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Sowerbutts AM, Burden S, Sremanakova J, French C, Knight SR, Harrison EM. Preoperative nutrition therapy in people undergoing gastrointestinal surgery. Cochrane Database Syst Rev 2024; 4:CD008879. [PMID: 38588454 PMCID: PMC11001290 DOI: 10.1002/14651858.cd008879.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
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.
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Affiliation(s)
- Anne Marie Sowerbutts
- School of Health Sciences, The University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Sorrel Burden
- School of Health Sciences, The University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Jana Sremanakova
- School of Health Sciences, The University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Chloe French
- School of Health Sciences, The University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Stephen R Knight
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
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Molenaar CJL, Minnella EM, Coca-Martinez M, ten Cate DWG, Regis M, Awasthi R, Martínez-Palli G, López-Baamonde M, Sebio-Garcia R, Feo CV, van Rooijen SJ, Schreinemakers JMJ, Bojesen RD, Gögenur I, van den Heuvel ER, Carli F, Slooter GD. Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial. JAMA Surg 2023; 158:572-581. [PMID: 36988937 PMCID: PMC10061316 DOI: 10.1001/jamasurg.2023.0198] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 11/19/2022] [Indexed: 03/30/2023]
Abstract
Importance Colorectal surgery is associated with substantial morbidity rates and a lowered functional capacity. Optimization of the patient's condition in the weeks prior to surgery may attenuate these unfavorable sequelae. Objective To determine whether multimodal prehabilitation before colorectal cancer surgery can reduce postoperative complications and enhance functional recovery. Design, Setting, and Participants The PREHAB randomized clinical trial was an international, multicenter trial conducted in teaching hospitals with implemented enhanced recovery after surgery programs. Adult patients with nonmetastasized colorectal cancer were assessed for eligibility and randomized to either prehabilitation or standard care. Both arms received standard perioperative care. Patients were enrolled from June 2017 to December 2020, and follow-up was completed in December 2021. However, this trial was prematurely stopped due to the COVID-19 pandemic. Interventions The 4-week in-hospital supervised multimodal prehabilitation program consisted of a high-intensity exercise program 3 times per week, a nutritional intervention, psychological support, and a smoking cessation program when needed. Main Outcomes and Measures Comprehensive Complication Index (CCI) score, number of patients with CCI score more than 20, and improved walking capacity expressed as the 6-minute walking distance 4 weeks postoperatively. Results In the intention-to-treat population of 251 participants (median [IQR] age, 69 [60-76] years; 138 [55%] male), 206 (82%) had tumors located in the colon and 234 (93%) underwent laparoscopic- or robotic-assisted surgery. The number of severe complications (CCI score >20) was significantly lower favoring prehabilitation compared with standard care (21 of 123 [17.1%] vs 38 of 128 [29.7%]; odds ratio, 0.47 [95% CI, 0.26-0.87]; P = .02). Participants in prehabilitation encountered fewer medical complications (eg, respiratory) compared with participants receiving standard care (19 of 123 [15.4%] vs 35 of 128 [27.3%]; odds ratio, 0.48 [95% CI, 0.26-0.89]; P = .02). Four weeks after surgery, 6-minute walking distance did not differ significantly between groups when compared with baseline (mean difference prehabilitation vs standard care 15.6 m [95% CI, -1.4 to 32.6]; P = .07). Secondary parameters of functional capacity in the postoperative period generally favored prehabilitation compared with standard care. Conclusions and Relevance This PREHAB trial demonstrates the benefit of a multimodal prehabilitation program before colorectal cancer surgery as reflected by fewer severe and medical complications postoperatively and an optimized postoperative recovery compared with standard care. Trial Registration trialregister.nl Identifier: NTR5947.
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Affiliation(s)
| | - Enrico Maria Minnella
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Miquel Coca-Martinez
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Department of Anesthesia, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Marta Regis
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Rashami Awasthi
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Raquel Sebio-Garcia
- Physical Medicine and Rehabilitation Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carlo Vittorio Feo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- Unit of Provincial General Surgery, Azienda Unità Sanitaria Locale Ferrara, Ferrara, Italy
| | | | | | - Rasmus Dahlin Bojesen
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Edwin R. van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Francesco Carli
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Shang J, Zhao G, Gong J, Su D, Wang Y, Wang L. Nutritional Risk Screening 2002 predicts surgical outcomes in 1532 patients undergoing total joint arthroplasty: A retrospective cohort study. Nutr Clin Pract 2022; 38:636-647. [PMID: 36446553 DOI: 10.1002/ncp.10934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/30/2022] [Accepted: 10/23/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Limited information exists about the predictive effect of Nutritional Risk Screening (NRS) 2002 on orthopedic surgery. The aim of the present study is to explore the role of NRS 2002 in postoperative complications and resource utilization in patients with total joint arthroplasty (TJA). METHODS We retrospectively collected the demographics and surgical results of nearly 2000 TJA patients admitted from 2016 to 2020 and assessed the differences in short- and long-term complications and resource utilization parameters. Multivariate linear, logistic regression, and subgroup analysis were subsequently used to control for potential confounders. Survival analysis was performed to further verify the cumulative incidence of postoperative complications. RESULTS We identified 1532 patients receiving TJA, 8.7% of which were at nutrition risk (NRS 2002 score ≥3 out of 7). Preoperative nutrition risk was associated with an increased risk of systemic complications, incisional complications, surgical site infection (SSI), incisional SSI, periprosthetic joint infection, dislocation, and periprosthetic fracture after TJA (odds ratio [OR], 3.62-31.99; all P < 0.05). Preoperative nutrition risk was further associated with an increased risk of cardiac complications, respiratory complications, urinary complications, and arthroplasty-related reoperation (OR, 3.16-12.29; all P < 0.01). Moreover, preoperative nutrition risk was associated with increased costs and length of stay, and increased risk of unplanned intensive care unit admission, arthroplasty-related readmission, infection-related readmission, and SSI-related readmission. CONCLUSIONS NRS 2002 is associated with an elevated risk of postoperative complications and increased resource utilization, following TJA. Thus, routine screening is recommended to identify nutrition risk statuses of patients undergoing elective TJA.
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Affiliation(s)
- Jingjing Shang
- Department of Pharmacy The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Gongyin Zhao
- Department of Orthopedics The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Jinhong Gong
- Department of Pharmacy The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Dan Su
- Department of Pharmacy The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Yuji Wang
- Department of Orthopedics The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Liangliang Wang
- Department of Orthopedics The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
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Preoperative Nutritional Optimization of the Oncology Patient: A Scoping Review. J Am Coll Surg 2022; 234:384-394. [PMID: 35213503 DOI: 10.1097/xcs.0000000000000055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Malnutrition is common among patients with cancer and is a known risk factor for poor postoperative outcomes; however, preoperative nutritional optimization guidelines are lacking in this high-risk population. The objective of this study was to review the evidence regarding preoperative nutritional optimization of patients undergoing general surgical operations for the treatment of cancer. METHODS A literature search was performed across the Ovid (MEDLINE), Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCOhost), and Web of Science (Clarivate) databases. Eligible studies included randomized clinical trials, observational studies, reviews, and meta-analyses published between 2010 and 2020. Included studies evaluated clinical outcomes after preoperative nutritional interventions among adult patients undergoing surgery for gastrointestinal cancer. Data extraction was performed using a template developed and tested by the study team. RESULTS A total of 5,505 publications were identified, of which 69 studies were included for data synthesis after screening and full text review. These studies evaluated preoperative nutritional counseling, protein-calorie supplementation, immunonutrition supplementation, and probiotic or symbiotic supplementation. CONCLUSIONS Preoperative nutritional counseling and immunonutrition supplementation should be considered for patients undergoing surgical treatment of gastrointestinal malignancy. For malnourished patients, protein-calorie supplementation should be considered, and for patients undergoing colorectal cancer surgery, probiotics or symbiotic supplementation should be considered.
