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Li J, Xiang QL, Zhu JX, Zhang YX, Li SQ. Comparison of enteral immunonutrition and enteral nutrition in patients undergoing gastric cancer surgery: a systematic review and meta-analysis of randomized, controlled trials. J Int Med Res 2024; 52:3000605231220870. [PMID: 38179793 PMCID: PMC10771076 DOI: 10.1177/03000605231220870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/24/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVE Enteral immunonutrition is a nutritional intervention that has been studied in postoperative patients with gastric cancer, but its effectiveness is controversial. This study aimed to investigate the effects of enteral immunonutrition and enteral nutrition on immune function in patients who undergo gastric cancer surgery. METHODS We performed a systematic review and meta-analysis. A comprehensive search was conducted in PubMed, Embase, Cochrane, Web of Knowledge, and ClinicalTrials.gov from the inception of the review until 10 March 2023. Twelve studies were included for qualitative and quantitative analyses. RESULTS We studied 1124 patients, including 565 patients in the enteral immunonutrition group and 559 in the enteral nutrition (controls) group. All included randomized, controlled trials were high quality. CD4+ levels, lymphocytes, transferrin concentrations, and systemic inflammatory response syndrome were not significantly different between the enteral immunonutrition and enteral nutrition groups. However, CD8+, immunoglobulins G and M, and proalbumin concentrations, CD4+/CD8+, and infectious complications were significantly higher in the enteral immunonutrition group than in the enteral nutrition group. A sensitivity analysis showed consistent results after excluding each study. Begg's test showed no publication bias. CONCLUSIONS Enteral immunonutrition is an effective nutritional intervention that improves immune function in patients who have undergone gastric cancer surgery.
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Affiliation(s)
- Ji Li
- General Surgery, Chongqing Western Hospital, 400051, Chongqing, China
| | - Qing-Lin Xiang
- Department of Gastrointestinal and Breast Surgery, the Chongqing Kaizhou District People’s Hospital, Chongqing 405400, China
| | - Jin-Xian Zhu
- General Surgery, Chongqing Western Hospital, 400051, Chongqing, China
| | - Yu-Xin Zhang
- General Surgery, Chongqing Western Hospital, 400051, Chongqing, China
| | - Shi-Qiang Li
- General Surgery, Chongqing Western Hospital, 400051, Chongqing, China
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Ridgeon E, Shadwell R, Wilkinson A, Odor PM. Mismatch of populations between randomised controlled trials of perioperative interventions in major abdominal surgery and current clinical practice. Perioper Med (Lond) 2023; 12:60. [PMID: 37974283 PMCID: PMC10655289 DOI: 10.1186/s13741-023-00344-w] [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: 07/27/2023] [Accepted: 10/14/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Demographics of patients undergoing major abdominal surgery are changing. External validity of relevant RCTs may be limited by participants not resembling patients encountered in clinical practice. We aimed to characterise differences in age, weight, BMI, and ASA grade between participants in perioperative trials in major abdominal surgery and patients in a reference real-world clinical practice sample. The secondary aim was to investigate whether time since trial publication was associated with increasing mismatch between these groups. METHODS MEDLINE and Embase were searched for multicentre RCTs from inception to September 2022. Studies of perioperative interventions in adults were included. Studies that limited enrolment based on age, weight, BMI, or ASA status were excluded. We compared trial cohort age, weight, BMI, and ASA distribution to those of patients undergoing major abdominal surgery at our tertiary referral hospital during September 2021 to September 2022. We used a local, single-institution reference sample to reflect the reality of clinical practice (i.e. patients treated by a clinician in their own hospital, rather than averaged nationally). Mismatch was defined using comparison of summary characteristics and ad hoc criteria based on differences relevant to predicted mortality risk after surgery. RESULTS One-hundred and six trials (44,499 participants) were compared to a reference cohort of 2792 clinical practice patients. Trials were published a median (IQR [range]) 13.4 (5-20 [0-35]) years ago. A total of 94.3% of trials were mismatched on at least one characteristic (age, weight, BMI, ASA). Recruitment of ASA 3 + participants in trials increased over time, and recruitment of ASA 1 participants decreased over time (Spearman's Rho 0.58 and - 0.44, respectively). CONCLUSIONS Patients encountered in our current local clinical practice are significantly different from those in our defined set of perioperative RCTs. Older trials recruit more low-risk than high-risk participants-trials may thus 'expire' over time. These trials may not be generalisable to current patients undergoing major abdominal surgery, and meta-analyses or guidelines incorporating these trials may therefore be similarly non-applicable. Comparison to local, rather than national cohorts, is important for meaningful on-the-ground evidence-based decision-making.
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Affiliation(s)
- Elliott Ridgeon
- Department of Anaesthetics and Perioperative Medicine, Wexham Park Hospital, Slough, UK.
- Department of Anaesthetics and Perioperative Medicine, University College London Hospitals, London, UK.
- Perioperative Medicine MSc, University College London, London, UK.
| | - Rory Shadwell
- Department of Critical Care, University College London Hospitals, London, UK
| | - Alice Wilkinson
- Department of Anaesthetics, University College London Hospitals, London, UK
| | - Peter M Odor
- Department of Anaesthetics and Perioperative Medicine, University College London Hospitals, London, UK
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Halle-Smith JM, Powell-Brett SF, Hall LA, Duggan SN, Griffin O, Phillips ME, Roberts KJ. Recent Advances in Pancreatic Ductal Adenocarcinoma: Strategies to Optimise the Perioperative Nutritional Status in Pancreatoduodenectomy Patients. Cancers (Basel) 2023; 15:cancers15092466. [PMID: 37173931 PMCID: PMC10177139 DOI: 10.3390/cancers15092466] [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: 03/26/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy for which the mainstay of treatment is surgical resection, followed by adjuvant chemotherapy. Patients with PDAC are disproportionately affected by malnutrition, which increases the rate of perioperative morbidity and mortality, as well as reducing the chance of completing adjuvant chemotherapy. This review presents the current evidence for pre-, intra-, and post-operative strategies to improve the nutritional status of PDAC patients. Such preoperative strategies include accurate assessment of nutritional status, diagnosis and appropriate treatment of pancreatic exocrine insufficiency, and prehabilitation. Postoperative interventions include accurate monitoring of nutritional intake and proactive use of supplementary feeding methods, as required. There is early evidence to suggest that perioperative supplementation with immunonutrition and probiotics may be beneficial, but further study and understanding of the underlying mechanism of action are required.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| | - Sarah F Powell-Brett
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| | - Lewis A Hall
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| | - Sinead N Duggan
- Department of Surgery, Trinity College Dublin, University of Dublin, Tallaght University Hospital, D24 NR0A Dublin, Ireland
| | - Oonagh Griffin
- Department of Nutrition and Dietetics, St. Vincent's University Hospital, D04 T6F4 Dublin, Ireland
| | - Mary E Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital, Guildford GU2 7XX, UK
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
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4
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Fan Y, Li N, Zhang J, Fu Q, Qiu Y, Chen Y. The Effect of immunonutrition in patients undergoing pancreaticoduodenectomy: a systematic review and meta-analysis. BMC Cancer 2023; 23:351. [PMID: 37069556 PMCID: PMC10108524 DOI: 10.1186/s12885-023-10820-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/06/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a complex and traumatic abdominal surgery with a high risk of postoperative complications. Nutritional support, including immunonutrition (IMN) with added glutamine, arginine, and ω-3 polyunsaturated fatty acids, can improve patients' prognosis by regulating postoperative inflammatory response. However, the effects of IMN on PD patients' outcomes require further investigation. METHODS PMC, EMbase, web of science databases were used to search literatures related to IMN and PD. Data such as length of hospital stay, infectious complications, non-infectious complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), mortality, systemic inflammatory response syndrome (SIRS) duration, IL-6, and C-reactive protein (CRP) were extracted, and meta-analyses were performed on these data to study their pooled results, heterogeneity, and publication bias. RESULTS This meta-analysis involved 10 studies and a total of 572 patients. The results showed that the use of IMN significantly reduced the length of hospital stay for PD patients (MD = -2.31; 95% CI = -4.43, -0.18; P = 0.03) with low heterogeneity. Additionally, the incidence of infectious complications was significantly reduced (MD = 0.42; 95% CI = 0.18, 1.00, P = 0.05), with low heterogeneity after excluding one study. However, there was no significant impact on non-infectious complications, the incidence of POPF and DGE, mortality rates, duration of SIRS, levels of IL-6 and CRP. CONCLUSION The use of IMN has been shown to significantly shorten hospital stays and decrease the frequency of infectious complications in PD patients. Early implementation of IMN is recommended for those undergoing PD. However, further research is needed to fully assess the impact of IMN on PD patients through larger and higher-quality studies.
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Affiliation(s)
- Yinyin Fan
- Department of Biliary-Pancreatic Surgery, Nanjing Drum Tower Hospital Clinical College of Jiangsu University, Nanjing, 210008, China
- Department of Biliary-Pancreatic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Nianxing Li
- Department of Biliary-Pancreatic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Jing Zhang
- Department of Biliary-Pancreatic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Qiaomei Fu
- Department of Biliary-Pancreatic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Yudong Qiu
- Department of Biliary-Pancreatic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Yan Chen
- Department of Biliary-Pancreatic Surgery, Nanjing Drum Tower Hospital Clinical College of Jiangsu University, Nanjing, 210008, China.
- Department of Biliary-Pancreatic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China.
