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Postoperative Diet with an Oligomeric Hyperproteic Normocaloric Supplement versus a Supplement with Immunonutrients in Colorectal Cancer Surgery: Results of a Multicenter, Double-Blind, Randomized Clinical Trial. Nutrients 2022; 14:nu14153062. [PMID: 35893914 PMCID: PMC9331223 DOI: 10.3390/nu14153062] [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: 06/11/2022] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Background: For normo-nourished colorectal cancer patients, the need for immunonutrients after elective surgery is not known. (2) Methods: Multicenter, randomized, double-blind, phase III clinical trial comparing the postoperative diet with 200 mL oligomeric hyperproteic normocaloric (OHN; experimental arm) supplement vs. 200 mL immunonutritional (IN) (active comparator) supplement twice a day for five days in 151 normo-nourished adult colorectal-resection patients following the multimodal rehabilitation ERAS protocol. The proportions of patients with complications (primary outcome) and those who were readmitted, hospitalized for <7 days, had surgical site infections, or died due to surgical complications (secondary outcome) were compared between the two groups until postoperative day 30. Tolerance to both types of supplement and blood parameters was also assessed until day 5. (3) Results: Mean age was 69.2 and 84 (58.7%) were men. Complications were reported in 41 (28.7%) patients and the incidence did not differ between groups (18 (25%) vs. 23 (32.4%) patients with OHN and IN supplement, respectively; p = 0.328). No significant differences were found for the rest of the variables. (4) Conclusions: IN supplement may not be necessary for the postoperative recovery of colorectal cancer patients under the ERAS regimen and with normal nutritional status at the time of surgery.
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Ongaro E, Buoro V, Cinausero M, Caccialanza R, Turri A, Fanotto V, Basile D, Vitale MG, Ermacora P, Cardellino GG, Nicoletti L, Fornaro L, Casadei-Gardini A, Aprile G. Sarcopenia in gastric cancer: when the loss costs too much. Gastric Cancer 2017; 20:563-572. [PMID: 28477106 DOI: 10.1007/s10120-017-0722-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/23/2017] [Indexed: 02/07/2023]
Abstract
Sarcopenia is a complex syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. Malignancy is a major determinant of sarcopenia, and gastric cancer (GC) is among the most common causes of this phenomenon. As sarcopenia is a well-recognized poor prognostic feature in GC and has been associated with worse tolerance of surgical and medical treatments, members of the multidisciplinary team should be aware of the clinical relevance, pathogenic mechanisms, and potential treatments for this syndrome. The importance of sarcopenia is often underestimated in everyday practice and clinical trials, particularly among elderly or fragile patients. As treatment options are improving in all disease stages, deeper knowledge and greater attention to the metabolic balance in GC patients could further increase the benefit of novel therapeutic strategies and dramatically impact on quality of life. In this review, we describe the role of sarcopenia in different phases of GC progression. Our aim is to provide oncologists and surgeons dealing with GC patients with a useful tool for comprehensive assessment and timely management of this potentially life-threatening condition.
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Affiliation(s)
- Elena Ongaro
- Department of Oncology, University and General Hospital, Udine, Italy
| | - Vanessa Buoro
- Department of Oncology, University and General Hospital, Udine, Italy
| | - Marika Cinausero
- Department of Oncology, University and General Hospital, Udine, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Annalisa Turri
- Clinical Nutrition Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Valentina Fanotto
- Department of Oncology, University and General Hospital, Udine, Italy
| | - Debora Basile
- Department of Oncology, University and General Hospital, Udine, Italy
| | | | - Paola Ermacora
- Department of Oncology, University and General Hospital, Udine, Italy
| | | | - Laura Nicoletti
- Department of Oncology, San Bortolo General Hospital, Azienda ULSS8 Berica, East District, Viale Rodolfi 37, 36100, Vicenza, Italy
| | - Lorenzo Fornaro
- Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Andrea Casadei-Gardini
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, FC, Italy
| | - Giuseppe Aprile
- Department of Oncology, University and General Hospital, Udine, Italy.
