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Ciulli C, Fogliati A, Scacchi A, Scotti MA, Aprigliano M, Braga M, Romano F, Garancini M. Early compliance to enhanced recovery protocol as a predictor of complications after liver surgery. Updates Surg 2025:10.1007/s13304-025-02148-7. [PMID: 40087243 DOI: 10.1007/s13304-025-02148-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 02/26/2025] [Indexed: 03/17/2025]
Abstract
BACKGROUND Enhanced Recovery Protocol (ERP) has the purpose of minimising postoperative hospitalisation and expediting the restoration of preoperative patient conditions. This study seeks to investigate the correlation between early non-compliance to postoperative items within ERP and complications in liver surgery. METHODS From January 2019 to December 2022 the ERP was proposed to all consecutive patients undergoing liver surgery. Nasogastric tube removal, resuming oral intake and mobilisation and obtaining an adequate glycaemic control were the postoperative items considered as non-compliance indicators. Data were prospectively collected and analysed. RESULTS 192 patients were included, comprising 99(51.6%) hepatocellular carcinoma, 58(30.2%) colorectal metastasis and 24(12.5%) benign/other pathology. A minimally invasive approach was adopted in 57.3% of cases. Postoperative morbidities occurred in 44.8% of patients, while major complications in 13% of patients. Cirrhosis (p < 0.001), minimally invasive approach (p < 0.004), early oral intake (p < 0.019) and early mobilisation (p < 0.019) significantly correlated to morbidity at multivariate analysis. The complication rate escalated from 26.9% in fully compliant patients, to 58% in patients with two non-compliance indicators and to 91.2% in fully non-compliant patients (p < 0.001). The same trend was confirmed for major complications (p < 0.001). CONCLUSIONS Early non-compliance to ERP postoperative items in liver surgery was significantly associated with overall and major morbidity.
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Affiliation(s)
- Cristina Ciulli
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy.
| | - Alessandro Fogliati
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
| | - Andrea Scacchi
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
| | - Mauro Alessandro Scotti
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
| | - Michele Aprigliano
- Department of Anesthesiology and Intensive Care Medicine, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
| | - Marco Braga
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
| | - Fabrizio Romano
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
| | - Mattia Garancini
- HPB Surgery Unit, Department of General Surgery, IRCCS San Gerardo dei Tintori Foundation, Via Pergolesi 33, 20900, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126, Milano, Italy
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Robertson RH, Russell K, Jordan V, Pandanaboyana S, Wu D, Windsor J. Postoperative nutritional support after pancreaticoduodenectomy in adults. Cochrane Database Syst Rev 2025; 3:CD014792. [PMID: 40084692 PMCID: PMC11907764 DOI: 10.1002/14651858.cd014792.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2025]
Abstract
BACKGROUND Resection of the head of the pancreas is most commonly done by a pancreaticoduodenectomy, known as a Whipple procedure. The most common indication for pancreaticoduodenectomy is malignancy, but can include benign tumours and chronic pancreatitis. Complete surgical resection, with negative margins, provides the best prospect of long-term survival. Pancreaticoduodenectomy involves specific and unique alterations to the digestive system and maintaining nutritional status (optimising outcomes and achieving resumption of a normal diet) in patients with cancer after major surgery is a challenge. Malnutrition is a risk factor following pancreaticoduodenectomy, due to the magnitude of the operation and the frequency of complications. Postoperatively, patients are fed either orally, enterally or parenterally. Oral intake may start with fluids and then progress to solid food, or may be ad libitum. Enteral feeding may be via a nasojejunal tube or feeding tube jejunostomy. Parenteral nutrition can be delivered via a central or peripheral intravenous line, and may provide full nutrition (TPN) or partial nutrition (supplemental PN). OBJECTIVES To assess the effects of postoperative nutritional support strategies on complications and recovery in adults after pancreaticoduodenectomy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS and CINAHL (from inception to October 2022), ongoing trials registers and other internet databases. We searched previous systematic reviews, relevant publications on the same topic and the references of included studies. SELECTION CRITERIA Randomised controlled trials of postoperative nutritional interventions in an inpatient setting for patients undergoing pancreaticoduodenectomy. We specifically looked for studies comparing route or timing rather than nutritional content. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, judged the risk of bias and extracted data. Studies requiring translation were assessed for inclusion, risk of bias and data extraction by an external translator and another author. We used GRADE to evaluate the certainty of the evidence. MAIN RESULTS We included 17 studies (1897 participants). Of these, eight studies could be included in a meta-analysis. The route, timing and target of nutritional support varied widely between studies. Enteral feeding (jejunostomy, nasojejunal or gastrojejunostomy) was used in at least 13 studies (one study did not specify the method of enteral route), parenteral nutrition (PN) was used in at least 10 studies (two studies had a control of 'surgeon's preference' and no further details were given) and oral intake was used in seven studies. Overall, the evidence presented in this review is of low to very low certainty. Four studies compared jejunostomy feeding with total parenteral nutrition. When we pooled these four studies, the evidence demonstrated that jejunostomy likely results in a reduced length of hospital stay (mean difference (MD) -1.61 days, 95% confidence interval (CI) -2.31 to -0.92; 3 studies, 316 participants; moderate-certainty evidence). The evidence suggested that there may be no difference in postoperative pancreatic fistula (risk ratio (RR) 0.77, 95% CI 0.41 to 1.47; 4 studies, 346 participants; low-certainty evidence) and that there may be no difference in delayed gastric emptying (RR 0.38, 95% CI 0.04 to 3.50; 2 studies, 270 participants; very low-certainty evidence) or post pancreatectomy haemorrhage (RR 0.36, 95% CI 0.06 to 2.29; 2 studies, 270 participants; very low-certainty evidence), but the evidence is uncertain. There were no data for major and minor complications defined by the Clavien-Dindo classification. Two studies compared nasojejunal feeding with total parenteral nutrition. When the two studies were pooled, the evidence suggested that there may be little to no difference between nasojejunal feeding and TPN in the length of hospital stay (MD 1.07 days, 95% CI -2.64 to 4.79; 2 studies, 242 participants; low-certainty evidence), delayed gastric emptying (RR 1.26, 95% CI 0.83 to 1.91; 2 studies, 242 participants; low-certainty evidence) or post pancreatectomy haemorrhage (RR 1.00, 95% CI 0.62 to 1.62; 2 studies, 242 participants; low-certainty evidence). TPN may slightly improve rates of clinically relevant postoperative pancreatic fistula (RR 2.13, 95% CI 1.21 to 3.74; 2 studies, 242 participants; low-certainty evidence). One study reported on major complications (RR 1.27, 95% CI 0.83 to 1.94; very low-certainty evidence) and minor complications (RR 1.01, 95% CI 0.68 to 1.50; 204 participants; very low-certainty evidence) defined by the Clavien-Dindo classification and there may be little to no difference in effect, but the evidence is uncertain. Two studies compared jejunostomy feeding with oral intake. Of note, one of the studies used a modified surgical technique as part of the intervention. We pooled these studies and found that there may be little to no difference in the length of hospital stay (MD -1.99 days, 95% CI -4.90 to 0.91; 2 studies, 301 participants; very low-certainty evidence) or delayed gastric emptying (RR 0.98, 95% CI 0.33 to 2.88; 2 studies, 307 participants; very low-certainty evidence). One study reported on major complications (RR 1.01, 95% CI 0.44 to 2.34; 247 participants; very low-certainty evidence) and minor complications (RR 0.83, 95% CI 0.59 to 1.15; 247 participants; very low-certainty evidence) defined by the Clavien-Dindo classification, postoperative pancreatic fistula (RR 0.86, 95% CI 0.30 to 2.50; 247 participants; very low-certainty evidence) and post pancreatectomy haemorrhage (RR 2.02, 95% CI 0.52 to 7.88; 247 participants; very low-certainty evidence) and there may be little to no difference in effect on these outcomes, but the evidence is uncertain. No difference in mortality was detected in any of the analyses (Clavien-Dindo Grade V) (very low-certainty evidence). AUTHORS' CONCLUSIONS When compared with parenteral nutrition, enteral nutrition by jejunostomy likely results in a decreased length of hospital stay and may lead to no difference in the incidence of postoperative complications. When compared with parenteral nutrition, enteral feeding by nasojejunal tube may result in no difference in the incidence of postoperative complications or length of hospital stay. When compared with oral nutrition, enteral nutrition by jejunostomy feeding may result in no difference in the incidence of postoperative complications or length of hospital stay, but the evidence is very uncertain. Further high-quality research is required and there are several ongoing studies. Given the number of different nutritional interventions available in the postoperative setting, a network meta-analysis would be more appropriate in future.
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Affiliation(s)
- Rachel H Robertson
- Department of General Surgery, Waikato Hospital, Te Whatu Ora Waikato, Hamilton, New Zealand
| | - Kylie Russell
- Nutrition and Dietetics, Auckland District Health Board, Auckland, New Zealand
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Vanessa Jordan
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- HPB and Liver Transplant Surgery, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dong Wu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Ramaswamy T, DeWane MP, Dashti HS, Lau M, Wischmeyer PE, Nagrebetsky A, Sparling J. Nine Myths about Enteral Feeding in Critically Ill Adults: An Expert Perspective. Adv Nutr 2025; 16:100345. [PMID: 39551432 PMCID: PMC11784768 DOI: 10.1016/j.advnut.2024.100345] [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: 05/24/2024] [Revised: 09/20/2024] [Accepted: 11/13/2024] [Indexed: 11/19/2024] Open
Abstract
Malnutrition is a well-studied and significant prognostic risk factor for morbidity and mortality in critically ill perioperative patients. Common nutrition myths in the critically ill may prevent early, consistent, and adequate delivery of enteral nutrition. We outlined 9 common intensive care unit (ICU) nutrition misconceptions and our recommendations to optimize enteral nutrition in critically ill patients based on the review of available literature. Our approach is to treat every patient admitted to the ICU as at risk for malnutrition and to initiate enteral nutrition upon admission in the absence of contraindications. Early enteral nutrition via the gastric route is more beneficial than delaying feeding while awaiting small bowel access and daytime-intermittent nutrition support can safely be initiated over continuous feeding. Gastric residual volumes to assess feeding tolerance should no longer be routinely measured. For perioperative nutrition, we recommend continuing enteral nutrition for most patients with secure airways undergoing anesthesia and resuming nutrition within 24 h of abdominal surgery; even patients with open abdomens can be safely fed in the absence of bowel injury. Critically ill patients who are proned, paralyzed, and on vasopressors can usually continue enteral nutrition. Finally, continuing enteral nutrition before extubation may optimize nutrition without compromising extubation success. In this review, we highlight several common misconceptions regarding ICU nutrition that may prevent achieving nutrition goals and subsequently lead to increased malnutrition, morbidity, and mortality. This knowledge may contribute to increased implementation of early and consistent enteral nutrition strategies to improve outcomes in critically ill adult patients.