- Department of Nursing, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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de Bakker JK, Suurmeijer JA, Toennaer JGJ, Bonsing BA, Busch OR, van Eijck CH, de Hingh IH, de Meijer VE, Molenaar IQ, van Santvoort HC, Stommel MW, Festen S, van der Harst E, Patijn G, Lips DJ, Den Dulk M, Bosscha K, Besselink MG, Kazemier G. Surgical Outcome After Pancreatoduodenectomy for Duodenal Adenocarcinoma Compared with Other Periampullary Cancers: A Nationwide Audit Study. Ann Surg Oncol 2023; 30:2448-2455. [PMID: 36536196 PMCID: PMC10027630 DOI: 10.1245/s10434-022-12701-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical outcome after pancreatoduodenectomy for duodenal adenocarcinoma could differ from pancreatoduodenectomy for other cancers, but large multicenter series are lacking. This study aimed to determine surgical outcome in patients after pancreatoduodenectomy for duodenal adenocarcinoma, compared with other periampullary cancers, in a nationwide multicenter cohort. METHODS After pancreatoduodenectomy for cancer between 2014 and 2019, consecutive patients were included from the nationwide, mandatory Dutch Pancreatic Cancer Audit. Patients were stratified by diagnosis. Baseline, treatment characteristics, and postoperative outcome were compared between groups. The association between diagnosis and major complications (Clavien-Dindo grade III or higher) was assessed via multivariable regression analysis. RESULTS Overall, 3113 patients, after pancreatoduodenectomy for cancer, were included in this study: 264 (8.5%) patients with duodenal adenocarcinomas and 2849 (91.5%) with other cancers. After pancreatoduodenectomy for duodenal adenocarcinoma, patients had higher rates of major complications (42.8% vs. 28.6%; p < 0.001), postoperative pancreatic fistula (International Study Group of Pancreatic Surgery [ISGPS] grade B/C; 23.1% vs. 13.4%; p < 0.001), complication-related intensive care admission (14.3% vs. 10.3%; p = 0.046), re-interventions (39.8% vs. 26.6%; p < 0.001), in-hospital mortality (5.7% vs. 3.1%; p = 0.025), and longer hospital stay (15 days vs. 11 days; p < 0.001) compared with pancreatoduodenectomy for other cancers. In multivariable analysis, duodenal adenocarcinoma was independently associated with major complications (odds ratio 1.14, 95% confidence interval 1.03-1.27; p = 0.011). CONCLUSION Pancreatoduodenectomy for duodenal adenocarcinoma is associated with higher rates of major complications, pancreatic fistula, re-interventions, and in-hospital mortality compared with patients undergoing pancreatoduodenectomy for other cancers. These findings should be considered in patient counseling and postoperative management.
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Affiliation(s)
- Jacob K de Bakker
- Amsterdam UMC, Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J Annelie Suurmeijer
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - Jurgen G J Toennaer
- Amsterdam UMC, Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R Busch
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, Utrecht, The Netherlands
| | - Martijn W Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Gijs Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch ziekenhuis, Den Bosch, The Netherlands
| | - Marc G Besselink
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
| | - Geert Kazemier
- Amsterdam UMC, Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Khan A, Wong J, Riedel B, Laing E, Beaumont A, Kong J, Warrier S, Heriot A. The Impact of Peri-operative Enteral Immunonutrition on Post-operative Complications in Gastrointestinal Cancer Surgery: A Meta-Analysis. Ann Surg Oncol 2023; 30:3619-3631. [PMID: 36820938 DOI: 10.1245/s10434-023-13265-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/01/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Immunonutrition (IMN) in gastrointestinal (GI) cancer surgery remains under-utilised and contentious. Despite previous meta-analysis reporting benefit, most recent randomised control trials (RCTs) have failed to demonstrate this and have recommended against its routine use. A contemporary meta-analysis may contribute to the recommendations for immunonutrition use and help select which patients may benefit. The objective of this study was to review IMN and its impact on post-operative outcomes in GI cancer surgery, exploring its role in both malnourished and non-malnourished populations, the optimal dose to use, cancer type of patients using IMN and the timing of IMN relative to the peri-operative period. PATIENTS AND METHODS The EMBASE and Medline databases were searched from 2000 to 2022 for RCTs evaluating IMN in adults undergoing GI cancer surgery. RESULTS Thirty-seven studies were included (22 pre-operative IMN studies, 11 peri-operative IMN trials and 9 post-operative IMN trials; 4 trials had multiple IMN protocols) that reported on 3793 patients. The main outcome of post-operative infectious complications was reduced with IMN [odds ratio (OR) 0.58, 95% confidence interval (CI) 0.47-0.72]. This association was significant in subgroup analysis only with pre-operative and peri-operative administration and in trials including upper GI cancers, colorectal cancer and 'mixed GI' cancer populations, and significance was independent of nutritional status. IMN in pooled analysis reduced surgical site infection (SSI) (OR 0.65, 95% CI 0.52-0.81), anastomotic leak (OR 0.67, 95% CI 0.47-0.93) and length of stay (LOS) by 1.94 days (95% CI - 3 to - 0.87). CONCLUSION Immunonutrition was associated with reduced post-operative complications. Peri-operative administration may be the preferred strategy in reducing infectious complications, anastomotic leak, SSI and LOS.
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Affiliation(s)
- Ayman Khan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia.
| | - Jean Wong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
| | - Bernhard Riedel
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
| | - Erin Laing
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Anna Beaumont
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Joseph Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
| | - Satish Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
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Shen J, Dai S, Li Z, Dai W, Hong J, Huang J, Chen J. Effect of Enteral Immunonutrition in Patients Undergoing Surgery for Gastrointestinal Cancer: An Updated Systematic Review and Meta-Analysis. Front Nutr 2022; 9:941975. [PMID: 35845793 PMCID: PMC9277464 DOI: 10.3389/fnut.2022.941975] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/09/2022] [Indexed: 11/15/2022] Open
Abstract
Background The efficacy of enteral immunonutrition (EIN) in patients undergoing gastrointestinal cancer surgery remains debatable. This meta-analysis aimed to investigate the effectiveness of EIN administration in patients undergoing surgery for gastrointestinal cancer. Methods From January 2000 to January 2022, PubMed, EMBASE, Cochrane Library, and Web of Science were thoroughly searched for randomized controlled trials (RCTs) with EIN versus standard diet or no supplement in patients undergoing surgery for gastrointestinal cancer. Overall complications and infectious complications were the primary outcomes. The secondary results were non-infectious complications, mortality, length of hospital stay, and enteral nutrition-related complications. Results Thirty-five studies reporting 3,692 patients undergoing surgery for gastrointestinal cancer (including gastric cancer, colorectal cancer, esophageal cancer, periampullary cancer, or pancreatic cancer) were included. Compared with the control group, EIN group had a significantly decreased incidence of overall complications (RR = 0.79, p < 0.001). Infectious complications in patients who received EIN were considerably lower than in the control group (RR = 0.66, p < 0.001). Compared to the control group, the incidence of surgical site infection, abdominal abscess, anastomotic leakage, bacteremia, duration of systemic inflammatory response syndrome (SIRS), and duration of antibiotic therapy was significantly lower in the specific infectious complications treated with EIN. Still, there was no significant difference between the two groups with other infectious complications. Moreover, a substantial shortening in the length of hospital stay was shown in EIN group compared with the control group. Still, no significant effect of EIN was demonstrated in non-infectious complicatios and mortality. The enteral nutrition-related complications had no significant difference between two groups. Conclusions EIN is safe and effective in reducing overall complications, infectious complications, and hospital stay in patients undergoing gastrointestinal cancer surgery (including gastric cancer, colorectal cancer, esophageal cancer, periampullary cancer, or pancreatic cancer).
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Affiliation(s)
- Jingyi Shen
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Senjie Dai
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zongze Li
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Wei Dai
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jiaze Hong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jin Huang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jingjie Chen
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China
- *Correspondence: Jingjie Chen
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Xue Y, Zhu X, Yan W, Zhang Z, Cui E, Wu Y, Li C, Pan J, Yan Q, Chai X, Zhao S. Dietary Supplementation With Acer truncatum Oil Promotes Remyelination in a Mouse Model of Multiple Sclerosis. Front Neurosci 2022; 16:860280. [PMID: 35585921 PMCID: PMC9109879 DOI: 10.3389/fnins.2022.860280] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Multiple sclerosis is a chronic demyelinating disease of uncertain etiology. Traditional treatment methods produce more adverse effects. Epidemiological and clinical treatment findings showed that unknown environmental factors contribute to the etiology of MS and that diet is a commonly assumed factor. Despite the huge interest in diet expressed by people with MS and the potential role diet plays in MS, very little data is available on the role of diet in MS pathogenesis and MS course, in particular, studies on fats and MS. The oil of Acer truncatum is potential as a resource to be exploited in the treatment of some neurodegenerative diseases. Objective Here, we investigated the underlying influences of Acer truncatum oil on the stimulation of remyelination in a cuprizone mouse model of demyelination. Methods Cuprizone (0.2% in chow) was used to establish a mouse model of demyelination. Acer truncatum oil was administrated to mice during remyelination. Following techniques were used: behavioral test, histochemistry, fluorescent immunohistochemistry, transmission electron microscope. Results Mice exposed to cuprizone for 6 weeks showed schizophrenia-like behavioral changes, the increased exploration of the center in the open field test (OFT), increased entries into the open arms of the elevated plus-maze, as well as demyelination in the corpus callosum. After cuprizone withdrawal, the diet therapy was initiated with supplementation of Acer truncatum oil for 2 weeks. As expected, myelin repair was greatly enhanced in the demyelinated regions with increased mature oligodendrocytes (CC1) and myelin basic protein (MBP). More importantly, the supplementation with Acer truncatum oil in the diet reduced the schizophrenia-like behavior in the open field test (OFT) and the elevated plus-maze compared to the cuprizone recovery group. The results revealed that the diet supplementation with Acer truncatum oil improved behavioral abnormalities, oligodendrocyte maturation, and remyelination in the cuprizone model during recovery. Conclusion Diet supplementation with Acer truncatum oil attenuates demyelination induced by cuprizone, indicating that Acer truncatum oil is a novel therapeutic diet in demyelinating diseases.
