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Sagawa M, Matsui R, Sano A, Sakai M, Hiraoka S, Tabei I, Imai T, Matsumoto H, Onogawa S, Sonoi N, Nagata S, Ogawa R, Wakiyama S, Miyazaki Y, Kumagai K, Tsutsumi R, Okabayashi T, Uneno Y, Higashibeppu N, Kotani J. Perioperative or combined preoperative and postoperative standard nutrition therapy for patients with head and neck or gastrointestinal cancer: A systematic review and meta-analysis. Clin Nutr ESPEN 2025; 67:567-577. [PMID: 40189145 DOI: 10.1016/j.clnesp.2025.03.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 03/19/2025] [Accepted: 03/25/2025] [Indexed: 04/13/2025]
Abstract
BACKGROUND & AIMS Since malnutrition is a risk factor for postoperative complications, preoperative nutritional therapy is recommended to reduce postoperative complications. Few meta-analyses conducted exclusively in cancer patients have shown that perioperative standard nutritional therapy reduces postoperative complications. This study examined whether preoperative or combined preoperative and postoperative standard nutritional therapy reduced postoperative complications in patients with head and neck or gastrointestinal (GI) cancer. METHODS We conducted randomized controlled trials in 1979-2021. Patients who received standard nutritional interventions were classified as the intervention group and those who did not receive any nutritional intervention as controls. The primary outcome was the total number of postoperative complications and infectious complications. RESULTS In total, 19 studies were included (n = 2047). Of 19 studies, 5 were for upper GI cancer, 8 were for lower GI cancer, 5 were for upper and lower GI cancers, and 1 was for head and neck cancer. Total postoperative and infectious complications were reported in 15 (n = 1762) and 9 (n = 905) studies. The meta-analysis showed that standard nutritional interventions may reduce the total complication rates (RR: 0.78, 95 % CI: 0.65-0.94) and infectious complications (RR: 0.67, 95 % CI: 0.51-0.87). There were no significant differences in subgroup analyses, according to the nutritional therapy timing and nutritional status. The risk of bias was high for random sequence generation, allocation concealment, and participants' and data analysts' blinding. COE for total postoperative and infectious complications was weak and inconsistent due to the high risk of bias and substantial heterogeneity. CONCLUSION Although the present study was inconclusive due to the small number of studies in head and neck cancer, preoperative or combined preoperative and postoperative standard nutrition therapy in patients with GI cancer may significantly reduce the incidence of postoperative complications. Further studies are needed to confirm these findings and to reduce the risk of bias.
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Affiliation(s)
- Masano Sagawa
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Surgery, Tokyo Women's Medical University Adachi Medical Center, Japan.
| | - Ryota Matsui
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Gastroenterological Surgery, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Japan.
| | - Akihiko Sano
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Division of Gastroenterological Surgery, Department of General Surgical Science, Gunma University, Graduate School of Medicine, Japan.
| | - Makoto Sakai
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Division of Gastroenterological Surgery, Department of General Surgical Science, Gunma University, Graduate School of Medicine, Japan.
| | - Shinichiro Hiraoka
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; 1st Department of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Osaka University, Japan.
| | - Isao Tabei
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Surgery, The Jikei University School of Medicine, Daisan Hospital, Japan.
| | - Takayuki Imai
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Head and Neck Surgery, Miyagi Cancer Center, Japan.
| | - Hideo Matsumoto
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Surgery, Public Mitsugi General Hospital, Japan.
| | - Seiji Onogawa
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Gastroenterology, Onomichi General Hospital, Japan.
| | - Norihiro Sonoi
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Center for Education in Medicine and Health Sciences, Okayama University, Japan.
| | - Shigeyuki Nagata
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Surgery, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Japan.
| | - Ryo Ogawa
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Japan.
| | - Shigeki Wakiyama
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Surgery, Machida Municipal Hospital, Japan.
| | - Yasuhiro Miyazaki
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Gastroenterological Surgery, Osaka General Medical Center, Japan.
| | - Koshi Kumagai
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Surgery, Tokyo Women's Medical University Adachi Medical Center, Japan.
| | - Rie Tsutsumi
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Nutrition and Metabolism, Institute of Health Biosciences, Tokushima University Graduate School, Japan.
| | - Takehiro Okabayashi
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Gastroenterological Surgery, Kochi Health Sciences Center, Japan.
| | - Yu Uneno
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Japan.
| | - Naoki Higashibeppu
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Japan.
| | - Joji Kotani
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Japan; Division of Disaster and Emergency Medicine, Department of Surgery Related Kobe University Graduate School of Medicine, Japan.
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Soh NH, Yau CRZ, Low XZ, Kadir HA, Fong WJ, Ramalingam MB, Tan PL, Ng KYY, Hsing YT, Cai M, Seo CJ, Ong JCA, Chia CS, Wong JSM. Prehabilitation Outcomes in Surgical Oncology Patients Undergoing Major Abdominal Surgery: A Meta-analysis of Randomized Control Trials. Ann Surg Oncol 2025; 32:1236-1247. [PMID: 39616295 DOI: 10.1245/s10434-024-16527-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 10/30/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND Prehabilitation has been increasingly utilized to optimize perioperative outcomes. In this study, we aim to evaluate the impact of uni- and multimodal prehabilitation on functional capacity and postoperative outcomes among surgical oncology patients undergoing major abdominal surgery. PATIENTS AND METHODS Three electronic databases (PubMed, Embase, Cochrane) were systematically searched up until December 2023. We included randomized controlled trials comparing prehabilitation to standard of care in surgical oncology patients undergoing major abdominal surgery. Our primary outcome was functional capacity as measured by the 6-min walk distance (6MWD). Secondary outcomes include postoperative complications, emergency readmissions, and length of stay (LOS). We stratified our findings to determine the impact of uni- versus multimodal prehabilitation on outcomes. RESULTS We included 27 studies with 2532 surgical oncology patients. Overall, patients undergoing prehabilitation demonstrated a significant improvement in preoperative functional capacity compared to those without prehabilitation (mean difference in 6MWD 28.32 meters [m], 95% CI 15.26, 41.39, p < 0.01). Prehabilitation was also associated with significantly lower odds of postoperative complications (odds ratio [OR] 0.60, 95% CI 0.46, 0.78, p < 0.01). There was no difference in emergency readmission (OR 0.90, 95% CI 0.59, 1.38, p = 0.61) or LOS (mean difference -0.42 days, 95% CI -1.01, 0.16, p = 0.15). Comparing uni- versus multimodal prehabilitation, multimodal prehabilitation was associated with greater improvements in functional capacity (6MWD 37.35 m versus 13.38 m) and lower odds of postoperative complications (OR 0.61, 95% CI 0.45, 0.82, p < 0.01 versus OR 0.63, 95% CI 0.36, 1.11, p = 0.10) CONCLUSION: Prehabilitation improves functional capacity and reduces postoperative complications among surgical oncology patients undergoing major abdominal surgery.
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Affiliation(s)
- Natalie Hann Soh
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore & Singapore General Hospital, Singapore, Singapore
| | | | - Xi Zhi Low
- Duke-NUS Medical School, Singapore, Singapore
| | - Hanis Abdul Kadir
- Health Services Research Unit, Singapore General Hospital, Singapore, Singapore
| | - Wei Jing Fong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore & Singapore General Hospital, Singapore, Singapore
| | - Mothi Babu Ramalingam
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore, Singapore
| | - Pei Ling Tan
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore, Singapore
| | - Kennedy Yao Yi Ng
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
- Division of Population Health and Integrated Care, Singapore General Hospital, Singapore, Singapore
| | - Ya Ting Hsing
- Department of Physiotherapy, Singapore General Hospital, Singapore, Singapore
| | - Mingzhe Cai
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore & Singapore General Hospital, Singapore, Singapore
| | - Chin Jin Seo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore & Singapore General Hospital, Singapore, Singapore
| | - Johnny Chin-Ann Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore & Singapore General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
- SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
- Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore, Singapore
- Institute of Molecular and Cell Biology, A*STAR Research Entities, Singapore, Singapore
| | - Claramae S Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore & Singapore General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - Jolene Si Min Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore & Singapore General Hospital, Singapore, Singapore.
- SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore.
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Cai H, Chen Y, Li JC, Wang YX, Chen AK, Jia HJ. A Novel Nutrition-Related Prognostic Biomarker for Predicting Survival in Patients with Colorectal Cancer. Nutr Cancer 2024; 77:221-229. [PMID: 39385542 DOI: 10.1080/01635581.2024.2412356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 09/25/2024] [Accepted: 09/27/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Colorectal cancer (CRC) is a prevalent global malignancy with substantial morbidity and mortality. Accurate prognostic evaluation is essential in CRC patient management. This study investigates the prognostic significance of red blood cell count (RBC) and Onodera's prognostic nutritional index (OPNI) in resectable CRC patients. METHODS A retrospective analysis of 210 CRC patients undergoing radical resection (January 2015-January 2017) assessed clinical and hematological factors, including RBC, albumin, hemoglobin, and OPNI. A novel comprehensive biomarker, R-OPNI, combining preoperative RBC with OPNI, was introduced. Correlations with patient survival were analyzed, and R-OPNI's independent prognostic value was assessed through univariate and multivariate Cox models. Predictive ability was compared to other factors using the receiver operating characteristic (ROC) method. RESULTS Higher RBC levels (≥ 3.9 × 1012/L) and elevated OPNI were associated with significantly improved overall survival. Lower R-OPNI scores (0 or 1) indicated notably poorer survival. Multivariate analysis confirmed R-OPNI's independent prognostic significance (HR: 0.273, 95% CI: 0.098-0.763, p = 0.013). R-OPNI (AUC = 0.732) demonstrated superior predictive value compared to individual prognostic factors. CONCLUSION R-OPNI emerges as a robust, independent prognostic predictor for resectable CRC patients, emphasizing the importance of assessing preoperative nutritional status.
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Affiliation(s)
- Hao Cai
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian-Cheng Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu-Xin Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - An-Kang Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hou-Jun Jia
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Triantafillidis JK, Papakontantinou J, Antonakis P, Konstadoulakis MM, Papalois AE. Enteral Nutrition in Operated-On Gastric Cancer Patients: An Update. Nutrients 2024; 16:1639. [PMID: 38892572 PMCID: PMC11174039 DOI: 10.3390/nu16111639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
It is well established that the preoperative nutritional status of gastric cancer (GC) patients significantly affects the prognosis of the operated patients, their overall survival, as well as the disease-specific survival. Existing data support that preoperative assessment of nutritional status and early correction of nutritional deficiencies exert a favorable effect on early postoperative outcomes. A variety of relevant indices are used to assess the nutritional status of GC patients who are candidates for surgery. The guidelines of almost all international organizations recommend the use of oral enteral nutrition (EN). Oncologically acceptable types of gastrectomy and methods of patient rehabilitation should take into account the expected postoperative nutritional status. The majority of data support that perioperative EN reduces complications and hospital stay, but not mortality. Oral EN in the postoperative period, albeit in small amounts, helps to reduce the weight loss that is a consequence of gastrectomy. Iron deficiency with or without anemia and low serum levels of vitamin B12 are common metabolic sequelae after gastrectomy and should be restored. EN also significantly helps patients undergoing neoadjuvant or adjuvant antineoplastic therapy. The occurrence of the so-called "postgastrectomy syndromes" requires dietary modifications and drug support. This review attempts to highlight the benefits of EN in GC patients undergoing gastrectomy and to emphasize the type of necessary nutritional management, based on current literature data.
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Affiliation(s)
- John K. Triantafillidis
- Department of IBD and Endoscopy, “Metropolitan General” Hospital, 15562 Holargos, Greece;
- Hellenic Society of Gastrointestinal Oncology, 15562 Athens, Greece
| | - John Papakontantinou
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, University of Athens, 10676 Athens, Greece; (J.P.); (P.A.); (M.M.K.)
| | - Pantelis Antonakis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, University of Athens, 10676 Athens, Greece; (J.P.); (P.A.); (M.M.K.)
| | - Manousos M. Konstadoulakis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, University of Athens, 10676 Athens, Greece; (J.P.); (P.A.); (M.M.K.)
| | - Apostolos E. Papalois
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, University of Athens, 10676 Athens, Greece; (J.P.); (P.A.); (M.M.K.)