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Perry R, Herbert G, Atkinson C, England C, Northstone K, Baos S, Brush T, Chong A, Ness A, Harris J, Haase A, Shah S, Pufulete M. Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis. BMJ Open 2021; 11:e050806. [PMID: 34593498 PMCID: PMC8487197 DOI: 10.1136/bmjopen-2021-050806] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery. DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020). SETTING Secondary care. PARTICIPANTS Patients (≥18 years) undergoing major elective surgery (curative or palliative). INTERVENTIONS Any intervention administered in the preoperative period with the aim of improving postoperative outcomes. OUTCOMES AND MEASURES Primary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use. REVIEW METHODS Two authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials. RESULTS 178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: -1.81 days, 95% CI -2.31 to -1.31; -2.11 days, 95% CI -3.07 to -1.15; -1.67 days, 95% CI -2.31 to -1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64). CONCLUSIONS Some prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low. PROSPERO REGISTRATION NUMBER CRD42015019191.
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Affiliation(s)
- Rachel Perry
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Georgia Herbert
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Charlotte Atkinson
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Clare England
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
- Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK
| | - Kate Northstone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Baos
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim Brush
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Chong
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Andy Ness
- NIHR Bristol BRC, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
- School of Oral and Dental Science, University of Bristol, Bristol, UK
| | - Jessica Harris
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK
| | - Anne Haase
- Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
| | - Sanjoy Shah
- University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK
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Challine A, Rives-Lange C, Danoussou D, Katsahian S, Ait Boudaoud A, Gaujoux S, Dousset B, Carette C, Lazzati A, Czernichow S. Impact of Oral Immunonutrition on Postoperative Morbidity in Digestive Oncologic Surgery: A Nation-wide Cohort Study. Ann Surg 2021; 273:725-731. [PMID: 30946082 DOI: 10.1097/sla.0000000000003282] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of the present study was to assess the effect of preoperative immunonutrition on a nationwide scale. BACKGROUND According to international guidelines, immunonutrition should be prescribed before major oncologic digestive surgery to decrease postoperative morbidity. Nevertheless, this practice remains controversial. METHODS We used a prospective national health database named "Echantillon généraliste des Bénéficiaires." Patients were selected with ICD10 codes of cancer and digestive surgery procedures from 2012 to 2016. Two groups were identified: with reimbursement of immunonutrition 45 days before surgery (IN-group) or not (no-IN-group). Primary outcome was 90-day severe morbidity. Secondary outcomes were postoperative length of stay (LOS) and overall survival. Logistic regression and survival analysis adjusted with IPW method were performed. RESULTS One thousand seven hundred seventy-one patients were included. The proportion of different cancers was as follows: 72% patients were included in the colorectal group, 14% in the hepato-pancreato-biliary group, and 12% in the upper gastrointestinal group. Patients from the IN-group (n = 606, 34%) were younger (67.1 ± 11.8 vs 69.2 ± 12.2 years, P < 0.001), with increased use of other oral nutritional supplements (49.5% vs 31.8%, P < 0.001) and had more digestive anastomoses (89.4% vs 83.0%, P < 0.001). There was no significant difference between the 2 groups for 90-day severe morbidity [odds ratio (OR): 0.91, 95% confidence interval (95% CI): 0.73-1.14] or in survival (hazard ratio: 0.89, 95% CI: 0.73-1.08). LOS were shorter in the IN-group [-1.26 days, 95% CI: -2.40 to -0.10)]. CONCLUSION The preoperative use of immunonutrition before major oncologic digestive surgery was not associated with any significant difference in morbidity or mortality. However, the LOS was significantly shorter in the IN-group.
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Affiliation(s)
- Alexandre Challine
- Assistance Publique - Hôpitaux de Paris, Hôpital européen Georges-Pompidou, Service de nutrition, Centre Spécialisé Obésité France, France
- Université Paris Descartes, Paris, France
| | - Claire Rives-Lange
- Assistance Publique - Hôpitaux de Paris, Hôpital européen Georges-Pompidou, Service de nutrition, Centre Spécialisé Obésité France, France
- Université Paris Descartes, Paris, France
| | - Divya Danoussou
- INSERM, UMR_S 1138, Université Paris Descartes, Centre de Recherche des Cordeliers, Paris, France
| | - Sandrine Katsahian
- INSERM, UMR_S 1138, Université Paris Descartes, Centre de Recherche des Cordeliers, Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital européen Georges-Pompidou, Unité d'Épidémiologie et de Recherche Clinique, Paris, France
- Université Paris Descartes, Paris, France
| | - Amel Ait Boudaoud
- Assistance Publique - Hôpitaux de Paris, Hôpital européen Georges-Pompidou, Service de nutrition, Centre Spécialisé Obésité France, France
- Université Paris Descartes, Paris, France
| | - Sébastien Gaujoux
- Assistance Publique - Hôpitaux de Paris, Hôpital Cochin, Service de Chirurgie digestive, Paris, France
- Université Paris Descartes, Paris, France
| | - Bertrand Dousset
- Assistance Publique - Hôpitaux de Paris, Hôpital Cochin, Service de Chirurgie digestive, Paris, France
- Université Paris Descartes, Paris, France
| | - Claire Carette
- Assistance Publique - Hôpitaux de Paris, Hôpital européen Georges-Pompidou, Service de nutrition, Centre Spécialisé Obésité France, France
| | - Andrea Lazzati
- INSERM, UMR_S 1138, Université Paris Descartes, Centre de Recherche des Cordeliers, Paris, France
- Centre Hospitalier Intercommunal de Créteil, Service de Chirurgie Digestive, Créteil, France
| | - Sébastien Czernichow
- Assistance Publique - Hôpitaux de Paris, Hôpital européen Georges-Pompidou, Service de nutrition, Centre Spécialisé Obésité France, France
- INSERM, U1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Methods of Therapeutic Evaluation of Chronic Diseases Team (METHODS), Paris, France
- Université Paris Descartes, Paris, France
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[de la evidencia y algoritmo adaptado Immunonutrition in fast-track surgical patients - Evidence review and adapted algorithm]. NUTR HOSP 2021; 38:601-6021. [PMID: 33878885 DOI: 10.20960/nh.03405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Surgical stress predisposes patients to have immune dysfunction and an increased risk of infection. Malnourished surgical patients have higher postoperative morbidity and mortality rates, higher readmission rates, and higher hospital costs. The use of an immunomodulatory formula is associated in the ESPEN guidelines with a reduction in wound healing problems, suture failure, and infectious and global complications. Several authors have suggested that, since most clinical trials evaluating the efficacy of immunonutrition have been carried out in a traditional perioperative setting, it would be interesting to investigate its efficacy in a more controlled setting, such as in the ERAS (Enhanced Recovery after Surgery) protocol. The objective of this work was: a) to define the role that immunonutrition should play in ERAS protocols based on the best scientific evidence available; b) to analyze the difficulties that continue to exist in real-life clinical practice to screen the nutritional risk of patients; c) to make a proposal of algorithms adapted to the characteristics of our environment regarding the screening, assessment, and nutritional treatment of surgical patients in fast-track surgery.
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Keller HH, Laur C, Dhaliwal R, Allard JP, Clermont-Dejean N, Duerksen DR, Elias E, Gramlich L, Lakananurak N, Laporte M. Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals. JPEN J Parenter Enteral Nutr 2020; 45:670-684. [PMID: 33236411 DOI: 10.1002/jpen.2047] [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: 10/22/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 01/04/2023]
Abstract
Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.