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Affiliation(s)
- Yuhuan Xue
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Xiaoyan Zhu
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Wenyong Yan
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Zhihan Zhang
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Enhui Cui
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Yongji Wu
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Cixia Li
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Jiarong Pan
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
| | - Qijiang Yan
- Multiple Sclerosis Research Center of New York, New York, NY, United States
| | - Xuejun Chai
- Department of Basic Medicine, Xi’an Medical University, Xi’an, China
| | - Shanting Zhao
- College of Veterinary Medicine, Northwest A&F University, Yangling, China
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Serrano PE, Parpia S, Simunovic M, Duceppe E, Pinto-Sanchez MI, Bhandari M, Levine M. Perioperative optimization with nutritional supplements in patients undergoing gastrointestinal surgery for cancer: A randomized, placebo-controlled feasibility clinical trial. Surgery 2022; 172:670-676. [DOI: 10.1016/j.surg.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022]
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Nutritional Interventions in Pancreatic Cancer: A Systematic Review. Cancers (Basel) 2022; 14:cancers14092212. [PMID: 35565341 PMCID: PMC9101959 DOI: 10.3390/cancers14092212] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary This systematic review investigates the impact of nutritional interventions on cachexia, malnutrition and weight loss in patients with pancreatic cancer. In total, 26 studies were included. Parenteral nutrition is associated with a higher incidence of complications. Enteral nutrition shows positive effects on length of stay in hospital, complications, weight loss and cytokines. Dietary supplements enriched with omega-3 fatty acids improve body weight and lean body mass. Considering the heterogeneous study situation as well as the high bias potential of the included RCTs, a recommendation for enteral nutrition and dietary supplements with omega-3 fatty acids can be given. Abstract (1) Background: Pancreatic cancer (PaCa) is directly related to malnutrition, cachexia and weight loss. Nutritional interventions (NI) are used in addition to standard therapy. The aim of this systematic review is to provide an overview of the types of NI and their effects. (2) Methods: We included RCTs with at least one intervention group receiving an NI and compared them with a control group with no NI, placebo or alternative treatment on cachexia, malnutrition or weight loss in patients with PaCa. Any available literature until 12 August 2021 was searched in the Pubmed and Cochrane databases. RCTs were sorted according to NI (parenteral nutrition, enteral nutrition, dietary supplements and mixed or special forms). (3) Results: Finally, 26 studies with a total of 2720 patients were included. The potential for bias was mostly moderate to high. Parenteral nutrition is associated with a higher incidence of complications. Enteral nutrition is associated with shorter length of stay in hospital, lower rate and development of complications, positive effects on cytokine rates and lower weight loss. Dietary supplements enriched with omega-3 fatty acids lead to higher body weight and lean body mass. (4) Conclusions: Enteral nutrition and dietary supplements with omega-3 fatty acids should be preferred in nutritional therapy of PaCa patients.
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Preoperative Nutritional Optimization of the Oncology Patient: A Scoping Review. J Am Coll Surg 2022; 234:384-394. [PMID: 35213503 DOI: 10.1097/xcs.0000000000000055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Malnutrition is common among patients with cancer and is a known risk factor for poor postoperative outcomes; however, preoperative nutritional optimization guidelines are lacking in this high-risk population. The objective of this study was to review the evidence regarding preoperative nutritional optimization of patients undergoing general surgical operations for the treatment of cancer. METHODS A literature search was performed across the Ovid (MEDLINE), Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCOhost), and Web of Science (Clarivate) databases. Eligible studies included randomized clinical trials, observational studies, reviews, and meta-analyses published between 2010 and 2020. Included studies evaluated clinical outcomes after preoperative nutritional interventions among adult patients undergoing surgery for gastrointestinal cancer. Data extraction was performed using a template developed and tested by the study team. RESULTS A total of 5,505 publications were identified, of which 69 studies were included for data synthesis after screening and full text review. These studies evaluated preoperative nutritional counseling, protein-calorie supplementation, immunonutrition supplementation, and probiotic or symbiotic supplementation. CONCLUSIONS Preoperative nutritional counseling and immunonutrition supplementation should be considered for patients undergoing surgical treatment of gastrointestinal malignancy. For malnourished patients, protein-calorie supplementation should be considered, and for patients undergoing colorectal cancer surgery, probiotics or symbiotic supplementation should be considered.
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Wang SY, Hung YL, Hsu CC, Hu CH, Huang RY, Sung CM, Li YR, Kou HW, Chen MY, Chang SC, Lee CW, Tsai CY, Liu KH, Hsu JT, Yeh CN, Yeh TS, Hwang TL, Jan YY, Chen MF. Optimal Perioperative Nutrition Therapy for Patients Undergoing Pancreaticoduodenectomy: A Systematic Review with a Component Network Meta-Analysis. Nutrients 2021; 13:nu13114049. [PMID: 34836308 PMCID: PMC8620471 DOI: 10.3390/nu13114049] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
Numerous strategies for perioperative nutrition therapy for patients undergoing pancreaticoduodenectomy (PD) have been proposed. This systematic review aimed to summarize the current relevant published randomized controlled trials (RCTs) evaluating different nutritional interventions via a traditional network meta-analysis (NMA) and component network meta-analysis (cNMA). EMBASE, MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched to identify the RCTs. The evaluated nutritional interventions comprised standard postoperative enteral nutrition by feeding tube (Postop-SEN), preoperative enteral feeding (Preop-EN), postoperative immunonutrients (Postop-IM), preoperative oral immunonutrient supplement (Preop-IM), and postoperative total parenteral nutrition (TPN). The primary outcomes were general, infectious, and noninfectious complications; postoperative pancreatic fistula (POPF); and delayed gastric emptying (DGE). The secondary outcomes were mortality and length of hospital stay (LOS). The NMA and cNMA were conducted with a frequentist approach. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Two primary outcomes, infectious complications and POPF, were positively influenced by nutritional interventions. Preop-EN plus Postop-SEN (OR 0.11; 95% CI 0.02~0.72), Preop-IM (OR 0.22; 95% CI 0.08~0.62), and Preop-IM plus Postop-IM (OR 0.11; 95% CI 0.03~0.37) were all demonstrated to be associated with a decrease in infectious complications. Postop-TPN (OR 0.37; 95% CI 0.19~0.71) and Preop-IM plus Postop-IM (OR 0.21; 95% CI 0.06~0.77) were clinically beneficial for the prevention of POPF. While enteral feeding and TPN may decrease infectious complications and POPF, respectively, Preop-IM plus Postop-IM may provide the best clinical benefit for patients undergoing PD, as this approach decreases the incidence of both the aforementioned adverse effects.
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Affiliation(s)
- Shang-Yu Wang
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan City 333, Taiwan
| | - Yu-Liang Hung
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Chih-Chieh Hsu
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Chia-Hsiang Hu
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Ruo-Yi Huang
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Chang-Mu Sung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan;
| | - Yan-Rong Li
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan;
| | - Hao-Wei Kou
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Ming-Yang Chen
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Shih-Chun Chang
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Chao-Wei Lee
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Chun-Yi Tsai
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Keng-Hao Liu
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Jun-Te Hsu
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Chun-Nan Yeh
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
- Correspondence: ; Fax: +886-3-3285818
| | - Ta-Sen Yeh
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Tsann-Long Hwang
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Yi-Yin Jan
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
| | - Miin-Fu Chen
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; (S.-Y.W.); (Y.-L.H.); (C.-C.H.); (C.-H.H.); (R.-Y.H.); (H.-W.K.); (M.-Y.C.); (S.-C.C.); (C.-W.L.); (C.-Y.T.); (K.-H.L.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.); (M.-F.C.)
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Sayın E, Özlüer YE, Şeker Yaşar K. Evaluating malnutrition in cancer patients in the emergency department. Am J Emerg Med 2021; 51:197-201. [PMID: 34763239 DOI: 10.1016/j.ajem.2021.10.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Malnutrition is an important contributing factor to mortality in cancer patients. Several scoring systems can be used to evaluate malnutrition in cancer patients. We hypothesized that one or more of these scoring systems should be used to assess malnutrition in emergency departments (EDs). METHODS This prospective observational study was conducted in the ED of a tertiary care center. From October 1, 2019, to March 31, 2020, we prospectively collected data on cancer patients aged 18 and over who were evaluated in the ED but did not present with any nutrition-related complaint, and not had any prior nutritional support. Malnutrition levels were determined using the Patient-Generated Subjective Global Assessment (PG-SGA1) instrument. The patients were grouped according to the presence and degree of malnutrition (PG-SGA categories A and B vs PG-SGA category C) and their need for nutritional intervention according to the Nutritional Triage Recommendation Scores (NTRS2 < 9 vs NTRS ≥9). RESULTS Twelve female (31.5%) and 26 male (68.5%) cancer patients, with a mean age of 70.29 ± 11.49 years, were enrolled in the study. According to the PG-SGA, 84.2% of the patients were at risk for malnutrition, and 97.4% required nutritional intervention. Thirty patients (78.9%) had experienced problems with eating in the preceding two weeks. There were statistically significant differences in these patients' body mass indexes (BMIs) (25.46 ± 4.3 kg/m2 vs 20.95 ± 3.66 kg/m2, p < 0.05) and ages (64.6 ± 10.5 years vs 74.9 ± 10.3 years, p < 0.05) according to the PG-SGA. There were also statistically significant differences between the patients' BMIs (25.73 ± 3.51 kg/m2 vs 22.11 ± 4.50 kg/m2, p < 0.05), according to the NTRS. There was no relationship between whether the patients had undergone surgery to remove tumors (p > 0.05), chemotherapy (p > 0.05), or radiotherapy (p > 0.05) according to the PG-SGA and NTRS. CONCLUSION Malnutrition is common in cancer patients. These patients may be malnourished even if their BMI is within normal limits. Malnutrition can be detected and evaluated in the ED using instruments such as the PG-SGA. We suggest that evaluation for malnutrition should be a standard component of patient care in the ED.
