Parenteral Nutrition Group Research Articles

Efficacy of Double-Lumen Biliary-Enteric Tube in Enteral Nutrition for Patients with Malignant Obstructive Jaundice

Objective This study aimed to evaluate the efficacy of a double-lumen biliary-enteric tube (DBET) for enteral nutrition (EN) in individuals with malignant obstructive jaundice (MOJ). Methods A retrospective cohort study was conducted using data from a prospectively maintained single-center database, including patients with MOJ. In the intervention group, DBET placement was performed concurrently with percutaneous transhepatic cholangiodrainage and biliary stenting, followed by postoperative EN (DBET-EN). In the control group, deep vein catheterization was undertaken after endoscopic biliary stenting, and parenteral nutrition (PN) was provided. A multivariable generalized linear model was used to assess the association between DBET-EN and 6-month mortality. Results A total of 74 patients were included in this study, comprising 28 patients in the intervention group (DBET-EN group) and 46 patients in the control group (PN group). Within the 6-month follow-up, 5 patients (17.9%) in the DBET-EN group and 20 (43.5%) in the PN group died. The multivariable generalized linear model demonstrated a significantly reduced 6-month mortality in the DBET-EN group compared to the PN group (adjusted odds ratio [OR]: 0.25, 95% CI: 0.08–0.81, P = 0.020). Secondary outcomes indicated that patients in the DBET-EN group had lower 9-month mortality rates and longer tube retention durations compared to the PN group (all adjusted P < 0.05). Postoperative liver function improved similarly in both groups. At 3, 6, and 9 months postoperatively, patient-generated subjective global assessment (PG-SGA) scores and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) scores were significantly higher in the DBET-EN group than in the PN group (P < 0.05). Conclusion The implementation of DBET for EN in patients in the advanced stage of MOJ proved to be a minimally invasive and safe intervention. It significantly improved patients’ nutritional status and quality of life while reducing mortality.

Survival study of enteral and parenteral nutrition pathways in critically ill patients receiving vasopressors: an analysis of the Medical Information Mart for Intensive Care-IV database.

This study compared survival outcomes between intensive care unit (ICU) patients receiving enteral nutrition (EN) and parenteral nutrition (PN) with vasopressor support, explored risk factors affecting clinical outcomes and established an evaluation model. Data from 1046 ICU patients receiving vasopressor therapy within 24 h from 2008 to 2019 were collected. Patients receiving nutritional therapy within 3 d of ICU admission were divided into EN or PN (including PN+EN) groups. Cox analysis and regression were used to determine relevant factors and establish a nomogram for predicting survival. The 28-d survival rate was significantly better in the EN group compared with the PN/PN+EN group. Risk factors included age, peripheral capillary oxygen saturation, red cell distribution width, international normalised ratio, potassium level, mean corpuscular Hg, myocardial infarction, liver disease, cancer status and nutritional status. The nomogram showed good predictive performance. In ICU patients receiving vasopressor drugs, patients receiving EN had a better survival rate than PN. Our nomogram had favourable predictive value for 28-d survival in patients. However, it needs further validation in prospective trials.

Comparison of prognosis of elderly patients with gastric and colorectal tumors receiving different nutritional support treatments

Objective: To compare the prognosis of elderly patients with gastric and colorectal cancer treated with different nutritional support methods. Methods: Elderly patients with gastrointestinal tumors who received surgical treatment in Beijing Hospital from January 2019 to June 2020 were retrospectively included and divided into malnourished group and non-malnourished group according to the Global Leadership Initiative on Malnutrition (GLIM). The patients were divided into parenteral nutrition (PN) group, enteral nutrition (EN) group and enteral+parenteral nutrition (EN+PN) group according to the nutritional support. The prognosis of patients with different nutritional support treatment was compared. Results: A total of 426 elderly patients with gastric and colorectal tumors underwent surgical treatment were included, including 287 males and 139 females, aged 65-91 (72±6) years. There were 186 cases in malnourished group and 240 cases in non-malnourished group. A total of 257 patients received nutritional support therapy, including 108 cases in PN group, 48 cases in EN group and 101 cases in EN+PN group. The body mass index (BMI) of malnutrition group was lower than that of non-malnutrition group [(20.5±3.4) vs (23.7±2.8) kg/m2, P<0.001], and the score of nutritional risk screening 2002 (NRS 2002) [M (Q1, Q3)] was higher than that of non-malnutrition group [4 (4, 5) vs 2 (2, 3) points, P<0.001]. The total hospitalization time of patients in EN group was shorter than that in PN group and EN+PN group [(11.9±4.0) vs (16.5±6.5) and (19.2±7.1) d, all P<0.001]. The total hospitalization time in PN group was shorter than that in EN+PN group [(16.5±6.5) vs (19.2±7.1) d, P=0.005]. The total incidence of complications in EN group was lower than that in PN group [0 vs 9.3% (10/108), P=0.030] and EN+PN group [0 vs 19.8% (20/101), P<0.001]. The incidence of total complications in PN group was lower than that in EN+PN group [9.3% (10/108) vs 19.8% (20/101), P=0.030]. Conclusion: Among the three nutritional supportive treatment modalities: EN, PN, and EN+PN, patients receiving EN support treatment have a shorter total hospitalization time and a lower complication rate.

