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Zhang J, Kong Q, Zhang J, Guo J. Effectiveness of nutritional support for clinical outcomes in gastric cancer patients: A meta-analysis of randomized controlled trials. Open Med (Wars) 2024; 19:20241023. [PMID: 39247438 PMCID: PMC11377983 DOI: 10.1515/med-2024-1023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 07/25/2024] [Accepted: 08/02/2024] [Indexed: 09/10/2024] Open
Abstract
Background Gastric cancer (GC) is a leading cause of cancer-related morbidity and mortality globally. This meta-analysis was conducted to assess the impact of nutritional interventions on clinical outcomes in GC patients. Methods Comprehensive search was conducted across four medical databases to identify randomized controlled trials (RCTs) that examined nutritional interventions in GC patients. The outcomes assessed included hospitalization duration, nutritional status, immune function, and complications. Results A total of 11 studies were included. Enteral nutrition (EN) significantly reduce hospital stay duration compared to no nutritional intervention (SMD = -1.22, 95% CI [-1.72, -0.73], P < 0.001) and parenteral nutrition (PN) (SMD = -1.30, 95% CI [-1.78, -0.82], P < 0.001), but showed no significant difference compared to immunonutrition (IN). EN also improved nutritional status, indicated by higher albumin prealbumin levels, and improved immune function by elevating CD4+ levels (SMD = 1.09, 95% CI [0.61, 1.57], P < 0.001). However, IN showed superior effects on immunoglobulin levels (IgG and IgM). No significant differences were observed in complication rates among EN, IN, and PN interventions. Conclusion Nutritional support, particularly EN and IN, can significantly improve hospitalization outcomes, nutritional status, and immune function. Customizing interventions according to patient requirements can optimize therapeutic outcomes, highlighting the need for further research in this area.
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Affiliation(s)
- Juping Zhang
- Department of Oncology, Xingtai People's Hospital, Xingtai, 054000, China
| | - Qian Kong
- Department of Oncology, Xingtai People's Hospital, Xingtai, 054000, China
| | - Jibo Zhang
- Department of Oncology, Xingtai People's Hospital, Xingtai, 054000, China
| | - Jun Guo
- Department of Oncology, Xingtai People's Hospital, 818 Xiangdu North Road, Xingtai, 054000, China
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Okamoto K, Takamura H, Nagayama T, Sannomiya Y, Hashimoto A, Nishiki H, Kaida D, Miyata T, Tsuji T, Fujita H, Kinami S, Ninomiya I, Inaki N. Usefulness of Perioperative Nutritional Therapy with the Glutamine/Arginine/Calcium β-Hydroxy-β-Methylbutyrate Product in Esophageal Cancer Surgery: A Single-Center Retrospective Study. Nutrients 2024; 16:2126. [PMID: 38999874 PMCID: PMC11243618 DOI: 10.3390/nu16132126] [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: 06/15/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/14/2024] Open
Abstract
A useful perioperative nutritional therapy for highly invasive esophageal cancer surgical cases needs to be developed. We clarified the usefulness of amino-acid-enriched nutritional therapy using glutamine (Gln)/arginine (Arg)/calcium β-hydroxy-β-methylbutyrate (HMB) products on the short-term postoperative outcomes of minimally invasive esophagectomy for esophageal cancer. Altogether, 114 patients (Gln/Arg/HMB group) received perioperative nutritional therapy with Gln/Arg/HMB products, and we retrospectively investigated the change in nutritional parameters including skeletal muscle mass, occurrence of postoperative complications, and short-term postoperative outcomes in this group. The results were compared between the Gln/Arg/HMB and control groups (79 patients not receiving the Gln/Arg/HMB products). The incidence of all postoperative complications, sputum expectoration disorder, and pleural effusion of grade ≥ III was significantly lower in the Gln/Arg/HMB group (62.0% vs. 38.6%, p = 0.001; 44.3% vs. 28.1%, p = 0.020; 27.8% vs. 13.2%, p = 0.011, respectively). The psoas muscle area and postoperative body weight were significantly higher at 1 month and 1 year after surgery in the Gln/Arg/HMB group than in the control group (93.5% vs. 99.9%, p < 0.001; 92.0% vs. 95.4%, p = 0.006). Perioperative amino-acid-enriched nutritional therapy may improve the short-term postoperative outcomes, nutritional status, and skeletal muscle mass of esophageal cancer surgical patients.
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Affiliation(s)
- Koichi Okamoto
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku 920-0293, Ishikawa, Japan; (H.T.); (T.N.); (Y.S.); (A.H.); (H.N.); (D.K.); (T.M.); (H.F.)
- Department of Gastrointestinal Surgery, Kanazawa University, 13-1 Takara-Machi, Kanazawa 920-8641, Ishikawa, Japan; (T.T.); (N.I.)
| | - Hiroyuki Takamura
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku 920-0293, Ishikawa, Japan; (H.T.); (T.N.); (Y.S.); (A.H.); (H.N.); (D.K.); (T.M.); (H.F.)
| | - Taigo Nagayama
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku 920-0293, Ishikawa, Japan; (H.T.); (T.N.); (Y.S.); (A.H.); (H.N.); (D.K.); (T.M.); (H.F.)
| | - Yuta Sannomiya
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku 920-0293, Ishikawa, Japan; (H.T.); (T.N.); (Y.S.); (A.H.); (H.N.); (D.K.); (T.M.); (H.F.)
| | - Akifumi Hashimoto
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku 920-0293, Ishikawa, Japan; (H.T.); (T.N.); (Y.S.); (A.H.); (H.N.); (D.K.); (T.M.); (H.F.)
| | - Hisashi Nishiki
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku 920-0293, Ishikawa, Japan; (H.T.); (T.N.); (Y.S.); (A.H.); (H.N.); (D.K.); (T.M.); (H.F.)
| | - Daisuke Kaida
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku 920-0293, Ishikawa, Japan; (H.T.); (T.N.); (Y.S.); (A.H.); (H.N.); (D.K.); (T.M.); (H.F.)
| | - Takashi Miyata
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku 920-0293, Ishikawa, Japan; (H.T.); (T.N.); (Y.S.); (A.H.); (H.N.); (D.K.); (T.M.); (H.F.)
| | - Toshikatsu Tsuji
- Department of Gastrointestinal Surgery, Kanazawa University, 13-1 Takara-Machi, Kanazawa 920-8641, Ishikawa, Japan; (T.T.); (N.I.)
| | - Hideto Fujita
- Department of General and Digestive Surgery, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinadamachi, Kahoku 920-0293, Ishikawa, Japan; (H.T.); (T.N.); (Y.S.); (A.H.); (H.N.); (D.K.); (T.M.); (H.F.)
| | - Shinichi Kinami
- Department of General and Digestive Surgery, Kanazawa Medical University Himi Municipal Hospital, Himi, Toyama 935-8531, Japan;
| | - Itasu Ninomiya
- Department of Surgery, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui 910-0846, Japan;
| | - Noriyuki Inaki
- Department of Gastrointestinal Surgery, Kanazawa University, 13-1 Takara-Machi, Kanazawa 920-8641, Ishikawa, Japan; (T.T.); (N.I.)
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Hua X, Liu Y, Zhou Y. Clinical Effect of Tumor-Specific Total Nutrients in Patients with Adjuvant Chemotherapy After Radical Gastric Cancer Resection: A Randomized Controlled Trial. J Gastrointest Cancer 2024; 55:845-851. [PMID: 38342837 PMCID: PMC11186903 DOI: 10.1007/s12029-024-01029-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND In this study, we combined adjuvant chemotherapy after radical gastric cancer resection with tumor-specific total nutrient therapy to analyze how it affects the nutritional state and immune function of the patient. METHOD We collected data from 106 patients having undergone adjuvant chemotherapy after radical gastric cancer resection between January 2020 and December 2021. We divided the patients into experimental and control groups (with 53 cases in each group) through single-blinded simple randomization using a random number table and the sealed envelope system. The control group received chemotherapy and the regular nutritional diet at the same time while the experimental group received tumor-specific total nutrients based on the control group. We analyzed the index results for the physical examination, nutritional status, and immune function of the patients in both groups recorded before and after one chemotherapeutic cycle. RESULTS The control and experimental group compositions were as follows: 58.5% and 52.8% males with a mean age ± standard deviation of 54.36 ± 12.68 and 55.15 ± 12.32 years, respectively. After one chemotherapeutic cycle and the nutritional intervention, the experimental group displayed better physical examination indicators than the control group concerning the weight (55.8 ± 5.41 vs. 54.8 ± 6.94, p = 0.621), body fat mass (13.3 ± 0.88 vs. 13.1 ± 0.91, p = 0.253), upper arm circumference (21.9 ± 0.94 vs. 21.2 ± 1.23 cm, p = 0.001), triceps skinfold thickness (15.1 ± 1.36 vs. 14.3 ± 1.62 cm, p = 0.007), and grip strength (23.0 ± 1.30 vs. 22.3 ± 1.33, p = 0.007). In addition, the experimental group yielded better nutritional-status indicators than the control, including albumin (35.2 ± 1.60 vs. 33.7 ± 1.44 g/L, p = 0.001), hemoglobin (115.7 ± 9.28 vs. 111.5 ± 10.56 g/L, p = 0.032), total protein (63.7 ± 5.85 vs. 60.5 ± 5.27 g/L, p = 0.004), transferrin (2.5 ± 0.53 vs. 2.2 ± 0.58 g/L, p = 0.007), and immune-function indicators CD4+ (32.8 ± 4.82 vs. 28.8 ± 3.76, p = 0.001), CD8+ (34.1 ± 3.36 vs. 37.2 ± 3.85, p = 0.001), CD4/CD8 (1.0 ± 0.28 vs. 0.8 ± 0.34, p = 0.001), IgA (2.7 ± 1.43 vs. 4.1 ± 1.47, p = 0.001), and IgG (8.8 ± 1.74 vs. 10.9 ± 1.28, p = 0.001). CONCLUSION Combined tumor-specific total nutrient and adjuvant chemotherapy application after radical gastric cancer surgery effectively improves the nutritional state and immune function of the patients and could be applied in clinical practice.
