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Is immunonutrition superior to standard enteral nutrition in reducing postoperative complications in patients undergoing esophagectomy? A meta-analysis of randomized controlled trials.
Zhuo, ZG, Luo, J, Song, HYDTN, Alai, GH, Shen, X, Lin, YD
Journal of B.U.ON. : official journal of the Balkan Union of Oncology. 2021;(1):204-210
Abstract
PURPOSE Perioperative enteral nutrition supports are recommended in esophagus cancer patients. Immunonutrition contains immuno-enhancing nutrients in addition to standard formula. These new nutrients are thought to be efficacious in reducing inflammatory response and improving postoperative immune response and they have been proved to be better than standard enteral nutrition in reducing postoperative complications in gastric cancer. However, if it would lead to a better clinical outcome in patients undergoing esophagectomy remains controversial. METHODS A systematic literature search was performed in the online database of PubMed, Medline, EMBASE and Cochrane Library. The relevant studies were screened out of the results by reading titles and abstracts. Then, we read the full-texts to finally confirm the studies included in this meta-analysis. RESULTS Six randomized controlled trials having enrolled 638 patients were included in the final analysis. The pooled analysis didn't show statistically significant difference between immunonutrition group and standard nutrition group in reducing postoperative complications. CONCLUSIONS The postoperative complications are comparable between immunonutrition and the standard enteral nutrition in patients undergoing esophagectomy, but its value in severe malnutrition patients is undetermined, whereas the high tolerance and other advantages brought by the immunonutrition should not be overlooked and need to be further proved.
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Effect of preoperative immunonutrition on outcomes of colon cancer surgery: study protocol for a randomized controlled trial.
Lee, SY, Yeom, SS, Kim, CH, Kim, HR
Trials. 2020;(1):628
Abstract
BACKGROUND Current guidelines recommend the prescription of immune-enriched oral nutritional supplements for malnourished patients before major gastrointestinal surgery. However, the benefit of preoperative immunonutrition is still controversial. This randomized controlled trial aims to evaluate the effect of preoperative immunonutrition on the outcomes of surgery for colon cancer. METHODS/DESIGN Patients with primary colon cancer will be included as study participants after screening. They will be randomly assigned (in a ratio of 1:1) to receive preoperative immunonutrition added to the normal diet (experimental arm) or consume normal diet alone (control arm). Patients in the experimental arm will receive oral supplementation (400 mL/day) with arginine and ω-3 fatty acids for 7 days before elective surgery. The primary endpoint is the rate of infectious complications, while the secondary endpoints are postoperative complication rate, change in body weight, length of hospital stay, and nature of fecal microbiome. The authors hypothesize that the rate of infectious complications would be 13% in the experimental arm and 30% in the control arm. With a two-sided alpha of 0.05 and a power of 0.8, the sample size is calculated as 176 patients (88 per arm). DISCUSSION Although there have been many studies demonstrating significant benefits of preoperative immunonutrition, these were limited by a small sample size and potential publication bias. Despite the recommendation of immunonutrition before surgery in nutritional guidelines, its role in reduction of rate of infectious complications is still controversial. This trial is expected to provide evidence for the benefits of administration of preoperative immunonutrition in patients with colon cancer. TRIAL REGISTRATION Clinical Research Information Service KCT0003770 . Registered on 15 April 2019.
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Impact of oral preoperative and perioperative immunonutrition on postoperative infection and mortality in patients undergoing cancer surgery: systematic review and meta-analysis with trial sequential analysis.
