Lack of preoperative enteral nutrition reduces gut-associated lymphoid cell numbers in colon cancer patients: a possible mechanism underlying increased postoperative infectious complications during parenteral nutrition

Effects of parenteral nutrition supplemented with beta-hydroxy-beta-methylbutyrate on gut-associated lymphoid tissue and morphology in mice

BACKGROUND

Parenteral nutrition (PN) without enteral nutrition (EN) leads to marked atrophy of gut-associated lymphoid tissue (GALT), causing mucosal defense failure in both the gut and the extraintestinal mucosal system. We evaluated the effects of beta-hydroxy-beta-methylbutyrate (HMB) on GALT and gut morphology in PN-fed mice.

METHODS

Experiment 1: male Institute of Cancer Research mice were assigned to the Chow (n = 12), Control (standard PN: n = 10), or H600 and H2000 (PN containing 600 mg/kg or H2000 mg/kg body weight of Ca-HMB: n = 12 and 10, respectively) groups. After 5 days of dietary manipulation, all mice were killed and the whole small intestine was harvested. GALT lymphocyte cell numbers and phenotypes of Peyer patch (PP), intraepithelial space, and lamina propria lymphocytes were evaluated. Experiment 2: 47 mice (Chow: n = 12; Control: n = 14; H600: n = 11; and H2000: n = 10) were fed for 5 days as in experiment 1. Proliferation and apoptosis of gut immune cells and mucosa, and protein expressions (mammalian target of rapamycin [mTOR], caspase-3, and Bcl2) were evaluated in the small intestine.

RESULTS

Compared with the Controls, the Chow and HMB groups showed significantly higher PP cell numbers, prevented gut mucosal atrophy, inhibited apoptosis of gut cells, and increased their proliferation in association with increased mTOR activity and Bcl2 expression.

CONCLUSION

HMB-supplemented PN is a potentially novel method of preserving GALT mass and gut morphology in the absence of EN.

Clinical characteristics and risk factors of post-operative intestinal flora disorder following laparoscopic colonic surgery: A propensity-score-matching analysis

BACKGROUND

Intestinal flora disorder (IFD) poses a significant challenge after laparoscopic colonic surgery, and no standard criteria exists for its diagnosis and treatment.

AIM

To analyze the clinical features and risk factors of IFD.

METHODS

Patients with colon cancer receiving laparoscopic surgery were included using propensity-score-matching (PSM) methods. Based on the occurrence of IFD, patients were categorized into IFD and non-IFD groups. The clinical characteristics and treatment approaches for patients with IFD were analyzed. Multivariate regression analysis was performed to identify the risk factors of IFD.

RESULTS

The IFD incidence after laparoscopic surgery was 9.0% (97 of 1073 patients). After PSM, 97 and 194 patients were identified in the IFD and non-IFD groups, respectively. The most common symptoms of IFD were diarrhea and abdominal, typically occurring on post-operative days 3 and 4. All patients were managed conservatively, including modulation of the intestinal flora (90.7%), oral/intravenous application of vancomycin (74.2%), and insertion of a gastric/ileus tube for decompression (23.7%). Multivariate regression analysis identified that pre-operative intestinal obstruction [odds ratio (OR) = 2.79, 95%CI: 1.04-7.47, P = 0.041] and post-operative antibiotics (OR = 8.57, 95%CI: 3.31-23.49, P < 0.001) were independent risk factors for IFD, whereas pre-operative parenteral nutrition (OR = 0.12, 95%CI: 0.06-0.26, P < 0.001) emerged as a protective factor.

CONCLUSION

A stepwise approach of probiotics, vancomycin, and decompression could be an alternative treatment for IFD. Special attention is warranted post-operatively for patients with pre-operative obstruction or early use of antibiotics.

Preoperative Elemental Diet before Laparoscopic Anterior Resection in Patients with Advanced Stenotic Rectal Cancer

Objectives:

To evaluate the feasibility of our new preoperative enteral nutrition protocol using Elental^Ⓡ without mechanical bowel preparation (MBP) before laparoscopic anterior resection (LAR) in patients with advanced stenotic rectal cancer.

Methods:

Among 74 patients with advanced rectal cancer (clinical stages T3 and T4) scheduled to undergo LAR, 42 patients with stenotic rectal cancer were administered Elental^Ⓡ (900 kcal/day) without MBP before LAR (group S). Thirty-two patients without stenosis (group NS) did not receive preoperative nutritional support but underwent MBP.