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Affiliation(s)
- Xiumei Hua
- Department of Critical Care Medicine, Affiliated Hai'an Hospital of Nantong University, Jiangsu Province, Hai'an County, Nantong City, 226600, China
| | - Yang Liu
- Department of Clinical Nutrition, Haian Hospital of Traditional Chinese MedicineNanjing University of Chinese MedicineJiangsu Province, Nantong, 226600, China
| | - Yaqing Zhou
- Department of Critical Care Medicine, Affiliated Hai'an Hospital of Nantong University, Jiangsu Province, Hai'an County, Nantong City, 226600, China.
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Fan X, Xu Y, Wan R, Zhang L, Han H, Chen J. A clinical study on gastric cancer patients administered EN and PN versus PN alone in enhanced recovery after surgery. Ann Med Surg (Lond) 2024; 86:1433-1440. [PMID: 38463057 PMCID: PMC10923272 DOI: 10.1097/ms9.0000000000001753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/28/2023] [Indexed: 03/12/2024] Open
Abstract
Background and objectives Enhanced recovery after surgery (ERAS) recommends avoiding enteral nutrition (EN) due to undesirable sequelae such as pulmonary aspiration and infections. Not using of EN in nongastric resections under ERAS pathways is often successful. However, parenteral nutrition (PN) alone followed by early postoperative oral feeding in gastric cancer patients, recommended by the ERAS guidelines, has unclear benefit and is only adopted after gastric resection. This study aimed to compute the postoperative outcomes of EN and PN compared to those of the ERAS-recommended nutritional pathway. Our secondary objective was to compare postoperative complications between the two groups. Materials and methods Of 173 gastrectomy patients, 116 patients were in the combined group (EN and PN), whereas 57 patients were in the PN alone group. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) version 26.0.0 software. The data were analyzed by one-way ANOVA, the independent sample t-test, or, in the case of several independent samples, by the Kruskal-Wallis test. Categorical data were analyzed by Pearson's χ2 test or Fisher's exact test. Results The observed indices included C-reactive protein (CRP), platelet (PLT), white blood cells (WBC), hemoglobin (Hb), albumin, and PRE-albumin. The secondary outcomes included length of hospital stay (LOS), cost, incidence of pulmonary infection, and total incidence of infection. Conclusion The combined mode of nutrition is feasible and is not associated with postoperative complications in gastric cancer patients under ERAS.
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Affiliation(s)
| | | | | | | | | | - Jixiang Chen
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, People’s Republic of China
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5
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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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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: 3] [Impact Index Per Article: 3.0] [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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Fu H, Li B, Liang Z. Effect of enteral immunonutrition compared with enteral nutrition on surgical wound infection, immune and inflammatory factors, serum proteins, and cellular immunity in subjects with gastric cancer undergoing a total gastrectomy: A meta-analysis. Int Wound J 2022; 19:1625-1636. [PMID: 35352476 PMCID: PMC9615293 DOI: 10.1111/iwj.13763] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/08/2022] [Accepted: 01/18/2022] [Indexed: 12/24/2022] Open
Abstract
We performed a meta-analysis to evaluate the effect of enteral immunonutrition compared with enteral nutrition on surgical wound infection, immune and inflammatory factors, serum proteins, and cellular immunity in subjects with gastric cancer undergoing a total gastrectomy. A systematic literature search up to November 2021 was done, and 10 studies included 1056 subjects with gastric cancer undergoing a total gastrectomy at the start of the study: 505 of them were provided with enteral immunonutrition, and 551 were enteral nutrition. They were reporting relationships about the effect of enteral immunonutrition compared with enteral nutrition on surgical wound infection, immune and inflammatory factors, serum proteins, and cellular immunity in subjects with gastric cancer undergoing a total gastrectomy. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs) to assess the effect of enteral immunonutrition compared with enteral nutrition on surgical wound infection, immune and inflammatory factors, serum proteins, and cellular immunity in subjects with gastric cancer undergoing a total gastrectomy using the dichotomous or contentious method with a random or fixed-effect model. Enteral immunonutrition had no significant difference in the surgical wound infection (OR, 0.77; 95% CI, 0.50-1.19, P = .24), the infectious complication (OR, 0.72; 95% CI, .48-1.09, P = .13), the systemic inflammatory response syndrome (MD, -0.50; 95% CI, -1.40 to 0.39, P = .27), the CD8+ level (MD, 1.34; 95% CI, 0-2.68, P = .05), the CD4+ level (MD, 1.21; 95% CI, -7.65 to 10.07, P = .79), the CD4-CD8+ (MD, 0.55; 95% CI, 0-1.10, P = .05), the lymphocyte (MD, -0.77; 95% CI, -1.87 to 0.33, P = .17), and the transferrin (MD, 0.03; 95% CI, -0.01 to 0.08, P = .14) compared with enteral nutrition in subjects with gastric cancer undergoing a total gastrectomy. However, enteral immunonutrition had significantly higher proalbumin (MD, 22.15; 95% CI, 3.57-40.72, P = .02), IgM (MD, 0.47; 95% CI, 0.43-0.50, P < .001), and IgG (MD, 1.98; 95% CI, 1.08-2.89, P < .001) compared with enteral nutrition in subjects with gastric cancer undergoing a total gastrectomy. Enteral immunonutrition had no significant difference in the surgical wound infection, the infectious complication, the systemic inflammatory response syndrome, the CD8+ level, the CD4+ level, the CD4+/CD8+, the lymphocyte, and the transferrin, and had significantly higher proalbumin, IgM, and IgG compared with enteral nutrition in subjects with gastric cancer undergoing a total gastrectomy. Further studies are required to validate these findings or to affect the confidence level.
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Affiliation(s)
- Houfeng Fu
- Department of general surgeryQionghai People's HospitalHainanChina
| | - Bing Li
- Department of general surgeryQionghai People's HospitalHainanChina
| | - Zhenxiong Liang
- Department of general surgeryQionghai People's HospitalHainanChina
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8
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Fang Y, Xu Y, Zhang Y, Ren F, Baker JS. Mixed Treatments Comparison of Oral Nutrition Interventions for Blood Immune Cell Parameters in Cancer Patients: Systematic Review and Network Meta-Analysis. Metabolites 2022; 12:868. [PMID: 36144272 PMCID: PMC9501584 DOI: 10.3390/metabo12090868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/07/2022] [Accepted: 09/11/2022] [Indexed: 12/01/2022] Open
Abstract
Oral nutrition interventions are commonly applied as an assistant therapeutic approach, which could affect the balance of the immunological response but with mixed evidence. The objective of this study is to identify the potential of different oral nutrition interventions for blood immune cell parameters in cancer patients. Randomized controlled trials, which were published in peer-reviewed journals in the language of English, and which identified the effects of different oral nutrition interventions on cancer patients, were screened and included in the databases of PubMed, Medline, Embase, and Web of Science. White blood cell count (WBC), lymphocyte count, CD4/CD8, and neutrophil count were selected as outcome measures. For the result, 11 trials were included. The agreement between authors reached a kappa value of 0.78. Beta-carotene supplementation has a high potential in inducing a positive effect on blood immune cell parameters for cancer patients (first positive for WBC and CD4/CD8, second positive for lymphocyte count), as well as a combination of physical exercise and hypocaloric healthy eating intervention (first positive for lymphocyte and neutrophil count, second positive for WBC). Oral nutrition supplementations with a single substance have less potential to provide a positive effect on blood immune cell parameters for cancer patients (glutamine: 0.30 and 0.28 to be the last selection for WBCs and lymphocytes; Omega 3: 0.37 to be the last selection for WBCs; Protein: 0.44 to be the last selection for lymphocytes; Zinc: 0.60 to be the last selection for neutrophils). In conclusion, the programs of immunonutrition therapy for different cancer patients might be different. The past perception that mixed oral nutritional supplementations are superior to oral nutritional supplements with a single substance might be wrong and the selection of oral nutritional supplementation need cautiousness. A combination of physical exercise might have a positive effect but also needs a higher level of evidence. Registration Number: CRD42021286396.
