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Shen Y, Cong Z, Ge Q, Huang H, Wei W, Wang C, Jiang Z, Wu Y. Effect of nutrition-based prehabilitation on the postoperative outcomes of patients with esophagogastric cancer undergoing surgery: A systematic review and meta-analysis. Cancer Med 2024; 13:e70023. [PMID: 39001679 PMCID: PMC11245637 DOI: 10.1002/cam4.70023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 05/17/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Meta-analyses have primarily focused on the effects of exercise-based prehabilitation on postoperative outcomes and ignored the role of nutritional intervention. In this study, we filled this gap by investigating the effect of nutrition-based prehabilitation on the postoperative outcomes of patients who underwent esophagectomy and gastrectomy. METHODS Five electronic databases, namely, PubMed, the Web of Science, Embase, Cochrane Library, and CINAHL, were searched. Adults diagnosed with esophagogastric cancer who were scheduled to undergo surgery and had undergone uni- or multimodal prehabilitation, with at least a week of mandatory nutritional intervention, were included. Forest plots were used to extract and visualize the data from the included studies. The occurrence of any postoperative complication was considered the primary endpoint. RESULTS Eight studies met the eligibility criteria, with five randomized controlled trials (RCTs) and three cohort studies. In total, 661 patients were included. Any prehabilitation, that is, unimodal (only nutrition) and multimodal prehabilitation, collectively decreased the risk of any postoperative complication by 23% (95% confidence interval [CI] = 0.66-0.90). A similar effect was exclusively observed for multimodal prehabilitation (risk ratio [RR] = 0.78, 95% CI = 0.66-0.93); however, it was not significant for unimodal prehabilitation. Any prehabilitation significantly decreased the length of hospital stay (LOS) (weighted mean difference = -0.77, 95% CI = -1.46 to -0.09). CONCLUSIONS Nutrition-based prehabilitation, particularly multimodal prehabilitation, confers protective effects against postoperative complications after esophagectomy and gastrectomy. Our findings suggest that prehabilitation slightly decreases LOS; however, the finding is not clinically significant. Therefore, additional rigorous RCTs are warranted for further substantiation.
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Affiliation(s)
- Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
- Department of Cardiothoracic Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhuangzhuang Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qiyue Ge
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Hairong Huang
- Department of Cardiothoracic Surgery, Jinling Hospital, Nanjing, China
| | - Wei Wei
- Department of Cardiothoracic Surgery, Jinling Hospital, Nanjing, China
| | - Changyong Wang
- Department of Cardiothoracic Surgery, Jinling Hospital, Nanjing, China
| | - Zhisheng Jiang
- Department of Cardiothoracic Surgery, Jinling Hospital, Nanjing, China
| | - Yuheng Wu
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
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Li S, Xie K, Xiao X, Xu P, Tang M, Li D. Correlation between sarcopenia and esophageal cancer: a narrative review. World J Surg Oncol 2024; 22:27. [PMID: 38267975 PMCID: PMC10809562 DOI: 10.1186/s12957-024-03304-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/13/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND In recent years, the research on the relationship between sarcopenia before and after the treatment of esophageal cancer, as well as its impact on prognosis of esophageal cancer, has increased rapidly, which has aroused people's attention to the disease of patients with esophageal cancer complicated with sarcopenia. This review examines the prevalence of sarcopenia in patients with esophageal cancer, as well as the relationship between sarcopenia (before and after surgery or chemotherapy) and prognosis in patients with esophageal cancer. Moreover, we summarized the potential pathogenesis of sarcopenia and pharmacologic and non-pharmacologic therapies. METHODS A narrative review was performed in PubMed and Web of Science using the keywords ("esophageal cancer" or "esophageal neoplasm" or "neoplasm, esophageal" or "esophagus neoplasm" or "esophagus neoplasms" or "neoplasm, esophagus" or "neoplasms, esophagus" or "neoplasms, esophageal" or "cancer of esophagus" or "cancer of the esophagus" or "esophagus cancer" or "cancer, esophagus" or "cancers, esophagus" or "esophagus cancers" or "esophageal cancer" or "cancer, esophageal" or "cancers, esophageal" or "esophageal cancers") and ("sarcopenia" or "muscular atrophy" or "aging" or "senescence" or "biological aging" or "aging, biological" or "atrophies, muscular" or "atrophy, muscular" or "muscular atrophies" or "atrophy, muscle" or "atrophies, muscle" or "muscle atrophies"). Studies reporting relationship between sarcopenia and esophageal cancer were analyzed. RESULTS The results of the review suggest that the average prevalence of sarcopenia in esophageal cancer was 46.3% ± 19.6% ranging from 14.4 to 81% and sarcopenia can be an important predictor of poor prognosis in patients with esophageal cancer. Patients with esophageal cancer can suffer from sarcopenia due to their nutritional deficiencies, reduced physical activity, chemotherapy, and the effects of certain inflammatory factors and pathways. When classic diagnostic values for sarcopenia such as skeletal muscle index (SMI) are not available clinically, it is also feasible to predict esophageal cancer prognosis using simpler metrics, such as calf circumference (CC), five-count sit-up test (5-CST), and six-minute walk distance (6MWD). CONCLUSIONS Identifying the potential mechanism of sarcopenia in patients with esophageal cancer and implementing appropriate interventions may hold the key to improving the prognosis of these patients.
