Effects of early postoperative enteral nutrition versus usual care on serum albumin, prealbumin, transferrin, time to first flatus and postoperative hospital stay for patients with colorectal cancer: A systematic review and meta-analysis

Promoting wound recovery through stable intestinal flora: Reducing post-operative complications in colorectal cancer surgery patients

In recent years, the relationship between intestinal flora and post-operative recovery, particularly in colorectal cancer (CRC) surgery patients, it has been hypothesized that intestinal flora stability influences wound healing, reduces complications and improves overall recovery outcomes after surgical interventions. This study examined the relationship between intestinal flora stability and post-operative recovery in patients undergoing CRC surgery. Between May 2020 and 2023, 80 CRC patients from our hospital's Colorectal Surgery Department were enrolled. A random number table was used to divide them into two categories. Both groups were subjected to distinct gastrointestinal preparation protocols. Indicators of clinical therapeutic effect, intestinal flora balance following surgery, post-operative complications and quality of life were evaluated. The observation group, which adhered to a distinct gastrointestinal regimen, demonstrated a statistically significant improvement in post-operative outcomes, with a clinical effectiveness rate of 97.5% compared to the control group's 75%. In addition, the observation group had a lower incidence of intestinal flora imbalance following surgery than the control group. The observation group had lower incidences of intestinal obstruction, infection, anastomotic leakage, incisional tumour implantation and delayed diarrhoea. Using the KPS score and the BMI, post-treatment assessments of the observation group's quality of life revealed significant enhancements in comparison to the control group. Additionally, wound healing rates were superior in the observation group, with a correlation between stable intestinal flora and decreased wound infection rates. The type of post-operative diet influenced the stabilization of the gut flora, with a high-fibre diet producing superior results in both groups. The stability of intestinal flora influences the post-operative rehabilitation of patients undergoing CRC surgery favourably. Appropriate bowel preparation and dietary considerations can reduce post-operative complications, improve wound healing rates and enhance overall quality of life.

Early vs delayed enteral nutrition or parenteral nutrition in hospitalized patients: An umbrella review of systematic reviews and meta-analyses of randomized trials

We conducted an umbrella review to summarize the existing evidence on the effect of early enteral nutrition (EEN) compared with other approaches, including delayed enteral nutrition (DEN), parenteral nutrition (PN), and oral feeding (OF) on clinical outcomes in hospitalized patients. We performed a systematic search up to December 2021, in MEDLINE (via PubMed), Scopus, and Institute for Scientific Information Web of Science. We included systematic reviews with meta-analyses (SRMAs) of randomized trials investigating EEN compared with DEN, PN, or OF for any clinical outcomes in hospitalized patients. We used "A Measurement Tool to Assess Systematic Reviews" (AMSTAR2) and the Cochrane risk-of-bias tool for assessing the methodological quality of the systematic reviews and their included trial, respectively. The certainty of the evidence was rated using the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. We included 45 eligible SRMAs contributing with a total of 103 randomized controlled trials. The overall meta-analyses showed that patients who received EEN had statistically significant beneficial effects on most outcomes compared with any control (ie, DEN, PN, or OF), including mortality, sepsis, overall complications, infection complications, multiorgan failure, anastomotic leakage, length of hospital stay, time to flatus, and serum albumin levels. No statistically significant beneficial effects were found for risk of pneumonia, noninfectious complications, vomiting, wound infection, as well as number of days of ventilation, intensive care unit days, serum protein, and pre-serum albumin levels. Our results indicate that EEN may be preferred over DEN, PN, and OF because of the beneficial effects on many clinical outcomes.

Perioperative nutritional assessment and interventions in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): A systematic review

BACKGROUND

Peritoneal carcinomatosis is a catabolic state and cytoreductive surgery (CRS) is a high morbidity operation. Optimising perioperative nutrition is crucial to improve outcomes. This systematic review sought to examine literature describing clinical outcomes related to preoperative nutrition status and nutrition interventions in patients undergoing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A systematic review was registered with PROSPERO (300326). A search of eight electronic databases was undertaken on 8th May 2022 and reported according to the PRISMA statement. Studies reporting nutrition status through use of screening and assessment tools, nutrition interventions or nutrition-related clinical outcomes for patients undergoing CRS with HIPEC were included.

