.05). There were significant differences in serum IgA and IgM levels and serum CD4+, CD8+, and CD4+/CD8+ ratios between the heavy and mild-to-moderate groups (P < 0.05). Multivariate analysis showed that IgA, IgM, GAS, and CCK serum levels influenced the severity of GU with depression (P < 0.05). The AUC of the ROC curve for serum IgA level predicting GU with depression severity was 0.808 [95% confidence interval (CI): 0.760-0.857], the AUC of the serum IgM level was 0.757 (95%CI: 0.700-0.814), the AUC of the serum GAS level was 0.853 (95%CI: 0.810-0.897), the AUC of the serum CCK level was 0.762 (95%CI: 0.709-0.822), the AUC of immune function (IgA, IgM) and gastrointestinal hormone levels (GAS, CCK) for the prediction of GU with depression severity was 0.958 (95%CI: 0.933-0.976).

CONCLUSION

Important factors influencing GU complicated with depression are serum IgA, IgM, GAS, and CCK indicators. They can be used as indicators to predict the severity of GU complicated with depression.

Harnessing interventions during the immediate perioperative period to improve the long-term survival of patients following radical gastrectomy

Although the incidence and mortality of gastric cancer (GC) have been decreasing steadily worldwide, especially in East Asia, the disease burden of this malignancy is still very heavy. Except for tremendous progress in the management of GC by multidisciplinary treatment, surgical excision of the primary tumor is still the cornerstone intervention in the curative-intent treatment of GC. During the relatively short perioperative period, patients undergoing radical gastrectomy will suffer from at least part of the following perioperative events: Surgery, anesthesia, pain, intraoperative blood loss, allogeneic blood transfusion, postoperative complications, and their related anxiety, depression and stress response, which have been shown to affect long-term outcomes. Therefore, in recent years, studies have been carried out to find and test interventions during the perioperative period to improve the long-term survival of patients following radical gastrectomy, which will be the aim of this review.

Mapping the global research landscape on nutritional support for patients with gastrointestinal malignancy: visualization analysis

BACKGROUND

Early nutritional treatment is crucial for the care of patients with operable and advanced gastrointestinal malignancies. Therefore, much research has focused on nutritional support for patients with gastrointestinal malignancies. Therefore, this study aimed to evaluate the global scientific output and activity with respect to nutritional support and gastrointestinal malignancy.

METHODS

We searched in Scopus for publications on gastrointestinal cancer and nutritional assistance published between January 2002 and December 2021. Then, using VOSviewer 1.6.18 and Microsoft Excel 2013, we conducted bibliometric analysis and visualization.

RESULTS

A total of 906 documents were published between 2002 and 2021, including 740 original articles (81.68%) and 107 reviews (11.81%). China ranked first (298 publications, 32.89%), Japan ranked second (86 publications, 9.49%) and the USA ranked third (84 publications, 9.27%). The organisation with the highest number of publications was the Chinese Academy of Medical Sciences & Peking Union Medical College from China, with 14 articles, followed by the Peking Union Medical College Hospital from China and the Hospital Universitari Vall d'Hebron from Spain (13 publications for each). Before 2016, most studies focused on 'nutrition support for patients undergoing gastrointestinal surgery'. However, the latest trends showed that 'nutrition support and clinical outcomes in gastrointestinal malignancies' and 'malnutrition in patients with gastrointestinal cancer' would be more widespread in the future.

CONCLUSIONS

This review is the first bibliometric study to provide a thorough and scientific analysis of gastrointestinal cancer and nutritional support trends worldwide over the last 20 years. This study can aid researchers in decision-making by helping them understand the frontiers and hotspots in nutrition support and gastrointestinal cancer research. Future institutional and international collaboration is expected to accelerate the advancement of gastrointestinal cancer and nutritional support research and investigate more efficient treatment methods.