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Affiliation(s)
- Evrim Sayın
- Adnan Menderes University Hospital, Department of Emergency Medicine, Efeler, Aydın, Turkey
| | - Yunus Emre Özlüer
- Adnan Menderes University Hospital, Department of Emergency Medicine, Efeler, Aydın, Turkey.
| | - Kezban Şeker Yaşar
- Adnan Menderes University Hospital, Department of Emergency Medicine, Efeler, Aydın, Turkey
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The clinical impacts of early using glutamine/arginine enriched high protein density formula at trophic dose in intolerant enteral nutrition cachectic hypoalbuminemic hospitalized patients. ACTA ACUST UNITED AC 2021; 58:153-160. [PMID: 32449700 DOI: 10.2478/rjim-2020-0014] [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: 03/03/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND We sought to evaluate the clinical impacts of the early administration of trophic doses of a glutamine/arginine enriched enteral nutrition formula (ENF) with a high protein density to cachectic hypoalbuminemic hospitalized patients intolerant to enteral nutrition. METHODS A retrospective analysis was conducted using the nutritional and non-nutritional data of patients admitted to our institution from April 2017 through August 2019. Patients who died or were discharged before completing ≥1 weeks of hospital admission, or those whose data could not be obtained were excluded. Among other variables, percent changes in serum albumin levels (%∆ALB), C - reactive protein (CRP) and their ratios were expressed as Mean ± SD using the Independent Samples T-test, while categorical variables were expressed as numbers with percentages by using χ2 test. Two tested groups were determined based on the use of ENF: Group I received trophic doses of ENF, while Group II received no enteral nutrition. RESULTS The overall hospital length of stay (LOS) and overall 28-day hospital mortality were significantly lower in Group I when compared with Group II with Means ± SDs of (11.32 ± 2.19 days vs 23.49 ± 4.33 days) and (13.13% vs. 28.16%), respectively. Also, significantly higher (%∆ALB) for Group I compared with group II (43.48% ± 7.89% vs. 33.45% ± 6.18%), respectively was observed. CONCLUSION In malnourished hypoalbuminemic patients suffering from feeding intolerance, early trophic administration of glutamine/arginine enriched high protein density ENF was well tolerated and may be associated with increased plasma albumin levels, reduced LOS, and overall 28-day mortality, and hence may be considered in such patients.
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Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13071669. [PMID: 33916294 PMCID: PMC8037133 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
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[de la evidencia y algoritmo adaptado Immunonutrition in fast-track surgical patients - Evidence review and adapted algorithm]. NUTR HOSP 2021; 38:601-6021. [PMID: 33878885 DOI: 10.20960/nh.03405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Surgical stress predisposes patients to have immune dysfunction and an increased risk of infection. Malnourished surgical patients have higher postoperative morbidity and mortality rates, higher readmission rates, and higher hospital costs. The use of an immunomodulatory formula is associated in the ESPEN guidelines with a reduction in wound healing problems, suture failure, and infectious and global complications. Several authors have suggested that, since most clinical trials evaluating the efficacy of immunonutrition have been carried out in a traditional perioperative setting, it would be interesting to investigate its efficacy in a more controlled setting, such as in the ERAS (Enhanced Recovery after Surgery) protocol. The objective of this work was: a) to define the role that immunonutrition should play in ERAS protocols based on the best scientific evidence available; b) to analyze the difficulties that continue to exist in real-life clinical practice to screen the nutritional risk of patients; c) to make a proposal of algorithms adapted to the characteristics of our environment regarding the screening, assessment, and nutritional treatment of surgical patients in fast-track surgery.
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Immunonutrition in Patients with Pancreatic Cancer Undergoing Surgical Intervention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 2020; 12:nu12092798. [PMID: 32932707 PMCID: PMC7551679 DOI: 10.3390/nu12092798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 12/19/2022] Open
Abstract
Immunonutrition is administered to improve the outcome of patients with pancreatic cancer undergoing surgery. However, its effect and mechanism of action remain unclear. Therefore, we conducted this systematic review and meta-analysis to assess its effects on postoperative outcome and the immune system. Randomized controlled trials (RCTs) were identified and data extracted by two reviewers independently from electronic databases from their inception to 31 October 2019. The result was expressed as the risk ratio (RR) for categorical variables and mean difference (MD) for continuous variables with 95% confidence intervals (CIs). Six RCTs published from 1999 and 2016, with a total of 368 patients, were included. The results revealed that immunonutrition significantly decreased the rate of infectious complications (RR = 0.47, 95% CI (0.23, 0.94), p = 0.03) and the length of hospital stay (MD = -1.90, 95% CI (-3.78, -0.02), p = 0.05) by modulating the immune system, especially in preoperative group in subgroup analysis. We therefore recommend that patients with pancreatic cancer undergoing surgery could take the advantage of immunonutrition, especially in the preoperative period.
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Jabłońska B, Mrowiec S. The Role of Immunonutrition in Patients Undergoing Pancreaticoduodenectomy. Nutrients 2020; 12:nu12092547. [PMID: 32842475 PMCID: PMC7551458 DOI: 10.3390/nu12092547] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 12/11/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is one of the most difficult and complex surgical procedures in abdominal surgery. Malnutrition and immune dysfunction in patients with pancreatic cancer (PC) may lead to a higher risk of postoperative infectious complications. Although immunonutrition (IN) is recommended for enhanced recovery after surgery (ERAS) in patients undergoing PD for 5-7 days perioperatively, its role in patients undergoing pancreatectomy is still unclear and controversial. It is known that the proper surgical technique is very important in order to reduce a risk of postoperative complications, such as a pancreatic fistula, and to improve disease-free survival in patients following PD. However, it has been proven that IN decreases the risk of infectious complications, and shortens hospital stays in patients undergoing PD. This is a result of the impact on altered inflammatory responses in patients with cancer. Both enteral and parenteral, as well as preoperative and postoperative IN, using various nutrients, such as glutamine, arginine, omega-3 fatty acids and nucleotides, is administered. The most frequently used preoperative oral supplementation is recommended. The aim of this paper is to present the indications and benefits of IN in patients undergoing PD.
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Hirahara N, Matsubara T, Fujii Y, Kaji S, Hyakudomi R, Yamamoto T, Uchida Y, Miyazaki Y, Ishitobi K, Kawabata Y, Tajima Y. Geriatric nutritional risk index as a prognostic marker of pTNM-stage I and II esophageal squamous cell carcinoma after curative resection. Oncotarget 2020; 11:2834-2846. [PMID: 32754301 PMCID: PMC7381097 DOI: 10.18632/oncotarget.27670] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/20/2020] [Indexed: 12/12/2022] Open
Abstract
The geriatric nutritional risk index (GNRI) is associated with mortality in several malignancies. We retrospectively analyzed whether the GNRI can predict long-term outcomes in 191 patients with esophageal squamous cell carcinoma (ESCC) after curative esophagectomies by evaluating their cancer-specific survival (CSS). In multivariate analyses, serum albumin (hazard ratio [HR], 2.498; p = 0.0043), GNRI (HR, 1.941; p = 0.0181), pathological tumor-node-metastasis (pTNM) stage (HR, 3.884; p < 0.0001), and tumor differentiation (HR, 2.307; p = 0.0066) were independent prognostic factors for CSS. In pTNM stage I, multivariate analysis identified C-reactive protein (HR, 7.172; p = 0.0483) and GNRI (HR, 5.579; p = 0.0291) as independent prognostic factors for CSS. In univariate analyses in pTNM stages II and III, only low GNRI (p = 0.0095) and low serum albumin levels (p = 0.0119), respectively, were significantly associated with worse CSS. In patients with low GNRI, CSS was significantly worse than in those with normal GNRI (p = 0.0011), especially in pTNM stages I (p = 0.0044) and II (p = 0.0036) groups, but not in stage III group (p = 0.5099). Preoperative GNRI may sort patients into low- or high-risk groups for shorter CSS, especially in those with pTNM stage I and II ESCC.
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Affiliation(s)
- Noriyuki Hirahara
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Takeshi Matsubara
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Yusuke Fujii
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Shunsuke Kaji
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Ryoji Hyakudomi
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Tetsu Yamamoto
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Yuki Uchida
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Yoshiko Miyazaki
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Kazunari Ishitobi
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Yoshitsugu Tajima
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
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Systematic review on immunonutrition in partial pancreatoduodenectomy. Langenbecks Arch Surg 2020; 405:585-593. [PMID: 32613544 DOI: 10.1007/s00423-020-01916-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/23/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The effect of immunonutrition (IM) on postoperative outcomes has been investigated in gastrointestinal cancer surgery; however, strong evidence regarding IM in partial pancreatoduodenectomy (PD) is lacking. This study evaluated the effect of IM on short-term outcomes in patients undergoing PD. METHODS A systematic literature review of randomized controlled trials was conducted to identify the studies investigating the IM effect on outcomes in PD. Random-effects meta-analyses were conducted to calculate the pooled risk ratio (RR). Studies were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS Five studies were included in the meta-analysis. IM was associated with a lower incidence of overall complications (RR 0.74; 95% confidence interval (CI) 0.58, 0.94; P = 0.01; I2 = 0%) and infectious complications (RR 0.60; 95% CI 0.42, 0.84; P = 0.003; I2 = 0%). However, no significant association was noted in the incidence of major complications (RR 0.68; 95% CI 0.41, 1.12; P = 0.13), mortality (RR 0.79; 95% CI 0.16, 3.99; P = 0.78), postoperative pancreatic fistula (RR 0.92, 95% CI 0.59, 1.46; P = 0.74), and delayed gastric emptying (RR 1.09; 95% CI 0.55, 2.15; P = 0.81). CONCLUSIONS IM administration in PD can prevent the incidence of overall and infectious complications postoperatively (GRADE recommendation: moderate). However, IM has no impact on major complications, mortality, and PD-specific complications (GRADE recommendation: low).
