Perioperative nutrition in elective gastrointestinal surgery--potential for improvement?

Effects of enteral immunonutrition in laparoscopic versus open resections in colorectal cancer surgery: A meta-analysis of randomised controlled trials

INTRODUCTION

Immunonutrition (IMN) modulates the activity of the immune system. However, the effects of IMN on cancer patients following colorectal surgery is still lacking. We performed a systematic review and meta-analysis to evaluate the outcomes of IMN in patients undergoing laparoscopic versus open colorectal surgery.

METHODS

A systematic search of multiple electronic data sources was conducted in accordance with PRISMA guidelines and included MEDLINE via PubMed, EMBASE, Scopus, and Web of Science. All eligible studies reporting comparative outcomes of immunonutrition in colorectal surgery were included. Subgroup analysis of outcomes of interest was performed and data were analysed using Review Manager (RevMan) Version 5.4.1.

RESULTS

Nine randomised controlled trials (RCTs) were identified. The final pooled analysis included 1199 patients (592 IMN group and 592 control group). Of these, 55.3 % (655/1184) had open colorectal surgery (OG) and 44.7 % (529/1184) underwent laparoscopic colorectal surgery (LG). IMN reduced the risk of wound infection significantly in the OG [risk ratio (RR) 0.48, 95 % confidence interval (CI) 0.32 to 0.72; p = 0.0005)] and the open and laparoscopic group (OLG) [RR 0.33, 95 % CI 0.15 to 0.76; p = 0.008]. Moreover, IMN was also associated with a significantly shorter length of hospital stay (MD - 2.37 days, 95 % CI - 3.39 to -1.36; p < 0.0001) in the OG. Other post-operative morbidities (anastomotic leak and ileus) and mortality outcomes in the OG, LG, and OLG were comparable.

CONCLUSIONS

Pre-operative IMN could reduce the wound infection rate and shorten length of hospital stay in patients following elective colorectal surgery. The benefit of these improved clinical outcomes could be further evaluated with a cost-benefit analysis. IMN should be recommended as nutritional adjunct in the Enhanced Recovery after Surgery (ERAS) pathway following colorectal surgery.

Preoperative nutrition therapy in people undergoing gastrointestinal surgery

BACKGROUND

Poor preoperative nutritional status has been consistently linked to an increase in postoperative complications and worse surgical outcomes. We updated a review first published in 2012.

OBJECTIVES

To assess the effects of preoperative nutritional therapy compared to usual care in people undergoing gastrointestinal surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, three other databases and two trial registries on 28 March 2023. We searched reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of people undergoing gastrointestinal surgery and receiving preoperative nutritional therapy, including parenteral nutrition, enteral nutrition or oral nutrition supplements, compared to usual care. We only included nutritional therapy that contained macronutrients (protein, carbohydrate and fat) and micronutrients, and excluded studies that evaluated single nutrients. We included studies regardless of the nutritional status of participants, that is, well-nourished participants, participants at risk of malnutrition, or mixed populations. We excluded studies in people undergoing pancreatic and liver surgery. Our primary outcomes were non-infectious complications, infectious complications and length of hospital stay. Our secondary outcomes were nutritional aspects, quality of life, change in macronutrient intake, biochemical parameters, 30-day perioperative mortality and adverse effects.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. We assessed risk of bias using the RoB 1 tool and applied the GRADE criteria to assess the certainty of evidence.

MAIN RESULTS

We included 16 RCTs reporting 19 comparisons (2164 participants). Seven studies were new for this update. Participants' ages ranged from 21 to 79 years, and 62% were men. Three RCTs used parenteral nutrition, two used enteral nutrition, eight used immune-enhancing nutrition and six used standard oral nutrition supplements. All studies included mixed groups of well-nourished and malnourished participants; they used different methods to identify malnutrition and reported this in different ways. Not all the included studies were conducted within an Enhanced Recovery After Surgery (ERAS) programme, which is now current clinical practice in most hospitals undertaking GI surgery. We were concerned about risk of bias in all the studies and 14 studies were at high risk of bias due to lack of blinding. We are uncertain if parenteral nutrition has any effect on the number of participants who had a non-infectious complication (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.36 to 1.02; 3 RCTs, 260 participants; very low-certainty evidence); infectious complication (RR 0.98, 95% CI 0.53 to 1.80; 3 RCTs, 260 participants; very low-certainty evidence) or length of hospital stay (mean difference (MD) 5.49 days, 95% CI 0.02 to 10.96; 2 RCTs, 135 participants; very low-certainty evidence). None of the enteral nutrition studies reported non-infectious complications as an outcome. The evidence is very uncertain about the effect of enteral nutrition on the number of participants with infectious complications after surgery (RR 0.90, 95% CI 0.59 to 1.38; 2 RCTs, 126 participants; very low-certainty evidence) or length of hospital stay (MD 5.10 days, 95% CI -1.03 to 11.23; 2 RCTs, 126 participants; very low-certainty evidence). Immune-enhancing nutrition compared to controls may result in little to no effect on the number of participants experiencing a non-infectious complication (RR 0.79, 95% CI 0.62 to 1.00; 8 RCTs, 1020 participants; low-certainty evidence), infectious complications (RR 0.74, 95% CI 0.53 to 1.04; 7 RCTs, 925 participants; low-certainty evidence) or length of hospital stay (MD -1.22 days, 95% CI -2.80 to 0.35; 6 RCTs, 688 participants; low-certainty evidence). Standard oral nutrition supplements may result in little to no effect on number of participants with a non-infectious complication (RR 0.90, 95% CI 0.67 to 1.20; 5 RCTs, 473 participants; low-certainty evidence) or the length of hospital stay (MD -0.65 days, 95% CI -2.33 to 1.03; 3 RCTs, 299 participants; low-certainty evidence). The evidence is very uncertain about the effect of oral nutrition supplements on the number of participants with an infectious complication (RR 0.88, 95% CI 0.60 to 1.27; 5 RCTs, 473 participants; very low-certainty evidence). Sensitivity analysis based on malnourished and weight-losing participants found oral nutrition supplements may result in a slight reduction in infections (RR 0.58, 95% CI 0.40 to 0.85; 2 RCTs, 184 participants). Studies reported some secondary outcomes, but not consistently. Complications associated with central venous catheters occurred in RCTs involving parenteral nutrition. Adverse events in the enteral nutrition, immune-enhancing nutrition and standard oral nutrition supplements RCTs included nausea, vomiting, diarrhoea and abdominal pain.