- Department of Oncology, San Bortolo General Hospital, Azienda ULSS8 Berica, East District, Viale Rodolfi 37, 36100, Vicenza, Italy.
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Prieto I, Montemuiño S, Luna J, de Torres MV, Amaya E. The role of immunonutritional support in cancer treatment: Current evidence. Clin Nutr 2016; 36:1457-1464. [PMID: 27931879 DOI: 10.1016/j.clnu.2016.11.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/12/2016] [Accepted: 11/14/2016] [Indexed: 01/01/2023]
Abstract
The significant role of the immune system in cancer treatment has given rise to an emerging field of study within oncology, and one that is attracting increasing attention from researchers. Immunotherapy has demonstrated that the immune system is crucial in the fight against cancer. This challenge has led researchers to analyze whether the immune influencing capacity of immunonutrition may aid in improving immune status, modulate the acquired immune response, decrease the treatment toxicity and improve patient outcomes. Immunonutrition, new developed formulas has been demonstrated to improve outcome in surgical patients. This improvement is related to the modulation of the inflammatory response in the peri-operative period. The aim of this review is to analyze current evidence on the benefit of immunonutrition in patients undergoing pro-inflammatory processes in cancer, such as receiving chemotherapy or radiation treatment. With this aim, authors have analyzed the problem studying different aspects: the role of the immune system in cancer treatment, current evidence regarding immunonutrition in perioperative period, current evidence regarding immunonutrition in cancer patients and the relation between immunity and radiotherapy. The conclusions of this review confirm that immunonutrition formulas could modulate inflammatory and immune response in cancer patients. This effect decreases acute toxicity, although the pathways and the measure of this immune response are unclear. Immunonutrition is an emerging field in oncology, and further research is needed.
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Affiliation(s)
- Isabel Prieto
- Radiation Oncology Department, Fundacion Jimenez Diaz, Oncohealth Institute, Avda. Reyes Católicos 2, 28040 Madrid, Spain.
| | - Sara Montemuiño
- Radiation Oncology Department, Hospital Universitario de Fuenlabrada, Calle Camino del Molino, 2, 28942 Fuenlabrada, Madrid, Spain.
| | - Javier Luna
- Radiation Oncology Department, Fundacion Jimenez Diaz, Oncohealth Institute, Avda. Reyes Católicos 2, 28040 Madrid, Spain.
| | - Maria Victoria de Torres
- Radiation Oncology Department, Hospital Universitario de Fuenlabrada, Calle Camino del Molino, 2, 28942 Fuenlabrada, Madrid, Spain.
| | - Enrique Amaya
- Radiation Oncology Department, Hospital Universitario Rey Juan Carlos I, C/ Gladiolo, s/n, 28933 Móstoles, Madrid, Spain.
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Luedike P, Totzeck M, Meyer C, Westenfeld R, Kindgen-Milles D, Kelm M, Rassaf T. Act fast and ventilate soft: the Düsseldorf hands-on translation of the acute respiratory distress syndrome Berlin definition. J Crit Care 2014; 29:883.e1-5. [PMID: 24768567 DOI: 10.1016/j.jcrc.2014.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/23/2014] [Accepted: 03/25/2014] [Indexed: 11/26/2022]
Abstract
Early identification of acute respiratory distress syndrome (ARDS) and forceful implementation of standardized therapy algorithms are the mandatory basis of an effective therapy to improve patient outcome. Recently, a new definition of ARDS was implemented, which simplified the diagnostic criteria for ARDS. Evidence-based therapies are rare, but some cornerstone interventions can be recommended. Lung-protective ventilation with high positive end-expiratory pressure and low tidal volume and early prone positioning in severe cases improve survival rate. We here present an integrated "Düsseldorf hands-on translation" in the form of a "one-page" standard operating procedure in order to fasten and standardize both diagnosis and therapeutic algorithms on an intensive care unit.