RESULTS

Of 276 screened studies, 25 studies were included for review. Commonly used nutrition assessment tools for CRS-HIPEC patients included Subjective Global Assessment (SGA), sarcopenia assessment with computed tomography, preoperative albumin, and body mass index (BMI). Three retrospective studies compared SGA with postoperative outcomes. Malnourished patients were more likely to have postoperative infectious complications (p = 0.042 SGA-B, p = 0.025 SGA-C). Malnutrition was significantly associated with increased hospital length of stay (LOS) in two studies (p = 0.006, p = 0.02), and with overall survival in another study (p = 0.006). Eight studies analysing preoperative albumin levels reported conflicting associations with postoperative outcomes. BMI in five studies was not associated with morbidity. One study did not support routine nasogastric tube (NGT) feeding.

CONCLUSIONS

Preoperative nutritional assessment tools, including SGA and objective sarcopaenia measures, have a role in predicting nutritional status for CRS-HIPEC patients. Optimisation of nutrition is important for preventing complications.

The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: Protocol for a systematic review and meta-analysis

Background

Given the ever-shorter length of hospital stay after surgical procedures, nowadays it is more important than ever to study interventions that may have an impact on surgical patients’ wellbeing. According to the ERAS (Enhanced Recovery After Surgery protocols) program, early feeding must be considered one of the key components to facilitate early recovery while improving outcomes and patients’ overall experiences. To date, the international literature has reported that early postoperative feeding compared with traditional (or late) timing is safe; nevertheless, small clinical outcomes effects has been reported, also for recovery of gastrointestinal function. Therefore, the effectiveness of early postoperative feeding to reduce postoperative ileus duration remains still debated.

Objective

To analyse the effects of early versus delayed oral feeding (liquids and food) on the recovery of intestinal motility after gastrointestinal surgery.

Search methods

Pubmed, Embase, Cinahl, Cochrane Central Register of Controlled Trials (CENTRAL), and the ClincalTrials.gov register will be searched to identify the RCTs of interest.

Study inclusion

Randomized clinical trials (RCTs) comparing the effect of early postoperative versus late oral feeding on major postoperative outcomes after gastrointestinal surgery will be included.

Data collection and analysis

Two review authors will independently screen titles and abstracts to determine the initially selected studies’ inclusion. Any disagreements will be resolved through discussion and consulting a third review author. The research team members will then proceed with the methodological evaluation of the studies and their eligibility for inclusion in the systematic review.

Effectiveness of the Tailored, Early Comprehensive Rehabilitation Program (t-ECRP) based on ERAS in improving the physical function recovery for patients following minimally invasive esophagectomy: a prospective randomized controlled trial

BACKGROUND

Perioperative rehabilitation management is essential to enhanced recovery after surgery (ERAS). Limited reports, however, have focused on quantitative, detailed early activity plans for patients receiving minimally invasive esophagectomy (MIE). The purpose of this research was to estimate the effectiveness of the Tailored, Early Comprehensive Rehabilitation Program (t-ECRP) based on ERAS in the recovery of bowel and physical functions for patients undergoing MIE.

METHODS

In this single-blind, 2-arm, parallel-group, randomized pilot clinical trial, patients admitted to the Affiliated Cancer Hospital of Zhengzhou University from June 2019 to February 2020 were selected and randomly assigned to an intervention group (IG) or a control group (CG). The participants in the IG received medical care based on the t-ECRP strategy during perioperative period, and participants in the CG received routine care. The recovery of bowel and physical functions, readiness for hospital discharge (RHD), and postoperative hospital stay were evaluated on the day of discharge.

RESULTS

Two hundred and fifteen cases with esophageal cancer (EC) were enrolled and randomized to the IG (n = 107) or CG (n = 108). The mean age was 62.58 years (SD 9.07) and 71.16% were male. For EC, 53.49% were mid-location cancers and 79.07% were classified as pathological stage II and III cancers. There were no significant differences between the two groups in terms of demographic and clinical characteristics and baseline physical functions. Participants in the IG group presented significantly shorter lengths of time to first flatus (P < 0.001), first postoperative bowel movement (P = 0.024), and for up and go test (P < 0.001), and lower scores of frailty (P < 0.001). The analysis also showed that participants in the IG had higher scores of RHD and shorter lengths of postoperative stay than in the CG (P < 0.05).