AUTHORS' CONCLUSIONS

We were unable to determine if parenteral nutrition, enteral nutrition, immune-enhancing nutrition or standard oral nutrition supplements have any effect on the clinical outcomes due to very low-certainty evidence. There is some evidence that standard oral nutrition supplements may have no effect on complications. Sensitivity analysis showed standard oral nutrition supplements probably reduced infections in weight-losing or malnourished participants. Further high-quality multicentre research considering the ERAS programme is required and further research in low- and middle-income countries is needed.

Effect of Fish Oil Parenteral Emulsion Supplementation on Inflammatory Parameters after Esophagectomy

(Background) Esophagectomy (EPG) presents high morbidity and mortality. Omega-3 fatty acids (ω-3FA) are a pharmaconutrient with benefits for postoperative morbidity. Studies of ω-3FA administered parenterally after esophagectomy are scarce. This study proposes to investigate the effect of combining fish oil lipid emulsions (LE) administered parenterally with enteral nutrition support. (Methods) Randomization was 1:1:1 in three groups: Group A received a LE mixture of 0.4 g/kg/day of fish oil and 0.4 g/kg/day of LCT/MCT 50:50, Group B received 0.8 g/kg/day of fish oil LE, and Group C received 0.8 g/kg/day of LCT/MCT 50:50. Variables were measured at recruitment time and day +1, +3, and +5. Inflammatory variables studied were Interlukin-6, C-reactive protein (CRP), tumoral necrosis factor-α (TNF-α), IL-10, IL-8 and CD25s. Safety, nutritional parameters and complications were analyzed. (Results) Administration of ω-3LE in the immediate postoperative period did not modulate the earlier inflammatory response. Statistically significant differences were found in IL-6 and CRP overall temporal evolution but were not found when studying the type of LE administered or in patients needing critical care. Administration of ω-3 resulted in safe and improved hypertriglyceridemia, depending on the dose. (Conclusions) ω-3FA has no impact on the early inflammatory postoperative response assessed for a short period but was safe. More studies for longer periods are needed.

Perioperative nutrition for gastrointestinal surgery: On the cutting edge

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.

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

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.

Clinical, randomized, double blind clinical trial to study the effect of parenteral supplementation with fish oil emulsion in the nutritional support in esophagectomized patients

INTRODUCTION

Esophagectomy is a major surgery with a high degree of catabolic and post-surgical inflammatory response accompanied by high morbidity and significant mortality. Post-surgical nutritional support via enteral administration of ω-3 fatty acids has been seen to be effective although its bad tolerance. There are few clinical trials with parenteral ω-3 fatty acids in these patients. We propose to investigate the effect of combining a parenteral fish oil lipid emulsion with the standard enteral nutrition (EN) support.

MATERIALS AND METHODS

Prospective, single-center, randomized, double-blind study in esophagectomized patients, and treated after surgery with parenteral lipid emulsions of ω-3 fatty acids or a mixture of ω-6 long-chain triglycerides/short-chain triglycerides 50%. These emulsions will be added to the standard nutritional support in continuous infusion until 5 days of treatment have been completed. Patients will be randomized 1:1:1 in Group A receiving 0.4 g/kg/d of fish-oil lipid emulsion and 0.4 g/kg/d of a lipid emulsion mixture of ω-6 long-chain fatty acids (LCT) plus medium-chain fatty acids (MCT) (total dose of 0.8 g/kg/d of lipid emulsion); Group B receiving 0.8 g/kg/d of fish oil lipid emulsion and Group C receiving 0.8 g/kg/d of LCT/MCT emulsion.The main objective is to determine whether 5 days administration of intravenous ω-3 fatty acid lipid emulsion is effective in normalizing interleukin-6 levels compared with LCT/MCT emulsions, and whether a 0.8 g/kg/d dose is more effective than 0.4 g/kg/d. Secondary outcomes include other inflammatory markers such as C-reactive protein, tumor necrosis factor alpha and interleukin-10, and parameters of morbidity, safety, nutrition and mortality.Samples will be collected at the time when surgery is indicated and on days 0, 1, 3, 5 and 21 to determine inflammatory, nutritional, hepatic and safety parameters. In addition, clinical follow-up will be continued throughout the hospital admision and up to 1 year after surgery.

DISCUSSION

Studies of ω-3 fatty acids administered parenterally in esophagectomized patients are scarce. This study proposes to investigate the effect of combining fish-oil lipid emulsions administered parenterally with EN support. Potential benefits include fast incorporation of lipids to the cellular membranes and to the inflammatory cascade, and the use of only 1 pharmaconutrient.

TRIAL REGISTRATION

FAR-NP-2017-01 EudraCT number: 2016-004978-17.https://reec.aemps.es/reec/public/detail.html searching the EudraCT number.

VERSION IDENTIFIER

Version 2, 08/06/2017.

Relationship between nutritional status and immediate complications in patients undergoing colorectal surgery

Introduction several complications may occur during colorectal surgical procedures and factors, such as nutritional status, substantially contribute to this problem.

Objective evaluate the relationship between nutritional status (determined by different tools) and the emergence of early postoperative complications, as well as analyze social parameters, lifestyle, food intake, and time to diet reintroduction.

Methods case series study conducted in the surgical proctologic ward of the Hospital Barão de Lucena, Recife, Pernambuco, with individuals of both sexes diagnosed with colorectal cancer who underwent a surgical procedure involving at least one anastomosis. Social, demographic and clinical data, life style, dietary intake, nutritional status, and the immediate postsurgical complications were evaluated.

Results among the 31 patients studied, there was a higher prevalence of females (74.2%), mean age of 61.9 ± 12.4 years old, and the rectum was the primary site of cancer in 54.8%. Most patients came from the countryside, were retirees, had lower education, consumed too much red meat, processed meats, and fats, with low consumption of fruits and vegetables, and were sedentary. Regarding nutritional status, nutritional risk was found in 58.1%, mean BMI of 25.7 ± 6.8 kg/m2, and 54.8% had significant weight loss. Additionally, 38.7% had some of the immediate complications, particularly paralytic ileus and abdominal distension. There was a delay in the onset of renourishment, and there was no association between nutritional status and immediate complications.

Conclusion colorectal cancer is closely related to eating habits and lifestyle. Patients with this malignancy have a marked weight loss; however, in this study, we found no association between nutritional status and the incidence of postoperative complications.

Risk Factors for Postoperative Anastomosis Leak After Esophagectomy for Esophageal Cancer

BACKGROUND/AIM

The present study aimed to identify risk factors for anastomosis leak (AL) after esophagectomy for esophageal cancer.

PATIENTS AND METHODS

One-hundred twenty-two patients who underwent esophagectomy for esophageal cancer between 2008 and 2018 were included. The rate of AL was measured based on the definition of leak as adapted from the Surgical Infection Study Group. To identify the risk factors for AL, logistic regression analysis was used.