Propyl acetate protects intestinal barrier during parenteral nutrition in mice and Caco-2 cells.

Gut microbiota dysbiosis induces intestinal barrier damage during parenteral nutrition (PN). However, the underlying mechanisms remain unclear. This study aimed to investigate gut microbiota dysbiosis, luminal short-chain fatty acids, and autophagy in a mouse model and how these short-chain fatty acids regulate autophagy. Eight-week-old male specific-pathogen-free mice were randomly divided into a Chow group (standard diet and intravenous normal saline infusion) and a PN group (continuous infusion of PN nutrient solution) for 7 days. Caco-2 cells were also treated with intestinal rinse solutions from Chow and PN mouse models. Compared with the Chow group, the PN group exhibited increased Proteobacteria and decreased Firmicutes, correlating with decreased propyl acetate. In the PN group, intestinal tissue exhibited elevated adenosine monophosphate-activated protein kinase (AMPK) phosphorylation, LC3II protein levels, and Atg3 and Atg7 messenger RNA levels. P62 protein levels were decreased, indicating an increase of autophagy flux in the PN group. In the Caco-2 cell model, cells treated with PN solution plus propyl acetate exhibited increased Claudin-1 and occluding along with decreased interleukin-6 and tumor necrosis factor α compared with those treated with PN solution alone. Propyl acetate addition inhibited the AMPK-mammalian target of rapamycin (mTOR) pathway, mitigating the excessive autophagy induced by the PN intestinal rinse solution in Caco-2 cells. PN led to a significant reduction in propyl acetate levels in the intestine, excessive activation of autophagy, and barrier dysfunction. Propyl acetate inhibited excessive autophagy via the AMPK/mTOR signaling pathway and protected the intestinal barrier during PN.

Effects of different nutritional support methods on nutritional status and immune function in patients undergoing radiotherapy for head and neck cancer.

This study aimed to analyze the effects of different nutritional support methods on nutritional status and immune function of patients undergoing radiotherapy for head and neck cancer (HNC). Patients with HNC were divided into the control (nutritional counseling and routine dietary guidance), parenteral nutrition (PN) (PN support on top of the control group), enteral nutrition (EN) (EN support on top of the control group), and EN + PN (EN combined with PN and routine dietary guidance) groups. After nutrition evaluation, the four groups were subjected to radiotherapy and nutritional support. Body mass index (BMI), serum albumin (ALB), prealbumin (PA), transferrin (TRF), hemoglobin (Hb), CD3+, CD4+, CD8+, CD4+/CD8+, natural killer (NK) and quality of life were compared among the four groups before radiotherapy and after radiotherapy dose irradiation completion. The incidence of adverse reactions was assessed and recorded at 2weeks, 4weeks and the end of radiotherapy. The four groups experienced some degree of malnutrition during radiotherapy and the EN + PN group possessed the lowest degree of malnutrition. After radiotherapy dose irradiation completion (T1), the PN, EN, and EN + PN groups possessed improved BMI (21.42 ± 1.62, 21.40 ± 1.68, 22.98 ± 1.87 vs. 20.18 ± 1.32), serum ALB (31.59 ± 3.49, 32.24 ± 4.23, 37.58 ± 3.23 vs. 26.67 ± 3.03), PA (182.63 ± 13.57, 183.43 ± 14.19, 201.59 ± 10.53 vs. 165.36 ± 20.13), TRF (162.46 ± 24.34, 157.36 ± 18.58, 182.36 ± 20.37 vs. 137.56 ± 23.19), and Hb (128.54 ± 9.21, 125.36 ± 10.23, 140.26 ± 7.23 vs. 103.24 ± 9.47) levels, higher CD3+ (63.59 ± 2.88, 63.25 ± 3.17, 66.54 ± 1.32 vs. 59.36 ± 3.24), CD4+ (39.92 ± 3.16, 39.87 ± 3.23, 43.36 ± 2.87 vs. 37.12 ± 4.29), CD4+/CD8+ (1.80 ± 0.06, 1.78 ± 0.06, 2.07 ± 0.03 vs. 1.54 ± 0.10) and NK-cells (33.87 ± 3.62, 33.26 ± 3.59, 36.82 ± 3.19 vs. 27.36 ± 4.21) levels, lower CD8+ (22.18 ± 1.07, 22.36 ± 1.04, 20.46 ± 1.09 vs. 24.09 ± 1.21) levels, and improved quality of life (79.97 ± 7.96, 80.13 ± 7.98, 91.78 ± 7.38 vs. 71.53 ± 11.70) versus the control group, and the EN + PN group possessed the most pronounced effects (All P < 0.05). During radiotherapy, the incidence of radiotherapy adverse reactions was increased with time (P < 0.05). PN and EN, alone or in combination, can improve the nutritional status, immune function and quality of life of patients undergoing radiotherapy for HNC, and PN combined with EN has the best improvement effect.

