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Short-term evaluation of immune levels and nutritional values of EN versus PN in gastric cancer: a systematic review and a meta-analysis.
Xin, F, Mzee, SAS, Botwe, G, He, H, Zhiyu, S, Gong, C, Said, ST, Jixing, C
World journal of surgical oncology. 2019;(1):114
Abstract
BACKGROUND Postsurgical patients' oral feeding begins with clear fluids 1-3 days after surgery. This might not be sufficiently nutritious to boost the host immune system and provide sufficient energy in gastric neoplastic patients to achieve the goal of enhanced recovery after surgery (ERAS). Our objective was to analyze the significance of early postoperative feeding tubes in boosting patients' immunity and decreasing incidence of overall complications and hospital stay in gastric cancer patients' post-gastrectomy. METHODS From January 2005 to May 24, 2019, PubMed and Cochrane databases were searched for studies involving enteral nutrition (EN) feeding tubes in comparison to parenteral nutrition (PN) in gastric cancer patients undergoing gastrectomy for gastric malignancies. Relative risk (RR), mean difference (MD), or standard mean difference (SMD) with 95% confidence interval (CI) were used to estimate the effect sizes, and heterogeneity was assessed by using Q and χ2 statistic with their corresponding P values. All the analyses were performed with Review Manager 5.3 and SPSS version 22. RESULTS Nine randomized trials (n = 1437) and 5 retrospective studies (n = 421) comparing EN feeding tubes and PN were deemed eligible for the pooled analyses, with a categorized time frame of PODs ≥ 7 and PODs < 7. Ratio of CD4+/CD8+ in EN feeding tubes was the only outcome of PODs < 7, which showed significance (MD 0.22, 95% CI 0.18-0.25, P < 0.00001). Regarding other immune indicators, significant outcomes in favor of EN feeding tubes were measured on POD ≥ 7: CD3+ (SMD 1.71; 95% CI 0.70, 2.72; P = 0.0009), CD4+ (MD 5.84; 95% CI 4.19, 7.50; P < 0.00001), CD4+/CD8+ (MD 0.28; 95% CI 0.20; 0.36, P < 0.00001), NK cells (SMD 0.94; 95% CI 0.54, 1.30; P < 0.00001), nutrition values, albumin (SMD 0.63; 95% CI 0.34, 0.91; P < 0.001), prealbumin (SMD 1.00; 95% CI 0.52, 1.48; P < 0.00001), and overall complications (risk ratio 0.73 M-H; fixed; 95% CI 0.58, 0.92; P = 0.006). CONCLUSION EN feeding tube support is an essential intervention to elevate patients' immunity, depress levels of inflammation, and reduce the risk of complications after gastrectomy for gastric cancer. Enteral nutrition improves the innate immune system and nutrition levels but has no marked significance on certain clinical outcomes. Also, EN reduces the duration of hospital stay and cost, significantly.
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Early enteral nutrition therapy in congenital cardiac repair postoperatively: A randomized, controlled pilot study.
