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Pettit MS, Crowder SL, Ackerman RS, Hafez O, Poch MA, Patel SY. Preoperative Nutritional Status and Enhanced Recovery after Surgery (ERAS) Prior to Radical Cystectomy: A Review of the Literature. Nutr Cancer 2023; 75:1743-1751. [PMID: 37553951 DOI: 10.1080/01635581.2023.2244172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
Preoperative nutritional status is an important and modifiable risk factor of a patient's recovery and outcome after radical cystectomy. There are multiple malnutrition screening tools and treatment options. In this review, we discuss the best indicators of this condition and how to optimize nutrition status prior to radical cystectomy.
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Affiliation(s)
- Matthew S Pettit
- University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Sylvia L Crowder
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Robert S Ackerman
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Osama Hafez
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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Holm MO, Mikkelsen S, Zacher N, Østergaard T, Rasmussen HH, Holst M. High risk of disease-related malnutrition in gastroenterology outpatients. Nutrition 2020; 75-76:110747. [PMID: 32247224 DOI: 10.1016/j.nut.2020.110747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/04/2019] [Accepted: 01/11/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Disease-related malnutrition (DRM) in hospitalized patients is known to have significant negative impact on clinical outcomes. Meanwhile, DRM in gastroenterology outpatients is scarcely investigated. The aim of this study was to investigate the prevalence of unintentional weight loss (UWL) and reduced food intake (RFI) as contributors to the risk of DRM in outpatients. Furthermore, the aim was to investigate if UWL may be used as initial screening for DRM, based on the correlation between UWL and RFI. METHODS All outpatients visiting the clinics for Medical and Surgery Gastroenterology, Aalborg University Hospital, Denmark, during 1 wk in September 2018, were invited to participate. Data regarding UWL within the past 3 mo, RFI the past week, and nutritional impact symptoms (NIS) were collected in this questionnaire-based cross-sectional study. Descriptive analysis, χ2 test, and multiple logistic regression analysis were used for statistics. RESULTS Out of 348 eligible patients, 346 were included at the medical clinic (n = 170) and surgery clinic (n = 176). UWL occurred in 26%, with a mean weight loss of 7.1 kg (standard deviation [SD] 5.2), and 24% had RFI. A significantly increased risk of UWL was identified in patients with body mass index <18.5 kg/m2 (odds ratio 6.1; confidence interval 2.0-18.7; P = 0.003). NIS were more common in the medical clinic. The main self-reported reasons for NIS affecting UWL were lack of appetite (15% versus 12%), pain (14% versus 8%), and nausea (12% versus 3%). CONCLUSIONS One in four outpatients experienced UWL to an extent that may have a significant negative impact on clinical outcome. A firm correlation was found between UWL and RFI. Thus, based on this superficial study, UWL may be used as initial screening for protein-energy malnutrition in the medical and surgery gastroenterology outpatient setting. The impact on clinical outcome and of early nutritional intervention in these settings need to be investigated.
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Affiliation(s)
- Mette O Holm
- Center for Nutrition and Bowel Disease, Aalborg University Hospital, Aalborg, Denmark
| | - Sabina Mikkelsen
- Department of Health Science and Technology, Aalborg University, Aalborg Denmark
| | - Nina Zacher
- Department of Health Science and Technology, Aalborg University, Aalborg Denmark
| | - Trine Østergaard
- Department of Health Science and Technology, Aalborg University, Aalborg Denmark
| | - Henrik H Rasmussen
- Center for Nutrition and Bowel Disease, Aalborg University Hospital, Aalborg, Denmark; Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Mette Holst
- Center for Nutrition and Bowel Disease, Aalborg University Hospital, Aalborg, Denmark; Clinical Institute, Aalborg University, Aalborg, Denmark.