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Affiliation(s)
- Yufei Fang
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, China
| | - Yining Xu
- Faculty of Sports Science, Ningbo University, Ningbo 315211, China
| | - Yuting Zhang
- Faculty of Sports Science, Ningbo University, Ningbo 315211, China
| | - Feng Ren
- Faculty of Sports Science, Ningbo University, Ningbo 315211, China
| | - Julien S. Baker
- Department of Sport and Physical Education, Hong Kong Baptist University, Hong Kong 999077, China
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9
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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: 9] [Impact Index Per Article: 4.5] [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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10
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Mulazzani GE, Corti F, Della Valle S, Di Bartolomeo M. Nutritional Support Indications in Gastroesophageal Cancer Patients: From Perioperative to Palliative Systemic Therapy. A Comprehensive Review of the Last Decade. Nutrients 2021; 13:nu13082766. [PMID: 34444926 PMCID: PMC8400027 DOI: 10.3390/nu13082766] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/04/2021] [Accepted: 08/10/2021] [Indexed: 02/07/2023] Open
Abstract
Gastric cancer treatments are rapidly evolving, leading to significant survival benefit. Recent evidence provided by clinical trials strongly encouraged the use of perioperative chemotherapy as standard treatment for the localized disease, whereas in the advanced disease setting, molecular characterization has improved patients’ selection for tailored therapeutic approaches, including molecular targeted therapy and immunotherapy. The role of nutritional therapy is widely recognized, with oncologic treatment’s tolerance and response being better in well-nourished patients. In this review, literature data on strategies or nutritional interventions will be critically examined, with particular regard to different treatment phases (perioperative, metastatic, and palliative settings), with the aim to draw practical indications for an adequate nutritional support of gastric cancer patients and provide an insight on future directions in nutritional strategies. We extensively analyzed the last 10 years of literature, in order to provide evidence that may fit current clinical practice both in terms of nutritional interventions and oncological treatment. Overall, 137 works were selected: 34 Randomized Clinical Trials (RCTs), 12 meta-analysis, 9 reviews, and the most relevant prospective, retrospective and cross-sectional studies in this setting. Eleven ongoing trials have been selected from clinicaltrial.gov as representative of current research. One limitation of our work lies in the heterogeneity of the described studies, in terms of sample size, study procedures, and both nutritional and clinical outcomes. Indeed, to date, there are no specific evidence-based guidelines in this fields, therefore we proposed a clinical algorithm with the aim to indicate an appropriate nutritional strategy for gastric cancer patients.
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Affiliation(s)
- Giulia E.G. Mulazzani
- Clinical Nutrition Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy; (G.E.G.M.); (S.D.V.)
| | - Francesca Corti
- Gastrointestinal Medical Oncology, Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy;
| | - Serena Della Valle
- Clinical Nutrition Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy; (G.E.G.M.); (S.D.V.)
| | - Maria Di Bartolomeo
- Gastrointestinal Medical Oncology, Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy;
- Correspondence: ; Tel.: +39-02-2390-2882
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11
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Niu JW, Zhou L, Liu ZZ, Pei DP, Fan WQ, Ning W. A Systematic Review and Meta-Analysis of the Effects of Perioperative Immunonutrition in Gastrointestinal Cancer Patients. Nutr Cancer 2020; 73:252-261. [PMID: 32285694 DOI: 10.1080/01635581.2020.1749291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jin-Wei Niu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Lei Zhou
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhi-Ze Liu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Dong-Po Pei
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Wen-Qiang Fan
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Wu Ning
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
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12
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Wu J, Lin M. Effects of specific nutrients on immune modulation in patients with gastrectomy. Ann Gastroenterol Surg 2020; 4:14-20. [PMID: 32021954 PMCID: PMC6992678 DOI: 10.1002/ags3.12299] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/23/2019] [Accepted: 10/27/2019] [Indexed: 12/20/2022] Open
Abstract
Gastric cancer (GC) is one of the most prevalent and lethal malignant neoplasms worldwide. The main treatment for GC is gastrectomy, which generally causes considerable metabolic stress to patients. To modulate cell function, maintain homeostasis of the immune response, reduce postoperative complications, and obtain favorable outcomes, physicians prescribe specific nutrients with immunomodulatory properties as supplementation to enteral or parenteral formulas, indicating immunonutrition. In the formulas, among the immunonutrients, glutamine, arginine, and n-3 polyunsaturated fatty acids are the most commonly used either alone or in combination. The present review summarizes and focuses on the evidence obtained from clinical trials and animal studies supporting the role of immunonutrients supplemented enterally or parenterally in total or subtotal gastrectomy. In addition, this review describes the possible molecular mechanisms underlying the protective action of these immunonutrients, which may contribute to therapeutic approaches to improve postoperative outcomes of gastrectomy. Combination of conventional therapy with immunonutrition seems to be a useful strategy to achieve synergistic effects in the treatment of GC patients.
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Affiliation(s)
- Jin‐Ming Wu
- Department of SurgeryNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
| | - Ming‐Tsan Lin
- Department of SurgeryNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
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13
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Yu K, Zheng X, Wang G, Liu M, Li Y, Yu P, Yang M, Guo N, Ma X, Bu Y, Peng Y, Han C, Yu K, Wang C. Immunonutrition vs Standard Nutrition for Cancer Patients: A Systematic Review and Meta-Analysis (Part 1). JPEN J Parenter Enteral Nutr 2019; 44:742-767. [PMID: 31709584 DOI: 10.1002/jpen.1736] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 09/28/2019] [Accepted: 10/15/2019] [Indexed: 01/08/2023]
Abstract
The aim of this study was to determine the efficacy of immunonutrition vs standard nutrition in cancer patients treated with surgery. Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, EBSCOhost, and Web of Science were searched. Sixty-one randomized controlled trials were included. Immunonutrition was associated with a significantly reduced risk of postoperative infectious complications (risk ratio [RR] 0.71 [95% CI, 0.64-0.79]), including a reduced risk of wound infection (RR 0.72 [95% CI, 0.60-0.87]), respiratory tract infection (RR 0.70 [95% CI, 0.59-0.84]), and urinary tract infection (RR 0.69 [95% CI, 0.51-0.94]) as well as a decreased risk of anastomotic leakage (RR 0.70 [95% CI, 0.53-0.91]) and a reduced hospital stay (MD -2.12 days [95% CI -2.72 to -1.52]). No differences were found between the 2 groups with regard to sepsis or all-cause mortality. Subgroup analyses revealed that receiving arginine + nucleotides + ω-3 fatty acids and receiving enteral immunonutrition reduced the rates of wound infection and respiratory tract infection. The application of immunonutrition at 25-30 kcal/kg/d for 5-7 days reduced the rate of respiratory tract infection. Perioperative immunonutrition reduced the rate of wound infection. For malnourished patients, immunonutrition shortened the hospitalization time. Therefore, immunonutrition reduces postoperative infection complications and shortens hospital stays but does not reduce all-cause mortality. Patients who are malnourished before surgery who receive arginine + nucleotides + ω-3 fatty acids (25-30 kcal/kg/d) via the gastrointestinal tract during the perioperative period (5-7 days) may show better clinical efficacy.
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Affiliation(s)
- Kaili Yu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xiaoya Zheng
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Guiyue Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Miao Liu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yuhang Li
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Pulin Yu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Mengyuan Yang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Nana Guo
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xiaohui Ma
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yue Bu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yahui Peng
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Ci Han
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Kaijiang Yu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Changsong Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, China
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Cho JM, Choi HS, Cho YS, Park SY, Kim DY, Lee JH. Effect of immune-enhancing enteral nutrition formula enriched with plant-derived n-3 fatty acids on natural killer cell activity in rehabilitation patients. Nutr Res Pract 2019; 13:384-392. [PMID: 31583057 PMCID: PMC6760982 DOI: 10.4162/nrp.2019.13.5.384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/24/2019] [Accepted: 06/17/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/OBJECTIVES Enteral nutrition formulas with immune-enhancing nutrients, such as n-3 fatty acids, may manage patients' nutritional status and pathophysiological processes. The aim of our study was to investigate natural killer (NK) cell activity alterations and related cytokine changes resulting from feeding with soybean oil-containing enteral nutrition formula (control group) and plant-derived n-3 fatty acid-enriched enteral nutrition formula. SUBJECTS/METHODS Subjects participated for 14 consecutive days and consumed enteral formula containing canola and flaxseed oil (n3EN, test group) in nonsurgical patients hospitalized for rehabilitation. Blood samples were collected on the first day and 14 days after the consumption of each formula daily, and anthropometric parameters were collected. Hematology and biochemical values were analyzed, and NK cell activities and serum cytokine concentration were measured. A total of sixty subjects were included in the analysis, excluding dropouts. RESULTS No significant differences were found in biochemical parameters. The n3EN group's NK cell activities at effector:tumor cell ratios of 10:1, 5:1, 2.5:1 and 0.625:1 were significantly higher than those of the control group after two weeks (P < 0.05). However, there were no statistically significant differences in serum cytokine interleukin (IL)-12, interferon-γ, IL-1β, IL-6 and tumor necrosis factor-α values between the two groups. CONCLUSIONS In conclusion, this study elucidates the beneficial effects of plant-derived n-3 fatty acid supplementation in enteral formula on NK cell activity.