Sahu, MK, Singal, A, Menon, R, Singh, SP, Mohan, A, Manral, M, Singh, D, Devagouru, V, Talwar, S, Choudhary, SK
Annals of cardiac anaesthesia. 2016;(4):653-661
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BACKGROUND AND OBJECTIVES Adequate nutritional supplementation in infants with cardiac malformations after surgical repair is a challenge. Critically ill infants in the early postoperative period are in a catabolic stress. The mismatch between estimated energy requirement (EER) and the intake in the postoperative period is multifactorial, predisposing them to complications such as immune deficiency, more infection, and growth failure. This study aimed to assess the feasibility and efficacy of enriched breast milk feed on postoperative recovery and growth of infants after open heart surgery. METHODOLOGY Fifty infants <6 months of age were prospectively randomized in the trial for enteral nutrition (EN) postoperatively from day 1 to 10, after obtaining the Institute Ethics Committee's approval. They were equally divided into two groups on the basis of the feed they received: Control group was fed with expressed breast milk (EBM; 0.65 kcal/ml) and intervention group was fed with EBM + energy supplementation/fortification with human milk fortifier (7.5 kcal/2 g)/Simyl medium-chain triglyceride oil (7.8 kcal/ml). Energy need for each infant was calculated as per EER at 90 kcal/kg/day, as the target requirement. The intra- and post-operative variables such as cardiopulmonary bypass and aortic cross-clamp times, ventilation duration, Intensive Care Unit (ICU), and hospital length of stay and mortality were recorded. Anthropometric and hematological parameters and infection control data were recorded in a predesigned pro forma. Data were analyzed using Stata 14.1 software. RESULTS The duration of mechanical ventilation, length of ICU stay (LOIS), length of hospital stay (LOHS), infection rate, and mortality rate were lower in the intervention group compared to the control group although none of the differences were statistically significant. Infants in control group needed mechanical ventilation for about a day more (i.e., 153.6 ± 149.0 h vs. 123.2 ± 107.0 h; P = 0.20) than those in the intervention group. Similarly, infants in control group stayed for longer duration in the ICU (13.2 ± 8.9 days) and hospital (16.5 ± 9.8 days) as compared to the intervention group (11.0 ± 6.1 days; 14.1 ± 7.0 days) (P = 0.14 and 0.17, respectively). The LOIS and LOHS were decreased by 2.2 and 2.4 days, respectively, in the intervention group compared to control group. The infection rate (3/25; 5/25) and mortality rate (1/25; 2/25) were lower in the intervention group than those in the control group. The energy intake in the intervention group was 40 kcal more (i.e., 127.2 ± 56.1 kcal vs. 87.1 ± 38.3 kcal) than the control group on the 10th postoperative day. CONCLUSIONS Early enteral/oral feeding after cardiac surgery is feasible and recommended. In addition, enriching the EBM is helpful in achieving the maximum possible calorie intake in the postoperative period. EN therapy might help in providing adequate nutrition, and it decreases ventilation duration, infection rate, LOIS, LOHS, and mortality.
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The effects of enteral immunonutrition in upper gastrointestinal surgery: A systematic review and meta-analysis.
Wong, CS, Aly, EH
International journal of surgery (London, England). 2016;:137-50
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AIM: The beneficial of immunonutrition on overall morbidity and mortality remains uncertain. We undertook a systematic review to evaluate the effects of immune-enhancing enteral nutrition (IEN) in upper gastrointestinal (GI) surgery. METHODS Main electronic databases [MEDLINE via Pubmed, EMBASE, Scopus, Web of Knowledge, Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library, and clinical trial registry (ClinicalTrial.gov)] were searched for studies reported clinical outcomes comparing standard enteral nutrition (SEN) and immunonutrition (IEN). The systematic review was conducted in accordance with the PRISMA guidelines and meta-analysis was analysed using fixed and random-effects models. RESULTS Nineteen RCTs with a total of 2016 patients (1017 IEN and 999 SEN) were included in the final pooled analysis. The ratio of patients underwent oesophagectomy:gastrectomy:pancreatectomy was 2.2:1.2:1.0. IEN, when administered post-operatively, was associated with a significantly lower risk of wound infection (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.40 to 0.88; p = 0.009) and shorter length of hospital stay (MD -2.92 days, 95% CI -3.89 to -1.95; p < 0.00001). No significant differences in other post-operative morbidities of interest (e.g. anastomotic leak and pulmonary infection) and mortality between the two groups were identified. CONCLUSIONS Overall, our analysis found that IEN decreases wound infection rates and reduces length of stay. It should be recommended as routine nutritional support as part of the Enhanced Recovery after Surgery (ERAS) programmes for upper GI Surgery.
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Prospective double-blind randomized study on the efficacy and safety of an n-3 fatty acid enriched intravenous fat emulsion in postsurgical gastric and colorectal cancer patients.