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Beloborodov V, Vorobev V, Hovalyg T, Seminskiy I, Sokolova S, Lapteva E, Mankov A. Fast Track Surgery as the Latest Multimodal Strategy of Enhanced Recovery after Urethroplasty. Adv Urol 2023; 2023:2205306. [PMID: 37214228 PMCID: PMC10195176 DOI: 10.1155/2023/2205306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 02/08/2023] [Accepted: 04/09/2023] [Indexed: 05/24/2023] Open
Abstract
Fast track surgery (FTS), as well as ERAS (enhanced recovery after surgery/rapid recovery programs), is the latest multimodal treatment strategy, designed to reduce the disability period and improve the medical care quality. The study aims to analyze the enhanced recovery protocol effectiveness in a comparative study of elective urethral stricture surgery. A prospective study included 54 patients with an established diagnosis of urethral stricture in 2019-2020 in the urological hospital of the Irkutsk City Clinical Hospital No. 1. All 54 patients have completed the study. There were two groups of patients FTS-group (group II, n = 25) and standard group (group I, n = 29). In terms of preoperative parameters, the comparison groups have statistical homogeneity. The comparative intergroup efficacy analysis of the treatment based on the criteria established in the study demonstrated good treatment results for 5 (17.2%) patients of group I and 20 (80%) patients of group II (p=0.004). The overall efficacy of urethroplasty surgeries, regardless of the treatment protocol, was comparable (86.2% vs 92%; p=0.870), as well as the likelihood of relapse within two years (p=0.512). The predictors of recurrence were technical complications and urethral suture failure (OR 4.36; 95% CI 1.6; 7.11; p=0.002). The FTS protocol reduced the treatment period (p < 0.001) and decreased the severity of postoperative pain (p < 0.001). The use of the "fast track surgery" protocol in urethroplasty with generally similar treatment results makes it possible to achieve a better functional and objective condition of patients in the postoperative period due to less pain, shorter catheterization, and hospitalization.
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Affiliation(s)
- Vladimir Beloborodov
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Vladimir Vorobev
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Temirlan Hovalyg
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Igor Seminskiy
- Department of Phatology, Irkutsk State Medical University, Irkutsk, Russia
| | - Svetlana Sokolova
- Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Ekaterina Lapteva
- Department of Geriatrics, Propaedeutics and Management in Nursing, North-Western State Medical University Named after I.I. Mechnikov, Saint Petersburg, Russia
| | - Aleksandr Mankov
- Department of Anesthesiology-Resuscitation, Irkutsk State Medical University, Irkutsk, Russia
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Parsons HM, Forte ML, Abdi HI, Brandt S, Claussen AM, Wilt T, Klein M, Ester E, Landsteiner A, Shaukut A, Sibley SS, Slavin J, Sowerby C, Ng W, Butler M. Nutrition as prevention for improved cancer health outcomes: a systematic literature review. JNCI Cancer Spectr 2023; 7:pkad035. [PMID: 37212631 PMCID: PMC10290234 DOI: 10.1093/jncics/pkad035] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment. METHODS We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature. RESULTS From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes. CONCLUSIONS Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.
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Affiliation(s)
- Helen M Parsons
- Minnesota Evidence-Based Practice Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Mary L Forte
- Minnesota Evidence-Based Practice Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Hamdi I Abdi
- Minnesota Evidence-Based Practice Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sallee Brandt
- Minnesota Evidence-Based Practice Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Amy M Claussen
- Minnesota Evidence-Based Practice Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Timothy Wilt
- Minnesota Evidence-Based Practice Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, MN, USA
- School of Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | - Mark Klein
- School of Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | | | - Adrienne Landsteiner
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, MN, USA
| | | | - Shalamar S Sibley
- School of Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | - Joanne Slavin
- Department of Food Science and Nutrition, College of Food, Agricultural and Natural Resource Sciences, St. Paul, MN, USA
| | - Catherine Sowerby
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, MN, USA
| | - Weiwen Ng
- Minnesota Evidence-Based Practice Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Mary Butler
- Minnesota Evidence-Based Practice Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Costa T, Nogueiro J, Ribeiro D, Viegas P, Santos-Sousa H. Impact of serum albumin concentration and neutrophil-lymphocyte ratio score on gastric cancer prognosis. Langenbecks Arch Surg 2023; 408:57. [PMID: 36689025 DOI: 10.1007/s00423-023-02799-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/22/2022] [Indexed: 01/24/2023]
Abstract
INTRODUCTION/AIM Serum albumin concentration (COA) and neutrophil-lymphocyte ratio (NLR) could reflect immunological and nutritional status. We aim to evaluate the impact of COA-NLR score on the prognosis of gastric cancer (GC). MATERIAL AND METHODS We perform a retrospective analysis on a database of 637 GC cases, between January 2010 and December 2017. In 396 patients, the inclusion criteria for this study were met (non-resectional or palliative surgery were excluded). Analytic data was only available in 203 patients. COA-NLR score was defined as follows: COA under 35 g/L and NLR value of 2.585 or higher, score 2; one of these conditions, score 1; and neither, score 0. RESULTS In our population (n = 203), 87 patients were classified as score 0, 82 as score 1 and 34 as score 2. COA-NLR score was significantly associated with DFS (HR 1.674; CI 95% 1.115-2.513; p = 0.013) and with OS (HR 2.072; CI 95% 1.531-2.805; p < 0.001). Kaplan-Meier curve analysis (log rank test) revealed that a higher score of COA-NLR predicted a worse OS (p < 0.001) and DFS (p = 0.03). COA-NLR was an independent prognostic factor for OS when adjusted to pStage and age (adjusted HR 1.566; CI 95% 1.145-2.143; p = 0.005). CONCLUSIONS Preoperative COA-NLR score was significantly associated with worse OS and DFS and, in this way, with worse prognosis on GC patients submitted to curative-intent resectional surgery.
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Affiliation(s)
- Teresa Costa
- Faculty of Medicine, University of Porto, Porto, Portugal.
- Surgery Department, Guarda Local Health Unit, Guarda, Portugal.
| | - Jorge Nogueiro
- Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery Department, São João University Medical Center, Porto, Portugal
| | - Daniel Ribeiro
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Pedro Viegas
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Hugo Santos-Sousa
- Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery Department, São João University Medical Center, Porto, Portugal
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Botdorf J, Nates JL. Intensive Care Considerations of the Cancer Patient. PERIOPERATIVE CARE OF THE CANCER PATIENT 2023:433-447. [DOI: 10.1016/b978-0-323-69584-8.00039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Aro R, Ohtonen P, Rautio T, Saarnio J, Mäkäräinen E, Häivälä R, Mäkinen MJ, Tuomisto A, Schwab U, Meriläinen S. Perioperative oral nutritional support for patients diagnosed with primary colon adenocarcinoma undergoing radical surgical procedures -Peri-Nutri Trial: study protocol for a randomized controlled trial. BMC Nutr 2022; 8:89. [PMID: 36050804 PMCID: PMC9438122 DOI: 10.1186/s40795-022-00591-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 08/21/2022] [Indexed: 11/30/2022] Open
Abstract
Background Colon cancer is one of the most common cancers in Finland and worldwide. Cancer-related malnutrition is a well-known risk factor for increased morbidity and mortality after surgery, and it is associated with complications and longer hospitalizations. There are no established recommendations on how to improve the nutritional status of colon cancer patients´ during the perioperative phase. Administration of simple oral nutritional supplements has been suggested to reduce complication rates, but evidence to support this practice is scarce. Methods The Peri-Nutri trial is a prospective, multicenter, randomized, controlled trial. Its primary endpoint is to evaluate whether perioperative oral nutritional support (ONS) decreases the number of complications during the 30-day follow-up after surgery. Secondary endpoints are to study the effect of ONS on quality of life after surgery, length of stay in institutional care, 90-day mortality rate, five-year disease-free survival and overall survival. The patients with a Nutritional risk screening 2002 (NRS-2002) questionnaire result between 2 and 5 (≥ 3 are classified at risk of malnutrition) will be randomized (1:1 ratio) into either the intervention or control group. The intervention group will receive preoperative ONS two weeks before the operation, and nutritional support will continue 10 days after the operation. The control group will not receive ONS. A total of 318 patients will be randomized into two groups and patients are followed five years. Discussion Peri-Nutri study evaluate the impact of ONS to short-term and long-term postoperative morbidity and mortality rates of colon cancer patients undergoing curative surgery. If ONS will decrease patients´ morbidity and mortality, that has a huge impact on patients´ quality of life and also to financial cost. Trial registration ClinicalTrials.gov, NCT03863236, Registered 25 February 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s40795-022-00591-y.
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Affiliation(s)
- Raila Aro
- Department of Gastrointestinal Surgery, Medical Research Center Oulu, Oulu University Hospital, PL 10, 90029 OYS, Oulu, Finland.
| | - Pasi Ohtonen
- Division of Operative Care, Medical Research Center Oulu, Oulu University Hospital, PL 10, 90029 OYS, Oulu, Finland
| | - Tero Rautio
- Department of Gastrointestinal Surgery, Medical Research Center Oulu, Oulu University Hospital, PL 10, 90029 OYS, Oulu, Finland
| | - Juha Saarnio
- Department of Gastrointestinal Surgery, Medical Research Center Oulu, Oulu University Hospital, PL 10, 90029 OYS, Oulu, Finland
| | - Elisa Mäkäräinen
- Department of Gastrointestinal Surgery, Medical Research Center Oulu, Oulu University Hospital, PL 10, 90029 OYS, Oulu, Finland
| | - Reetta Häivälä
- Department of Gastrointestinal Surgery, Medical Research Center Oulu, Oulu University Hospital, PL 10, 90029 OYS, Oulu, Finland
| | - Markus J Mäkinen
- Department of Pathology, Cancer and Translational Medicine Research Unit, University of Oulu, Oulu University Hospital and Medical Research Center Oulu, Oulu, Finland
| | - Anne Tuomisto
- Department of Pathology, University of Oulu, Oulu University Hospital and Medical Research Center Oulu, Oulu, Finland
| | - Ursula Schwab
- School of Medicine, Institute of Public Health and Clinical Nutrition, Finland and Department of Medicine, Endocrinology and Clinical Nutrition, University of Eastern, Kuopio University Hospital, Kuopio, Finland
| | - Sanna Meriläinen
- Department of Gastrointestinal Surgery, Medical Research Center Oulu, Oulu University Hospital, PL 10, 90029 OYS, Oulu, Finland.
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10
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Knight SR, Qureshi AU, Drake TM, Lapitan MCM, Maimbo M, Yenli E, Tabiri S, Ghosh D, Kingsley PA, Sundar S, Shaw C, Valparaiso AP, Bhangu A, Brocklehurst P, Magill L, Morton DG, Norrie J, Roberts TE, Theodoratou E, Weiser TG, Burden S, Harrison EM. The impact of preoperative oral nutrition supplementation on outcomes in patients undergoing gastrointestinal surgery for cancer in low- and middle-income countries: a systematic review and meta-analysis. Sci Rep 2022; 12:12456. [PMID: 35864290 PMCID: PMC9304351 DOI: 10.1038/s41598-022-16460-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/11/2022] [Indexed: 12/24/2022] Open
Abstract
Malnutrition is an independent predictor for postoperative complications in low- and middle-income countries (LMICs). We systematically reviewed evidence on the impact of preoperative oral nutrition supplementation (ONS) on patients undergoing gastrointestinal cancer surgery in LMICs. We searched EMBASE, Cochrane Library, Web of Science, Scopus, WHO Global Index Medicus, SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) databases from inception to March 21, 2022 for randomised controlled trials evaluating preoperative ONS in gastrointestinal cancer within LMICs. We evaluated the impact of ONS on all postoperative outcomes using random-effects meta-analysis. Seven studies reported on 891 patients (446 ONS group, 445 control group) undergoing surgery for gastrointestinal cancer. Preoperative ONS reduced all cause postoperative surgical complications (risk ratio (RR) 0.53, 95% CI 0.46-0.60, P < 0.001, I2 = 0%, n = 891), infection (0.52, 0.40-0.67, P = 0.008, I2 = 0%, n = 570) and all-cause mortality (0.35, 0.26-0.47, P = 0.014, I2 = 0%, n = 588). Despite heterogeneous populations and baseline rates, absolute risk ratio (ARR) was reduced for all cause (pooled effect -0.14, -0.22 to -0.06, P = 0.006; number needed to treat (NNT) 7) and infectious complications (-0.13, -0.22 to -0.06, P < 0.001; NNT 8). Preoperative nutrition in patients undergoing gastrointestinal cancer surgery in LMICs demonstrated consistently strong and robust treatment effects across measured outcomes. However additional higher quality research, with particular focus within African populations, are urgently required.