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Affiliation(s)
- Tara Ramaswamy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States.
| | - Michael P DeWane
- Department of Surgery, Division of Trauma, Emergency Surgery & Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Hassan S Dashti
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Meghan Lau
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Paul E Wischmeyer
- Department of Anesthesiology, Division of Critical Care Medicine, Duke University Hospital, Durham, NC, United States
| | - Alexander Nagrebetsky
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Jamie Sparling
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
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Boyle E, Elliott JA. Novel nutrition strategies in gastric and esophageal cancer. Expert Rev Gastroenterol Hepatol 2025; 19:89-104. [PMID: 39864091 DOI: 10.1080/17474124.2025.2457444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2024] [Revised: 12/16/2024] [Accepted: 01/20/2025] [Indexed: 01/28/2025]
Abstract
INTRODUCTION Advances in treatment strategies for gastric and esophageal cancer have led to improved long-term outcomes, however the local and systemic effects of the primary tumor, neoadjuvant therapies and surgery, result in specific nutritional challenges. Comprehensive nutritional evaluation and support represents a core component of multidisciplinary holistic care for this patient population. AREAS COVERED We provide a detailed overview of nutritional challenges in gastric and esophageal cancer, with a focus on malignant obstruction, preoperative optimization and survivorship. We discuss current management strategies and evidence base, and describe future therapeutic targets. EXPERT OPINION Data to support the optimal management of malignant dysphagia and obstruction, particularly regarding patient reported outcomes, is currently lacking. The advantages of nutritional optimization in the pre- and immediate postoperative phase are well described, but further research is needed to inform optimal personalised strategies. Emerging data regarding the physiologic regulation of appetite and body weight have provided key insights and informed the development of novel therapeutic targets to improve nutritional status among patients undergoing treatment for oesophageal and gastric cancer.
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Affiliation(s)
- Ellen Boyle
- Department of Surgery, Trinity St. James's Cancer Institute, Dublin, Ireland
| | - Jessie A Elliott
- Department of Surgery, Trinity St. James's Cancer Institute, Dublin, Ireland
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Dongare PA, Bala Bhaskar S, Goneppanavar U. Breaking the fast, and overcoming the physical and mental barriers for early resumption of postoperative feeding. Indian J Anaesth 2024; 68:743-745. [PMID: 39386412 PMCID: PMC11460819 DOI: 10.4103/ija.ija_800_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 08/06/2024] [Accepted: 08/06/2024] [Indexed: 10/12/2024] Open
Affiliation(s)
- Pradeep A. Dongare
- Department of Anaesthesiology, ESIC Medical College and PGIMSR, Kalaburagi, Karnataka, India
| | - S Bala Bhaskar
- Department of Anaesthesiology, Ballari Medical College and Research Centre, Ballari, Karnataka, India
| | - Umesh Goneppanavar
- Department of Operation Theatre, Jerudong Park Medical Centre, Brunei Darussalam
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Ljungqvist O, Weimann A, Sandini M, Baldini G, Gianotti L. Contemporary Perioperative Nutritional Care. Annu Rev Nutr 2024; 44:231-255. [PMID: 39207877 DOI: 10.1146/annurev-nutr-062222-021228] [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] [Indexed: 09/04/2024]
Abstract
Over the last decades, surgical complication rates have fallen drastically. With the introduction of new surgical techniques coupled with specific evidence-based perioperative care protocols, patients today run half the risk of complications compared with traditional care. Many patients who in previous years needed weeks of hospital care now recover and can leave in days. These remarkable improvements are achieved by using nutritional stress-reducing care elements for the surgical patient that reduce metabolic stress and allow for the return of gut function. This new approach to nutritional care and how it is delivered as an integral part of enhancing recovery after surgery are outlined in this review. We also summarize the new and increased understanding of the effects of the routes of delivering nutrition and the role of the gut, as well as the current recommendations for artificial nutritional support.
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Affiliation(s)
- Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Orebro University Hospital and Orebro University, Orebro, Sweden;
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Arved Weimann
- Department of General, Visceral, and Oncologic Surgery, Saint George Hospital, Leipzig, Germany
| | - Marta Sandini
- Department of Medicine, Surgery, and Neuroscience and Unit of General and Oncologic Surgery, University of Siena, Siena, Italy
| | - Gabriele Baldini
- Section of Anesthesia and Critical Care, Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- HPB Surgery, Foundation IRCCS San Gerardo Hospital, Monza, Italy
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Bozzetti F. Evolving concepts on perioperative nutrition of sarcopenic cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106748. [PMID: 36376142 DOI: 10.1016/j.ejso.2022.10.008] [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: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/13/2022]
Abstract
The recent recognition of the association of sarcopenia with an increased risk of complications after a surgical procedure calls for rethinking the proper approach of the perioperative care in cancer patients. Sarcopenia is broadly considered in literature according to three different definitions: loss of muscle mass, loss of muscle mass plus reduced muscle function and myosteatosis. The aim of this short review on this issue is to define the excess of risk by type of primary and of surgical procedure, depending on the definition of sarcopenia, to speculate on this association (casual versus causal) and to examine the current therapeutical approaches. The analysis of the data shows that sarcopenia, defined as loss of muscle mass plus reduced muscle function, has the higher predictive power for the occurrence of postoperative complications than the two other definitions, and any definition of sarcopenia works better than the usual indexes or scores of surgical risk. Our analysis supports the concept that: a) sarcopenia is frequently associated with inflammation, but inflammation cannot be considered the only or the absolute cause for sarcopenia, b) sarcopenia is not a simple marker of risk but can have a direct role in the increase of risk. Data on perioperative care of sarcopenic cancer patients are scanty but a correct approach cannot rely on nutritional support alone but on a combined approach of optimized nutrition and exercise, hopefully associated with an anti-inflammatory treatment. This strategy should be applied proactively in keeping with the recent recommendations of the American Society of Clinical Oncology for the medical treatment of advanced cancer patients even if a clear demonstration of effectiveness is still lacking.
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Affiliation(s)
- Federico Bozzetti
- University of Milan, Faculty of Medicine, via Festa del Perdono, 20100, Milano, Italy.
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Funk Debleds P, Chambrier C, Slim K. Postoperative nutrition in the setting of enhanced recovery programmes. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106866. [PMID: 36914532 DOI: 10.1016/j.ejso.2023.03.006] [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: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/10/2023]
Abstract
Patients undergoing major surgery for gastrointestinal cancer are at high risk of developing or worsening malnutrition and sarcopenia. In malnourished patients, preoperative nutritional support may not be sufficient and so postoperative support is advised. This narrative review addresses several aspects of postoperative nutritional care in the setting of enhanced recovery programmes. Early oral feeding, therapeutic diet, oral nutritional supplements, immunonutrition, and probiotics are discussed. When postoperative intake is insufficient, nutritional support favouring the enteral route is recommended. Whether this approach should use a nasojejunal tube or jejunostomy is still a matter of debate. In the setting of enhanced recovery programmes with early discharge, nutritional follow-up and care should be continued beyond the short time in hospital. In enhanced recovery programmes, the main specific aspects of nutrition are patient education, early oral intake, and post-discharge care. The other aspects do not differ from conventional care.
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Affiliation(s)
- Pamela Funk Debleds
- Department of Supportive Care, Centre de Lutte Contre le Cancer Léon Bérard, Lyon, France
| | - Cécile Chambrier
- Intensive Clinical Nutrition Department, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre-Bénite, France
| | - Karem Slim
- Department of Digestive Surgery, University Hospital, CHU, Clermont-Ferrand, France; Francophone Group for Enhanced Recovery After Surgery, France.
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Braga M, Sandrucci S. The evolution of nutritional care in surgical oncology. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106869. [PMID: 36935224 DOI: 10.1016/j.ejso.2023.03.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/13/2023]
Affiliation(s)
- Marco Braga
- Milano-Bicocca University, School of Medicine and Surgery, Monza, Italy.
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Hong Z, Lu Y, Li H, Cheng T, Sheng Y, Cui B, Wu X, Jin D, Gou Y. Effect of Early Versus Late Oral Feeding on Postoperative Complications and Recovery Outcomes for Patients with Esophageal Cancer: A Systematic Evaluation and Meta-Analysis. Ann Surg Oncol 2023; 30:8251-8260. [PMID: 37610489 DOI: 10.1245/s10434-023-14139-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/27/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND This study aimed to systematically evaluate the effect of early oral feeding (EOF) versus late oral feeding (LOF) on postoperative complications and rehabilitation outcomes for patients with esophageal cancer. METHODS This study searched relevant literature published up to March 2023 by computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science. A meta-analysis was performed using Review Manager 5.4 software to compare the effects of EOF and LOF on postoperative complications and recovery outcomes of patients with esophageal cancer. RESULTS The study included 14 articles, including 9 retrospective studies, 4 randomized controlled trials (RCTs), and 1 prospective study. The 2555 patients included in the study comprised 1321 patients who received EOF and 1234 patients who received LOF. The results of the meta-analysis showed that compared with the LOF group, the EOF group has a shorter time to the first flatus postoperatively (mean difference [MD], - 1.12; 95% confidence interval [CI], (- 1.25 to - 1.00; P < 0.00001), a shorter time to the first defecation postoperatively (MD, - 1.31; 95% CI, - 1.67 to - 0.95;, P < 0.00001], and a shorter hospital stay postoperatively (MD, - 2.87; 95% CI, - 3.84 to - 1.90; P < 0.00001). The two groups did not differ significantly statistically in terms of postoperative anastomotic leakage rate (P = 0.10), postoperative chyle leakage rate (P = 0.10), or postoperative pneumonia rate (P = 0.15). CONCLUSION Early oral feeding after esophageal cancer surgery can shorten the time to the first flatus and the first defecation postoperatively, shorten the hospital stay, and promote the recovery of patients. Moreover, it has no significant effect on the incidence of postoperative complications.