CONCLUSIONS

The t-ECRP appears to improve bowel and physical function recovery, ameliorate RHD, and shorten postoperative hospital stay for patients undergoing MIE. Clinicians should consider prescribing quantitative, detailed, and individualized early activity plans for these patients.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT01998230).

The clinical effect of early enteral nutrition in liver-transplanted patients: a systematic review and meta-analysis

BACKGROUND

Appropriate nutritional support is critical for patients undergoing liver transplantation (LT). Early enteral nutrition (EEN) has been considered effective in critically ill patients. However, the clinical effect of EEN on liver-transplanted patients is unclear.

AIM

To evaluate the clinical effect of early enteral nutrition in patients receiving a liver transplant.

METHODS

A systematic search was performed on the Cochrane Library, PubMed, CINAHL, EMBASE, Web of Science, WanFang database, Chinese Biomedical Literature Database and China National Knowledge Infrastructure to collect relevant studies up to January, 2020. The results of these studies were pooled to calculate relative risk and mean differences with 95% confidence intervals for dichotomous data and continuous data. All statistical analysis was carried out by Review Manager 5.3.

RESULTS

9 RCTs and 10 cohort studies with 1300 patients were included in this meta-analysis. Compared with TPN, EEN reduced postoperative infection rates, ICU hours, length of hospitalization, and the duration of bowel ventilation as well as strengthening the nutritional status and liver function of LT patients. There is no difference in mortality rates, blood glucose levels or gastrointestinal complications. Compared to TPN, the combined EN + PN method more effectively prevented infection.

CONCLUSION

For patients undergoing liver transplantation, early enteral nutrition with or without combination may considered as a better nutritional therapy than total parenteral nutrition.

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.

Prognostic Significance of Preoperative Fibrinogen-to-Prealbumin Ratio in Patients with Stage I-III Colorectal Cancer Undergoing Surgical Resection: A Retrospective Cohort Study

Background

The objective of this study was to explore the role of preoperative fibrinogen-to-prealbumin ratio (FPR) in evaluating the prognosis of patients with stage I–III colorectal cancer (CRC).

Methods

This retrospective study enrolled 584 stage I–III CRC patients undergoing surgical resection. Logistic regression analysis was used to explore the correlation between FPR and postoperative complications. The Kaplan-Meier curve and Cox proportional hazards model were used to identify the prognostic factors. The nomograms were constructed based on the prognostic factors. The concordance index and calibration curve were used to determine the accuracy of the nomograms. Time-dependent receiver operating characteristic was used to compare the predictive prognostic efficacy of nomograms and TNM stage.

Results

FPR was determined to be an independent factor affecting postoperative complications. Patients with a low-FPR had a significantly better prognosis than those with a high-FPR (disease-free survival, p = 0.028; overall survival, p = 0.027), especially patients with stage I CRC (disease-free survival, p = 0.015; overall survival, p = 0.017). The Cox proportional hazards model identified FPR as an independent poor prognostic factor of disease-free survival (hazard ratio (HR) = 1.459, 95% confidence interval (CI) = 1.074–1.954, p = 0.011) and overall survival (HR = 1.405, 95% CI = 1.034–1.909, p = 0.030). The prognostic nomograms had good accuracy and were superior to the traditional TNM stage.

Conclusions

FPR is a potential indicator for predicting short- and long-term prognosis of stage I–III CRC patients undergoing surgical resection.

Perioperative Enteral Nutrition Improves Postoperative Recovery for Patients with Primary Liver Cancer: A Randomized Controlled Clinical Trial

OBJECTIVE

The role of perioperative protein-enriched enteral nutrition for patients with primary liver cancer is unclear. We investigated the efficacy of perioperative protein-enriched enteral nutrition for patients with primary liver cancer followed hepatectomy.

METHODS

Patients with primary liver cancer that underwent hepatectomy between January 2016 and 2018 were enrolled. Patients in the treatment group was given enteral nutrition (TP-MCT) in addition to the regular diet. The primary outcome measures were duration of hospital stay and length of postoperative hospital stay. Secondary outcome measures included time to first flatus and time to first defecation.