Impact of various nutritional interventions on the physical and mental state of patients undergoing surgery for oral and maxillofacial tumor: guiding patients' informed choices.

To compare the effects of oral nutritional supplements (ONS), parenteral nutrition (PN), and enteral nutrition (EN) on the recovery of patients who underwent oral and maxillofacial surgery. The shared decision-making process assigned 37, 56, and 35 patients to the ONS, PN, and EN groups, respectively. Details such as demographic data, duration of hospitalization, cost of nutritional therapy, nutritional assessments, patients' satisfaction, and compliance, Hamilton Anxiety Rating Scale (HAM-A) score, and relevant biochemical indices were systematically recorded and compared between the groups. Patients with healthier biochemical indices and physical states at baseline, including a higher body mass index, preferred ONS. Patients using dentures and those with medical insurance often chose EN, while patients with recurrent disease preferred PN. Patients receiving EN had a similar duration of hospitalization to patients receiving ONS and also had the lowest nutritional costs. Patients receiving ONS had higher lymphocyte counts and levels of hemoglobin, albumin, and C-reactive protein. Patients in the PN group had elevated levels of serum potassium, chlorine, and sodium, while those receiving EN reported higher HAM-A scores, indicating greater anxiety than their counterparts. Predischarge surveys showed higher satisfaction and compliance in the PN and ONS groups than in the EN group. The PN group reported more adverse symptoms. At 7days post-discharge, patients with EN reported a greater feeling of well-being. ONS is the optimal choice for patients in good preoperative conditions, while PN is preferred during disease recurrence or when financially feasible. EN is suitable for patients using dentures or those with limited finances despite its potential psychological discomfort. Future studies with increased sample sizes and longer follow-up duration are necessary to corroborate our findings. The Trial Registration Number is ChiCTR2100049547. The date of registration isAugust 2, 2021.

Early Enteral Nutrition Does Not Cause Excessive Inflammatory Response in Veno-Arterial Extracorporeal Membrane Oxygenation Patients

Background: To evaluate the safety between early enteral nutrition (EN) and parenteral nutrition (PN) by observing changes in inflammatory cytokines and gastrointestinal hormones in veno-arterial extracorporeal membrane oxygenation (VA ECMO) patients. Methods: This study was a prospective, observational study that enrolled patients receiving VA ECMO treatment from 1 January 2020 to 31 December 2023. Patients were enrolled in an EN group or a PN group according to the inclusion criteria. The concentration of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor α (TNF-α) on the first five days of VA ECMO treatement were tested in both groups. Serum concentrations of Motilin (MOT), Gastrin (GAS), Cholecystokinin (CCK), and Calcitonin gene-related peptide (CGRP) were measured for the EN group. Student t test or Fisher test was used to compare the difference between the two groups. Results: 28 patients were enrolled in this study; 16 in the EN group and 12 in the PN group. The baseline characteristics were comparable between the two groups. The concentration of IL-1β in the EN group was significantly lower than that of the PN group on day 3 and day 4 (day 3: 0.65 ± 0.17 pg/mL vs. 0.93 ± 0.09 pg/mL, p &lt; 0.01, day 4: 0.52 ± 0.16 pg/mL vs. 0.74 ± 0.12 pg/mL, p &lt; 0.01). The concentration of IL-6 and TNF-α in the EN group were also significantly lower than in the PN group on day 3 and day 4. There was no statistical difference in IL-10 serum concentration between the EN group and the PN group from day 1 to day 5. On day 3, the concentration of MOT, GAS and CCK reached the highest level and then gradually decreased. Conclusions: Implementation of early EN in patients receiving VA ECMO does not cause significant elevation of pro-inflammatory cytokines with an excessive inflammatory response.

