The Effects of Immediate Enteral Feeding with a Formula Containing High Levels of ω-3 Fatty Acids in Patients After Surgery for Esophageal Cancer

The Effects of Omega-3 Fatty Acids Supplementation on Inflammatory Factors in Cancer Patients: A Systematic Review and Dose-Response Meta-Analysis of Randomized Clinical Trials

Until now, no study evaluated the impact of optimum intake of omega-3 fatty acids on inflammatory factors. We aimed to investigate the dose-dependent effects of omega-3 fatty acids supplementation on inflammatory factors in cancer patients. PubMed, Scopus and ISI Web of Science were searched until July 2022 to find randomized controlled trials (RCTs) for examining the efficacy of omega-3 fatty acids on inflammatory factors. Our primary outcomes were interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP), and albumin. The results of 33 trials (2068 participants) revealed that each 1 g/day omega-3 fatty acids (oral/enteral) significantly reduced IL-6 (SMD: -1.17 pg/ml; 95% CI: -1.78, -0.55; p < 0.001; GRADE = moderate), and TNF-α (SMD: -2.15 pg/ml; 95% CI: -3.14, -1.16; p < 0.001; GRADE = very low). Moreover, each 0.5 g/kg/day omega-3 fatty acids (parenteral) significantly reduced TNF-α (SMD: -1.11 pg/ml; 95% CI: -2.02, -0.19; p = 0.017; GRADE = low). With moderate and very low evidence certainty, each 1 g/day of omega-3 fatty acids supplementation (oral/enteral) has a beneficial effect on IL-6 and TNF-α. Each 0.5 g/kg/day omega-3 fatty acids (parenteral) could also exert a favorable impact on TNF-α, but the certainty of the evidence was low.

Network meta-analysis of the optimal time of applying enteral immunonutrition in esophageal cancer patients receiving esophagectomy

BACKGROUND

Enteral immunonutrition (EIN) has been extensively applied in cancer patients; however, its role in esophageal cancer (EC) patients receiving esophagectomy remains unclear. We performed this network meta-analysis to investigate the impact of EIN on patients undergoing surgery for EC and further determine the optimal time of applying EIN.

METHODS

We searched PubMed, EMBASE, Cochrane library, and China National Knowledgement Infrastructure (CNKI) to identify eligible studies. Categorical data was expressed as the odds ratio with 95% confidence interval (CI), and continuous data was expressed as mean difference (MD) with 95% CI. Meta-analysis with head-to-head approach and network meta-analysis was performed to evaluate the impact of EIN on clinical outcomes using RevMan 5.3 and ADDIS V.1.16.8 software. The surface under the cumulative ranking curve (SUCRA) was calculated to rank all nutritional regimes.

RESULTS

Total 14 studies involving 1071 patients were included. Meta-analysis with head-to-head approach indicated no difference between EIN regardless of the application time and standard EN (SEN); however, subgroup analyses found that postoperative EIN was associated with decreased incidence of total infectious complications (OR = 0.47; 95%CI = 0.26 to 0.84; p = 0.01) and pneumonia (OR = 0.47; 95%CI = 0.25 to 0.90; p = 0.02) and shortened the length of hospitalization (LOH) (MD =  - 1.01; 95%CI =  - 1.44 to - 0.57; p < 0.001) compared to SEN, which were all supported by network meta-analyses. Ranking probability analysis further indicated that postoperative EIN has the highest probability of being the optimal option in terms of these three outcomes.

CONCLUSIONS

Postoperative EIN should be preferentially utilized in EC patients undergoing esophagectomy because it has optimal potential of decreasing the risk of total infectious complications and pneumonia and shortening LOH.

OSF REGISTRATION NUMBER

10.17605/OSF.IO/KJ9UY.

N-3 Long-Chain Polyunsaturated Fatty Acids, Eicosapentaenoic and Docosahexaenoic Acid, and the Role of Supplementation during Cancer Treatment: A Scoping Review of Current Clinical Evidence

Simple Summary

There has been extensive research into the beneficial anticancer effects of n-3 long-chain polyunsaturated fatty acids (LCPUFA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in preclinical models of cancer. However, clinical evidence is limited. The aim of this scoping review was to summarize the current clinical evidence of n-3 LCPUFA supplementation in cancer treatment and highlight areas where more clinical evidence is needed. We summarized the results of 57 clinical trials with an EPA/DHA intervention and determined that supplementation could improve a variety of outcomes important to the patient and the disease process, including immune system modulation, improved weight maintenance and increased disease-free or progression-free survival. There is, however, a need for larger, well-controlled, statistically powered randomized controlled trials to move n-3 supplementation to clinical practice.

Abstract

This scoping review examines the evidence for n-3 long-chain polyunsaturated fatty acid [LCPUFA, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] supplementation in clinical cancer therapy. A comprehensive literature search was performed to identify relevant clinical intervention studies conducted through August 2020. Fifty-seven unique cancer trials, assessing EPA and/or DHA supplementation pre- or post-treatment, concomitant with neoadjuvant chemotherapy, radiation or surgery, or in palliative therapy were included. Breast, head and neck, gastrointestinal, gastric, colorectal/rectal, esophageal, leukemia/lymphoma, lung, multiple myeloma and pancreatic cancers were investigated. Across the spectrum of cancers, the evidence suggests that supplementation increased or maintained body weight, increased progression-free and overall survival, improved overall quality of life, resulted in beneficial change in immune parameters and decreased serious adverse events. Taken together, the data support that EPA and/or DHA could be used to improve outcomes important to the patient and disease process. However, before incorporation into treatment can occur, there is a need for randomized clinical trials to determine the dose and type of n-3 LCPUFA intervention required, and expansion of outcomes assessed and improved reporting of outcomes.

Immunonutritional support as an important part of multidisciplinary anti-cancer therapy

Immunonutrition is one of the most important parts of nutritional treatment in patients with cancer. There are studies which confirm positive effects of using immunonutrition (arginine, glutamine, omega-3 fatty acids, nucleotides, pre- and probiotics) among others on the reduction of the pro-inflammatory cytokines concentrations, shortening of the hospital stay and improvement of the nutritional status. Arginine takes part not only in wound healing process, but also it improves body’s immunity and reduces the incidence of infections. Glutamine reduces the incidence of acute grade 2 and 3 esophagitis and improves quality of life of gastric cancer patients. Omega 3-fatty acids have the ability to inhibit the activity of NF-κB. They also reduce the symptoms of graft-versus-host disease in patients undergoing hematopoietic cell transplantation. Nucleotides support the regeneration of intestinal villi. Probiotics play many roles, mainly inhibit the process of carcinogenesis, reduce the incidence of diarrhea and modify intestinal microbiome. However, there are studies indicating the lack of advantages of using immunonutrition compared to standard nutrition. Currently, there is no clear evidence for the use of formulae enriched with immunonutrients versus standard oral nutritional supplements exclusively in the preoperative period. This review summarizes the current knowledge about the role of immunonutrition in supporting treatment of cancer diseases.