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Affiliation(s)
- Jung Min Cho
- National Leading Research Laboratory of Clinical Nutrigenetics/Nutrigenomics, College of Human Ecology, Yonsei University, Seoul 03722, Republic of Korea.,Department of Food and Nutrition, College of Human Ecology, Yonsei University, Seoul 03722, Republic of Korea
| | - Hyo Seon Choi
- Department of Rehabilitation Medicine, Nowon Eulji Medical Center, Eulji University, Seoul 01830, Republic of Korea
| | - Youn Soo Cho
- Department of Nutrition and Dietetics, Yonsei University Severance Hospital, Seoul 03722, Republic of Korea
| | - So Young Park
- Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Deog Young Kim
- Department & Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jong Ho Lee
- National Leading Research Laboratory of Clinical Nutrigenetics/Nutrigenomics, College of Human Ecology, Yonsei University, Seoul 03722, Republic of Korea.,Department of Food and Nutrition, College of Human Ecology, Yonsei University, Seoul 03722, Republic of Korea
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15
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Xin F, Mzee SAS, Botwe G, He H, Zhiyu S, Gong C, Said ST, Jixing C. Short-term evaluation of immune levels and nutritional values of EN versus PN in gastric cancer: a systematic review and a meta-analysis. World J Surg Oncol 2019; 17:114. [PMID: 31269969 PMCID: PMC6609406 DOI: 10.1186/s12957-019-1658-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/24/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Postsurgical patients' oral feeding begins with clear fluids 1-3 days after surgery. This might not be sufficiently nutritious to boost the host immune system and provide sufficient energy in gastric neoplastic patients to achieve the goal of enhanced recovery after surgery (ERAS). Our objective was to analyze the significance of early postoperative feeding tubes in boosting patients' immunity and decreasing incidence of overall complications and hospital stay in gastric cancer patients' post-gastrectomy. METHODS From January 2005 to May 24, 2019, PubMed and Cochrane databases were searched for studies involving enteral nutrition (EN) feeding tubes in comparison to parenteral nutrition (PN) in gastric cancer patients undergoing gastrectomy for gastric malignancies. Relative risk (RR), mean difference (MD), or standard mean difference (SMD) with 95% confidence interval (CI) were used to estimate the effect sizes, and heterogeneity was assessed by using Q and χ2 statistic with their corresponding P values. All the analyses were performed with Review Manager 5.3 and SPSS version 22. RESULTS Nine randomized trials (n = 1437) and 5 retrospective studies (n = 421) comparing EN feeding tubes and PN were deemed eligible for the pooled analyses, with a categorized time frame of PODs ≥ 7 and PODs < 7. Ratio of CD4+/CD8+ in EN feeding tubes was the only outcome of PODs < 7, which showed significance (MD 0.22, 95% CI 0.18-0.25, P < 0.00001). Regarding other immune indicators, significant outcomes in favor of EN feeding tubes were measured on POD ≥ 7: CD3+ (SMD 1.71; 95% CI 0.70, 2.72; P = 0.0009), CD4+ (MD 5.84; 95% CI 4.19, 7.50; P < 0.00001), CD4+/CD8+ (MD 0.28; 95% CI 0.20; 0.36, P < 0.00001), NK cells (SMD 0.94; 95% CI 0.54, 1.30; P < 0.00001), nutrition values, albumin (SMD 0.63; 95% CI 0.34, 0.91; P < 0.001), prealbumin (SMD 1.00; 95% CI 0.52, 1.48; P < 0.00001), and overall complications (risk ratio 0.73 M-H; fixed; 95% CI 0.58, 0.92; P = 0.006). CONCLUSION EN feeding tube support is an essential intervention to elevate patients' immunity, depress levels of inflammation, and reduce the risk of complications after gastrectomy for gastric cancer. Enteral nutrition improves the innate immune system and nutrition levels but has no marked significance on certain clinical outcomes. Also, EN reduces the duration of hospital stay and cost, significantly.
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Affiliation(s)
- Fan Xin
- Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China
| | - Said Abdulrahman Salim Mzee
- Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China. .,Overseas Education College, Jiangsu University, No. 301 Xuefu Road, Zhenjiang, 212013, Jiangsu, People's Republic of China.
| | - Godwin Botwe
- Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China
| | - Han He
- Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China
| | - Sun Zhiyu
- Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China
| | - Chen Gong
- Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China
| | | | - Chen Jixing
- Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China
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16
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Liu L, Hong YL, Liu GY. Role of rational diet in postoperative treatment of gastric cancer and application prospect of traditional Chinese medicine diet. Shijie Huaren Xiaohua Zazhi 2018; 26:2057-2063. [DOI: 10.11569/wcjd.v26.i35.2057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The toxic side effects of postoperative radiotherapy and chemotherapy in gastric cancer (GC) often cause patients to have cancer cachexia and poor quality of life. Dietary adjuvant therapy can significantly promote GC patients to recover the body function, alleviate inflammation, improve anticancer treatment tolerance, improve postoperative quality of life and prolong survival. Given the advantages of diet in the postoperative treatment of GC, this paper discusses the role of modern medicine's elemental nutrition diet and traditional Chinese medicine diet in the postoperative treatment of GC, which can help clinicians better understand traditional Chinese medicine treatment in relieving the overall dysfunction of the body. Furthermore, the combination of traditional Chinese medicine diet with the modern medical nutrition diet evaluation system can expand the use of traditional Chinese medicine diet in the clinical treatment of GC.
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Affiliation(s)
- Lei Liu
- School of Pharmaceutical Sciences Xiamen University, Huayan Science and Technology Cancer Prevention and Rehabilitation Research Center, Xiamen 361000, Fujian Province, China
| | - Yu-Ling Hong
- School of Pharmaceutical Sciences Xiamen University, Huayan Science and Technology Cancer Prevention and Rehabilitation Research Center, Xiamen 361000, Fujian Province, China
| | - Guo-Yan Liu
- Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen 361000, Fujian Province, China
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17
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Cheng Y, Zhang J, Zhang L, Wu J, Zhan Z. Enteral immunonutrition versus enteral nutrition for gastric cancer patients undergoing a total gastrectomy: a systematic review and meta-analysis. BMC Gastroenterol 2018; 18:11. [PMID: 29338698 PMCID: PMC5771223 DOI: 10.1186/s12876-018-0741-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 01/09/2018] [Indexed: 01/10/2023] Open
Abstract
Background Nutrition support is a common means for patients with gastric cancer, especially for those undergoing elective surgery. Recently, enteral immunonutrition (EIN) was increasingly found to be more effective than enteral nutrition (EN) in enhancing the host immunity and eventually improving the prognosis of gastric cancer patients undergoing gastrectomy. However, the results reported were not consistent. This meta-analysis aimed to assess the impact of EIN for patients with GC on biochemical, immune indices and clinical outcomes. Methods Four electronical databases (Medline, EMBASE, Scopus and Cochrane library) were used to search articles in peer-reviewed, English-language journals. Mean difference (MD), Relative risk (RR), or standard mean difference (SMD) with 95% confidence interval (CI) were calculated. Heterogeneity was assessed by Cochrane Q and I2 statistic combined with corresponding P-value. The analysis was carried out with RevMan 5.3. Results Seven studies involving 583 patients were eligible for the pooled analysis. EIN, when beyond a 7-day time-frame post-operatively (D ≥ 7), increased level of CD4+ (SMD = 0.99; 95% CI, 0.65–1.33; P < 0.00001), CD4+/ CD8+ (SMD = 0.34; 95% CI, 0.02–0.67; P = 0.04), the IgM (SMD = 1.15; 95% CI, 0.11–2.20; P = 0.03), the IgG (SMD = 0.98; 95% CI, 0.55–1.42; P < 0.0001), the lymphocyte (SMD = 0.69; 95% CI, 0.32–1.06; P = 0.0003), and the proalbumin (SMD = 0.73; 95% CI, 0.33–1.14; P = 0.0004). However, those increased effects were not obvious within a 7-day time-frame post-operatively (D < 7). The levels of CD8+ and other serum proteins except proalbumin were not improved both on D ≥ 7 and D < 7. Clinical outcomes such as systemic inflammatory response syndrone (SIRS) (MD, - 0.89 days; 95% CI, - 1.40 to - 0.39; P = 0.005), and postoperative complications (RR, 0.29; 95% CI, 0.14–0.60; P = 0.001) were significantly reduced in EIN group. Pulmonary infection and length of hospitalization (LHS) were not improved no matter what time after surgery. Conclusions EIN was found to improve the cellular immunity, modulate inflammatory reaction and reduce postoperative complication for GC patients undergoing radical gastrointestinal surgery. Exclusion of grey literature and non-English language studies was the key limitation in this study.