Risk factors, impact and treatment of postoperative lymphatic leakage in children with abdominal neuroblastoma operated on by laparotomy

BackgroundLymphatic leakage is one of the postoperative complications of neuroblastoma. The purpose of this study is to summarize the clinical characteristics and risk factors of lymphatic leakage and try to find effective prevention and treatment measures.MethodsA retrospective study included 186 children with abdominal neuroblastoma, including 32 children of lymphatic leakage and 154 children of non-lymphatic leakage. The clinical information, surgical data, postoperative abdominal drainage, treatment of lymphatic leakage and prognosis of the two groups were collected and analyzed.ResultsThe incidence of lymphatic leakage in this cohort was 14% (32 children). Through univariate analysis of lymphatic leakage group and non-lymphatic leakage group, we found that lymphatic leakage increased the complications, prolonged the time of abdominal drainage and hospitalization, and delayed postoperative chemotherapy (p < 0.05). In this cohort, the median follow-up time was 46 (95% CI: 44–48) months. The follow-up data of 7 children were partially missing. 147 children survived, of which 23 had tumor recurrence (5 children recurred in the surgical area). 37 children died, of which 32 had tumor recurrence (9 children recurred in the operation area). In univariate analysis, there was no statistical difference in overall survival (p = 0.21) and event-free survival (p = 0.057) between lymphatic leakage group and non-lymphatic leakage group, while 3-year cumulative incidence of local progression was higher in lymphatic leakage group (p = 0.015). However, through multivariate analysis, we found that lymphatic leakage did not affect event-free survival, overall survival and cumulative incidence of local progression in children with neuroblastoma. Resection of 5 or more lymphatic regions was an independent risk factor for lymphatic leakage after neuroblastoma surgery. All 32 children with lymphatic leakage were cured by conservative treatment without surgery. Of these, 75% (24/32) children were cured by fat-free diet or observation, 25% (8/32) children were cured by total parenteral nutrition. The median drain output at diagnosis in total parenteral nutrition group was higher than that in non-total parenteral nutrition group (p < 0.001). The cut-off value was 17.2 ml/kg/day.ConclusionsLymphatic leakage does not affect the prognosis of children with neuroblastoma, but long-term drain output caused by lymphatic leakage will still adversely affect postoperative complications and follow-up treatment, which requires attention and active treatment measures. More attention should be paid to the children with 5 or more lymphatic regions resection, and the injured lymphatic vessels should be actively found and ligated after tumor resection to reduce the postoperative lymphatic leakage. Early application of total parenteral nutrition is recommended for those who have drain output at diagnosis of greater than 17.2 ml/kg/day.Level of evidenceLevel III, Treatment study (Retrospective comparative study).

The impact of post-operative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an EAST multicenter trial.

Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(β -24.9, 95%CI -39.0 to -10.7,p < 0.001). EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. IV.

The relationship between baseline nutritional status with subsequent parenteral nutrition and clinical outcomes in cancer patients undergoing cytoreductive surgery: a retrospective study.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) with Cytoreductive Surgery (CRS) is the preferred treatment for peritoneal malignancies. This highly complex operation is associated with a high incidence of complications, particularly due to malnutrition. This study aimed to investigate the potential association between preoperative nutritional status and postoperative clinical outcomes in adult cancer patients who underwent CRS/HIPEC for peritoneal malignancy. A retrospective study with 140 adult cancer patients, on parenteral nutrition (PN) (n = 40) and not on PN (n = 100) who underwent CRS with or without HIPEC, was conducted. Patients who received PN had significantly longer post-operative, hospital, and ICU LOS than those who did not (p = 0.001). ICU admission was significantly higher in the non-PN receiving group compared to the PN receiving group. When compared to the PN group, the majority of patients not receiving PN were at low risk of malnutrition (91% vs. 75%, p = 0.020), whereas 17.5% of PN patients were at risk of malnutrition during hospitalization. Multiple regression analyses revealed a strong positive relationship between patients with increased risk of malnutrition and ICU LOS (p = 0.047). Routine preoperative nutrition assessment is essential to identify patients who are at higher nutritional risk, and nutrition support should be provided preoperatively.