Ma, CJ, Wu, JM, Tsai, HL, Huang, CW, Lu, CY, Sun, LC, Shih, YL, Chen, CW, Chuang, JF, Wu, MH, et al
Nutrition journal. 2015;:9
Abstract
BACKGROUND A lipid emulsion composed of soybean oil (long-chain triglycerides, LCT), medium-chain triglycerides (MCT) and n-3 poly-unsaturated fatty acids (PUFAs) was evaluated for immune-modulation efficacy, safety, and tolerance in patients undergoing major surgery for gastric and colorectal cancer. METHODS In a prospective, randomized, double-blind study, 99 patients with gastric and colorectal cancer receiving elective surgery were recruited and randomly assigned to either the study group, receiving the n-3 PUFAs enriched intravenous fat emulsion (IVFE), or the control group, receiving a lipid emulsion comprised of soybean oil and MCTs (0.8 - 1.5 g · kg-1 · day-1) as part of total parenteral nutrition (TPN) regimen from surgery (day -1) up to post-operative day 7. Safety and efficacy parameters were assessed on day -1 and post-operative visits on day 1, 3, and 7. Adverse events were documented daily and compared between the groups. RESULTS Pro-inflammatory markers, laboratory parameters, and adverse events did not differ prominently between the 2 groups, with the exception of net changes (day 7 minus day -1) of free fatty acids (FFAs), triglyceride, and high-density lipoprotein (HDL). Net decrease of FFAs was remarkably higher in the study group, while the net increase of triglyceride and decrease of HDL was significantly lower. CONCLUSIONS The n-3 PUFA-enriched IVFE showed improvements in lipid metabolism. In respect of efficacy, safety and tolerance both IVFE were comparable. In patients with severe stress, there is an inflammation-attenuating effect of n-3 PUFAs. Further, adequately powered clinical trials will be necessary to address this question in postsurgical GI cancer patients. TRIAL REGISTRATION US ClinicalTrials.gov NCT00798447.
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Perioperative immunonutrition in surgical cancer patients: a summary of a decade of research.
Klek, S, Szybinski, P, Szczepanek, K
World journal of surgery. 2014;(4):803-12
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BACKGROUND Immunonutrition is assumed to enhance immune system function. In surgical patients, it is supposed to reduce postoperative complications. However, results of recent clinical trials have been puzzling and have not supported this theory. AIM: The aim of our study was to evaluate the value of enteral and parenteral postoperative immunonutrition. METHODS After initial evaluation of 969 patients, the intent-to-treat analysis included 776 patients (female 407, male 466, mean age 61.1 years) undergoing gastric or pancreatic resections between 2001 and 2009. All patients were randomly assigned after surgery to one of the following groups: standard enteral nutrition (SEN), immunomodulating enteral nutrition (IMEN), standard parenteral nutrition (SPN), or immunomodulating parenteral nutrition (IMPN). All malnourished patients received preoperative parenteral nutrition. Number and type of postoperative complications, length of hospitalization (length of stay [LOS]), and vital organ function were assessed. RESULTS No statistically significant differences were observed in well-nourished patients, during either enteral or parenteral intervention, independent of the type of intervention (standard or immunomodulating). However, analysis of the malnourished group revealed the positive impact of enteral immunonutrition on reduction of postoperative complications (28.3 vs. 39.2 %, respectively; p = 0.043) and LOS (17.1 and 13.1 days, respectively; p < 0.05) compared with a standard enteral diet. The cross-analysis of SEN, IMEN, SPN, and IMPN was insignificant. CONCLUSIONS The type of postoperative nutrition was of no importance in well-nourished patients. However, in malnourished patients, enteral immunonutrition helped to improve treatment outcome. These findings suggest its use as a method of choice during the postoperative period.
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Fast-track improves post-operative nutrition and outcomes of colorectal surgery: a single-center prospective trial in China.