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Affiliation(s)
- Shenglan Li
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, 410008, China
- Institute of Hospital Pharmacy, Central South University, Changsha, 410008, China
| | - Kaiqiang Xie
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, 410008, China
- Institute of Hospital Pharmacy, Central South University, Changsha, 410008, China
| | - Xiaoxiong Xiao
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Pingsheng Xu
- Phase I Clinical Trial Center, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Mimi Tang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410008, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China.
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, 410008, China.
- Institute of Hospital Pharmacy, Central South University, Changsha, 410008, China.
| | - Dai Li
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China.
- Phase I Clinical Trial Center, Xiangya Hospital, Central South University, Changsha, 410008, China.
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Fang P, Yang Q, Zhou J, Yang Y, Luan S, Xiao X, Li X, Gu Y, Shang Q, Zhang H, Chen L, Zeng X, Yuan Y. The impact of geriatric nutritional risk index on esophageal squamous cell carcinoma patients with neoadjuvant therapy followed by esophagectomy. Front Nutr 2022; 9:983038. [PMID: 36337651 PMCID: PMC9631310 DOI: 10.3389/fnut.2022.983038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background The Geriatric Nutritional Index (GNRI) has been indicated as a nutritional index which is highly associated with complications and mortality in older hospitalized patients. Moreover, early studies had suggested that GNRI is a potential prognostic indicator for some malignances. However, the prognostic value of GNRI in esophageal squamous cell carcinoma (ESCC) patients underwent neoadjuvant therapy followed by esophagectomy remains elusive. Materials and methods This retrospective study incorporated 373 patients with ESCC who had underwent neoadjuvant therapy followed by radical esophagectomy at West China Hospital of Sichuan University between April 2011 and September 2021. The GNRI formula was: 1.489 × albumin (g/dl) + 41.7 × current weight/ideal weight. Patients were classified as GNRI-low (GNRI < 98.7) or GNRI high (GNRI ≥ 98.7). The association between GNRI and clinical survival status were assessed utilizing Kaplan-Meier methods and Cox regression analysis. Results Three hundred and seventy three patients were retrospectively included in this study. 80 (21.5%) and 293 (78.5%) patients had been divided into the GNRI-low and GNRI-high groups respectively. Pathological T stage and the rate of nodal metastasis were significantly higher in the GNRI low group than in the GNRI high group (P = 0.003 and P = 0.001, respectively) among the examined demographic parameters. Furthermore, GNRI was significantly correlated with postoperative complications, patients with lower GNRI had a higher postoperative complication rate as compared with GNRI high group [Odds ratio: 2.023; 95% confidence interval (CI): 1.208–3.389; P = 0.007]. Univariate analysis of 5-year overall survival (OS) and disease-free survival (DFS) found that the rate of survival was considerably lower in the GNRI-low group than in the GNRI-high group (P < 0.001). However, multivariate analysis demonstrated that GNRI was not an independent risk factor. Conclusion In patients with ESCC, low GNRI exhibited a poor nutritional indicator and related to postoperative complications after neoadjuvant therapy. Intensive follow-up after surgery should be performed for ESCC patients with low GNRI.