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Affiliation(s)
- Stephen R Knight
- Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX, UK.
| | - Ahmad U Qureshi
- Department of Surgery, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Thomas M Drake
- Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX, UK
| | - Marie Carmela M Lapitan
- Department of Surgery, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Mayaba Maimbo
- Department of General Surgery, Kitwe Teaching Hospital, Kitwe, Zambia
| | - Edwin Yenli
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Stephen Tabiri
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
- Dean of School of Medicine, University for Development Studies, Tamale, Ghana
| | - Dhruva Ghosh
- Department of Paediatric Surgery, Christian Medical College, Ludhiana, India
| | - Pamela A Kingsley
- Department of Radiation Oncology Department, Christian Medical College, Ludhiana, India
| | - Sudha Sundar
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Catherine Shaw
- Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX, UK
| | - Apple P Valparaiso
- Department of Surgery, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Aneel Bhangu
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Laura Magill
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Dion G Morton
- Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - John Norrie
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Tracey E Roberts
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Evropi Theodoratou
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, USA
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Sorrel Burden
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX, UK
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11
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Bechtold ML, Brown PM, Escuro A, Grenda B, Johnston T, Kozeniecki M, Limketkai BN, Nelson KK, Powers J, Ronan A, Schober N, Strang BJ, Swartz C, Turner J, Tweel L, Walker R, Epp L, Malone A. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr 2022; 46:1470-1496. [PMID: 35838308 DOI: 10.1002/jpen.2364] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
Abstract
Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.
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Affiliation(s)
| | | | | | - Brandee Grenda
- Morrison Healthcare at Atrium Health Navicant, Charlotte, North Carolina, USA
| | - Theresa Johnston
- Nutrition Support Team, Christiana Care Health System, Newark, Delaware, USA
| | | | | | | | - Jan Powers
- Nursing Research and Professional Practice, Parkview Health System, Fort Wayne, Indiana, USA
| | - Andrea Ronan
- Fanconi Anemia Research Fund, Eugene, Oregon, USA
| | - Nathan Schober
- Cancer Treatment Centers of America - Atlanta, Newnan, Georgia, USA
| | | | - Cristina Swartz
- Northwestern Medicine Delnor Cancer Center, Chicago, Illinois, USA
| | - Justine Turner
- Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | | | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA
| | - Lisa Epp
- Mayo Clinic, Rochester, Minnesota, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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12
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Fay KA, Maeder ME, Emond JA, Hasson RM, Millington TM, Finley DJ, Phillips JD. Residing in a food desert is associated with an increased risk of readmission following esophagectomy for cancer. J Thorac Dis 2022; 14:1854-1868. [PMID: 35813712 PMCID: PMC9264063 DOI: 10.21037/jtd-21-1637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 05/19/2022] [Indexed: 11/06/2022]
Abstract
Background Nutritional status is related to treatment outcomes for esophageal cancer. Residing in a food desert (FD) has been associated with worse outcomes in breast and colon cancer. We assessed the association of residing in a FD on 30-day outcomes of esophageal cancer patients who received tri-modality therapy. Methods A retrospective review of patients who underwent esophagectomy (1/2015 to 7/2020, in New Hampshire, USA) was performed. Patients were excluded if they did not undergo neo-adjuvant treatment, required treatment outside of standard Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) protocol, or lacked both pre and post neo-adjuvant treatment computed tomography (CT) scans for review. Demographics, nutrition parameters, treatment characteristics, 30-day complications and 90-day mortality were reviewed. FD status was defined by the United States Department of Agriculture (USDA) Food Access Research Atlas and cross-referenced with patients' home zip code. Readmission was defined as readmission to any hospital for any reason within 30-day of discharge. Univariable analysis was conducted using Student's t-test or Wilcoxon rank-sum for continuous variables, and Fisher's exact test for categorical variables. Multivariable logistic regression was then used to model readmission status on FD status adjusted for measures statistically associated with readmission status at the P<0.10 in univariable analyses. Results Seventy-eight patients were included in the analysis. Overall pre-treatment prevalence of sarcopenia was 11.5% (9/78) and did not vary by FD status. Univariable analysis, demonstrated few significant differences between those who were readmitted and those who were not. On unadjusted analysis, patients who lived in a FD were 5 times more likely to be readmitted [5.16; 95% confidence interval (CI): 1.70-15.67] compared to those who did not. Residing in a FD remained a significant risk factor for readmission after adjustment for operative time, discharge to a rehabilitation facility and development of a grade III/IV complication [adjusted odds ratio (OR): 6.38; 95% CI: 1.45-28.08]. Conclusions Our data suggest that residing in a FD is a prognostic factor for readmission after tri-modality therapy for esophageal cancer. Clinicians need to be aware that previously established nutritional markers may not completely capture nutritional status and living in a FD may significantly increase the risk of readmission in these patients.
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Affiliation(s)
- Kayla A Fay
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Matthew E Maeder
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jennifer A Emond
- Department of Biomedical Data Sciences, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Rian M Hasson
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Timothy M Millington
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - David J Finley
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Joseph D Phillips
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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13
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Franchini Melani AG, Capochin Romagnolo LG. Management of postoperative complications during laparoscopic anterior rectal resection. Minerva Surg 2021; 76:324-331. [PMID: 33944518 DOI: 10.23736/s2724-5691.21.08890-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Laparoscopic anterior resection (LAR) is currently a routine practice in specialized high-volume centers, with equivalent oncological outcomes in historical, open surgery. Appropriate pelvic dissection can be measured by the adequacy of circumferential margin (CRM) and distal margin, both are risk factors of local recurrence. Among the various operative procedures for colorectal cancer, low anterior resection (LAR) for rectal cancer is one of the most demanding procedures because it requires resection of cancer with surrounding mesorectal tissue and reconstruction with anastomosis in the narrow pelvis while preserving the autonomic nerves of the urogenital organs particularly in the male pelvis. Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, and asymptomatic patients infected with COVID-19 submitted to elective could be at higher risk which sometimes result in post operative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential to prevent it. The importance of some risk factors such as age, nutrition status of the patient, experience of the surgeon and many other factors that influence outcome of colorectal surgery which could be modified pre operatively to prevent post operative complications. In the other hand long term post operative complications may promote tumor recurrence and decrease survival. The severity of these complications was evaluated by Clavien-Dindo classification (Table1) initiated in 1992 is based on the type of therapy needed to correct the complication. The principle of the classification is simple, reproducible, flexible, and applicable. The Clavien-Dindo Classification(1) appears reliable and may represent a compelling tool for quality assessment in surgery. Post-operative complications can also be classified according to time-line related to surgery as such, early postoperative complications can be defined where morbidity rates occurred within 30 days of the procedure (25%-32%)- (Table 2) or long-term as those that take place between the 30th post-operative day to 3 years following. The aims of this review are to provide an overview of the current literature on post operative complications of rectal surgery and to describe risk factors and strategies to prevent, treat or reduce complications.
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Affiliation(s)
- Armando G Franchini Melani
- Americas Medical City, Rio de Janeiro, Brazil - .,Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil -
| | - Luis G Capochin Romagnolo
- Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil.,Department of Colon and Rectal Surgery, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
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14
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Lee B, Han HS, Yoon YS, Cho JY, Lee JS. Impact of preoperative malnutrition, based on albumin level and body mass index, on operative outcomes in patients with pancreatic head cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:1069-1075. [PMID: 33128839 DOI: 10.1002/jhbp.858] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/20/2020] [Accepted: 10/14/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND To investigate whether preoperative malnutrition in patients who underwent curative pancreaticoduodenectomy (PD) in pancreatic head cancer correlated with short-term outcomes. METHODS This study was a retrospective review of medical records from January 2004 to December 2018. Preoperative malnutrition was defined as body mass index (BMI) <18.5 kg/m2 , or hypoalbuminemia with serum albumin level < 3.5 g/dL within 30 days before surgery. RESULTS Of the 289 eligible patients, 60 patients (20.7%) were classified as the malnutrition group. The estimated blood loss (EBL, mL) (964.1 ± 879.7 vs 597.7 ± 501.7, P = .044) and transfusion rate (51.7% vs 18.8%, P < .001) was significantly higher in the malnutrition group than no-malnutrition group. The hospital stay (days) (20.5 ± 12.2 vs 18.1 ± 13.6, P = .05) was significantly longer in the malnutrition group. The open conversion rate (45.4% vs 6.67%, P < .001) and major complication rate (36.7% vs 21.8%, P = .032) was significantly higher in the malnutrition group. In multivariate analysis, preoperative malnutrition was found to be the predictor of postoperative complication (HR 1.971 95% confidence interval 1.071-3.624, P = .029). CONCLUSION Preoperative malnutrition in patients who underwent curative PD for pancreatic head cancer is associated with adverse short-term outcomes.
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Affiliation(s)
- Boram Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
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15
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Li Q, Huang LY, Xue HP. Comparison of prognostic factors in different age groups and prognostic significance of neutrophil-lymphocyte ratio in patients with gastric cancer. World J Gastrointest Oncol 2020; 12:1146-1166. [PMID: 33133383 PMCID: PMC7579735 DOI: 10.4251/wjgo.v12.i10.1146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/04/2020] [Accepted: 09/02/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastric cancer (GC) is one of the most common malignant tumors in the world. Although in recent years tremendous progress has been made in its early detection, the postoperative overall survival (OS) of GC patients remains extremely low. A number of studies have shown that age, to varying degrees, affects the prognosis of patients with GC. Therefore, this study retrospectively analyzed the clinical and pathologic data of patients with GC to explore the differences in the clinical characteristics and prognostic factors in different age groups.
AIM To explore the difference in clinicopathological characteristics and prognostic factors in GC patients in different age groups.
METHODS In this retrospective study, we analyzed 1037 GC patients admitted to Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from May 2010 to January 2013. The patients were divided into two groups based on age: Younger group (less than 70 years old) and older group (no less than 70 years old). In the younger group, we subdivided the patients in two subgroups by a cut-off value of 45 years. The clinical features and prognostic factors were analyzed in both groups. Subsequently, we retrieved studies that evaluated the predictive role of neutrophil-lymphocyte ratio (NLR) by searching two medical databases, PubMed and EMBASE, to conduct a meta-analysis. Random-effects model was used to pool the data.
RESULTS In the retrospective study, the mean OS time of the younger group (64.7 mo) was significantly longer than that of the older group (48.1 mo) (P < 0.001). Among patients under 70 years of age, hospitalization time, tumor–node–metastasis (TNM) stage, vascular invasion, and preoperative low pre-albumin were independently associated with OS (P < 0.005). In patients aged 70 years and above, TNM stage, esophageal invasion, histological type, and preoperative NLR were independent factors for OS (P < 0.05). The OS of these older patients was also significantly shorter (P < 0.05). In the meta-analysis, 19 retrieved studies included a total of 8312 patients, among whom 3558 had elevated NLR values. The results showed that high NLR value was a risk factor for the prognosis of GC (P < 0.01).
CONCLUSION The OS of elderly patients is significantly worse than that of younger patients. There are significant differences in clinicopathological characteristics and prognostic factors between younger and older patients. NLR is a convenient, inexpensive, and reproducible marker that can be used as an important predictor of the prognosis of GC.