Results:

Group S patients were maintained in a fasting state and received an elemental diet approximately 10 days preoperatively without severe adverse effects. The incidence of postoperative complications (Clavien-Dindo classification ≥ grade 2) was significantly lower in group S than that in group NS (adjusted odds ratio [OR]: 6.046, P = 0.008). Logistic regression analysis revealed that group NS exhibited higher risks of developing postoperative complications than those exhibited by group S (OR: 4.32, 95% confidence interval [CI]: 1.28-17.28, P = 0.018). Among preoperative characteristics, the clinical tumor stage indicated a significant intergroup difference. Thus, the clinical stage was selected as a covariate and adjusted in the logistic regression model to calculate a covariate-adjusted OR. Group NS exhibited a higher incidence of postoperative complications than group S (adjusted OR: 6.05, 95% CI: 1.58-28.35, P = 0.008).

Conclusions:

Administration of an elemental diet using Elental^Ⓡ without MBP before LAR is a feasible strategy in patients with advanced stenotic rectal cancer. Application of this research may encourage use of Elental^Ⓡ in the clinical setting.

The effect of enteral stimulation on the immune response of the intestinal mucosa and its application in nutritional support

The intestine plays a fundamental role as a regulator of the mucosal immune response, mostly through the production and secretion of secretory Immunoglobulin A (sIgA) by the gut-associated lymphoid tissue (GALT). Enteral stimulation, a balance between the commensal microbiota and pathogenic microorganisms, in addition to an adequate nutritional status is required for the optimal immune function of the intestine. Fasting subjects or those supported only with parenteral nutrition, show a progressive anatomical and physiological deterioration of the GALT, triggering a series of alterations resulting in a decrease in the intestinal immune response, modification in the type of microbiota, and changes that lead to or aggravate malnutrition. Patients with malnutrition present an increase in the rate of nosocomial infections, hospital length of stay, and mortality. An adequate nutritional assessment at hospital admission and avoiding long periods of fasting are paramount to prevent these unfavorable outcomes. Herein, we present a mini-state of the art review on the role and importance of enteral stimulation by GALT-mediated immune response.

Effect of preoperative nutrition therapy type and duration on short-time outcomes in gastric cancer patient with gastric outlet obstruction

Objective

To avoid perioperative complications caused malnutrition, nutrition therapy is necessary in gastric outlet obstruction (GOO) patients. Compared to parenteral nutrition (PN), enteral nutrition (EN) is associated with many advantages. This study aimed to investigate whether preoperative EN has beneficial clinical effects compared to preoperative PN in gastric cancer patients with GOO undergoing surgery.

Methods

According to the methods of preoperative nutrition therapy, 143 patients were divided into EN group (n=42) and PN group (n=101) between January 2013 and December 2017 at the Chinese People’s Liberation Army General Hospital. Multiple logistic regression models were used to assess the association between the methods of preoperative nutrition therapy and postoperative day of flatus passage. The generalized additive model and two-piecewise linear regression model were used to calculate the inflection point of the preoperative nutritional therapy time on the postoperative day of flatus passage in the PN group.

Results

EN shortened the postoperative day of flatus passage in gastric cancer patients with GOO, which is a protective factor, especially in patients who underwent non-radical operations and the postoperative day of flatus passage reduced when the preoperative PN therapy was up to 3 d and a longer PN therapy (>3 d) did not accelerate the postoperative recovery of gastrointestinal functions.

Conclusions

Preoperative EN therapy would benefit gastric cancer patients with GOO by accelerating postoperative recovery. For patients with absolute obstruction, no more than 3-day PN therapy is recommended if patients can tolerate general anesthesia and surgery.

Prognostic nutritional index and postoperative outcomes in patients with colon cancer after laparoscopic surgery

PURPOSE

The prognostic nutritional index (PNI) is calculated using the serum albumin and peripheral lymphocyte counts. We sought to assess the correlation between the preoperative PNI and postoperative outcomes in patients with colon cancer treated with laparoscopic surgery.

METHODS

We included 896 colon cancer patients who underwent curative laparoscopic colectomy between January 2013 and March 2016. To identify any predictors of the postoperative outcomes, we compared the clinical characteristics and immunonutritional parameters, including the PNI, between patients classified as the Clavien-Dindo grade 2 or higher (n = 99) with those classified as grade 0 or 1 (n = 797).