Parenteral Versus Enteral Nutrition on Perioperative Cognitive Function in Anesthesia Patients

This study evaluated the impact of enteral nutrition versus parenteral nutrition on perioperative cognitive function and related outcomes in patients undergoing different surgeries. From April to December 2023, 240 patients in Shanghai, China, undergoing elective surgery were randomly assigned to receive either enteral or parenteral nutrition postoperatively. This cross-sectional study represented a wide range of clinical applications and surgical procedures. Outcomes, including longterm hospital stays, complication rates, dietary compliance, 30-day readmission rates, patient satisfaction, inflammatory markers, immunological response, stress response, and perioperative cognitive function, measured by Mini-Mental State Examination and Montreal Cognitive Assessment scores, were investigated in this study. Compared to patients in the parenteral nutrition group, those in the enteral nutrition group exhibited considerably shorter hospital stays (8.7 ± 1.9 days versus 9.4 ± 2.0 days, P &lt; 0.05), lower complication rates (22% versus 30%, P &lt; 0.05), and lower 30-day readmission rates (10% versus 15%, P &lt; 0.05). The enteral nutrition group exhibited higher patient satisfaction rates (9.1 ± 2.1 versus 8.2 ± 1.6, P &lt; 0.05). Additionally, enteral nutrition was linked to better immunological and inflammatory profiles and lower stress marker levels (cortisol, lymphocyte count, and C-reactive protein). After various surgical procedures, enteral nutrition recipients achieved higher scores on postoperative cognitive tests. Compared to parenteral nutrition, enteral nutrition provides better results regarding hospital stay, complication rate, readmission rate, patient satisfaction, and cognitive function. These results support the preferential use of enteral nutrition in postoperative treatment and contribute to the growing evidence demonstrating the physiological advantages of enteral nutrition and its beneficial effects on postoperative recovery and cognitive preservation.

Lack of clinical benefit from preoperative short-term parenteral nutrition on the clinical prognosis of patients treated with radical gastrectomy for gastric cancer: a two-center retrospective study based on propensity score matching analysis.

Preoperative nutritional support studies for patients undergoing gastrointestinal (GI) surgery mostly focused on enteral nutrition (EN) or long-term (≥7 days) parenteral nutrition (PN). Some studies also found that preoperative short-term PN could improve the postoperative short-term nutritional status of tumor patients. But whether short-term PN support (1-6 days) before surgery can improve the prognosis of patients undergoing surgery for gastric cancer (GC) remains unclear. Therefore, we focused on assessing the effect of preoperative short-term PN on the outcomes of patients undergoing radical surgery for GC. A retrospective analysis of 1,155 patients who underwent radical gastrectomy for GC between July 2014 and February 2019 was conducted. According to whether patients received short-term (1-6 days) PN support before surgery, patients were divided into non-PN group and PN group. After 1:1 propensity score matching (PSM), two groups of patients with similar baseline clinical characteristics were obtained. The incidence of various complications and overall survival (OS) rate were compared between the two groups, and logistic regression analysis for complications, Cox regression analysis for OS, and subgroup analysis were performed. Each group had 478 patients after PSM, and the clinical characteristics were balanced. There were no significant differences in overall postoperative complications (pre-PSM: P=0.495; post-PSM: P>0.99), postoperative length of stay (LOS; pre-PSM: P=0.092; post-PSM: P=0.460), or readmission rate within 30 days (pre-PSM: P=0.496; post-PSM: P=0.793) between the two groups before and after PSM. The OS of PN group before matching was lower than that of non-PN group (P=0.023), but this difference was not significant after matching (P=0.950), but the PN group's hospitalization expenses were substantially greater than those of the control group (post-PSM: P<0.001). Preoperative short-term PN support was not an independent factor in the incidence of postoperative complications (P>0.99) and OS (P=0.949). Subgroup analyses failed to identify those patients who might benefit from preoperative short-term PN support. Preoperative short-term PN support may have no significant benefit on short-term postoperative complications or the long-term OS of patients with GC but increase hospitalization costs. It thus should not be the first choice of treatment for these patients.