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Affiliation(s)
- Pinhao Fang
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Yang
- Anesthesia Operation Center of West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
| | - Jianfeng Zhou
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Yushang Yang
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Siyuan Luan
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Xiao
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaokun Li
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Yimin Gu
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Qixin Shang
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Hanlu Zhang
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Longqi Chen
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoxi Zeng
- Biomedical Big Data Center of West China Hospital, Med+X Center for Informatics, Sichuan University, Chengdu, China
| | - Yong Yuan
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Yong Yuan,
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Zhang C, Hu LW, Qiang Y, Cong ZZ, Zheng C, Gu WF, Luo C, Xie K, Shen Y. Home enteral nutrition for patients with esophageal cancer undergoing esophagectomy: A systematic review and meta-analysis. Front Nutr 2022; 9:895422. [PMID: 35967793 PMCID: PMC9366554 DOI: 10.3389/fnut.2022.895422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/16/2022] [Indexed: 12/09/2022] Open
Abstract
Introduction Home enteral nutrition (HEN) is a relatively new nutritional intervention that provides patients with EN support at home through jejunostomy or nasogastric feeding tubes. We conducted this systematic review and meta-analysis to explore the safety and effect of HEN compared with normal oral diet (NOD) in postoperative patients with esophageal cancer (EC). Methods EMBASE, Medline, Web of Science, and the Cochrane Library were used to search articles in English-language journals. The intervention effect was expressed using risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures, with 95% confidence intervals (95% CIs). The chi-square test and I-square test were used to test heterogeneity among studies. Results Four studies were eventually included in this meta-analysis. Compared with NOD, HEN has a favorable impact on postoperative body mass index (BMI) (weighted mean difference [WMD] = 0.70, 95% CI: 0.09–1.30, P = 0.02), lean body mass (LBM) (WMD = 0.76, 95% CI: 0.04–1.48, P = 0.04), and appendicular skeletal muscle mass index (ASMI) (WMD = 0.30, 95% CI: 0.02–0.58, P = 0.03). Physical function (WMD = 9.26, 95% CI: 8.00–10.53, P < 0.001), role function (WMD = 9.96, 95% CI: 8.11–11.82, P < 0.001), and social function (WMD = 8.51, 95% CI: 3.48–13.54, P = 0.001) of the HEN group were better than those of the NOD group at 3 months, and HEN could reduce the fatigue of patients (WMD = −12.73, 95% CI: −14.8 to −10.66, P < 0.001) and the incidence of postoperative pneumonia (RR = 0.53, 95% CI: 0.34–0.81, P = 0.004). There was no significant difference in albumin between HEN and NOD groups (WMD = 0.05, 95% CI: −0.03 to 0.13, P = 0.20). Conclusion HEN improved nutritional status and quality of life (QOL) in postoperative patients with EC and reduced fatigue and the incidence of postoperative pneumonia. All in all, the results of our meta-analysis support the use of HEN after esophagectomy.
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Affiliation(s)
- Chi Zhang
- Department of Cardiothoracic Surgery, Medical School of Nanjing University, Jinling Hospital, Nanjing, China
| | - Li-Wen Hu
- Department of Cardiothoracic Surgery, Medical School of Nanjing University, Jinling Hospital, Nanjing, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, School of Medicine, Jinling Hospital, Southeast University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Medical School of Nanjing University, Jinling Hospital, Nanjing, China
| | - Chao Zheng
- Department of Cardiothoracic Surgery, School of Medicine, Jinling Hospital, Southeast University, Nanjing, China
| | - Wen-Feng Gu
- Department of Cardiothoracic Surgery, Medical School of Nanjing University, Jinling Hospital, Nanjing, China
| | - Chao Luo
- Department of Cardiothoracic Surgery, School of Clinical Medicine, Jinling Hospital, Southern Medical University, Guangzhou, China
| | - Kai Xie
- Department of Cardiothoracic Surgery, School of Clinical Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Medical School of Nanjing University, Jinling Hospital, Nanjing, China.,Department of Cardiothoracic Surgery, School of Medicine, Jinling Hospital, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, School of Clinical Medicine, Jinling Hospital, Southern Medical University, Guangzhou, China.,Department of Cardiothoracic Surgery, School of Clinical Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
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Liu F, Pan X, Zhao S, Ren R, Chang G, Mao Y. Effect of Home Enteral Nutritional Support Compared With Normal Oral Diet in Postoperative Subjects With Upper Gastrointestinal Cancer Resection: A Meta-Analysis. Front Surg 2022; 9:844475. [PMID: 35252342 PMCID: PMC8894329 DOI: 10.3389/fsurg.2022.844475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/18/2022] [Indexed: 12/24/2022] Open
Abstract