RESULTS

A longer surgical time and a preoperative low PNI (< 49.8) (odds ratio; 1.913, p = 0.002) were independent predictors of postoperative complications according to a multivariate analysis. A preoperative low PNI was significantly associated with an older age, a lower performance status, a lower BMI, higher CEA levels, an advanced T status, lymph node metastasis, a longer operative time, a higher blood loss, a larger tumor size, treatment with a combined resection, a longer time to bowel recovery, a longer postoperative hospital stay, and a poor overall survival.

CONCLUSIONS

A preoperative low PNI was found to be significantly associated with the incidence of postoperative complications, an advanced tumor status, and a poor prognosis. Further research is needed to understand how to best clinically utilize this promising parameter.

Role of nutrition in gastroenterological surgery

Nutrition plays important roles in recovery after gastroenterological surgery. Severe surgical stress increases muscle breakdown and lipolysis, thereby accelerating wound healing and enhancing host defense against microbes. Malnourished patients have insufficient amounts of muscle and body fat. Therefore, they may not appropriately respond to surgical stress. Perioperative nutritional therapy maintaining nutritional status reduces postoperative complications and accelerates recovery after surgery, particularly for malnourished patients. In addition, perioperative oral or enteral nutrition is now recommended for preserving host defense mechanisms against microbes. Lack of enteral nutrition impairs gut and hepatic immunity, systemic mucosal defense and peritoneal host defense, even when nutrient amounts supplied by parenteral nutrition are adequate. Thus, surgeons should avoid no oral or enteral nutrition periods. Supplemental administration of specific nutrients such as glutamine, arginine and ω-3 fatty acids is termed "immunonutrition", and is expected to reduce the morbidity of infectious complications and length of hospital stay. Nutritional therapy is important even after discharge to maintain body weight and compensate for abnormalities in the digestion and absorption of nutrients. Understanding the significance of nutrition in gastroenterological patients leads to better outcomes.

Influences of Short-Term Fasting and Carbohydrate Supplementation on Gut Immunity and Mucosal Morphology in Mice

BACKGROUND

Preoperative carbohydrate (CHO) supplementation has been recommended in enhanced recovery after surgery protocols. However, the effects of CHO supplementation on gut and systemic immunity are not well understood.

METHODS

Mice (n = 60) were randomized to 1 of the following 5 groups: control (ad lib feeding), 12-hour fasting without CHO administration (fasting), and 12 hours of fasting with CHO administration at 2, 4, and 8 hours before sacrifice. Then, lymphocytes were isolated from gut-associated lymphoid tissue, that is, Peyer's patches, the intraepithelial space, and the lamina propria of the small intestine. These lymphocyte numbers and phenotypes were evaluated. IgA levels in respiratory and small-intestinal washings were determined by ELISA. Morphology, proliferation, and apoptosis of the intestinal epithelium were also evaluated histologically.

RESULTS

Although there were no significant differences in IgA levels among the 5 groups, fasting decreased intraepithelial and lamina propria, but not Peyer's patches lymphocyte numbers. CHO at 2 hours prevented lymphocyte loss in intraepithelial, whereas CHO at 4 hours reversed lamina propria lymphocytes numbers. Percentages of lymphocyte phenotypes were similar in each site among the 5 groups. Fasting caused villous atrophy; however, CHO at 2 hours restored villous structure along with maintenance of epithelial cell proliferation rate.

CONCLUSIONS

Only 12 hours of fasting causes marked gut-associated lymphoid tissue cell loss along with gut atrophy. However, CHO at 2 hours preserves gut immunity and morphology not completely but moderately.

Effects of semielemental diet containing whey peptides on Peyer's patch lymphocyte number, immunoglobulin A levels, and intestinal morphology in mice

BACKGROUND

Enteral nutrition (EN) is the gold standard of nutritional therapy for critically ill or severely injured patients, because EN promotes gut and hepatic immunity, thereby preventing infectious complications as compared with parenteral nutrition. However, there are many EN formulas with different protein and fat contents. Their effects on gut-associated lymphoid tissue remain unclear. Recently, semielemental diets (SEDs) containing whey peptides as a nitrogen source have been found to be beneficial in patients with malabsorption or pancreatitis. Herein, we examined the influences of various dietary formulations on gut immunity to clarify the advantages of SEDs over elemental diets.