Buzquurz, F, Bojesen, RD, Grube, C, Madsen, MT, Gögenur, I
BJS open. 2020;(5):764-775
Abstract
BACKGROUND Infectious complications occur in 4-22 per cent of patients undergoing surgical resection of malignant solid tumours. Improving the patient's immune system in relation to oncological surgery with immunonutrition may play an important role in reducing postoperative infections. A meta-analysis was undertaken to evaluate the potential clinical benefits of immunonutrition on postoperative infections and 30-day mortality in patients undergoing oncological surgery. METHODS PubMed, Embase and Cochrane Library databases were searched to identify eligible studies. Eligible studies had to include patients undergoing elective curative surgery for a solid malignant tumour and receiving immunonutrition orally before surgery, including patients who continued immunonutrition into the postoperative period. The main outcome was overall infectious complications; secondary outcomes were surgical-site infection (SSI) and 30-day mortality, described by relative risk (RR) with trial sequential analysis (TSA). Risk of bias was assessed according to Cochrane methodology. RESULTS Some 22 RCTs with 2159 participants were eligible for meta-analysis. Compared with the control group, immunonutrition reduced overall infectious complications (RR 0·58, 95 per cent c.i. 0·48 to 0·70; I2 = 7 per cent; TSA-adjusted 95 per cent c.i. 0·28 to 1·21) and SSI (RR 0·65, 95 per cent c.i. 0·50 to 0·85; I2 = 0 per cent; TSA-adjusted 95 per cent c.i. 0·21 to 2·04). Thirty-day mortality was not altered by immunonutrition (RR 0·69, 0·33 to 1·40; I2 = 0 per cent). CONCLUSION Immunonutrition reduced overall infectious complications, even after controlling for random error, and also reduced SSI. The quality of evidence was moderate, and mortality was not affected by immunonutrition (low quality). Oral immunonutrition merits consideration as a means of reducing overall infectious complications after cancer surgery.
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An observational study of perioperative nutrition and postoperative outcomes in patients undergoing laparotomy at Queen Elizabeth Central Hospital in Blantyre, Malawi.
Katundu, KG, Mutafya, TW, Lozani, NC, Nyirongo, PM, Uebele, ME
Malawi medical journal : the journal of Medical Association of Malawi. 2018;(2):79-85
Abstract
BACKGROUND Nutritional status in patients undergoing surgery can influence their immune function, tissue repair and, hence, clinical outcomes. This study aimed to assess the perioperative nutrition and postoperative outcome of patients undergoing laparotomy at a tertiary hospital in Malawi. METHODS A total of 25 patients were included in this prospective, observational study. The Subjective Global Assessment was used to classify each patient according to nutritional status. Handgrip strength was measured for each patient preoperatively and at day 3 postoperatively. Anthropometric measurements were also done. Protein and energy requirements for each participant were estimated and compared to the quantities provided by the hospital diet. Patients were followed up until discharge and outcome variables which included length of hospital stay and wound dehiscence or infectious complications were recorded. RESULTS Of the study participants, 20% were well-nourished, 52% were moderately malnourished and 28% were severely malnourished. The median handgrip strength decreased at day 3 postoperatively from the preoperative handgrip strength. Well-nourished patients had higher handgrip strength than malnourished patients both preoperatively and postoperatively. Total energy and protein provided by the hospital diet were significantly lower than the estimated requirements for the patients. Severely malnourished patients had increased median length of hospital stay and increased rate of postoperative complications. Preoperative and postoperative day 3 handgrip strength correlated negatively with the number of postoperative complications and length of hospital stay. CONCLUSION This study showed high rates of malnutrition and inadequate in-hospital nutritional support which were associated with poor clinical outcomes, especially in severely malnourished patients. Proper nutritional assessment and provision of adequate nutritional support should be reinforced in surgical patients to promote favourable clinical outcomes postoperatively. Further studies with larger sample sizes in other patient populations and hospitals in Malawi are required in this area.
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Clinical Significance of the Prognostic Nutritional Index for Predicting Short- and Long-Term Surgical Outcomes After Gastrectomy: A Retrospective Analysis of 7781 Gastric Cancer Patients.