IntroductionWe performed a meta-analysis to evaluate the influence of a home enteral nutritional support compared with a normal oral diet in postoperative subjects with upper gastrointestinal cancer resection.MethodsA systematic literature search up to December 2021 was done and 23 studies included 3,010 subjects with upper gastrointestinal cancer resection at the start of the study; 1,556 of them were given home enteral nutritional support and 1,454 were normal oral diet. We calculated the odds ratio (OR) and mean difference (MD) with 95% CIs to evaluate the influence of home enteral nutritional support compared with a normal oral diet in postoperative subjects with upper gastrointestinal cancer resection by the dichotomous or continuous methods with a random or fixed-influence model.ResultsHome enteral nutritional support had significantly higher quality of life (MD, 2.08; 95% CI, 1.50–2.67, p < 0.001), better body weight change (MD, 1.87; 95% CI, 1.31–2.43, p < 0.001), higher albumin (MD, 1.27; 95% CI, 0.72–1.82, p < 0.001), and higher pre-albumin (MD, 30.79; 95% CI, 7.29–54.29, p = 0.01) compared to the normal oral diet in subjects with upper gastrointestinal cancer resection. However, home enteral nutritional support had no significant impact on the hemoglobin (MD, 4.64; 95% CI, −4.17 to 13.46, p = 0.30), and complications (OR, 1.03; 95% CI, 0.76–1.40, p = 0.83) compared to the normal oral diet in subjects with upper gastrointestinal cancer resection.ConclusionsHome enteral nutritional support had a significantly higher quality of life, better body weight change, higher albumin, and higher pre-albumin, and had no significant impact on the hemoglobin and complications compared to the normal oral diet in subjects with upper gastrointestinal cancer resection. Further studies are required.
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Affiliation(s)
- Fang Liu
- Department of Nursing, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Xuling Pan
- General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - SuQing Zhao
- Health Management Center, The First Hospital of Hohhot, Hohhot, China
| | - RuiJun Ren
- Interventional Department, The First Hospital of Hohhot, Hohhot, China
| | - GuiXia Chang
- Thoracic Surgery, The First Hospital of Hohhot, Hohhot, China
| | - Yu Mao
- Thoracic Surgery, The First Hospital of Hohhot, Hohhot, China
- *Correspondence: Yu Mao
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Gliwska E, Guzek D, Przekop Z, Sobocki J, Głąbska D. Quality of Life of Cancer Patients Receiving Enteral Nutrition: A Systematic Review of Randomized Controlled Trials. Nutrients 2021; 13:nu13124551. [PMID: 34960103 PMCID: PMC8705712 DOI: 10.3390/nu13124551] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/08/2021] [Accepted: 12/15/2021] [Indexed: 11/27/2022] Open
Abstract
Most studies confirm the beneficial effects of enteral nutrition on the quality of life, but some studies indicate an inverse association and its detrimental impacts. However, there are insufficient data on the effects of enteral nutrition on the quality of life of cancer patients. This systematic review aimed to describe the influence of applied enteral nutrition on the quality of life of cancer patients, based on the results of randomized controlled trials. It was registered in the PROSPERO database (CRD42021261226) and conducted based on the PRISMA guidelines. The searching procedure was conducted using the PubMed and Web of Science databases, as well as Cochrane Library, and it included studies published until June 2021. It was conducted to select randomized controlled trials assessing the influence of enteral nutrition (compared with the other model of nutrition) on the quality of life of cancer patients. A general number of 761 records were screened and a final number of 16 studies were included in the systematic review. The studies were included and assessed by two independent researchers, while the risk of bias was analyzed using the Newcastle–Ottawa Scale (NOS). Studies compared patients treated with and without enteral nutrition, patients treated with various methods of enteral nutrition or with enteral diets of various content, as well as patients treated with enteral and parenteral nutrition. Within the included studies, the majority were conducted in patients with cancers located in various parts of the body, or diverse areas within the gastrointestinal system, while some studies were conducted in specific populations of patients with a defined cancer location—esophagus, stomach, or ovary. The duration of applied enteral nutrition within the included studies was diversified—from two weeks or less to half a year or even more. The vast majority of studies used well-known and validated tools to assess the quality of life, either developed for a specific group of head/neck, esophagus/stomach, and ovary cancer patients or developed for more general patient populations. Most studies concerning patients treated with and without enteral nutrition supported applying enteral nutrition, which was concluded in seven studies out of ten (including four studies with a low risk of bias). The other important observations to be emphasized—formulated based on the studies with a low risk of bias—presented the role of oral supportive nutrition guided by a dietitian, as well as the beneficial role of enteral and parenteral nutrition, combined. In spite of a relatively low number of randomized controlled trials assessing the influence of enteral nutrition on the quality of life of cancer patients, which should be considered as a limitation, the results were promising. Most studies supported the positive influence of enteral nutrition on the quality of life, either assessed based on the psychological measures of the quality of life or by considering the other potential determinants (e.g., malnutrition, complications, etc.). Taking this into account, enteral nutrition should be applied whenever possible, both to prevent and treat malnutrition in cancer patients. However, considering the limited number of studies conducted so far, further research conducted in homogenic populations of patients is necessary.