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Affiliation(s)
- Ziqiang Hong
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Yingjie Lu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Hongchao Li
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Tao Cheng
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | | | - Baiqiang Cui
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Xusheng Wu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dacheng Jin
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Yunjiu Gou
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China.
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Ridgeon E, Shadwell R, Wilkinson A, Odor PM. Mismatch of populations between randomised controlled trials of perioperative interventions in major abdominal surgery and current clinical practice. Perioper Med (Lond) 2023; 12:60. [PMID: 37974283 PMCID: PMC10655289 DOI: 10.1186/s13741-023-00344-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/14/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Demographics of patients undergoing major abdominal surgery are changing. External validity of relevant RCTs may be limited by participants not resembling patients encountered in clinical practice. We aimed to characterise differences in age, weight, BMI, and ASA grade between participants in perioperative trials in major abdominal surgery and patients in a reference real-world clinical practice sample. The secondary aim was to investigate whether time since trial publication was associated with increasing mismatch between these groups. METHODS MEDLINE and Embase were searched for multicentre RCTs from inception to September 2022. Studies of perioperative interventions in adults were included. Studies that limited enrolment based on age, weight, BMI, or ASA status were excluded. We compared trial cohort age, weight, BMI, and ASA distribution to those of patients undergoing major abdominal surgery at our tertiary referral hospital during September 2021 to September 2022. We used a local, single-institution reference sample to reflect the reality of clinical practice (i.e. patients treated by a clinician in their own hospital, rather than averaged nationally). Mismatch was defined using comparison of summary characteristics and ad hoc criteria based on differences relevant to predicted mortality risk after surgery. RESULTS One-hundred and six trials (44,499 participants) were compared to a reference cohort of 2792 clinical practice patients. Trials were published a median (IQR [range]) 13.4 (5-20 [0-35]) years ago. A total of 94.3% of trials were mismatched on at least one characteristic (age, weight, BMI, ASA). Recruitment of ASA 3 + participants in trials increased over time, and recruitment of ASA 1 participants decreased over time (Spearman's Rho 0.58 and - 0.44, respectively). CONCLUSIONS Patients encountered in our current local clinical practice are significantly different from those in our defined set of perioperative RCTs. Older trials recruit more low-risk than high-risk participants-trials may thus 'expire' over time. These trials may not be generalisable to current patients undergoing major abdominal surgery, and meta-analyses or guidelines incorporating these trials may therefore be similarly non-applicable. Comparison to local, rather than national cohorts, is important for meaningful on-the-ground evidence-based decision-making.
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Affiliation(s)
- Elliott Ridgeon
- Department of Anaesthetics and Perioperative Medicine, Wexham Park Hospital, Slough, UK.
- Department of Anaesthetics and Perioperative Medicine, University College London Hospitals, London, UK.
- Perioperative Medicine MSc, University College London, London, UK.
| | - Rory Shadwell
- Department of Critical Care, University College London Hospitals, London, UK
| | - Alice Wilkinson
- Department of Anaesthetics, University College London Hospitals, London, UK
| | - Peter M Odor
- Department of Anaesthetics and Perioperative Medicine, University College London Hospitals, London, UK
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Valla FV, Uberti T, Henry C, Slim K. Perioperative nutritional assessment and support in visceral surgery. J Visc Surg 2023; 160:356-367. [PMID: 37587003 DOI: 10.1016/j.jviscsurg.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Malnutrition in visceral surgery is frequent; it calls for screening prior to an operation, and its postoperative occurrence should be sought out and prevented, if possible. Organization of an individualized nutritional support strategy is based on systematic nutritional assessment and adapted to the type of surgery, the objectives being to forestall malnutrition and to reduce induced morbidity (immunosuppression, delayed wound healing, anastomotic fistulas…). Nutritional support is part and parcel of enhanced recovery after surgery (ERAS), and has shown effectiveness in the field of visceral surgery. Oral feeding should always be privileged to the greatest possible extent, complemented if necessary by nutritional supplements. If nutritional support is required, enteral nutrition should be favored over parenteral nutrition. As for the role of pharmaco-nutrition or immuno-nutrition, it remains ill-defined. Lastly, each type of visceral surgery entails specific modifications of the anatomy of the digestive system and is liable to have specific functional consequences, which should be known and taken into account in view of effectively tailoring nutritional support.
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Affiliation(s)
- Frederic V Valla
- Nutrition Support Team, Hospices Civils de Lyon, 69310 Lyon - Pierre-Bénite, France.
| | - Thomas Uberti
- Anesthesiology and Critical Care Department, Hôpital E.-Herriot Hospital, Hospices Civils de Lyon, 69003 Lyon, France
| | - Caroline Henry
- Nutrition Support Team, Hospices Civils de Lyon, 69310 Lyon - Pierre-Bénite, France
| | - Karem Slim
- Digestive Surgery Department and Ambulatory Surgery Unit, 63003 Clermont-Ferrand, France
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Hao W, Gao K, Li K, Li Y, Wang Z, Sun H, Xing W, Zheng Y. The Feasibility of Early Oral Feeding After Neoadjuvant Chemotherapy Combined With "Non-Tube No Fasting"-Enhanced Recovery. Ann Surg Oncol 2023; 30:1564-1571. [PMID: 36417005 DOI: 10.1245/s10434-022-12620-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/28/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study aimed to investigate the feasibility of early oral feeding (EOF) after neoadjuvant chemotherapy (nCT) combined with "non-tube no fasting"-enhanced recovery after minimally invasive esophagectomy (MIE). METHODS This retrospective study investigated patients who underwent nCT combined with non-tube no fasting-enhanced recovery after MIE in the Department of Thoracic Surgery, Ward I, of the authors' hospital from January 2014 to August 2017. These patients were divided into an early oral feeding (EOF) group (n = 112) and a late oral feeding (LOF) group (n = 69). The postoperative complications were compared between the two groups. RESULTS The study enrolled 181 patients (112 patients in the EOF group and 69 patients in the LOF group). No significant differences were found between the two groups in the incidence rates of complications such as anastomotic leakage (P = 0.961), pneumonia (P = 0.450), respiratory failure (P = 0.944), heart failure (P = 1.000), acute respiratory distress syndrome (ARDS) (P = 0.856), and unplanned reoperation (P = 0.440), whereas the time to the first postoperative flatus/bowel movement (P < 0.001) and the postoperative length of stay (P < 0.001) were significantly better in the EOF group than in the LOF group.. CONCLUSIONS In this study, EOF after nCT combined with non-tube no fasting-enhanced recovery after MIE did not significantly increase complications, but significantly shortened the time to the first postoperative flatus/bowel movement and the postoperative length of stay.
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Affiliation(s)
- Wentao Hao
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, 450008, People's Republic of China
| | - Kun Gao
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, 450008, People's Republic of China
| | - Keting Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, 450008, People's Republic of China
| | - Yin Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, 450008, People's Republic of China
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zongfei Wang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, 450008, People's Republic of China
| | - Haibo Sun
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, 450008, People's Republic of China
| | - Wenqun Xing
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, 450008, People's Republic of China
| | - Yan Zheng
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, 450008, People's Republic of China.
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Noorian S, Kwaan MR, Jaffe N, Yaceczko SD, Chau LW. Perioperative nutrition for gastrointestinal surgery: On the cutting edge. Nutr Clin Pract 2023; 38:539-556. [PMID: 36847684 DOI: 10.1002/ncp.10970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 01/16/2023] [Accepted: 01/28/2023] [Indexed: 03/01/2023] Open
Abstract
Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.
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Affiliation(s)
- Shaya Noorian
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Mary R Kwaan
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Nancee Jaffe
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Lydia W Chau
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
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Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg 2023; 47:11-34. [PMID: 36310325 PMCID: PMC9726826 DOI: 10.1007/s00268-022-06732-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature. METHODS A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system. RESULTS A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy. CONCLUSIONS These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.
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Schipper RJ, de Hingh IH, Luyer MD. Teres ligamentum wrap covering the pancreaticojejunostomy following pancreatoduodenectomy is associated with a lower rate of postoperative pancreas fistula: a prospective cohort study. HPB (Oxford) 2023; 25:116-123. [PMID: 36280427 DOI: 10.1016/j.hpb.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/26/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative pancreas fistula (POPF) is a common complication after pancreatoduodenectomy (PD). A Teres Ligamentum (TL)-wrap covering the pancreaticojejunostomy (PJ) is suggested as a potential solution to reduce POPF. The aim of this study was to compare POPF incidence (grade B/C) in patients with or without a TL-wrap. METHODS A prospective cohort study was performed between January 2019-December 2021. All consecutive patients were included. Patient, tumor and surgical characteristics and postoperative complications were compared in both open and robot-assisted surgery. RESULTS A total of 118 consecutive patients were included. The first 57 patients were treated without and the following 61 patients with a TL-wrap. There were no statistically significant differences between both groups regarding patient, pre-operative treatment and surgical characteristics. The occurrence of POPF was strongly reduced in the TL-wrap group compared to patients without a TL-wrap (3.3% vs 28.1%, P < 0.001). Also mean length of hospital stay was reduced (11.5 vs 18.8 days, P = 0.030). CONCLUSION The use of a TL-wrap covering the PJ as addition to the modified Blumgart anastomosis technique is associated with a significantly reduced POPF rate and a reduced length of hospital stay. A TL-wrap is a simple addition to a PJ that may be considered to improve postoperative outcome. This association must be studied more definitively in a randomized controlled trial.
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Affiliation(s)
| | - Ignace Hjt de Hingh
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
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Muacevic A, Adler JR, Konanur Srinivasa NK, Gande A, Anusha M, Dar H. Nutrition Care in Cancer Surgery Patients: A Narrative Review of Nutritional Screening and Assessment Methods and Nutritional Considerations. Cureus 2022; 14:e33094. [PMID: 36721576 PMCID: PMC9884126 DOI: 10.7759/cureus.33094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2022] [Indexed: 12/30/2022] Open
Abstract
Malignancy is a catabolic state, which is precipitated with surgical intervention. Malnutrition is one of the main risk factors for poor outcomes of cancer surgery. We need to screen oncological patients for malnutrition using standardized screening tools, by which patients found to be at nutritional risk are then referred to a registered dietitian for further management. A detailed assessment is required in such patients, which helps in categorizing the patients based on the severity and rendering proper care. Preoperative nutrition care is often overlooked because of the urgency of operating on a cancer patient. Still, studies have shown preoperative nutritional building gives better surgical outcomes and good postoperative quality of life. Preoperative nutrition care includes both early and late preoperative care. For efficient preoperative nutrition care publishing, standard operating procedures at every healthcare center are recommended. Postoperative nutrition care is given to build the patient tackle the surgical trauma, and their diet mainly includes protein to minimize catabolism. Regardless of the route of nutrition delivery, providing appropriate nutrition care in the postoperative period improves cancer patients' condition drastically. Early postoperative nutrition is studied in different cancer surgeries and is considered ideal in cancer surgical patients. There is a need for consensus on the composition of postoperative nutrition. The diet of a cancer patient should include micronutrients like vitamins D and B and minerals along with the usual nutrition care. The use of special diets like branched-chain amino acids and immune nutrition is to be considered on a case-by-case basis and introducing them into the routine care of a patient needs to be studied extensively.