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Affiliation(s)
- Peter Luedike
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Matthias Totzeck
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Meyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Detlef Kindgen-Milles
- Division of Anaesthesiology, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tienush Rassaf
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty Heinrich-Heine-University, University Hospital Düsseldorf, Düsseldorf, Germany.
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Williams TA, Leslie GD, Leen T, Mills L, Dobb GJ. Reducing interruptions to continuous enteral nutrition in the intensive care unit: a comparative study. J Clin Nurs 2013; 22:2838-48. [DOI: 10.1111/jocn.12068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2012] [Indexed: 12/26/2022]
Affiliation(s)
- Teresa A Williams
- Discipline of Emergency Medicine (M516); School of Primary; Aboriginal and Rural Health Care (SPARHC); The University of Western Australia and Research Fellow; ICU Royal Perth Hospital; Perth WA Australia
| | - Gavin D Leslie
- School of Nursing & Midwifery; Curtin Health Innovation Research Institute; Faculty Health Science; Curtin University; Perth WA Australia
| | - Tim Leen
- Intensive Care Unit; Royal Perth Hospital; Perth WA Australia
| | - Lauren Mills
- Intensive Care Unit; Royal Perth Hospital; Perth WA Australia
| | - Geoff J Dobb
- Intensive Care Unit; Royal Perth Hospital; Perth WA Australia
- School of Medicine and Pharmacology ; The University of Western Australia; Perth WA Australia
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Verotti CCG, Torrinhas RSMDM, Cecconello I, Waitzberg DL. Selection of Top 10 Quality Indicators for Nutrition Therapy. Nutr Clin Pract 2012; 27:261-7. [DOI: 10.1177/0884533611432317] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
| | | | - Ivan Cecconello
- University of São Paulo Medical School, Department of Gastroenterology, Digestive Surgery Discipline (LIM 35), São Paulo, Brazil
| | - Dan Linetzky Waitzberg
- University of São Paulo Medical School, Department of Gastroenterology, Digestive Surgery Discipline (LIM 35), São Paulo, Brazil
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Sánchez Álvarez C, Zabarte Martínez de Aguirre M, Bordejé Laguna L. Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Cirugía del aparato digestivo. Med Intensiva 2011; 35 Suppl 1:42-7. [DOI: 10.1016/s0210-5691(11)70009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Post-PEG feeding time: a web based national survey amongst gastroenterologists. Dig Liver Dis 2011; 43:768-71. [PMID: 21622036 DOI: 10.1016/j.dld.2011.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 03/09/2011] [Accepted: 04/03/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Literature suggests early post-percutaneous endoscopic gastrostomy (PEG) feeding is as safe as delayed feeding. No consensus exists regarding feeding initiation after PEG placement. We performed a national survey to assess current practice regarding feeding initiation after PEG placement as well as clinical and practitioner based factors associated with early or delayed feeding. METHODS A survey assessing feeding initiation in general ward and intensive care unit patients, current literature knowledge, motility agent use, number of PEG placed per year, along with physician demographics was emailed to 5256 gastroenterologists. Statistical analysis was done using SAS software (V.9). RESULTS 28% of gastroenterologists responded. Amongst respondents, 59% were private consultants, 25% academic physicians and 16% trainees. Private gastroenterologists initiated feeding earlier (≤12 h) compared to academic gastroenterologists in general ward and intensive care unit patients (p<0.0001). Amongst respondents, 41% of physicians were aware of current literature on post-PEG feeding times. Physicians aware of current literature started feeding earlier (<12h) compared to those not aware in general ward and intensive care unit patients (p=0.0002). Male physicians instituted feeding earlier than females (p<0.0001). CONCLUSIONS Feeding initiation after PEG placement varies amongst gastroenterologists. Further studies are required to explore obstacles in standardizing post-PEG feeding practices.