METHODS

Forty-four male Institute of Cancer Research mice were randomized to four groups: chow (CH: n = 5), intragastric total parenteral nutrition (IG-TPN: n = 13), elemental diet (ED: n = 13), and SED (n = 13). The CH group received CH diet ad libitum, whereas the IG-TPN, ED (Elental, Ajinomoto, Japan), and SED (Peptino, Terumo, Japan) groups were given their respective diets for 5 day via gastrostomy. After 5 days, the mice were killed to obtain whole small intestines. Peyer's patch (PP) lymphocytes were harvested and counted. Their subpopulations were evaluated by flow cytometry. Immunoglobulin A (IgA) levels in intestinal and respiratory tract washings were measured with enzyme-linked immunosorbent assay. Villous height (VH) and crypt depth in the distal intestine were measured by light microscopy.

RESULTS

SED increased the PP cell number and intestinal or respiratory IgA levels to those of CH mice, while ED partially restored these parameters. The IG-TPN group showed the lowest PP cell number and IgA levels among the four groups. VH was significantly greater in the CH than in the other groups. VH in the ED and SED groups also exceeded in the IG-TPN group, while being similar in these two groups. No significant crypt depth differences were observed among the four groups.

CONCLUSIONS

SED administration can be recommended for patients unable tolerate complex enteral diets or a normal diet in terms of not only absorption and tolerability but also maintenance of gut immunity.

Systematic review of peri-operative nutritional support for patients undergoing hepatobiliary surgery

BACKGROUND

Malnutrition is prevalent among peri-operative patients undergoing hepatobiliary surgery and is an important prognostic factor. Both hepatobiliary disease and surgical trauma significantly affects body's metabolism and environment. Therefore, it is very important for patients with liver diseases undergoing hepatobiliary surgery to receive essential nutritional support during peri-operative period.

METHODS

We summarized our clinical experience and reviewed of related literature to find the way for implementing the appropriate nutritional strategy.

RESULTS

We found after comprehensively evaluating nutrition status, function of liver and gastrointestinal tract, nutritional strategy would be selected correctly. In severe malnutrition, initiation of enteral nutrition (EN) and/or parenteral nutrition (PN) with essential or special formulae is often recommended. Especially nasojejunal feeding is indicated that early application can improve nutritional status and liver function, reduce complications and prolong survival.

CONCLUSIONS

The reasonable peri-operative nutritional support therapy can improve the effect of surgical treatment and promote the patients' recovery.

Computed Tomography (CT) Scanning Facilitates Early Identification of Neonatal Cystic Fibrosis Piglets

Background

Cystic Fibrosis (CF) is the most prevalent autosomal recessive disease in the Caucasian population. A cystic fibrosis transmembrane conductance regulator knockout (CFTR-/-) pig that displays most of the features of the human CF disease has been recently developed. However, CFTR^-/- pigs presents a 100% prevalence of meconium ileus that leads to death in the first hours after birth, requiring a rapid diagnosis and surgical intervention to relieve intestinal obstruction. Identification of CFTR^-/- piglets is usually performed by PCR genotyping, a procedure that lasts between 4 to 6 h. Here, we aimed to develop a procedure for rapid identification of CFTR^-/- piglets that will allow placing them under intensive care soon after birth and immediately proceeding with the surgical correction.

Methods and Principal Findings

Male and female CFTR^+/- pigs were crossed and the progeny was examined by computed tomography (CT) scan to detect the presence of meconium ileus and facilitate a rapid post-natal surgical intervention. Genotype was confirmed by PCR. CT scan presented a 94.4% sensitivity to diagnose CFTR^-/- piglets. Diagnosis by CT scan reduced the birth-to-surgery time from a minimum of 10 h down to a minimum of 2.5 h and increased the survival of CFTR^-/- piglets to a maximum of 13 days post-surgery as opposed to just 66 h after later surgery.

Conclusion

CT scan imaging of meconium ileus is an accurate method for rapid identification of CFTR^-/- piglets. Early CT detection of meconium ileus may help to extend the lifespan of CFTR^-/- piglets and, thus, improve experimental research on CF, still an incurable disease.