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Affiliation(s)
- Ying Cheng
- School of medicine and life sciences, Nanjing University of Chinese Medicine, 138 Xianlin Rd, Nanjing, China
| | - Junfeng Zhang
- School of medicine and life sciences, Nanjing University of Chinese Medicine, 138 Xianlin Rd, Nanjing, China
| | - Liwei Zhang
- School of medicine and life sciences, Nanjing University of Chinese Medicine, 138 Xianlin Rd, Nanjing, China
| | - Juan Wu
- School of medicine and life sciences, Nanjing University of Chinese Medicine, 138 Xianlin Rd, Nanjing, China.
| | - Zhen Zhan
- School of medicine and life sciences, Nanjing University of Chinese Medicine, 138 Xianlin Rd, Nanjing, China.
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18
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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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19
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Probst P, Ohmann S, Klaiber U, Hüttner FJ, Billeter AT, Ulrich A, Büchler MW, Diener MK. Meta-analysis of immunonutrition in major abdominal surgery. Br J Surg 2017; 104:1594-1608. [DOI: 10.1002/bjs.10659] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 06/14/2017] [Accepted: 06/28/2017] [Indexed: 12/13/2022]
Abstract
Abstract
Background
The objective of this study was to evaluate the potential benefits of immunonutrition in major abdominal surgery with special regard to subgroups and influence of bias.
Methods
A systematic literature search from January 1985 to July 2015 was performed in MEDLINE, Embase and CENTRAL. Only RCTs investigating immunonutrition in major abdominal surgery were included. Outcomes evaluated were mortality, overall complications, infectious complications and length of hospital stay. The influence of different domains of bias was evaluated in sensitivity analyses. Evidence was rated according to the GRADE Working Group grading of evidence.
Results
A total of 83 RCTs with 7116 patients were included. Mortality was not altered by immunonutrition. Taking all trials into account, immunonutrition reduced overall complications (odds ratio (OR) 0·79, 95 per cent c.i. 0·66 to 0·94; P = 0·01), infectious complications (OR 0·58, 0·51 to 0·66; P < 0·001) and shortened hospital stay (mean difference –1·79 (95 per cent c.i. –2·39 to –1·19) days; P < 0·001) compared with control groups. However, these effects vanished after excluding trials at high and unclear risk of bias. Publication bias seemed to be present for infectious complications (P = 0·002). Non-industry-funded trials reported no positive effects for overall complications (OR 1·13, 0·88 to 1·46; P = 0·34), whereas those funded by industry reported large effects (OR 0·66, 0·48 to 0·91; P = 0·01).
Conclusion
Immunonutrition after major abdominal surgery did not seem to alter mortality (GRADE: high quality of evidence). Immunonutrition reduced overall complications, infectious complications and shortened hospital stay (GRADE: low to moderate). The existence of bias lowers confidence in the evidence (GRADE approach).
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Affiliation(s)
- P Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - S Ohmann
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - U Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - F J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - A T Billeter
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - A Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
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20
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Feinberg J, Nielsen EE, Korang SK, Halberg Engell K, Nielsen MS, Zhang K, Didriksen M, Lund L, Lindahl N, Hallum S, Liang N, Xiong W, Yang X, Brunsgaard P, Garioud A, Safi S, Lindschou J, Kondrup J, Gluud C, Jakobsen JC. Nutrition support in hospitalised adults at nutritional risk. Cochrane Database Syst Rev 2017; 5:CD011598. [PMID: 28524930 PMCID: PMC6481527 DOI: 10.1002/14651858.cd011598.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support. OBJECTIVES To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016. SELECTION CRITERIA We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. MAIN RESULTS We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence). AUTHORS' CONCLUSIONS There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.
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Affiliation(s)
- Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kirstine Halberg Engell
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Marie Skøtt Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kang Zhang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Maria Didriksen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Lisbeth Lund
- Danish Committee for Health Education5. sal, Classensgade 71CopenhagenDenmark2100
| | - Niklas Lindahl
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sara Hallum
- Cochrane Colorectal Cancer Group23 Bispebjerg BakkeBispebjerg HospitalCopenhagenDenmarkDK 2400 NV
| | - Ning Liang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Wenjing Xiong
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Xuemei Yang
- Fujian University of Traditional Chinese MedicineResearch Base of TCM syndromeNo。1,Qiu Yang RoadShangjie town,Minhou CountyFuzhouFujian ProvinceChina350122
| | - Pernille Brunsgaard
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Alexandre Garioud
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jane Lindschou
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jens Kondrup
- Rigshospitalet University HospitalClinical Nutrition UnitAmager Boulevard 127, 2th9 BlegdamsvejKøbenhavn ØDenmark2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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Song GM, Liu XL, Bian W, Wu J, Deng YH, Zhang H, Tian X. Systematic review with network meta-analysis: comparative efficacy of different enteral immunonutrition formulas in patients underwent gastrectomy. Oncotarget 2017; 8:23376-23388. [PMID: 28423579 PMCID: PMC5410311 DOI: 10.18632/oncotarget.15580] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 02/10/2017] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Optimal enteral immunonutrition (EIN) regime for gastric cancer (GC) patients underwent gastrectomy remains uncertainty. To assess comparative efficacy of different EIN formulas in GC patients underwent gastrectomy, we performed network meta-analysis. RESULTS We included 11 RCTs enrolling 840 patients. Pairwise meta-analysis indicated that EIN (RR 0.56, 95% CI 0.36-0.86; MD -0.42, 95% CI -0.74-0.10), Arg+RNA+ω-3-FAs (RR 0.37, 95% CI 0.22-0.63; MD -0.42, 95% CI -0.75-0.07), Arg+Gln+ω-3-FAs (RR 0.22, 95% CI 0.05-0.94; MD -0.69, 95% CI -1.22-1.07) reduced ICs and LOS. Network meta-analysis confirmed the potential of Arg+RNA+ω-3-FAs for ICs (OR 0.27, 95% Crl 0.12-0.49) and Arg+Gln+ω-3-FAs for CIs (OR 0.22, 95% Crl 0.02-0.84) and LOS (SMD -0.63, 95% Crl -1.07-0.13), and indicated that Arg+RNA+ω-3-FAs was superior to Arg+RNA and Arg+Gln for ICs as well. MATERIALS AND METHODS We performed direct and network meta-analyses for randomized controlled trials comparing EIN formulas with each other or standard enteral nutrition (SEN) in reducing infectious complications (ICs), noninfectious complications (NICs) and length of hospital stay (LOS), through January 2016. The surface under the cumulative ranking curve (SCURA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used to rank regimes and rate qualities of evidences respectively. CONCLUSIONS As for GC patients underwent gastrectomy, Arg+RNA+ω-3-FAs and Arg+Gln+ω-3-FAs are the optimal regimes of reducing ICs and LOS.
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Affiliation(s)
- Guo-Min Song
- Department of Nursing, Tianjin Hospital, Tianjin 300211, China
| | - Xiao-Ling Liu
- Department of Gastroenterology, Chongqing Cancer Institute and Hospital and Cancer Center, Chongqing 400030, China
| | - Wei Bian
- Ophthalmology Department, Southwest Hospital, Third Military Medical University, Chongqing 400031, China
| | - Jing Wu
- Department of Gastroenterology, Chongqing Cancer Institute and Hospital and Cancer Center, Chongqing 400030, China
| | - Yong-Hong Deng
- Graduate College, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China
| | - Hui Zhang
- Graduate College, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China
| | - Xu Tian
- Department of Gastroenterology, Chongqing Cancer Institute and Hospital and Cancer Center, Chongqing 400030, China
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Ohkura Y, Haruta S, Tanaka T, Ueno M, Udagawa H. Effectiveness of postoperative elemental diet (Elental®) in elderly patients after gastrectomy. World J Surg Oncol 2016; 14:268. [PMID: 27756322 PMCID: PMC5070231 DOI: 10.1186/s12957-016-1013-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/28/2016] [Indexed: 12/18/2022] Open
Abstract
Background We aimed to investigate the efficacy of postoperative early intervention with an elemental diet to reduce weight loss and enhance recovery after gastrectomy. Nutritional status and gastrointestinal immune function tend to worsen, and postoperative weight loss is inevitable in these patients; therefore, improvement in their postoperative condition is important, especially in gastric cancer patients aged ≥80 years. Methods Clinical outcomes and postoperative nutritional status were compared between 21 and 22 consecutive elderly patients aged ≥80 years who underwent distal gastrectomy before and after the introduction of postoperative oral elemental diet (Elental®, 300 kcal/day), respectively, between October 2011 and June 2016. Results A significant reduction in postoperative complications was noted in the nutrition support group (N-group) as compared with the control group (C-group). In particular, the prevalence of systemic complications was significantly lower in the N-group (33.3 vs. 4.5 %, p = 0.015), whereas no significant difference was observed in the prevalence of locoregional complications. The percentage of weight loss and reduction in BMI from 1 month to 1 year after surgery was significantly lower in the N-group (p = 0.012 each). The nutrition status (albumin, total protein, hemoglobin, and C-reactive protein levels) at 1 month after surgery showed improvements (p = 0.005, p = 0.048), and hospital stay was decreased in the N-group as compared to the C-group (16.0 vs. 12.5 days, p = 0.041). Conclusions Early intervention with an elemental diet after distal gastrectomy is valuable for reducing perioperative weight loss and improving nutritional management and may be associated with enhanced postoperative recovery in elderly patients.