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Affiliation(s)
- Heather H Keller
- Schlegel-University of Waterloo Research institute for Aging, Waterloo, Ontario, Canada
| | - Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, and Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
| | - Rupinder Dhaliwal
- Canadian Malnutrition Task Force, Canadian Nutrition Society, Ottawa, Ontario, Canada
| | - Johane P Allard
- Department of Medicine, University of Toronto, Toronto General Hospital, University Health Network Toronto, Toronto, Ontario, Canada
| | - Nayima Clermont-Dejean
- Clinical Nutrition, Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Donald R Duerksen
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Evan Elias
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Narisorn Lakananurak
- Department of Medicine, University of Alberta, Edmonton, Canada.,Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Manon Laporte
- Department of Clinical Nutrition, Réseau de santé Vitalité Health Network, Campbellton Regional Hospital, New Brunswick, Canada
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Zhang X, Chen X, Yang J, Hu Y, Li K. Effects of nutritional support on the clinical outcomes of well-nourished patients with cancer: a meta-analysis. Eur J Clin Nutr 2020; 74:1389-1400. [PMID: 32203230 DOI: 10.1038/s41430-020-0595-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/19/2020] [Accepted: 02/19/2020] [Indexed: 02/05/2023]
Abstract
The effects of nutritional support on well-nourished patients have been investigated, but the results were inconsistent among different articles. We performed the meta-analysis to examine the existing evidence. We systematically retrieved articles from PubMed, Web of Science and the Cochrane Library to identify the evidence of nutritional support for well-nourished patients. Methodological quality assessment was assessed based on the Cochrane Handbook and GRADE. Nine randomized controlled trials (RCTs) and one non-RCT with 1400 participants were included in this meta-analysis. Nutritional support, particularly immunonutrition, was associated with a significant reduction in postoperative infectious complications (OR = 0.74, 95% CI: 0.57-0.96), and a decreasing trends in morbidity and the length of the hospital stay (LOS) were observed. However, the mortality rates were comparable between two groups. The quality of evidence was moderate to high. Nutritional support, particularly immunonutrition supplementation, is likely to reduce infectious complications, morbidity and LOS without influencing mortality and may be a safe and preferred choice for well-nourished patients undergoing surgery for cancer. However, additional RCTs are warranted to determine the effects of nutritional support on well-nourished patients.
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Affiliation(s)
- Xingxia Zhang
- West China School of Nursing, Sichuan University, Chengdu, 610041, China
| | - Xinrong Chen
- West China School of Nursing, Sichuan University, Chengdu, 610041, China
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yanjie Hu
- West China School of Nursing, Sichuan University, Chengdu, 610041, China
| | - Ka Li
- West China School of Nursing, Sichuan University, Chengdu, 610041, China.
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Preoperative immunonutrition in frail patients with colorectal cancer: an intervention to improve postoperative outcomes. Int J Colorectal Dis 2020; 35:19-27. [PMID: 31754818 DOI: 10.1007/s00384-019-03438-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study is to evaluate whether preoperative immunonutrition can shorten length of stay and improve postoperative outcomes in frail patients who are candidates for major oncologic colorectal surgery. METHODS A single center retrospective analysis of a prospectively collected database of frail patients, who underwent surgery with curative intent for colorectal cancer between January 2014 and December 2017, was performed. From March 2016, frail oncological patients undergoing major surgery were recommended to receive preoperative immunonutrition; their postoperative outcomes were compared to those of patients not treated with any preoperative nutritional support. Propensity score matching in a 1:1 ratio was used to balance patient characteristics. RESULTS Overall, 175 patients were included in the study. Of 74 patients receiving immunonutrition, 65 were matched with the group not treated with immunonutrition (n = 101). Baseline characteristics were comparable after matching. Although differences in postoperative length of stay were nonsignificant (p = 0.38), patients who received immunonutrition showed a shorter gastrointestinal (GI) recovery time (3.00 [2.00-4.00] versus 4.00 [2.00-5.00], p = 0.04), a lower rate of situs site infections complications (0.31 [0.10, 0.94], p = 0.04) and less need of antibiotic treatment (0.19 [0.06, 0.64], p = 0.01). CONCLUSION Preoperative immunonutrition was found to reduce both postoperative situs site infections and need of antibiotic treatment during the postoperative course. This study encourages the use of preoperative immune-enhancing nutrition as a part of multimodal prehabilitation programs in the management of frail colorectal cancer patients.
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11
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[Impact of preoperative oral nutrition therapy in patients undergoing surgery for colorectal cancer]. NUTR HOSP 2019; 36:1150-1156. [PMID: 31545068 DOI: 10.20960/nh.02548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Objective: the aim of the study is to evaluate the effect of preoperative and postoperative oral nutritional therapy in the prevention of malnutrition and postsurgical complications in colorectal cancer Patients and methods: patients who underwent oncological colorectal surgery between June 2014 and December 2015 are included. An evaluation of preoperative nutritional status is performed. Patients received IMPACT® (2/day) for 5-10 days previous surgery. In the postoperative period, patients received IMPACT®/24h from 3rd to 7th postoperative day. Patients with low rates of albumin (< 2.5) or postoperative ileus received parenteral nutrition. Data were analyzed with the statistical package SPSS 21.0. Results: two hundred and twenty colorectal cancer patients were included. Twenty-eight patients did not take the preoperative oral supplements. Following the intake of nutritional supplements, an improvement of prealbumin and transferrin was noticed. One hundred and twenty-one patients received oral nutrition and 41 received parenteral nutrition in the postoperative period. There were more postoperative complications among patients without preoperative nutritional supplements (50% vs 28.1%; p = 0.019), and hospital stay was higher 14.64 ± 11.86 vs 9.36 ± 5.5; p < 0.005). There were more complications among patients without postoperative oral nutritional supplements (24% vs 18.2%; p < 0.005), with more wound infection (1.9% vs 0.8%) and leaks (1.9% vs 0.8%). They also had a higher average stay (9.15 4.6 vs 7.57 2.5 days; p = 0.021). Conclusion: in our study, patients that received oral nutritional supplements prior and following colorectal surgery had a lower rate of complications and a shorter hospital stay.
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12
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Hogan S, Solomon M, Rangan A, Ferrie S, Carey S. The Impact of Preoperative Immunonutrition and Standard Polymeric Supplements on Patient Outcomes After Pelvic Exenteration Surgery, Taking Compliance Into Consideration: A Randomized Controlled Trial. JPEN J Parenter Enteral Nutr 2019; 44:806-814. [PMID: 31531997 DOI: 10.1002/jpen.1709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effect of immunonutrition vs standard polymeric nutrition in the preoperative phase on patient outcomes is still unclear, which could be due to contributing factors such as poorly reported compliance and unequal provision of protein, energy, and volume. The aim of this study was to examine the effects of preoperative immunonutrition compared with standard polymeric supplements matched for energy, protein, volume, length of stay, and postoperative complications in pelvic exenteration surgery, taking into consideration compliance. METHODS This was a single-blinded, randomized, controlled trial in patients undergoing pelvic exenteration surgery. Fifty-two participants were randomly assigned to consume 3 immunonutrition supplements/d for 5 days preoperatively, and 56 participants were randomly assigned to consume 3 standard polymeric supplements/d for 5 days preoperatively. Primary and secondary outcome measures were assessed. Compliance with each nutrition regime was recorded during the intervention, and subanalysis was conducted. RESULTS There was no significant difference between immunonutrition and standard polymeric supplements on length of stay (P = 0.988) or postoperative complications (P = 0.179) after pelvic exenteration surgery. Compliance with nutrition supplements was significantly less in malnourished (n = 33) compared with well-nourished participants (n = 74) (P = 0.016). Compliance varied between study groups, although not significant. CONCLUSION Preoperative immunonutrition did not significantly impact length of stay or postoperative complications compared with standard polymeric supplements after pelvic exenteration surgery, despite controlling for protein, energy, and volume. Compliance, protein, and energy may considerably impact the effect of immunonutrition, particularly in malnourished patients.