A double-blind randomized controlled trial of the effects of eicosapentaenoic acid supplementation on muscle inflammation and physical function in patients undergoing colorectal cancer resection

BACKGROUND

Resection of colorectal cancer (CRC) initiates inflammation, mediated at least partly by NFĸB (nuclear factor kappa-light-chain-enhancer of activated B-cells), leading to muscle catabolism and reduced physical performance. Eicosapentaenoic acid (EPA) has been shown to modulate NFĸB, but evidence for its benefit around the time of surgery is limited.

OBJECTIVE

To assess the effect of EPA supplementation on muscle inflammation and physical function around the time of major surgery.

DESIGN

In a double-blind randomized control trial, 61 patients (age: 68.3 ± 0.95 y; 42 male) scheduled for CRC resection, received 3 g per day of EPA (n = 32) or placebo (n = 29) for 5-days before and 21-days after operation. Lean muscle mass (LMM) (via dual energy X-ray absorptiometry (DXA)), anaerobic threshold (AT) (via cardiopulmonary exercise testing (CPET)) and hand-grip strength (HG) were assessed before and 4-weeks after surgery, with muscle biopsies (m. vastus lateralis) obtained for the assessment of NF-ĸB protein expression.

RESULTS

There were no differences in muscle NFĸB between EPA and placebo groups (mean difference (MD) -0.002; 95% confidence interval (CI) -0.19 to 0.19); p = 0.98). There was no difference in LMM (MD 704.77 g; 95% CI -1045.6 g-2455.13 g; p = 0.42) or AT (MD 1.11 mls/kg/min; 95% CI -0.52 mls/kg/min to 2.74 mls/kg/min; p = 0.18) between the groups. Similarly, there was no difference between the groups in HG at follow up (MD 0.1; 95% CI -1.88 to 2.08; p = 0.81). Results were similar when missing data was imputed.

CONCLUSION

EPA supplementation confers no benefit in terms of inflammatory status, as judged by NFĸB, or preservation of LMM, aerobic capacity or physical function following major colorectal surgery.

CLINICAL TRIALS REFERENCE

NCT01320319.

Stable isotope ratios of carbon, nitrogen and selenium concentration in the scalp hair of Crohn's disease patients who ingested the elemental diet Elental®

RATIONALE

Elental^® is an elemental diet widely used as a nutritional supplement for Crohn's disease (CD) patients in Japan. Elental^® contains amino acids as nitrogen sources and does not contain selenium (Se), and the δ¹³ C and δ¹⁵ N values of Elental^® are markedly higher and lower, respectively, than those of a normal diet.

METHODS

We compared the δ¹³ C and δ¹⁵ N values and Se concentration in the scalp hair of CD patients with those of control subjects who ate a regular diet, and estimated the amount of Elental^® ingested as a supplement. The δ¹³ C and δ¹⁵ N values and the Se concentrations were quantified using isotope ratio mass spectrometry (IRMS) and inductively coupled plasma mass spectrometry (ICP-MS), respectively.

RESULTS

An increase in Elental^® ingestion increased the δ¹³ C value in the hair of CD patients (p <0.05), while it reduced the δ¹⁵ N value (p <0.05) and tended to reduce the Se concentration in female patients.

CONCLUSIONS

The amount of Elental^® ingested could be estimated by the δ¹³ C and δ¹⁵ N values in the hair of CD patients. Furthermore, the Se deficiency in female patients may be predicted from the δ¹³ C and δ¹⁵ N values.

Multicentre factorial randomized clinical trial of perioperative immunonutrition versus standard nutrition for patients undergoing surgical resection of oesophageal cancer

BACKGROUND

Preoperative immunonutrition has been proposed to reduce the duration of hospital stay and infective complications following major elective surgery in patients with gastrointestinal malignancy. A multicentre 2 × 2 factorial RCT was conducted to determine the impact of preoperative and postoperative immunonutrition versus standard nutrition in patients with oesophageal cancer.

METHODS

Patients were randomized before oesophagectomy to immunonutrition (IMPACT^® ) versus standard isocaloric/isonitrogenous nutrition, then further randomized after operation to immunonutrition versus standard nutrition. Clinical and quality-of-life outcomes were assessed at 14 and 42 days after operation on an intention-to-treat basis. The primary outcome was the occurrence of infective complications. Secondary outcomes were other complications, duration of hospital stay, mortality, nutritional and quality-of-life outcomes (EuroQol EQ-5D-3 L™, European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC QLQ-OES18). Patients and investigators were blinded until the completion of data analysis.

RESULTS

Some 278 patients from 11 Australian sites were randomized; two were excluded and data from 276 were analysed. The incidence of infective complications was similar for all groups (37 per cent in perioperative standard nutrition group, 51 per cent in perioperative immunonutrition group, 34 per cent in preoperative immunonutrition group and 40 per cent in postoperative immunonutrition group; P = 0·187). There were no significant differences in any other clinical or quality-of-life outcomes.

CONCLUSION

Use of immunonutrition before and/or after surgery provided no benefit over standard nutrition in patients undergoing oesophagectomy. Registration number: ACTRN12611000178943 ( https://www.anzctr.org.au).

Air Bubble Sign: A New Screening Method for Anastomotic Leakage After Esophagectomy for Esophageal Cancer

BACKGROUND

Contrast esophagography often is performed to screen for anastomotic leakage (AL) after esophagectomy. However, its sensitivity remains low. Adverse events also have been reported. This report describes a new screening method to detect AL on computed tomography (CT) after esophagectomy.

METHODS

From January 2012 to December 2015, 185 patients with esophageal cancer underwent surgical resection at the authors' institution. The study comparatively reviewed patient characteristics, surgical outcomes, and findings from postoperative CT images and contrast esophagrams of 142 patients who underwent esophagectomy followed by primary gastric conduit reconstruction through a posterior mediastinum route.