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Ying Y, Xu HZ, Han ML. Enhanced recovery after surgery strategy to shorten perioperative fasting in children undergoing non-gastrointestinal surgery: A prospective study. World J Clin Cases 2022; 10:5287-5296. [PMID: 35812657 PMCID: PMC9210880 DOI: 10.12998/wjcc.v10.i16.5287] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/02/2022] [Accepted: 04/28/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery strategies are increasingly implemented to improve the management of surgical patients.
AIM To evaluate the effects of new perioperative fasting protocols in children ≥ 3 mo of age undergoing non-gastrointestinal surgery.
METHODS This prospective pilot study included children ≥ 3 mo of age undergoing non-gastrointestinal surgery at the Children’s Hospital (Zhejiang University School of Medicine) from January 2020 to June 2020. The children were divided into either a conventional group or an ERAS group according to whether they had been enrolled before or after the implementation of the new perioperative fasting strategy. The children in the conventional group were fasted using conventional strategies, while those in the ERAS group were given individualized fasting protocols preoperatively (6-h fasting for infant formula/non-human milk/solids, 4-h fasting for breast milk, and clear fluids allowed within 2 h of surgery) and postoperatively (food permitted from 1 h after surgery). Pre-operative and postoperative fasting times, pre-operative blood glucose, the incidence of postoperative thirst and hunger, the incidence of perioperative vomiting and aspiration, and the degree of satisfaction were evaluated.
RESULTS The study included 303 patients (151 in the conventional group and 152 in the ERAS group). Compared with the conventional group, the ERAS group had a shorter pre-operative food fasting time [11.92 (4.00, 19.33) vs 13.00 (6.00, 20.28) h, P < 0.001), shorter preoperative liquid fasting time [3.00 (2.00, 7.50) vs 12.00 (3.00, 20.28) h, P < 0.001], higher preoperative blood glucose level [5.6 (4.2, 8.2) vs 5.1 (4.0, 7.4) mmol/L, P < 0.001], lower incidence of thirst (74.5% vs 15.3%, P < 0.001), shorter time to postoperative feeding [1.17 (0.33, 6.83) vs 6.00 (5.40, 9.20), P < 0.001], and greater satisfaction [7 (0, 10) vs 8 (5, 10), P < 0.001]. No children experienced perioperative aspiration. The incidences of hunger, perioperative vomiting, and fever were not significantly different between the two groups.
CONCLUSION Optimizing fasting and clear fluid drinking before non-gastrointestinal surgery in children ≥ 3 mo of age is possible. It is safe and feasible to start early eating after evaluating the recovery from anesthesia and the swallowing function.
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Affiliation(s)
- Yan Ying
- Department of General Surgery, Children's Hospital of Zhejiang University School of Medicine, Hangzhou 310052, Zhejiang Province, China
| | - Hong-Zhen Xu
- Department of General Surgery, Children's Hospital of Zhejiang University School of Medicine, Hangzhou 310052, Zhejiang Province, China
| | - Meng-Lan Han
- Department of General Surgery, Children's Hospital of Zhejiang University School of Medicine, Hangzhou 310052, Zhejiang Province, China
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19
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Fransen LFC, Janssen THJB, Aarnoudse M, Nieuwenhuijzen GAP, Luyer MDP. Direct Oral Feeding After a Minimally Invasive Esophagectomy: A Single-Center Prospective Cohort Study. Ann Surg 2022; 275:919-923. [PMID: 32541215 DOI: 10.1097/sla.0000000000004036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this single-center cohort study was to compare direct oral feeding (DOF) to standard of care after a minimally invasive esophagectomy (MIE) performed in a center with a stable and acceptable postoperative complication rate. BACKGROUND A recent multicenter, international randomized controlled trial showed that DOF following a MIE is comparable to standard of care (nil-by-mouth). However, the effect of DOF was potentially influenced by postoperative complications. METHODS Patients in this single-center prospective cohort study received either DOF (intervention) or nil-by-mouth for 5 days postoperative and tube feeding (standard of care, control group) following a MIE with intrathoracic anastomosis. Primary outcome was time to functional recovery and length of hospital stay. Secondary outcomes included anastomotic leakage, pneumonia, and other surgical complications. RESULTS Baseline characteristics were similar in the intervention (n = 85) and control (n = 111) group. Median time to functional recovery was 7 and 9 days in the intervention and control group (P < 0.001), respectively. Length of hospital stay was 8 versus 10 days (P < 0.001), respectively. Thirty-day postoperative complication rate was significantly reduced in the intervention group (57.6% vs 73.0%, P = 0.024). Chyle leakage only occurred in the control group (18.9%, P < 0.001). Anastomotic leakage, pneumonia, and other postoperative complications did not differ between groups. CONCLUSION Direct oral feeding following a MIE results in a faster time to functional recovery and lower 30-day postoperative complication rate compared to patients that were orally fasted.
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Affiliation(s)
- Laura F C Fransen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
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Deng H, Li B, Qin X. Early versus delay oral feeding for patients after upper gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials. Cancer Cell Int 2022; 22:167. [PMID: 35488274 PMCID: PMC9052660 DOI: 10.1186/s12935-022-02586-y] [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: 01/01/2022] [Accepted: 04/05/2022] [Indexed: 01/30/2023] Open
Abstract
PURPOSE To evaluate the efficacy and safety of early oral feeding (EOF) in patients after upper gastrointestinal surgery through meta-analysis of randomized controlled trials (RCTs). METHODS We analyzed the endpoints of patients including the length of stay (LOS), time of first exhaust, anastomotic leakage and pneumonia from included studies. And we retrieved RCTs from medical literature databases. Weighted mean difference (WMD), risk ratios (RR) and 95% confidence intervals (CI) were calculated to compare the endpoints. RESULTS In total, we retrieved 12 articles (13 trial comparisons) which contained 1771 patients. 887 patients (50.1%) were randomized to EOF group whereas 884 patients (49.9%) were randomized to delay oral feeding group. The result showed that compared with the delay oral feeding group, EOF after upper gastrointestinal surgery significantly shorten the LOS [WMD = - 1.30, 95% CI - 1.79 to - 0.80, I2 = 0.0%] and time of first exhaust [WMD = - 0.39, 95% CI - 0.58 to - 0.20, I2 = 62.1%]. EOF also reduced the risk of pneumonia (RR: 0.74, 95% CI 0.55 to 0.99, I2 = 0.0%). There is no significant difference in the risk of anastomotic leak, anastomotic bleeding, abdominal abscess, reoperation, readmission and mortality. CONCLUSIONS Overall, compared with the traditional oral feeding, EOF could shorten the LOS and time of first exhaust without increasing complications after upper gastrointestinal surgery.
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Affiliation(s)
- Huachu Deng
- Department of Gastrointestinal and Gland Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Baibei Li
- Department of Hepatobiliary, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xingan Qin
- Department of Gastrointestinal and Gland Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
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Wang Y, Zhang Y, Hu X, Wu H, Liang S, Jin J, Wu Y, Cen Y, Wei Z, Wang D. Impact of Early Oral Feeding on Nasogastric Tube Reinsertion After Elective Colorectal Surgery: A Systematic Review and Meta-Analysis. Front Surg 2022; 9:807811. [PMID: 35392054 PMCID: PMC8980315 DOI: 10.3389/fsurg.2022.807811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/26/2022] [Indexed: 12/24/2022] Open
Abstract
BackgroundColorectal cancer is a common malignant tumor appearing in the gastrointestinal tract. Surgical resection is recognized as the best means to improve patient survival. However, it is controversial whether early oral feeding (EOF) after elective colorectal resection demonstrates safety and efficacy in concerned clinical outcomes.MethodsWe searched PubMed, Embase, Cochrane Library, and CNKI from inception to September 2021. Two authors independently screened the retrieved records and extracted data. EOF was defined as feeding within 24 h after surgery, while traditional oral feeding (TOF) was defined as feeding that started after the gastrointestinal flatus or ileus was resolved. The primary outcome was nasogastric tube insertion, and the secondary outcomes were the length of hospital stay and total complications. Categorical data were combined using odds ratio (OR), and continuous data were combined using mean difference (MD).ResultsWe screened 10 studies from 34 records after full-text reading, with 1,199 patients included in the analysis. Nasogastric tube reinsertion (OR 1.69; 95% CI 1.08 to 2.64, p=0.02) was more frequent in the EOF group, and older ages (>60 years) were associated with higher risk of nasogastric tube reinsertion (OR 2.05; 95% CI 1.05 to 3.99, p = 0.04). Reduced length of hospital stay (MD −1.76; 95% CI −2.32 to −1.21; p < 0.01) and the rate of total complications (OR 0.49; 95% CI 0.37 to 0.65, p < 0.01) were observed in EOF compared with TOF.ConclusionsEOF was safe and effective for patients undergoing elective colorectal surgery, but the higher rate of nasogastric tube reinsertion compared with TOF should not be ignored.
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Affiliation(s)
- Yan Wang
- Sichuan Cancer Hospital, Chengdu, China
| | - Yanji Zhang
- The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xing Hu
- Sichuan Cancer Hospital, Chengdu, China
| | - Hui Wu
- Sichuan Cancer Hospital, Chengdu, China
| | | | - Jing Jin
- Sichuan Cancer Hospital, Chengdu, China
| | - Yunjun Wu
- Sichuan Cancer Hospital, Chengdu, China
| | - Yao Cen
- Sichuan Cancer Hospital, Chengdu, China
| | - Zairong Wei
- The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Dali Wang
- Zunyi Medical University, Zunyi, China
- *Correspondence: Dali Wang
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22
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Sungkar AA, Adyana IBBS. The Short-term Outcome of Early Oral Feeding as Recovery Protocols on Resectable Gastric Cancer. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.7190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Gastric cancer is the fourth most common malignancy. Surgical resection is the only treatment. Giving early oral feeding after gastric surgery is controversial.