RESULTS

There was a significant reduction of time to first flatus and time to first defecation in the treatment group, when compared with the control group (time to first flatus: P = 0.001, time to first defecation: P < 0.001).

CONCLUSIONS

It is found that addition of protein-enriched enteral nutrition (TP-MCT) improved postoperative recovery for patients with primary liver cancer following hepatectomy, with a significant reduction in time to first flatus and time to first defecation.

Effect of Chin-down-plus-larynx-tightening maneuver on swallowing function after minimally invasive esophagectomy: A randomized controlled trail

Background

The incidence of swallowing abnormality was high after minimally invasive esophagectomy (MIE) for esophageal cancer (EC). Few reports, however, focused on interventions for dysphagia after esophagectomy.

Aim

The purpose of this research was to estimate the effect of Chin‐down‐plus‐larynx‐tightening maneuver on swallowing function for patients receiving esophagectomy.

Method

This was a 2‐arm, parallel‐group, single‐blind randomized clinical trial, performed in patients suffered from EC from November 2018 to January 2020. Patients were randomly assigned to the intervention group (IG) or the control group (CG). The participants in CG received routine care, and the IG received Chin‐down‐plus‐larynx‐tightening maneuver during feeding. The incidence of choking cough, swallowing function, and dietary outcomes were evaluated before and after intervention for 7 days.

Results

A total of 237 EC cases were enrolled and randomized to the IG (n = 118) or CG (n = 119). There was no significant difference between the two groups in terms of demographic and clinical characteristics. Postoperative choking cough occurred in 5 of 118 cases (4.24%) in IG and 18 of 119 cases (19.4%) in CG, the differences showed statistically significant (P < .001). The analysis showed that the participants in the IG compared with the CG have more total caloric intake of 24 hours and higher K/R (the ratio of calories oral achieved to total calories required of body) significantly from D1 to D7 of intervention (P < .05).

Conclusion

The findings suggest that the Chin‐down‐plus‐larynx‐tightening maneuver can improve swallowing function recovery and oral total food intake and calories in EC patients undergoing MIE.

Diagnostic value of fibrinogen to prealbumin ratio and gamma-glutamyl transpeptidase to platelet ratio in the progression of AFP-negative hepatocellular carcinoma

Background

This study aimed to comprehensively assess the diagnostic value of fibrinogen to prealbumin ratio (FPR) and gamma-glutamyl transpeptidase to platelet ratio (GPR) as single markers or in combination in patients with alpha-fetoprotein-negative (AFP-negative) hepatocellular carcinoma (HCC).

Methods

A total of 199 healthy controls and 515 AFP-negative patients were enrolled in this study, including 180 HCC inpatients, 151 liver cirrhosis (LC) patients, and 184 chronic hepatitis (CH) cases. Mann-Whitney U or Kruskal-Wallis H test were used to analyze differences between groups in laboratory parameters and clinicopathological features. The diagnostic value of FPR and GPR, alone or in combination, in AFP-negative HCC (AFP-NHCC) patients was determined via a receiver operating characteristic (ROC) curve.

Results

The levels of FPR and GPR were gradually increased in the development of AFP-NHCC and positively correlated with the tumor size and Barcelona Clinic Liver Cancer (BCLC) stages. Moreover, GPR was associated with Edmondson-Steiner grades. After univariate logistic regression analysis, FPR and GPR remained independent predictors of adverse outcomes. The combination of FPR and GPR had a good ability to detect AFP-NHCC from the control group (area under curve [AUC] = 0.977), AFP-negative CH (AUC = 0.745), and AFP-negative LC (AUC = 0.666). FPR combined with GPR possessed a larger area (0.943, 0.971) and sensitivity (87.50%, 89.81%) than FPR or GPR alone for differentiating AFP-NHCC with tumor size < 3 cm or at the BCLC-A stage.

Conclusions

The pretreatment levels of FPR and GPR played vital roles in the development of AFP-NHCC, especially in patients with early or small AFP-NHCC.