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Affiliation(s)
- Qiong Li
- Department ofGastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Lin-Yi Huang
- Department ofGastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Hui-Ping Xue
- Department ofGastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
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16
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Lazarow H, Singer R, Compher C, Gilmar C, Kucharczuk CR, Mangan P, Salam K, Cunningham K, Stadtmauer EA, Landsburg DJ. Effect of malnutrition-driven nutritional support protocol on clinical outcomes in autologous stem cell transplantation patients. Support Care Cancer 2020; 29:997-1003. [PMID: 32556621 DOI: 10.1007/s00520-020-05571-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 06/11/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE Poor nutrition status in patients receiving high-dose chemotherapy and autologous stem cell transplant (ASCT) has been associated with inferior clinical outcomes. We aim to determine whether a malnutrition-driven nutritional support protocol can improve these outcomes. METHODS In this prospective cohort study, we assessed adults for malnutrition who were consecutively admitted for ASCT between October 2017 and March 2019 (n = 251), and provided enteral or parenteral nutrition (EN/PN) to patients who were malnourished early in the transplantation admission. We compared their clinical outcomes with those of a historical cohort admitted between May 2016 and October 2017 (n = 257) for whom nutrition assessment and initiation of EN/PN were not protocol-driven. RESULTS Patients receiving ASCT during the intervention period experienced decreased odds of prolonged hospital stay (p = 0.023), central line-associated bloodstream infection (p = 0.015), mucosal barrier injury (p = 0.037), and high weight loss (p = 0.002), in a multivariate analysis as compared with those receiving ASCT during the control period. Outcomes for ICU transfer, deconditioning on discharge, time to platelet engraftment, and unplanned 30-day hospital readmission did not differ significantly between groups. CONCLUSION A malnutrition-driven nutritional support protocol may improve outcomes for ASCT patients.
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Affiliation(s)
- Heather Lazarow
- Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Ryan Singer
- Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Charlene Compher
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Cheryl Gilmar
- Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen R Kucharczuk
- Department of Advanced Practice, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Patricia Mangan
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly Salam
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathleen Cunningham
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward A Stadtmauer
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel J Landsburg
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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17
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Lakananurak N, Gramlich L. The Role of Preoperative Parenteral Nutrition. Nutrients 2020; 12:1320. [PMID: 32384662 PMCID: PMC7285090 DOI: 10.3390/nu12051320] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/28/2020] [Accepted: 05/04/2020] [Indexed: 12/30/2022] Open
Abstract
Malnutrition is associated with poor surgical outcomes, and therefore optimizing nutritional status preoperatively is very important. The purpose of this paper is to review the literature related to preoperative parenteral nutrition (PN) and to provide current evidence based guidance. A systemic online search of PubMed, Medline, and Cochrane Databases from January 1990 to February 2020 was done. Sixteen studies were included in this narrative review, including four meta-analyses and twelve clinical trials. The majority of studies have demonstrated benefits of preoperative PN on postoperative outcomes, including reduced postoperative complications (8/10 studies) and postoperative length of stay (3/4 studies). Preoperative PN is indicated in malnourished surgical patients who cannot achieve adequate nutrient intake by oral or enteral nutrition. It can be seen that most studies showing benefits of preoperative PN often included patients with upper gastrointestinal cancer and inflammatory bowel disease (10/12 studies), which gastrointestinal problems are commonly seen and enteral nutrition may be not feasible. When preoperative PN is indicated, adequate energy and protein should be provided, and patients should receive at least seven days of PN prior to surgery. The goal of preoperative PN is not weight regain, but rather repletion of energy, protein, micronutrients, and glycogen stores. Complications associated with preoperative PN are rarely seen in previous studies. In order to prevent and mitigate the potential complications such as refeeding syndrome, optimal monitoring and early management of micronutrient deficiencies is required.
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Affiliation(s)
- Narisorn Lakananurak
- Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada;
| | - Leah Gramlich
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada;
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18
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Nutritional Assistance by Software Improves Surgical Outcomes of Elective Colorectal Surgery. Int Surg 2020. [DOI: 10.9738/intsurg-d-16-00214.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
The present study analyzes nutrition support in a group of patients undergoing colorectal surgery managed by nutritional requirement software compared to a group of consecutive patients undergoing colorectal surgery with conventional nutrition
Materials and Methods
A total of 485 patients were treated between January 2000 and January 2013 with colorectal resection. Outcomes (mortality, morbidity according to Clavien classification, length of hospital stay, type of colorectal disease) in a group of patients who received nutrition support through software (SG) were compared to those in a previous series, control group (CG) with conventional nutrition support
Results
Of the patients, 59.6% were men and the median age of the population was 68.2 years (range, 19–95 years), with no difference between the 2 groups. There were significantly more malnourished patients in the SG group (SG 63.8% versus 45.2% CG; P < 0.0001). The overall mortality was 2.1% lower in the SG group, but without a significant difference (SG 0.7% versus 2.7% CG). There were more severe stage III to IV complications according to Clavien classification in the SG group (SG 10.7 GC versus 17% NS), with significantly greater collections (SG 8% versus 16.9% CG; P = 0.015) and greater anastomotic leaks (SG 4% versus 13.9% CG; P < 0.001). The median hospital stay was lower in the SG group (SG 12 days versus 15 days CG; P = 0.049).
Conclusion
The proposed software could contribute to optimizing the strategy of nutritional support in hospitalized patients.
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19
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Jeong H, Choi JW, Ahn HJ, Choi YS, Kim JA, Yang M, Kim JK, Kim DK, Shin BS, Lee SH, Kim YR, Park M, Chung YJ. The effect of preventive use of corticosteroids on postoperative complications after esophagectomy: A retrospective cohort study. Sci Rep 2019; 9:11984. [PMID: 31427671 PMCID: PMC6700144 DOI: 10.1038/s41598-019-48349-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022] Open
Abstract
Corticosteroids have been empirically administered to reduce the rate of acute respiratory distress syndrome (ARDS) after esophagectomy. However, their efficacy remains controversial, and corticosteroids may increase the risk of graft dehiscence and infection, which are major concerns after esophagectomy. Therefore, we compared the incidence of composite complications (ARDS, graft dehiscence and infection) after esophagectomy between patients who received a preventive administration of corticosteroids and those who did not. All patients who underwent esophagectomy from 2010 to 2015 at a tertiary care university hospital were reviewed retrospectively (n = 980). Patients were divided into Steroid (n = 120) and Control (n = 860) groups based on the preventive administration of 100 mg hydrocortisone during surgery. The primary endpoint was the incidence of composite complications. The incidence of composite complications was not different between the Control and Steroid groups (17.4% vs. 21.7% respectively; P = 0.26). The incidence rates of complications in each category were not different between the Control and Steroid groups: ARDS (3.8% vs. 5.0%; P = 0.46), graft dehiscence (4.8% vs. 6.7%; P = 0.37), and infection (12.8% vs. 15.8%; P = 0.36). Propensity score matching revealed that composite complications (20.0% vs. 21.7%; P = 0.75), ARDS (4.3% vs. 5.2%; P = 0.76) and infection (16.5% vs. 15.7%; P = 0.86) were not different between the Control and Steroid group, but the incidence of graft dehiscence was higher in the Steroid group than in the Control group (0.9% vs. 7.0%; P = 0.0175). In conclusions, the preventive use of corticosteroids did not reduce the incidence of ARDS, but may be related to an increased incidence of graft dehiscence. Therefore, routine administration of corticosteroids to prevent ARDS is not recommended in esophagectomy.
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Affiliation(s)
- Heejoon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Yong Soo Choi
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jie Ae Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jin Kyoung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Byung Seop Shin
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Young Ri Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Mihye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Yoon Joo Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
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20
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Quilliot D, Michot N, Germain L, Krier J, Lopez A, Bresler L, Ayav A, Malgras A, Nguyen-Thi PL. Feasibility, acceptability of enteral tube feeding and self-insertion of a nasogastric tube in the nutritional management of digestive cancers, impact on quality of life. Clin Nutr 2019; 39:1785-1792. [PMID: 31402277 DOI: 10.1016/j.clnu.2019.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 06/24/2019] [Accepted: 07/12/2019] [Indexed: 11/27/2022]
Abstract
No study has evaluated the feasibility of enteral tube feeding (ETF) in undernourished patients with newly diagnosed gastrointestinal (GI) cancer. OBJECTIVES Evaluate the acceptability of ETF in patients unable to increase their dietary intake and with a weight loss >10% or albuminemia <30 g/L or BMI <18.5 before surgery, or a weight loss >5% during chemotherapy. The feasibility of self-insertion of a nasogastric tube was also assessed. RESULTS A total of 308 patients were nutritionally screened during a one-year period. ETF was indicated in 123 cases. Overall acceptability was 78.9% and was higher when weight loss was >10% (p < 0.0001) and before surgery (p < 0.0001), lower during chemotherapy (p < 0.0001), while not influenced by dietary intake or location of the cancer. Forty patients managed a daily self-insertion of the feeding tube (45.5%) and 48 had a nasogastric tube maintained in place. All Quality of Life (QoL) parameters were significantly improved, notably physical role functioning (+20.9% ± 24.0, p < 0.005) and mental health (+21.0% ± 17.7 p < 0.005). CONCLUSION According to the present algorithm, ETF was indicated in 39.9% of cases and accepted in 78.9% of newly diagnosed patients with primary GI cancer while improving QoL. This study strengthens the place of self-insertion of feeding tubes in clinical practise.
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Affiliation(s)
- Didier Quilliot
- Unité d'Assistance Nutritionnelle, Nancy Regional University Hospital, Nancy, France.
| | - Niasha Michot
- Unité d'Assistance Nutritionnelle, Nancy Regional University Hospital, Nancy, France
| | - Lucie Germain
- UTEP, Evaluation et Information Médicales, Nancy Regional University Hospital, Nancy, France
| | - Justine Krier
- Unité d'Assistance Nutritionnelle, Nancy Regional University Hospital, Nancy, France
| | - Anthony Lopez
- Hepato-gastro-entérologie, CHRU de Nancy, Nancy Regional University Hospital, Nancy, France
| | - Laurent Bresler
- Chirurgie digestive, hépatobiliaire, endocrinienne et cancérologique, Nancy, France
| | - Ahmet Ayav
- Chirurgie digestive, hépatobiliaire, endocrinienne et cancérologique, Nancy, France
| | - Aurélie Malgras
- Unité d'Assistance Nutritionnelle, Nancy Regional University Hospital, Nancy, France
| | - Phi-Linh Nguyen-Thi
- UTEP, Evaluation et Information Médicales, Nancy Regional University Hospital, Nancy, France
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21
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Loncar Y, Lefevre T, Nafteux L, Genser L, Manceau G, Lemoine L, Vaillant JC, Eyraud D. Preoperative nutrition forseverely malnourished patients in digestive surgery: A retrospective study. J Visc Surg 2019; 157:107-116. [PMID: 31366442 DOI: 10.1016/j.jviscsurg.2019.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Malnutrition increases postoperative morbidity and mortality. The objective of this study was to evaluate preoperative refeeding in malnourished patients at risk of refeeding syndrome (RS). METHODOLOGY A retrospective study, conducted between June 2016 and January 2017, reported to the CNIL, compared two groups of malnourished patients: a group of refeeding patients (RP) and a group of non-refeeding patients (NRP). The inclusion criteria were weight loss of more than 10% or albuminemia less than 35g/L and RS risk factor. The primary endpoint was postoperative morbidity. The secondary endpoints were weight change and serum albumin over 6 months. RESULTS Seventy-three patients (30 RP and 43 NRP) were included. At the time of initial management, median weight loss was 18% [1-71], while albuminemia was 26g/L [13-40] in the RP group and 32.5g/L [32-48] in the NRP group (P=0.01). The overall postoperative morbidity rate was 88% (83% RP versus 90% NRP, P=0.47), and there was no significant difference between the 2 groups. The rate of anastomotic complications was 4% for RP versus 26% for NRP (P=0.03) after exclusion of liver surgery. Medium-term weight loss tended to be greater in RP (P=0.7). Nutritional support was continued until the third postoperative month in 13% of RPs vs. no NRPs (P=0.0002). CONCLUSION After preoperative renutrition, we did not observe a decrease in morbidity but rather a decrease in the rate of anastomotic complications in favor of the RP group. This study underscores the middle-term importance of nutritional management in view of preserving the benefits of preoperative renutrition.