Body composition after implementation of an enhanced parenteral nutrition protocol in the neonatal intensive care unit: a randomised pilot trial

Background Very low birthweight (VLBW) infants are at risk for growth failure and poor neurodevelopment. Optimised parenteral nutrition may help promote optimal growth and development, but concerns that provision of enhanced nutrition may contribute to increased early adiposity and later metabolic disease remain. Aim To determine associations between provision of an early enhanced parenteral nutrition protocol or standard parenteral nutrition protocol and growth and body composition for VLBW preterm infants in the neonatal intensive care unit. Subjects This is a secondary analysis of data from a clinical trial aimed at assessing the feasibility and safety of randomising VLBW preterm infants to Standard (n = 45) or Intervention (n = 42) parenteral nutrition groups between August 2017 and June 2019. Methods We evaluated associations between weekly infant growth and body composition measurements from n = 55 infants (Standard = 29, Intervention = 26) that were clinically stable enough to have body composition measurements taken before discharge using mixed effects linear regression models. Result No statistically significant associations between nutrition group and infant growth or body composition measures were observed (p >.05). Conclusion In this pilot trial, enhanced parenteral nutrition in the first week of life was not associated with significant differences in infant growth or body composition during hospitalisation.

Comparative Analysis of Enteral and Parenteral Nutrition Impact on Outcomes in Esophageal Cancer Patients: A Paradigm for Nutritional Optimization in Oncology

Background: Individuals diagnosed with esophageal cancer face a pronounced risk of malnutrition, primarily attributed to the early onset of gastrointestinal obstruction. This risk persists and may even intensify following therapeutic interventions and the subsequent reconstruction of gastrointestinal passages. The current study focuses on elucidating the differential impact of enteral vs. parenteral nutrition on outcomes in patients hospitalized with esophageal cancer. Methods: The study analyzed adult discharges related to esophageal cancer from 2019 and 2020 using data from the National Inpatient Sample. Exclusion criteria included discharges involving minors and mixed nutritional regimens. Enteral nutrition and parenteral nutrition subgroups were identified using International Classification of Diseases, 10th revision codes. Outcome variables were determined through ICD-10 codes in the NIS dataset. Multivariable regression analyses were used to investigate associations between mode of nutrition and specified outcomes. Results: In this study involving 28,015 hospitalizations for esophageal cancer, 756(2.7%) received enteral nutrition, and 1064(3.8%) received parenteral nutrition. After adjusting for confounding variables, parenteral nutrition emerged as an independent predictor of mortality (OR 1.75, P=0.023), while enteral nutrition showed no association with higher mortality (OR 0.56, P=0.162). Both nutrition modes were associated with increased length of stay, with patients on parenteral nutrition having significantly longer stays (+9.07 days, P&lt;0.001 vs 3.07 days, P=0.001). While both nutrition modes were linked to high total hospitalization charges, patients with parenteral nutrition experienced a significantly more significant increase in total treatment cost compared to those on enteral nutrition (112,093 USD, P&lt;0.001 vs 54,953 USD, P=0.01) patients on enteral nutrition had lower odds of pneumonia compared to the parenteral nutrition group. The parenteral nutrition group had higher odds of various complications, including esophageal perforation, constipation, diarrhea, acute kidney injury, ICU admission, and acute respiratory failure, than those on enteral nutrition. Both forms of nutrition were associated with increased odds of malnutrition, fluid and electrolyte disorders, and septic shock. Conclusion: Parenteral nutrition has a higher risk of mortality compared to enteral nutrition. Both types are linked to longer hospital stays, increased treatment costs, and other adverse outcomes, with parenteral nutrition leading to more complications than enteral nutrition.

Can supplementation of tryptophan in parenteral nutrition increase melatonin and alleviate inflammatory response?

Endogenous melatonin is produced from tryptophan which is an essential amino acid. Besides its role in the regulation of sleep patterns, melatonin has anti-inflammatory effects. In this case-control study, we aimed to compare tryptophan and melatonin levels and their relationship with the inflammatory response, specifically serum interleukin-1, interleukin-6, and c-reactive protein levels following major abdominal surgery in patients with food restriction and who receive parenteral nutritional therapy. We enrolled 40 patients between the ages of 18 and 65 years in the study. We collected blood and urine samples 48 h before the operation and on postoperative days 1, 3, and 5. The tryptophan levels in the experimental group were higher than in the control group but failed to reach any statistical difference. Melatonin levels were increased in both groups following the surgery compared with preoperative levels. The increase in the experimental group was statistically different 3 days after the surgery. The difference in the level of interleukin-1 between the control and the experimental groups was greatest on postoperative day 3. On postoperative day 3, the interleukin-6 level in the treatment group was slightly higher than in the control group. We did not find any difference in the levels of c-reactive protein between the groups. As a result, the levels of tryptophan and melatonin were increased in the parenteral nutrition group, irrespective of the postoperative inflammatory response.