RESULTS

AL was found in 44 of the 122 patients (36.1%). Among the factors examined, the lymph node dissection status (p=0.007) and preoperative serum albumin level (p=0.022) were significant independent risk factors for AL. The incidence of AL was 26.7% (20 of 75) among patients who received 2-field lymph node dissection and 51.1% (24 of 47) among those who received 3-field lymph node dissection. The incidence of AL was 29.9% (23 of 77) in the preoperative serum albumin levels ≥4.0 g/dl group and 46.7% (21 of 45) in the serum albumin levels <4.0 g/dl group.

CONCLUSION

Lymph node dissection status and preoperative serum albumin levels were risk factors for AL in patients who received esophagectomy for esophageal cancer.

Immunonutrition in Patients with Pancreatic Cancer Undergoing Surgical Intervention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Immunonutrition is administered to improve the outcome of patients with pancreatic cancer undergoing surgery. However, its effect and mechanism of action remain unclear. Therefore, we conducted this systematic review and meta-analysis to assess its effects on postoperative outcome and the immune system. Randomized controlled trials (RCTs) were identified and data extracted by two reviewers independently from electronic databases from their inception to 31 October 2019. The result was expressed as the risk ratio (RR) for categorical variables and mean difference (MD) for continuous variables with 95% confidence intervals (CIs). Six RCTs published from 1999 and 2016, with a total of 368 patients, were included. The results revealed that immunonutrition significantly decreased the rate of infectious complications (RR = 0.47, 95% CI (0.23, 0.94), p = 0.03) and the length of hospital stay (MD = -1.90, 95% CI (-3.78, -0.02), p = 0.05) by modulating the immune system, especially in preoperative group in subgroup analysis. We therefore recommend that patients with pancreatic cancer undergoing surgery could take the advantage of immunonutrition, especially in the preoperative period.

Malnutrition-Related Factors Increased the Risk of Anastomotic Leak for Rectal Cancer Patients Undergoing Surgery

Objective

To study the possible risk factors and related prediction indexes of anastomotic leakage (AL) in patients with rectal cancer during the perioperative period and to provide effective indexes for predicting whether AL will occur in postoperative patients with rectal cancer and whether early nutritional support is needed.

Background

AL after rectal cancer surgery is a common and serious complication. Many of the risk factors for AL have been confirmed. Nevertheless, the evidence of the effect of perioperative malnutrition on AL is still insufficient. This article will make a further study on this point.

Methods

We collected perioperative clinical data from 382 patients with rectal cancer who underwent surgery from September 2015 to May 2017. After 1 month of follow-up, relevant risk factor data were collected and analyzed.

Results

Data analysis showed that the incidence of AL was 14.65%. In single factor analysis, patients with high score of NRS-2002, high score of PG-SGA, diabetes, perioperative blood transfusion, postoperative diarrhea, later tumor stage, high score of ASA, low postoperative albumin, and rectal cancer patients with tumor close to the anus may led to AL. Multivariate analysis revealed that low postoperative albumin (p = 0.044), tumor close to the anus (p = 0.004), diabetes (p = 0.003), perioperative blood transfusion (p < 0.001), diarrhea (p = 0.005), later tumor stage, and high score of PG-SGA (p < 0.001) were the independent risk factors for postoperative AL.

Conclusions

AL in rectal cancer operation is a common postoperative complication. Patients with diabetes or high PG-SGA score or low perioperative albumin will have increased risk factors of AL, which should be paid enough attention in the perioperative period and nutritional support should be provided as soon as possible. Patients who have incomplete intestinal obstruction but can make effective intestinal preparation or who receive neoadjuvant chemotherapy have no increased risk of AL.

Effect of Preoperative Administration of Oral Arginine and Glutamine in Patients with Enterocutaneous Fistula Submitted to Definitive Surgery: a Prospective Randomized Trial

BACKGROUND

The use of glutamine and arginine has shown several advantages in postoperative outcomes in patients after gastrointestinal surgery. We determined the effects of its use in patients with enterocutaneous fistula after operative treatment.

PATIENTS AND METHODS

Forty patients with enterocutaneous fistula were randomly assigned to one of two groups. The control group received the standard medical care while the patients of the experimental group were supplemented with enteral administration of 4.5 g of arginine and 10 g of glutamine per day for 7 days prior to the surgery. The primary outcome variable was the recurrence of the fistula and the secondary outcomes were preoperative and postoperative serum concentrations of interleukin 6 and C-reactive protein and postoperative infectious complications.

RESULTS

Twenty patients were assigned to each group. The fistula recurred in two patients (10%) of the experimental group and in nine patients (45%) of the control group (P < 0.001). We found a total of 13 infectious complications in six patients of the control group (all with fistula recurrence) and none in the experimental group. Mean preoperative serum concentrations of interleukin 6 and C-reactive protein were lower in patients from the experimental group. In addition, these levels were lower in patients who had recurrence if compared to patients that did not recur.

CONCLUSION

Preoperative administration of oral arginine and glutamine could be valuable in the postoperative recovery of patients with enterocutaneous fistulas submitted to definitive surgery.

Assessment of Nutrition and Supplementation in Patients With Hip Fractures

Introduction:

Malnutrition is common in older people, is known to interact with frailty, and is a risk factor for wound complications and poor functional outcomes postoperatively. Sustaining a hip fracture is a significant life event, often resulting in a decline in mobility and functional ability. A poor nutritional state may further impede recovery and rehabilitation, so strategies to improve perioperative nutrition are of considerable importance. We provide a review of nutritional supplement practices in this vulnerable and growing population.

Method:

Systematic review of preoperative oral nutritional supplementation (ONS) in hip fracture patients.

Results:

We identified 12 articles pertaining to this important area of perioperative care. The findings suggest postoperative ONS can improve postoperative outcomes in hip fracture patients, especially in terms of increasing total serum protein, improving nutritional status to near-optimum levels, and decreasing postoperative complications.

Discussion:

There is an absence of evidence specific to preoperative ONS in patients admitted following hip fracture. Literature relating to other populations is encouraging but is yet to be robustly studied. It is unclear whether these results are generalizable to the frailer hip fracture population. There is a need for studies clearly defining outcome measurement and complication assessment pertaining to preoperative ONS. The potential benefit is considerable, and this review will provide a means to inform the construction of meaningful trials in preoperative ONS of patients sustaining hip fracture.

Conclusion:

Oral nutritional supplementation in hip fracture patients may decrease postoperative complications while increasing elderly patient’s nutritional state to a near-optimum level. This is extrapolated from postoperative literature, however with a clear gap in research pertaining specifically to preoperative care. The need for well-constructed studies focused on the impact and assessment of early ONS in this population is transparent.