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Buzquurz F, Bojesen RD, Grube C, Madsen MT, Gögenur I. Impact of oral preoperative and perioperative immunonutrition on postoperative infection and mortality in patients undergoing cancer surgery: systematic review and meta-analysis with trial sequential analysis. BJS Open 2020; 4:764-775. [PMID: 32573977 PMCID: PMC7528521 DOI: 10.1002/bjs5.50314] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/26/2020] [Indexed: 12/14/2022] Open
Abstract
Background Infectious complications occur in 4–22 per cent of patients undergoing surgical resection of malignant solid tumours. Improving the patient's immune system in relation to oncological surgery with immunonutrition may play an important role in reducing postoperative infections. A meta‐analysis was undertaken to evaluate the potential clinical benefits of immunonutrition on postoperative infections and 30‐day mortality in patients undergoing oncological surgery. Methods PubMed, Embase and Cochrane Library databases were searched to identify eligible studies. Eligible studies had to include patients undergoing elective curative surgery for a solid malignant tumour and receiving immunonutrition orally before surgery, including patients who continued immunonutrition into the postoperative period. The main outcome was overall infectious complications; secondary outcomes were surgical‐site infection (SSI) and 30‐day mortality, described by relative risk (RR) with trial sequential analysis (TSA). Risk of bias was assessed according to Cochrane methodology. Results Some 22 RCTs with 2159 participants were eligible for meta‐analysis. Compared with the control group, immunonutrition reduced overall infectious complications (RR 0·58, 95 per cent c.i. 0·48 to 0·70; I2 = 7 per cent; TSA‐adjusted 95 per cent c.i. 0·28 to 1·21) and SSI (RR 0·65, 95 per cent c.i. 0·50 to 0·85; I2 = 0 per cent; TSA‐adjusted 95 per cent c.i. 0·21 to 2·04). Thirty‐day mortality was not altered by immunonutrition (RR 0·69, 0·33 to 1·40; I2 = 0 per cent). Conclusion Immunonutrition reduced overall infectious complications, even after controlling for random error, and also reduced SSI. The quality of evidence was moderate, and mortality was not affected by immunonutrition (low quality). Oral immunonutrition merits consideration as a means of reducing overall infectious complications after cancer surgery.
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Affiliation(s)
- F Buzquurz
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark.,Centre for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - R D Bojesen
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark.,Centre for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - C Grube
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark.,Centre for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - M T Madsen
- Centre for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - I Gögenur
- Centre for Surgical Science, Zealand University Hospital, Køge, Denmark
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22
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Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44:2056-2084. [DOI: 10.1007/s00268-020-05462-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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23
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Tumas J, Jasiūnas E, Strupas K, Šileikis A. Effects of Immunonutrition on Comprehensive Complication Index in Patients Undergoing Pancreatoduodenectomy. ACTA ACUST UNITED AC 2020; 56:medicina56020052. [PMID: 31991566 PMCID: PMC7074545 DOI: 10.3390/medicina56020052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 02/07/2023]
Abstract
Background and objectives: Immunonutrition is recommended by enhanced recovery after surgery in patients undergoing pancreatoduodenectomy for 5–7 days perioperatively as it may reduce the rate of infectious complications. However, data on effect of immunonutrition on the overall complication rate are contradictory and it is not clear, which groups of patients benefit most. The aims of this study are to evaluate the effects of immunonutrition on the overall complication rate and the rate of severe and/or multiple complications in patients with pancreatic tumours stratified according to final histological diagnosis—patients with pancreatic ductal adenocarcinoma (PDAC) vs. other tumours—and nutritional state, using more sensitive Comprehensive Complication Index. Materials and Methods: Seventy consecutive patients scheduled for pancreatoduodenectomy because of pancreatic tumours were randomised into immunonutrition vs. control groups and stratified according to final histological diagnosis and nutritional status. Surgical outcomes were assessed postoperatively using Clavien—Dindo classification (CDC) and Comprehensive Complication Index (CCI). Results: No significant differences in the overall complication rates in immunonutrition vs. control, patients with malnutrition vs. no malnutrition, PDAC vs. other pancreatic tumours groups were detected. However, significant differences in the rates of severe and/or multiple complications in immunonutrition vs. control groups and in PDAC patients segregated according to immunonutrition were obtained using CCI. Conclusions: Patients with PDAC may experience greater benefits of immunonutrition as compared to patients with benign pancreatic diseases or less aggressive tumours, while nutritional status was not a determining factor for the efficacy of immunonutrition.
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Affiliation(s)
- Jaroslav Tumas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (K.S.); (A.Š.)
- Correspondence: ; Tel.: +370-618-49925
| | - Eugenijus Jasiūnas
- Centre of Informatics and Development, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania;
| | - Kęstutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (K.S.); (A.Š.)
| | - Audrius Šileikis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (K.S.); (A.Š.)
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Martin D, Joliat GR, Halkic N, Demartines N, Schäfer M. Perioperative nutritional management of patients undergoing pancreatoduodenectomy: an international survey among surgeons. HPB (Oxford) 2020; 22:75-82. [PMID: 31257012 DOI: 10.1016/j.hpb.2019.05.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/02/2019] [Accepted: 05/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is still a lack of good evidence regarding the optimal perioperative nutritional management for patients undergoing pancreatoduodenectomy (PD). The aim of this international survey was to assess the current practice among pancreatic surgeons. METHODS A web survey of 30 questions was sent to the members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA). All members were invited by email to answer the online survey. A reminder was sent after 4 weeks. RESULTS In total 420 out of 2500 surgeons (17%) answered the survey. Almost half of the surgeons (44%) did not organize a preoperative nutritional consultation for their patients. Seventy-seven percent of the participants did not have specific nutritional thresholds before the operation. A majority (66%) routinely used biological parameters to detect or follow malnutrition. Regarding intraoperative details, 69% of the respondents routinely leaved a nasogastric tube at the end of PD for gastric drainage. Sixty-six percent of the participants reported a postoperative nutritional follow-up consultation during hospitalization, and 58% of them had established local standardized protocols for postoperative nutritional support. CONCLUSION Management of perioperative nutrition in patients undergoing PD was very disparate internationally. No specific preoperative nutritional thresholds were used, and postoperative feeding routes and timing were diverse.
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Affiliation(s)
- David Martin
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | | | - Nermin Halkic
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland.
| | - Markus Schäfer
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
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25
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Compliance and Adherence to Enteral Nutrition Treatment in Adults: A Systematic Review. Nutrients 2019; 11:nu11112627. [PMID: 31684024 PMCID: PMC6893592 DOI: 10.3390/nu11112627] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 01/30/2023] Open
Abstract
Objective: To review the scientific literature that has verified and/or assessed compliance and adherence to enteral nutrition (EN) in adult patients. Method: This study involved a critical analysis of articles retrieved from MEDLINE (PubMed), The Cochrane Library, Embase, Scopus and Web of Science using the terms “Treatment Adherence and Compliance” and “Enteral Nutrition”, applying the filters “Comparative Study” or “Clinical Trial”, “Humans” and “Adults”. Date of the search: 25 October 2018. Results: A total of 512 references were retrieved, of which 23 documents were selected after applying the inclusion and exclusion criteria. The techniques measuring adherence to EN were determined by dietary intake, self-reporting, counts of leftover containers or presence of complications; however, in no case were validated questionnaires used. The time and periodicity of the assessment presented very heterogeneous results, with measurement predominantly being done at the beginning and at the end of the study. The best adherence rates were obtained in hospitalized patients (approximately 80%). Conclusions: Frequent and regular monitoring of the adherence of patients under prolonged treatment with EN is necessary, and the use of measurement techniques that allow obtaining information on the causes of non-adherence facilitates early interventions to optimize treatment outcomes. Patient and/or caregiver education in the management of EN and the intervention of the community pharmacy in monitoring patients can be key to improving the adherence to EN.
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26
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Takagi K, Domagala P, Hartog H, van Eijck C, Groot Koerkamp B. Current evidence of nutritional therapy in pancreatoduodenectomy: Systematic review of randomized controlled trials. Ann Gastroenterol Surg 2019; 3:620-629. [PMID: 31788650 PMCID: PMC6875945 DOI: 10.1002/ags3.12287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/10/2019] [Accepted: 08/29/2019] [Indexed: 12/24/2022] Open
Abstract
AIM Evidence of nutritional therapies in pancreatoduodenectomy (PD) has been shown. However, few studies focus on the association between different nutritional therapies and outcomes. The aim of this review was to summarize the current evidence of nutritional therapies such as enteral nutrition (EN), immunonutrition, and synbiotics on postoperative outcomes after PD. METHODS A systematic literature search of Embase, Medline Ovid, and Cochrane CENTRAL was done to summarize the available evidence, including randomized controlled trials, meta-analyses and reviews, regarding nutritional therapy in PD. RESULTS A total of 20 randomized controlled trials were included in this review. Safety and tolerability of EN in PD was shown. Giving postoperative EN can shorten length of stay compared to parenteral nutrition; however, the effect of EN on postoperative complications remains controversial. Postoperative EN should be given only on selective indications rather than routinely used, and preoperative EN is indicated only in patients with severe malnutrition. Giving preoperative immunonutrition is considered to reduce the incidence of infectious complications; however, evidence level is moderate and recommendation grade is weak. The beneficial effect of perioperative synbiotics on postoperative infectious complications is limited. Furthermore, the effectiveness of other nutritional supplements remains unclear. CONCLUSION Recently, evidence of enhanced recovery after surgery (ERAS) in PD has been increasing. Early oral intake with systematic nutritional support is an important aspect of the ERAS concept. Future well-designed studies should investigate the impact of systematic nutritional therapies on outcomes following PD.