Li, K, Li, JP, Peng, NH, Jiang, LL, Hu, YJ, Huang, MJ
Asia Pacific journal of clinical nutrition. 2014;(1):41-7
Abstract
Fast-track (FT) has been shown to enhance post-operative recovery. The aim of this study was to compare the effects of FT and traditional nutrition on post-operative rehabilitation, as well as evaluate the feasibility of applying FT in nutrition management of colorectal surgery. A prospective and randomized controlled trial was performed. This study included 464 patients who underwent colorectal surgery. The patients were randomly assigned into an FT group and a traditional group. The nutritional risk screening (NRS 2002) score, post-operative recovery index and surgical complications were compared between the FT and traditional groups. The NRS 2002 score in the FT group was better than the traditional group (p<0.05). Serum indicators for nutrition (HGB, ALB, A/G) and immune function (lymphocyte rate [LYMPH%], IgA, and CD4+) in the FT group were superior to those in the traditional group (p<0.05) on post-operative day 5. The first time to aerofluxus, defecation, oral intake and ambulation in the FT group was shorter when compared to the traditional group (p<0.05). The complication incidence was significantly lower in the FT group than in the traditional group (p<0.05). In particular, the occurrence rate of anastomotic leakage was higher in the traditional group than in the FT group (0.5% vs 2.8%, p<0.05). Taken together, these data suggest that FT management can improve the nutritional condition and outcomes of colorectal surgical patients.
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Bench-to-bedside review: Routine postoperative use of the nasogastric tube - utility or futility?
Tanguy, M, Seguin, P, Mallédant, Y
Critical care (London, England). 2007;(1):201
Abstract
This article provides a summary of current information on rational postoperative use of the nasogastric tube, based on a review of literature related to postoperative gastrointestinal discomfort and management with the nasogastric tube. Routine gastric decompression after major surgery neither hastens the return of bowel function nor diminishes the incidence of postoperative nausea and vomiting. The multimodal postoperative rehabilitation programme is a modern and more efficient approach. Omission of nasogastric tube decompression does not increase the incidence of anastomotic leakage or wound dehiscence. Conversely, early enteral feeding is feasible and safe, favours local immunity and gut integrity, and improves nutritional status. With the objective to feeding, nasogastric tube could be used in selected patients. To conclude, use of the nasogastric tube to prevent or limit postoperative gastrointestinal discomfort must be challenged. In contrast to gastric decompression, early gastric feeding must be considered within the new concept of fast track surgery.
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Nutritional support after open liver resection: a systematic review.
Richter, B, Schmandra, TC, Golling, M, Bechstein, WO
Digestive surgery. 2006;(3):139-45
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BACKGROUND Perioperative nutrition in patients with limited liver function after partial hepatic resection is still controversial. In particular, the significance of perioperative total enteral nutrition remains unresolved. The aim of this review is to investigate the impact of early postoperative total enteral nutrition on convalescence after partial liver resection. MATERIALS AND METHODS In an internet-based Medline-Search (time course: 1960-08/2005) a total of five prospective, randomized controlled trials were found comparing the impact of enteral and parenteral nutrition after liver resection. After study validity had been established, a systematic review was undertaken (odds ratio, 95% confidence interval, p < 0.05 level of significance; Review Manager 4.2, The Cochrane Collaboration). Primary endpoints were complication rate (infection, organ malfunction) and mortality. Standardized immune parameters were also surveyed. RESULTS Statistical analysis showed that enteral nutrition resulted in a significantly lower rate (p = 0.04) of wound infection and catheter-related complications than parenteral nutrition did. No statistically significant differences in mortality due to enteral or parenteral nutrition could be found. Patients receiving enteral nutrition showed better postoperative immune competence. CONCLUSION Early enteral nutrition after liver resection is a safe procedure. Compared to parenteral nutrition it is associated with a decreased incidence of postoperative complications. Facing the inhomogeneity of these trials, especially in nutrition protocols and end points, this first systematic review stresses the need for an update of the importance of early enteral nutrition after liver resection within randomized controlled multicenter trials.