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Altintas ND, Aydin K, Türkoğlu MA, Abbasoğlu O, Topeli A. Effect of enteral versus parenteral nutrition on outcome of medical patients requiring mechanical ventilation. Nutr Clin Pract 2011; 26:322-9. [PMID: 21531737 DOI: 10.1177/0884533611405790] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Early enteral nutrition (EN) in patients receiving mechanical ventilation commonly has been advocated, based mainly on studies conducted in mixed populations of trauma and surgery patients. In this study, ventilator-associated pneumonia rates and outcomes were compared in mechanically ventilated medical intensive care unit (ICU) patients receiving enteral versus parenteral nutrition. METHODS Patients fulfilling inclusion criteria between February 1, 2004, and January 31, 2006, were included. Patients were randomized to enteral or parenteral nutrition (PN) within 48 hours of intubation. Development of ventilator-associated pneumonia, assessment as to whether day feeding goal was attained, duration of mechanical ventilation, ICU and hospital length of stay (LOS), and mortality rates were recorded. RESULTS Of 249 consecutive patients receiving mechanical ventilation, 71 patients were included. Thirty (42.3%) patients received EN, and 41 (57.7%) received PN. There was no difference between groups for age, sex, body mass index, and scores on the Acute Physiology and Chronic Health Evaluation II. Ventilator-associated pneumonia rate, ICU and hospital LOS, and mortality rates were similar for both groups. In the parenterally fed group, duration of mechanical ventilation was longer (p = .023), but the feeding goal was attained earlier (p = .012). CONCLUSIONS In mechanically ventilated patients in the medical ICU, ventilator-associated pneumonia rates, ICU and hospital lengths of stay, and ICU and hospital mortality rates of patients receiving PN are not significantly different than those in patients receiving EN, and feeding goals can more effectively be attained by PN. Yet, duration of mechanical ventilation is slightly longer in patients receiving PN.
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The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients. Intensive Care Med 2011; 37:601-9. [PMID: 21340655 DOI: 10.1007/s00134-011-2146-z] [Citation(s) in RCA: 341] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 11/26/2010] [Indexed: 01/15/2023]
Abstract
PURPOSE To determine whether nutritional support guided by repeated measurements of resting energy requirements improves the outcome of critically ill patients. METHODS This was a prospective, randomized, single-center, pilot clinical trial conducted in an adult general intensive care (ICU) unit. The study population comprised mechanically ventilated patients (n = 130) expected to stay in ICU more than 3 days. Patients were randomized to receive enteral nutrition (EN) with an energy target determined either (1) by repeated indirect calorimetry measurements (study group, n = 56), or (2) according to 25 kcal/kg/day (control group, n = 56). EN was supplemented with parenteral nutrition when required. RESULTS The primary outcome was hospital mortality. Measured pre-study resting energy expenditure (REE) was similar in both groups (1,976 ± 468 vs. 1,838 ± 468 kcal, p = 0.6). Patients in the study group had a higher mean energy (2,086 ± 460 vs. 1,480 ± 356 kcal/day, p = 0.01) and protein intake (76 ± 16 vs. 53 ± 16 g/day, p = 0.01). There was a trend towards an improved hospital mortality in the intention to treat group (21/65 patients, 32.3% vs. 31/65 patients, 47.7%, p = 0.058) whereas length of ventilation (16.1 ± 14.7 vs. 10.5 ± 8.3 days, p = 0.03) and ICU stay (17.2 ± 14.6 vs. 11.7 ± 8.4, p = 0.04) were increased. CONCLUSIONS In this single-center pilot study a bundle comprising actively supervised nutritional intervention and providing near target energy requirements based on repeated energy measurements was achievable in a general ICU and may be associated with lower hospital mortality.