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Affiliation(s)
- Kosei Takagi
- Department of SurgeryErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
- Department of Gastroenterological SurgeryOkayama University Graduate School of Medicine, Dentistry, and Pharmaceutical SciencesOkayamaJapan
| | - Piotr Domagala
- Department of SurgeryErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
- Department of General and Transplantation SurgeryThe Medical University of WarsawWarsawPoland
| | - Hermien Hartog
- Department of SurgeryErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Casper van Eijck
- Department of SurgeryErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Bas Groot Koerkamp
- Department of SurgeryErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
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27
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Zhang B, Najarali Z, Ruo L, Alhusaini A, Solis N, Valencia M, Sanchez MIP, Serrano PE. Effect of Perioperative Nutritional Supplementation on Postoperative Complications-Systematic Review and Meta-Analysis. J Gastrointest Surg 2019; 23:1682-1693. [PMID: 31062270 DOI: 10.1007/s11605-019-04173-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perioperative carbohydrate loading, increased protein intake, and immunonutrition may decrease postoperative complications. Studies on the topic have led to controversial results. METHODS We searched Medline, EMBASE, and CENTRAL up to August 2018 for randomized trials comparing the effect of perioperative nutritional supplements (intervention) versus control on postoperative complications in patients undergoing gastrointestinal cancer surgery. Secondary outcomes included infectious complications and length of hospital stay (LOS). Random effects model was used to estimate the pooled risk ratio (RR) of treatment effects. Pooled mean difference (MD) was used to compare LOS. Heterogeneity was assessed using I2. Sources of heterogeneity were explored through subgroup analysis by nutritional supplementation protocol, type of surgery, and type of nutritional supplement. Risk of bias and quality of the evidence were assessed. RESULTS Of 3951 articles, we identified 56 trials (n = 6370). Perioperative nutrition was associated with a lower risk of postoperative complications (RR 0.74, 95% confidence interval (CI) 0.69-0.80); postoperative infections (RR 0.71, 95% CI 0.64-0.79, n = 4582); and postoperative non-infectious complications (RR 0.79, 95% CI 0.71-0.87, n = 4883). There were no significant heterogeneity outcomes analyzed (I2 = 14%, 1%, and 7%, respectively). LOS was shorter for the intervention group, MD - 1.58 days; 95% CI - 1.83 to - 1.32; I2 = 89%). Subgroup analysis did not identify sources of heterogeneity. The quality of evidence for postoperative complications was high and for LOS was moderate. CONCLUSION Perioperative nutritional optimization decreases the risk of postoperative infectious and non-infectious complications. It also decreases LOS in patients undergoing gastrointestinal cancer surgery, but these findings should be taken with caution given the high heterogeneity.
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Affiliation(s)
- Betty Zhang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zainab Najarali
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Postgraduate Medical Education, University of Toronto, Toronto, ON, Canada
| | - Leyo Ruo
- Department of Oncology, McMaster University, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Natalie Solis
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Marlie Valencia
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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28
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Freitas RDS, Campos MM. Protective Effects of Omega-3 Fatty Acids in Cancer-Related Complications. Nutrients 2019; 11:nu11050945. [PMID: 31035457 PMCID: PMC6566772 DOI: 10.3390/nu11050945] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 12/24/2022] Open
Abstract
Omega-3 polyunsaturated fatty acids (PUFAs) are considered immunonutrients and are commonly used in the nutritional therapy of cancer patients due to their ample biological effects. Omega-3 PUFAs play essential roles in cell signaling and in the cell structure and fluidity of membranes. They participate in the resolution of inflammation and have anti-inflammatory and antinociceptive effects. Additionally, they can act as agonists of G protein-coupled receptors, namely, GPR40/FFA1 and GPR120/FFA4. Cancer patients undergo complications, such as anorexia-cachexia syndrome, pain, depression, and paraneoplastic syndromes. Interestingly, the 2017 European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines for cancer patients only discuss the use of omega-3 PUFAs for cancer-cachexia treatment, leaving aside other cancer-related complications that could potentially be managed by omega-3 PUFA supplementation. This critical review aimed to discuss the effects and the possible underlying mechanisms of omega-3 PUFA supplementation in cancer-related complications. Data compilation in this critical review indicates that further investigation is still required to assess the factual benefits of omega-3 PUFA supplementation in cancer-associated illnesses. Nevertheless, preclinical evidence reveals that omega-3 PUFAs and their metabolites might modulate pivotal pathways underlying complications secondary to cancer, indicating that this is a promising field of knowledge to be explored.
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Affiliation(s)
- Raquel D S Freitas
- Centro de Pesquisa em Toxicologia e Farmacologia, Escola de Ciências da Saúde, PUCRS, Porto Alegre 90619-900, RS, Brazil.
- Programa de Pós-graduação em Medicina e Ciências da Saúde, Escola de Medicina, PUCRS, Porto Alegre 90619-900, RS, Brazil.
| | - Maria M Campos
- Centro de Pesquisa em Toxicologia e Farmacologia, Escola de Ciências da Saúde, PUCRS, Porto Alegre 90619-900, RS, Brazil.
- Programa de Pós-graduação em Medicina e Ciências da Saúde, Escola de Medicina, PUCRS, Porto Alegre 90619-900, RS, Brazil.
- Programa de Pós-graduação em Odontologia, Escola de Ciências da Saúde, PUCRS, Porto Alegre 90619-900, RS, Brazil.
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Li K, Xu Y, Hu Y, Liu Y, Chen X, Zhou Y. Effect of Enteral Immunonutrition on Immune, Inflammatory Markers and Nutritional Status in Gastric Cancer Patients Undergoing Gastrectomy: A Randomized Double-Blinded Controlled Trial. J INVEST SURG 2019; 33:950-959. [PMID: 30885012 DOI: 10.1080/08941939.2019.1569736] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Backgrounds: Enteral immunonutrition (EIN) has received increasing attention, however, evidence on its immunomodulatory and anti-inflammatory function in gastric cancer patients undergoing gastrectomy is poorly investigated. Objectives of this study were to evaluate the effect of EIN on immune function, inflammation response and nutrition status when compared to standard enteral nutrition (SEN). Methods: Totally 124 gastric cancer patients after gastrectomy were randomized to receive early 5-days postoperative EIN (formula enriched with arginine, glutamine, omega-3 fatty acids and nucleotide), or SEN. The primary end-points were CD4+ T-cells, CD3+ T-cells as well as counts of CD4+/CD8+, IgG, IgM, and IgA levels. Second-points included white blood cell (WBC), C-reactive protein (CRP), procalcitonin (PCT), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) levels and nutritional index such as serum albumin, prealbumin, and transferrin concentration. Results: There existed significant difference in primary end-points between EIN group and SEN group. The proportion of CD4+ T-cells, CD3+ T-cells and the counts of CD4+/CD8+, IgG, IgM, and IgA were higher in EIN group eventually. Meanwhile, the level of WBC, CRP and TNF-α were significantly lower in EIN group finally. But there were no other significant differences in nutritional markers between two groups. Conclusion: Early postoperative EIN significantly improves immune function and inflammatory response in gastric cancer patients undergoing gastrectomy.