Lee, JY, Kim, HI, Kim, YN, Hong, JH, Alshomimi, S, An, JY, Cheong, JH, Hyung, WJ, Noh, SH, Kim, CB
Medicine. 2016;(18):e3539
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To evaluate the predictive and prognostic significance of the prognostic nutritional index (PNI) in a large cohort of gastric cancer patients who underwent gastrectomy.Assessing a patient's immune and nutritional status, PNI has been reported as a predictive marker for surgical outcomes in various types of cancer.We retrospectively reviewed data from a prospectively maintained database of 7781 gastric cancer patients who underwent gastrectomy from January 2001 to December 2010 at a single center. From this data, we analyzed clinicopathologic characteristics, PNI, and short- and long-term surgical outcomes for each patient. We used the PNI value for the 10th percentile (46.70) of the study cohort as a cut-off for dividing patients into low and high PNI groups.Regarding short-term outcomes, multivariate analysis showed a low PNI (odds ratio [OR] = 1.505, 95% CI = 1.212-1.869, P <0.001), old age, male sex, high body mass index, medical comorbidity, total gastrectomy, and combined resection to be independent predictors of postoperative complications. Among these, only low PNI (OR = 4.279, 95% CI = 1.760-10.404, P = 0.001) and medical comorbidity were independent predictors of postoperative mortality. For long-term outcomes, low PNI was a poor prognostic factor for overall survival, but not recurrence (overall survival: hazard ratio [HR] = 1.383, 95% CI = 1.221-1.568, P < 0.001; recurrence-free survival: HR = 1.142, 95% CI = 0.985-1.325, P = 0.078).PNI can be used to predict patients at increased risk of postoperative morbidity and mortality. Although PNI was an independent prognostic factor for overall survival, the index was not associated with cancer recurrence.
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Perioperative Standard Oral Nutrition Supplements Versus Immunonutrition in Patients Undergoing Colorectal Resection in an Enhanced Recovery (ERAS) Protocol: A Multicenter Randomized Clinical Trial (SONVI Study).
Moya, P, Soriano-Irigaray, L, Ramirez, JM, Garcea, A, Blasco, O, Blanco, FJ, Brugiotti, C, Miranda, E, Arroyo, A
Medicine. 2016;(21):e3704
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To compare immunonutrition versus standard high calorie nutrition in patients undergoing elective colorectal resection within an Enhanced Recovery After Surgery (ERAS) program.Despite progress in recent years in the surgical management of patients with colorectal cancer (ERAS programs), postoperative complications are frequent. Nutritional supplements enriched with immunonutrients have recently been introduced into clinical practice. However, the extent to which the combination of ERAS protocols and immunonutrition benefits patients undergoing colorectal cancer surgery is unknown.The SONVI study is a prospective, multicenter, randomized trial with 2 parallel treatment groups receiving either the study product (an immune-enhancing feed) or the control supplement (a hypercaloric hypernitrogenous supplement) for 7 days before colorectal resection and 5 days postoperatively.A total of 264 patients were randomized. At baseline, both groups were comparable in regards to age, sex, surgical risk, comorbidity, and analytical and nutritional parameters. The median length of the postoperative hospital stay was 5 days with no differences between the groups. A decrease in the total number of complications was observed in the immunonutrition group compared with the control group, primarily due to a significant decrease in infectious complications (23.8% vs. 10.7%, P = 0.0007). Of the infectious complications, wound infection differed significantly between the groups (16.4% vs. 5.7%, P = 0.0008). Other infectious complications were lower in the immunonutrition group but were not statistically significantly different.The implementation of ERAS protocols including immunonutrient-enriched supplements reduces the complications of patients undergoing colorectal resection.This study is registered with ClinicalTrial.gov: NCT02393976.
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Effect of nutritional support on clinical outcomes in perioperative malnourished patients: a meta-analysis.
Zhong, JX, Kang, K, Shu, XL
Asia Pacific journal of clinical nutrition. 2015;(3):367-78
Abstract
Malnutrition is an independent risk factor for complications, mortality, wound healing, length of hospital stay, and costs. Associations between nutritional support and surgical patients remain controversial. Databases, including Pubmed, EMBASE, Web of Science, CNKI, VIP, and the Cochrane Library, were searched to find randomized controlled trials (RCTs) that assessed the effect of nutritional support on clinical outcomes in perioperative malnourished patients. The methodological quality of each included trial was assessed. A meta-analysis was conducted with Rev Man 5.2. Fifteen RCTs, involving 3831 patients, were included in this meta-analysis. Compared with control group, results showed that nutritional support was more effective in decreasing the incidence of infectious [relative risk (RR): 0.58; 95% CI: 0.50, 0.68; p<0.01] and non-infectious complications (RR: 0.74; 95% CI: 0.63, 0.88; p<0.01), and shortening the length of hospital stay [weighted mean difference (WMD): -2.64; 95% CI: -5.13, -0.16; p<0.05]. Moreover, the incidence of infectious complications in the immune nutrition group was significantly lower than that in the standard nutrition group (RR: 0.75; 95% CI: 0.58, 0.97; p<0.05). However, changes in hospital costs (WMD: 894; 95% CI: -1140, 2928; p>0.05) and postoperative mortality (RR: 0.77; 95% CI: 0.41, 1.44; p>0.05) between the nutritional support group and control group were not significantly different. In conclusion, perioperative nutritional support was superior in improving clinical outcomes in malnourished patients, which could significantly reduce the incidence of complications and effectively shorten the length of hospital stay.