Serum albumin levels predict which patients are at increased risk for complications following surgical management of acute osteoporotic vertebral compression fractures

BACKGROUND

Osteoporotic vertebral compression fractures (OVCF) account for a substantial portion of the US healthcare financial burden. With a growing elderly population, the number of fractures contributing to sagittal imbalance is expected to increase. For those patients undergoing surgery, preoperative markers, such as albumin, may help to predict the occurrence of postoperative complications.

PURPOSE

To evaluate the association between preoperative serum albumin levels and the incidence of postoperative complications, mortality, and 30-day readmissions following surgical intervention for OVCF.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Patient data were obtained from the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSIP) database between the years 2007 and 2014.

OUTCOME MEASURES

No outcome measures related to self-reporting, physiology, or functionality were evaluated in this study. Primary outcome measures analyzed included various postoperative complications, patient mortality, and 30-day readmission.

METHODS

A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database between 2007 and 2014 was performed, identifying 1,979 patients who met inclusion criteria. Patients were subcategorized into three groups based on preoperative nutritional status as defined by albumin levels. Outcome measures for this study included minor postoperative complication(s), major postoperative complication(s), patient mortality, 30-day readmission due to any cause, 30-day readmission related to OVCF, and total length of hospital stay. Analysis of variance was used to evaluate for associations between continuous variables and preoperative albumin levels. Spearman's rank correlation coefficient, chi-square trend, and Kruskal-Wallis analyses were utilized, as appropriate, for categorical variables. A multivariate logistic regression analysis was then conducted to calculate odds ratios with corresponding p values and 95% confidence intervals.

RESULTS

Functional status showed a statistically significant decline when correlated with preoperative albumin levels. Sepsis, septic shock, pulmonary embolism, reintubation, prolonged intubation, and major complications in general are statistically more likely to occur in patients with hypoalbuminemia. Among minor complications evaluated in this study, only surgical site complications failed to demonstrate a statistical correlation with nutritional status. No statistically significant associations were identified between postoperative outcomes and age, sex, or BMI.

CONCLUSIONS

Preoperative albumin levels were statistically correlated to the likelihood of minor complications, major complications, or mortality.

Differential Expression and Diagnostic Significance of Pre-Albumin, Fibrinogen Combined with D-Dimer in AFP-Negative Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most malignant cancers with high morbidity and mortality. Nowadays, AFP-negative hepatocellular carcinoma (AFP-NHCC) has been found in many HCC patients and AFP analysis can't be used to screen HCC in these cases. In this study, we have examined the expression patterns of pre-albumin (PA), fibrinogen, D-Dimer and their clinical significance in AFP-NHCC. We recruited 214 AFP-NHCC patients and 210 controls in the study. PA, fibrinogen and D-Dimer levels were detected by turbidimetry, clauss and immunoturbidimetry methods, respectively. Serum PA levels were significantly lower in AFP-NHCC (84.5 ± 24.7 mg/L) than that in the controls (240.6 ± 59.4 mg/L, P < 0.05). For plasma fibrinogen levels, there was no difference between the controls (2.9 ± 0.7 g/L) and AFP-NHCC (2.5 ± 0.7 g/L). Compared with AFP-NHCC (0.8 ± 0.2 mg/L), plasma D-Dimer levels were significantly lower in controls (0.1 ± 0.0 mg/L, P < 0.05). The levels of PA, fibrinogen and D-Dimer were significantly correlated with differentiation (P < 0.01), and the PA and D-Dimer values were correlated with TNM stage (P < 0.05). Moreover, PA levels were correlated with tumor size (P = 0.034). Receiver operating characteristic curve (ROC) analyses elaborated that combination of PA, fibrinogen and D-Dimer possessed a higher sensitivity (93.4%) for differentiating AFP-NHCC from the controls, but the diagnostic specificity was reduced due to the combination of fibrinogen. After adjusting for all significant outcome predictors of the univariate logistic regression analysis, low levels of PA and high levels of D-Dimer were remained independent unfavorable outcome predictors (P < 0.05). Our data suggested that the expression levels of PA, fibrinogen and D-Dimer played critical roles in AFP-NHCC tumorigenesis. Moreover, PA and D-Dimer might be considered as potential diagnostic indicators in AFP-NHCC.