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Talebi S, Zeraattalab-Motlagh S, Vajdi M, Nielsen SM, Talebi A, Ghavami A, Moradi S, Sadeghi E, Ranjbar M, Habibi S, Sadeghi S, Mohammadi H. Early vs delayed enteral nutrition or parenteral nutrition in hospitalized patients: An umbrella review of systematic reviews and meta-analyses of randomized trials. Nutr Clin Pract 2023; 38:564-579. [PMID: 36906848 DOI: 10.1002/ncp.10976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/02/2023] [Accepted: 02/05/2023] [Indexed: 03/13/2023] Open
Abstract
We conducted an umbrella review to summarize the existing evidence on the effect of early enteral nutrition (EEN) compared with other approaches, including delayed enteral nutrition (DEN), parenteral nutrition (PN), and oral feeding (OF) on clinical outcomes in hospitalized patients. We performed a systematic search up to December 2021, in MEDLINE (via PubMed), Scopus, and Institute for Scientific Information Web of Science. We included systematic reviews with meta-analyses (SRMAs) of randomized trials investigating EEN compared with DEN, PN, or OF for any clinical outcomes in hospitalized patients. We used "A Measurement Tool to Assess Systematic Reviews" (AMSTAR2) and the Cochrane risk-of-bias tool for assessing the methodological quality of the systematic reviews and their included trial, respectively. The certainty of the evidence was rated using the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. We included 45 eligible SRMAs contributing with a total of 103 randomized controlled trials. The overall meta-analyses showed that patients who received EEN had statistically significant beneficial effects on most outcomes compared with any control (ie, DEN, PN, or OF), including mortality, sepsis, overall complications, infection complications, multiorgan failure, anastomotic leakage, length of hospital stay, time to flatus, and serum albumin levels. No statistically significant beneficial effects were found for risk of pneumonia, noninfectious complications, vomiting, wound infection, as well as number of days of ventilation, intensive care unit days, serum protein, and pre-serum albumin levels. Our results indicate that EEN may be preferred over DEN, PN, and OF because of the beneficial effects on many clinical outcomes.
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Affiliation(s)
- Sepide Talebi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Sheida Zeraattalab-Motlagh
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Vajdi
- Student Research Committee, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan, Iran
| | - Sabrina Mai Nielsen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Ali Talebi
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Abed Ghavami
- Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sajjad Moradi
- Halal Research Center of IRI, FDA, Tehran, Iran.,Nutritional Sciences Department, School of Nutritional Sciences and Food Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Erfan Sadeghi
- Research Consultation Center (RCC), Shiraz University Of Medical Sciences, Shiraz, Iran
| | - Mahsa Ranjbar
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Sajedeh Habibi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Sadeghi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Mohammadi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
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Noorian S, Kwaan MR, Jaffe N, Yaceczko SD, Chau LW. Perioperative nutrition for gastrointestinal surgery: On the cutting edge. Nutr Clin Pract 2023; 38:539-556. [PMID: 36847684 DOI: 10.1002/ncp.10970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 01/16/2023] [Accepted: 01/28/2023] [Indexed: 03/01/2023] Open
Abstract
Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.
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Affiliation(s)
- Shaya Noorian
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Mary R Kwaan
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Nancee Jaffe
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Lydia W Chau
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
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Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg 2023; 47:11-34. [PMID: 36310325 PMCID: PMC9726826 DOI: 10.1007/s00268-022-06732-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature. METHODS A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system. RESULTS A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy. CONCLUSIONS These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.
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Berlana D. Parenteral Nutrition Overview. Nutrients 2022; 14:4480. [PMID: 36364743 PMCID: PMC9659055 DOI: 10.3390/nu14214480] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/17/2022] [Accepted: 10/22/2022] [Indexed: 09/10/2023] Open
Abstract
Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.