n-3 PUFA can reduce IL-6 and TNF levels in patients with cancer

Current studies on inhibitory effects of n-3 PUFA on pro-inflammatory cytokines have inconsistent results. Thus, a meta-analysis of randomised controlled trials was conducted to identify the effects of n-3 PUFA administration on circulating IL-6 and TNF in patients with cancer. Studies that examined the effects of n-3 PUFA administration on circulating IL-6 and TNF in patients with cancer were identified by searching PubMed and EMBASE from January 1975 to February 2021. Differences in n-3 PUFA administration and control conditions were determined by calculating standardised mean differences (SMD) with 95 % CI. Twenty studies involving 971 patients met the inclusion criteria. The overall SMD were 0·485 (95 % CI 0·087, 0·883) for IL-6 and 0·712 (95 % CI 0·461, 0·962) for TNF between n-3 PUFA administration and control conditions. Sources of heterogeneity were not found through subgroup and meta-regression analyses. Publication bias was observed in TNF with a slight contribution to the effect size. n-3 PUFA can reduce circulating IL-6 and TNF levels in patients with cancer. Results supported the recommendation of n-3 PUFA as adjuvant therapy for patients with cancer, possibly excluding head and neck cancer, owing to their anti-inflammatory properties.

Effect of Enteral Immunonutrition in Patients Undergoing Surgery for Gastrointestinal Cancer: An Updated Systematic Review and Meta-Analysis

Background

The efficacy of enteral immunonutrition (EIN) in patients undergoing gastrointestinal cancer surgery remains debatable. This meta-analysis aimed to investigate the effectiveness of EIN administration in patients undergoing surgery for gastrointestinal cancer.

Methods

From January 2000 to January 2022, PubMed, EMBASE, Cochrane Library, and Web of Science were thoroughly searched for randomized controlled trials (RCTs) with EIN versus standard diet or no supplement in patients undergoing surgery for gastrointestinal cancer. Overall complications and infectious complications were the primary outcomes. The secondary results were non-infectious complications, mortality, length of hospital stay, and enteral nutrition-related complications.

Results

Thirty-five studies reporting 3,692 patients undergoing surgery for gastrointestinal cancer (including gastric cancer, colorectal cancer, esophageal cancer, periampullary cancer, or pancreatic cancer) were included. Compared with the control group, EIN group had a significantly decreased incidence of overall complications (RR = 0.79, p < 0.001). Infectious complications in patients who received EIN were considerably lower than in the control group (RR = 0.66, p < 0.001). Compared to the control group, the incidence of surgical site infection, abdominal abscess, anastomotic leakage, bacteremia, duration of systemic inflammatory response syndrome (SIRS), and duration of antibiotic therapy was significantly lower in the specific infectious complications treated with EIN. Still, there was no significant difference between the two groups with other infectious complications. Moreover, a substantial shortening in the length of hospital stay was shown in EIN group compared with the control group. Still, no significant effect of EIN was demonstrated in non-infectious complicatios and mortality. The enteral nutrition-related complications had no significant difference between two groups.

Conclusions

EIN is safe and effective in reducing overall complications, infectious complications, and hospital stay in patients undergoing gastrointestinal cancer surgery (including gastric cancer, colorectal cancer, esophageal cancer, periampullary cancer, or pancreatic cancer).

Effect of enteral immunonutrition compared with enteral nutrition on surgical wound infection, immune and inflammatory factors, serum proteins, and cellular immunity in subjects with gastric cancer undergoing a total gastrectomy: A meta-analysis

We performed a meta‐analysis to evaluate the effect of enteral immunonutrition compared with enteral nutrition on surgical wound infection, immune and inflammatory factors, serum proteins, and cellular immunity in subjects with gastric cancer undergoing a total gastrectomy. A systematic literature search up to November 2021 was done, and 10 studies included 1056 subjects with gastric cancer undergoing a total gastrectomy at the start of the study: 505 of them were provided with enteral immunonutrition, and 551 were enteral nutrition. They were reporting relationships about the effect of enteral immunonutrition compared with enteral nutrition on surgical wound infection, immune and inflammatory factors, serum proteins, and cellular immunity in subjects with gastric cancer undergoing a total gastrectomy. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs) to assess the effect of enteral immunonutrition compared with enteral nutrition on surgical wound infection, immune and inflammatory factors, serum proteins, and cellular immunity in subjects with gastric cancer undergoing a total gastrectomy using the dichotomous or contentious method with a random or fixed‐effect model. Enteral immunonutrition had no significant difference in the surgical wound infection (OR, 0.77; 95% CI, 0.50‐1.19, P = .24), the infectious complication (OR, 0.72; 95% CI, .48‐1.09, P = .13), the systemic inflammatory response syndrome (MD, ‐0.50; 95% CI, −1.40 to 0.39, P = .27), the CD8+ level (MD, 1.34; 95% CI, 0‐2.68, P = .05), the CD4+ level (MD, 1.21; 95% CI, −7.65 to 10.07, P = .79), the CD4‐CD8+ (MD, 0.55; 95% CI, 0‐1.10, P = .05), the lymphocyte (MD, −0.77; 95% CI, −1.87 to 0.33, P = .17), and the transferrin (MD, 0.03; 95% CI, −0.01 to 0.08, P = .14) compared with enteral nutrition in subjects with gastric cancer undergoing a total gastrectomy. However, enteral immunonutrition had significantly higher proalbumin (MD, 22.15; 95% CI, 3.57‐40.72, P = .02), IgM (MD, 0.47; 95% CI, 0.43‐0.50, P < .001), and IgG (MD, 1.98; 95% CI, 1.08‐2.89, P < .001) compared with enteral nutrition in subjects with gastric cancer undergoing a total gastrectomy. Enteral immunonutrition had no significant difference in the surgical wound infection, the infectious complication, the systemic inflammatory response syndrome, the CD8+ level, the CD4+ level, the CD4+/CD8+, the lymphocyte, and the transferrin, and had significantly higher proalbumin, IgM, and IgG compared with enteral nutrition in subjects with gastric cancer undergoing a total gastrectomy. Further studies are required to validate these findings or to affect the confidence level.