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Affiliation(s)
- Yu Ohkura
- Hepato Pancreato Biliary Surgery Unit, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
| | - Shusuke Haruta
- Hepato Pancreato Biliary Surgery Unit, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Tsuyoshi Tanaka
- Hepato Pancreato Biliary Surgery Unit, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Masaki Ueno
- Hepato Pancreato Biliary Surgery Unit, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Harushi Udagawa
- Hepato Pancreato Biliary Surgery Unit, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
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Yan X, Zhou FX, Lan T, Xu H, Yang XX, Xie CH, Dai J, Fu ZM, Gao Y, Chen LL. Optimal postoperative nutrition support for patients with gastrointestinal malignancy: A systematic review and meta-analysis. Clin Nutr 2016; 36:710-721. [PMID: 27452745 DOI: 10.1016/j.clnu.2016.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To improve clinical outcomes, parenteral nutrition, standard enteral nutrition and immuno-enhanced nutrition are widely used in the gastrointestinal tumor patients undergoing surgery, but the optimal management of postoperative nutrition support remains uncertain. METHODS We systematically searched the PUBMED, EMBASE and CNKI to identify latent studies which the effects of standard EN compared with PN or IEN on gastrointestinal tumor patients until the end of November, 2015. The quality of included trials was assessed according to the handbook for Cochrane reviewer. Statistical analysis was carried out by RevMan5.1 software. RESULTS 30 randomized controlled trials containing 3854 patients were contained in our meta-analysis, the results indicated that postoperative SEN could absolutely reduce the incidence of postoperative infectious (P < 0.00001) and non-infectious complications (P = 0.0003), together with its positive effect on the length of hospital stay (P < 0.00001). Additionally, enteral nutrition enhanced with immune stimulation was confirmed to be better, with a significant difference between groups in terms of total infectious (P < 0.00001) and non-infectious complications (P = 0.04), and IEN could also significantly shorten the length of hospital stay (P < 0.00001). CONCLUSION Early use of Enteral nutrition in digestive tumor patients after surgery could significantly reduce the postoperative complications and shorten the length of hospital stay, IEN should be the optimal management, while the use of parenteral nutrition should be restrict to few patients with severe intolerance to enteral nutrition.
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Affiliation(s)
- Xia Yan
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China
| | - Fu-Xiang Zhou
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China.
| | - Tian Lan
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China
| | - Hui Xu
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China
| | - Xiao-Xi Yang
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China
| | - Cong-Hua Xie
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China
| | - Jing Dai
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China
| | - Zhen-Ming Fu
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China
| | - Yan Gao
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China
| | - Lu-Lu Chen
- Zhongnan Hospital of Wuhan University, Department of Oncology, Wuhan University, Wuhan, 430071, China
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The effects of enteral immunonutrition in upper gastrointestinal surgery: A systematic review and meta-analysis. Int J Surg 2016; 29:137-50. [DOI: 10.1016/j.ijsu.2016.03.043] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/05/2016] [Accepted: 03/22/2016] [Indexed: 01/10/2023]
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Imamura H, Nishikawa K, Kishi K, Inoue K, Matsuyama J, Akamaru Y, Kimura Y, Tamura S, Kawabata R, Kawada J, Fujiwara Y, Kawase T, Fukui J, Takagi M, Takeno A, Shimokawa T. Effects of an Oral Elemental Nutritional Supplement on Post-gastrectomy Body Weight Loss in Gastric Cancer Patients: A Randomized Controlled Clinical Trial. Ann Surg Oncol 2016; 23:2928-35. [PMID: 27084538 DOI: 10.1245/s10434-016-5221-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Post-gastrectomy weight loss is associated with deterioration in quality of life, and influences the long-term prognosis of gastric cancer patients. We conducted a prospective, randomized controlled, open-label study to examine whether an oral elemental diet (Elental(®), Ajinomoto Pharmaceuticals, Tokyo, Japan; hereafter referred to as ED) prevents postoperative weight loss in post-gastrectomy patients. METHODS Patients were randomly divided to receive the ED or control diet. The ED group received 300 kcal of ED plus their regular diet for 6-8 weeks after surgery, starting from the day the patient started a soft rice or equivalent diet after surgery, while the control group received the regular diet alone. The primary endpoint was the percentage of body weight loss (%BWL) from the presurgical body weight to that at 6-8 weeks after surgery. Secondary endpoints were dietary adherence, nutrition-related blood parameters, and adverse events. RESULTS This study included 112 patients in eight hospitals. The mean treatment compliance rate in the ED group was 68.7 ± 30.4 % (median 81.2 %). The %BWL was significantly different between the ED and control groups (4.86 ± 3.72 vs. 6.60 ± 4.90 %, respectively; p = 0.047). In patients who underwent total gastrectomy, the %BWL was significantly different between the two groups (5.03 ± 3.65 vs. 9.13 ± 5.43 %, respectively; p = 0.012). In multivariate analysis, ED treatment, surgery type, and preoperative performance status were independently associated with %BWL. No significant differences were observed in the other clinical variables. CONCLUSIONS ED supplementation reduced postoperative weight loss in gastric cancer patients undergoing gastrectomy.
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Affiliation(s)
- Hiroshi Imamura
- Department of Surgery, Toyonaka Municipal Hospital, 4-14-1 Shibahara-cho, Toyonaka, Japan.
| | | | - Kentaro Kishi
- Department of Surgery, Osaka Police Hospital, Osaka, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - Jin Matsuyama
- Department of Surgery, Yao Municipal Hospital, Osaka, Japan
| | - Yusuke Akamaru
- Department of Surgery, Ikeda Municipal Hospital, Osaka, Japan
| | - Yutaka Kimura
- Department of Surgery, Sakai Municipal Hospital, Osaka, Japan
| | | | | | - Junji Kawada
- Department of Surgery, Kaizuka City Hospital, Osaka, Japan
| | | | - Tomono Kawase
- Department of Surgery, Toyonaka Municipal Hospital, 4-14-1 Shibahara-cho, Toyonaka, Japan
| | - Junichi Fukui
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - Mari Takagi
- Department of Pharmacy, Osaka General Medical Center, Osaka, Japan
| | - Atsushi Takeno
- Department of Surgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Toshio Shimokawa
- Clinical Study Support Center, Wakayama Medical University, Wakayama, Japan
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Song GM, Tian X, Liang H, Yi LJ, Zhou JG, Zeng Z, Shuai T, Ou YX, Zhang L, Wang Y. Role of Enteral Immunonutrition in Patients Undergoing Surgery for Gastric Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Medicine (Baltimore) 2015; 94:e1311. [PMID: 26252314 PMCID: PMC4616579 DOI: 10.1097/md.0000000000001311] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Gastric cancer (GC) is one of the most common upper gastrointestinal malignancies. Surgical resection remains the mainstay of curative treatment for GC. Enteral immunonutrition (EIN) has been increasingly used to enhance host immunity and relieve inflammatory response of patients undergoing surgery for GC; however, conclusions across studies still remain unclear. We aimed to evaluate the effects of EIN for such patients.We searched some electronic databases including PubMed, EBSCO-Medline, Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE to identify any latent studies which investigated the effects of EIN compared with standard EN on GC patients who undergoing surgery until the end of December 30, 2014. Relative risk (RR), mean difference (MD), or standard mean difference (SMD) with 95% confidence interval (CI) were calculated and we also assessed heterogeneity by using Cochrane Q and I statistic combined with corresponding P-value.We included 9 eligible studies which included 785 patients eventually. The meta-analysis results shown that EIN increased level of IgA (MD, 0.31; 95% CI, 0.12-0.51), IgG (MD, 1.5; 95% CI, 0.73-2.28), IgM (MD, 0.22; 95% CI, 0.06-0.39), CD4 (SMD, 0.81; 95% CI, 0.53-1.09), CD3 (SMD, 0.68; 95% CI, 0.21-1.15), CD4/CD8 ratio (MD, 0.56; 95% CI, 0.12-1.01), and NK cell (MD, 2.35; 95% CI, 0.66-4.05); decreased IL-6 (MD, -98.22; 95% CI, -156.16 to -40.28) and TNF-α (MD, -118.29; 95% CI, -162.00 to -74.58), but not improve remained outcomes of interest involving postoperative complications, length of hospitalization, serum total protein, and CD8. Descriptive analysis suggested that EIN also increased the concentration of IL-2 but not CRP. Impact on lymphocytes remains inconsistent.EIN is effective for enhancing host immunity and relieving the inflammatory response in GC patients undergoing gastrectomy, but clinical outcomes cannot be benefit from it. Heterogeneity caused by different compositions and timing of administration of EIN regimes and not enough sample size and number of eligible studies in most of sensitive analyses with subgroup analysis may impaired the power of our study, and thus some large-scale and well-designed studies are warranted to further establish effects.