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Affiliation(s)
- Sophie Hogan
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Michael Solomon
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Anna Rangan
- University of Sydney, Sydney, New South Wales, Australia
| | - Suzie Ferrie
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Sharon Carey
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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13
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Adiamah A, Skořepa P, Weimann A, Lobo DN. The Impact of Preoperative Immune Modulating Nutrition on Outcomes in Patients Undergoing Surgery for Gastrointestinal Cancer: A Systematic Review and Meta-analysis. Ann Surg 2019; 270:247-256. [PMID: 30817349 DOI: 10.1097/sla.0000000000003256] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To define the influence of preoperative immune modulating nutrition (IMN) on postoperative outcomes in patients undergoing surgery for gastrointestinal cancer. BACKGROUND Although studies have shown that perioperative IMN may reduce postoperative infectious complications, many of these have included patients with benign and malignant disease, and the optimal timing of such an intervention is not clear. METHODS The Embase, Medline, and Cochrane databases were searched from 2000 to 2018, for prospective randomized controlled trials evaluating preoperative oral or enteral IMN in patients undergoing surgery for gastrointestinal cancer. The primary endpoint was the development of postoperative infectious complications. Secondary endpoints included postoperative noninfectious complications, length of stay, and up to 30-day mortality. The analysis was performed using RevMan v5.3 software. RESULTS Sixteen studies reporting on 1387 patients (715 IMN group, 672 control group) were included. Six of the included studies reported on a mixed population of patients undergoing all gastrointestinal cancer surgery. Of the remaining, 4 investigated IMN in colorectal cancer surgery, 2 in pancreatic surgery, and another 2 in patients undergoing surgery for gastric cancer. There was 1 study each on liver and esophageal cancer. The formulation of nutrition used in all studies in the treated patients was Impact (Novartis/Nestlé), which contains ω-3 fatty acids, arginine, and nucleotides. Preoperative IMN in patients undergoing surgery for gastrointestinal cancer reduced infectious complications [odds ratio (OR) 0.52, 95% confidence interval (CI) 0.38-0.71, P < 0.0001, I = 16%, n = 1387] and length of hospital stay (weighted mean difference -1.57 days, 95% CI -2.48 to -0.66, P = 0.0007, I = 34%, n = 995) when compared with control (isocaloric isonitrogeneous feed or normal diet). It, however, did not affect noninfectious complications (OR 0.98, 95% CI 0.73-1.33, P = 0.91, I = 0%, n = 1303) or mortality (OR 0.55, 95% CI 0.18-1.68, P = 0.29, I = 0%, n = 955). CONCLUSION Given the significant impact on infectious complications and a tendency to shorten length of stay, preoperative IMN should be encouraged in routine practice in patients undergoing surgery for gastrointestinal cancer.
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Affiliation(s)
- Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Pavel Skořepa
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health, Sciences, University of Defence, Hradec Kralove, Czech Republic
| | - Arved Weimann
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Leipzig, Germany
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- MRC/ARUK Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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14
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Wischmeyer PE, Carli F, Evans DC, Guilbert S, Kozar R, Pryor A, Thiele RH, Everett S, Grocott M, Gan TJ, Shaw AD, Thacker JKM, Miller TE, Hedrick TL, McEvoy MD, Mythen MG, Bergamaschi R, Gupta R, Holubar SD, Senagore AJ, Abola RE, Bennett-Guerrero E, Kent ML, Feldman LS, Fiore JF. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Anesth Analg 2019; 126:1883-1895. [PMID: 29369092 DOI: 10.1213/ane.0000000000002743] [Citation(s) in RCA: 209] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Perioperative malnutrition has proven to be challenging to define, diagnose, and treat. Despite these challenges, it is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Although perioperative caregivers consistently express recognition of the importance of nutrition screening and optimization in the perioperative period, implementation of evidence-based perioperative nutrition guidelines and pathways in the United States has been quite limited and needs to be addressed in surgery-focused recommendations. The second Perioperative Quality Initiative brought together a group of international experts with the objective of providing consensus recommendations on this important topic with the goal of (1) developing guidelines for screening of nutritional status to identify patients at risk for adverse outcomes due to malnutrition; (2) address optimal methods of providing nutritional support and optimizing nutrition status preoperatively; and (3) identifying when and how to optimize nutrition delivery in the postoperative period. Discussion led to strong recommendations for implementation of routine preoperative nutrition screening to identify patients in need of preoperative nutrition optimization. Postoperatively, nutrition delivery should be restarted immediately after surgery. The key role of oral nutrition supplements, enteral nutrition, and parenteral nutrition (implemented in that order) in most perioperative patients was advocated for with protein delivery being more important than total calorie delivery. Finally, the role of often-inadequate nutrition intake in the posthospital setting was discussed, and the role of postdischarge oral nutrition supplements was emphasized.
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Affiliation(s)
- Paul E Wischmeyer
- From the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | | | - David C Evans
- Department of Surgery, Division of Trauma, Critical Care, and Burn, Ohio State University, Columbus, Ohio
| | | | - Rosemary Kozar
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Aurora Pryor
- Department of Surgery, Stony Brook Medicine, Stony Brook, New York
| | - Robert H Thiele
- Departments of Anesthesiology and Biomedical Engineering, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Sotiria Everett
- Nutrition Division, Department of Family, Population, Preventive Medicine, Stony Brook Medicine, Stony Brook, New York
| | - Mike Grocott
- Respiratory and Critical Care Research Area, National Institute of Health Research Biomedical Research Centre, University Hospital Southampton, Southampton, United Kingdom.,Southampton National Health Service Foundation Trust, Integrative Physiology and Critical Illness Group, Southampton, United Kingdom.,Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.,Morpheus Collaboration, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, New York
| | - Andrew D Shaw
- Vanderbilt University School of Medicine, Nashville, Tennessee.,Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Julie K M Thacker
- Department of Surgery, Division of Advanced Oncologic and Gastrointestinal Surgery
| | - Timothy E Miller
- Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Durham, North Carolina
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15
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Russell K, Zhang HG, Gillanders LK, Bartlett ASJR, Fisk HL, Calder PC, Swan PJ, Plank LD. Preoperative immunonutrition in patients undergoing liver resection: A prospective randomized trial. World J Hepatol 2019; 11:305-317. [PMID: 30967908 PMCID: PMC6447421 DOI: 10.4254/wjh.v11.i3.305] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/22/2019] [Accepted: 03/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Preoperative supplementation with immunonutrients, including arginine and n-3 fatty acids, has been shown in a number of systematic reviews to reduce infectious complications in patients who have undergone gastrointestinal surgery. Limited information, however, is available on the benefits of nutritional supplementation enriched with arginine and n-3 fatty acids in patients undergoing liver resection.
AIM To evaluate the effects of preoperative nutritional supplementation enriched with arginine and n-3 fatty acids on inflammatory and immunologic markers and clinical outcome in patients undergoing liver resection.
METHODS Thirty-four patients undergoing liver resection were randomized to either five days of preoperative Impact® [1020 kcal/d, immunonutrition (IMN) group], or standard care [no supplementation, standard care (STD) group]. Nutritional status was measured at study entry by subjective global assessment (SGA). Functional assessments (grip strength, fatigue and performance status) were carried out at study entry, on the day prior to surgery, and on postoperative day (POD) 7 and 30. Inflammatory and immune markers were measured at study entry, on the day prior to surgery, and POD 1, 3, 5, 7, 10 and 30. Postoperative complications were recorded prospectively until POD30.
RESULTS A total of 32 patients (17 IMN and 15 STD) were analysed. All except four patients were SGA class A. The plasma ratio of (eicosapentaenoic acid plus docosahexaenoic acid) to arachidonic acid was higher in IMN patients on the day prior to surgery and POD 1, 3, 5 and 7 (P < 0.05). Plasma interleukin (IL)-6 concentrations were elevated in the IMN group (P = 0.017 for POD7). No treatment effect was detected for functional measures, immune response (white cell count and total lymphocytes) or markers of inflammation (C-reactive protein, tumour necrosis factor-α, IL-8, IL-10). There were 10 patients with infectious complications in the IMN group and 4 in the STD group (P = 0.087). Median hospital stay was 9 (range 4–49) d in the IMN group and 8 (3-34) d in the STD group (P = 0.476).
CONCLUSION In well-nourished patients undergoing elective liver resection, this study failed to show any benefit of preoperative immunonutrition.
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Affiliation(s)
- Kylie Russell
- Nutrition Services, Auckland City Hospital, Auckland 1023, New Zealand
| | - Han-Guang Zhang
- Department of Surgery, University of Auckland, Auckland 1023, New Zealand
| | - Lyn K Gillanders
- Nutrition Services, Auckland City Hospital, Auckland 1023, New Zealand
| | - Adam SJR Bartlett
- Department of Surgery, University of Auckland, Auckland 1023, New Zealand
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland 1023, New Zealand
| | - Helena L Fisk
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton SO171BJ, United Kingdom
| | - Philip C Calder
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton SO171BJ, United Kingdom
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton SO166YD, United Kingdom
| | - Peter J Swan
- Department of Surgery, University of Auckland, Auckland 1023, New Zealand
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland 1023, New Zealand
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16
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Exploring reasons behind patient compliance with nutrition supplements before pelvic exenteration surgery. Support Care Cancer 2018; 27:1853-1860. [DOI: 10.1007/s00520-018-4445-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 08/26/2018] [Indexed: 12/14/2022]
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17
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Probst P, Ohmann S, Klaiber U, Hüttner FJ, Billeter AT, Ulrich A, Büchler MW, Diener MK. Meta-analysis of immunonutrition in major abdominal surgery. Br J Surg 2017; 104:1594-1608. [DOI: 10.1002/bjs.10659] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 06/14/2017] [Accepted: 06/28/2017] [Indexed: 12/13/2022]
Abstract
Abstract
Background
The objective of this study was to evaluate the potential benefits of immunonutrition in major abdominal surgery with special regard to subgroups and influence of bias.