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Affiliation(s)
- David Berlana
- Pharmacy Department, Vall Hebron Barcelona Campus Hospital, 08035 Barcelona, Spain;
- Pharmacology, Toxicology and Therapeutic Chemistry Department, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
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Gao X, Liu Y, Zhang L, Zhou D, Tian F, Gao T, Tian H, Hu H, Gong F, Guo D, Zhou J, Gu Y, Lian B, Xue Z, Jia Z, Chen Z, Wang Y, Jin G, Wang K, Zhou Y, Chi Q, Yang H, Li M, Yu J, Qin H, Tang Y, Wu X, Li G, Li N, Li J, Pichard C, Wang X. Effect of Early vs Late Supplemental Parenteral Nutrition in Patients Undergoing Abdominal Surgery: A Randomized Clinical Trial. JAMA Surg 2022; 157:384-393. [PMID: 35293973 PMCID: PMC8928091 DOI: 10.1001/jamasurg.2022.0269] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance The effect of and optimal timing for initiating supplemental parenteral nutrition (SPN) remain unclear after major abdominal surgery for patients in whom energy targets cannot be met by enteral nutrition (EN) alone. Objective To examine the effect of early supplemental parenteral nutrition (E-SPN) (day 3 after surgery) or late supplemental parenteral nutrition (L-SPN) (day 8 after surgery) on the incidence of nosocomial infections in patients undergoing major abdominal surgery who are at high nutritional risk and have poor tolerance to EN. Design, Setting, and Participants A multicenter randomized clinical trial was conducted from April 1, 2017, to December 31, 2018, in the general surgery department of 11 tertiary hospitals in China. Participants were those undergoing major abdominal surgery with high nutritional risk and poor tolerance to EN (≤30% of energy targets from EN on postoperative day 2, calculated as 25 and 30 kcal/kg of ideal body weight daily for women and men, respectively) and an expected postoperative hospital stay longer than 7 days. Data analysis was performed from February 1 to October 31, 2020. Interventions Random allocation to E-SPN (starting on day 3 after surgery) or L-SPN (starting on day 8 after surgery). Main Outcomes and Measures The primary outcome was the incidence of nosocomial infections between postoperative day 3 and hospital discharge. Results A total of 230 patients (mean [SD] age, 60.1 [11.2] years; 140 men [61.1%]; all patients were of Han race and Asian ethnicity) were randomized (115 to the E-SPN group and 115 to the L-SPN group). One patient in the L-SPN group withdrew informed consent before the intervention. The E-SPN group received more mean (SD) energy delivery between days 3 and 7 compared with the L-SPN group (26.5 [7.4] vs 15.1 [4.8] kcal/kg daily; P < .001). The E-SPN group had significantly fewer nosocomial infections compared with the L-SPN group (10/115 [8.7%] vs 21/114 [18.4%]; risk difference, 9.7%; 95% CI, 0.9%-18.5%; P = .04). No significant differences were found between the E-SPN group and the L-SPN group in the mean (SD) number of noninfectious complications (31/115 [27.0%] vs 38/114 [33.3%]; risk difference, 6.4%; 95% CI, -5.5% to 18.2%; P = .32), total adverse events (75/115 [65.2%] vs 82/114 [71.9%]; risk difference, 6.7%; 95% CI, -5.3% to 18.7%; P = .32), and rates of other secondary outcomes. A significant difference was found in the mean (SD) number of therapeutic antibiotic days between the E-SPN group and the L-SPN group (6.0 [0.8] vs 7.0 [1.1] days; mean difference, 1.0 days; 95% CI, 0.2-1.9 days; P = .01). Conclusion and Relevance In this randomized clinical trial, E-SPN was associated with reduced nosocomial infections in patients undergoing abdominal surgery and seems to be a favorable strategy for patients with high nutritional risk and poor tolerance to EN after major abdominal surgery. Trial Registration ClinicalTrials.gov Identifier: NCT03115957.