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Affiliation(s)
- Ka Li
- West China School of Nursing and Department of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Yujie Xu
- West China School of Nursing and Department of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Yanjie Hu
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yuwei Liu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xinrong Chen
- West China School of Nursing and Department of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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30
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Serrano PE, Parpia S, Nair S, Ruo L, Simunovic M, Levine O, Duceppe E, Rodrigues C. Perioperative Optimization With Nutritional Supplements in Patients Undergoing Gastrointestinal Surgery for Cancer (PROGRESS): Protocol for a Feasibility Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e10491. [PMID: 30381282 PMCID: PMC6257881 DOI: 10.2196/10491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/03/2018] [Accepted: 07/03/2018] [Indexed: 01/27/2023] Open
Abstract
Background Postoperative morbidity following gastrointestinal tract major surgery ranges between 40% and 60%. Malnutrition, poor protein intake, and surgery-related impairment of the immune system and its function have been associated with postoperative infections. Supplemental perioperative nutrition may improve nutrition by increasing protein intake to influence cell-mediated immunity, thereby reducing the rate of postoperative infectious complications. Objective The primary objective of our trial is to determine the proportion of eligible patients randomized in an 18-month period. The primary feasibility outcome will be to (1) stop, main study not feasible: estimated proportion of randomized patients <40.0% (40/100); (2) continue with protocol modifications: estimated proportion of randomized patients 40.0% (40/100) to 59.0% (50/100); or (3) continue without modification: estimated proportion of randomized patients ≥60.0% (60/100). The secondary objectives are to evaluate compliance with the nutritional supplements and to estimate differences in postoperative complications, global health-related quality of life (QoL), and median length of hospital stay between the groups. Methods This is a double-blind randomized placebo-controlled feasibility trial. The intervention comprises three nutritional supplements: a protein isolate powder (ISOlution); immunomodulation (INergy-FLD), formulated liquid diet; and carbohydrate loading (PreCovery). Patients will consume 1 serving of the protein supplement per day from the randomization time up to 6 days before surgery (30 days in total). The immunomodulation, a solution that contains arginine, protein isolate, omega-6 fatty acids, and RNA, aims to attenuate excessive inflammatory responses and to replenish nutrients. This solution will be consumed as 3 doses per day for 5 days before and after surgery. Carbohydrate loading helps to reduce the stress from surgery by decreasing insulin resistance. Patients will have 2 servings the evening before surgery and 1 serving 2-3 hours before surgery. To be eligible, patients must have a resectable gastrointestinal cancer for which an elective operation is planned. Patients will be stratified according to nutritional status. The operation should occur within 4 weeks from enrollment. Results We expect to screen 165 eligible patients; 60.6% (100/165) of them will be randomized to either intervention or placebo. Assuming a two-sided alpha of .05, this will give us a 95% CI around the estimate of 53%-68%. A sample size of 50 per group will enable us to estimate the treatment effect and corresponding variance of the complication rate and QoL measures with adequate precision. The success is defined as the proportion of eligible patients randomized as ≥60.0% (60/100). Patients’ compliance is defined as an intake of at least 70% (41/58) sachets of the intervention volume. Conclusions The results will help to determine the feasibility of a larger randomized controlled trial to implement a perioperative nutritional supplement program for patients undergoing gastrointestinal surgery for cancer. Trial Registration ClinicalTrials.gov NCT03445260; https://clinicaltrials.gov/ct2/show/NCT03445260 (Archived by WebCite at http://www.webcitation.org/72CAmMzgP) International Registered Report Identifier (IRRID) PRR1-10.2196/10491
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Affiliation(s)
- Pablo Emilio Serrano
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Oncology, Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Sameer Parpia
- Department of Oncology, Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada.,Department of Oncology, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Saeda Nair
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Leyo Ruo
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Oncology, Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Marko Simunovic
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Oncology, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Oren Levine
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Emmanuelle Duceppe
- Department of General Internal Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Carol Rodrigues
- Juravinski Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
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31
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de-Aguilar-Nascimento JE, Salomão AB, Waitzberg DL, Dock-Nascimento DB, Correa MITD, Campos ACL, Corsi PR, Portari Filho PE, Caporossi C. ACERTO guidelines of perioperative nutritional interventions in elective general surgery. Rev Col Bras Cir 2017; 44:633-648. [DOI: 10.1590/0100-69912017006003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 07/20/2017] [Indexed: 12/22/2022] Open
Abstract
ABSTRACT Objective: to present recommendations based on the ACERTO Project (Acceleration of Total Post-Operative Recovery) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures. Methods: review of relevant literature from 2006 to 2016, based on a search conducted in the main databases, with the purpose of answering guiding questions previously formulated by specialists, within each theme of this guideline. We preferably used randomized controlled trials, systematic reviews and meta-analyzes but also selected some cohort studies. We contextualized each recommendation-guiding question to determine the quality of the evidence and the strength of this recommendation (GRADE). This material was sent to authors using an open online questionnaire. After receiving the answers, we formalized the consensus for each recommendation of this guideline. Results: the level of evidence and the degree of recommendation for each item is presented in text form, followed by a summary of the evidence found. Conclusion: this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons, the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery. The prescription of these recommendations can accelerate the postoperative recovery of patients submitted to elective general surgery, with decrease in morbidity, length of stay and rehospitalization, and consequently, of costs.
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Arends J, Baracos V, Bertz H, Bozzetti F, Calder PC, Deutz NEP, Erickson N, Laviano A, Lisanti MP, Lobo DN, McMillan DC, Muscaritoli M, Ockenga J, Pirlich M, Strasser F, de van der Schueren M, Van Gossum A, Vaupel P, Weimann A. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr 2017; 36:1187-1196. [PMID: 28689670 DOI: 10.1016/j.clnu.2017.06.017] [Citation(s) in RCA: 655] [Impact Index Per Article: 93.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 06/15/2017] [Indexed: 12/13/2022]
Abstract
Patients with cancer are at particularly high risk for malnutrition because both the disease and its treatments threaten their nutritional status. Yet cancer-related nutritional risk is sometimes overlooked or under-treated by clinicians, patients, and their families. The European Society for Clinical Nutrition and Metabolism (ESPEN) recently published evidence-based guidelines for nutritional care in patients with cancer. In further support of these guidelines, an ESPEN oncology expert group met for a Cancer and Nutrition Workshop in Berlin on October 24 and 25, 2016. The group examined the causes and consequences of cancer-related malnutrition, reviewed treatment approaches currently available, and built the rationale and impetus for clinicians involved with care of patients with cancer to take actions that facilitate nutrition support in practice. The content of this position paper is based on presentations and discussions at the Berlin meeting. The expert group emphasized 3 key steps to update nutritional care for people with cancer: (1) screen all patients with cancer for nutritional risk early in the course of their care, regardless of body mass index and weight history; (2) expand nutrition-related assessment practices to include measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure, and physical function; (3) use multimodal nutritional interventions with individualized plans, including care focused on increasing nutritional intake, lessening inflammation and hypermetabolic stress, and increasing physical activity.
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Affiliation(s)
- J Arends
- Department of Medicine I, Medical Center - University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - V Baracos
- Department of Oncology, University of Alberta, Edmonton, Canada
| | - H Bertz
- Department of Medicine I, Medical Center - University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - F Bozzetti
- Faculty of Medicine, University of Milan, Milan, Italy
| | - P C Calder
- Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - N E P Deutz
- Center for Translational Research in Aging & Longevity, Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA
| | - N Erickson
- Comprehensive Cancer Center, Ludwig-Maximilian-University Hospital, Munich, Germany
| | - A Laviano
- Department of Clinical Medicine, Sapienza University, Rome, Italy
| | - M P Lisanti
- Department of Translational Medicine, University of Salford, Salford, UK
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - D C McMillan
- Department of Surgical Science, University of Glasgow, Glasgow, UK
| | - M Muscaritoli
- Department of Clinical Medicine, Sapienza University, Rome, Italy
| | - J Ockenga
- Department of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, Germany
| | - M Pirlich
- Department of Internal Medicine, Elisabeth Protestant Hospital, Berlin, Germany
| | - F Strasser
- Department Internal Medicine and Palliative Care Centre, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - M de van der Schueren
- Department of Nutrition and Dietetics, VU University Medical Center, Amsterdam, The Netherlands; Department of Nutrition and Health, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - A Van Gossum
- Gastroenterology Service, Hôpital Erasme, University Hospitals of Brussels, Brussels, Belgium
| | - P Vaupel
- Department of Radiation Oncology and Radiotherapy, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - A Weimann
- Department of General, Visceral, and Oncological Surgery, Hospital St Georg, Leipzig, Germany
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Current status of perioperative management for elderly patients. Nihon Ronen Igakkai Zasshi 2017; 54:299-313. [PMID: 28855453 DOI: 10.3143/geriatrics.54.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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d'Engremont C, Vernerey D, Pointet AL, Simone G, Fein F, Heyd B, Koch S, Vuitton L, Kim S, Jary M, Lamfichek N, Turco C, Lakkis Z, Berger A, Bonnetain F, Taieb J, Bachellier P, Borg C. Additive value of pre-operative and one-month post-operative lymphocyte count for death-risk stratification in patients with resectable pancreatic cancer: a multicentric study. BMC Cancer 2016; 16:823. [PMID: 27782813 PMCID: PMC5080693 DOI: 10.1186/s12885-016-2860-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 10/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background Pancreatic adenocarcinoma (PDAC) incidence is increasing worldwide. Several studies have shown that lymphopenia was correlated with a poor prognosis but the potential interest to measure lymphopenia in the pre and post-operative setting as well as its added value among conventional prognostic factors was never investigated. Methods Data from two independent cohorts in whom patients underwent resection for pancreatic carcinoma were retrospectively recorded. We examined the association between perioperative findings, pre and post-operative lymphocyte counts and overall survival (OS) in univariate and multivariate analyses. Performance assessment and internal validation of the final model were evaluated with Harrell’s C-index, calibration plot and bootstrap sample procedures. Results Three hundred ninety patients were included in the analysis between 2000 and 2011. Pre and post-operative lymphocyte counts were independent prognostic factors associated with OS in multivariate analysis (p = 0.0128 and p = 0.0764, respectively). The addition of lymphocyte count variable to the conventional parameters identified in multivariate analysis (metastatic lymph node ratio, veinous emboli and adjuvant chemotherapy) significantly improved the model discrimination capacity (bootstrap mean difference = 0.04; 95 % CI, 0.01–0.06). The use of a threshold and combining the categorical (≥1000; <1000) information in pre and post lymphocyte counts permitted the identification of 4 subgroups of patients with different prognosis (p < 0.0001). Finally, the description of patients in long-term remission showed that only 3 of 65 (4.6 %) patients with post-operative lymphocyte count under 1000/mm3 were alive 4 years after surgery contrary to 54 of 236 (22.8 %) patients with a post-operative lymphocyte count above 1000/mm3. Conclusion Pre and post-operative lymphopenia are independent prognostic factors for OS and they have an additive value regarding conventional prognostic factors for death-risk stratification and to predict long-term survival. Lymphopenia should be included as stratification factors in future clinical trial assessing overall survival in pancreatic cancer patients. Electronic supplementary material The online version of this article (doi:10.1186/s12885-016-2860-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Dewi Vernerey
- Methodology and Quality of Life in Oncology Unit, University Hospital of Besançon, Besançon, France
| | - Anne-Laure Pointet
- Department of Gastroenterology and GI oncology, Paris Descartes University, Georges Pompidou European Hospital, Paris, France
| | - Gaël Simone
- Department of Digestive Surgery and Liver Transplantation, University hospital of Strasbourg, Strasbourg, France
| | - Francine Fein
- Department of Gastroenterology, University Hospital of Besançon, Besançon, France
| | - Bruno Heyd
- Department of Digestive Surgery and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Stéphane Koch
- Department of Gastroenterology, University Hospital of Besançon, Besançon, France
| | - Lucine Vuitton
- Department of Gastroenterology, University Hospital of Besançon, Besançon, France
| | - Stefano Kim
- Department of Medical Oncology, University Hospital of Besançon, Besançon, France
| | - Marine Jary
- Department of Medical Oncology, University Hospital of Besançon, Besançon, France
| | - Najib Lamfichek
- Department of Digestive Surgery, Hospital of Belfort-Montbeliard, Montbeliard, France
| | - Celia Turco
- Department of Digestive Surgery and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Zaher Lakkis
- Department of Digestive Surgery and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Anne Berger
- Department of GI Surgery, Paris Descartes University, Georges Pompidou European Hospital, Paris, France
| | - Franck Bonnetain
- Methodology and Quality of Life in Oncology Unit, University Hospital of Besançon, Besançon, France
| | - Julien Taieb
- Department of Gastroenterology and GI oncology, Paris Descartes University, Georges Pompidou European Hospital, Paris, France
| | - Philippe Bachellier
- Department of Digestive Surgery and Liver Transplantation, University hospital of Strasbourg, Strasbourg, France
| | - Christophe Borg
- Department of Medical Oncology, University Hospital of Besançon, Besançon, France. .,Centre investigation Clinique en biothérapie, CIC-1431, Besançon, France. .,UMR1098 INSERM/Université de Franche Comté/Etablissement Français du Sang, Besançon, France. .,Department of Oncology, University Hospital of Besançon, 3 Boulevard Alexander Fleming, Besancon, F-25030, France.