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Effect of Qihuang Decoction Combined with Enteral Nutrition on Postoperative Gastric Cancer of Nutrition and Immune Function. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:1795107. [PMID: 32215032 PMCID: PMC7079248 DOI: 10.1155/2020/1795107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/03/2020] [Indexed: 12/29/2022]
Abstract
Objective Early nutritional support in patients with gastric cancer can improve their nutritional status, but the impact on immune function has not been confirmed. This study aimed to analyze the effects of Qihuang decoction combined with enteral nutrition on nutrition and the immune function of postoperative gastric cancer. Methods 120 patients with postoperative gastric cancer in the study group and 117 in the control group were selected as the study subjects from our hospital at random. Indications of nutrition and immune and the rates of complications were compared the day before surgery and 1, 3, 7, and 14 days after surgery. Results Indications of nutrition except hemoglobin (HB) in the study group were significantly higher than those before operation and the albumin (ALB) and prealbumin (TP) were significantly increased 7 and 14 days after surgery (P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 and P < 0.001 versus P < 0.001 and P < 0.001) and the protein (PA) 3, 7, and 14 days after surgery (P=0.011, P=0.002, and P=0.022) in the study group compared to those in the control group. Cellular and humoral immunity indications in the study group are significantly higher than those before operation compared to those in the control group, and the CD3+, CD4+, and CD4+/CD8+ were significantly increased 7 and 14 days after surgery (P=0.027 and P < 0.001 versus P=0.008 and P < 0.001 versus P=0.010 and P < 0.001) and IgA, IgG, and IgM 3, 7, and 14 days after surgery in the study group (P < 0.001, P < 0.001, and P < 0.001 versus P < 0.001, P < 0.002, and P < 0.001 versus P < 0.001, P < 0.001, and P < 0.001). The complications such as abdominal, lung, wound, and urinary infection were also significantly decreased (Pχ2=0.017; P < 0.001 and P < 0.001 versus P < 0.001 and P < 0.001) and the protein (PA) 3, 7, and 14 days after surgery (P=0.011, P=0.002, and P=0.022) in the study group compared to those in the control group. Cellular and humoral immunity indications in the study group are significantly higher than those before operation compared to those in the control group, and the CD3+, CD4+, and CD4+/CD8+ were significantly increased 7 and 14 days after surgery (P=0.027 and P < 0.001 versus P=0.008 and P < 0.001 versus P=0.010 and P < 0.001) and IgA, IgG, and IgM 3, 7, and 14 days after surgery in the study group (P < 0.001, P < 0.001, and P < 0.001 versus P < 0.001, P < 0.002, and P < 0.001 versus P < 0.001, P < 0.001, and P < 0.001). The complications such as abdominal, lung, wound, and urinary infection were also significantly decreased (Pχ2=0.017; P < 0.001 and P < 0.001 versus P < 0.001 and P < 0.001) and the protein (PA) 3, 7, and 14 days after surgery (P=0.011, P=0.002, and P=0.022) in the study group compared to those in the control group. Cellular and humoral immunity indications in the study group are significantly higher than those before operation compared to those in the control group, and the CD3+, CD4+, and CD4+/CD8+ were significantly increased 7 and 14 days after surgery (P=0.027 and P < 0.001 versus P=0.008 and P < 0.001 versus P=0.010 and P < 0.001) and IgA, IgG, and IgM 3, 7, and 14 days after surgery in the study group (P < 0.001, P < 0.001, and P < 0.001 versus P < 0.001, P < 0.002, and P < 0.001 versus P < 0.001, P < 0.001, and P < 0.001). The complications such as abdominal, lung, wound, and urinary infection were also significantly decreased (Pχ2=0.017; P < 0.001 and P < 0.001 versus P < 0.001 and P < 0.001) and the protein (PA) 3, 7, and 14 days after surgery (P=0.011, P=0.002, and P=0.022) in the study group compared to those in the control group. Cellular and humoral immunity indications in the study group are significantly higher than those before operation compared to those in the control group, and the CD3+, CD4+, and CD4+/CD8+ were significantly increased 7 and 14 days after surgery (P=0.027 and P < 0.001 versus P=0.008 and P < 0.001 versus P=0.010 and P < 0.001) and IgA, IgG, and IgM 3, 7, and 14 days after surgery in the study group (P < 0.001, P < 0.001, and P < 0.001 versus P < 0.001, P < 0.002, and P < 0.001 versus P < 0.001, P < 0.001, and P < 0.001). The complications such as abdominal, lung, wound, and urinary infection were also significantly decreased (Pχ2=0.017; Pχ2=0.036; Pχ2=0.041; Pχ2=0.004). Conclusions Qihuang decoction combined with enteral nutrition can promote the absorption of enteral nutrition with improving the immune and reducing complications of infection.
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Herbert G, Perry R, Andersen HK, Atkinson C, Penfold C, Lewis SJ, Ness AR, Thomas S. Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications. Cochrane Database Syst Rev 2019; 7:CD004080. [PMID: 31329285 PMCID: PMC6645186 DOI: 10.1002/14651858.cd004080.pub4] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation. OBJECTIVES To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA). MAIN RESULTS We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I2 = 81, %, Chi2 = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I2 = 0%, Chi2 = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I2 = 0%, Chi2 = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence). AUTHORS' CONCLUSIONS This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.