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Affiliation(s)
- Guo-Min Song
- From the Department of Nursing, Tianjin Hospital, Tianjin, People's Republic of China (G-MS); Graduate College, Tianjin University of Traditional Chinese Medicine, Tianjin, People's Republic of China (XT, L-JY, ZZ, TS, LZ); School of Nursing, Tianjin Medical University, Tianjin, People's Republic of China (HL); Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, People's Republic of China (J-GZ); College of TCM, Tianjin University of Traditional Chinese Medicine, Tianjin, People's Republic of China (Y-XO); and School of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin, People's Republic of China (XT, L-JY, ZZ, TS, YW)
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Song GM, Tian X, Zhang L, Ou YX, Yi LJ, Shuai T, Zhou JG, Zeng Z, Yang HL. Immunonutrition Support for Patients Undergoing Surgery for Gastrointestinal Malignancy: Preoperative, Postoperative, or Perioperative? A Bayesian Network Meta-Analysis of Randomized Controlled Trials. Medicine (Baltimore) 2015; 94:e1225. [PMID: 26200648 PMCID: PMC4602990 DOI: 10.1097/md.0000000000001225] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Enteral immunonutrition (EIN) has been established to be as a significantly important modality to prevent the postoperative infectious and noninfectious complications, enhance the immunity of host, and eventually improve the prognosis of gastrointestinal (GI) cancer patients undergoing surgery. However, different support routes, which are the optimum option, remain unclear. To evaluate the effects of different EIN support regimes for patients who underwent selective surgery for resectable GI malignancy, a Bayesian network meta-analysis (NMA) of randomized controlled trials (RCTs) was conducted. A search of PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) was electronically searched until the end of December 2014. Moreover, we manually checked reference lists of eligible trials and review and retrieval unpublished literature. RCTs which investigated the comparative effects of EIN versus standard enteral nutrition (EN) or different EIN regimes were included if the clinical outcomes information can be extracted from it. A total of 27 RCTs were incorporated into this study. Pair-wise meta-analyses suggested that preoperative (relative risk [RR], 0.58; 95% confidence interval [CI], 0.43-0.78), postoperative (RR, 0.63; 95% CI, 0.52-0.76), and perioperative EIN methods (RR, 0.46; 95% CI, 0.34-0.62) reduced incidence of postoperative infectious complications compared with standard EN. Moreover, perioperative EIN (RR, 0.65; 95% CI, 0.44-0.95) reduced the incidence of postoperative noninfectious complications, and the postoperative (mean difference [MD], -2.38; 95% CI, -3.4 to -1.31) and perioperative EIN (MD, -2.64; 95% CI, -3.28 to -1.99) also shortened the length of postoperative hospitalization compared with standard EN. NMA found that EIN support effectively improved the clinical outcomes of patients who underwent selective surgery for GI cancer compared with standard EN. Our results suggest EIN support is promising alternative for operation management in comparison with standard EN, and perioperative EIN regime is the optimum option for managing clinical status of patients who underwent selective surgery for GI cancer.
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Affiliation(s)
- Guo-Min Song
- Form the Department of Nursing (G-MS), Tianjin Hospital, Tianjin; Graduate College (XT, LZ, Y-XO, L-JY, TS, ZZ), Tianjin University of Traditional Chinese Medicine, Tianjin; Department of Oncology (J-GZ), Affiliated Hospital of Zunyi Medical University, Zunyi; and Acupuncture & Moxibustion Department (H-LY), First Teaching Hospital affiliated Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Lee HO, Han SR, Choi SI, Lee JJ, Kim SH, Ahn HS, Lim H. Effects of intensive nutrition education on nutritional status and quality of life among postgastrectomy patients. Ann Surg Treat Res 2015; 90:79-88. [PMID: 26878015 PMCID: PMC4751149 DOI: 10.4174/astr.2016.90.2.79] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/15/2015] [Accepted: 10/19/2015] [Indexed: 12/04/2022] Open
Abstract
Purpose We examined the effects of 3 months of intensive education (IE) after hospital discharge compared to conventional education (CE) on nutritional status and quality of diet and life among South Korean gastrectomy patients. Methods The study was conducted among 53 hospitalized gastrectomy in-patients (IE group, n = 28; CE group, n = 25) at Kyung Hee University Hospital at Gangdong. Baseline data were collected from electronic medical records and additional information was gathered via anthropometric measurements, assessment of nutritional status through a patient-generated, subjective global assessment (PG-SGA), diet assessment, and measures of self-efficacy and satisfaction with meals for 3 months following hospital discharge. Results Total PG-SGA scores were significantly higher in the CE group than in the IE group at 3-week post-discharge (5.2 in the IE group vs. 10.4 in the CE group, P < 0.001), with higher scores indicating a greater severity of malnutrition. Energy intake over the 3 months increased in both the IE group (from 1,390 to 1,726 kcal/day) and the CE group (from 1,227 to 1,540 kcal/day). At 3-week post-discharge, the IE group had significantly higher daily protein and fat intake (P < 0.05). Self-efficacy improved in each category (P < 0.001), except for 'difficulty eating adequate food'. When assessing satisfaction with meals, there was a difference in the 'satisfaction with the current meal size' (P < 0.001) and 'satisfaction with the menu content' (P < 0.001). Conclusion Nutritional status among gastrectomy patients in the IE group improved. Relative to the CE control, the IE group demonstrated improved self-efficacy and meal satisfaction 3-week post-discharge.
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Affiliation(s)
- Hye Ok Lee
- Nutrition Team, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - So Ra Han
- Department of Food and Nutrition, Sungshin Women's University, Seoul, Korea
| | - Sung Il Choi
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jung Joo Lee
- Nutrition Team, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sang Hyun Kim
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Hong Seok Ahn
- Department of Food and Nutrition, Sungshin Women's University, Seoul, Korea
| | - Hyunjung Lim
- Department of Medical Nutrition, Graduate School of East-West Medical Science, Kyung Hee University, Yongin, Korea.; Institute of Medical Nutrition, Kyung Hee University, Seoul, Korea
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Effect of glutamine dipeptide supplementation on primary outcomes for elective major surgery: systematic review and meta-analysis. Nutrients 2015; 7:481-99. [PMID: 25584966 PMCID: PMC4303850 DOI: 10.3390/nu7010481] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/04/2015] [Indexed: 12/15/2022] Open
Abstract
To evaluate if glutamine (GLN) supplementation may affect primary outcomes in patients undergoing major elective abdominal operations, we performed a systematic literature review of randomized clinical trials (RCTs) published from 1983 to 2013 and comparing intravenous glutamine dipeptide supplementation to no supplementation in elective surgical abdominal procedures. A meta-analysis for each outcome (overall and infectious morbidity and length of stay) of interest was carried out. The effect size was estimated by the risk ratio (RR) or by the weighted mean difference (WMD). Nineteen RCTs were identified with a total of 1243 patients (640 receiving GLN and 603 controls). In general, the studies were underpowered and of medium or low quality. GLN supplementation did not affect overall morbidity (RR = 0.84, 95% CI 0.51 to 1.36; p = 0.473) and infectious morbidity (RR = 0.64; 95% CI = 0.38 to 1.07; p = 0.087). Patients treated with glutamine had a significant reduction in length of hospital stay (WMD = −2.67; 95% CI = −3.83 to −1.50; p < 0.0001). In conclusion, GLN supplementation appears to reduce hospital stay without affecting the rate of complications. The positive effect of GLN on time of hospitalization is difficult to interpret due to the lack of significant effects on surgery-related morbidity.