Novel nomogram with microvascular density in the surgical margins can accurately predict the risk for anastomotic leakage after anterior resection for rectal cancer

BACKGROUND

Anastomotic leakage (AL) is a serious complication after anterior resection. The purpose of this study was to determine the role of microvascular density (MVD) in AL and to develop a nomogram to accurately predict AL.

METHODS

This study retrospectively enrolled 477 consecutive patients who underwent anterior resection for rectal cancer from January 2011 to January 2019. Tissue samples of the resection margins were assessed for MVD. Univariate and multivariate regression analyses were used to identify the risk factors for AL.

RESULTS

The incidence of clinical AL was 6.7%. MVD in the distal margin was associated with AL (P < .001). Univariate and multivariate regression analysis identified the following variables as independent risk factors for AL: preoperative albumin ≤35 g/L (odds ratio [OR] = 2.511), neoadjuvant treatment (OR = 3.560), location of tumor ≤7 cm (OR = 3.381), blood loss ≥100 mL (OR = 2.717), and MVD in the distal margin ≤20 (OR = 4.265). Then, a nomogram including these predictors was developed. The nomogram showed good discrimination (AUC = 0.816) and calibration (concordance index = 0.816). The decision curve analysis demonstrated that the nomogram was clinically useful.

CONCLUSIONS

MVD in the distal margin is closely associated with AL. The nomogram can be used for individualized prediction of AL after anterior resection for patients with rectal cancer.

Effect of early and delay starting of enteral feeding in post-pancreaticoduodenectomy patients

Backgrounds/Aims

This study was undertaken to see the effect of early starting of enteral feeding after pancreatoduodenectomy (PD). The results were compared with existing nutritional practice in which enteral feeding started, usually after 7 to 8 postoperative day (PODs) in our institute.

Methods

Thirty patients whome underwent a PD from January 2016 to December 2016 were included in the study. They were divided into two groups, I and II. In group I (n=15), enteral feeding was started from the 2^nd POD through the nasojejunal feeding tube along with parenteral partial nutrition support. In group II (n=15), no enteral feeding was given up to seventh and eighth PODs, except the perenteral feeding. Post-operatively, serum albumin levels, total lymphocyte count, total bilirubin levels, serum alkaline phosphate levels were measured for two weeks postoperatively in all the patients for assessing nutritional, immunological and cholestasis status. The mortality, morbidity and lengths of post-operative hospital stay were also recorded.

Results

Postoperatively, the serum albumin level and lymphocyte count decreased from the pre-operative level on the third POD and it gradually increased from the seventh POD onwards in both groups. However, they remained persistently higher in group I than group II. The total bilirubin and alkaline phosphatase decreased to normal levels within the seventh POD in Group I. However, they remained higher than normal levels on POD 14 in Group II. The morbidity and hospital stay was significantly lower in group I than group II.

Conclusions

Early enteral feeding should be considered after PD. This is because it will improve nutritional, immunological status and cholestasis. Therefore, it reduces morbidity and shortens the hospital stay.

Vitamin C deficiency in an Australian cohort of metropolitan surgical patients

Vitamin C is an essential micronutrient in the human diet. While large population studies measuring vitamin C have been performed in other countries, there are few studies of deficiency in the Australian population. This study aimed to quantify vitamin C deficiency, identify scorbutic symptoms and examine dietary associations in a cohort of preoperative general surgical patients. Vitamin C levels were determined in a cohort of patients referred to a single surgeon between January 2011 and December 2013. Baseline data were collected along with data on fruit consumption, weekly citrus fruit intake and presence of scorbutic symptoms. A total of 309 patients were included in the study and 21.4% of our cohort showed a vitamin C level ≤11.4 μmol/L (deficient). Mean citrus fruit intake was significantly higher in the normal vitamin C groups (>28.4 μmol/L) and patients with vitamin C levels ≤28.4 were more likely to consume no fruit (p=0.0004) which was also significant on multivariate analysis. Neither age nor gender appeared predictive of suboptimal vitamin C levels. No symptoms were significantly related to vitamin C levels on multivariate analysis. Vitamin C deficiency was common in Australian adults attending a surgical practice within south western Sydney. Review of the Australian recommended daily allowance for vitamin C is suggested, not only in clinically well patients but particularly in ICU and hospital inpatients. Larger studies examining the prevalence and impact of vitamin C deficiency in the Australian population are required to further investigate these findings.

The Impact of Postoperative Enteral Immunonutrition on Postoperative Complications and Survival in Gastric Cancer Patients - Randomized Clinical Trial

BACKGROUND

Immunomodulating enteral nutrition in the perioperative period may reduce postoperative complications in cancer patients. Little is known if this effect translates to the better survival. The aim of study was to assess the impact of postoperative immunomodulating enteral nutrition on postoperative complications and survival of gastric cancer patients.

METHODS

A group of 98 gastric cancer patients was randomly assigned for postoperative immunomodulating enteral nutrition n = 44 (Reconvan, Fresenius Kabi, Bad Homburg, Germany), or standard enteral nutrition n = 54 (Peptisorb, Nutricia, Schipol, The Netherlands). Postoperative complications, mortality, 6-mo and 1-yr survival were analyzed.

RESULTS

The overall postoperative morbidity did not differ between the groups. The rate of pulmonary complications (excluding pneumonia) was significantly lower in immunomodulation group (0% vs 9.3%, p = 0.044), as well as 60-day mortality (0% vs. 11.1%, p = 0.037). There was no difference in 6-mo and 1-yr survival between the groups.

CONCLUSIONS

Postoperative immunomodulating enteral nutrition may reduce respiratory complications and postoperative mortality in comparison to standard enteral nutrition. Despite this effect, it did not improve 6-mo and 1-yr survival in immunomodulation group. Probably the beneficial effect of immunomodulating enteral nutrition is too weak to be significant in such a number of patients.

Enteral immunonutrition versus enteral nutrition for gastric cancer patients undergoing a total gastrectomy: a systematic review and meta-analysis

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.

Immune-Enhancing Formulas for Patients With Cancer Undergoing Esophagectomy: Systematic Review Protocol

BACKGROUND

Adult patients with an esophageal cancer can potentially be compromised with postoperative leaks or fistulae if patients' nutritional status is in a vulnerable stage. Currently in Australia, there is a growing need for clinicians to know whether use of immune-enhancing formulas (IEFs) containing Arg, omega-3, and RNA are a cost-effective approach compared with isonitrogenous-isocaloric formulas to reduce postoperative infectious complications in esophagectomy patients. Since IEFs may carry higher costs, this has led to inconsistencies in practice among clinicians and hospitals.