Comparison of Different Blood Transfusion Methods in Patients Undergoing Cesarean Section

Purpose

To compare the effect of allogeneic transfusion and acute normovolemic hemodilution (ANH) autologous transfusion in patients undergoing cesarean section.

Methods

Patients who underwent cesarean section and received blood transfusion therapy from February 2019 to July 2021 in our hospital were observed and divided into the allogeneic group (n = 55) who received allogeneic transfusion therapy and the autologous group (n = 55) who received ANH autologous transfusion therapy according to the mode of transfusion. Observations included vital signs [heart rate (HR), mean arterial pressure (MAP), stroke volume variation (SVV)], blood routine [red blood cells (RBC), platelets (PLT), hematocrit (HCT), hemoglobin (Hb)], T-cell subsets (CD4⁺, CD8⁺, CD4⁺/CD8⁺), immunoglobulins (IgA, IgM, IgG), inflammatory factors [C-reactive protein (CRP), tumor necrosis factor (TNF)-α, interleukin (IL)-6], and adverse effects were counted in both groups.

Results

There was no statistical significance in the intra-group and inter-group comparisons of HR, MAP, and SVV between the two groups before transfusion and transfusion for 10 min (P > 0.05). 5d after operation, the RBC, PLT, HCT, and Hb of the allogeneic group were lower than those before operation, and the autologous group was higher than that of the allogeneic group (P < 0.05). 5d after operation, the CRP, TNF-α, and IL-6 of the allogeneic group were higher than those before operation, and the autologous group was lower than that of the allogeneic group (P < 0.05). 5d after operation, the CD4⁺, CD4⁺/CD8⁺ of the allogeneic group were lower than before operation, and the CD8⁺ was higher than before operation. The CD4⁺ and CD4⁺/CD8⁺ of the autologous group were higher than that of the allogeneic group, and CD8⁺ was lower than that of the allogeneic group (P < 0.05). 5d after operation, the IgA, IgG, and IgM of the allogeneic group were lower than those before operation, and the autologous group was higher than that of the allogeneic group (P < 0.05). During blood transfusion, there was no significant difference in the adverse reaction rate between the two groups (P > 0.05).

Conclusion

Both allogeneic transfusion and ANH autologous transfusion have little effect on the vital signs of patients undergoing cesarean section, but ANH autologous transfusion is more helpful to the stability of blood routine, T-cell subsets, immunoglobulin, and inflammation levels after surgery, which is a safe and effective way of blood transfusion.

Perioperative nutrition management for gastric cancer

Gastric cancer is one of the most frequently diagnosed and the leading cause of cancer death worldwide. Malnutrition is a substantial problem in patients with gastric cancer, associated with poor treatment tolerance and increased morbidity. It has also been recognized as an independent prognostic factor in individuals with cancer. Early detection of malnutrition and effective perioperative nutrition intervention play an important role in the treatment of gastric cancer. Nutrition screening and assessment are the first steps in nutrition management and provide a basis for further nutrition support. Several tools, including the Nutrition Risk Screening-2002 and Patient-Generated Subjective Global Assessment, have been developed for nutrition screening and assessment. Effective nutrition support can significantly improve nutritional and immune status, reduce the incidence of postoperative complications, and accelerate recovery. The aim of this review was to focus on preoperative nutrition risk screening and assessment, and perioperative nutrition support, which may serve as a framework of perioperative nutrition management for gastric cancer.