RESULTS

In this study, 24 patients (15.5%) had AL (leakage-positive group), and 120 patients (84.5%) did not (leakage-negative group). Both groups had comparable backgrounds. The number of air bubbles around the anastomotic site and the mediastinal space on postoperative CT images were significantly greater in the leakage-positive group than in the leakage-negative group. The cutoff value for the number of air bubbles required for a positive diagnosis of AL ("air bubble sign") was calculated to be 3 by receiver operating characteristic curve. Compared with contrast esophagography, the air bubble sign on CT demonstrated a significantly higher sensitivity (86.4 vs. 50.0%) and an equivalent specificity (95.8 vs. 100.0%). Contrast esophagography altered the postoperative management of only five patients (3.5%).

CONCLUSIONS

A positive air bubble sign on CT is an objective and noninvasive screening method for AL after esophagectomy for esophageal cancer and may replace contrast esophagography as a screening test for AL.

[Effects of propofol combined with indomethacin on contraction of isolated human pulmonary arteries]

OBJECTIVE

To investigate the effects of propofol combined with indomethacin on the contractile function of isolated human pulmonary arteries.

METHODS

Human pulmonary artery preparations were obtained from patients undergoing surgery for lung carcinoma. The intrapulmonary arteries were dissected and cut into rings under microscope for treatment with propofol or propofol combined with indomethacin. In each group, the rings were divided into endothelium-intact and endothelium-denuded groups and mounted in a Multi Myograph system. In propofol group, the rings were preconstricted by U46619 to induce a sustained contraction, and propofol (10-300 mmol/L) was then applied cumulatively. In the combined treatment group, the rings were pretreated with indomethacin (100 µmol/L) for 30 min before application of U46619 to induce sustained contraction, and propofol (10-300 µmol/L) was added cumulatively after the tension became stable.

RESULTS

Propofol (10-100 µmol/L) induced constrictions at low concentrations and caused relaxations at higher concentrations (100-300 µmol/L) in the pulmonary artery rings with prior U46619-induced contraction. Propofol caused stronger constrictions in endothelium-intact rings [EC₅₀=4.525∓0.37, Emax=(30.44∓2.92)%] than in endothelium-denuded rings [EC₅₀=4.699∓0.12, Emax=(31.19∓5.10)%, P<0.05]. Pretreatment of the rings with indomethacin abolished constrictions, and the relaxation was more obvious in endothelium-intact group [pD₂=3.713∓0.11, Emax=(98.72∓0.34)%] than in endothelium- denuded group [pD₂=3.54∓0.03, Emax=(94.56∓0.53)%, P<0.05].

CONCLUSION

Propofol induces constriction at low concentrations and relaxation at high concentrations in human intrapulmonary arteries with U46619-induced contraction. Indomethacin abolishes the constriction induced by propofol in isolated intrapulmonary arteries, suggesting that propofol potentiates U46619-mediated pulmonary vasoconstriction by promoting the concomitant production of prostaglandin by cyclooxygenase in pulmonary artery smooth muscle cells, and the mechanism for its relaxation effect may partly depend on the endothelium.

Effects of Parenteral Fish-Oil Emulsion (Omegaven) on Cutaneous Wound Healing in Rats Treated With Dexamethasone

BACKGROUND

The aim was to assess wound healing when parenteral fish-oil emulsion is given to rats receiving dexamethasone.

METHODS

For 5 days after skin wounding, group S (control; n = 7) received saline 1 mL/kg intraperitoneal (IP); group D (n = 7), dexamethasone 0.2 mg/kg IP; and group DO (n = 9), dexamethasone 0.2 mg/kg IP plus 1 mL/kg Omegaven (Fresenius Kabi, Austria). Wound specimens were assessed for hydroxyproline level, wound depth, histology (epidermal/dermal regeneration, granulation tissue thickness, and angiogenesis), and expression of transforming growth factor-beta (TGF-beta) and platelet-derived growth factor-AA (PDGF-AA).

RESULTS

Compared with D and DO specimens, controls had higher hydroxyproline (p < .01), deeper wounds (p < .05), and better histologic scores (p < .01 angiogenesis; others p < .05). There were no significant differences between the group D and DO means for hydroxyproline level, wound depth, or histologic scores (p > .05 for all). Controls had higher TGF-beta expression scores than the other groups (p < .01 for both) and a higher PDGF-AA expression score than group DO (p < .01). Groups D and DO had statistically similar TGF-beta scores, but group D had a higher PDGF-AA score (2.71 +/- 0.75 vs 1.55 +/- 0.72, respectively; p < .05).

CONCLUSIONS

According to the parameters we studied, adding parenteral omega-3 and omega-6 fatty acids to the nutrition regimen of rats treated with dexamethasone does not seem to have adverse effects on wound healing, and effects on wound healing may not need to be considered when determining if these agents should be supplemented in nutrition support regimens.

Effects of α-linolenic acid-enriched diets on gene expression of key inflammatory mediators in immune and milk cells obtained from Holstein dairy cows

Immune system and inflammatory responses are affected by α-linolenic acid (αLA: 18:3 ω-3). The objective of this study was to determine the effects of αLA-enriched rations on gene expression of systemic (blood) and local (mammary gland) inflammatory markers in Holstein dairy cattle. Further, the effect of dietary treatments was evaluated on the concentration of αLA in serum phospholipids. Camelina (Camelina sativa) meal (containing 24.2% αLA) was fed at 0, 3, 6, and 9% (dry matter basis) replacing canola meal (rich in 18:1 ω-9) to provide rations with incremental concentrations of αLA. Lactating primiparous Holstein cows (n = 18) were randomly assigned to a treatment sequence in a 4 × 4 Latin square design. Each period lasted 16 d and milk and blood samples were collected during the final 2 d of each period. Peripheral blood mononuclear cells (PBMC) and milk cells (MC) were harvested, and RNA extracted and converted to complementary DNA for quantitative real time PCR analysis. The effect of dietary treatments (αLA) on the relative abundance of pro- and anti-inflammatory genes in the PBMC and MC was tested by the MIXED procedure of SAS. Expression of pro-inflammatory tumour necrosis factor (TNF)-α in MC was linearly reduced (up to 40%) as dietary αLA increased. Expression of pro-inflammatory markers interleukin (IL)-1β, IL-8, and TNF-α was reduced (29, 20, and 27%, respectively) in PBMC isolated from cows fed 6% camelina meal ration as compared with cows fed 0% (control). Expression of IL-6 was, however, increased with inclusion of camelina meal. Greater dietary αLA linearly increased serum phospholipids αLA contents, and when fed up to 6% DM down-regulated expression of some of the local (milk) and systemic (blood) pro-inflammatory markers in vivo.