Methods
A systematic literature search from January 1985 to July 2015 was performed in MEDLINE, Embase and CENTRAL. Only RCTs investigating immunonutrition in major abdominal surgery were included. Outcomes evaluated were mortality, overall complications, infectious complications and length of hospital stay. The influence of different domains of bias was evaluated in sensitivity analyses. Evidence was rated according to the GRADE Working Group grading of evidence.
Results
A total of 83 RCTs with 7116 patients were included. Mortality was not altered by immunonutrition. Taking all trials into account, immunonutrition reduced overall complications (odds ratio (OR) 0·79, 95 per cent c.i. 0·66 to 0·94; P = 0·01), infectious complications (OR 0·58, 0·51 to 0·66; P < 0·001) and shortened hospital stay (mean difference –1·79 (95 per cent c.i. –2·39 to –1·19) days; P < 0·001) compared with control groups. However, these effects vanished after excluding trials at high and unclear risk of bias. Publication bias seemed to be present for infectious complications (P = 0·002). Non-industry-funded trials reported no positive effects for overall complications (OR 1·13, 0·88 to 1·46; P = 0·34), whereas those funded by industry reported large effects (OR 0·66, 0·48 to 0·91; P = 0·01).
Conclusion
Immunonutrition after major abdominal surgery did not seem to alter mortality (GRADE: high quality of evidence). Immunonutrition reduced overall complications, infectious complications and shortened hospital stay (GRADE: low to moderate). The existence of bias lowers confidence in the evidence (GRADE approach).
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Affiliation(s)
- P Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - S Ohmann
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - U Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - F J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - A T Billeter
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - A Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
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18
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Koretz RL. JPEN Journal Club 26. Small Trials With Dramatic Findings. JPEN J Parenter Enteral Nutr 2017; 41:517-519. [DOI: 10.1177/0148607116686331] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Ronald L. Koretz
- Olive View–UCLA Medical Center, David Geffen–UCLA School of Medicine, Sylmar and Los Angeles, California, USA
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19
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Martin RCG, Agle S, Schlegel M, Hayat T, Scoggins CR, McMasters KM, Philips P. Efficacy of preoperative immunonutrition in locally advanced pancreatic cancer undergoing irreversible electroporation (IRE). Eur J Surg Oncol 2017; 43:772-779. [PMID: 28162818 DOI: 10.1016/j.ejso.2017.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/22/2016] [Accepted: 01/04/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Improved preoperative immunonutrition has been shown to decrease the length of stay (LOS) and complications among patients undergoing elective gastrointestinal cancer surgeries. The purpose of this study was to determine whether preoperative immunonutrition supplementation decreases postoperative LOS, infectious complications, and morbidity in patients undergoing irreversible electroporation (IRE) surgery for locally advanced pancreatic cancer (LAPC). METHODS At a regional hepatopancreatobiliary referral center within an academic medical center 71 patients receiving IRE treatment of LAPC were included in the study. The participants were divided into those receiving preoperative immunonutrition (n = 44) and those receiving no supplemental preoperative immunonutrition (n = 27). Main outcomes and measures were LOS, postoperative complications, nutritional risk index (NRI), and albumin levels. RESULTS Patients in both groups were similar for preoperative nutrition parameters and operative therapy. Patients in the immunonutrition group experienced a statistically significant decrease in postoperative complications (p = 0.05) and LOS (10.7 vs. 17.4, p = 0.01), and less of a decrease in nutritional risk index (-12.6 vs. -16.2, p = 0.03) and albumin levels (-1.1 vs. -1.5, p < 0.01). CONCLUSION Preoperative immunonutrition was clinically significant in decreasing postoperative complications, LOS, and improving post-surgery NRI and albumin levels in patients receiving elective IRE treatment of non-resectable pancreatic cancer. These results indicate that preoperative immunonutrition is effective and feasible in this subset of cancer patients.
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Affiliation(s)
- R C G Martin
- Division of Surgical Oncology, Department of Surgery and James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA.
| | - S Agle
- Division of Surgical Oncology, Department of Surgery and James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA
| | - M Schlegel
- Division of Surgical Oncology, Department of Surgery and James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA
| | - T Hayat
- Division of Surgical Oncology, Department of Surgery and James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA
| | - C R Scoggins
- Division of Surgical Oncology, Department of Surgery and James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA
| | - K M McMasters
- Division of Surgical Oncology, Department of Surgery and James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA
| | - P Philips
- Division of Surgical Oncology, Department of Surgery and James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA
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Abstract
BACKGROUND Randomized controlled trials demonstrate the efficacy of arginine-enriched nutritional supplements (immunonutrition) in reducing complications after surgery. The effectiveness of preoperative immunonutrition has not been evaluated in a community setting. OBJECTIVE This study aims to determine whether immunonutrition before elective colorectal surgery improves outcomes in the community at large. DESIGN This is a prospective cohort study with a propensity score-matched comparative effectiveness evaluation. SETTINGS This study was conducted in Washington State hospitals in the Surgical Care Outcomes Assessment Program from 2012 to 2015. PATIENTS Adults undergoing elective colorectal surgery were selected. INTERVENTIONS Surgeons used a preoperative checklist that recommended that patients take oral immunonutrition (237 mL, 3 times daily) for 5 days before elective colorectal resection. MAIN OUTCOME MEASURES Serious adverse events (infection, anastomotic leak, reoperation, and death) and prolonged length of stay were the primary outcomes measured. RESULTS Three thousand three hundred seventy-five patients (mean age 59.9 ± 15.2 years, 56% female) underwent elective colorectal surgery. Patients receiving immunonutrition more commonly were in a higher ASA class (III-V, 44% vs 38%; p = 0.01) or required an ostomy (18% vs 14%; p = 0.02). The rate of serious adverse events was 6.8% vs 8.3% (p = 0.25) and the rate of prolonged length of stay was 13.8% vs 17.3% (p = 0.04) in those who did and did not receive immunonutrition. After propensity score matching, covariates were similar among 960 patients. Although differences in serious adverse events were nonsignificant (relative risk, 0.76; 95% CI, 0.49-1.16), prolonged length of stay (relative risk, 0.77; 95% CI, 0.58-1.01 p = 0.05) was lower in those receiving immunonutrition. LIMITATIONS Patient compliance with the intervention was not measured. Residual confounding, including surgeon-level heterogeneity, may influence estimates of the effect of immunonutrition. CONCLUSIONS Reductions in prolonged length of stay, likely related to fewer complications, support the use of immunonutrition in quality improvement initiatives related to elective colorectal surgery. This population-based study supports previous trials of immunonutrition, but shows a lower magnitude of benefit, perhaps related to compliance or a lower rate of adverse events, highlighting the value of community-based assessments of comparative effectiveness.