AIM: This study aimed to provide short-term outcomes in resectable gastric cancer patients by early oral feeding.
METHODS: A retrospective descriptive study with a cross-sectional approach was conducted with all gastric cancer patients treated and performed tumor resection who underwent early oral feeding protocol at RSUD Dr. Moewardi Surakarta in January 2018–August 2019. The data, especially age, gender, tumor location, resection, reconstruction, and short-term outcome (anastomotic leak and surgical site infection), were taken from the medical records.
RESULTS: A total of seven patients were included in the study. Six patients were >50 yearsold (60.14 + 1.29 years). Four patients (57.14%) were female. One patient (14.28%) had Roux-en-Y esophagojejunostomy anastomoses, two patients (28.57%) had a Billroth while four patients (57.15%) were performed Billroth II. There was no significant correlation between early oral feeding and short-term outcome.
CONCLUSION: This description of short-term outcome in resectable gastric cancer which performed early oral feeding protocols has not shown any complications. However, this research needs further research with more significant number of samples and post-operative complications.
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Kapoor D, Barreto SG, Perwaiz A, Singh A, Chaudhary A. Can we predict the need for nutritional support following pancreatoduodenectomy? Pancreatology 2022; 22:160-167. [PMID: 34893447 DOI: 10.1016/j.pan.2021.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/08/2021] [Accepted: 11/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The practice of routine placement of a tube jejunostomy at the time of pancreatoduodenectomy has given way to a more selective approach. However, the indications of establishing enteral access at the time of surgery remain poorly defined. This study aimed to assess the preoperative and intraoperative factors associated with the need for nutritional support after pancreatoduodenectomy, to guide decision-making for the establishment of intraoperative feeding access. METHODS Retrospective study, analyzing the data of 562 consecutive patients, who underwent pancreatoduodenectomy between March 2013 to December 2020. Univariate and multiple logistic regression analysis was carried out to ascertain the factors associated with the initiation of and need for nutritional support for more than 7 days postop. The utility of tube jejunostomy was studied in patients in whom it was performed. RESULTS Of 562 patients, 105 (18.7%) needed nutritional support. A tube jejunostomy was performed in 46 (8.2%) patients, parenteral nutrition was used in 83 (14.8%), and nasojejunal tube placed in 28 (4.9%) patients. On logistic regression analysis, age, serum albumin <3.0 gm/dl and operative blood loss were independently associated with the initiation of supportive nutrition, while preoperative gastric outlet obstruction (OR 3.105, 95% CI1.201-8.032, p = 0.019) and serum albumin <3.0 gm/dl (OR 2.669, 95% CI 1.131-6.300, p = 0.025) were associated with the need for prolonged nutritional support. The maximal benefit of tube jejunostomy was in patients with mental health disorders (83.3%). CONCLUSION Tube jejunostomy for nutritional support after pancreatoduodenectomy can be considered in patients with preoperative gastric outlet obstruction, serum albumin <3.0 gm/dl and mental health disorders.
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Affiliation(s)
- Deeksha Kapoor
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Savio George Barreto
- Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
| | - Azhar Perwaiz
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Amanjeet Singh
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Adarsh Chaudhary
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
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Lee Y, Lu JY, Malhan R, Shargall Y, Finley C, Hanna W, Agzarian J. Effect of Routine Jejunostomy Tube Insertion in Esophagectomy: A Systematic Review and Meta-Analysis. J Thorac Cardiovasc Surg 2022; 164:422-432.e17. [DOI: 10.1016/j.jtcvs.2021.12.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 12/17/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
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25
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Major Abdominal Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00033-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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26
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Enhanced Recovery After Surgery protocol for elderly gastric cancer patients: A prospective study for safety and efficacy. Asian J Surg 2022; 45:2168-2171. [DOI: 10.1016/j.asjsur.2021.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/21/2021] [Accepted: 10/25/2021] [Indexed: 01/17/2023] Open
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Thibault R, Abbasoglu O, Ioannou E, Meija L, Ottens-Oussoren K, Pichard C, Rothenberg E, Rubin D, Siljamäki-Ojansuu U, Vaillant MF, Bischoff SC. ESPEN guideline on hospital nutrition. Clin Nutr 2021; 40:5684-5709. [PMID: 34742138 DOI: 10.1016/j.clnu.2021.09.039] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/17/2021] [Indexed: 12/16/2022]
Abstract
In hospitals through Europe and worldwide, the practices regarding hospital diets are very heterogeneous. Hospital diets are rarely prescribed by physicians, and sometimes the choices of diets are based on arbitrary reasons. Often prescriptions are made independently from the evaluation of nutritional status, and without taking into account the nutritional status. Therapeutic diets (low salt, gluten-free, texture and consistency modified, …) are associated with decreased energy delivery (i.e. underfeeding) and increased risk of malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) proposes here evidence-based recommendations regarding the organization of food catering, the prescriptions and indications of diets, as well as monitoring of food intake at hospital, rehabilitation center, and nursing home, all of these by taking into account the patient perspectives. We propose a systematic approach to adapt the hospital food to the nutritional status and potential food allergy or intolerances. Particular conditions such as patients with dysphagia, older patients, gastrointestinal diseases, abdominal surgery, diabetes, and obesity, are discussed to guide the practitioner toward the best evidence based therapy. The terminology of the different useful diets is defined. The general objectives are to increase the awareness of physicians, dietitians, nurses, kitchen managers, and stakeholders towards the pivotal role of hospital food in hospital care, to contribute to patient safety within nutritional care, to improve coverage of nutritional needs by hospital food, and reduce the risk of malnutrition and its related complications.
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Affiliation(s)
- Ronan Thibault
- Unité de Nutrition, CHU Rennes, INRAE, INSERM, Univ Rennes, Nutrition Metabolisms and Cancer Institute, NuMeCan, Rennes, France.
| | - Osman Abbasoglu
- Department of Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elina Ioannou
- Department of Nutrition, Limassol General Hospital, Cyprus
| | - Laila Meija
- Riga Stradins University, Pauls Stradins Clinical University Hospital, Latvia
| | - Karen Ottens-Oussoren
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Claude Pichard
- Unité de Nutrition, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Elisabet Rothenberg
- Faculty of Health Sciences Kristianstad University Kristianstad Sweden, Sweden
| | - Diana Rubin
- Vivantes Netzwerk für Gesundheit GmbH, Humboldt Klinikum und Klinikum Spandau, Berlin, Germany
| | | | | | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
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Huang H, Zhang Y, Shen L, Huang Y. Level of ERAS understanding affects practitioners' practice and perception of early postoperative resumption of oral intake: a nationwide survey. BMC Anesthesiol 2021; 21:279. [PMID: 34763674 PMCID: PMC8588702 DOI: 10.1186/s12871-021-01500-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/02/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Early postoperative resumption of oral intake is supposed to be safe and beneficial to patients recovery. However, practitioners still have great confusion and disagreement about postoperative resumption of oral intake. This is a nationwide survey to investigate the current status of clinical practice and practitioners' attitude toward postoperative resumption of oral intake along with their level of understanding of the ERAS guidelines. METHODS An anonymous web-based survey questionnaire via mobile social platform was carried out in mainland China from December 11-20, 2020. The Wilcoxon signed rank test or chi-square test was used to compare the propensity of the resumption of oral intake. RESULTS Totally 5370 responses were received, and 89% of them were from anesthesiology departments. The nature of the responses from clinical practitioners was highly diverse, but each of the three surgery types showed unique patterns of ERAS implementation. The respondents were more conservative regarding the commencement of both fluid and solid diets after gastrointestinal (GI) and hepato-pancreato-biliary (HPB) surgery than after non-abdominal (NA) surgery. Most respondents agreed that early oral intake is beneficial to reduce postoperative complications improve bowel recovery and overall outcome. 55% respondents considered themselves to have a better understanding of ERAS and tended to initiate oral intake early for all three surgery types (P < 0.001). CONCLUSIONS The postoperative resumption of oral intake is highly variable among GI, HPB and NA surgeries. A better understanding of ERAS would encourage practitioners to commence oral intake resumption much earlier.
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Affiliation(s)
- Huizhen Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Le Shen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China.
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
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29
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Lassen K. The tube, the pancreatoduodenectomy-and the dogma. BJS Open 2021; 5:zrab113. [PMID: 34922332 PMCID: PMC8684476 DOI: 10.1093/bjsopen/zrab113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 11/16/2022] Open
Abstract
Routine use of NG-tubes following pancreatoduodenectomies is not indicated
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Affiliation(s)
- Kristoffer Lassen
- HPB-Surgery, Oslo University Hospital at Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, Arctic University of Norway, Tromsø, Norway
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30
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Flick KF, Soufi M, Yip-Schneider MT, Simpson RE, Colgate CL, Nguyen TK, Ceppa EP, House MG, Zyromski NJ, Nakeeb A, Schmidt CM. Routine Gastric Decompression after Pancreatoduodenectomy: Treating the Surgeon? J Gastrointest Surg 2021; 25:2902-2907. [PMID: 33772404 DOI: 10.1007/s11605-021-04971-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The decision to routinely leave a nasogastric tube after pancreatoduodenectomy remains controversial. We sought to determine the impact of immediate nasogastric tube removal versus early nasogastric tube removal (<24 h) on postoperative outcomes. METHODS A retrospective review of our institution's prospective ACS-NSQIP database identified patients that underwent pancreatoduodenectomy from 2015 to 2018. Outcomes were compared among patients with immediate nasogastric tube removal versus early nasogastric tube removal. RESULTS A total of 365 patients were included in primary analysis (no nasogastric tube, n = 99; nasogastric tube removed <24 h, n = 266). Thirty-day mortality and infectious, renal, cardiovascular, and pulmonary morbidity were similar in comparing those with no nasogastric tube versus early nasogastric tube removal on univariable and multivariable analyses (P > 0.05). Incidence of delayed gastric emptying (11.1 versus 13.2%) was similar between groups. Patients with no nasogastric tube less frequently required nasogastric tube reinsertion (n = 4, 4%) compared to patients with NGT <24 h (n = 39, 15%) (OR = 3.83, 95% CI [1.39-10.58]; P = 0.009). CONCLUSION Routine gastric decompression can be safely avoided after uneventful pancreaticoduodenectomy.