Anti-inflammatory effects of docosahexaenoic acid: Implications for its cancer chemopreventive potential

The implication of inflammatory tissue damage in pathophysiology of human cancer as well as some metabolic disorders has been under intense investigation. Numerous studies have identified a series of critical signaling molecules involved in cellular responses to inflammatory stimuli. These include nuclear factor κB, peroxisome proliferator-activated receptor γ, nuclear factor erythroid 2 p45-related factor 2 and sterol regulatory element-binding protein 1. The proper regulation of these transcription factors mediating pro- and anti-inflammatory signaling hence provides an important strategy for the chemoprevention of inflammation-associated cancer. There is compelling evidence supporting that dietary supplementation with fish oil-derived ω-3 polyunsaturated fatty acids including docosahexaenoic acid (DHA) ameliorates symptomatic inflammation associated with cancer as well as other divergent human disorders. Acute or physiologic inflammation is an essential body's first line of defence to microbial infection and tissue injuries, but it must be properly completed by a process termed 'resolution'. Failure of resolution mechanisms can result in persistence of inflammation, leading to chronic inflammatory conditions and related malignancies. The phagocytic engulfment of apoptotic neutrophils and clearance of their potentially histotoxic contents by macrophages, called efferocytosis is an essential component in resolving inflammation. Of note, DHA is a precursor of endogenous proresolving lipid mediators which regulate the leukocyte trafficking and recruitment and thereby facilitate efferocytosis. Therefore, DHA and its metabolites may have a preventive potential in the management of human cancer which arises as a consequence of impaired resolution of inflammation as well as chronic inflammation.

Omega-3 polyunsaturated fatty acids and cancer: lessons learned from clinical trials

Over the past decades, extensive studies have addressed the therapeutic effects of omega-3 polyunsaturated fatty acids (omega-3 FAs) against different human diseases such as cardiovascular and neurodegenerative diseases, cancer, etc. A growing body of scientific research shows the pharmacokinetic information and safety of these natural occurring substances. Moreover, during recent years, a plethora of studies has demonstrated that omega-3 FAs possess therapeutic role against certain types of cancer. It is also known that omega-3 FAs can improve efficacy and tolerability of chemotherapy. Previous reports showed that suppression of nuclear factor-κB, activation of AMPK/SIRT1, modulation of cyclooxygenase (COX) activity, and up-regulation of novel anti-inflammatory lipid mediators such as protectins, maresins, and resolvins, are the main mechanisms of antineoplastic effect of omega-3 FAs. In this review, we have collected the available clinical data on the therapeutic role of omega-3 FAs against breast cancer, colorectal cancer, leukemia, gastric cancer, pancreatic cancer, esophageal cancer, prostate cancer, lung cancer, head and neck cancer, as well as cancer cachexia. We also discussed the chemistry, dietary source, and bioavailability of omega-3 FAs, and the potential molecular mechanisms of anticancer and adverse effects.

Low fat-containing elemental formula is effective for postoperative recovery and potentially useful for preventing chyle leak during postoperative early enteral nutrition after esophagectomy

BACKGROUND AND AIMS

Transthoracic esophagectomy using 3-field lymphadenectomy (TTE-3FL) for esophageal cancer is one of the most aggressive gastrointestinal surgeries. Early enteral nutrition (EN) for TTE-3FL patients is useful and valid for early recovery; however, EN using a fat-containing formula risks inducing chyle leak. In the present study, we retrospectively examined esophageal cancer patients treated byTTE-3FL and administered postoperative EN to elucidate the validity of lowering the fat levels in elemental formulas to prevent postoperative chyle leak and improve postoperative recovery.

METHODS

A total of 74 patients who received TTE-3FL for esophageal cancer were retrospectively examined. Patients were classified into two groups according to the type of postoperative EN: Group LF patients received a low-fat elemental formula, and Group F patients received a standard fat-containing polymeric formula. The following clinical factors were compared between the groups: EN start day, maximum EN calories administered, duration of respirator use, length of ICU stay, incidence of postoperative infectious complications, use of parenteral nutrition (PN), and incidence of postoperative chyle leak.

RESULTS

Patients in Group LF were started on EN significantly earlier after surgery and they consumed significantly higher maximum EN calories compared to Group F patients (P < 0.01). Duration of respirator use and length of ICU stay were also significantly shorter, and TPN was used significantly less in Group LF compared to Group F (P < 0.05). Postoperative chyle leak was observed in six patients in total (8.1%); five patients in Group F and one patient in Group LF, although there was no significant difference in frequency of chyle leak per patient between Group LF and Group F.

CONCLUSIONS

Early EN using low-fat elemental formula after esophagectomy with three-field lymphadenectomy was safe and valid for postoperative recovery and potentially useful in preventing chyle leak.

Potential applications of fish oils rich in omega-3 polyunsaturated fatty acids in the management of gastrointestinal cancer

BACKGROUND & AIMS

Despite advances in chemotherapeutic agents and surgical approaches for its management, gastrointestinal cancer still accounts for 27% of new cancer cases and 35% of cancer related mortality worldwide. Omega-3 polyunsaturated fatty acids (PUFAs) specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have anti-inflammatory and anticancer activities and are used as immuno-nutrients.

METHODS

A literature search was conducted to identify primary research reporting on applications of the omega-3 PUFAs in gastrointestinal cancer.

RESULTS

Reported laboratory studies indicate a clear role for omega-3 PUFAs in preventing cancer development at various stages including cancer cell proliferation, survival, angiogenesis, inflammation and metastasis. In clinical settings, omega-3 PUFAs have been reported to improve the immune response, maintain lean body mass, improve quality of life and improve overall survival in patients with colorectal and pancreatic cancer. In contrast to other GI cancers, there is a strong connection between inflammation and oesophageal cancer.

CONCLUSIONS

Little work has been done exploring the role for omega-3 PUFAs in oesophageal cancer prevention and management. The authors are conducting a clinical trial investigating the use of parenteral omega-3 PUFAs supplementary to the standard of care (epirubicin, oxaliplatin and capecitabine palliative chemotherapy) in patients with advanced oesophagogastric cancer as a promising new therapeutic approach.

Perioperative care with fast-track management in patients undergoing pancreaticoduodenectomy

BACKGROUND

It has been considered that allowing patients to return to daily life earlier after surgery helps recovery of physiological function and reduces postoperative complications and hospital stay. We investigated the usefulness of fast-track management in perioperative care of patients undergoing pancreaticoduodenectomy (PD).