Enteral nutrient deprivation in patients leads to a loss of intestinal epithelial barrier function

OBJECTIVE

To investigate the effect of nutrient withdrawal on human intestinal epithelial barrier function (EBF). We hypothesized that unfed mucosa results in decreased EBF. This was tested in a series of surgical small intestinal resection specimens.

DESIGN

Small bowel specifically excluding inflamed tissue, was obtained from pediatric patients (aged 2 days to 19 years) undergoing intestinal resection. EBF was assessed in Ussing chambers for transepithelial resistance (TER) and passage of fluorescein isothiocyanate (FITC)-dextran (4 kD). Tight junction and adherence junction proteins were imaged with immunofluorescence staining. Expression of Toll-like receptors (TLR) and inflammatory cytokines were measured in loop ileostomy takedowns in a second group of patients.

RESULTS

Because TER increased with patient age (P < .01), results were stratified into infant versus teenage groups. Fed bowel had significantly greater TER versus unfed bowel (P < .05) in both age populations. Loss of EBF was also observed by an increase in FITC-dextran permeation in enteral nutrient-deprived segments (P < .05). Immunofluorescence staining showed marked declines in intensity of ZO-1, occludin, E-cadherin, and claudin-4 in unfed intestinal segments, as well as a loss of structural formation of tight junctions. Analysis of cytokine and TLR expression showed significant increases in tumor necrosis factor (TNF)-α and TLR4 in unfed segments of bowel compared with fed segments from the same individual.

CONCLUSION

EBF declined in unfed segments of human small bowel. This work represents the first direct examination of EBF from small bowel derived from nutrient-deprived humans and may explain the increased incidence of infectious complications seen in patients not receiving enteral feeds.

Outcomes for patients with obstructing colorectal cancers treated with one-stage surgery using transanal drainage tubes

BACKGROUND

Acute colorectal obstruction requires immediate surgical treatment. Although one-stage surgery with transanal drainage tubes (TDT) is reportedly safe and feasible, the long-term outcome of this procedure remains unclear.

AIM

To assess the outcome of one-stage surgery using TDT in the acute left colon or rectal obstructions due to colorectal carcinomas.

METHODS

Clinicopathological data were recorded from patients with colorectal cancer with acute obstructions between 2006 and 2013.

RESULTS

A total of 43 patients were enrolled including 29 males and 14 females. Among 39 patients, TDT was successful in 33 (84 %) and was incomplete in 6. Thus, 33 patients received one-stage surgery with TDT decompression, and 9 patients, including 6 with incomplete decompression, received one-stage surgery with no decompression. No significant differences in clinicopathological factors were observed between decompression and non-decompression groups. Adjusted analyses revealed that decompression using TDT was significantly associated with OS (hazard ratio 0.24; 95 % confidence interval, 0.08-0.72; p = 0.01). Furthermore, OS in the TDT decompression group was significantly longer than that in the non-decompression group (p = 0.01).

CONCLUSIONS

One-stage surgery with decompression using TDT may be effective to avoid stomas and to improve overall survival in patients with obstructing colorectal cancers.

Impact of the feeding route on gut mucosal immunity

PURPOSE OF REVIEW

Enteral nutrition is recommended as a standard nutritional therapy in clinical settings. The rationale behind enteral nutrition may be decreased infectious morbidities compared with parenteral nutrition. However, the mechanism may not be well understood.

RECENT FINDINGS

Animal studies have revealed that enteral nutrition, compared with parenteral nutrition, preserves the gut-associated lymphoid tissue mass and function with well controlled gut cytokine milieu and intracellular signaling pathway, leading to the maintenance of intestinal and extraintestinal acquired mucosal immunity. Moreover, enteral nutrition can enhance the gut innate immunity by increasing the antimicrobial peptides, such as secretory phospholipase A2. More importantly, a recent clinical study demonstrated preoperative parenteral nutrition without enteral nutrition to decrease the number of T cells, IgA-producing cells, and mature dendritic cells in human terminal ileum, which are consistent with the data obtained from animal studies. Investigation of the mechanism has given us some surrogates of enteral nutrition during parenteral nutrition, such as glutamine, butyric acid, cytokines, and other mediators. However, to date, no surrogates can restore parenteral-nutrition-induced impairment of host defense completely.

SUMMARY

Because enteral nutrition is a practical way to preserve gut immunity, clinicians should make any efforts to shorten the period of enteral nutrition absence and increase the dose according to the degree of tolerance.