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21
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Manzanares Campillo MDC, Martín Fernández J, Amo Salas M, Casanova Rituerto D. [A randomized controlled trial of preoperative oral immunonutrition in patients undergoing surgery for colorectal cancer: hospital stay and health care costs]. CIR CIR 2016; 85:393-400. [PMID: 27955850 DOI: 10.1016/j.circir.2016.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 10/24/2016] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
| | - Jesús Martín Fernández
- Servicio de Cirugía General, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Mariano Amo Salas
- Departamento de Matemáticas, Facultad de Medicina de Ciudad Real, Universidad de Castilla la Mancha, Ciudad Real, España
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Kudsk KA, Munoz-Del-Rio A, Busch RA, Kight CE, Schoeller DA. Stratification of Fat-Free Mass Index Percentiles for Body Composition Based on National Health and Nutrition Examination Survey III Bioelectric Impedance Data. JPEN J Parenter Enteral Nutr 2016; 41:249-257. [PMID: 26092851 DOI: 10.1177/0148607115592672] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Loss of protein mass and lower fat-free mass index (FFMI) are associated with longer length of stay, postsurgical complications, and other poor outcomes in hospitalized patients. Normative data for FFMI of U.S. populations do not exist. This work aims to create a stratified FFMI percentile table for the U.S. population using the large bioelectric impedance analysis data obtained from National Health and Nutrition Examination Surveys (NHANES). METHODS Fat-free mass (FFM) was calculated from the NHANES III bioelectric impedance analysis and anthropometric data for males and females ages 12 to >90 years for 3 race/ethnicities (non-Hispanic white, non-Hispanic black, and Mexican American). FFM was normalized by subject height to create an FFMI distribution table for the U.S. POPULATION Selected percentiles were obtained by age, sex, and race/ethnicity. Data were collapsed by race/ethnicity before and after removing obese and underweight participants to create an FFMI decile table for males and females 12 years and older for the healthy-weight U.S. POPULATION RESULTS FFMI increased during adolescent growth but stabilized in the early 20s. The FFMI deciles were similar by race/ethnicity, with age group remaining relatively stable between ages 25 and 80 years. The FFMI deciles for males and females were significantly different. CONCLUSIONS After eliminating the obese and extremely thin, FFMI percentiles remain stable during adult years allowing creation of age- and race/ethnicity-independent decile tables for males and females. These tables allow stratification of individuals for nutrition intervention trials to depict changing nutrition status during medical, surgical, and nutrition interventions.
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Affiliation(s)
- Kenneth A Kudsk
- 1 Veteran Administration Surgical Service, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA.,2 Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Alejandro Munoz-Del-Rio
- 2 Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,3 Departments of Radiology and Medical Physics, University of Wisconsin, Madison, Wisconsin, USA
| | - Rebecca A Busch
- 2 Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Cassandra E Kight
- 4 Clinical Nutrition Services, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Dale A Schoeller
- 5 Department of Nutritional Sciences, University of Wisconsin, Madison, Wisconsin, USA
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Muscaritoli M, Krznarić Z, Singer P, Barazzoni R, Cederholm T, Golay A, Van Gossum A, Kennedy N, Kreymann G, Laviano A, Pavić T, Puljak L, Sambunjak D, Utrobičić A, Schneider SM. Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology. Clin Nutr 2016; 36:939-957. [PMID: 27448948 DOI: 10.1016/j.clnu.2016.06.022] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Disease-related malnutrition has deleterious consequences on patients' outcome and healthcare costs. The demonstration of improved outcome by appropriate nutritional management is on occasion difficult. The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed the Nutrition Education Study Group (ESPEN-NESG) to increase recognition of nutritional knowledge and support in health services. METHODS To obtain the best available evidence on the potential effects of malnutrition on morbidity, mortality and hospital stay; cost of malnutrition; effect of nutritional treatment on outcome parameters and pharmaco-economics of nutritional therapy, a systematic review of the literature was performed following Cochrane methodology, to answer the following key questions: Q1) Is malnutrition an independent predictive factor for readmission within 30 days from hospital discharge? Q2) Does nutritional therapy reduce the risk of readmission within 30 days from hospital discharge? Q3) Is nutritional therapy cost-effective/does it reduce costs in hospitalized patients? and Q4) Is nutritional therapy cost effective/does it reduce costs in outpatients? RESULTS For Q1 six of 15 identified observational studies indicated that malnutrition was predictive of re-admissions, whereas the remainder did not. For Q2 nine randomized controlled trials and two meta-analyses gave non-conclusive results whether re-admissions could be reduced by nutritional therapy. Economic benefit and cost-effectiveness of nutritional therapy was consistently reported in 16 identified studies for hospitalized patients (Q3), whereas the heterogeneous and limited corresponding data on out-patients (Q4) indicated cost-benefits in some selected sub-groups. CONCLUSIONS This result of this review supports the use of nutritional therapy to reduce healthcare costs, most evident from large, homogeneous studies. In general, reports are too heterogeneous and overall of limited quality for conclusions on impact of malnutrition and its treatment on readmissions.
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Affiliation(s)
- Maurizio Muscaritoli
- Department of Clinical Medicine, Sapienza- University of Rome, Viale dell'Università, 37, 00185 Roma, Italy.
| | - Zeljko Krznarić
- Department of Gastroenterology and Centre for Clinical Nutrition, Clinical Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Pierre Singer
- General Intensive Care Department and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Italy
| | - Tommy Cederholm
- Departments of Geriatric Medicine, Uppsala University Hospital and Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden
| | - Alain Golay
- Service of Therapeutic Education for Chronic Diseases, Geneva University Hospitals, Villa Soleillane, Chemin Venel 7, 1206 Geneva, Switzerland
| | - André Van Gossum
- Department of Gastroenterology, Clinic of Intestinal Diseases and Nutritional Support, Hopital Erasme, Free University of Brussels, Brussels, Belgium
| | - Nicholas Kennedy
- Department of Clinical Medicine, Trinity Centre for Health Sciences, Dublin, Ireland
| | - Georg Kreymann
- Baxter Health Care SA Europe, CH 8010 Zurich, Switzerland
| | - Alessandro Laviano
- Department of Clinical Medicine, Sapienza- University of Rome, Viale dell'Università, 37, 00185 Roma, Italy
| | - Tajana Pavić
- Department of Gastroenterology and Hepatology, Clinical Hospital Center "Sisters of Mercy", Zagreb, Croatia
| | - Livia Puljak
- Cochrane Croatia, University of Split School of Medicine, Soltanska 2, Split, Croatia
| | - Dario Sambunjak
- Department of Nursing, Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Ilica 242, Zagreb, Croatia
| | - Ana Utrobičić
- Cochrane Croatia, University of Split School of Medicine, Soltanska 2, Split, Croatia
| | - Stéphane M Schneider
- Department of Gastroenterology and Clinical Nutrition, University Hospital and University of Nice Sophia-Antipolis, Nice, France
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24
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Silvestri S, Franchello A, Deiro G, Galletti R, Cassine D, Campra D, Bonfanti D, De Carli L, Fop F, Fronda GR. Preoperative oral immunonutrition versus standard preoperative oral diet in well nourished patients undergoing pancreaticoduodenectomy. Int J Surg 2016; 31:93-9. [PMID: 27267949 DOI: 10.1016/j.ijsu.2016.05.071] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/19/2016] [Accepted: 05/29/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy is still associated to high morbility, especially due to pancreatic surgery related and infectious complications: many risk factors have already been advocated. Aim of this study is to evaluate the role of preoperative oral immunonutrition in well nourished patients scheduled for pancreaticoduodenectomy. METHODS From February 2014 to June 2015, 54 well nourished patients undergoing pancreaticoduodenectomy were enrolled for 5 days preoperative oral immunonutrition. A series of consecutive patients submitted to the same intervention in the same department, with preoperative standard oral diet, was matched 1:1. For analysis demographic, pathological and surgical variables were considered. Mortality rate, overall postoperative morbility, pancreatic fistula, post pancreatectomy haemorrhage, delayed gastric emptying, infectious complications and length of hospital stay were described for each groups. Chi squared test, Fisher's Exact test and Student's T test were used for comparison. Differences were considered statistically significant at p < 0.05. Statistics was performed using a freeware Microsoft Excel (®) based program and SPSS v 10.00. RESULTS No statistical differences in term of mortality (2.1% in each groups) and overall morbility rate (41.6% vs 47.9%) occurred between the groups as well as for pancreatic surgery related complications. Conversely, statistical differences were found for infectious complications (22.9% vs 43.7%, p = 0.034) and length of hospital stay (18.3 ± 6.8 days vs 21.7 ± 8.3, p = 0.035) in immunonutrition group. CONCLUSION Preoperative oral immunonutrition is effective for well nourished patients scheduled for pancreaticoduodenectomy; it helps to reduce the risk of postoperative infectious complications and length of hospital stays.
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Affiliation(s)
- S Silvestri
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - A Franchello
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - G Deiro
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - R Galletti
- Dietetics and Clinical Nutrition Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - D Cassine
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - D Campra
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - D Bonfanti
- Dietetics and Clinical Nutrition Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - L De Carli
- Dietetics and Clinical Nutrition Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - F Fop
- Kidney Transplantation Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
| | - G R Fronda
- 4th General Surgery Department, Azienda Ospedaliera ed Universitaria, Città della Salute e della Scienza, Corso Bramante 88, 10129, Turin, Italy.