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Affiliation(s)
- Georgia Herbert
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Rachel Perry
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Henning Keinke Andersen
- Bispebjerg Hospital, Building 39NThe Cochrane Colorectal Cancer Group23 Bispebjerg BakkeCopenhagenDenmarkDK 2400 CPH NV
| | - Charlotte Atkinson
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Christopher Penfold
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Stephen J Lewis
- Derriford HospitalDepartment of GastroenterologyDerriford RoadPlymouthDevonUKPL6 8DH
| | - Andrew R Ness
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Steven Thomas
- University Hospitals Bristol NHS TrustHead & Neck SurgeryMarlborough StreetBristolUKBS1 3NU
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Wuensch T, Quint J, Mueller V, Mueller A, Wizenty J, Kaffarnik M, Kern B, Stockmann M, Biebl M, Pratschke J, Aigner F. Identification of serological markers for pre- and postoperative fasting periods. Clin Nutr ESPEN 2019; 30:131-137. [PMID: 30904213 DOI: 10.1016/j.clnesp.2019.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/07/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS Prolonged preoperative fasting periods lead to catabolic states and decelerate recovery after surgery. Valid plasma markers reflecting the patients' metabolic state may improve tailored nutrition support before surgery. Within this study, we sought to advance the knowledge on fasting time-sensitive plasma markers that allow the metabolic characterisation of surgical patients for an optimised preoperative metabolic preparation. METHODS Patients scheduled for elective surgery of the upper (n = 23) or lower (n = 27) gastrointestinal tract participated in a prospective observational study. Patients' charateristics and nutritional status were recorded and blood samples were drawn on the day of admission. Further blood samples were collected before skin incision of the surgical procedure, on postoperative day 3 and on the day of discharge. Values of clinical chemistry, electrolytes, hemograms and plasma amino acids were determined and correlated with fasting times. RESULTS Preoperative fasting times were positively correlated with plasma levels of valine, leucine, serine, α-amino butyric acid, free fatty acids, 3-hydroxy butyric acid and significantly negative correlated with chloride and glutamic acid. Postoperative fasting times were correlated with erythrocytes, leukocytes and plasma levels of albumin, CRP, HDL, asparagine and 3-methylhistidine. The multivariate regression analysis revealed glutamic acid and valine as significant independent predictors of preoperative fasting periods. The regression model showed best performance (sensitivity of 90.91% and specificity of 92.31%) to detect patients fasted for ≥20 h. CONCLUSION Valine and glutamic acid appear as independent metabolic markers for accurate prediction of prolonged fasting periods, independent of the overall nutritional status, age or BMI of patients.
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Affiliation(s)
- Tilo Wuensch
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Janina Quint
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Verena Mueller
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Anne Mueller
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jonas Wizenty
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Magnus Kaffarnik
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Barbara Kern
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Martin Stockmann
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthias Biebl
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Aigner
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Iresjö BM, Engström C, Smedh U, Lundholm K. Overnight Steady-State Infusions of Parenteral Nutrition on Myosin Heavy Chain Transcripts in Rectus Abdominis Muscle Related to Amino Acid Transporters, Insulin-like Growth Factor 1, and Blood Amino Acids in Patients Aimed at Major Surgery. JPEN J Parenter Enteral Nutr 2018; 43:497-507. [PMID: 30350380 DOI: 10.1002/jpen.1458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 09/12/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Evaluation of improvements by nutrition support to severely ill patients requires sensitive methods to demonstrate activation of protein synthesis in various tissues from groups with a limited number of patients to be statistically efficient. This study examines effects of standard parenteral nutrition (PN) on abdominal muscle transcripts of amino acid (AA) transporters, myosin heavy chains (MHCs), and the insulin-like growth factor 1 and its receptor (IGF-1/IGF-1R) in patients aimed at major surgery. METHODS Twenty-two randomized patients received steady-state PN (0.16 gN/kg/d, 30 kcal/kg/d) or saline infusions for 12 hours before operation. Blood samples and muscle biopsies were obtained at operation start. Muscle messenger RNA (mRNA) levels of AA transporters (solute carrier family members SNAT2, LAT1, LAT3, LAT4, TAUT, PAT1, CD98), IGF-1, IGF-1R, MHC isoforms (MHC1, MHC2A, MHC2X), and LAT3 protein were quantified and related to concentrations of AA, IGF-1, insulin, and metabolic substrates in blood. RESULTS Muscle mRNA LAT3, LAT4, IGF-1R, and MHC2A increased by PN infusion, with correlations to specific AA transporters and MHC isoforms (P < .01-.05). TAUT and LAT3 correlated to slow (MHC1) and fast (MHC2A, MHC2X) isoforms (P < .001-.02). Muscle IGF-1 mRNA correlated to plasma essential AAs, whereas IGF-1R mRNA was related to LAT3, MHC2A, and serum IGF-1 (P < .001-.03). CONCLUSIONS The results confirm that short-term preoperative PN activates transcription of AA transporters and myosin isoforms. Thus, combinations of methods on gene transcription and translation of muscle proteins can be applied to define efficient combinations of nutrition and hormones to catabolic patients in preoperative and postoperative settings.