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Affiliation(s)
- K F Flick
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA
| | - M Soufi
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA
| | - M T Yip-Schneider
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA
- Walther Oncology Center, Indianapolis, IN, USA
- Indiana University Simon Cancer Center, Indianapolis, IN, USA
- Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN, USA
| | - R E Simpson
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA
| | - C L Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - T K Nguyen
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA
| | - E P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA
| | - M G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA
| | - N J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA
| | - A Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA
| | - C M Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN, USA.
- Walther Oncology Center, Indianapolis, IN, USA.
- Indiana University Simon Cancer Center, Indianapolis, IN, USA.
- Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN, USA.
- Department of Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
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31
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Matsugu Y, Ito K, Oshita A, Nobuhara H, Tanaka J, Akita T, Itamoto T. Postoperative oral energy and protein intakes for an enhanced recovery after surgery program incorporating early enteral nutrition for pancreaticoduodenectomy: A retrospective study. Nutr Clin Pract 2021; 37:654-665. [PMID: 34672385 DOI: 10.1002/ncp.10791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Although postoperative early oral feeding in the enhanced recovery after surgery (ERAS) program for pancreaticoduodenectomy (PD) is deemed safe, the assessment of oral intakes has been insufficient. This study aimed to investigate postoperative oral intakes and the effectiveness of an ERAS program incorporating early enteral nutrition (EN). METHODS In total, 203 patients with PD were enrolled retrospectively. The first group (group E1; n = 61) comprised 11 ERAS care elements, whereas the second group (group E2; n = 106) comprised 19 elements. The control group (group C; n = 36) was managed using traditional care before ERAS was implemented. Postoperative energy and protein requirements were estimated at 25-30 kcal per kilogram of ideal body weight and 1.2-1.5 g per kilogram of ideal body weight, respectively, and were investigated along with the length of hospital stay (LOS). RESULTS The oral energy and protein intakes from the diets in the ERAS groups at postoperative day 7 significantly increased compared with those in group C. Intakes in groups E1 and E2 were not significantly different and provided <30% of the requirements. However, the total intakes, which were compensated by EN, were maintained at >80% of the requirements. LOS was significantly shorter in groups E1 (31 days) and E2 (19 days) than in group C (52 days). CONCLUSIONS Postoperative early oral energy and protein intakes of this modified ERAS program failed to meet the dietary requirements. However, early EN compensated for the shortages and contributed to the reduction of LOS.
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Affiliation(s)
- Yasuhiro Matsugu
- Department of Clinical Nutrition, Hiroshima Prefectural Hospital, Hiroshima, Japan.,Department of Gastroenterological, Breast and Transplant Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Keiko Ito
- Department of Clinical Nutrition, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Akihiko Oshita
- Department of Gastroenterological, Breast and Transplant Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Hiroshi Nobuhara
- Department of Dentistry, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Junko Tanaka
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tomoyuki Akita
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshiyuki Itamoto
- Department of Gastroenterological, Breast and Transplant Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
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Peng Y, Xiao D, Xiao S, Yang L, Shi H, He Q, Xu H, Zhu X, Zhong W, Yu J. Early enteral feeding versus traditional feeding in neonatal congenital gastrointestinal malformation undergoing intestinal anastomosis: A randomized multicenter controlled trial of an enhanced recovery after surgery (ERAS) component. J Pediatr Surg 2021; 56:1479-1484. [PMID: 33838898 DOI: 10.1016/j.jpedsurg.2021.02.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/04/2021] [Accepted: 02/17/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE the aim of this clinical trial was to evaluate the safety and efficacy of early enteral feeding (EEN) following intestinal anastomosis in neonates with congenital gastrointestinal malformation. METHODS a multicenter, prospective, randomized controlled trial (registered under chictr.org.cn Identifier no.ChiCTR-INR-17014179) was conducted between 2018 and 2019. Four centers in China analyzed 156 newborns of congenital gastrointestinal malformation undergoing intestinal anastomosis to EEN group (n = 78) or control (C) group (n = 78). The primary outcomes of this study were length of postoperative stay (LOPS) and time to full feeds. Secondary outcomes included morbidity of complications, parenteral nutrition (PN) duration, feeding intolerance, 30 day mortality rate and 30 day readmission rate. RESULTS the mean time to full feeds and LOPS in the EEN group were 15.0 (9.8-22.8) days and 17.6 (12.0-29.8) days, while that were 18.0 (12.0-24.0) days and 20.0 (15.0-30.3) days in C groups respectively. There was no significant difference between two groups(P >0.05). No significant intergroup difference was found with respect to postoperative morbidity, PN duration or feeding intolerance(P >0.05). CONCLUSIONS early enteral feeding following intestinal anastomosis in neonates with congenital gastrointestinal malformation is safe. Post-operative outcomes demonstrated a trend toward improvement. LEVEL OF EVIDENCE Level Ⅰ.
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Affiliation(s)
- Yanfen Peng
- Department of Neonatal Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Dong Xiao
- Department of General Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Shangjie Xiao
- Department of Neonatal Surgery, Guangdong Women and Children's Hospital, Guangdong, China
| | - Liucheng Yang
- Department of General Surgery, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Hui Shi
- Guangzhou Women and Children's Medical Center, Institute of Pediatrics, Guangzhou, China
| | - Qiuming He
- Department of Neonatal Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Haozhong Xu
- Department of General Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Xiaochun Zhu
- Department of Neonatal Surgery, Guangdong Women and Children's Hospital, Guangdong, China
| | - Wei Zhong
- Department of Neonatal Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Jiakang Yu
- Department of Neonatal Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China.
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33
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Fransen LFC, Luyer MDP. Response to the Comment on "Direct Oral Feeding After Minimally Invasive Esophagectomy (NUTRIENT II trial) an International, Multicenter, Open-label Randomized Controlled Trial". Ann Surg 2021; 274:e196-e197. [PMID: 32209892 DOI: 10.1097/sla.0000000000003685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wu Y, Mu J, Cao J, Li D, Dai Y. Research Status and Progress of Nutritional Support Therapy for Ovarian Cancer. Nutr Cancer 2021; 74:1519-1526. [PMID: 34323140 DOI: 10.1080/01635581.2021.1957132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Ovarian cancer is one of the most fatal gynecological cancers. For most ovarian cancer patients, nutritional risk or malnutrition may accompany them for life. Regular nutritional risk screening, timely nutritional assessment and necessary nutritional treatment play an extremely important role in the process of comprehensive treatment of ovarian cancer. The nutritional status and influence of ovarian cancer patients, preoperative screening and assessment of nutritional risk, preoperative and postoperative nutritional treatment indicate that nutritional treatment of ovarian cancer is one of the key factors in the treatment of cancer. We have summarized the status and progress of nutritional support therapy for ovarian cancer. We are aimed to improve the understanding of the impact of nutritional support therapy for ovarian cancer and to guide the clinical work.
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Affiliation(s)
- Yue Wu
- Department of Gynecology, Women's Hospital of Nanjing Medical University, (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Juan Mu
- Department of Nutrition, Women's Hospital of Nanjing Medical University, (Nanjing Maternity and Child Health Care Hospital), Nanjing, Jiangsu, China
| | - Jian Cao
- Department of Gynecology, Women's Hospital of Nanjing Medical University, (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Dake Li
- Department of Gynecology, Women's Hospital of Nanjing Medical University, (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Yongmei Dai
- Department of Nutrition, Women's Hospital of Nanjing Medical University, (Nanjing Maternity and Child Health Care Hospital), Nanjing, Jiangsu, China
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Hao T, Liu Q, Lv X, Qiu J, Zhang HR, Jiang HP. Efficacy and safety of early oral feeding in postoperative patients with upper gastrointestinal tumor: A systematic review and meta-analysis. World J Gastrointest Surg 2021; 13:717-733. [PMID: 34354804 PMCID: PMC8316844 DOI: 10.4240/wjgs.v13.i7.717] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/04/2021] [Accepted: 06/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early oral feeding (EOF) is an important measure for early recovery of patients with gastrointestinal tumors after surgery, which has emerged as a safe and effective postoperative strategy for improving clinical outcomes.
AIM To determine the safety and efficacy of early oral feeding in postoperative patients with upper gastrointestinal tumor.
METHODS This meta-analysis was analyzed using Review Manager version 5.3 and Stata version 14. All clinical studies that analyzed efficacy and safety of EOF for postoperative patients with upper gastrointestinal tumor were included.
RESULTS Fifteen studies comprising 2100 adult patients met all the inclusion criteria. A significantly lower risk of pneumonia was presented in the EOF compared with TOF group [relative risk (RR) = 0.63, 95% confidence interval (CI): 0.44–0.89, P = 0.01]. Length of hospital stay was significantly shorter in the EOF group than in the TOF group [weighted mean difference (WMD) = -1.91, 95%CI: -2.42 to -1.40; P < 0.01]. Cost of hospitalization was significantly lower (WMD = -4.16, 95%CI: -5.72 to -2.61; P < 0.01), and CD4 cell count and CD4/CD8 cell ratio on postoperative day 7 were significantly higher in the EOF group than in the TOF group: CD4 count (WMD = 7.17, 95%CI: 6.48–7.85; P < 0.01), CD4/CD8 ratio (WMD = 0.29, 95%CI: 0.23–0.35; P < 0.01). There was no significant difference in risk of anastomotic leak and total postoperative complications.
CONCLUSION EOF as compared with TOF was associated with lower risk of pneumonia, shorter hospital length of stay, lower cost of hospitalization, and significantly improved postoperative immune function of patients.
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Affiliation(s)
- Tao Hao
- The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Qian Liu
- Department of Cardiology, The Affiliated Hospital of Binzhou Medical College, Binzhou 256600, Shandong Province, China
| | - Xin Lv
- Department of General Surgery, The First Affiliated Hospital of Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Jun Qiu
- Department of General Surgery, The First Affiliated Hospital of Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Hao-Ran Zhang
- Department of General Surgery, The First Affiliated Hospital of Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Hai-Ping Jiang
- Department of General Surgery, The First Affiliated Hospital of Jinan University, Guangzhou 510632, Guangdong Province, China
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale RG, Waitzberg D, Bischoff SC, Singer P. ESPEN practical guideline: Clinical nutrition in surgery. Clin Nutr 2021; 40:4745-4761. [PMID: 34242915 DOI: 10.1016/j.clnu.2021.03.031] [Citation(s) in RCA: 329] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 02/07/2023]
Abstract
Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.