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Innate immune function after breast, lung, and colorectal cancer surgery. J Surg Res 2014; 194:185-93. [PMID: 25475022 DOI: 10.1016/j.jss.2014.10.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 10/03/2014] [Accepted: 10/17/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND The cytotoxic activity and count of natural killer (NK) cells appear to be reduced after surgery; however, it is unknown whether the magnitude of this immune suppression is similar among different types of oncological surgery. In this study, we compared the innate immune function of patients undergoing three different oncological surgeries. METHODS We compared the number and function of NK cells obtained from patients who had undergone mastectomies (n = 17), thoracotomies (n = 21), or liver resections for cancer (n = 22). Cytotoxicity assays were performed to measure the function of NK cells. We also determined the plasma concentrations of interleukins (IL) 2 and 4, interferon-γ, granzyme B, perforin, soluble major histocompatibility complex class I-related chain A, and epinephrine, both before and 24 h after surgery. Differences in immunologic parameters were compared preoperatively and postoperatively and by type of surgery. P values <0.05 were considered statistically significant. RESULTS The preoperative NK cell count differed statistically (P < 0.006) among all three types of surgeries; however, within surgery postoperative counts and changes compared with baseline did not. The postoperative function of NK cells was similar among types of surgeries, but was significantly reduced compared with preoperative levels (mastectomy P < 0.0001, thoracotomy P = 0.001, and liver resections P = 0.002). We observed a significant increase in the postoperative plasma concentrations of epinephrine, whereas the concentrations of major histocompatibility class I polypeptide-related sequence A and the IL-2 and/or IL-4 ratio remained unchanged before and after surgery. CONCLUSIONS The magnitude of innate immune suppression is similar among different oncological procedures. More studies are needed to better understand this complex phenomenon.
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Abstract
BACKGROUND Glutamine is a non-essential amino acid which is abundant in the healthy human body. There are studies reporting that plasma glutamine levels are reduced in patients with critical illness or following major surgery, suggesting that glutamine may be a conditionally essential amino acid in situations of extreme stress. In the past decade, several clinical trials examining the effects of glutamine supplementation in patients with critical illness or receiving surgery have been done, and the systematic review of this clinical evidence has suggested that glutamine supplementation may reduce infection and mortality rates in patients with critical illness. However, two recent large-scale randomized clinical trials did not find any beneficial effects of glutamine supplementation in patients with critical illness. OBJECTIVES The objective of this review was to:1. assess the effects of glutamine supplementation in critically ill adults and in adults after major surgery on infection rate, mortality and other clinically relevant outcomes;2. investigate potential heterogeneity across different patient groups and different routes for providing nutrition. SEARCH METHODS We searched the Cochrane Anaesthesia Review Group (CARG) Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 5); MEDLINE (1950 to May 2013); EMBASE (1980 to May 2013) and Web of Science (1945 to May 2013). SELECTION CRITERIA We included controlled clinical trials with random or quasi-random allocation that examined glutamine supplementation versus no supplementation or placebo in adults with a critical illness or undergoing elective major surgery. We excluded cross-over trials. DATA COLLECTION AND ANALYSIS Two authors independently extracted the relevant information from each included study using a standardized data extraction form. For infectious complications and mortality and morbidity outcomes we used risk ratio (RR) as the summary measure with the 95% confidence interval (CI). We calculated, where appropriate, the number needed to treat to benefit (NNTB) and the number needed to treat to harm (NNTH). We presented continuous data as the difference between means (MD) with the 95% CI. MAIN RESULTS Our search identified 1999 titles, of which 53 trials (57 articles) fulfilled our inclusion criteria. The 53 included studies enrolled a total of 4671 participants with critical illness or undergoing elective major surgery. We analysed seven domains of potential risk of bias. In 10 studies the risk of bias was evaluated as low in all of the domains. Thirty-three trials (2303 patients) provided data on nosocomial infectious complications; pooling of these data suggested that glutamine supplementation reduced the infectious complications rate in adults with critical illness or undergoing elective major surgery (RR 0.79, 95% CI 0.71 to 0.87, P < 0.00001, I² = 8%, moderate quality evidence). Thirty-six studies reported short-term (hospital or less than one month) mortality. The combined rate of mortality from these studies was not statistically different between the groups receiving glutamine supplement and those receiving no supplement (RR 0.89, 95% CI 0.78 to 1.02, P = 0.10, I² = 22%, low quality evidence). Eleven studies reported long-term (more than six months) mortality; meta-analysis of these studies (2277 participants) yielded a RR of 1.00 (95% CI 0.89 to 1.12, P = 0.94, I² = 30%, moderate quality evidence). Subgroup analysis of infectious complications and mortality outcomes did not find any statistically significant differences between the predefined groups. Hospital length of stay was reported in 36 studies. We found that the length of hospital stay was shorter in the intervention group than in the control group (MD -3.46 days, 95% CI -4.61 to -2.32, P < 0.0001, I² = 63%, low quality evidence). Slightly prolonged intensive care unit (ICU) stay was found in the glutamine supplemented group from 22 studies (2285 participants) (MD 0.18 days, 95% CI 0.07 to 0.29, P = 0.002, I² = 11%, moderate quality evidence). Days on mechanical ventilation (14 studies, 1297 participants) was found to be slightly shorter in the intervention group than in the control group (MD - 0.69 days, 95% CI -1.37 to -0.02, P = 0.04, I² = 18%, moderate quality evidence). There was no clear evidence of a difference between the groups for side effects and quality of life, however results were imprecise for serious adverse events and few studies reported on quality of life. Sensitivity analysis including only low risk of bias studies found that glutamine supplementation had beneficial effects in reducing the length of hospital stay (MD -2.9 days, 95% CI -5.3 to -0.5, P = 0.02, I² = 58%, eight studies) while there was no statistically significant difference between the groups for all of the other outcomes. AUTHORS' CONCLUSIONS This review found moderate evidence that glutamine supplementation reduced the infection rate and days on mechanical ventilation, and low quality evidence that glutamine supplementation reduced length of hospital stay in critically ill or surgical patients. It seems to have little or no effect on the risk of mortality and length of ICU stay, however. The effects on the risk of serious side effects were imprecise. The strength of evidence in this review was impaired by a high risk of overall bias, suspected publication bias, and moderate to substantial heterogeneity within the included studies.
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Affiliation(s)
- Kun‐Ming Tao
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Xiao‐Qian Li
- Changhai Hospital, Second Military Medical UniversityDepartment of Traditional Chinese MedicineRoom 2201, School of TCM, No.800 Xiangyin RoadShanghaiShanghaiChina200433
| | - Li‐Qun Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Wei‐Feng Yu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Zhi‐Jie Lu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Yu‐Ming Sun
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Fei‐Xiang Wu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
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Intravenous alanyl-L-glutamine balances glucose–insulin homeostasis and facilitates recovery in patients undergoing colonic resection. Eur J Anaesthesiol 2014; 31:212-8. [DOI: 10.1097/eja.0b013e328360c6b9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Zhao H, Zhao H, Wang Y, Jing H, Ding Q, Xue J. Randomized clinical trial of arginine-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing gastric cancer surgery. J Cancer Res Clin Oncol 2013; 139:1465-70. [PMID: 23812551 DOI: 10.1007/s00432-013-1466-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 06/20/2013] [Indexed: 01/16/2023]
Abstract
PURPOSE Significant malnutrition exists in a high percentage of patients with gastric cancer. It is, therefore, crucial to establish an effective means to provide nutrition for these patients. This prospective, randomized, double-blinded clinical trial aims to assess the long-term survival of arginine-supplementation enteral nutrition versus standard enteral nutrition in malnourished patients with gastric cancer. METHODS The control group (36 cases) received postoperative standard enteral nutrition. Meanwhile, the arginine-supplementation group (37 cases) adopted the same nutrition product but enriched with arginine (9.0 g/L). The primary study objective was overall survival (OS). Secondary endpoints were progression-free survival (PFS); serum parameters including total protein, albumin, proalbumin, and transferrin obtained on preoperative day 1, postoperative day 2, and day 12; CD4(+) and CD8(+) T cells, natural killer (NK) cells, immunoglobulin M (IgM), and immunoglobulin G (IgG) obtained on preoperative day 1 and postoperative day 7. RESULTS No significant differences in baseline characteristics were observed between groups. The group receiving arginine-enriched nutrition had a significantly better OS (P = 0.03, 41 vs. 30.5 months) and better PFS (P = 0.02, 18 vs. 11.5 months). On postoperative day 7, CD4(+) T cells, NK cells, IgM and IgG levels of the arginine-supplemented group increased prominently and were significantly higher than those of the control group and those on preoperative day 1. There is no significant difference in the serum total protein, albumin, proalbumin, and transferrin levels between the two arms. CONCLUSIONS Arginine-supplemented enteral nutrition significantly improves long-term survival and restores immunity in malnourished gastric cancer.
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Affiliation(s)
- Hongyan Zhao
- Department of Intensive Care Unit, Daqing Oilfield General Hospital, Daqing, 163001, China
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