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Affiliation(s)
- Britt-Marie Iresjö
- Surgical Metabolic Research Lab, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Cecilia Engström
- Surgical Metabolic Research Lab, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ulrika Smedh
- Surgical Metabolic Research Lab, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Kent Lundholm
- Surgical Metabolic Research Lab, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
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7
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Herbert G, Perry R, Andersen HK, Atkinson C, Penfold C, Lewis SJ, Ness AR, Thomas S. Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications. Cochrane Database Syst Rev 2018; 10:CD004080. [PMID: 30353940 PMCID: PMC6517065 DOI: 10.1002/14651858.cd004080.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation. OBJECTIVES To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA). MAIN RESULTS We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I2 = 81, %, Chi2 = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I2 = 0%, Chi2 = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I2 = 0%, Chi2 = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence). AUTHORS' CONCLUSIONS This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.
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Affiliation(s)
- Georgia Herbert
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Rachel Perry
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Henning Keinke Andersen
- Bispebjerg Hospital, Building 39NThe Cochrane Colorectal Cancer Group23 Bispebjerg BakkeCopenhagenDenmarkDK 2400 CPH NV
| | - Charlotte Atkinson
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Christopher Penfold
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Stephen J Lewis
- Derriford HospitalDepartment of GastroenterologyDerriford RoadPlymouthUKPL6 8DH
| | - Andrew R Ness
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Steven Thomas
- University Hospitals Bristol NHS TrustHead & Neck SurgeryMarlborough StreetBristolUKBS1 3NU
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Lipid-rich enteral nutrition controls intestinal inflammation, improves intestinal motility and mucosal barrier damage in a rat model of intestinal ischemia/reperfusion injury. J Surg Res 2017; 213:75-83. [DOI: 10.1016/j.jss.2017.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/22/2017] [Accepted: 02/14/2017] [Indexed: 01/09/2023]
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9
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Mukherjee K, Kavalukas SL, Barbul A. Nutritional Aspects of Gastrointestinal Wound Healing. Adv Wound Care (New Rochelle) 2016; 5:507-515. [PMID: 27867755 DOI: 10.1089/wound.2015.0671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/23/2015] [Indexed: 02/07/2023] Open
Abstract
Significance: Although the wound healing cascade is similar in many tissues, in the gastrointestinal tract mucosal healing is critical for processes such as inflammatory bowel disease and ulcers and healing of the mucosa, submucosa, and serosal layers is needed for surgical anastomoses and for enterocutaneous fistula. Failure of wound healing can result in complications including infection, prolonged hospitalization, critical illness, organ failure, readmission, new or worsening enterocutaneous fistula, and even death. Recent Advances: Recent advances are relevant for the role of specific micronutrients, such as vitamin D, trace elements, and the interplay between molecules with pro- and antioxidant properties. Our understanding of the role of other small molecules, genes, proteins, and macronutrients is also rapidly changing. Recent work has elucidated relationships between oxidative stress, nutritional supplementation, and glucose metabolism. Thresholds have also been established to define adequate preoperative nutritional status. Critical Issues: Further work is needed to establish standards and definitions for measuring the extent of wound healing, particularly for inflammatory bowel disease and ulcers. In addition, a mounting body of evidence has determined the need for adequate preoperative nutritional supplementation for elective surgical procedures. Future Directions: A large portion of current work is restricted to model systems in rodents. Therefore, additional clinical and translational research is needed in this area to promote gastrointestinal wound healing in humans, particularly those suffering from critical illness, patients with enterocutaneous fistula, inflammatory bowel disease, and ulcers, and those undergoing surgical procedures.
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Affiliation(s)
- Kaushik Mukherjee
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra L. Kavalukas
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adrian Barbul
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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10
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High-fat enteral nutrition controls intestinal inflammation and improves intestinal motility after peritoneal air exposure. J Surg Res 2016; 201:408-15. [DOI: 10.1016/j.jss.2015.11.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 11/16/2015] [Accepted: 11/24/2015] [Indexed: 12/15/2022]
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