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Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
| | - Marco Braga
- University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Franco Carli
- Department of Anesthesia of McGill University, School of Nutrition, Montreal General Hospital, Montreal, Canada
| | | | - Martin Hübner
- Service de chirurgie viscérale, Centre Hospitalier Universitaire de Lausanne, Lausanne, Switzerland
| | - Stanislaw Klek
- General Surgical Oncology Clinic, National Cancer Institute, Krakow, Poland
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
| | | | - Dan Waitzberg
- University of Sao Paulo Medical School, Ganep, Human Nutrition, Sao Paulo, Brazil
| | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
| | - Pierre Singer
- Institute for Nutrition Research, Rabin Medical Center, Beilison Hospital, Petah Tikva, Israel
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37
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Xie J, Deng J, Li L. Letter regarding "The effect of early oral feeding afteresophagectomy on the incidence of anastomotic leakage: An updated review". Postgrad Med 2021; 133:771. [PMID: 34096453 DOI: 10.1080/00325481.2021.1940220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Jian Xie
- Department of Cardiology, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Jinling Deng
- Department of Medical Imaging, Guangxi Medical University, Nanning, China
| | - Lang Li
- Department of Cardiology, Guangxi Medical University First Affiliated Hospital, Nanning, China
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38
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Current situation, consensus and controversy of perioperative nutrition management in pancreatic surgery: A narrative review. JOURNAL OF PANCREATOLOGY 2021. [DOI: 10.1097/jp9.0000000000000066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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39
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Impact of Early Oral Feeding on Anastomotic Leakage Rate After Esophagectomy: A Systematic Review and Meta-analysis. World J Surg 2021; 44:2709-2718. [PMID: 32227277 DOI: 10.1007/s00268-020-05489-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Esophageal cancer occupies a vital position in fatal cancer-related disease, with esophagectomy procedures helping to improve patient survival. The timing when oral intake should be resumed after esophagectomy and whether early oral feeding (EOF) or delayed oral feeding (DOF) should be the optimal regimen are controversial. METHODS Databases (PubMed, Embase, Cochrane library) were searched. All records were screened by two authors through full-text reading. Data on the anastomotic leakage rate were extracted and synthesized in meta-analyses. Postoperative pneumonia rate and length of hospital stay were also assessed. RESULTS Seven studies from 49 records were included after full-text reading; 1595 patients were totally included in the analysis. No significant difference was observed between the EOF and DOF groups (odds ratio [OR] 1.68; 95% confidence interval [CI] 0.70-4.03; p = 0.2495; I2 = 70%). Higher anastomotic leakage rate was observed in EOF compared with DOF (OR 2.89; 95% CI 1.56-5.34; p = 0.0007; I2 = 10%) in the open subgroup. No significant difference was observed in the MIE (OR 0.48; 95% CI 0.22-1.02; p = 0.0564; I2 = 0%). Patients performed similarly in pneumonia (OR 1.12; 95% CI 0.57-2.21; p = 0.745; I2 = 34%). In cervical subgroup, anastomosis leakage may be less in DOF (OR 2.42 95% CI 1.26-4.64; p = 0.0651; I2 = 58%), while in thoracic subgroup, there is no obvious difference (OR 0.86 95% CI 0.46-1.61; p = 0.01; I2 = 84.9%). CONCLUSIONS Anastomotic leakage related to the timing of oral feeding after open esophagectomy, which is more favorable to the DOF regimen. However, timing of oral feeding did not impair anastomotic healing in patients undergoing MIE.
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Dalgatov KD, Kozodaeva MV, Titkova SM, Smirnova OA, Sazhin AV. [Safety of enhanced recovery after surgery (ERAS) protocol in the treatment of patients undergoing pancreatoduodenectomy]. Khirurgiia (Mosk) 2021:19-26. [PMID: 34786912 DOI: 10.17116/hirurgia202111119] [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] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To study the effectiveness of enhanced recovery after surgery (ERAS) protocol versus traditional perioperative management in patients with hepatopancreatobiliary tumors undergoing pancreatoduodenectomy. MATERIAL AND METHODS The study included 111 patients who have undergone pancreatoduodenectomy between January 2014 and December 2019. Patients were divided into 2 groups: perioperative ERAS protocol (85 patients) and traditional treatment (26 patients). Postoperative complications, length of hospital-stay and incidence of readmissions were analyzed. RESULTS Mean length of hospital-stay for ERAS protocol was 13.4±7.6 days, conventional management - 16.5±7.5 days (p=0.004). Postoperative 30-day mortality was 8.24 and 7.7% in both groups, respectively (p=1.0). Intraoperative blood loss was significantly less in the ERAS group (248.24±214.0 vs. 321.15±155.0 ml, p=0.004). Overall incidence of postoperative complications was 56.5% and 65.4%, respectively (p=0.420). However, incidence of Clavien-Dindo grade IV complications was significantly higher in case of traditional treatment (19.2 vs. 4.7%, p=0.015). Readmission rate within 30 days was slightly less in the ERAS group (6.4 vs. 20.8%, p=0.052). CONCLUSION Enhanced recovery after surgery protocol is safe, reduces the number of postoperative complications, length of hospital-stay and rate of readmissions.
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Affiliation(s)
- K D Dalgatov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M V Kozodaeva
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - S M Titkova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - O A Smirnova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
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Feasibility of enhanced recovery protocol in minimally invasive McKeown esophagectomy. Esophagus 2021; 18:537-547. [PMID: 33604816 PMCID: PMC7891490 DOI: 10.1007/s10388-021-00823-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/05/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Implementation of enhanced recovery after surgery has generally been applied to gastrointestinal surgeries; however, few studies have investigated minimally invasive McKeown esophagectomy. In this study, we aimed to evaluate the safety and feasibility of an enhanced recovery protocol after minimally invasive McKeown esophagectomy. METHODS Data were collected between January 2015 and April 2020 for patients who underwent esophagectomy. Of these patients, those who underwent minimally invasive McKeown esophagectomy was selected for the investigation. Perioperative outcomes and nutritional index were compared using propensity score matching between the conventional group and the enhanced recovery group. RESULTS A total of 119 patients were enrolled in this study. Of these, 73 and 46 were treated with conventional and enhanced recovery protocol, respectively. Forty-two pairs were matched in two groups. The enhanced recovery group showed a lower rate of pulmonary complications (9.5% vs. 28.5%, p = 0.0235), abdominal dysfunctions (16.7% vs. 42.9%, p = 0.0078), and shorter hospital stay as compared with the conventional group (17.5 days vs. 23 days, p = 0.0034). The loss of body weight (6.3% vs. 7.7%, p = 0.0065) and body mass index (5.6% vs. 8.1%, p = 0.0017) were significantly lower in the enhanced recovery group than in the conventional group. In contrast, nutritional biochemistry data did not differ significantly between the two groups. CONCLUSIONS This study shows that the promotion of an enhanced recovery protocol in minimally invasive McKeown esophagectomy maintains nutritional status without increasing postoperative complications.
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Roslan F, Kushairi A, Cappuyns L, Daliya P, Adiamah A. The Impact of Sham Feeding with Chewing Gum on Postoperative Ileus Following Colorectal Surgery: a Meta-Analysis of Randomised Controlled Trials. J Gastrointest Surg 2020; 24:2643-2653. [PMID: 32103455 PMCID: PMC7595968 DOI: 10.1007/s11605-019-04507-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/16/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Chewing gum as a form of sham feeding is an inexpensive and well-tolerated means of promoting gastrointestinal motility following major abdominal surgery. Although recognised by the Enhanced Recovery After Surgery (ERAS) Society as one of the multimodal approaches to expedite recovery after surgery, strong evidence to support its use in routine postoperative practice is lacking. METHODOLOGY A comprehensive literature review of all randomised controlled trials (RCTs) was performed in the Medline and Embase databases between 2000 and 2019. Studies were selected to compare the use of chewing gum versus standard care in the management of postoperative ileus (POI) in adults undergoing colorectal surgery. The primary outcome assessed was the incidence of POI. Secondary outcomes included time to passage of flatus, time to defecation, total length of hospital stay and mortality. RESULTS Sixteen RCTs were included in the systematic review, of which ten (970 patients) were included in the meta-analysis. The incidence of POI was significantly reduced in patients utilising chewing gum compared to those having standard care (RR 0.55, 95% CI 0.39, 0.79, p = 0.0009). These patients also had a significant reduction in time to passage of flatus (WMD - 0.31, 95% CI - 0.36, - 0.26, p < 0.00001) and time to defecation (WMD - 0.47, 95% CI - 0.60, - 0.34, p < 0.00001), without significant differences in the total length of hospital stay or mortality. CONCLUSION The use of chewing gum after colorectal surgery is a safe and effective intervention in reducing the incidence of POI and merits routine use alongside other ERAS pathways in the postoperative setting.
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Affiliation(s)
- Farah Roslan
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK
- East Midlands Surgical Academic Network (EMSAN), Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK
| | - Anisa Kushairi
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK
- East Midlands Surgical Academic Network (EMSAN), Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK
| | - Laura Cappuyns
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK
- East Midlands Surgical Academic Network (EMSAN), Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK
| | - Prita Daliya
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK
- East Midlands Surgical Academic Network (EMSAN), Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK
| | - Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK.
- East Midlands Surgical Academic Network (EMSAN), Queen's Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK.
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Lobo DN, Gianotti L, Adiamah A, Barazzoni R, Deutz NEP, Dhatariya K, Greenhaff PL, Hiesmayr M, Hjort Jakobsen D, Klek S, Krznaric Z, Ljungqvist O, McMillan DC, Rollins KE, Panisic Sekeljic M, Skipworth RJE, Stanga Z, Stockley A, Stockley R, Weimann A. Perioperative nutrition: Recommendations from the ESPEN expert group. Clin Nutr 2020; 39:3211-3227. [PMID: 32362485 DOI: 10.1016/j.clnu.2020.03.038] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. METHODS This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. RESULTS Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. CONCLUSIONS Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.