OBJECTIVE

Our aim is to compile and present the most up-to-date nutrition evidence available regarding the provision of IEFs containing Arg, omega-3, and RNA to help clinicians develop an evidence-based nutrition care plan; identify available evidence of whether an esophagectomy patient should receive IEF; determine the cost-effectiveness and safety of such nutrition; and determine appropriate administration quantity and timing (pre-, peri-, or postesophagectomy).

METHODS

This review will include RCTs involving the use of IEFs enriched with Arg, omega-3 polyunsaturated fatty acids, and RNA in the pre-, peri-, or postoperative period (for at least 5-7 days) given orally or via enteral feeding tube, in adult cancer patients undergoing esophageal resection. Lower gastrointestinal, gastric, or head cancer surgery with parenteral nutrition or non-IEF or use of isolated immunonutrient (Arg vs omega-3 vs RNA) will be excluded. Primary outcome comprises postoperative infectious complications. Secondary outcomes (pre/postoperatively) consist of cost-effectiveness, length of stay, survival/mortality, quality of life, nutritional status, percentage of weight loss, and biochemical changes. The risk of bias will be independently assessed by the reviewers, using a domain-based evaluation tool. Blinding will be assessed for subjective and objective outcome measures. Publication bias will be visually assessed by funnel plots. A meta-analysis will be generated by the Review Manager 5.3 software and represented in forest plots.

RESULTS

The first results are expected in 2018. Outlining the protocol will ensure transparency for the completed review.

CONCLUSIONS

This protocol for a systematic review and meta-analysis will enable a comprehensive appraisal of the literature to help determine whether overall institutional savings are associated with this approach. Findings will form a knowledge base relevant to stakeholders across the health system and researchers who are involved in decision making on evidence-based nutrition care plan pathways for patients undergoing esophagectomy, as well as the use of IEF, timing, and administration quantity.

TRIAL REGISTRATION

PROSPERO Registration Number: CRD42017056908; http://www.crd.york.ac.uk/PROSPERO/ display_record.asp? ID=CRD42017056908 (Archived by WebCite at http://www.webcitation.org/6rLyeqaD6).

[A randomized controlled trial of preoperative oral immunonutrition in patients undergoing surgery for colorectal cancer: hospital stay and health care costs]

BACKGROUND

The use of enteral formulas with immunonutrients in patients with gastrointestinal malignancies susceptible to surgery can reduce postoperative morbidity, at the expense of reduced infectious complications, with the consequent reduction in hospital stay and health care costs.

MATERIAL AND METHODS

Prospective randomized study. 84 patients operated on a scheduled basis for resectable colorectal cancer were recruited. In the group YES IN Impact © Oral was administered for 8 days (3 sachets a day), compared with the NOT IN group who did not receive it.

RESULTS

40.5% (17) patients without immunonutrition suffered infectious complications vs. 33.3% (14) of YES IN. In patients with rectal cancer NOT IN, 50% (8) suffered minor infectious complications (p=.028). In each group (YES IN, NOT IN, colon and rectal cancer) when infectious complications were observed, the variables total hospital stay and costs doubled, with significant differences. These variables showed higher values in the group NOT IN compared with those who received immunonutrition, although these differences were not statistically significant.

CONCLUSIONS

NOT IN patients suffered infectious complications more frequently than YES IN, with significant results in the subgroup of patients with rectal cancer. The total hospital stay and costs were slightly higher in the group not supplemented, doubling in each category significantly (YES IN, NOT IN, colon and rectal cancer), when infectious complications were observed.

Preoperative inflammation increases the risk of infection after elective colorectal surgery: results from a prospective cohort

BACKGROUND

Septic complications after colorectal surgery are frequent and sometimes life threatening. It is well known that inflammation impairs the healing process. It has been suggested that preoperative ongoing inflammation could increase the risk of postoperative infections. This study aimed to elucidate the role of preoperative inflammation on postoperative infectious complications and to understand if, through biological markers, it is possible to identify preoperatively patients at higher risk of infection.

METHODS

A prospective, observational study was conducted in three centers from November 2011 to April 2014. Consecutive patients undergoing elective colorectal surgery with anastomosis were included. Any ongoing infection was an exclusion criterion. C-reactive protein, albumin, prealbumin, and procalcitonin plasma levels were measured preoperatively. Postoperative infections were recorded according to the definitions of the Centers for Diseases Control. The areas under the receiver operating characteristic curve were analyzed and compared to assess the accuracy of each preoperative marker.

RESULTS

Four-hundred and seventy two patients were analyzed. Infectious complications occurred in 118 patients (25 %) and mortality in 6 patients (1.3 %). In the univariate analysis, preoperative C-reactive protein and albuminemia were found significantly associated with postoperative infectious complications (P = 0.008 and P = 0.0002, respectively). Areas under the ROC curve for preoperative C-reactive protein and albuminemia were 0.57and 0.62, respectively.

CONCLUSIONS

This study confirms the association between preoperative inflammatory activity, hypoalbuminemia, and the onset of infections after surgery. Trials aiming to decrease the inflammatory activity before surgery in order to prevent postoperative complications are warranted.

Risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer: results from a prospective, multicentric study of 1102 patients

BACKGROUND

Studies focused on postoperative outcome after oncologic right colectomy are lacking. The main objective was to determine pre-/intraoperative risk factors for anastomotic leak after elective right colon resection for cancer. Secondary objectives were to determine risk factors for postoperative morbidity and mortality.

METHODS

Fifty-two hospitals participated in this prospective, observational study (September 2011-September 2012), including 1102 patients that underwent elective right colectomy. Forty-two pre-/intraoperative variables, related to patient, tumor, surgical procedure, and hospital, were analyzed as potential independent risk factors for anastomotic leak and postoperative morbidity and mortality.

RESULTS

Anastomotic leak was diagnosed in 93 patients (8.4 %), and 72 (6.5 %) of them needed radiological or surgical intervention. Morbidity, mortality, and wound infection rates were 29.0, 2.6, and 13.4 %, respectively. Preoperative serum protein concentration was the only independent risk factor for anastomotic leak (p < 0.0001, OR 0.6 per g/dL). When considering only clinically relevant anastomotic leaks, stapled technique (p = 0.03, OR 2.1) and preoperative serum protein concentration (p = 0.004, OR 0.6 g/dL) were identified as the only two independent risk factors. Age and preoperative serum albumin concentration resulted to be risk factors for postoperative mortality. Male gender, pulmonary or hepatic disease, and open surgical approach were identified as risk factors for postoperative morbidity, while male gender, obesity, intraoperative complication, and end-to-end anastomosis were risk factors for wound infection.

CONCLUSIONS

Preoperative nutritional status and the stapled anastomotic technique were the only independent risk factors for clinically relevant anastomotic leak after elective right colectomy for cancer. Age and preoperative nutritional status determined the mortality risk, while laparoscopic approach reduced postoperative morbidity.