Could Immunonutrition Help in the Fight against COVID-19 in Cancer Patient?

The rapid and widespread global pandemic of 2019 coronavirus disease (COVID-19) has had unprecedented negative health and economic impacts. Immune responses play a key role in the development of COVID-19, including the disruption of immune balance and cytokine storms caused by excessive inflammatory responses. Due to the effects of cancer itself and treatment, patients often accompanied by immunosuppression appear to be a susceptible population for COVID-19. Worryingly, COVID-19 with cancer is associated with a poor prognosis. Cancer patients are a vulnerable group, threatened by COVID-19, finding a way to combat COVID-19 for them is urgent. Immunonutrition is closely related to balance and strong immune function. Supplementary immunonutrition can improve the immune function and inflammatory response of cancer patients after surgery, which provides evidence for the role of immunonutrition in combating COVID-19. We reviewed possible mechanisms of immunonutrition against COVID-19, including enhancing immune cell function, increasing immune cell count, ameliorating excessive inflammatory response, and regulating gut microbiota. Immunonutrition supplementation in cancer patients may be beneficial to enhance immune function in the early stage of COVID-19 infection and control excessive inflammatory response in the late stage. Therefore, immunonutrition is a potential strategy for the prevention and treatment of COVID-19 in cancer.

Cancer related nutritional and inflammatory markers as predictive parameters of immediate postoperative complications and long-term survival after hepatectomies

BACKGROUND

The overall survival (OS), disease-free survival (DFS) and complications after liver resections is unsatisfactory. Cancer-related malnutrition and inflammation have an effect on survival but not studied/not clear on postoperative complications.

METHODS

We retrospectively analyzed prospectively maintained database of 309 patients. The outcome variables included complications in terms of Clavien-Dindo (CD) Score, OS and DFS; We studied effect of preoperative albumin globulin ratio (AGR), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and aspartate transaminase to platelet ratio index (APRI) and dynamic change from pre-operative to postoperative value (Delta-AGR, Delta-NLR, Delta-PLR and Delta-APRI) on complications, OS and DFS.

RESULTS

Total 98 patients (31.71%) had postoperative complications. Fifty patients had CD 1 & 2 and 35 (11.33%) had CD 3 & 4, and 13 (4.12%) had mortality (CD 5). Low AGR, high NLR, high PLR and high Delta-AGR and high Delta-APRI predicted increased major complications. Preoperative high NLR predicted worse OS and low AGR predicted worse OS and DFS. Delta-APRI showed trends towards worse OS and DFS.

CONCLUSION

These serum inflammatory markers can predict immediate postoperative complications. Preoperative AGR and preoperative NLR can predict survival after liver resections. High Delta-AGR, which is a new entity, is predicting more postoperative complications and needs further detailed studies.

Omega-3 Polyunsaturated Fatty Acids Can Reduce C-Reactive Protein in Patients with Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

ABSTRACTSOmega-3 polyunsaturated fatty acids (PUFAs) possess anti-inflammatory properties. There is a lack of consensus regarding the effects of omega-3 PUFAs on C-reactive protein (CRP), a marker of systemic inflammation, in cancer patients. Herein, a meta-analysis of randomized controlled trials was conducted to evaluate the effects of omega-3 PUFAs on CRP levels in patients with cancer. PubMed and EMBASE were searched until May 2020 to identify randomized controlled trials that examined the effects of omega-3 PUFA administration on CRP levels in cancer patients. Standardized mean differences (SMDs) with their 95% confidence intervals (CIs) were calculated to determine the differences in omega-3 PUFA administration and control conditions. Seventeen eligible studies involving 916 cancer patients were included in this meta-analysis. Significant heterogeneity was present among individual studies (P_{heterogeneity} = 0.000; I² = 74.5%). The overall SMDs of CRP levels between omega-3 PUFA administration and control conditions were 0.628 (95% CI: 0.342-0.914) and 0.456 (95% CI: 0.322-0.590) by the random-effect and fixed-effect models, respectively. Sources of heterogeneity were not found through subgroup and meta-regression analyses. Existing publication bias contributed slightly to the effect size. Omega-3 PUFAs can reduce systemic inflammation, as indicated by CRP levels in cancer patients. The use of omega-3 PUFAs is recommended for cancer patients due to their anti-inflammatory properties.