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Affiliation(s)
- Xuejin Gao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yuxiu Liu
- Department of Medical Statistics, Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Li Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Da Zhou
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Feng Tian
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Tingting Gao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Hao Tian
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Hao Hu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Fangyou Gong
- Department of General Surgery, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Dong Guo
- Department of Gastrointestinal Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Junde Zhou
- Department of General Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yingchao Gu
- Department of General Surgery, the Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Bo Lian
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Zhigang Xue
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhenyi Jia
- Department of General Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhida Chen
- Department of General Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yong Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Kunhua Wang
- Department of General Surgery, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qiang Chi
- Department of General Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hua Yang
- Department of General Surgery, the Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Mengbin Li
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Jianchun Yu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Huanlong Qin
- Department of General Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yun Tang
- Department of General Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaoting Wu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Guoli Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Claude Pichard
- Nutrition Unit, Geneva University Hospital, Lausanne, Switzerland
| | - Xinying Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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6
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Li K, Wang D, Zhang X, Yang J, Chen X. Efficacy of early enteral nutrition versus total parenteral nutrition for patients with gastric cancer complicated with diabetes mellitus: A systematic review and meta-analysis. Nutr Diet 2022; 79:129-139. [PMID: 35233912 DOI: 10.1111/1747-0080.12721] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/28/2021] [Accepted: 01/01/2022] [Indexed: 02/05/2023]
Abstract
AIM This study aimed to synthesise available data and evaluate the clinical evidence regarding the effect of early enteral nutrition versus total parenteral nutrition on nutritional status and blood glucose in patients with gastric cancer complicated with diabetes mellitus after gastrectomy. METHODS This systematic review and meta-analysis was designed, conducted and reported following the PRISMA guideline. We performed searches in PubMed, Embase, Medline, Web of Science, Cochrane Library, Chinese Biomedicine Literature Database, Chinese Scientific Journal Database, Chinese National Knowledge Infrastructure and Wanfang Database. The study designs were randomised controlled trials, quasi-randomised controlled trials, and controlled clinical trials. The trials compared early enteral nutrition (experimental group) with total parenteral nutrition (control group) in patients with gastric cancer complicated with diabetes mellitus after gastrectomy. The risk of bias was assessed using the Cochrane risk of bias tool. RESULTS A total of 19 trials (1255 patients) were included. Meta-analysis showed a significantly shorter length of hospital stay (days; mean difference -5.07, 95% confidence interval [CI] [-6.28, -3.86], p < 0.00001) and a lower post-operative complications rate (%; odds ratio 0.29, 95% CI [0.16, 0.50], p < 0.0001) in the early enteral nutrition group than in the total parenteral nutrition group. Compared with the total parenteral nutrition group, the early enteral nutrition group had lower blood glucose fluctuation values (mmol/L; mean difference -2.03, 95% CI [-2.44, -1.61], p < 0.00001), lower levels of glycosylated haemoglobin (%; mean difference -0.62, 95% CI [-1.22, -0.03], p = 0.04), higher levels of prealbumin (g/L; p = 0.002), transferrin (g/L; p = 0.002), total protein (g/L; p = 0.001) and haemoglobin (g/L; p = 0.005). CONCLUSIONS Early enteral nutrition may maintain stable blood glucose levels and improve nutritional status, leading to better therapeutic effectiveness in gastric cancer complicated with diabetes mellitus patients.
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Affiliation(s)
- Ka Li
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Dan Wang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Xingxia Zhang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xinrong Chen
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
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7
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Pimiento JM, Evans DC, Tyler R, Barrocas A, Hernandez B, Araujo-Torres K, Guenter P. Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States. J Gastrointest Oncol 2021; 12:864-873. [PMID: 34012673 DOI: 10.21037/jgo-20-326] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Malnutrition, particularly under-nutrition, is highly prevalent among adult patients with a diagnosis of gastrointestinal (GI) cancer and negatively affects patient outcomes. Malnutrition is associated with clinical and surgical complications for patients undergoing therapy for GI cancers and the costs associated with those complications is a high burden for the US health system. Our objective was to identify high-quality evidence for nutrition support interventions associated with cost savings for patient care, followed by a complex economic value analysis to project cost savings for the US health system. A narrative literature search was conducted in which combined keywords in the areas of therapeutic nutrition (nutrition, malnutrition), a specific therapeutic area [GI cancer (esophageal, gastric, gallbladder, pancreatic, liver/hepatic, small and large intestine, colorectal)], and clinical outcomes and healthcare cost, to look for nutrition interventions that could significantly improve clinical outcomes. Medicare claims data were then analyzed using the findings of these identified studies and this modeling exercise supported identifying the cost and healthcare resource utilization implications of specific populations to determine the impact of nutrition support on reducing these costs as reflected in the summary of the evidence. Eight studies were found that provided clinical outcomes and health cost savings data, 2 of those had the strongest level of evidence and were used for Value Analysis calculations. Nutrition interventions such as oral diet modifications, enteral nutrition (EN) supplementation, and parenteral nutrition (PN) have been studied especially in the peri-operative setting. Specifically, peri-operative immunonutrition administration and utilization of enhanced recovery pathways after surgery have been associated with significant improvement in postoperative complications and decreased length of hospital stay (LOS). Utilizing economic modeling of Medicare claims data from GI cancer patients, potential annual cost savings of $242 million were projected by the widespread adoption of these interventions. Clinical outcomes can be improved with the use of nutrition interventions in patients with GI cancers. Healthcare costs can be reduced as a result of fewer in-hospital complications and shorter lengths of hospital stay. The application of nutrition intervention provides a positive clinical and economic value proposition to the healthcare system for patients with GI cancers.