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Bharadwaj S, Trivax B, Tandon P, Alkam B, Hanouneh I, Steiger E. Should perioperative immunonutrition for elective surgery be the current standard of care? Gastroenterol Rep (Oxf) 2016; 4:87-95. [PMID: 27081153 PMCID: PMC4863194 DOI: 10.1093/gastro/gow008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 02/23/2016] [Indexed: 12/22/2022] Open
Abstract
Postoperative infectious complications are independently associated with increased hospital length of stay (LOS) and cost and contribute to significant inpatient morbidity. Many strategies such as avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, metabolic control and early mobilization have been used to either prevent or reduce the incidence of postoperative infections. Despite these efforts, it remains a big challenge to our current healthcare system to mitigate the cost of postoperative morbidity. Furthermore, preoperative nutritional status has also been implicated as an independent risk factor for postoperative morbidity. Perioperative nutritional support using enteral and parenteral routes has been shown to decrease postoperative morbidity, especially in high-risk patients. Recently, the role of immunonutrition (IMN) in postoperative infectious complications has been studied extensively. These substrates have been found to positively modulate postsurgical immunosuppression and inflammatory responses. They have also been shown to be cost-effective by decreasing both tpostoperative infectious complications and hospital LOS. In this review, we discuss the postoperative positive outcomes associated with the use of perioperative IMN, their cost-effectiveness, current guidelines and future clinical implications.
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Affiliation(s)
- Shishira Bharadwaj
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Brandon Trivax
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Parul Tandon
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Bilal Alkam
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ibrahim Hanouneh
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ezra Steiger
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
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Clinical impact of malnutrition on complication rate and length of stay in elective ENT patients: a prospective cohort study. Eur Arch Otorhinolaryngol 2016; 273:2231-7. [PMID: 26993656 DOI: 10.1007/s00405-016-3974-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 03/07/2016] [Indexed: 01/10/2023]
Abstract
Malnutrition is considered as an independent risk factor for morbidity, mortality and a prolonged hospital stay for in-hospital patients. While most available data on the impact of malnutrition on health-related and financial implications refer to gastroenterologic or abdominal surgery patients, little is known about the impact of malnutrition on Ear Nose Throat (ENT)/head and neck surgery patients. The objective of this study was to investigate the impact of malnutrition on morbidity and length of hospital stay in an elective ENT/head and neck surgery patient cohort. The study was performed as a single-center, prospective cohort study at a tertiary referral centre. Nutritional risk at admission was assessed using the NRS-2002 screening tool. Multivariate regression models were used to determine independent risk factors for complications and a prolonged hospitalization. Three hundred fifty one participants were included in the study. A malignant disease was found in 62 participants (17.7 %). 62 patients (17.7 %) were at a moderate to severe risk of malnutrition. A bad general health condition and complications during hospital stay could be identified as independent risk factors for a prolonged hospitalization. Patients with a malignant tumor showed a more than fourfold higher risk of developing at least one complication. Malnutrition, however, was not statistically associated with a higher complication rate or a prolonged hospital stay. Our data suggests that malnutrition does not seem to play such an important role as a risk factor for complications and a prolonged hospital stay in ENT patients as it does in other disciplines like abdominal surgery or gastroenterology.
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27
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Effects of malnutrition on complication rates, length of hospital stay, and revenue in elective surgical patients in the G-DRG-system. Nutrition 2016; 32:249-54. [DOI: 10.1016/j.nut.2015.08.021] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 08/10/2015] [Accepted: 08/20/2015] [Indexed: 01/10/2023]
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Steven BR, Carey S. Nutritional management in patients with chyle leakage: a systematic review. Eur J Clin Nutr 2015; 69:776-80. [DOI: 10.1038/ejcn.2015.48] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 08/24/2014] [Accepted: 01/23/2015] [Indexed: 01/10/2023]
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Hegazi RA, Hustead DS, Evans DC. Preoperative Standard Oral Nutrition Supplements vs Immunonutrition: Results of a Systematic Review and Meta-Analysis. J Am Coll Surg 2014; 219:1078-87. [DOI: 10.1016/j.jamcollsurg.2014.06.016] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 06/20/2014] [Accepted: 06/20/2014] [Indexed: 12/16/2022]
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Li H, Shen YH. Value of acute gastrointestinal injury grading system in assessing gastrointestinal dysfunction in critically ill patients: Application in early enteral nutrition. Shijie Huaren Xiaohua Zazhi 2014; 22:4668-4673. [DOI: 10.11569/wcjd.v22.i30.4668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the value of acute gastrointestinal injury (AGI) grading system in assessing gastrointestinal dysfunction in critically ill patients and to assess its application in early enteral nutrition (EN).
METHODS: Seventy-eight patients with gastrointestinal dysfunction admitted to intensive care unit (ICU) from January 2013 to January 2014 were divided into different groups using the AGI grading system: gradeⅠ(35 cases), grade Ⅱ (22 cases), grade Ⅲ (12 cases), and grade Ⅳ (9 cases). The patients were given appropriate treatment based on the AGI guideline. The nutritional status before and after EN implementation, severity, rate of adequate intake, changes in the function of the gastrointestinal mucosa were compared between the two groups. The relationship between AGI grading and EN feeding rate and rate of adequate calories was also analyzed.
RESULTS: The levels of APACHE Ⅱ score, serum albumin (ALB), nitrogen balance (NB), total protein (TP), gastric pH, lactate, and PgCO2 showed no significant differences among the four groups before treatment (P > 0.05); after 7 d of treatment, the APACHE Ⅱ score, lactate, and PgCO2 significantly decreased (P < 0.05), and the levels of ALB, NB, TP, and pH value significantly increased in grades Ⅰ-Ⅲ groups (P < 0.05). The APACHE Ⅱ score, lactate, and PgCO2 were significantly higher (P < 0.05), and the values of NB, TP, and pH before treatment were significantly lower in grade Ⅳ group than in grades Ⅰ-Ⅲ groups (P < 0.05), although the level of ALB showed no significant difference among the four groups (P > 0.05). The 4-h feeding rates in grades Ⅰ-Ⅳ groups were 91.43%, 68.18%, 50.00%, and 0.00%, respectively, and the 48-h feeding rates were 100.00%, 81.82%, 58.33%, and 0.00%. The 7-d rate of adequate calories in grades Ⅰ-Ⅳ groups were 100.00%, 81.82%, 66.67% and 22.22%, respectively.
CONCLUSION: AGI grading has a good correlation with EN treatment and can be used for gastrointestinal function evaluation in critically ill patients.
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Ho JWC, Wu AHW, Lee MWK, Lau SY, Lam PS, Lau WS, Kwok SSS, Kwan RYH, Lam CF, Tam CK, Lee SO. Malnutrition risk predicts surgical outcomes in patients undergoing gastrointestinal operations: Results of a prospective study. Clin Nutr 2014; 34:679-84. [PMID: 25175758 DOI: 10.1016/j.clnu.2014.07.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 07/03/2014] [Accepted: 07/21/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS Patients undergoing gastrointestinal operations are at risk of malnutrition which may increase the chance of adverse surgical outcomes. This prospective study aimed at correlating nutritional status of patients having gastrointestinal operations with their short-term surgical outcomes captured by a territory-wide Surgical Outcomes Monitoring and Improvement Program. METHODS The preoperative malnutrition risk of Chinese adult patients undergoing elective/emergency ultra-major/major gastrointestinal operations in two surgical departments over a 12-month period were assessed by Chinese version of Malnutrition Universal Screening Tool. Their perioperative risk factors and clinical outcomes, including length of hospital stay, mortality and morbidity, were retrieved from the above mentioned program. Correlation of malnutrition risk with clinical outcomes was assessed by logistic regression analysis after controlling for known confounders. RESULTS 943 patients (58% male; mean age 65.9 ± 14.8 years) underwent gastrointestinal operations (40.3% emergency operation; 52.7% ultra-major procedures; 66.9% bowel resections) had analyzable data. 15.8% and 17.1% of patients were at medium and high risk of malnutrition, respectively. Malnutrition risk score according to the screening tool was an independent predictor of length of hospital stay, 30-day mortality, 60-day mortality and minor medical complications. Similar correlations were found for various sub-scores of malnutrition risk. Weight loss sub-score was predictive of 30-day mortality, 60-day mortality and minor medical complications. Body mass index was predictive of mortality (30- and 60- day) whereas the acute disease sub-score was predictive of length of hospital stay. CONCLUSIONS Preoperative malnutrition was an important predictor of poor clinical outcomes in patients undergoing gastrointestinal operations in Hong Kong.