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Affiliation(s)
- Elwira Gliwska
- Department of Food Market and Consumer Research, Institute of Human Nutrition Sciences, Warsaw University of Life Sciences (WULS-SGGW), 159C Nowoursynowska Street, 02-776 Warsaw, Poland;
- Cancer Epidemiology and Primary Prevention Department, The Maria Sklodowska-Curie National Research Institute of Oncology, 15B Wawelska Street, 02-034 Warsaw, Poland
| | - Dominika Guzek
- Department of Food Market and Consumer Research, Institute of Human Nutrition Sciences, Warsaw University of Life Sciences (WULS-SGGW), 159C Nowoursynowska Street, 02-776 Warsaw, Poland;
- Correspondence: ; Tel.: +48-225-937-134
| | - Zuzanna Przekop
- Department of Clinical Dietetics, Faculty of Health Sciences, Medical University of Warsaw, 27 Ciołka Street, 01-445 Warsaw, Poland;
| | - Jacek Sobocki
- Department of General Surgery and Clinical Nutrition, Centre of Postgraduate Medical Education in Warsaw, 231 Czerniakowska Street, 00-416 Warsaw, Poland;
| | - Dominika Głąbska
- Department of Dietetics, Institute of Human Nutrition Sciences, Warsaw University of Life Sciences (WULS-SGGW), 159C Nowoursynowska Street, 02-776 Warsaw, Poland;
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Takahashi K, Nishikawa K, Tanishima Y, Ishikawa Y, Masuda T, Kurogochi T, Yuda M, Tanaka Y, Matsumoto A, Yano F, Eto K. Risk stratification of anastomotic leakage using eGFR and FIB-4 index in patients undergoing esophageal cancer surgery. Langenbecks Arch Surg 2021; 406:1867-1874. [PMID: 34313831 DOI: 10.1007/s00423-021-02272-z] [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: 04/26/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Renal insufficiency and liver cirrhosis are identified as independent risk factors for anastomotic leakage (AL) after esophagectomy. However, research evaluating the incidence of AL using quantitative data to measure renal function and liver fibrosis remain to be limited. Therefore, this study was conducted to evaluate postoperative AL after esophagectomy using estimated glomerular filtration rate (eGFR) and fibrosis-4 (FIB-4) index. METHODS In total, 184 patients who underwent esophagectomy were included in this study; then, they were divided into the non-AL group (n = 161) and AL group (n = 23), after which their background data and intraoperative and postoperative outcomes were compared. In addition, risk factors for AL were evaluated using a logistic regression model. RESULTS Preoperative body mass index of ≥21.5 kg/m2, hemoglobin A1c level of ≥7.3%, FIB-4 index of ≥1.44, and eGFR of <59 ml/min/1.73 m2 were found to be significantly frequent in the AL group compared with the non-AL group. Multivariate analysis revealed FIB-4 index of ≥1.44 (p = 0.013; OR, 3.780; 95% CI, 1.320-10.800) and eGFR of <59 ml/min/1.73 m2 (p = 0.018; OR, 3.110; 95% CI, 1.220-8.020) as the independent risk factors for AL. In addition, we stratified the patients into three groups based on the incidence of AL as follows: low risk (5.5%, low FIB-4 index), intermediate risk (13.0%, high FIB-4 index and eGFR), and high risk (37.5%, high FIB-4 index and low eGFR). CONCLUSION Preoperative eGFR and FIB-4 index were found to be useful markers to predict AL after esophagectomy.