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Affiliation(s)
- Jose M Pimiento
- Gastrointestinal Oncology Department, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - David C Evans
- Ohio Health Trauma and Surgical Services, Columbus OH, USA
| | - Renay Tyler
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Albert Barrocas
- Surgery Department, Tulane School of Medicine, New Orleans, LA, USA
| | | | | | - Peggi Guenter
- American Society for Parenteral Nutrition, Silver Spring, MD, USA
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Koemans WJ, Houwink A, van der Kaaij RT, Wassenaar ECE, Boerma D, Hahn C, Imhof O, Brandt MG, Ariëns MP, Veenhof AAFA, Hartemink KJ, van Sandick JW. Perioperative Management of Gastric Cancer Patients Treated With (Sub)Total Gastrectomy, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): Lessons Learned. Ann Surg Oncol 2021; 28:4647-4654. [PMID: 33389293 DOI: 10.1245/s10434-020-09465-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 11/25/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The PERISCOPE I study was designed to assess the safety and feasibility of (sub)total gastrectomy, cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin and docetaxel for gastric cancer patients who have limited peritoneal dissemination. The current analysis investigated changes in perioperative management together with their impact on postoperative outcomes. METHODS Patients with resectable gastric cancer and limited peritoneal dissemination were administered (sub)total gastrectomy, CRS, and HIPEC with oxaliplatin (460 mg/m2) and docetaxel (escalating scheme: 0, 50, 75 mg/m2). Of the 25 patients who completed the study protocol, 14 were treated in the dose-escalation cohort and 11 were treated in the expansion cohort (to optimize perioperative management). RESULTS A significant proportion of the patients in the dose-escalation cohort (n = 7, 50%) had ileus-related complications. In this cohort, enteral nutrition was started immediately after surgery at 20 ml/h, which was increased on day 1 to meet nutritional needs. In the expansion cohort, enteral nutrition was administered at 10 ml/h until day 3, then restricted to 20 ml/h until day 6, supplemented with total parenteral nutrition to meet nutritional needs. Ileus-related complications occurred for two patients (18%) of the expansion cohort. The intensive care unit (ICU) readmission rate decreased from 50 (n = 7) to 9% (n = 1; p = 0.04). CONCLUSION The implementation of a strict nutritional protocol during the PERISCOPE I study was associated with a decrease in postoperative complications. Based on these results, a perioperative care path was described for the gastric cancer HIPEC patients in the PERISCOPE II study.
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Affiliation(s)
- W J Koemans
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A Houwink
- Department of Anesthesiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - R T van der Kaaij
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E C E Wassenaar
- Department of Dietetics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - D Boerma
- Department of Dietetics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - C Hahn
- Department of Anesthesiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - O Imhof
- Clinical Perfusion, Heartbeat, Eemnes, The Netherlands
| | - M G Brandt
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M P Ariëns
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A A F A Veenhof
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - K J Hartemink
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - J W van Sandick
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44:2056-2084. [DOI: 10.1007/s00268-020-05462-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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10