FASTING IN ELECTIVE SURGICAL PATIENTS: COMPARISON AMONG THE TIME PRESCRIBED, PERFORMED AND RECOMMENDED ON PERIOPERATIVE CARE PROTOCOLS

BACKGROUND

Prolonged preoperative fasting may impair nutritional status of the patient and their recovery. In contrast, some studies show that fasting abbreviation can improve the response to trauma and decrease the length of hospital stay.

AIM

Investigate whether the prescribed perioperative fasting time and practiced by patients is in compliance with current multimodal protocols and identify the main factors associated.

METHODS

Cross-sectional study with 65 patients undergoing elective surgery of the digestive tract or abdominal wall. We investigated the fasting time in the perioperative period, hunger and thirst reports, physical status, diabetes diagnosis, type of surgery and anesthesia.

RESULTS

The patients were between 19 and 87 years, mostly female (73.8%). The most performed procedure was cholecystectomy (47.69%) and general anesthesia the most used (89.23%). The most common approach was to start fasting from midnight for liquids and solids, and most of the patients received grade II (64.6%) to the physical state. The real fasting average time was 16 h (9.5-41.58) was higher than prescribed (11 h, 6.58 -26.75). The patients submitted to surgery in the afternoon were in more fasting time than those who did in the morning (p<0.001). The intensity of hunger and thirst increased in postoperative fasting period (p=0.010 and 0.027). The average period of postoperative fasting was 18.25 h (3.33-91.83) and only 23.07% restarted feeding on the same day.

CONCLUSION

Patients were fasted for prolonged time, higher even than the prescribed time and intensity of the signs of discomfort such as hunger and thirst increased over time. To better recovery and the patient's well-being, it is necessary to establish a preoperative fasting abbreviation protocol.

Peri-Surgical Nutrition: Perspectives and Perceptions

Peri-surgical nutrition of veterinary patients is in its infancy, with considerable research to be performed to help improve quality of life in our small animal patients. Clues from human immunonutrition may be starting places for investigation. Considerations for future investigations should include essential nutrients, the underlying disease process, therapeutic goals, and species (dog or cat). There are guidelines for caloric requirements. Planning for nutritional support before surgery takes place is likely to be beneficial to patient outcomes. Taking into account case history, method of feeding, metabolic abnormalities, and possible immunonutrition should be part of a complete surgical nutritional plan.

An exploration of food and the lived experience of individuals after treatment for colorectal cancer using a phenomenological approach

BACKGROUND

There is a paucity of qualitative literature investigating people's experiences of food and nutrition after treatment for cancer. The present study aimed to explore people's relationships with food and nutrition throughout their colorectal cancer journey.

METHODS

In-depth semi-structured interviews were conducted with 25 participants who had undergone surgery for colorectal cancer. The study design was informed by principles of phenomenology. Data were collected then transcribed and analysed using an inductive coding process and a thematic analysis to allow the themes to highlight people's lived experiences.

RESULTS

Data enabled five primary themes to be drawn including: 'appetite swings', 'emotions on a changing physicality', 'the medicalisation of food', 'taking control of symptom management' and a cross-cutting theme 'drivers and vehicles for action'. Feelings and emotions described by participants around their relationship with food and nutritional status often guided decisions on what was eaten more than objective nutritional measure or dietary advice. Participants used weight changes, appetite and food as barometers to measure their overall recovery. Food was an area over which people exhibited control of their lives and they could quantify, in measurable units, their overall well-being and rehabilitation. They did this either by using the currency of body weight in pounds or the size of portions eaten.

CONCLUSIONS

Appetite, weight and symptoms influenced dietary intake substantially and were poignant issues affecting people's lives. The relationship people have with food determines their eating habits and an understanding of the essences and nuances of their experiences is essential to enable the delivery of patient-centred care.

Clinical feasibility and nutritional effects of early oral feeding after pancreaticoduodenectomy

Backgrounds/Aims

Pancreaticoduodenctomy (PD) is associated with high rates of postoperative morbidity and mortality. Although many studies have shown that early postoperative enteral nutrition improves postoperative outcomes, limited clinical information is available on postoperative early oral feeding (EOF) after PD. The aim of this study was to evaluate the clinical feasibility, safety, and nutritional effects of EOF after PD.

Methods

Clinical outcomes were investigated in 131 patients who underwent PD between 2003 and 2013, including 81 whose oral feeding was commenced within 48 hours (EOF group) and 50 whose oral feeding was commenced after resumption of bowel movements (traditional oral feeding [TOF] group). Postoperative complications, energy intake, and length of stay (LOS) were reviewed.

Results

Demographic factors were similar in the two groups. The EOF group had a significantly shorter LOS (25.9±8.5 days vs. 32.3±16.3 days; p=0.01) than the TOF group. The rates of anastomotic leak (1.2% vs. 16%, p=0.00) and reoperation (3.7% vs. 20%, p=0.01) were significantly lower in the EOF group. In the clinically acute phase from postoperative day 1 to day 5, the mean daily calorie intake (847.0 kcal vs. 745.6 kcal; p=0.04) and mean daily protein intake (42.2 g vs. 31.9 g; p=0.00) in the EOF group were significantly higher than that in the TOF group.

Conclusions

Postoperative EOF is a clinically safe, feasible, and effective method of nutritional support after PD.

Effects of ω-3 fish oil lipid emulsion combined with parenteral nutrition on patients undergoing liver transplantation

BACKGROUND

The effect of parenteral nutrition (PN) support supplemented with ω-3 fatty acids was investigated in a randomized, controlled clinical trial at the Affiliated Drum Tower Hospital, Medical School of Nanjing University.

MATERIALS AND METHODS

Ninety-eight patients with the diagnosis of end-stage liver disease or hepatic cellular carcinoma were admitted for orthotopic liver transplantation at the Affiliated Drum Tower Hospital. The patients were randomly divided into 3 groups: diet group (n = 32), PN group (n = 33), and polyunsaturated fatty acid (PUFA) group (n = 33). Patients in the PN and PUFA groups received isocaloric and isonitrogenous PN for 7 days after surgery. Venous heparin blood samples were obtained for assay on days 2 and 9 after surgery. A pathological test was performed after reperfusion of the donor liver and on day 9.

RESULTS

Alanine aminotransferase levels were improved significantly by PUFA treatment compared with traditional PN support (P < .05). Compared with the results on day 9 in the PN group, a significant difference was seen in the extent of increase of the prognostic nutrition index and prealbumin in the PUFA group. The pathological results also showed that ω-3 fatty acid supplementation reduced hepatic cell injury. PUFA therapy also decreased the incidence of infectious morbidities and shortened the posttransplant hospital stay significantly.