Enteral Versus Parenteral Nutrition in Patients Undergoing Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-Analysis

Purpose : The purpose of this study is to conduct a systematic review to compare the nutritional support level, tolerance, and clinical outcomes obtained with enteral and parenteral nutrition in patients undergoing hematopoietic stem cell transplantation(HSCT). Methods: A computerized search of studies published from database inception to June 12, 2023 was conducted in English language databases including Pubmed, Cochrane Library, Embase, and Web of Science, and in Chinese language databases including China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Database, and Chinese Biomedical Literature Database (Sinomed). The search strategy was constructed using a combination of subject headings and free-text terms. Search terms included “Stem Cell Transplantat*” “Bone Marrow Transplantation” “Enteral Nutrition” “Parenteral Nutrition”. The inclusion criteria for this intervention study are studies that include patients undergoing hematopoietic stem cell transplantation and compare enteral nutrition versus parenteral nutrition as an intervention. The outcome measures include changes in patient nutritional status, nutritional support tolerance, incidence of infection, incidence of GVHD, length of hospital stay, and number of days to neutrophil engraftment. Studies including conference abstracts and those without full-text availability were excluded. Results: A total of 3,175 relevant articles were identified through the search, and after duplicates and screening, 10 studies with 339 patients were included. The literature screening process is shown in Figure 1, and the included study characteristics are presented in Table 1. The average duration of enteral nutrition in HSCT patients was 10-16 days, while parenteral nutrition lasted on average 14-17.5 days. Nasogastric tube feeding provided 50%-90% of the required nutrition, while intravenous nutrition provided 58%-97% of the required nutrition. Meta-analysis results showed that patients receiving enteral nutrition had a higher degree of weight loss compared to those receiving parenteral nutrition after HSCT [MD=1.97, 95%CI(0.81, 3.12), P&amp;lt;0.001], but had a lower degree of serum albumin decline [MD=2.49, 95%CI(0.82, 4.17), P=0.003], as shown in Figures 2-3. In terms of tolerance, 45%-100% of patients switched from enteral to parenteral nutrition before completing nutritional support, with common reasons being repeated tube displacement, inability to meet nutritional demands, nausea, and diarrhea. Only one study reported bleeding rates, which were 23% for the enteral nutrition group and 30% for the parenteral nutrition group. Meta-analysis results showed no significant differences in the incidence of grade 3-4 GVHD, grade 3-4 gastrointestinal mucositis, incidence of infection, and mean length of hospital stay between the two groups, as shown in Figures 4-7. The quality assessment of included studies is presented in Figure 8. Conclusion: Previous studies have suggested that enteral nutrition may be a cost-effective alternative to parenteral nutrition and could potentially prevent bacterial translocation by stimulating the gastrointestinal mucosa. The American Society for Parenteral and Enteral Nutrition recommends that enteral nutrition should be prioritized for HSCT patients who cannot meet their nutritional needs through oral intake. This study found that enteral and parenteral nutrition provided similar levels of nutritional support, and there were no statistically significant differences in clinical outcomes, such as the incidence of grade 3-4 GVHD, grade 3-4 gastrointestinal mucositis, incidence of infection, and mean length of hospital stay. However, based on patient tolerance, factors such as repeated tube displacement, inability to meet nutritional demands, nausea, and diarrhea may lead to the removal of the tube before reaching the nutritional target, and a switch to parenteral nutrition support. Therefore, when choosing enteral nutrition support, it is essential to evaluate the patient's nutritional needs, nasal and skin mucosa condition, and gastrointestinal function. As the studies included in this review were small sample studies, there may be some bias in the results. Future multi-center, large-sample prospective studies are needed to further compare the risks and benefits of different nutritional support modalities for HSCT patients.

Changes of gut microbiota under different nutritional methods in elderly patients with severe COVID-19 and their relationship with prognosis.