METHODS

Patients (n = 90) who received conventional perioperative management from 2005 to 2009 were included as the 'conventional group' (historical control group), and patients who received perioperative care with fast-track management (n = 100) from 2010 to March 2013 were included as the 'fast-track group'. To evaluate the efficacy of perioperative care with fast-track management, the incidence of postoperative complications and the length of hospital stay were compared between the two groups (comparative study). For statistical analysis, univariate analysis was performed using the χ (2) test or Fisher's exact test.

RESULTS

There was no significant difference between the two groups in sex, mean age, presence/absence of diabetes mellitus, preoperative drainage for jaundice, previous disease, operative procedure, mean duration of operation, or blood loss (p < 0.01). The incidence of surgical site infection in the conventional group and fast-track group was 28.9 and 14.0 %, respectively, with a significant difference between the two groups (p = 0.019). In addition, the incidence of pancreatic fistula (grade B, C) significantly differed between the two groups (27.8 % in the conventional group, 9.0 % in the fast-track group; p = 0.001). The mean postoperative hospital stay was 36.3 days in the conventional group and 21.9 days in the fast-track group (p < 0.001).

CONCLUSIONS

Perioperative care with fast-track management may reduce postoperative complications and decrease the length of hospital stay in patients undergoing PD.

Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines

OBJECTIVE

This article aims to provide the first systematic review of enhanced recovery after surgery (ERAS) programs for esophagectomy and generate guidelines.

BACKGROUND

ERAS programs use multimodal approaches to reduce complications and accelerate recovery. Although ERAS is well established in colorectal surgery, experience after esophagectomy has been minimal. However, esophagectomy remains an extremely high-risk operation, commonly performed in patients with significant comorbidities. Consequently, ERAS may have a significant role to play in improving outcomes. No guidelines or reviews have been published in esophagectomy.

METHODS

We undertook a systematic review of the PubMed, EMBASE, and the Cochrane databases in July 2012. The literature was searched for descriptions of ERAS in esophagectomy. Components of successful ERAS programs were determined, and when not directly available for esophagectomy, extrapolation from related evidence was made. Graded recommendations for each component were then generated.

RESULTS

Six retrospective studies have assessed ERAS for esophagectomy, demonstrating favorable morbidity, mortality, and length of stay. Methodological quality is, however, low. Overall, there is little direct evidence for components of ERAS, with much derived from nonesophageal thoracoabdominal surgery.

CONCLUSIONS

ERAS in principle seems logical and safe for esophagectomy. However, the underlying evidence is poor and lacking. Despite this, a number of recommendations for practice and research can be made.

Response to nutritional support and therapeutic approaches of amino acid and protein metabolism in surgical patients

The response to critical illness involves alterations in all aspects of metabolic control, favoring catabolism of body protein. In particular, body protein loss occurring as a result of the alteration of protein metabolism has been reported to be inversely correlated with the survival of critically ill patients. Despite the availability of various therapeutic modalities aiming to prevent loss of the body protein pool, such as total parenteral nutrition, enteral nutrition designed to provide excessive calories as a form of energy substrate, and protein itself, the loss of body protein cannot be prevented by any of these. Loss of the boyd protein store occurs as a consequence of the alteration of the intermediate metabolism that works for the production of energy substrate. This alteration of substrate metabolism may be linked to the alteration of protein metabolism. However, no specific factors regulating amino acid and protein metabolism have been identified. Thus, further investigations evaluating amino acid and protein metabolism are required to obtain better understanding of metabolic regulation in the body, which may lead to the development of novel and more effective therapeutic modalities for nutrition in the future.

Surgical quality of care in esophageal malignancies

Aim: Esophagectomy is the primary surgical treatment for localized malignant neoplasms of the esophagus, and while outcomes have shown that substantial improvement has been made, the ceiling for improvement is still high. Methods: A total of 2506 publications published from January 2002 to March 2012 were identified from PubMed, MEDLINE and the Cochrane Library using the keywords: ‘esophagectomy’, ‘esophagus’, ‘neoplasm’ and ‘cancer’ to identify quality key surgical articles in esophagectomy that were broken down into three groups: preoperative, intraoperative and postoperative care. Discussion: There have been limited preoperative surgical trials, mostly in preoperative antibiotic use, which have led to changes in surgical management. Key and substantial changes have occurred in the intraoperative management for esophageal malignancies around surgical anastomosis technique and anesthesia. Nutritional outcomes still remain a key challenge, and currently there is no established standard of care in the postoperative management of esophagectomy patients. Conclusion: We established quality parameters for leak rates, overall morbidity and mortality, and these form the foundation from which all esophageal surgeons should rank their results. We then utilized the techniques described above to maintain those rates or, better yet, to significantly improve those rates in each surgeons’ practice.

Pharmaceutical care for patients undergoing s-1 plus Cisplatin therapy for unresectable recurrent gastric cancer

We examined the adverse gastrointestinal events associated with tegafur/gimeracil/oteracil potassium (S-1) plus cisplatin therapy for unresectable recurrent gastric cancer and risk factors for discontinuing therapy due to adverse events. A total of 65 subjects who had received S-1 plus cisplatin therapy for gastric cancer at Ogaki Municipal Hospital were examined. We found that the risk factors for discontinuation of the therapy due to adverse events were serum albumin (Alb) level less than 3.5 g/dL (odds ratio [OR]: 321.14, P = .0015), creatinine clearance (CrCl) rate less than 78 mL/min (OR: 35.23, P = .0123), and performance status (PS) more than 1 (OR:12.62, P = .0243). Moreover, grade 3 or 4 nonhematological toxicities (including malaise and anorexia) were significantly higher in subjects with Alb less than 3.5 g/dL and CrCl less than 78 mL/min (P < .01). In conclusion, we should pay attention to the safety and continuity of S-1 plus cisplatin therapy in cases where the Alb level is <3.5 g/dL, CrCl level is <78 mL/min, and PS level is >1. Pharmacists should consider reducing the treatment dosage and providing nutritional support in such cases.