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Affiliation(s)
- Keita Takahashi
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Katsunori Nishikawa
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yuichiro Tanishima
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yoshitaka Ishikawa
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takahiro Masuda
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takanori Kurogochi
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masami Yuda
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yujiro Tanaka
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Akira Matsumoto
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Fumiaki Yano
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ken Eto
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Huang C, Liang X, Du S, He J, Bai Q, Feng X, Liu X, Tian X, Wang J. Therapeutic Effect and Cost-Benefit Analysis of Three Different Nutritional Schemes for Esophageal Cancer Patients in the Early Post-operative Period. Front Nutr 2021; 8:651596. [PMID: 34222299 PMCID: PMC8247476 DOI: 10.3389/fnut.2021.651596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/18/2021] [Indexed: 12/09/2022] Open
Abstract
Objective: To retrospectively investigate the comparative efficacy, safety and cost-benefits of three nutritional treatment schemes including short peptide jejunal nutrition (SPJN), whole protein jejunal nutrition (WPJN), and partial parenteral nutrition (PPN) in patients underwent esophagectomy for esophageal cancer in our hospital. This study was carried out in accordance with the conceptual framework of nutritional therapy in fast-track rehabilitation surgery. Methods: We retrospectively reviewed 305 patients who were assigned to receive esophagectomy for esophageal cancer. Eligible patients was naturally divided into SPJN group [n = 98 (32.1%)], WPJN group [n = 95 (31.1%)], and PPN group [n = 112 (36.7%)] according to the type of nutritional scheme which was actually prescribed to patients by the attendingphysician in clinical practice. The differences of the serum total protein (TP), albumin (ALB), pre-albumin (PA), hemoglobin (HGB), white blood cells (WBCs), red blood cells (RBCs) and neutrophils were compared among 3 nutritional schemes groups. We also investigated the relationship of the fluid intake, urine output, gastric juice drainage volume and thoracic drainage volume among 3 nutritional groups at 3 days after surgery. Moreover, the differences of cost-benefit indexes, complications, length of hospitalization and hospital expenditure were also compared. Results: The serum TP, ALB, and PA in the SPJN group were all higher than those in the WPJN and PPN groups (p < 0.05). The gastric juice volume of gastrointestinal decompression drainage and fluid volume of thoracic drainage in the SPJN group were all less than that in the WPJN group (p < 0.05). The overall hospital stay and post-operative hospital stay in the SPJN group were all shorter than that in WPJN group (p < 0.05). Moreover, the incidence of post-operative complications including anastomotic leakage, infection, and gastrointestinal reaction was remarkably lower in the SPJN group compared to the WPJN group (p < 0.05). Interesting, hospital expenditure in the PPN group was less than that in the SPJN and the WPJN groups (p < 0.001). Conclusion: Patients may obtain benefits in improving protein level after receiving SPJN scheme at the early stage after esophagectomy. Meanwhile, patients may obtain benefits in improving post-operative complications and hospital stay after receiving SPJN or PPN compared to WPJN protocol. However, the difference between SPJN and PPN requires further study because no difference was detected in terms of clinical outcomes including complications and the length of hospitalization although PPN may achieve a possible decrease of medical expenditure.
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Affiliation(s)
- Chen Huang
- Department of Nutrition, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xinyu Liang
- Department of Nutrition, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Shanshan Du
- Department of Nutrition, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Jie He
- Department of Orthopedics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qian Bai
- Department of Nutrition, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xiaoqing Feng
- Department of Nutrition, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xiaoqing Liu
- Department of Thoracic Surgery, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xu Tian
- Nursing Department, Universitat Rovira i Virgili, Tarragona, Spain.,Department of Gastroenterology, Chongqing University Cancer Hospital, Chongqing, China
| | - Jian Wang
- Department of Nutrition, Xinqiao Hospital of Army Medical University, Chongqing, China
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9