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Affiliation(s)
- Y Loncar
- Department of anesthesia and resuscitation, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France; Dietetics unit, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France.
| | - T Lefevre
- Department of anesthesia and resuscitation, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
| | - L Nafteux
- Dietetics unit, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France.
| | - L Genser
- Visceral and hepato-biliary surgery and transplantation unit, hospital group Pitié-Salpêtrière Charles Foix, université de la Sorbonne, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
| | - G Manceau
- Visceral and hepato-biliary surgery and transplantation unit, hospital group Pitié-Salpêtrière Charles Foix, université de la Sorbonne, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
| | - L Lemoine
- Department of anesthesia and resuscitation, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France.
| | - J C Vaillant
- Visceral and hepato-biliary surgery and transplantation unit, hospital group Pitié-Salpêtrière Charles Foix, université de la Sorbonne, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
| | - D Eyraud
- Department of anesthesia and resuscitation, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
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22
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Boet S, Etherington C, Nicola D, Beck A, Bragg S, Carrigan ID, Larrigan S, Mendonca CT, Miao I, Postonogova T, Walker B, De Wit J, Mohamed K, Balaa N, Lalu MM, McIsaac DI, Moher D, Stevens A, Miller D. Anesthesia interventions that alter perioperative mortality: a scoping review. Syst Rev 2018; 7:218. [PMID: 30497505 PMCID: PMC6267894 DOI: 10.1186/s13643-018-0863-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 10/30/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND With over 230 million surgical procedures performed annually worldwide, better application of evidence in anesthesia and perioperative medicine may reduce widespread variation in clinical practice and improve patient care. However, a comprehensive summary of the complete available evidence has yet to be conducted. This scoping review aims to map the existing literature investigating perioperative anesthesia interventions and their potential impact on patient mortality, to inform future knowledge translation and ultimately improve perioperative clinical practice. METHODS Searches were conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library databases from inception to March 2015. Study inclusion criteria were adult patients, surgical procedures requiring anesthesia, perioperative intervention conducted/organized by a professional with training in anesthesia, randomized controlled trials (RCTs), and patient mortality as an outcome. Studies were screened for inclusion, and data was extracted in duplicate by pairs of independent reviewers. Data were extracted, tabulated, and reported thematically. RESULTS Among the 10,505 publications identified, 369 RCTs (n = 147,326 patients) met the eligibility criteria. While 15 intervention themes were identified, only 7 themes (39 studies) had a significant impact on mortality: pharmacotherapy (n = 23), nutritional (n = 3), transfusion (n = 4), ventilation (n = 5), glucose control (n = 1), medical device (n = 2), and dialysis (n = 1). CONCLUSIONS By mapping intervention themes, this scoping review has identified areas requiring further systematic investigation given their potential value for reducing patient mortality as well as areas where continued investment may not be cost-effective given limited evidence for improving survival. This is a key starting point for future knowledge translation to optimize anesthesia practice.
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Affiliation(s)
- Sylvain Boet
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, K1H 8L6, Canada.
| | - Cole Etherington
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - David Nicola
- Family Medicine, McGill University, Montreal, Canada
| | - Andrew Beck
- Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Susan Bragg
- Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Ian D Carrigan
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Sarah Larrigan
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
- University of Ottawa, Ottawa, Canada
| | - Cassandra T Mendonca
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, K1H 8L6, Canada
| | - Isaac Miao
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, K1H 8L6, Canada
| | | | - Benjamin Walker
- Department of Anesthesia, University of Utah, Salt Lake City, UT, 84132, USA
| | - José De Wit
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, K1H 8L6, Canada
| | - Karim Mohamed
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, K1H 8L6, Canada
| | - Nadia Balaa
- Department of Family Medicine, Montfort Hospital, University of Ottawa, Ottawa, Canada
| | - Manoj Mathew Lalu
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Canada
- Clinical Epidemiology and Regenerative Medicine Programs, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Adrienne Stevens
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Donald Miller
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, K1H 8L6, Canada
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23
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Brown JK, Singh K, Dumitru R, Chan E, Kim MP. The Benefits of Enhanced Recovery After Surgery Programs and Their Application in Cardiothoracic Surgery. Methodist Debakey Cardiovasc J 2018; 14:77-88. [PMID: 29977464 DOI: 10.14797/mdcj-14-2-77] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The perioperative care of the surgical patient is undergoing a paradigm shift. Enhanced Recovery After Surgery (ERAS) programs are becoming the standard of care and best practice in many surgical specialties throughout the world. ERAS is a multimodal, multidisciplinary, evidence-based approach to care of the surgical patient that aims to optimize perioperative management and outcomes. Implementation, however, has been slow because it challenges traditional surgical doctrine. The key elements of ERAS Pathways strive to reduce the response to surgical stress, decrease insulin resistance, and maintain anabolic homeostasis to help the patient return to baseline function more quickly. Data suggest that these pathways have produced not only improvements in clinical outcome and quality of care but also significant cost savings. Large trials reveal an increase in 5-year survival and a decrease in immediate complication rates when strict compliance is maintained with all pathway components. Years of success using ERAS in colorectal surgery have helped to establish a body of evidence through a number of randomized controlled trials that encourage application of these pathways in other surgical specialties.
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Affiliation(s)
| | | | | | | | - Min P Kim
- HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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24
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Zhao Q, Li Y, Yu B, Yang P, Fan L, Tan B, Tian Y. Effects of Preoperative Enteral Nutrition on Postoperative Recent Nutritional Status in Patients with Siewert II and III Adenocarcinoma of Esophagogastric Junction after Neoadjuvant Chemoradiotherapy. Nutr Cancer 2018; 70:895-903. [PMID: 30273016 DOI: 10.1080/01635581.2018.1490780] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Qun Zhao
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Yong Li
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Bin Yu
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Peigang Yang
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Liqiao Fan
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Bibo Tan
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Yuan Tian
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
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25
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Nutritional risk screening score is an independent predictive factor of anastomotic leakage after rectal cancer surgery. Eur J Clin Nutr 2018; 72:489-495. [PMID: 29459787 DOI: 10.1038/s41430-018-0112-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/19/2017] [Accepted: 01/11/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND/OBJECTIVES Nutritional risk screening (NRS) score has been reported as a predictor of postoperative outcomes in patients undergoing abdominal surgery, although the correlation between NRS and anastomotic leakage (AL) after rectal cancer surgery is uncertain. This study aimed to evaluate the association between NRS score and AL following rectal cancer surgery. SUBJECT/METHODS We retrospectively reviewed data of rectal cancer patients from a tertiary referral center in South Korea, and included 1063 patients with primary rectal cancer who underwent sphincter-preserving surgery between January 2011 and December 2015. We utilized the Chonnam National University Hwasun Hospital-Nutritional Risk Screening Tool (CNUHH-NRST), which was developed and cross-validated on the basis of the NRS 2002 and MST, as a screening tool of nutritional risk. Patients with NRS scores ≥4 were compared with those with NRS scores <4, and the risk factors for AL were analyzed. RESULTS One-hundred-nineteen (11.2%) patients had high nutritional risk (NRS score ≥4). The patients with a nutritional risk had more advanced tumor stages than those without nutritional risk. AL occurred in 69 (6.5%) patients. The multivariate logistic regression analysis showed high American Society of Anesthesiologists score (odds ratio (OR) = 2.435, 95% confidence interval (CI) = 1.085-5.469), long operative time (OR = 1.975, 95% CI = 1.177-3.313), and high NRS score (OR = 2.044, 95% CI = 1.085-3.851) as independent risk factors of AL. CONCLUSIONS The NRS score was an independent predictive factor of AL after rectal cancer surgery. Patients with nutritional risks who require rectal cancer surgery should be carefully managed.
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26
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Kang MC, Kim JH, Ryu SW, Moon JY, Park JH, Park JK, Park JH, Baik HW, Seo JM, Son MW, Song GA, Shin DW, Shin YM, Ahn HY, Yang HK, Yu HC, Yun IJ, Lee JG, Lee JM, Lee JH, Lee TH, Yim H, Jeon HJ, Jung K, Jung MR, Jeong CY, Lim HS, Hong SK. Prevalence of Malnutrition in Hospitalized Patients: a Multicenter Cross-sectional Study. J Korean Med Sci 2018; 33:e10. [PMID: 29215819 PMCID: PMC5729651 DOI: 10.3346/jkms.2018.33.e10] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/14/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Malnutrition is associated with many adverse clinical outcomes. The present study aimed to identify the prevalence of malnutrition in hospitalized patients in Korea, evaluate the association between malnutrition and clinical outcomes, and ascertain the risk factors of malnutrition. METHODS A multicenter cross-sectional study was performed with 300 patients recruited from among the patients admitted in 25 hospitals on January 6, 2014. Nutritional status was assessed by using the Subjective Global Assessment (SGA). Demographic characteristics and underlying diseases were compared according to nutritional status. Logistic regression analysis was performed to identify the risk factors of malnutrition. Clinical outcomes such as rate of admission in intensive care units, length of hospital stay, and survival rate were evaluated. RESULTS The prevalence of malnutrition in the hospitalized patients was 22.0%. Old age (≥ 70 years), admission for medical treatment or diagnostic work-up, and underlying pulmonary or oncological disease were associated with malnutrition. Old age and admission for medical treatment or diagnostic work-up were identified to be risk factors of malnutrition in the multivariate analysis. Patients with malnutrition had longer hospital stay (SGA A = 7.63 ± 6.03 days, B = 9.02 ± 9.96 days, and C = 12.18 ± 7.24 days, P = 0.018) and lower 90-day survival rate (SGA A = 97.9%, B = 90.7%, and C = 58.3%, P < 0.001). CONCLUSION Malnutrition was common in hospitalized patients, and resulted in longer hospitalization and associated lower survival rate. The rate of malnutrition tended to be higher when the patient was older than 70 years old or hospitalized for medical treatment or diagnostic work-up compared to elective surgery.
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Affiliation(s)
- Min Chang Kang
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Ji Hoon Kim
- Department of Surgery, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Seung Wan Ryu
- Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Young Moon
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Je Hoon Park
- Department of Surgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Jong Kyung Park
- Division of Colorectal Surgery, Department of Surgery, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jong Hoon Park
- Department of Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Hyun Wook Baik
- Department of Internal Medicine, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Jeong Meen Seo
- Division of Pediatric Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myoung Won Son
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Geun Am Song
- Division of Gastroenterology, Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Dong Woo Shin
- Department of Surgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Yeon Myung Shin
- Division of Gastrointestinal Surgery, Department of Surgery, Kosin University College of Medicine, Gospel Hospital, Busan, Korea
| | - Hong Yup Ahn
- Department of Statistics, Dongguk University, Seoul, Korea
| | - Han Kwang Yang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Chul Yu
- Department of Surgery, Chonbuk National University Medical School, Jeonju, Korea
| | - Ik Jin Yun
- Department of Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Myeong Lee
- Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jung Hwa Lee
- Nutrition Team, Kyung Hee University Medical Center, Seoul, Korea
| | - Tae Hee Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Haejun Yim
- Department of Burn Surgery and Critical Care, Burn Center, Hallym University Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyun Jeong Jeon
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Kyuwhan Jung
- Department of Surgery, Jeju National University Hospital, Jeju, Korea
| | - Mi Ran Jung
- Division of Gastroenterologic Surgery, Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Chi Young Jeong
- Department of Surgery, Gyeongsang National University Hospital, Jinju, Korea
| | - Hee Sook Lim
- Department of Food and Nutrition, Yeonsung University, Anyang, Korea
| | - Suk Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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27
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Gebauer B, Meyer F, Ptok H, Steinert R, Otto R, Lippert H, Gastinger I. Impact of Body Mass Index on Early Postoperative and Long-Term Outcome after Rectal Cancer Surgery. Visc Med 2017; 33:373-382. [PMID: 29177167 DOI: 10.1159/000479852] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background The aim of this study was to investigate the impact of obesity and underweight onto early postoperative and long-term oncological outcome after surgery for rectal cancer. Methods Data from 2008 until 2011 was gathered by a German prospective multicenter observational study. 62 items were reported by the physicians in charge, and a consecutive follow-up was performed if the patient had signed a consent form. Patients were subclassified into: underweight, normal weight, overweight, and obese - using the definitions of the World Health Organization. Results In total, 9,920 patients were included, of whom 2.1% were underweight and 19.4% obese. The mean age was 68 years (range 21-99 years). Postoperative morbidity (mean 38.0%) was significantly increased in underweight and obese patients (p < 0.001). In-hospital mortality was 3.1% on average with no significant differences among patient groups (p = 0.176). The 5-year overall survival ranged between 36.9 and 61.3% and was worse in underweight and prolonged in overweight and obese patients compared to those with normal weight (p < 0.001 each). While the 5-year disease-free survival was increased in overweight and obese patients (p < 0.05 each), the 5-year local recurrence rate showed no correlation (p > 0.05 each). Multivariate analysis revealed that advanced age, higher ASA scoring, postoperative morbidity, and advanced tumor growth worsened the long-term survival independently. Conclusions Underweight patients had a worse early and long-term outcome after rectal cancer surgery. Overweight and obesity were associated with a significantly better long-term survival.