Effects of an immuno-enhanced diet containing antioxidants in esophageal cancer surgery following neoadjuvant therapy

Neoadjuvant therapy-induced immunological deterioration may be a key factor in postoperative morbidity in patients with esophageal cancer. This study aimed to determine the effects of perioperative feeding with an immuno-enhanced diet on immune competence in patients treated with neoadjuvant therapy followed by surgery. Because an immuno-enhanced diet that contained several antioxidants was used, perioperative oxidative stress and the effects of the immuno-enhanced diet on this stress were also investigated. Of 39 patients with esophageal cancer who underwent similar surgical procedures, 26 patients who received chemotherapy or chemoradiation therapy before surgery were randomly divided into two groups: group 1 (n= 14) was given an immuno-enhanced diet for 5 days before surgery, and group 2 (n= 12) received no enteral feeding products before surgery. Group 3 (n= 13) consisted of patients that did not receive neoadjuvant therapy and received no enteral feeding products before surgery. Several markers for coagulation and fibrinolysis were determined and immunological assessments were performed for each patient. To measure reactive oxygen metabolites and the total antioxidant capacity, diacron-reactive oxygen metabolites (d-ROMs) and OXY-adsorbent tests were performed using a free radical elective evaluator. Significant depression in lymphocyte numbers was observed in groups 1 and 2 before and early after surgery as compared to group 3. Numbers of B cells, CD4/CD8 ratio, and phytohemagglutinin-induced lymphocyte transformation tests were also significantly decreased in groups 1 and 2 on postoperative day 1. Fibrin and fibrinogen degradation products were significantly elevated in group 2 compared to group 1. d-ROMs and OXY-adsorbent test values were elevated before surgery and were decreased transiently early after surgery. Compared to groups 2 and 3, d-ROMs values were significantly lower in group 1 patients throughout the postoperative period, while OXY-adsorbent test values were significantly higher in group 2 patients. Oxidative index was significantly suppressed in group 1 compared to group 3. No significant intergroup differences were observed with regard to morbidity after surgery. Although the baseline levels of immunological function might have been different because of less-advanced cancer stages in group 3, neoadjuvant therapy significantly affected several immunological parameters. Preoperative administration of an immuno-enhanced diet did not significantly prevent neoadjuvant therapy-induced immunological deterioration prior to esophageal cancer surgery. Patients with esophageal cancer had elevated levels of oxidant and antioxidant activities before surgery, which were transiently decreased early after surgery. Although the underlying mechanisms for these perioperative changes are unclear, this study showed that an immuno-enhanced diet containing several antioxidants may reduce oxidative stress following esophageal cancer surgery. After these mechanisms are studied further, oxidative stress control may become another tool for perioperative management to reduce morbidity after esophageal cancer surgery.

Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis

BACKGROUND

A meta-analysis evaluating surgical outcomes following nutritional provision provided proximal to the anastomosis within 24 hours of gastrointestinal surgery compared with traditional postoperative management was conducted.

METHODS

Databases were searched to identify randomized controlled trials comparing the outcomes of early and traditional postoperative feeding. Trials involving gastrointestinal tract resection followed by patients receiving nutritionally significant oral or enteral intake within 24 hours after surgery were included for analysis.

RESULTS

Fifteen studies involving a total of 1240 patients were analyzed. A statistically significant reduction (45%) in relative odds of total postoperative complications was seen in patients receiving early postoperative feeding (odds ratio [OR] 0.55; confidence interval [CI], 0.35 -0.87, P = .01). No effect of early feeding was seen with relation to anastomotic dehiscence (OR 0.75; CI, 0.39-1.4, P = .39), mortality (OR 0.71; CI, 0.32-1.56, P = .39), days to passage of flatus (weighted mean difference [WMD] -0.42; CI, -1.12 to 0.28, P = .23), first bowel motion (WMD -0.28; CI, -1.20 to 0.64, P = .55), or reduced length of stay (WMD -1.28; CI, -2.94 to 0.38, P = .13); however, the direction of clinical outcomes favored early feeding. Nasogastric tube reinsertion was less common in traditional feeding interventions (OR 1.48; CI, 0.93-2.35, P = .10).

CONCLUSIONS

Early postoperative nutrition is associated with significant reductions in total complications compared with traditional postoperative feeding practices and does not negatively affect outcomes such as mortality, anastomotic dehiscence, resumption of bowel function, or hospital length of stay.

Immunonutrition in patients undergoing esophageal cancer resection

Specialized nutritional support containing immunonutrients such as arginine, omega-3 fatty acids, and ribonucleic acid significantly reduces the incidence of postoperative infective complications and hospital length of stay in elective surgery patients. However, immunonutrition use is not standard practice in esophago-gastric units internationally. This review provides a clinical update regarding the use of immunonutrition in patients undergoing major gastrointestinal surgery and, in particular, esophageal cancer resection, and provides direction for future collaborative research. A review of MEDLINE and Cochrane Library databases was conducted for randomized controlled trials or meta-analyses. A recent meta-analysis demonstrated that preoperative immunonutrition use significantly reduces hospital length of stay and the incidence of postoperative complications in patients undergoing major elective surgery, particularly for gastrointestinal malignancies. Only three small randomized controlled trials have evaluated immunonutrition use in patients exclusively undergoing esophageal cancer surgery. These were unable to determine whether immune-enhancing formulae positively influence key clinical outcomes such as mortality, hospital and intensive care unit length of stay, and postoperative morbidity in this patient group. Currently, there is insufficient evidence to recommend routine use of immunonutrition in patients undergoing esophageal cancer surgery. Future collaborative research should evaluate whether: (i) immunonutrition use positively influences key clinical outcomes in this population; (ii) these patients benefit from preoperative supplementation with an immune-enhancing formula or whether they require postoperative continuation (perioperative approach) to combat their risk of complications after surgery; and (iii) these formulae can be used safely in those patients who develop sepsis.

Oral nutritional supplements containing (n-3) polyunsaturated fatty acids affect the nutritional status of patients with stage III non-small cell lung cancer during multimodality treatment

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), (n-3) fatty acids from fish oil, have immune-modulating effects and may improve nutritional status in cancer. The objective of this study was to investigate the effects of an oral nutritional supplement containing (n-3) fatty acids on nutritional status and inflammatory markers in patients with non-small cell lung cancer (NSCLC) undergoing multimodality treatment. In a double-blind experiment, 40 patients with stage III NSCLC were randomly assigned to receive 2 cans/d of a protein- and energy-dense oral nutritional supplement containing (n-3) fatty acids (2.0 g EPA + 0.9 g DHA/d) or an isocaloric control supplement. EPA in plasma phospholipids, energy intake, resting energy expenditure (REE), body weight, fat free mass (FFM), mid-upper arm circumference (MUAC), and inflammatory markers were assessed. Effects of intervention were analyzed by generalized estimating equations and expressed as regression coefficients (B). The intervention group (I) had a better weight maintenance than the control (C) group after 2 and 4 wk (B = 1.3 and 1.7 kg, respectively; P < 0.05), a better FFM maintenance after 3 and 5 wk (B = 1.5 and 1.9 kg, respectively; P < 0.05), a reduced REE (B = -16.7% of predicted; P = 0.01) after 3 wk, and a trend for a greater MUAC (B = 9.1; P = 0.06) and lower interleukin-6 production (B = -27.9; P = 0.08) after 5 wk. After 4 wk, the I group had a higher energy and protein intake than the C group (B = 2456 kJ/24 h, P = 0.03 and B = 25.0 g, P = 0.01, respectively). In conclusion, a protein- and energy-dense oral nutritional supplement containing (n-3) fatty acids beneficially affects nutritional status during multimodality treatment in patients with NSCLC.