CONCLUSION

Posttransplant PN support can greatly improve metabolism of protein and nutrition states of patients. ω-3 fatty acid-supplemented PN significantly reduces injury of the transplanted liver, decreases the incidence of infectious morbidities, and shortens posttransplant hospital stay.

Pre-operative nutrition support in patients undergoing gastrointestinal surgery

BACKGROUND

Post-operative management in gastrointestinal (GI) surgery is becoming well established with 'Enhanced Recovery After Surgery' protocols starting 24 hours prior to surgery with carbohydrate loading and early oral or enteral feeding given to patients the first day following surgery. However, whether or not nutritional intervention should be initiated earlier in the preoperative period remains unclear. Poor pre-operative nutritional status has been linked consistently to an increase in post-operative complications and poorer surgical outcome.

OBJECTIVES

To review the literature on preoperative nutritional support in patients undergoing gastrointestinal surgery (GI).

SEARCH METHODS

The searches were initially run in March 2011 and subsequently updated in February 2012. Databases including all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA and NHSEED) MEDLINE, EMBASE, AMED, British Nursing Index Archive using OvidSP were included and a search was run on each database separately after which duplicates were excluded.

SELECTION CRITERIA

The inclusion criteria were randomised controlled trials that evaluated pre-operative nutritional support in GI surgical participants using a nutritional formula delivered by a parenteral, enteral or oral route. The primary outcomes included post-operative complications and length of hospital stay.

DATA COLLECTION AND ANALYSIS

Two observers screened the abstracts for inclusion in the review and performed data extraction. Bias was assessed for each of the included studies using the bias assessment tables in the Cochrane Software Review Manager (version 5.1, Cochrane Collaboration). The trials were analysed using risk ratios with Mantel-Haenszel in fixed effects methods displayed with heterogeneity. Meta-analyses were undertaken on trials evaluating immune enhancing (IE) nutrition, standard oral supplements, enteral and parenteral nutrition (PN) which were administered pre-operatively.Study characteristics were summarised in tables. Dichotomous and ratio data were entered into meta-analyses for the primary outcomes. These were then summarised in tables with assumed and corresponding risk with relative effect giving 95% confidence intervals.

MAIN RESULTS

The searches identified 9900 titles and, after excluding duplicates, 6433 titles were initially screened. After the initial title screen, 6266 were excluded. Abstracts were screened for 167 studies and 33 articles were identified as meeting the inclusion criteria, of which 13 were included in the review after an assessment of the complete manuscripts.Seven trials evaluating IE nutrition were included in the review, of which 6 were combined in a meta-analysis. These studies showed a low to moderate level of heterogeneity and significantly reduced total post-operative complications (risk ratio (RR) 0.67 CI 0.53 to 0.84). Three trials evaluating PN were included in a meta-analysis and a significant reduction in post-operative complications was demonstrated (RR 0.64 95% CI 0.46 to 0.87) with low heterogeneity, in predominantly malnourished participants. Two trials evaluating enteral nutrition (RR 0.79, 95% CI 0.56 to 1.10) and 3 trials evaluating standard oral supplements (RR 1.01 95% CI 0.56 to 1.10) were included, neither of which showed any difference in the primary outcomes.

AUTHORS' CONCLUSIONS

There have been significant benefits demonstrated with pre-operative administration of IE nutrition in some high quality trials. However, bias was identified which may limit the generalizability of these results to all GI surgical candidates and the data needs to be placed in context with other recent innovations in surgical management (eg-ERAS). Some unwanted effects have also been reported with components of IE nutrition in critical care patients and it is unknown whether there would be detrimental effects by administering IE nutrition to patients who could require critical care support after their surgery. The studies evaluating PN demonstrated that the provision of PN to predominantly malnourished surgical candidates reduced post-operative complications; however, these data may not be applicable to current clinical practice, not least because they have involved a high degree of 'hyperalimentation'. Trials evaluating enteral or oral nutrition were inconclusive and further studies are required to select GI surgical patients for these nutritional interventions.

Compliance with and effects of preoperative immunonutrition in patients undergoing pancreaticoduodenectomy

BACKGROUND/PURPOSE

This study was conducted to ascertain the feasibility and effectiveness of preoperative enteral immunonutrition using an immune-enhanced formula (Impact) in patients undergoing pancreaticoduodenectomy.

METHODS

Twenty-five patients undergoing an elective pancreaticoduodenectomy were asked to ingest Impact for 5 days (750 mL/day) prior to surgery in addition to their normal diets. We retrospectively compared the early postoperative outcomes of the Impact group (n = 18), which consisted of patients who fully complied with the study protocol, and a control group (n = 13), which consisted of patients who had not ingested Impact prior to surgery.

RESULTS

Overall, 82.6% of the patients complied with the preoperative oral ingestion of Impact; all but four patients tolerated a daily intake of 750 mL. While the clinical backgrounds of the Impact and control groups were not significantly different, the frequency of incisional wound infection was lower (0 vs. 30.8%, p = 0.012) and the change in systemic severity as evaluated using the acute physiology and chronic health evaluation (APACHE)-II scoring system was milder (p = 0.033) in the Impact group than in the control group.

CONCLUSION

The preoperative oral ingestion of Impact was well tolerated and appeared to be effective for preventing incisional wound infection and reducing the response to surgical stress in patients undergoing a pancreaticoduodenectomy.

The future developments in nutrition

Malnutrition is both a cause and consequence of disease. It is imperative that evidence-based approaches to detect and treat malnutrition are embedded into routine practice; these can range from routine malnutrition screening, the safe and appropriate use of enteral feeding and managing more complex patients with intestinal failure. This article outlines service developments over the next 5 years that may enable all hospitals to achieve optimal standards of care for a malnourished patient and examines the role of developments in clinical nutrition over the next 5-10 years.

Correlation between the pretherapeutic neutrophil to lymphocyte ratio and the pathologic response to neoadjuvant chemotherapy in patients with advanced esophageal cancer

BACKGROUND

An elevation in the neutrophil-to-lymphocyte ratio (NLR) has been shown to be associated with a poorer prognosis in patients with various tumors. The aim of this retrospective study was to clarify the correlation of the pretherapeutic NLR with the prognostic value of the pathologic response to neoadjuvant chemotherapy (NAC) in patients with advanced esophageal cancer.

METHODS

This study was a retrospective review of 83 patients undergoing NAC for advanced esophageal cancer following esophagectomy. The NLR was measured before NAC, and the pathologic responses to NAC were evaluated.