Immunonutrition in elective colorectal surgery and early inflammatory response

BACKGROUND

Immunonutrition has gained increasing interest over years, enough to be recommended in several international guidelines and to be included in the ERAS protocol for colorectal surgery. Although clinical advantages have been proved for malnourished cancer-affected patients, its role is more controversial in other settings. We have evaluated the impact of immunonutrition in major colorectal elective surgery for benign and malignant diseases, regardless of the preoperative nutritional status.

METHODS

We conducted a single center retrospective analysis of a database of patients who underwent elective major colon-rectal surgery for benign and malignant diseases between January 2018 and February 2020. In January 2019 we started a protocol to define which patients should receive preoperative immunonutrition, regardless of their nutritional status. We compared early postoperative outcomes and laboratory data of this group (IMN) to those of patients who met all the characteristics to be included in the protocol, but who did not receive immunonutrition (CTRL).

RESULTS

The IMN group showed significantly lower total leukocytes and neutrophils values and a lower pathological leukocytosis rate on 1st postoperative day compared to the CTRL group (p=0.004). Although differences in early postoperative clinical outcomes were not significant, patients belonging to the IMN group needed less postoperative antibiotic treatment (p = 0.047).

CONCLUSIONS

Immunonutrition could affect granulocytopoiesis and neutrophils recruitment in damaged tissues. This could lead to better and faster tissue healing and, consequently, to a reduction in postoperative complications even in normo-nourished patients. The lower need for antibiotic treatment could reflect a reduced susceptibility to postoperative infections.

Immunonutritional support as an important part of multidisciplinary anti-cancer therapy

Immunonutrition is one of the most important parts of nutritional treatment in patients with cancer. There are studies which confirm positive effects of using immunonutrition (arginine, glutamine, omega-3 fatty acids, nucleotides, pre- and probiotics) among others on the reduction of the pro-inflammatory cytokines concentrations, shortening of the hospital stay and improvement of the nutritional status. Arginine takes part not only in wound healing process, but also it improves body’s immunity and reduces the incidence of infections. Glutamine reduces the incidence of acute grade 2 and 3 esophagitis and improves quality of life of gastric cancer patients. Omega 3-fatty acids have the ability to inhibit the activity of NF-κB. They also reduce the symptoms of graft-versus-host disease in patients undergoing hematopoietic cell transplantation. Nucleotides support the regeneration of intestinal villi. Probiotics play many roles, mainly inhibit the process of carcinogenesis, reduce the incidence of diarrhea and modify intestinal microbiome. However, there are studies indicating the lack of advantages of using immunonutrition compared to standard nutrition. Currently, there is no clear evidence for the use of formulae enriched with immunonutrients versus standard oral nutritional supplements exclusively in the preoperative period. This review summarizes the current knowledge about the role of immunonutrition in supporting treatment of cancer diseases.

Prognostic Value of the Preoperative Lymphocyte-to-C-Reactive Protein Ratio and Albumin-to-Globulin Ratio in Patients with Osteosarcoma

Purpose

Growing evidence indicates that preoperative biomarkers could be identified as independent prognostic factors in various cancers. The purpose of this study was to assess prognostic value of the preoperative lymphocyte-to-C-reactive protein ratio (LCR), albumin-to-globulin ratio (AGR), lymphocyte-monocyte ratio (LMR), and C-reactive protein to albumin ratio (CAR) in patients with osteosarcoma.

Methods

A total of 137 osteosarcoma patients treated at our hospital between 2011 and 2019 were enrolled in the study. Patient demographics, clinical characteristics, and laboratory data were collected and analyzed. The optimal cutoff values of LCR, AGR, LMR, and CAR were assessed with receiver operating characteristic (ROC) analysis. Kaplan-Meier analysis was performed to estimate overall survival (OS). Univariate and multivariate Cox regression models were employed to determine the independent prognostic factors. The hazard ratios (HR) and 95% confidence intervals (95% CI) were calculated to evaluate relative risk.