Development of clinical application for a nutritional prescription support system for total parenteral/enteral nutrition

One of the important roles of pharmacists as members of a nutrition support team is nutritional prescription support. We developed a nutritional prescription support system (NPSS) that facilitates prescription support and analysis and evaluated its usefulness in nutritional therapy. An NPSS for prescription support and the management of patient information was created. With this NPSS, the nutritional status was assessed, and, on the basis of the results, such variables as the total energy expenditure were calculated. This system allows prescription support for parenteral nutrition (PN) therapy, enteral nutrition (EN) therapy, and the transition period between them. This system was used for 2 representative patients and evaluated. In a malnourished patient receiving oral warfarin, EN solutions were compared by means of the NPSS, and an appropriate EN solution was selected. In addition, the prothrombin time-international normalized ratio was monitored, and favorable results were obtained regarding the adjustment of the warfarin dose and nutritional management. In a patient with aspiration pneumonia, continuous nutritional management to EN from PN therapy was straightforwardly performed with the NPSS. This NPSS allows rapid, comprehensive nutritional management during the transition period to EN from PN therapy, despite these therapies being considered separately in conventional nutritional management. The NPSS is useful for simplifying prescription support and facilitating information sharing among members of a nutrition support team.

Comparison of enteral nutrition with combined enteral and parenteral nutrition in post-pancreaticoduodenectomy patients: a pilot study

Background

Many clinical studies have demonstrated that early postoperative enteral nutrition (EN) improved the postroperative course. Post-pancreaticoduodenectomy (PD), patients tend to suffer from postoperative nausea, abdominal distention, and diarrhoea, causing difficulty in the introduction of EN. In this pilot study, we investigated the appropriate nutritional mode post-pancreatic surgery.

Methods

Between October 2006 and March 2007 2 postoperative nutritional methods were implemented in 17 patients in a prospective single-centere study. Eight patients received only enteral nutrition (EN group) and 9 patients received enteral nutrition combined with parenteral nutrition (EN + PN group).

Results

There were no differences in the patient characteristics and postoperative morbidity between the 2 groups. The rate of discontinuance of enteral feeding was significantly high in the EN group, and the duration of enteral feeding was significantly longer in the EN + PN group. The central venous line was retained for a significantly longer period in the EN + PN group, but there was no difference in the frequency of catheter-related infection between the 2 groups.

Conclusion

EN combined with PN is more adequate for patients after pancreatic surgery.

The nutrient formula containing eicosapentaenoic acid and docosahexaenoic acid benefits the fatty acid status of patients receiving long-term enteral nutrition

Currently, various formulas with different fatty acid compositions are used for enteral nutrition (EN). All formulas contain various concentrations of essential fatty acids: linoleic acid (LA) and alpha-linolenic acid (ALA); LA is biotransformed into arachidonic acid (AA) and ALA into eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in vivo. Some formulas contain preformed EPA and DHA. However, the effects of the differences in the fatty acid composition on the fatty acid status of patients receiving long-term EN is not clear. We measured serum fatty acid concentrations in 50 patients with neurological diseases receiving long-term EN. The data were then compared retrospectively with reference to the fatty acid compositions of the formulas used. All of the patients received almost their entire nutritional intake via EN for at least 1 year. Blood samples were obtained just before injecting the EN solution. Among the formulas that did not include EPA or DHA, formulas with low ALA concentrations were associated with low serum EPA and DHA. Conversely, the ALA-enriched formulas with reduced LA concentrations significantly increased EPA and DHA levels, although the levels remained lower than the control values. With the formula containing EPA and DHA, the EPA and DHA levels reached control values. Therefore, the fatty acid composition of the EN formulas affected the fatty acid status of patients receiving long-term EN. Formulas containing preformed EPA and DHA with suitable amounts of essential fatty acids may benefit these patients.

Enteral nutrition enriched with eicosapentaenoic acid (EPA) preserves lean body mass following esophageal cancer surgery: results of a double-blinded randomized controlled trial

BACKGROUND

Esophagectomy represents an exemplar of controlled major trauma, with marked metabolic, immunologic, and physiologic changes as well as an associated high incidence of complications. Eicosapentaenoic acid (EPA) enriched enteral nutrition (EN) modulates immune function and limits catabolism in patients with advanced cancer, but its impact in the peri-operative period is unclear.

OBJECTIVES

To examine the effects of perioperative EPA enriched EN on the metabolic, nutritional, and immuno-inflammatory response to esophagectomy, and on postoperative complications.

METHODS

In a double-blind design, patients were randomized to a standard EN formula or a formula enriched with 2.2 g EPA/d for 5 days preoperatively (orally) and 21 days postoperatively (jejunostomy). Segmental bioelectrical impedance analysis was performed preoperatively and on POD 21. Postoperative complications were monitored, as well as the acute phase response, coagulation markers, and serum cytokines.

RESULTS

Fifty-three patients (28 EPA, 25 standard) completed the study, and both groups were well matched. Serum and peripheral blood mononuclear cell (PBMC) membrane EPA levels were significantly increased in the EPA group. There was no difference in the incidence of major complications. The EPA group maintained all aspects of body composition postoperatively, whereas patients in the standard EN group lost significant amounts of fat-free mass (1.9 kg, P = 0.030) compared with the EPA group [leg (0.3 kg, P = 0.05), arm (0.17 kg, P = 0.01), and trunk (1.44 kg, P = 0.03)]. The EPA group had a significantly (P < 0.05) attenuated stress response for TNFalpha, IL-10, and IL-8 compared with the standard group.

CONCLUSIONS

EPA supplemented early EN is associated with preservation of lean body mass post esophagectomy compared with a standard EN. These properties may merit longer-term study to address its impact on recovery of function and quality of life in models of complex surgery or multimodal cancer treatment regimens.