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Tyler R, Barrocas A, Guenter P, Araujo Torres K, Bechtold ML, Chan L, Collier B, Collins NA, Evans DC, Godamunne K, Hamilton C, Hernandez BJD, Mirtallo JM, Nadeau WJ, Partridge J, Perugini M, Valladares A. Value of Nutrition Support Therapy: Impact on Clinical and Economic Outcomes in the United States. JPEN J Parenter Enteral Nutr 2020; 44:395-406. [DOI: 10.1002/jpen.1768] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/21/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Renay Tyler
- University of Maryland Medical Center Baltimore Maryland USA
| | | | - Peggi Guenter
- Clinical Practice, Quality, and AdvocacyAmerican Society for Parenteral Nutrition Silver Spring Maryland USA
| | | | - Matthew L. Bechtold
- Division of Gastroenterology & HepatologyDepartment of Medicine University Hospital & Clinics Columbia Missouri USA
| | - Lingtak‐Neander Chan
- Department of PharmacyInterdisciplinary FacultyNutritional Sciences ProgramUniversity of Washington Seattle Washington USA
| | - Bryan Collier
- Virginia Tech Carilion School of Medicine Roanoke Virginia USA
| | - Nilsa A. Collins
- Clinical Integration ProgramsWellStar Clinical Partners Marietta Atlanta Georgia USA
| | - David C. Evans
- Ohio Health Trauma and Surgical Services Columbus Ohio USA
| | | | - Cindy Hamilton
- Digestive Disease and Surgery Institute Cleveland Clinic Cleveland Ohio USA
| | | | - Jay M. Mirtallo
- Clinical Practice, Quality, and AdvocacyAmerican Society for Parenteral Nutrition Silver Spring Maryland USA
- The Ohio State UniversityCollege of Pharmacy Columbus Ohio USA
| | | | - Jamie Partridge
- Field Health Economics and Outcomes ResearchBayer Pharmaceuticals Whippany New Jersey USA
| | - Moreno Perugini
- Global Head of Medical Affairs & Marketing AccessNestlé Health Science Bridgewater New Jersey USA
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Nors J, Funder JA, Swain DR, Verwaal VJ, Cecil T, Laurberg S, Moran BJ. Postoperative paralytic ileus after cytoreductive surgery combined with heated intraperitoneal chemotherapy. Pleura Peritoneum 2019; 5:20190026. [PMID: 32934973 PMCID: PMC7469504 DOI: 10.1515/pp-2019-0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/09/2019] [Indexed: 12/26/2022] Open
Abstract
Background Patients with peritoneal malignancy treated by cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) are prone to develop postoperative paralytic ileus (POI). POI is associated with significant increase in both morbidity and mortality. CRS and HIPEC commonly result in prolonged POI (PPOI). The objective was to clarify the extent of PPOI in patients treated by CRS and HIPEC for peritoneal malignancy. Methods This was a prospective multicenter study including patients operated with CRS and HIPEC at the Department of Surgery, Aarhus University Hospital, Denmark and the Peritoneal Malignancy Institute, Basingstoke, United Kingdom. A total of 85 patients were included over 5 months. Patients prospectively reported parameters of postoperative gastrointestinal function in a diary from post-operative day 1 (POD1) until discharge. PPOI was defined as first defecation on POD6 or later. Results Median time to first flatus passage was 4 days (range 1–12). Median time to first defecation was 6 days (1–14). Median time to removal of nasojejunal tube was 4 days (3–13) and 7 days (1–43) for nasogastric tube. Forty-six patients (54%) developed PPOI. Patients with PPOI had longer time to first flatus (p<0.0001) and longer time to removal of nasojejunal tube (p=0.001). Duration of surgery correlated to time to first flatus (p=0.015) and time to removal of nasogastric or nasojejunal tube (p<0.0001) but not to time to first defecation (p=0.321). Conclusions Postoperative gastrointestinal paralysis remains a common and serious problem in patients treated with CRS and HIPEC.