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Affiliation(s)
- Björn Gebauer
- Institute of Quality Assurance in Operative Medicine, Otto-von-Guericke University at Magdeburg, Magdeburg, Germany.,Department of General, Abdominal, Vascular and Transplant Surgery, University Hospital, Magdeburg, Germany
| | - Frank Meyer
- Institute of Quality Assurance in Operative Medicine, Otto-von-Guericke University at Magdeburg, Magdeburg, Germany.,Department of General, Abdominal, Vascular and Transplant Surgery, University Hospital, Magdeburg, Germany
| | - Henry Ptok
- Institute of Quality Assurance in Operative Medicine, Otto-von-Guericke University at Magdeburg, Magdeburg, Germany.,Department of General, Abdominal, Vascular and Transplant Surgery, University Hospital, Magdeburg, Germany
| | - Ralf Steinert
- Department of General and Abdominal Surgery, St Joseph Hospital, Salzkotten, Germany
| | - Ronny Otto
- Institute of Quality Assurance in Operative Medicine, Otto-von-Guericke University at Magdeburg, Magdeburg, Germany
| | - Hans Lippert
- Institute of Quality Assurance in Operative Medicine, Otto-von-Guericke University at Magdeburg, Magdeburg, Germany
| | - Ingo Gastinger
- Institute of Quality Assurance in Operative Medicine, Otto-von-Guericke University at Magdeburg, Magdeburg, Germany
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Manzanares MDC, Martín J, Amo-Salas M, Casanova D. Reducción de la morbilidad postoperatoria en el cáncer colorrectal programado: inmunonutrición oral preoperatoria. REVISTA CHILENA DE CIRUGÍA 2017; 69:389-396. [DOI: 10.1016/j.rchic.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2025]
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Manzanares Campillo MDC, Martín Fernández J, Amo Salas M, Casanova Rituerto D. [A randomized controlled trial of preoperative oral immunonutrition in patients undergoing surgery for colorectal cancer: hospital stay and health care costs]. CIR CIR 2017; 85:393-400. [PMID: 27955850 DOI: 10.1016/j.circir.2016.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 10/24/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND The use of enteral formulas with immunonutrients in patients with gastrointestinal malignancies susceptible to surgery can reduce postoperative morbidity, at the expense of reduced infectious complications, with the consequent reduction in hospital stay and health care costs. MATERIAL AND METHODS Prospective randomized study. 84 patients operated on a scheduled basis for resectable colorectal cancer were recruited. In the group YES IN Impact © Oral was administered for 8 days (3 sachets a day), compared with the NOT IN group who did not receive it. RESULTS 40.5% (17) patients without immunonutrition suffered infectious complications vs. 33.3% (14) of YES IN. In patients with rectal cancer NOT IN, 50% (8) suffered minor infectious complications (p=.028). In each group (YES IN, NOT IN, colon and rectal cancer) when infectious complications were observed, the variables total hospital stay and costs doubled, with significant differences. These variables showed higher values in the group NOT IN compared with those who received immunonutrition, although these differences were not statistically significant. CONCLUSIONS NOT IN patients suffered infectious complications more frequently than YES IN, with significant results in the subgroup of patients with rectal cancer. The total hospital stay and costs were slightly higher in the group not supplemented, doubling in each category significantly (YES IN, NOT IN, colon and rectal cancer), when infectious complications were observed.
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Affiliation(s)
| | - Jesús Martín Fernández
- Servicio de Cirugía General, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Mariano Amo Salas
- Departamento de Matemáticas, Facultad de Medicina de Ciudad Real, Universidad de Castilla la Mancha, Ciudad Real, España
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Feinberg J, Nielsen EE, Korang SK, Halberg Engell K, Nielsen MS, Zhang K, Didriksen M, Lund L, Lindahl N, Hallum S, Liang N, Xiong W, Yang X, Brunsgaard P, Garioud A, Safi S, Lindschou J, Kondrup J, Gluud C, Jakobsen JC, Cochrane Hepato‐Biliary Group. Nutrition support in hospitalised adults at nutritional risk. Cochrane Database Syst Rev 2017; 5:CD011598. [PMID: 28524930 PMCID: PMC6481527 DOI: 10.1002/14651858.cd011598.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support. OBJECTIVES To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016. SELECTION CRITERIA We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. MAIN RESULTS We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence). AUTHORS' CONCLUSIONS There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.
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Affiliation(s)
- Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kirstine Halberg Engell
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Marie Skøtt Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kang Zhang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Maria Didriksen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Lisbeth Lund
- Danish Committee for Health Education5. sal, Classensgade 71CopenhagenDenmark2100
| | - Niklas Lindahl
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sara Hallum
- Cochrane Colorectal Cancer Group23 Bispebjerg BakkeBispebjerg HospitalCopenhagenDenmarkDK 2400 NV
| | - Ning Liang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Wenjing Xiong
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Xuemei Yang
- Fujian University of Traditional Chinese MedicineResearch Base of TCM syndromeNo。1，Qiu Yang RoadShangjie town,Minhou CountyFuzhouFujian ProvinceChina350122
| | - Pernille Brunsgaard
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Alexandre Garioud
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jane Lindschou
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jens Kondrup
- Rigshospitalet University HospitalClinical Nutrition UnitAmager Boulevard 127, 2th9 BlegdamsvejKøbenhavn ØDenmark2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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Abstract
Postgastrectomy syndromes result from altered form and function of the stomach. Gastrectomy disrupts reservoir capacity, mechanical digestion and gastric emptying. Early recognition of symptoms with prompt evaluation and treatment is essential. Many syndromes resolve with minimal intervention or dietary modifications. Re-operation is not common but often warranted for afferent and efferent loop syndromes and bile reflux gastritis. Preoperative nutritional assessment and treatment of common vitamin and mineral deficiencies after gastrectomy can reduce the incidence of chronic complications. An integrated team approach to risk assessment, patient education, and postoperative management is critical to optimal care of patients with gastric cancer.
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Ueno D, Matsumoto H, Kubota H, Higashida M, Akiyama T, Shiotani A, Hirai T. Prognostic factors for gastrectomy in elderly patients with gastric cancer. World J Surg Oncol 2017; 15:59. [PMID: 28284210 PMCID: PMC5346248 DOI: 10.1186/s12957-017-1131-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 03/06/2017] [Indexed: 12/11/2022] Open
Abstract
Background The aim of the present study was to investigate the age-specific prognostic factors in patients who underwent gastrectomy for gastric cancer. Methods The medical records of 366 patients with gastric cancer who underwent surgical resection at our hospital between January 2007 and December 2014 were retrospectively reviewed. Of the 366 patients, 117 were aged 75 years or older and 249 were aged 74 years or younger. All factors that were identified as significant using univariate analysis were included in the multivariate analysis. Results The median follow-up duration was 52.9 months (range, 1.0–117.5 months). We found that in patients aged 75 years or older, postoperative complications and the extent of cancer were independent prognostic factors of overall survival and disease-free survival. In contrast, in patients aged 74 years or younger, only the lymph node status and postoperative chemotherapy were independent prognostic factors for overall survival and disease-free survival, respectively. Conclusions Pathological outcomes and postoperative complications are important prognostic factors for survival in patients aged 75 years or older with gastric cancer, whereas pathological outcomes and postoperative chemotherapy are important prognostic factors for survival in patients aged 74 years or younger. Because the prevention of postoperative complications may contribute to improvements in the prognosis of elderly patients with gastric cancer, we suggest that it is necessary to consider limited surgery instead of radical surgery, depending on the patient’s general condition and co-morbidities.
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Affiliation(s)
- Daisuke Ueno
- Department of Digestive Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan.
| | - Hideo Matsumoto
- Department of Digestive Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Hisako Kubota
- Department of Digestive Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Masaharu Higashida
- Department of Digestive Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Takashi Akiyama
- Department of Pathology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Akiko Shiotani
- Department of Gastroenterology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Toshihiro Hirai
- Department of Digestive Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
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Worthington P, Balint J, Bechtold M, Bingham A, Chan LN, Durfee S, Jevenn AK, Malone A, Mascarenhas M, Robinson DT, Holcombe B. When Is Parenteral Nutrition Appropriate? JPEN J Parenter Enteral Nutr 2017; 41:324-377. [PMID: 28333597 DOI: 10.1177/0148607117695251] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.
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Affiliation(s)
| | - Jane Balint
- 2 Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Angela Bingham
- 4 University of the Sciences, Philadelphia, Pennsylvania, USA
| | | | - Sharon Durfee
- 6 Central Admixture Pharmacy Services, Inc, Denver, Colorado, USA
| | | | | | - Maria Mascarenhas
- 9 The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel T Robinson
- 10 Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Beverly Holcombe
- 11 American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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Dupuis M, Kuczewski E, Villeneuve L, Bin-Dorel S, Haine M, Falandry C, Gilbert T, Passot G, Glehen O, Bonnefoy M. Age Nutrition Chirugie (ANC) study: impact of a geriatric intervention on the screening and management of undernutrition in elderly patients operated on for colon cancer, a stepped wedge controlled trial. BMC Geriatr 2017; 17:10. [PMID: 28061830 PMCID: PMC5219771 DOI: 10.1186/s12877-016-0402-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 12/21/2016] [Indexed: 01/16/2023] Open
Abstract
Background Undernutrition prior to major abdominal surgery is frequent and increases morbidity and mortality, especially in older patients. The management of undernutrition reduces postoperative complications. Nutritional management should be a priority in patient care during the preoperative period. However undernutrition is rarely detected and the guidelines are infrequently followed. Preoperative undernutrition screening should allow a better implementation of the guidelines. Methods/design The ANC (“Age Nutrition Chirurgie”) study is an interventional, comparative, prospective, multicenter, randomized protocol based on the stepped wedge trial design. For the intervention, the surgeon will inform the patient of the establishment of a systematic preoperative geriatric assessment that will allow the preoperative diagnosis of the nutritional status and the implementation of an adjusted nutritional support in accordance with the nutritional guidelines. The primary outcome measure is to determine the impact of the geriatric intervention on the level of perioperative nutritional management, in accordance with the current European guidelines. The implementation of the intervention in the five participating centers will be rolled-out sequentially over six time periods (every six months). Investigators must recommend that all patients aged 70 years or over and who are consulting for a surgery for a colorectal cancer should consider participating in this study. Discussion The ANC study is based on an original methodology, the stepped wedge trial design, which is appropriate for evaluating the implementation of a geriatric and nutritional assessment during the perioperative period. We describe the purpose of this geriatric intervention, which is expected to apply the ESPEN and SFNEP recommendations through the establishment of an undernutrition screening and a management program for patients with cancer. This intervention should allow a decrease in patient morbidity and mortality due to undernutrition. Trial registration This study is registered in ClinicalTrials.gov NCT02084524 on March 11, 2014 (retrospectively registered).