RESULTS

A comparison was performed for those whose pathology responded (responders) (G3/G2/G1b) and nonresponders (G1a/G0). In a univariate analysis, the cStage (P = 0.005), cN (P = 0.0001), and NLR (P = 0.005) were statistically significant parameters. A multivariate analysis revealed that the factors independently associated with pathologic responses were the pretreatment NLR (<2.2/≥2.2) (P = 0.043) and lymph nodes metastasis (P = 0.002). The pretreatment NLR (<2.2/≥2.2) was found to be a statistically significant useful predictive marker for a pathologic response (P = 0.001). The pathologic response rates were 56% in the patients with an NLR <2.2 and 21% in patients with an NLR of ≥2.2.

CONCLUSIONS

Our study is the first to demonstrate that the pretherapeutic NLR can be used as a predictor for chemosensitivity of thoracic esophageal cancer. Preoperative evaluation based on the clinical N stage and NLR may be easily used in routine clinical practice.

[Evaluation of changes made in the peri-operative care in patients submitted to elective abdominal surgery]

OBJECTIVE

To evaluate the results of the introduction of new measures to accelerate the postoperative recovery of patients undergoing elective abdominal surgery.

METHODS

We observed 162 patients and interviewed them on two distinct periods: the first between October to December 2009 (n = 81) comprised patients who underwent conventional perioperative monitoring (pre-intervention) and the second between March and May 2010 (n = 81), formed by a new group of patients, submitted to the new protocol of perioperative monitoring. Data collection in the two periods occurred without the knowledge of the professionals in the service. The variables were: indication for preoperative nutritional support, duration of fasting, post-operative volume of hydration, use of catheters and drains, length of stay and postoperative morbidity.

RESULTS

when comparing the two periods we observed a decrease of 2.5 hours in the time of preoperative fasting (p = 0.0002) in the post-intervention group. As for the reintroduction of oral diet, there was no difference between the two periods (p = 0.0007). When considering the patients without postoperative complications, there was a significantly decreased length of stay (p = 0.001325). There was a reduction of approximately 50% in antibiotic use in the post-intervention group (p = 0.00001).

CONCLUSION

The adoption of multidisciplinary perioperative measures is feasible within our reality, and although there was no statistically significant changes in the present study, it may improve morbidity and reduce length of stay in general surgery.

Peri-operative nutritional management

The metabolic response to surgical trauma is mainly characterised by an increase in BMR, a negative N balance, increased gluconeogenesis and increased synthesis of acute-phase proteins. These reactions aim at ensuring the availability of endogenous substrates for healing wounds while the synthesis of acute-phase proteins enhances the scavenging process and helps repair. However, if this process is excessive or continues for too long, it leads to a progressive depletion of body compartment with a consequent adverse outcome. Obviously, the severity of such depletion is magnified if the patient is starving or is already malnourished and the consumption of lean body mass is not compensated by an exogenous supply of nutrients. The nutritional control of this metabolic reaction represents the traditional rationale for nutritional support of surgical patients. Subsequent data have shown that the negative effects of starvation are not simply due to the starvation per se but due to the starving gut, and peri-operative enteral nutrition has proven successful in blunting the metabolic response after injury and improving protein kinetics, net balance and amino acid flux across peripheral tissue and consequently in decreasing the complications. Finally, further clinical research has shown that many post-operative infections may result from immune suppression and that such state might be reversed to some degree by modulation of the immune response through specialised nutritional support in surgical patients, regardless of their nutritional status. This paper will focus on the updated evidence-based research on peri-operative nutrition (parenteral, enteral and immune-enhancing) in patients undergoing major surgery.

Perioperative nutrition in abdominal surgery: recommendations and reality

Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown. Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice. Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious) complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.

Immunonutrition in gastrointestinal surgery

BACKGROUND

Patients undergoing major gastrointestinal surgery are at increased risk of developing complications. The use of immunonutrition (IN) in such patients is not widespread because the available data are heterogeneous, and some show contradictory results with regard to complications, mortality and length of hospital stay.

METHODS

Randomized controlled trials (RCTs) published between January 1985 and September 2009 that assessed the clinical impact of perioperative enteral IN in major gastrointestinal elective surgery were included in a meta-analysis.

RESULTS

Twenty-one RCTs enrolling a total of 2730 patients were included in the meta-analysis. Twelve were considered as high-quality studies. The included studies showed significant heterogeneity with respect to patients, control groups, timing and duration of IN, which limited group analysis. IN significantly reduced overall complications when used before surgery (odds ratio (OR) 0·48, 95 per cent confidence interval (c.i.) 0·34 to 0·69), both before and after operation (OR 0·39, 0·28 to 0·54) or after surgery (OR 0·46, 0·25 to 0·84). For these three timings of IN administration, ORs of postoperative infection were 0·36 (0·24 to 0·56), 0·41 (0·28 to 0·58) and 0·53 (0·40 to 0·71) respectively. Use of IN led to a shorter hospital stay: mean difference -2·12 (95 per cent c.i. -2·97 to -1·26) days. Beneficial effects of IN were confirmed when low-quality trials were excluded. Perioperative IN had no influence on mortality (OR 0·90, 0·46 to 1·76).

CONCLUSION

Perioperative enteral IN decreases morbidity and hospital stay but not mortality after major gastrointestinal surgery; its routine use can be recommended.

Perioperative oral nutritional supplements in normally or mildly undernourished geriatric patients submitted to surgery for hip fracture: a randomized clinical trial

BACKGROUND

Oral nutritional supplements have been recommended after orthopedic surgery in geriatric patients. This has been shown to be effective even in normally nourished or mildly undernourished geriatric patients. Whether perioperative administration of these products is also effective and suitable is not known.

METHODS

Randomized, controlled, open, paralleled two-arms clinical trial, comparing energy-protein supplements (40 g of protein and 400 kcal per day), with no intervention in normally nourished or mildly undernourished patients. Outcomes were serum proteins, body mass index, postoperative complications among others.

RESULTS

60 Elderly patients were included. Patients in the intervention group (n = 30) ingested 52.2 ± 12.1% of the prescribed supplements per day for 5.8 ± 1.8 days before surgery and until hospital discharge. There was a significant change in serum albumin at follow-up (F = 22.536, P < 0.001), and between the two groups (F = 5.763, P = 0.002), favouring the intervention. The same was observed for serum prealbumin (F = 6.654, P = 0.001 within subjects, F = 2.865, P = 0.045 for interaction). Logistic regression showed that only supplemented proteins per day (OR[95%CI] = 0.925[0.869-0.985]) were associated with less postoperative complications (R(2) = 0.323, χ(2) = 11.541, P = 0.003).

CONCLUSION

Perioperative supplements in geriatric patients with hip fracture submitted to surgery showed better recovery of plasma proteins. Higher daily protein intakes were associated with less postoperative complications.