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Role of preoperative carbohydrate loading: a systematic review.
Bilku, DK, Dennison, AR, Hall, TC, Metcalfe, MS, Garcea, G
Annals of the Royal College of Surgeons of England. 2014;(1):15-22
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INTRODUCTION Surgical stress in the presence of fasting worsens the catabolic state, causes insulin resistance and may delay recovery. Carbohydrate rich drinks given preoperatively may ameliorate these deleterious effects. A systematic review was undertaken to analyse the effect of preoperative carbohydrate loading on insulin resistance, gastric emptying, gastric acidity, patient wellbeing, immunity and nutrition following surgery. METHODS All studies identified through PubMed until September 2011 were included. References were cross-checked to ensure capture of cited pertinent articles. RESULTS Overall, 17 randomised controlled trials with a total of 1,445 patients who met the inclusion criteria were identified. Preoperative carbohydrate drinks significantly improved insulin resistance and indices of patient comfort following surgery, especially hunger, thirst, malaise, anxiety and nausea. No definite conclusions could be made regarding preservation of muscle mass. Following ingestion of carbohydrate drinks, no adverse events such as apparent or proven aspiration during or after surgery were reported. CONCLUSIONS Administration of oral carbohydrate drinks before surgery is probably safe and may have a positive influence on a wide range of perioperative markers of clinical outcome. Further studies are required to determine its cost effectiveness.
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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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Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians.
Lawrence, VA, Cornell, JE, Smetana, GW, ,
Annals of internal medicine. 2006;(8):596-608
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BACKGROUND Postoperative pulmonary complications are as frequent and clinically important as cardiac complications in terms of morbidity, mortality, and length of stay. However, there has been much less research and no previous systematic reviews of the evidence of interventions to prevent pulmonary complications. PURPOSE To systematically review the literature on interventions to prevent postoperative pulmonary complications after noncardiothoracic surgery. DATA SOURCES MEDLINE English-language literature search, 1 January 1980 through 30 June 2005, plus bibliographies of retrieved publications. STUDY SELECTION Randomized, controlled trials (RCTs); systematic reviews; or meta-analyses that met predefined inclusion criteria. DATA EXTRACTION Using standardized forms, the authors abstracted data on study methods, quality, intervention and control groups, patient characteristics, surgery, postoperative pulmonary complications, and adverse events. DATA SYNTHESIS The authors qualitatively synthesized, without meta-analysis, evidence from eligible studies. Good evidence (2 systematic reviews, 5 additional RCTs) indicates that lung expansion interventions (for example, incentive spirometry, deep breathing exercises, and continuous positive airway pressure) reduce pulmonary risk. Fair evidence suggests that selective, rather than routine, use of nasogastric tubes after abdominal surgery (2 meta-analyses) and short-acting rather than long-acting intraoperative neuromuscular blocking agents (1 RCT) reduce risk. The evidence is conflicting or insufficient for preoperative smoking cessation (1 RCT), epidural anesthesia (2 meta-analyses), epidural analgesia (6 RCTs, 1 meta-analysis), and laparoscopic (vs. open) operations (1 systematic review, 1 meta-analysis, 2 additional RCTs), although laparoscopic operations reduce pain and pulmonary compromise as measured by spirometry. While malnutrition is associated with increased pulmonary risk, routine total enteral or parenteral nutrition does not reduce risk (1 meta-analysis, 3 additional RCTs). Enteral formulations designed to improve immune status (immunonutrition) may prevent postoperative pneumonia (1 meta-analysis, 1 additional RCT). LIMITATIONS The overall quality of the literature was fair: Ten of 20 RCTs and 6 of 11 systematic reviews were good quality. CONCLUSIONS Few interventions have been shown to clearly or possibly reduce postoperative pulmonary complications.