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Affiliation(s)
- Marine Dupuis
- Unité de Recherche Clinique, Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.
| | - Elisabetta Kuczewski
- Service d'Hygiène Épidémiologie Infectiovigilance et Prévention, Hospices Civils de Lyon, Lyon, France
| | - Laurent Villeneuve
- Unité de Recherche Clinique, Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, EAM Parcours Santé Systémique, 4128, Lyon, France.,Université Lyon 1, Lyon, France
| | - Sylvie Bin-Dorel
- Unité de Recherche Clinique, Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, EAM Parcours Santé Systémique, 4128, Lyon, France.,Université Lyon 1, Lyon, France
| | - Max Haine
- Service de Médecine Gériatrique, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Claire Falandry
- Université Lyon 1, EMR 3738, Oullins, France.,Oncologie Médicale, Centre d'Investigation des Thérapeutiques en Oncologie et Hématologie de Lyon (CITOHL), Centre Hospitalier Lyon-Sud, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), Lyon, France
| | - Thomas Gilbert
- Service de Médecine Gériatrique, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Guillaume Passot
- Université Lyon 1, EMR 3738, Oullins, France.,Service de Chirurgie Viscérale et Endocrinienne, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Olivier Glehen
- Université Lyon 1, EMR 3738, Oullins, France.,Service de Chirurgie Viscérale et Endocrinienne, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Marc Bonnefoy
- Université Lyon 1, Lyon, France.,Service de Médecine Gériatrique, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France.,INSERM U1060, Laboratoire CarMeN (cardiovasculaire, métabolisme, diabétologie et nutrition), Université Claude Bernard Lyon 1, Pierre-Bénite, France
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Mosquera C, Koutlas NJ, Edwards KC, Strickland A, Vohra NA, Zervos EE, Fitzgerald TL. Impact of malnutrition on gastrointestinal surgical patients. J Surg Res 2016; 205:95-101. [DOI: 10.1016/j.jss.2016.05.030] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/28/2016] [Accepted: 05/18/2016] [Indexed: 11/30/2022]
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Preoperative hypoalbuminemia is associated with worse outcomes in colon cancer patients. Clin Nutr 2016; 36:1333-1338. [PMID: 27612919 DOI: 10.1016/j.clnu.2016.08.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/05/2016] [Accepted: 08/23/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS The National Veterans' Affairs Surgical Risk Study identified preoperative hypoalbuminemia as an independent risk factor for postoperative morbidity and mortality. Since that time, few studies have investigated the use of preoperative markers as tools to risk stratify colon cancer patients. The purpose of our study is to determine if there is an association between preoperative hypoalbuminemia and 30-day patient morbidity and mortality in colon cancer patients using the Targeted-Colectomy American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP). METHODS Stage I, II, and III elective colon resections with ileocolostomy or colocolostomy were identified within the ACS-NSQIP targeted colectomy database from 2012 through 2013. Hypoalbuminemia was defined as albumin <3.5 g/dL. Patients with hypoalbuminemia were compared to those with a normal albumin level in terms of 30-day morbidity and mortality. The albumin level at which point 30-day morbidity and mortality increased was identified. RESULTS A total of 5143 patients met inclusion criteria; 4397 (85.5%) patients had a normal albumin level while 746 (14.5%) had hypoalbuminemia. Preoperative hypoalbuminemia significantly increased the risk of 30-day mortality (p < 0.0001). The association of hypoalbuminemia with 30-day outcomes was more significant in patients who underwent open surgery and had an intra-abdominal anastomosis. The risk of an adverse event was observed to increase at an albumin level ≤3.1 g/dL. CONCLUSIONS Preoperative hypoalbuminemia is associated with an increased risk of early patient morbidity and mortality in patients undergoing surgery for colon cancer. Preoperative optimization of this patient population warrants further investigation in order to prevent delay from surgical intervention to adjuvant therapy.
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Chemotherapy dose intensity predicted by baseline nutrition assessment in gastrointestinal malignancies: A multicentre analysis. Eur J Cancer 2016; 63:189-200. [PMID: 27362999 DOI: 10.1016/j.ejca.2016.05.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 05/05/2016] [Accepted: 05/10/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Malnutrition is prevalent in cancer patients and is associated with inferior outcomes. We examined the association between malnutrition, as measured by the Subjective Global Assessment (SGA), and chemotherapy dose reduction in patients with gastrointestinal malignancies. We hypothesised that malnutrition, defined by a patient's baseline SGA, would be associated with a greater degree of chemotherapy dose-reduction, with the implication of greater chemotherapy related toxicity. DESIGN We reviewed chemotherapy dosing and treatment related toxicity for patients enrolled in a prospective Gastrointestinal Cancer Registry over their first 8 weeks of treatment. We compared results between well-nourished and malnourished patients. RESULTS Malnourished patients were more likely than well-nourished patients to have their starting chemotherapy dose reduced from standard published dosing (67% versus 35%, p=0.0001). Despite attenuated initial dosing, malnourished patients received a smaller fraction of planned chemotherapy (mean 80±23% versus 90±15% of cycle 1, p=0.005), primarily due to toxicity-related dose reductions. After controlling for age, gender, Eastern Cooperative Oncology Group performance status (ECOG), albumin, smoking status, body habitus, and weight loss, malnutrition remained the strongest independent predictor of the magnitude of chemotherapy dose reduction (estimate -10.3%, 95% confidence interval -19.0 to -0.1.6%, p=0.020). CONCLUSIONS Malnutrition is an independent predictor of chemotherapy dose-reduction for toxicity. This study highlights the practical significance of malnutrition in gastrointestinal malignancies and provides a baseline for future nutrition intervention studies to improve chemotherapy tolerability in malnourished patients.
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38
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Zhao XF, Wu N, Zhao GQ, Liu JF, Dai YF. Enteral nutrition versus parenteral nutrition after major abdominal surgery in patients with gastrointestinal cancer: a systematic review and meta-analysis. J Investig Med 2016; 64:1061-74. [DOI: 10.1136/jim-2016-000083] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2016] [Indexed: 12/14/2022]
Abstract
To clarify the benefits of enteral nutrition (EN) versus total parenteral nutrition (TPN) in patients with gastrointestinal cancer who underwent major abdominal surgery. Medline, Cochrane, EMBASE, and Google Scholar were searched for studies published until July 10, 2015, reporting outcomes between the two types of postoperative nutritional support. Only randomized controlled trials (RCTs) were included. A χ2-based test of homogeneity was performed using Cochran's Q statistic and I2. A total of 2540 patients (1268 who received EN and 1272 who received TPN; average age range: 58.3–67.7 years) from 18 RCTs were included for assessment. Patients who received EN had shorter lengths of hospital stay (pooled difference in mean=−1.74, 95% CI −2.41 to −1.07, p<0.001, shorter time to flatus (pooled difference in mean=−1.27, 95% CI −1.69 to −0.85, p<0.001), and significantly greater increases in albumin levels (pooled difference in mean=−1.33, 95% CI −2.18 to −0.47, p=0.002) compared with those who received TPN after major abdominal surgery, based on a random-effects model of analysis. EN after major abdominal surgery provided better outcomes compared with TPN in patients with gastrointestinal cancer.
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Rosania R, Chiapponi C, Malfertheiner P, Venerito M. Nutrition in Patients with Gastric Cancer: An Update. Gastrointest Tumors 2016; 2:178-87. [PMID: 27403412 DOI: 10.1159/000445188] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Nutritional management of patients with gastric cancer (GC) represents a challenge. SUMMARY This review provides an overview of the present evidence on nutritional support in patients with GC undergoing surgery as well as in those with advanced disease. KEY MESSAGE For patients undergoing surgery, the preoperative nutritional condition directly affects postoperative prognosis, overall survival and disease-specific survival. Perioperative nutritional support enriched with immune-stimulating nutrients reduces overall complications and hospital stay but not mortality after major elective gastrointestinal surgery. Early enteral nutrition after surgery improves early and long-term postoperative nutritional status and reduces the length of hospitalization as well. Vitamin B12 and iron deficiency are common metabolic sequelae after gastrectomy and warrant appropriate replacement. In malnourished patients with advanced GC, short-term home complementary parenteral nutrition improves the quality of life, nutritional status and functional status. Total home parenteral nutrition represents the only modality of caloric intake for patients with advanced GC who are unable to take oral or enteral nutrition. PRACTICAL IMPLICATIONS Early evaluations of nutritional status and nutritional support represent key aspects in the management of GC patients with both operable and advanced disease.
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Affiliation(s)
- Rosa Rosania
- Departments of Gastroenterology, Hepatology and Infectious Diseases, Magdeburg, Germany
| | - Costanza Chiapponi
- Departments of General, Visceral and Vascular Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Peter Malfertheiner
- Departments of Gastroenterology, Hepatology and Infectious Diseases, Magdeburg, Germany
| | - Marino Venerito
- Departments of Gastroenterology, Hepatology and Infectious Diseases, Magdeburg, Germany
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Chiang JM, Chang CJ, Jiang SF, Yeh CY, You JF, Hsieh PS, Huang HY. Pre-operative serum albumin level substantially predicts post-operative morbidity and mortality among patients with colorectal cancer who undergo elective colectomy. Eur J Cancer Care (Engl) 2015; 26. [PMID: 26526411 DOI: 10.1111/ecc.12403] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 11/30/2022]
Abstract
The quantitative relationship between serum albumin level and surgical outcomes has not been clearly established. This study included 3732 patients with colon cancer who underwent a potentially curative colectomy. Post-operative mortality and morbidity were analysed according to the patients' demographic data, pre-operative comorbidities, and tumour-related factors. Age, asthma, renal impairment, and albumin level were significantly associated with post-operative morbidity and mortality in the multivariate analyses. Logistic regression analysis revealed linear relationships of post-operative morbidity and mortality with albumin level. The morbidity and mortality rates decreased by 7.3% and 15.6%, respectively, for each 0.1 g/dL increase in albumin level. This finding remained significant in the hypoalbuminaemia subgroup but not in the normoalbuminaemia subgroup. That is, the morbidity and mortality rates significantly decreased by 8.7% and 17.7%, respectively (both P < 0.001), in the former group and decreased by 2.7% (P = 0.112) and 11.6% (P = 0.092), respectively, in the latter group. This study demonstrated that serum albumin level linearly predicted the post-operative morbidity and mortality among the colorectal cancer patients. Pre-operative serum albumin level may therefore be used as a continuous rather than a categorical marker of disease severity, especially among patients with hypoalbuminaemia.
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Affiliation(s)
- J M Chiang
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - C J Chang
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Tao-Yuan, Taiwan
| | - S F Jiang
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - C Y Yeh
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - J F You
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - P S Hsieh
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - H Y Huang
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
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Lim HS, Cho GS, Park YH, Kim SK. Comparison of Quality of Life and Nutritional Status in Gastric Cancer Patients Undergoing Gastrectomies. Clin Nutr Res 2015; 4:153-9. [PMID: 26251833 PMCID: PMC4525131 DOI: 10.7762/cnr.2015.4.3.153] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 07/10/2015] [Accepted: 07/23/2015] [Indexed: 12/23/2022] Open
Abstract
The aim of this study was to compare the quality of life (QoL) depending on the postoperative survival period or nutritional status in gastric cancer patients. Surviving gastric cancer patients (n = 222) after the gastrectomy were included in the study at Soonchunhyang University Bucheon Hospital from April 2010 to August 2012. The Korean versions of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and a gastric cancer-specific module, the EORTC QLQ-STO22, were used to assess the QoL. The postoperative survival period of the patients fell into two groups; the less-than-1-year group or the more-than-1-year group, and the nutritional status of the patients fell into three groups by a score of patient generated-subjective global assessment (SGA)-A, B, and C. As a result, the rate of malnutrition was 34.5% in the less-than-1-year group and 19.8% in the more-than-1-year group, respectively. Score for the fatigue (p = 0.006), loss of appetite (p = 0.002), reflux (p = 0.027) and body image (p = 0.004) in which the QoL was significantly lower in the less-than-1-year group than in the more-than-1-year group. The score of QoL according to the nutritional status of all subjects, overall health status (p = 0.043), physical functioning (p = 0.016), fatigue (p = 0.006), pain (p = 0.028), loss of appetite (p = 0.017), reflux (p = 0.003), eating restriction (p = 0.002), anxiety (p = 0.010), and body image (p = 0.001) was significantly lower in the SGA-C group than in other SGA groups. These results suggest that the nutritional status of the gastrectomy patients with stomach cancer may impact on their QoL. It is necessary to to develop nutritional intervention to improve QoL in gastric cancer patients with postoperative malnutrition.