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Liu L, Wang YC, Liu QW, Zhong JD, Li JB, Wu XD, Qin HY. Home enteral nutrition after esophagectomy for esophageal cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e21988. [PMID: 32899043 PMCID: PMC7478745 DOI: 10.1097/md.0000000000021988] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Not only has the placement rate of enteral feeding tubes during operations for esophageal cancer increased, but also has number of patients who choose to continue enteral feeding at home instead of removing the feeding tube at discharge. The impacts of home enteral nutrition (HEN) after esophagectomy in esophageal cancer patients are analyzed. METHODS A systematic review was conducted in accordance with PRISMA and Cochrane guidelines. English and Chinese databases, including PubMed, Embase, Web of Science, The Cochrane Library, Scopus, CBM, CNKI, and Wan Fang were searched from inception to December 7, 2019. Randomized controlled trials evaluating the short-term outcomes of HEN following esophagectomy in cancer patients were included. The risk of bias of the included studies was appraised according to the Cochrane risk of bias tool. The summary of relative risk/weighted mean difference (WMD) estimates and corresponding 95% confidence interval (95% CI) were calculated using fixed- and random-effects models. RESULTS Nine randomized controlled trials involving 757 patients were included in the meta-analysis. Compared with oral diet, HEN was associated with significantly increased body weight (WMD 3 kg, 95% CI 2.36-3.63, P < .001), body mass index (WMD 0.97 kg/m, 95% CI 0.74-1.21, P < .001), albumin (WMD 3.43 g/L, 95% CI 2.35-4.52, P < .001), hemoglobin (WMD 7.23 g/L, 95% CI 5.87-8.59, P < .001), and total protein (WMD 5.13 g/L, 95% CI 3.7-6.56, P < .001). No significant differences were observed in prealbumin and gastrointestinal adverse reactions. Physical (WMD 8.82, 95% CI 6.69-10.95, P < .001) and role function (WMD 12.23, 95% CI 2.72-21.74, P = .01) were also significantly better in the HEN group. The nausea/vomiting (WMD -5.43, 95% CI -8.29 to -2.57, P = .002) and fatigue symptoms (WMD -11.76, 95% CI -16.21 to -7.32, P < .001) were significantly reduced. Appetite loss (WMD -8.48, 95% CI -14.27 to -4.88, P = .001), diarrhea (WMD -3.9, 95% CI -7.37 to -0.43, P = .03), and sleep disturbance (WMD -7.64, 95% CI -12.79 to -2.5, P = .004) in the HEN group were also significantly less than the control group. CONCLUSIONS HEN improved nutrition status, physical and role function, and reduced nausea/vomiting, fatigue, appetite loss, diarrhea, and sleep disturbance compared with an oral diet in esophageal cancer patients postsurgery. HEN did not increase adverse reactions.
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Affiliation(s)
- Li Liu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine
| | - Yu-cui Wang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian-wen Liu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine
| | - Jiu-di Zhong
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine
| | - Jin-bo Li
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine
| | - Xiao-dan Wu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine
| | - Hui-ying Qin
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine
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Liu K, Sun S, Liu X, Luo J, Gao X, Xu Z, Zhang Q, Bao J, Ren B. Esophageal cancer patients of heavier weight have more nutritional risk of inadequate calorie intake immediately after esophagectomy: a retrospective study. Support Care Cancer 2020; 29:1265-1274. [PMID: 32621261 DOI: 10.1007/s00520-020-05538-2] [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: 11/30/2019] [Accepted: 05/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Perioperative malnutrition is common in patients undergoing esophagectomy, and nutritional support is critical for postoperative recovery in these patients. But few studies reported which characteristics of these patients were associated with post-esophagectomy inadequate calorie intake. This study aimed to explore which patients were more likely to have inadequate calories immediately after esophagectomy and the impact on clinical outcomes. METHODS From January 2018 to June 2019, patients undergoing esophagectomy were retrospectively divided into the "adequate calorie group" and the "inadequate calorie group" according to whether they met daily calorie requirements in a week after esophagectomy. Caloric requirements met rate and clinical outcomes were compared between patients with and without complications, and with weight > 70 kg or ≤ 70 kg. RESULTS Patients in the inadequate calorie group (n = 104) had significantly higher weight (p < 0.001), lean body mass (p = 0.028), and BMI (p = 0.001) than the adequate calorie group (n = 46). Weight loss after esophagectomy was reduced (p = 0.043) in the adequate calorie group. Patients with complications had lower rate of adequate calorie intake (72.8% vs. 63.8%). The caloric requirements met rate in patients with weigh ≤ 70 kg was significantly higher than those weight > 70 kg (80.2% vs. 43.2%, p < 0.001). CONCLUSION The weights of patients having inadequate calories in a week after esophagectomy were significantly heavier than those having adequate calories. Heavier patients after esophagectomy should attract more attention to their nutrition support. TRIAL REGISTRATION This trial was registered ( ChiCTR1900025557 ).
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Affiliation(s)
- Kaichao Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Nanjing, China
| | - Saisai Sun
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China.,Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Nanjing, China
| | - Xiaolin Liu
- Department of Clinical Pharmacy, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China
| | - Jing Luo
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Nanjing, China
| | - Xiang Gao
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China.,Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Nanjing, China
| | - Zhiyun Xu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China.,Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Nanjing, China
| | - Qin Zhang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China. .,Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Nanjing, China.
| | - Jun Bao
- Department of Clinical Pharmacy, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China.
| | - Binhui Ren
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China. .,Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Nanjing, China.