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Affiliation(s)
- Judy W C Ho
- Department of Surgery, Queen Mary Hospital, Hong Kong.
| | - Arthur H W Wu
- Department of Surgery, United Christian Hospital, Hong Kong
| | | | - So-ying Lau
- Department of Surgery, United Christian Hospital, Hong Kong
| | - Pui-shan Lam
- Department of Surgery, United Christian Hospital, Hong Kong
| | - Wai-shan Lau
- Department of Surgery, United Christian Hospital, Hong Kong
| | - Sam S S Kwok
- Department of Surgery, United Christian Hospital, Hong Kong
| | - Rosa Y H Kwan
- Department of Surgery, United Christian Hospital, Hong Kong
| | - Cheuk-fan Lam
- Department of Surgery, Queen Mary Hospital, Hong Kong
| | - Chun-kit Tam
- Department of Surgery, Queen Mary Hospital, Hong Kong
| | - Suk-on Lee
- Department of Surgery, Queen Mary Hospital, Hong Kong
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Galas A, Kulig P, Kulig J. Dietary inflammatory index as a potential determinant of a length of hospitalization among surgical patients treated for colorectal cancer. Eur J Clin Nutr 2014; 68:1168-74. [PMID: 25005677 PMCID: PMC4197458 DOI: 10.1038/ejcn.2014.120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 05/07/2014] [Accepted: 05/20/2014] [Indexed: 12/22/2022]
Abstract
Background/objectives: Inflammation is a central process responsible for health outcomes among surgical patients. Immunonutrition has been investigated as a promising modifying factor; however, inflammatory properties of habitual diet have not yet been investigated. The purpose of this study was to describe inflammatory properties of diet measured by the dietary inflammatory index (DII) among surgical patients treated for colorectal cancer and to link inflammatory properties of habitual diet with a duration of hospitalization. Subjects/methods: A follow-up study among colorectal cancer patients treated surgically was performed in Krakow, Poland. In total, 689 patients were recruited for the study. Habitual diet was assessed using a standardized semiquantitative food frequency questionnaire. Overall, 23 dietary items (including macro-and micronutrients) were used to calculate individuals' DII. Gender, age, marital status, body mass index, smoking status, lifetime physical activity, taking vitamin supplements, number of chronic diseases, cancer site, Duke's staging and surgery type were considered as potential covariates. Results: Participants were aged 58 years, with the average hospitalization time of 11 days. Higher DII (meaning diet with higher anti-inflammatory properties) was negatively associated with the duration of hospitalization (univariable linear regression: b=−0.59; P=0.005). Multivariable logistic regression has shown the decrease of the risk of longer stays (>7 days) among patients with the DII >−4.25, but only among younger (⩽60 years) patients, irrespective of Duke's staging. Conclusions: The DII might be used as a potential predictor of longer hospitalization among colorectal cancer patients treated surgically. The study provides evidence for the role of dietary-related low-grade inflammation among surgical patients.
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Affiliation(s)
- A Galas
- Department of Epidemiology, Jagiellonian University Medical College, Krakow, Poland
| | - P Kulig
- Department of Gastroenterological Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - J Kulig
- Department of Gastroenterological Surgery, Jagiellonian University Medical College, Krakow, Poland
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Low-grade dietary-related inflammation and survival after colorectal cancer surgery. J Cancer Res Clin Oncol 2014; 140:1517-25. [PMID: 24863751 PMCID: PMC4131135 DOI: 10.1007/s00432-014-1711-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/11/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE Prolong inflammation is a central process observed in several chronic conditions and may be responsible for survival. There is an increasing evidence showing the role of diet in inflammation and habitual diet may be responsible for low-grade inflammation. The purpose of our study was to assess the effect of inflammatory properties of habitual diet measured by the Dietary Inflammatory Index (DII) on survival among surgical patients treated for colorectal cancer (CRC). METHODS A follow-up study among 689 CRC patients (mean age 58 years, ±8.9; 56.7 % males) treated surgically was performed in Krakow, Poland. Habitual diet was assessed by a standardized semiquantitative food frequency questionnaire. Next, 23 dietary items were used to calculate DIIs. Vital records were verified to determine status of the participants. RESULTS Study has shown linear association between DII and survival time among CRC patients with totally removed cancer treated by chemotherapy (b = -0.13, p = 0.024). After adjustment for several important covariates, DII was associated with survival during up to 3 years after surgery, but only in patients without distant metastases (3-year HRDII>-2.27 = 0.61, 95 % CI 0.38-0.99). CONCLUSIONS The results of the investigation have shown the usefulness of the DII as a potential predictor of survival among patients without distant metastases treated surgically for CRC.
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Evans DC, Martindale RG, Kiraly LN, Jones CM. Nutrition optimization prior to surgery. Nutr Clin Pract 2013; 29:10-21. [PMID: 24347529 DOI: 10.1177/0884533613517006] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Optimization of metabolic state prior to major surgery leads to improved surgical outcomes. Nutrition screening protocols should be implemented in the preoperative evaluation, possibly as part of a bundle. Strategies to minimize hyperglycemia and insulin resistance by aggressive preoperative nutrition and carbohydrate loading may promote maintenance of a perioperative anabolic state, improving healing, reducing complications, and shortening the time to recovery of bowel function and hospital discharge. Short courses of preoperative immune-modulating formulas, using combinations of arginine, ω-3 fatty acids, and other nutrients, have been associated with improved surgical outcomes. These immune-modulating nutrients are key elements of metabolic pathways that promote attenuation of the metabolic response to stress and improve both wound healing and immune function. Patients with severe malnutrition and gastrointestinal dysfunction may benefit from preoperative parenteral nutrition. Continuation of feeding through the intraoperative period for severely stressed hypermetabolic patients undergoing nongastrointestinal surgery is another strategy to optimize metabolic state and reduce prolonged nutrition deficits. In this paper, we review the importance of preoperative nutrition and strategies for effective preoperative nutrition optimization.
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Affiliation(s)
- David C Evans
- Christopher M. Jones, University of Louisville, Hiram C. Polk Jr MD Department of Surgery, Ambulatory Care Building, 2nd Floor, Louisville, KY 40292, USA.
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Rasmussen HH, Irtun &O, Olesen SS, Drewes AM, Holst M. Nutrition in chronic pancreatitis. World J Gastroenterol 2013; 19:7267-7275. [PMID: 24259957 PMCID: PMC3831208 DOI: 10.3748/wjg.v19.i42.7267] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 09/24/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023] Open
Abstract
The pancreas is a major player in nutrient digestion. In chronic pancreatitis both exocrine and endocrine insufficiency may develop leading to malnutrition over time. Maldigestion is often a late complication of chronic pancreatic and depends on the severity of the underlying disease. The severity of malnutrition is correlated with two major factors: (1) malabsorption and depletion of nutrients (e.g., alcoholism and pain) causes impaired nutritional status; and (2) increased metabolic activity due to the severity of the disease. Nutritional deficiencies negatively affect outcome if they are not treated. Nutritional assessment and the clinical severity of the disease are important for planning any nutritional intervention. Good nutritional practice includes screening to identify patients at risk, followed by a thoroughly nutritional assessment and nutrition plan for risk patients. Treatment should be multidisciplinary and the mainstay of treatment is abstinence from alcohol, pain treatment, dietary modifications and pancreatic enzyme supplementation. To achieve energy-end protein requirements, oral supplementation might be beneficial. Enteral nutrition may be used when patients do not have sufficient calorie intake as in pylero-duodenal-stenosis, inflammation or prior to surgery and can be necessary if weight loss continues. Parenteral nutrition is very seldom used in patients with chronic pancreatitis and should only be used in case of GI-tract obstruction or as a supplement to enteral nutrition.
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