Results

The optimal cutoff values of LCR, AGR, LMR, and CAR were 0.14, 1.79, 3.05 and 0.24, respectively. According to the univariate analysis, OS was remarkably associated with neoadjuvant chemotherapy (P < 0.001), pathological fracture (P < 0.001), local recurrence (P = 0.020), metastasis (P < 0.001), LCR (P = 0.035), AGR (P = 0.028), LMR (P = 0.010), and CAR (P = 0.004). In multivariate analyses, pathological fracture (P = 0.025), metastasis (P < 0.001), LCR (P = 0.012), and AGR (P = 0.001) were identified as independent risk predictors for OS.

Conclusion

The present study provides new evidence that the preoperative LCR and AGR could serve as independent prognostic factors for patients with osteosarcoma. These findings will help physicians to stratify patients for appropriate treatment protocols and facilitate decision-making so as to improve the patients' survival condition.

Clinical efficacy of different nutritional methods in patients after laparoscopic radical surgery for distal gastric cancer

BACKGROUND

The incidence of gastric cancer (GC) in Asian countries remains high. Surgical resection is the most effective treatment for GC. The postoperative nutritional support methods mainly include total parenteral nutrition (TPN), total enteral nutrition (TEN), and enteral parenteral nutrition (EPN). However, it is still controversial over the optimal postoperative nutrition method for GC patients.

AIM

To analyze the clinical efficacy of different nutritional methods in patients after laparoscopic radical surgery for distal GC.

METHODS

The patients who underwent laparoscopic radical surgery for distal GC at Jinhua Central Hospital from January 2017 to December 2019 were randomly divided into three groups (50 patients each) and given TPN, TEN, and EPN, respectively. The clinical efficacy, incidence of complications, postoperative hospitalization time, time to anal exhaust, and time to solid food intake were compared among the three groups.

RESULTS

On the 8^th day after surgery, the levels of plasma albumin and prealbumin were significantly higher in the TEN and EPN groups than in the TPN group (P < 0.05), and in the EPN group than in the TEN group (P < 0.05); the levels of C-reactive protein (CRP) were significantly lower in the TEN and EPN groups than in the TPN group (P < 0.05), and in the EPN group than in the TEN group (P < 0.05); the lymphocyte counts increased significantly compared with those on the 1st day after surgery in the TEN and EPN groups (P < 0.05), and the lymphocyte count in the EPN group was significantly higher than those in the TPN and TEN groups (P < 0.05). The incidence rates of postoperative complications in the TEN and EPN groups were significantly lower than that in the TPN group (P < 0.05). The postoperative hospitalization time (8.5 ± 0.7 d), time to anal exhaust (3.1 ± 0.3 d), and time to solid food intake (6.1 ± 0.6 d) in the EPN group were all significantly shorter than those in the TPN and TEN groups (P < 0.05).

CONCLUSION

The nutritional approach of EPN can improve the nutritional status of patients after laparoscopic radical surgery for distal GC, reduce the occurrence of complications, and shorten the length of hospital stay.

Effect of Qihuang Decoction Combined with Enteral Nutrition on Postoperative Gastric Cancer of Nutrition and Immune Function

Objective

Early nutritional support in patients with gastric cancer can improve their nutritional status, but the impact on immune function has not been confirmed. This study aimed to analyze the effects of Qihuang decoction combined with enteral nutrition on nutrition and the immune function of postoperative gastric cancer.

Methods

120 patients with postoperative gastric cancer in the study group and 117 in the control group were selected as the study subjects from our hospital at random. Indications of nutrition and immune and the rates of complications were compared the day before surgery and 1, 3, 7, and 14 days after surgery.