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Diedler J, Sykora M, Hacke W. Critical Care of the Patient with Acute Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mongardon N, Singer M. The evolutionary role of nutrition and metabolic support in critical illness. Crit Care Clin 2010; 26:443-50, vii-viii. [PMID: 20643298 DOI: 10.1016/j.ccc.2010.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Maintenance of nutritional status is particularly challenging during critical illness. There is a common perception of a race against the clock to adequately feed the patient to prevent or minimize the sometimes catastrophic muscle wasting and general catabolic state that can result in the patient's deterioration. However, the course of critical illness may be separated into 3 phases, each with highly differing metabolic needs. The initial phase, in which the body attempts to fight the acute insult, is generally hypermetabolic. When the body fails to overcome the insult, it enters into a second phase, which is akin to hibernation. This stage is characterized by a functional metabolic shutdown triggered either by a lack of adequate energy supply or perhaps by the direct switching off of metabolism to spare excess use of a dwindling substrate and energy resource. Those strong enough to survive this phase enter into a period of recovery during which appetite returns, anabolism recommences, and organ function is restored. Nutrition should perhaps closely follow these nonlinear requirements, so as to avoid deleterious under- or overnutrition during the appropriate phase. This approach fits a teleologic argument that enabled many sick people to survive well before the advent of modern medicine and explains why catabolism still occurs despite adequate feeding.
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Affiliation(s)
- Nicolas Mongardon
- Bloomsbury Institute of Intensive Care Medicine, Wolfson Institute for Biomedical Research, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
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Gatt M, MacFie J. Randomized clinical trial of gut-specific nutrients in critically ill surgical patients. Br J Surg 2010; 97:1629-36. [DOI: 10.1002/bjs.7155] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Inadequate gut function is common and may adversely affect prognosis. However, it is difficult to measure and treatment options are limited. This study evaluated whether gut-specific nutrients (GSNs) could stimulate the return of gut function in critically ill patients, and assessed what effect, if any, this would have on patient outcomes.
Methods
Consecutive critically ill patients intolerant to enteral feeding were randomized to receive a cocktail of GSNs or placebo. Administration was for 1 month and patients were followed for 3 months. The primary endpoint was the time to return of normal gut function.
Results
Twenty-five patients were randomized to each group. GSN administration was associated with a quicker return of normal gut function (median 164 versus 214 h; P = 0·016), attenuation of the acute-phase response and a lower incidence of sepsis (4 versus 13 patients, P = 0·015) compared with placebo. There were fewer deaths by 3 months in the GSN group but this did not achieve significance (2 versus 7 deaths; P = 0·138).
Conclusion
GSNs expedite the return of gut function in the critically ill and improve outcomes. Inadequate gut function may be associated with poor prognosis similar to that of other single organ failures. Registration number: ISRCTN61157513 (http://www.controlled-trials.com).
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Affiliation(s)
- M Gatt
- Combined Gastroenterology Research Unit, Scarborough Hospital, Scarborough, UK
| | - J MacFie
- Combined Gastroenterology Research Unit, Scarborough Hospital, Scarborough, UK
- Postgraduate Medical Institute, University of Hull, Hull, UK
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Abstract
PURPOSE OF REVIEW This special commentary addresses recent clinical reviews regarding appropriate nutrition and metabolic support in the critical care setting. RECENT FINDINGS There are divergent approaches between North America and Europe for the use of early nutrition support and combined enteral nutrition and parenteral nutrition support possibly due to the commercial availability of specific parenteral nutrients. The advent of intensive insulin therapy has changed the landscape of metabolic support in the intensive care unit, and previous notions about infective risk of parenteral nutrition will need to be re-addressed. Patients with brain failure may benefit from an intensive insulin therapy with a blood glucose target that is higher than that used in patients without brain failure. Patients with heart failure may benefit from the addition of nutritional pharmacology that targets proximate oxidative pathophysiological pathways. Intradialytic parenteral nutrition may be viewed as another form of supplemental parenteral nutrition when enteral nutrition is insufficient in patients on hemodialysis in the intensive care unit. SUMMARY It is proposed that intensive metabolic support be routinely implemented in the intensive care unit based on the following steps: intensive insulin therapy with an appropriate blood glucose target, nutrition risk assessment, early and if needed combined enteral nutrition and parenteral nutrition to target 20-25 kcal/kg/day and 1.2-1.5 g protein/kg/day, and nutritional and metabolic monitoring.
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Affiliation(s)
- Jeffrey I Mechanick
- Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine, New York, New York, USA.
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