Multi-targeted therapy of cancer by omega-3 fatty acids

Omega-3 (n-3) and omega-6 (n-6) polyunsaturated fatty acids (PUFAs) are essential fatty acids necessary for human health. Currently, the Western diet contains a disproportionally high amount of n-6 PUFAs and low amount of n-3 PUFAs, and the resulting high n-6/n-3 ratio is thought to contribute to cardiovascular disease, inflammation, and cancer. Studies in human populations have linked high consumption of fish or fish oil to reduced risk of colon, prostate, and breast cancer, although other studies failed to find a significant association. Nonetheless, the available epidemiological evidence, combined with the demonstrated effects of n-3 PUFAs on cancer in animal and cell culture models, has motivated the development of clinical interventions using n-3 PUFAs in the prevention and treatment of cancer, as well as for nutritional support of cancer patients to reduce weight loss and modulate the immune system. In this review, we discuss the rationale for using long-chain n-3 PUFAs in cancer prevention and treatment and the challenges that such approaches pose in the design of clinical trials.

Physico-chemical characterisation of lipids from Mytilus galloprovincialis (L.) and Rapana venosa and their healing properties on skin burns

Black Sea molluscs and gastropods are the most studied organisms from the Romanian littoral zone. In particular, those from the Mytilidae species are of great interest because biochemical investigations have shown that they can be sources of biological active substances which can have different applications (e.g. food additives). We report here the extraction of lipids from two different species of molluscs (Mytilus galloprovincialis L., Mediterranean mussel) and gastropods (Rapana venosa, hard-shell clam). The extracts were evaluated in terms of antioxidant and composition properties and their healing properties were tested on skin burns in Wistar rats. Our studies proved that the two lipid extracts contained a relatively complex distribution of compounds, in terms of characteristic indices, polyunsaturated fatty acids (PUFA) and vitamins E and D. The presence of such compounds rendered the extracts very efficient in healing induced skin burns in Wistar rats. The histological analysis showed a reduction in the time of healing (12-13 and 13-15 days for the Mytilus galloprovincialis (L.) Rapana venosa extracts, respectively) compared to 20-22 for untreated animals, based on results from tissues and blood samples. Our investigations have been proved to be promising in terms of future potential applications of the extracts as skin-care products, cosmetics and/or pharmaceutical preparations owing to their dermorestitutive properties.

Enteral immuno-enhanced diets with arginine are safe and beneficial for patients early after esophageal cancer surgery

We previously reported that provision of immediate enteral nutrition (EN) with a certain amount of omega (omega)-3 fatty acids (FAs) in patients after esophageal cancer surgery resulted in reduced platelet aggregation, coagulation activity, and cytokine production. We investigated whether EN using immuno-enhanced diet (IED) containing a large amount of omega-3 FAs as well as arginine and RNA affected the above-described responses. We also attempted to reveal whether arginine in the IED can potentially harm patients who undergo esophageal cancer surgery. Twenty-nine patients with esophageal cancer who underwent similar surgical procedures were selected. All patients received EN starting immediately after surgery. Fourteen patients received the formula with fewer omega-3 FAs, and fifteen patients received the IED. Administration of the IED tended to inhibit postoperative decrease in platelet count. Prothrombin activity and thrombin-antithrombin III complex levels were significantly reduced in the IED group. Plasma IL-8 levels were significantly lower (P < 0.05) in patients without the IED on the fifth postoperative day (POD). The proportion of T-cells was significantly higher (P < 0.05) in the IED group on PODs 1 and 7. Nitrate/nitrite levels did not differ significantly between the two groups. Early EN with an IED may enhance the inhibitory effects on postoperative platelet aggregation and hypercoagulation, and appeared to be advantageous to T-cell proliferation. These effects are expected to be beneficial in patients at risk of developing infectious complications. This study also showed that the IED could be safely used without any adverse effects for patients early after a radical surgery for the esophageal cancer.

Docosahexaenoic acid enhances the toxic effect of imatinib on Bcr-Abl expressing HL-60 cells

The effect of docosahexaenoic acid (DHA) on the killing efficacy of imatinib on HL-60 cells expressing the Bcr-Abl protein was investigated. Imatinib is an Abl tyrosine kinase inhibitor used in the treatment of patients with chronic myeloid leukemia. The pre-treatment with DHA for 24 h raised the effect of imatinib at 100 microM concentration only. On the other hand, after 72 h pre-treatment, all concentrations of DHA tested (25, 50 and 100 microM) enhanced the toxic effect of imatinib. These results indicate that long-term pre-treatment with DHA makes Bcr-Abl HL-60 cells more susceptible to the toxic effect of imatinib.

Clinical Significance of Perioperative Immunonutrition for Patients with Esophageal Cancer

BACKGROUND

We hypothesized that preoperative and/or postoperative enteral immune-enhanced formulas that are supplemented with arginine, omega-3 fatty acids, and RNA may reduce postoperative complications in patients undergoing esophagectomy for thoracic esophageal squamous cell carcinoma (ESCC).

METHODS

Forty patients who underwent esophagectomy were divided into three groups: group A (n = 20) received a control enteral diet (Erental) through the jejunostomy after surgery. group B (n = 6) received an enteral diet supplemented with immune-enhancing substrates (Impact) containing arginine, omega-3 fatty acids, and RNA after surgery. group C (n = 14) received the impact before and after surgery.

RESULTS

Lymphocyte counts in group C on postoperative day (POD) 7 were somewhat higher than that in group A (p = 0.07) and significantly higher than in group B (p = 0.03). Furthermore the incidence of incisional wound infection in group C was significantly lower than that in group A (p = 0.03). Moreover, the duration of postoperative systemic inflammatory response syndrome (SIRS) was significantly shorter in group C than in group A (p < 0.05).

CONCLUSIONS

This study reveals that the perioperative immune-enhanced formula may be superior to postoperative control enteral formulas in terms of reducing surgical wound infection and postoperative SIRS, which may result in serious postoperative complications for patients who have undergone esophagectomy.

Prise en charge anesthésique de l'œsophagectomie: avancées et perspectives

Oesophagectomy is still characterized by a high postoperative mortality and respiratory morbidity. Nevertheless, epidemiological, medical and surgical advances have improved the management of this surgical procedure. The anaesthesiologist influence is present at each level, from the preoperative evaluation to the management of postoperative complications. The preoperative period is improved by the use of assessment scores, the better knowing of respiratory risk factors and of the neoadjuvant therapy adverse effects. The main objective of the operative period is to ensure a rapid weaning procedure and stability of the respiratory and haemodynamic functions, warranting the anastomotic healing. The interest of the association between respiratory rehabilitation and thoracic epidural analgesia is highlighted in the postoperative period. The management of postoperative complications, mainly represented by respiratory failure and anastomotic leakages, requires a multidisciplinary analysis. The potential interest of non-invasive ventilation and of the modulation of postoperative inflammatory response needs further investigation.