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Affiliation(s)
- Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Nicolaas E P Deutz
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, TX, 77843-4253, USA
| | - Ketan Dhatariya
- Department of Diabetes, Endocrinology and General Medicine, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust and University of East Anglia, Colney Lane, Norwich, NR4 7UY, UK
| | - Paul L Greenhaff
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Michael Hiesmayr
- Division of Cardio-Thoracic-Vascular Surgical Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Stanislaw Klek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Zeljko Krznaric
- University Hospital Centre Zagreb and Zagreb School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Donald C McMillan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Royal Infirmary, Glasgow, UK
| | - Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Marina Panisic Sekeljic
- Military Medical Academy, Clinic for General Surgery, Department for Perioperative Nutrition, Crnostravska Street 17, Belgrade, Serbia
| | - Richard J E Skipworth
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Audrey Stockley
- Patient Public Involvement Group, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Ralph Stockley
- Patient Public Involvement Group, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Arved Weimann
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Delitzscher Straße 141, 04129, Leipzig, Germany
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Carroll PA, Yeung JC, Darling GE. Elimination of Routine Feeding Jejunostomy After Esophagectomy. Ann Thorac Surg 2020; 110:1706-1713. [DOI: 10.1016/j.athoracsur.2020.04.072] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 01/15/2023]
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Zheng R, Rios-Diaz AJ, Liem S, Devin CL, Evans NR, Rosato EL, Palazzo F, Berger AC. Is the placement of jejunostomy tubes in patients with esophageal cancer undergoing esophagectomy associated with increased inpatient healthcare utilization? An analysis of the National Readmissions Database. Am J Surg 2020; 221:141-148. [PMID: 32828519 DOI: 10.1016/j.amjsurg.2020.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients undergoing esophagectomy often receive jejunostomy tubes (j-tubes) for nutritional supplementation. We hypothesized that j-tubes are associated with increased post-esophagectomy readmissions. STUDY DESIGN We identified esophagectomies for malignancy with (EWJ) or without (EWOJ) j-tubes using the 2010-2015 Nationwide Readmissions Database. Outcomes include readmission, inpatient mortality, and complications. Outcomes were compared before and after propensity score matching (PSM). RESULTS Of 22,429 patients undergoing esophagectomy, 16,829 (75.0%) received j-tubes. Patients were similar in age and gender but EWJ were more likely to receive chemotherapy (24.2% vs. 15.1%, p < 0.01). EWJ was associated with decreased 180-day inpatient mortality (HR 0.72 [0.52-0.99]) but not with higher readmissions at 30- (15.2% vs. 14.0%, p = 0.16; HR 0.9 [0.77-1.05]) or 180 days (25.2% vs. 24.3%, p = 0.37; HR 0.94 [0.79-1.10]) or increased complications (p = 0.37). These results were confirmed in the PSM cohort. CONCLUSION J-tubes placed in the setting of esophagectomy do not increase inpatient readmissions or mortality.
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Affiliation(s)
- Richard Zheng
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA.
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Spencer Liem
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Courtney L Devin
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Nathaniel R Evans
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Ernest L Rosato
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam C Berger
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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Qiao YQ, Zheng L, Jia B, Wang WH, Zheng XH, Fan LL, Xie YB, Tian YT. Risk factors for surgical-site infections after radical gastrectomy for gastric cancer: a study in China. Chin Med J (Engl) 2020; 133:1540-1545. [PMID: 32568869 PMCID: PMC7386359 DOI: 10.1097/cm9.0000000000000860] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND About 10% of patients get a surgical-site infection (SSI) after radical gastrectomy for gastric cancer, but SSI remains controversial among surgeons. The aim of this study was to explore the risk factors for SSIs after radical gastrectomy in patients with gastric cancer to guide clinical therapies and reduce the incidence of SSI. METHODS The study was a retrospective cohort study in patients who underwent radical gastrectomy for gastric cancer. SSI was defined in accordance with the National Nosocomial Infection Surveillance System. We evaluated patient-related and peri-operative variables that could be risk factors for SSIs. The Chi-squared test and logistic regression analysis were used to assess the association between these risk factors and SSI. RESULTS Among the 590 patients, 386 were men and 204 were women. The mean age was 56.6 (28-82) years and 14.2% (84/590) of these patients had an SSI. Among them, incisional SSI was observed in 23 patients (3.9%) and organ/space SSI in 61 patients (10.3%). Multivariate logistic regression analysis identified sex (odds ratios [ORs] = 2.548, and 95% confidence interval [CI]: 1.268-5.122, P = 0.009), total gastrectomy (OR = 2.327, 95% CI: 1.352-4.004, P = 0.002), albumin level (day 3 after surgery) <30 g/L (OR = 1.868, 95% CI: 1.066-3.274, P = 0.029), and post-operative total parenteral nutrition (OR = 2.318, 95% CI: 1.026-5.237, P = 0.043) as independent risk factors for SSI. CONCLUSIONS SSI was common among patients after radical gastrectomy for gastric cancer. The method supporting post-operative nutrition and the duration of prophylactic antibiotics may be important modifiable influencing factors for SSI.
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Affiliation(s)
- Yong-Qi Qiao
- Department of Pharmacy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Li Zheng
- Department of General Surgery, Beijing Dongcheng First People's Hospital, Beijing 100075, China
| | - Bei Jia
- Department of Pharmacy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Wei-Hua Wang
- Department of Pharmacy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiao-Hao Zheng
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Lin-Lin Fan
- Department of Pharmacy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yi-Bin Xie
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yan-Tao Tian
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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Gianotti L, Sandini M, Romagnoli S, Carli F, Ljungqvist O. Enhanced recovery programs in gastrointestinal surgery: Actions to promote optimal perioperative nutritional and metabolic care. Clin Nutr 2020; 39:2014-2024. [PMID: 31699468 DOI: 10.1016/j.clnu.2019.10.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/20/2019] [Indexed: 02/06/2023]
Abstract
The enhanced recovery after surgery (ERAS) pathway is an evidence-based approach to the use of care elements along the patient perioperative pathway. All care elements that may impact on clinically relevant outcomes have been considered and reviewed. The combined ERAS actions allow a quicker return to bowel function, oral feeding, nutritional and metabolic equilibrium, normal activity and ultimately to achieve better outcomes. Because of the multi factorial approach and the commitment of all the professionals caring for the patient, it is necessary to have the engagement of all disciplines, such as surgery, anesthesiology, clinical nutrition, nursing, physiatry, involved. ERAS is a dynamic process and new evidence are constantly integrated into the program. The primary endpoint of this review is to give updated information on the key ERAS actions to achieve optimal perioperative nutritional and metabolic care.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, Milano - Bicocca University, Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marta Sandini
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Stefano Romagnoli
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Franco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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Zhang C, Zhang M, Gong L, Wu W. The effect of early oral feeding after esophagectomy on the incidence of anastomotic leakage: an updated review. Postgrad Med 2020; 132:419-425. [PMID: 32090663 DOI: 10.1080/00325481.2020.1734342] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Early oral feeding (EOF) is considered to be an important component of enhanced recovery after surgery (ERAS), but raises the concern of increased risk of anastomotic leakage (AL) in patients receiving esophagectomy. This review aimed to elucidate the correlation of EOF and the incidence of AL after esophageal resection. METHODS We searched PubMed, Web of Science, Scopus, Cochrane Library and Google Scholar from their inception to February 2020 for published articles that compared AL after EOF (oral feeding initiated within postoperative day [POD] 3) vs. conventional feeding regimen (nil-by-mouth with enteral tube nutrition support, until oral feeding since POD 4 and beyond) following esophagectomy. RESULTS A total of 11 full articles were included in this review, including 5 registered randomized controlled trials (RCTs) and 6 observational studies that compared EOF with conventional care after esophagectomy. Meta-analysis was not possible due to significant heterogeneity, bias, and small sample sizes. Among the 11 included studies, 9 (including the 5 RCTs) showed that EOF did not increase AL rate, whereas the other 2 retrospective studies indicated that delayed oral feeding resulted in fewer AL. CONCLUSIONS EOF after esophagectomy probably does not increase the incidence of AL, and it is a promising strategy in line with the essence of ERAS. However, more and better evidence from high-quality RCTs are still needed.
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Affiliation(s)
- Chu Zhang
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine) , Shaoxing, Zhejiang, China
| | - Miao Zhang
- Department of Surgery, Xuzhou Central Hospital, Southeast University School of Medicine , Xuzhou, Jiangsu, People's Republic of China
| | - Longbo Gong
- Department of Surgery, Xuzhou Central Hospital, Southeast University School of Medicine , Xuzhou, Jiangsu, People's Republic of China
| | - Wenbin Wu
- Department of Surgery, Xuzhou Central Hospital, Southeast University School of Medicine , Xuzhou, Jiangsu, People's Republic of China
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Kitagawa M, Uesugi Y, Kawata N, Shimamura Y. Comparison of unpalatable meal contents between patients who underwent total and distal gastrectomies. Clin Nutr ESPEN 2020; 37:134-140. [PMID: 32359735 DOI: 10.1016/j.clnesp.2020.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 02/20/2020] [Accepted: 03/09/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Unpalatable meal contents have several impacts on the dietary life of patients who undergo gastrectomy. However, few studies have focused on the unpalatable meal contents according to surgical procedure. This study aims to clarify the differences in the unpalatable meal contents between the patients who underwent total and distal gastrectomies (TG and DG, respectively). METHODS This study involved patients (n = 341) who underwent TG or DG within 5 years, and a questionnaire of unpalatable meal contents was used. The data on the demographics, operation types, Dysfunction After Upper Gastrointestinal Surgery 20 (DAUGS20) scoring system, and nutrition conditions were confirmed. Furthermore, these were analyzed using descriptive statistics and compared between TG (n = 180) and DG (n = 161) groups. RESULTS The unpalatable meal contents that were significantly different between two groups were big in size (p = 0.013), solid (p = 0.040), rough (p = 0.041), and dry (p = 0.045), which were more difficulty in the TG group. Furthermore, the strong sour taste was more difficulty in the DG group (p = 0.031). DISCUSSION The meals which the TG group had difficulty eating were characteristic of sticking or stagnating in the digestive tract, making the passage of food more difficult in the TG patients. This was because they had a smaller storage for foods and a narrower space at the anastomotic region than those who underwent DG. CONCLUSION The meal contents were assumed to have been influenced by the surgical procedure. We conclude that the patients in the TG group felt more difficulty in eating the meal contents that could stagnate at the anastomotic region than those in the DG group.
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Affiliation(s)
- Megumi Kitagawa
- Department of Public Health, Kobe University, Graduate School of Health Sciences, Hyogo, Japan.
| | - Yuko Uesugi
- Department of Public Health, Kobe University, Graduate School of Health Sciences, Hyogo, Japan
| | - Naomi Kawata
- Department of Surgery, Matsuyama Shimin Hospital, Ehime, Japan
| | - Yasuhiro Shimamura
- Department of Nutrition Management, Nishi Kobe Medical Center, Hyogo, Japan
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