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11
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Li XK, Zhou H, Xu Y, Cong ZZ, Wu WJ, Luo J, Jiang ZS, Shen Y. Enteral immunonutrition versus enteral nutrition for patients undergoing oesophagectomy: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2020; 30:854-862. [PMID: 32206808 DOI: 10.1093/icvts/ivaa022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES According to retrospective studies, oesophageal carcinoma is the second deadliest gastrointestinal cancer after gastric cancer. Enteral immunonutrition (EIN) has been increasingly used to enhance host immunity and relieve the inflammatory response of patients undergoing oesophagectomy; however, conclusions across studies remain unclear. We aimed to evaluate the effect of EIN on the clinical and immunological outcomes of patients undergoing oesophagectomy. METHODS Four electronic databases (MEDLINE, Embase, Web of Science and Cochrane Library) were used to search articles in peer-reviewed, English-language journals. The mean difference, relative risk or standard mean difference with 95% confidence interval were calculated. Heterogeneity was assessed by the Cochran's Q test and I2 statistic combined with the corresponding P-value. The analysis was carried out with RevMan 5.3. RESULTS Six articles were finally included, with a total of 320 patients with oesophageal cancer. The meta-analysis results showed that EIN did not improve clinical outcomes (such as infectious complications, pneumonia, surgical site infection, anastomotic leak and postoperative hospital stay) or immune indices [referring to C-reactive protein, interleukin (IL)-6, IL-8, tumour necrosis factor-α]. Descriptive analysis suggested that EIN also increased the serum concentrations of IgG and the percentage of the B-cell fraction. Thus, its impact on IL-8 and IL-6 remains inconsistent. CONCLUSIONS The early-stage impact of EIN on immunological status in patients undergoing oesophagectomy is still unclear. According to the results of this meta-analysis, whether EIN could improve the clinical outcomes or biological status after oesophagectomy compared to standard enteral nutrition is uncertain. Since the impact of EIN is unclear, current guidelines that strongly advise the use of EIN should be changed, as the utility of EIN is very uncertain. More appropriately powered clinical studies are warranted to confirm its effectiveness.
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Affiliation(s)
- Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Hai Zhou
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhi-Sheng Jiang
- Department of Cardiothoracic Surgery, Jingling Hospital, Bengbu Medical College, Anhui, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
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12
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Triantafyllou T, Olson MT, Theodorou D, Schizas D, Singhal S. Enhanced recovery pathways vs standard care pathways in esophageal cancer surgery: systematic review and meta-analysis. Esophagus 2020; 17:100-112. [PMID: 31974853 DOI: 10.1007/s10388-020-00718-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/12/2020] [Indexed: 02/03/2023]
Abstract
Enhanced recovery after surgery (ERAS) protocols vs standard care pathways after esophagectomy for malignancy have gained wide popularity among surgeons. However, the current literature is still lacking level-I evidence to show a clear superiority of one approach. The present study is a detailed systematic review and meta-analysis of the published trials. A systematic review of literature databases was conducted for randomized controlled trials (RCTs) and non-randomized, prospective, comparative studies between January 1990 and September 2019, comparing ERAS pathway group with standard care for esophageal resection for esophageal cancer. Mean difference (MD) for continuous variables and odds ratio (OR) or risk difference (RD) for dichotomous variables with 95% confidence interval (CI) were used. Between-study heterogeneity was evaluated. Eight studies with a total of 1133 patients were included. Hospital stay [Standard mean difference (Std. MD) = - 1.92, 95% CI - 2.78, - 1.06, P < 0.0001], overall morbidity (OR 0.68, CI 0.49, 0.96, P = 0.03), pulmonary complications (OR 0.45, CI 0.31, 0.65, P < 0.0001), anastomotic leak rate (OR 0.37, CI 0.18, 0.74, P = 0.005), time to first flatus and defecation (Std. MD = -5.01, CI - 9.53, - 0.49, P = 0.03), (Std. MD = - 1.36, CI - 1.78, - 0.94, P < 0.00001) and total hospital cost (Std. MD = - 1.62, CI - 2.24, - 1.01, P < 0.00001) favored the ERAS group. Patients who undergo ERAS have a clear benefit over the standard care protocol. However, existing protocols in different centers are followed by great variability, while the evaluated parameters suffer from significant heterogeneity. A well-formulated, standardized protocol should be standard-of-care at all centers.
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Affiliation(s)
- Tania Triantafyllou
- 1st Propaedeutic Department of Surgery, Hippocration General Hospital of Athens, University of Athens, Athens, Greece
| | - Michael T Olson
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Dimitrios Theodorou
- 1st Propaedeutic Department of Surgery, Hippocration General Hospital of Athens, University of Athens, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital of Athens, Athens, Greece
| | - Saurabh Singhal
- Department of GI Surgery and Liver Transplantation, Indraprastha Apollo Hospital, New Delhi, India.
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