Results

Indications of nutrition except hemoglobin (HB) in the study group were significantly higher than those before operation and the albumin (ALB) and prealbumin (TP) were significantly increased 7 and 14 days after surgery (P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 versus P < 0.001 and P < 0.001) and the protein (PA) 3, 7, and 14 days after surgery (P=0.011, P=0.002, and P=0.022) in the study group compared to those in the control group. Cellular and humoral immunity indications in the study group are significantly higher than those before operation compared to those in the control group, and the CD3⁺, CD4⁺, and CD4⁺/CD8⁺ were significantly increased 7 and 14 days after surgery (P=0.027 and P < 0.001 versus P=0.008 and P < 0.001 versus P=0.010 and P < 0.001) and IgA, IgG, and IgM 3, 7, and 14 days after surgery in the study group (P < 0.001, P < 0.001, and P < 0.001 versus P < 0.001, P < 0.002, and P < 0.001 versus P < 0.001, P < 0.001, and P < 0.001). The complications such as abdominal, lung, wound, and urinary infection were also significantly decreased (P^χ2=0.017; P < 0.001 and P < 0.001 versus P < 0.001 and P < 0.001) and the protein (PA) 3, 7, and 14 days after surgery (P=0.011, P=0.002, and P=0.022) in the study group compared to those in the control group. Cellular and humoral immunity indications in the study group are significantly higher than those before operation compared to those in the control group, and the CD3⁺, CD4⁺, and CD4⁺/CD8⁺ were significantly increased 7 and 14 days after surgery (P=0.027 and P < 0.001 versus P=0.008 and P < 0.001 versus P=0.010 and P < 0.001) and IgA, IgG, and IgM 3, 7, and 14 days after surgery in the study group (P < 0.001, P < 0.001, and P < 0.001 versus P < 0.001, P < 0.002, and P < 0.001 versus P < 0.001, P < 0.001, and P < 0.001). The complications such as abdominal, lung, wound, and urinary infection were also significantly decreased (P^χ2=0.017; P < 0.001 and P < 0.001 versus P < 0.001 and P < 0.001) and the protein (PA) 3, 7, and 14 days after surgery (P=0.011, P=0.002, and P=0.022) in the study group compared to those in the control group. Cellular and humoral immunity indications in the study group are significantly higher than those before operation compared to those in the control group, and the CD3⁺, CD4⁺, and CD4⁺/CD8⁺ were significantly increased 7 and 14 days after surgery (P=0.027 and P < 0.001 versus P=0.008 and P < 0.001 versus P=0.010 and P < 0.001) and IgA, IgG, and IgM 3, 7, and 14 days after surgery in the study group (P < 0.001, P < 0.001, and P < 0.001 versus P < 0.001, P < 0.002, and P < 0.001 versus P < 0.001, P < 0.001, and P < 0.001). The complications such as abdominal, lung, wound, and urinary infection were also significantly decreased (P^χ2=0.017; P < 0.001 and P < 0.001 versus P < 0.001 and P < 0.001) and the protein (PA) 3, 7, and 14 days after surgery (P=0.011, P=0.002, and P=0.022) in the study group compared to those in the control group. Cellular and humoral immunity indications in the study group are significantly higher than those before operation compared to those in the control group, and the CD3⁺, CD4⁺, and CD4⁺/CD8⁺ were significantly increased 7 and 14 days after surgery (P=0.027 and P < 0.001 versus P=0.008 and P < 0.001 versus P=0.010 and P < 0.001) and IgA, IgG, and IgM 3, 7, and 14 days after surgery in the study group (P < 0.001, P < 0.001, and P < 0.001 versus P < 0.001, P < 0.002, and P < 0.001 versus P < 0.001, P < 0.001, and P < 0.001). The complications such as abdominal, lung, wound, and urinary infection were also significantly decreased (P^χ2=0.017; P^χ2=0.036; P^χ2=0.041; P^χ2=0.004).

Conclusions

Qihuang decoction combined with enteral nutrition can promote the absorption of enteral nutrition with improving the immune and reducing complications of infection.

Effects of specific nutrients on immune modulation in patients with gastrectomy

Gastric cancer (GC) is one of the most prevalent and lethal malignant neoplasms worldwide. The main treatment for GC is gastrectomy, which generally causes considerable metabolic stress to patients. To modulate cell function, maintain homeostasis of the immune response, reduce postoperative complications, and obtain favorable outcomes, physicians prescribe specific nutrients with immunomodulatory properties as supplementation to enteral or parenteral formulas, indicating immunonutrition. In the formulas, among the immunonutrients, glutamine, arginine, and n-3 polyunsaturated fatty acids are the most commonly used either alone or in combination. The present review summarizes and focuses on the evidence obtained from clinical trials and animal studies supporting the role of immunonutrients supplemented enterally or parenterally in total or subtotal gastrectomy. In addition, this review describes the possible molecular mechanisms underlying the protective action of these immunonutrients, which may contribute to therapeutic approaches to improve postoperative outcomes of gastrectomy. Combination of conventional therapy with immunonutrition seems to be a useful strategy to achieve synergistic effects in the treatment of GC patients.

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.