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Affiliation(s)
- Hee-Sook Lim
- Department of Clinical Nutrition, Soonchunhyang University Bucheon Hospital, Bucheon 420-767, Korea. ; Department of Preventive Medicine, Soonchunhyang University College of Medicine, Cheonan 330-930, Korea
| | - Gyu-Seok Cho
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Bucheon 420-767, Korea
| | - Yoon-Hyung Park
- Department of Preventive Medicine, Soonchunhyang University College of Medicine, Cheonan 330-930, Korea
| | - Soon-Kyung Kim
- Department of Food Science & Nutrition, Soonchunhyang University, Asan 336-745, Korea
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Abstract
Fast-track surgery is a multimodal approach to patient care using a combination of several evidence-based peri-operative interventions to expedite recovery after surgery. It is an extension of the critical pathway that integrates modalities in surgery, anesthesia, and nutrition, enforces early mobilization and feeding, and emphasizes reduction of the surgical stress response. It entails a great partnership between a surgeon and an anesthesiologist with several other specialists to form a multi-disciplinary team, which may then engage in patient care. The practice of fast-track surgery has yielded excellent results and there has been a significant reduction in hospital stay without a rise in complications or re-admissions. The effective implementation begins with the formulation of a protocol, carrying out each intervention and gathering outcome data. The care of a patient is divided into three phases: Before, during, and after surgery. Each stage needs active participation of few or all the members of the multi-disciplinary team. Other than surgical technique, anesthetic drugs, and techniques form the cornerstone in the ability of the surgeon to carry out a fast-track surgery safely. It is also the role of this team to keep abreast with the latest development in fast-track methodology and make appropriate changes to policy. In the Indian healthcare system, there is a huge benefit that may be achieved by the successful implementation of a fast-track surgery program at an institutional level. The lack of awareness regarding this concept, fear and apprehension regarding its implementation are the main barriers that need to be overcome.
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Affiliation(s)
- Aditya J Nanavati
- Department of General Surgery, K.B. Bhabha Hospital, Bandra, Mumbai, Maharashtra, India
| | - S Prabhakar
- Department of General Surgery, L.T.M.G.H., Sion, Mumbai, Maharashtra, India
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Afaneh C, Gerszberg D, Slattery E, Seres DS, Chabot JA, Kluger MD. Pancreatic cancer surgery and nutrition management: a review of the current literature. Hepatobiliary Surg Nutr 2015; 4:59-71. [PMID: 25713805 PMCID: PMC4318958 DOI: 10.3978/j.issn.2304-3881.2014.08.07] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 08/06/2014] [Indexed: 12/18/2022]
Abstract
Surgery remains the only curative treatment for pancreaticobiliary tumors. These patients typically present in a malnourished state. Various screening tools have been employed to help with preoperative risk stratification. Examples include the subjective global assessment (SGA), malnutrition universal screening tool (MUST), and nutritional risk index (NRI). Adequate studies have not been performed to determine if perioperative interventions, based on nutrition risk assessment, result in less morbidity and mortality. The routine use of gastric decompression with nasogastric sump tubes may be unnecessary following elective pancreatic resections. Instead, placement should be selective and employed on a case-by-case basis. A wide variety of feeding modalities are available, oral nutrition being the most effective. Artificial nutrition may be provided by temporary nasal tube (nasogastric, nasojejunal, or combined nasogastrojejunal tube) or surgically placed tube [gastrostomy (GT), jejunostomy (JT), gastrojejunostomy tubes (GJT)], and intravenously (parenteral nutrition, PN). The optimal tube for enteral feeding cannot be determined based on current data. Each is associated with a specific set of complications. Dual lumen tubes may be useful in the presence of delayed gastric emptying (DGE) as the stomach may be decompressed while feeds are delivered to the jejunum. However, all feeding tubes placed in the small intestine, except direct jejunostomies, commonly dislodge and retroflex into the stomach. Jejunostomies are associated with less frequent, but more serious complications. These include intestinal torsion and bowel necrosis. PN is associated with septic, metabolic, and access-related complications and should be the feeding strategy of last-resort. Enteral feeds are clearly preferred over parental nutrition. A sound understanding of perioperative nutrition may improve patient outcomes. Patients undergoing pancreatic cancer surgery should undergo multidisciplinary nutrition screening and intervention, and the surgical/oncological team should include nutrition professionals in managing these patients in the perioperative period.
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Ciacio O, Voron T, Pittau G, Lewin M, Vibert E, Adam R, Sa Cunha A, Cherqui D, Schielke A, Soubrane O, Scatton O, Salloum C, Azoulay D, Benoist S, Goyer P, Vaillant JC, Hannoun L, Boleslawski E, Agostini H, Samuel D, Castaing D. Interest of preoperative immunonutrition in liver resection for cancer: study protocol of the PROPILS trial, a multicenter randomized controlled phase IV trial. BMC Cancer 2014; 14:980. [PMID: 25523036 PMCID: PMC4302113 DOI: 10.1186/1471-2407-14-980] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Malnutrition is an independent risk factor of postoperative morbidity and mortality and it's observed in 20 to 50% of surgical patients. Preoperative interventions to optimize the nutritional status, reduce postoperative complications and enteral nutrition has proven to be superior to the parenteral one. Moreover, regardless of the nutritional status of the patient, surgery impairs the immunological response, thus increasing the risk of postoperative sepsis. Immunonutrition has been developed to improve the immunometabolic host response in perioperative period and it has been proven to reduce significantly postoperative infectious complications and length of hospital stay in patients undergoing elective gastrointestinal surgery for tumors. We hypothesize that a preoperative oral immunonutrition (ORAL IMPACT®) can reduce postoperative morbidity in liver resection for cancer. METHODS/DESIGN Prospective multicenter randomized placebo-controlled double-blind phase IV trial with two parallel treatment groups receiving either study product (ORAL IMPACT®) or control supplement (isocaloric isonitrogenous supplement--IMPACT CONTROL®) for 7 days before liver resection for cancer. A total of 400 patients will be enrolled. Patients will be stratified according to the type of hepatectomy, the presence of chronic liver disease and the investigator center. The main end-point is to evaluate in intention-to-treat analysis the overall 30-day morbidity. Secondary end-points are to assess the 30-day infectious and non-infectious morbidity, length of antibiotic treatment and hospital stay, modifications on total food intake, compliance to treatment, side-effects of immunonutrition, impact on liver regeneration and sarcopenia, and to perform a medico-economic analysis. DISCUSSION The overall morbidity rate after liver resection is 22% to 42%. Infectious post-operative complications (12% to 23%) increase the length of hospital stay and costs and are responsible for a quarter of 30-day mortality. Various methods have been advocated to decrease the rate of postoperative complications but there is no evidence to support or refute the use of any treatment and further trials are required. The effects of preoperative oral immunonutrition in non-cirrhotic patients undergoing liver resection for cancer are unknown. The present trial is designed to evaluate whether the administration of a short-term preoperative oral immunonutrition can reduce postoperative morbidity in non-cirrhotic patients undergoing liver resection for cancer. TRIAL REGISTRATION Clinicaltrial.gov: NCT02041871.
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Affiliation(s)
- Oriana Ciacio
- Centre Hépato-biliaire, Paul Brousse Hospital - APHP, 12-14 Avenue Paul Vaillant Couturier, 94800 Villejuif, France.
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Hébuterne X, Lemarié E, Michallet M, de Montreuil CB, Schneider SM, Goldwasser F. Prevalence of malnutrition and current use of nutrition support in patients with cancer. JPEN J Parenter Enteral Nutr 2014; 38:196-204. [PMID: 24748626 DOI: 10.1177/0148607113502674] [Citation(s) in RCA: 510] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The aim of this study was to evaluate on 1 day the prevalence of malnutrition in different types of cancer and the use of nutrition support in patients with cancer. METHODS A 1-day prevalence survey was carried out in 154 French hospital wards. Malnutrition was defined as a body mass index (BMI) <18.5 in patients <75 years old or <21 in patients ≥75 years old and/or body weight loss >10% since disease onset. Oral food intake was measured using a visual analog scale. RESULTS Nutrition status was collected for 1903 patients (1109 men and 794 women, 59.3 ± 13.2 years). Cancer was local in 25%, regional in 31%, and metastatic in 44% of patients. Performance status was 0 or 1 in 49.8%, 2 in 23.7%, 3 or 4 in 19.6% and not available in 6.5% of patients. Overall, 39% of patients were malnourished. The prevalence of malnutrition by disease site was as follows: head and neck, 48.9%; leukemia/lymphoma, 34.0%; lung, 45.3%; colon/rectum, 39.3%; esophagus and/or stomach, 60.2%; pancreas, 66.7%; breast, 20.5%; ovaries/uterus, 44.8%; and prostate, 13.9%. Regional cancer (odds ratio, 1.96; 95% confidence interval, 1.42-2.70), metastatic cancer (2.97; 2.14-4.12), previous chemotherapy (1.41; 1.05-1.89), and previous radiotherapy (1.53; 1.21-1.92) were associated with malnutrition. Only 28.4% of non-malnourished patients and 57.6% of malnourished patients received nutrition support. In all, 55% of patients stated that they were eating less than before the cancer, while 41.4% of patients stated that they had received nutrition counseling. CONCLUSIONS The prevalence of malnutrition is high in patients with cancer, and systematic screening for and treatment of malnutrition is necessary.
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Affiliation(s)
- Xavier Hébuterne
- Gastroenterology and Clinical Nutrition, Nice Teaching Hospital (CHU), University of Nice Sophia-Antipolis, Nice
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Henry L. Effect of Malnutrition on Cancer Patients. Nutr Cancer 2013. [DOI: 10.1002/9781118788707.ch4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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The role of dietary nutrition in stomach cancer. Contemp Oncol (Pozn) 2013; 17:343-5. [PMID: 24592120 PMCID: PMC3934052 DOI: 10.5114/wo.2013.37213] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 02/17/2013] [Accepted: 03/14/2013] [Indexed: 01/16/2023] Open
Abstract
Stomach cancer mortality still represents a significant proportion of all cancer deaths. The majority of patients with advanced cancer experience cancer anorexia-cachexia syndrome with weight loss, reduced appetite, fatigue, and weakness. Neoplastic cachexia is a very common clinical manifestation of upper gastrointestinal (GI) tract cancer and is generally assumed to be secondary to the mechanical effects of the tumor on the upper digestive tract. The main reasons are obstruction to swallowing, early satiety, nausea and vomiting. Another reason for weight loss is the co-existence of systemic inflammation. Nutritional treatment in the group of patients with gastric cancer is still used too rarely and the knowledge about it is still very limited. Nutritional support should be given for patients both in the pre- and postoperative period. Nutrition should also be used in palliative treatment in patients with unresectable stomach cancer. The main principles of nutritional support and its influence are presented in this publication.
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Miller KR, Wischmeyer PE, Taylor B, McClave SA. An Evidence-Based Approach to Perioperative Nutrition Support in the Elective Surgery Patient. JPEN J Parenter Enteral Nutr 2013; 37:39S-50S. [DOI: 10.1177/0148607113493928] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Keith R. Miller
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Paul E. Wischmeyer
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora
| | | | - Stephen A. McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
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Ligthart-Melis GC, Weijs PJM, te Boveldt ND, Buskermolen S, Earthman CP, Verheul HMW, de Lange-de Klerk ESM, van Weyenberg SJB, van der Peet DL. Dietician-delivered intensive nutritional support is associated with a decrease in severe postoperative complications after surgery in patients with esophageal cancer. Dis Esophagus 2013; 26:587-93. [PMID: 23237356 DOI: 10.1111/dote.12008] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to evaluate the effect of dietician-delivered intensive nutritional support (INS) on postoperative outcome in patients with esophageal cancer. Approximately 50-80% of patients with esophageal cancer are malnourished at the time of diagnosis. Malnutrition enhances the risk of postoperative complications, resulting in delay of postoperative recovery and impairment of quality of life. Sixty-five patients with esophageal cancer were included. All patients who received surgery (n = 28) in the time frame between March 2009 and April 2010, the first year after the start of INS, were included in the INS intervention group. The control group (n = 37) consisted of patients who received surgery during the 3 years before the start of INS. Logistic regression analysis was used to compare differences in severity of postoperative complications using the Dindo classification. Linear regression was applied to evaluate differences in preoperative weight change. The adjusted odds ratio for developing serious complications after surgery of INS compared with the control group was 0.23 (95% confidence interval: 0.053-0.97; P = 0.045). Benefit was mainly observed in patients who received neoadjuvant therapy before esophagectomy (n = 35). The INS program furthermore resulted in a relative preoperative weight gain in comparison with the control group of +4.8% (P = 0.009, adjusted) in these neoadjuvant-treated patients. This study shows that dietician-delivered INS preserves preoperative weight and decreases severe postoperative complications in patients with esophageal cancer.
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Affiliation(s)
- G C Ligthart-Melis
- Nutrition & Dietetics, Department of Internal Medicine, VU University Medical Center (VUmc), Amsterdam, The Netherlands.
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