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Affiliation(s)
- Jesper Nors
- Department of Surgery, Aarhus University Hospital Skejby, Aarhus N, Denmark
| | | | - David Richard Swain
- Peritoneal Malignancy Unit, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | | | - Tom Cecil
- Peritoneal Malignancy Institute Basingstoke, Basingstoke, UK
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital Skejby, Aarhus N, Denmark
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Preoperative nutritional status and use of total parenteral nutrition in pediatric and adolescent patients undergoing continent urinary tract reconstruction. J Pediatr Urol 2018; 14:572.e1-572.e7. [PMID: 30154048 DOI: 10.1016/j.jpurol.2018.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/26/2018] [Indexed: 12/29/2022]
Abstract
INTRODUCTION A nutritional assessment is a critical but often neglected aspect of a preoperative evaluation. Malnutrition is clearly associated with worse surgical outcomes in adults undergoing major abdominal surgery, whereas a paucity of evidence is available in the pediatric population. OBJECTIVE The objectives were to describe the preoperative nutritional status of pediatric and adolescent patients undergoing continent urinary tract reconstruction and to determine the association among malnutrition, use of total parenteral nutrition (TPN), and surgical outcomes. STUDY DESIGN A retrospective cohort study was performed for patients aged up to 20 years who underwent continent urinary tract reconstruction between January 2012 and November 2016. Malnutrition was classified with body mass index and height for age z-scores on admission as well as change in z-scores and weight over the 3-6 months before surgery. Primary outcomes included the duration of intensive care and hospitalization as well as readmissions and complications within 30 days. RESULTS A total of 123 patients who underwent 130 continent urinary tract reconstructions were identified during the study period. Demographic and perioperative data are provided in the Table. Anthropometric and biochemical measurements as well as the early initiation of TPN (≤2 days) were not associated with any primary outcomes. In a subgroup analysis of patients with a bowel anastomosis, the early initiation of TPN was an independent predictor for duration of hospitalization (P < 0.0001) and 30-day complications (odds ratio 9.51, P = 0.005) after adjusting for other statistically significant and clinically relevant variables. DISCUSSION The few available studies on surgical nutrition have primarily focused on infants and young children undergoing cardiac surgery and provided no consensus on a preoperative nutritional assessment. The findings on TPN from the present study favorably compare with a growing body of evidence in adult and pediatric critically ill and surgical patients. The limitations of the present study include its retrospective design at a single institution, potential misclassification of nutritional status, and selection bias from the initiation of TPN at the discretion of the primary surgeon. CONCLUSIONS Malnutrition was identified in greater than 20% of pediatric and adolescent patients undergoing continent urinary tract reconstruction. Anthropometric and biochemical parameters were not associated with surgical outcomes, although the early initiation of TPN did not offer any benefit for nutritional support. In a subset of patients with a bowel anastomosis, TPN was associated with worse surgical outcomes, including a longer duration of hospitalization and development of 30-day complications.
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Total parenteral nutrition versus early enteral nutrition after cystectomy: a meta-analysis of postoperative outcomes. Int Urol Nephrol 2018; 51:1-7. [DOI: 10.1007/s11255-018-2031-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 11/10/2018] [Indexed: 12/21/2022]
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Abstract
PURPOSE OF REVIEW Cachexia is a negative prognostic factor in cancer patients. The pathogenesis is related to a variable combination of reduced food intake and metabolic changes. However, whether nutritional support may contribute to effectively prevent and treat cachexia remains a debated issue. RECENT FINDINGS Consistent evidence demonstrates that anabolic windows of opportunity occur during the clinical trajectory of cancer patients. Also, the use of specific nutrients, namely omega-3 fatty acids, may enhance the efficacy of nutritional support when tumor-driven inflammatory response is high. Of greater interest, it is now becoming clearer that the use of nutritional support at key time points in the clinical journey of cancer patients (i.e., perioperative period) may extend its clinical benefits beyond those on nutritional status. SUMMARY Nutritional support plays a role in managing cancer cachexia, when it is timely delivered, when it provides adequate amounts of calories and proteins, and when it is part of a concurrent palliative care approach. Specific nutrients, that is, omega-3 fatty acids, may help in those cancer patients with high-inflammatory response, and may also contribute to positively influence long-term clinical outcomes.
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Simoes PK, Woo KM, Shike M, Mendelsohn RB, Gerdes H, Markowitz AJ, Ludwig E, Shah PM, Schattner MA. Direct Percutaneous Endoscopic Jejunostomy: Procedural and Nutrition Outcomes in a Large Patient Cohort. JPEN J Parenter Enteral Nutr 2017; 42:898-906. [DOI: 10.1002/jpen.1023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 09/19/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Priya K. Simoes
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York; New York USA
| | - Kaitlin M. Woo
- Division of Epidemiology and Biostatistics; Memorial Sloan Kettering Cancer Center, New York; New York USA
| | - Moshe Shike
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York; New York USA
| | - Robin B. Mendelsohn
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York; New York USA
| | - Hans Gerdes
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York; New York USA
| | - Arnold J. Markowitz
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York; New York USA
| | - Emmy Ludwig
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York; New York USA
| | - Pari M. Shah
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York; New York USA
| | - Mark A. Schattner
- Gastroenterology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York; New York USA
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36:623-650. [DOI: 10.1016/j.clnu.2017.02.013] [Citation(s) in RCA: 944] [Impact Index Per Article: 134.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023]
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