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Silvestri S, Franchello A, Deiro G, Galletti R, Cassine D, Campra D, Bonfanti D, De Carli L, Fop F, Fronda GR. Preoperative oral immunonutrition versus standard preoperative oral diet in well nourished patients undergoing pancreaticoduodenectomy. Int J Surg 2016; 31:93-9. [PMID: 27267949 DOI: 10.1016/j.ijsu.2016.05.071] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/19/2016] [Accepted: 05/29/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy is still associated to high morbility, especially due to pancreatic surgery related and infectious complications: many risk factors have already been advocated. Aim of this study is to evaluate the role of preoperative oral immunonutrition in well nourished patients scheduled for pancreaticoduodenectomy. METHODS From February 2014 to June 2015, 54 well nourished patients undergoing pancreaticoduodenectomy were enrolled for 5 days preoperative oral immunonutrition. A series of consecutive patients submitted to the same intervention in the same department, with preoperative standard oral diet, was matched 1:1. For analysis demographic, pathological and surgical variables were considered. Mortality rate, overall postoperative morbility, pancreatic fistula, post pancreatectomy haemorrhage, delayed gastric emptying, infectious complications and length of hospital stay were described for each groups. Chi squared test, Fisher's Exact test and Student's T test were used for comparison. Differences were considered statistically significant at p < 0.05. Statistics was performed using a freeware Microsoft Excel (®) based program and SPSS v 10.00. RESULTS No statistical differences in term of mortality (2.1% in each groups) and overall morbility rate (41.6% vs 47.9%) occurred between the groups as well as for pancreatic surgery related complications. Conversely, statistical differences were found for infectious complications (22.9% vs 43.7%, p = 0.034) and length of hospital stay (18.3 ± 6.8 days vs 21.7 ± 8.3, p = 0.035) in immunonutrition group. CONCLUSION Preoperative oral immunonutrition is effective for well nourished patients scheduled for pancreaticoduodenectomy; it helps to reduce the risk of postoperative infectious complications and length of hospital stays.
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Affiliation(s)
- S Silvestri
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - A Franchello
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - G Deiro
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - R Galletti
- Dietetics and Clinical Nutrition Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - D Cassine
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - D Campra
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - D Bonfanti
- Dietetics and Clinical Nutrition Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - L De Carli
- Dietetics and Clinical Nutrition Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - F Fop
- Kidney Transplantation Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - G R Fronda
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
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Takeishi K, Maeda T, Yamashita YI, Tsujita E, Itoh S, Harimoto N, Ikegami T, Yoshizumi T, Shirabe K, Maehara Y. A Cohort Study for Derivation and Validation of Early Detection of Pancreatic Fistula After Pancreaticoduodenectomy. J Gastrointest Surg 2016; 20:385-91. [PMID: 26597269 DOI: 10.1007/s11605-015-3030-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 11/12/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic fistula (PF) remains the most important morbidity after pancreaticoduodenectomy (PD). Early drain removal was recently recommended. However, this is not applicable to all cases because the development of severe PF may not be obvious until a later postoperative day (POD). This study aimed to discover ways to detect clinically relevant PF early during the postoperative stage after PD. METHODS We studied 120 patients who underwent PD. Grades B/C PF classified according to the International Study Group of Pancreatic Surgery guidelines were defined as clinically relevant PF. Logistic regression was used to identify detection factors for clinically relevant PF. Receiver operating characteristic curves were used to identify the optimal cutoff value for clinically relevant PF, and the k-fold cross-validation model to validate the cutoff value. RESULTS Drain amylase on POD 1 and C-reactive protein (CPR) on POD 2 were independent factors for clinically relevant PF. Drain amylase >1300 IU/l on POD 1 and CRP >12.8 g/dl on POD 2 were the best cutoff values for clinically relevant PF detection and were confirmed by k-fold cross-validation. The sensitivity and specificity values were 79 and 81 %, respectively. CONCLUSIONS Values of drain amylase and CRP combined were useful to distinguish clinically relevant PF.
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Affiliation(s)
- Kazuki Takeishi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, Hiroshima, 730-8619, Japan.
| | - Takashi Maeda
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, Hiroshima, 730-8619, Japan
| | - Yo-Ichi Yamashita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, Hiroshima, 730-8619, Japan
| | - Eiji Tsujita
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, Hiroshima, 730-8619, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Norifumi Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Yao H, Bian X, Mao L, Zi X, Yan X, Qiu Y. Preoperative Enteral Nutritional Support in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma: A Strengthening the Reporting of Observational Studies in Epidemiology Article. Medicine (Baltimore) 2015; 94:e2006. [PMID: 26579806 PMCID: PMC4652815 DOI: 10.1097/md.0000000000002006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
To compare the short-term outcomes between hepatocellular carcinoma (HCC) patients with and those without preoperative nutrition on the basis of postoperative enteral nutrition.HCC patients with postoperative enteral nutrition who underwent liver resection between February 2010 and December 2014 in Nanjing Drum Tower Hospital were considered for the study: 43 patients with and 36 patients without preoperative nutrition. Primary endpoint was the incidence of overall complications. Secondary endpoints were infectious and major complications.In the preoperative enteral nutrition group, shorter length of postoperative hospital stay (10.5 ± 2.7 versus 13.7 ± 6.3 days, P = 0.007), less exogenous albumin infusion (10.2 ± 22.4 versus 47.8 ± 97.7 g, P = 0.030), earlier first exhaust time (2.7 ± 0.8 versus 3.0 ± 0.9 days, P = 0.043), and first defection time (3.5 ± 0.9 versus 4.4 ± 1.4 days, P = 0.001) were observed. No significant differences were observed in the incidence of overall complications (32.6% versus 52.8%, P = 0.070), infectious complications (7.0% versus 8.3%, P = 1), and major complications (14.0% versus 11.1%, P = 0.969) between the preoperative enteral nutrition and control group.Preoperative enteral nutrition could improve short-term outcomes of HCC patients via accelerating the recovery of gastrointestinal function and shortening the length of postoperative hospital stay.
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Affiliation(s)
- Hui Yao
- From the Department of Hepatopancreatobiliary Surgery, Drum Tower Hospital, Medical School of Nanjing University (HY, XB, LM, XY, YQ) and Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China (XZ)
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Hagan KB, Bhavsar S, Raza SM, Arnold B, Arunkumar R, Dang A, Gottumukkala V, Popat K, Pratt G, Rahlfs T, Cata JP. Enhanced recovery after surgery for oncological craniotomies. J Clin Neurosci 2015; 24:10-6. [PMID: 26474504 DOI: 10.1016/j.jocn.2015.08.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/02/2015] [Indexed: 01/12/2023]
Abstract
Enhanced recovery after surgery (ERAS) initiatives in the fields of gastrointestinal and pelvic surgery have contributed to improved postoperative functional status for patients and decreased length of stay. A similar comprehensive protocol is lacking for patients undergoing craniotomy for tumor resection. A literature search was performed using PubMed. These references were reviewed with a preference for recent high quality studies. Cohort and retrospective studies were also included if higher levels of evidence were lacking. A literature search was conducted for scalp blocks and minimally invasive craniotomies. Papers were scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria for evidence level and recommendation grade. Seventeen ERAS items were reviewed and recommendations made. The current body of evidence is insufficient to create a standardized protocol for craniotomy and tumor resection. However, this initial review of the literature supports pursuing future research initiatives that explore modalities to improve functional recovery and decrease length of stay in craniotomy patients.
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Affiliation(s)
- Katherine B Hagan
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Shreyas Bhavsar
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benjamin Arnold
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Radha Arunkumar
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Anh Dang
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Vijay Gottumukkala
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Keyuri Popat
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Greg Pratt
- Systems Analyst, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Rahlfs
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Juan P Cata
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Anesthesia and Surgical Oncology Research Group, Houston, TX, USA.
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