The clinical progression of individuals afflicted with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection exhibits significant heterogeneity, particularly affecting the elderly population to a greater extent. Consequently, the association between nutrition and microbiota has garnered considerable interest. Hence, the objective of this study was to gather clinical data pertaining to the influence of diverse nutritional support interventions on the prognosis of geriatric patients with COVID-19, while additionally examining the fecal microbiota of these individuals to assess the repercussions of microecological alterations on their prognostic outcomes. A total of 71 elderly patients diagnosed with severe COVID-19 were included in this study. These patients were subsequently divided into two groups, namely the enteral nutrition (EN) group and the parenteral nutrition (PN) group, based on the type of nutritional support therapy they received after admission. The occurrence of complications was observed in 10.4% of patients in the EN group, whereas it was significantly higher at 69.6% in the PN group (P<0.001). Furthermore, the 60-day mortality rate was 2.1% (1/48) in the EN group, while it was notably higher at 30.4% (7/23) in the PN group (P=0.001). To identify the independent predictors of 60-day mortality, stepwise logistic regression analysis was employed. Among different bacterial groups, Enterococcus_faecium (18.19%) and Pseudomonas_aeruginosa (1.91%) had higher average relative abundance in the PN group (P<0.05). However, the relative abundance of Ruminococcus was higher in the EN group. Further Spearman correlation analysis showed that Enterococcus_faecium was positively correlated with poor clinical prognosis, while Ruminococcus was negatively correlated with poor clinical prognosis. This study shows that the changes in the composition of intestinal flora in elderly COVID-19 patients receiving different nutritional support strategies may be related to different clinical outcomes. The abundance of Enterococcus_faecium in elderly COVID-19 patients receiving PN is significantly increased and is closely related to poor clinical outcomes. It highlights the potential of microbiome-centric interventions to mitigate and manage COVID-19 in older adults with different nutritional support options.

Unexpected Serum and Urine Aluminum Concentrations in Pediatric Patients on Home Parenteral Nutrition.

The intravenous supply of aluminum (Al) present in parenteral nutrition solutions poses a high risk of the absorption of this element, which can result in metabolic bone disease, anemia, and neurological complications. The aim of this study is to determine the impact of long-term parenteral nutrition (PN) in children on serum Al concentration and its urinary excretion compared to healthy children. We evaluated serum Al concentrations and its urinary excretion in patients enrolled in the Polish home parenteral nutrition (HPN) program between 2004 and 2022. The study group included 83 patients and the control group consisted of 121 healthy children. In children whose PN was started in the neonatal period, we found higher serum Al concentrations and higher urinary Al excretion than in other subjects whose PN was started later. Only 12% of the children on chronic parenteral nutrition had serum Al concentrations of less than 5 μg/L. Healthy children in the control group had higher serum Al concentrations than those in the parenteral nutrition group, which may indicate the influence of one's environment and diet on Al serum levels.

Effectiveness and safety of early postpyloric feeding during therapeutic hypothermia in patients with large hemispheric infarction: A retrospective cohort study.

What kind of feeding should be provided during therapeutic hypothermia (TH) in patients with large hemispheric infarction (LHI) is not clear. Therefore, we conducted a retrospective observational study to determine whether providing early postpyloric feeding (PPF) (<24 h after admission) is beneficial or harmful for patients with this condition. This study retrospectively screened 78 patients with LHI who were treated with TH from one neurological intensive care unit (ICU). The patients were receiving either early PPF (n = 52) or early parenteral nutrition (PN) (n = 26). Data regarding 30-day mortality, neurological outcome, nutrition-related laboratory indicators, ICU hospitalization time, mechanical ventilation (MV) duration, and complications were collected. A greater number of patients who received early PPF had favorable neurologic outcome than those who received early PN (57.7% vs 30.7%, P = 0.025). The early PPF group had a lower severity of pulmonary infection than the early PN group, as measured by the Clinical Pulmonary Infection Score (7.33 ± 0.96 vs 9.42 ± 2.11, P = 0.006). The total protein and hemoglobin levels in the early PPF group were higher than those in the early PN group (59.56 ± 5.09 vs 56.52 ± 7.94 g/L, P = 0.046; 131.06 ± 19.58 vs 122.07 ± 17.72 g/L, P = 0.045). The MV duration and ICU hospitalization time were shorter in the early PPF group (13 [9;21] vs 21 [14;30] days, P = 0.006; 28 [22;36] vs 34 [33;51] days, P = 0.014). There were no significant differences in the incidence of catheter-related bloodstream infections, 30-day mortality, or nutrition intolerance between the two groups. Early PPF is an effective and safe enteral nutrition method for patients with LHI receiving TH.

Timing of parenteral nutrition initiation in critically ill children: a randomized clinical trial.

The optimal timing of parenteral nutrition (PN) initiation in critically ill children remains controversial. To identify the optimal timing of PN initiation in critically ill children. This randomized clinical trial was conducted in the pediatric intensive care unit (PICU) of Menoufia University Hospital. A total of 140 patients were randomized to receive early or late PN. The early PN group consisted of 71 well-nourished and malnourished patients who received PN on the first day of PICU admission. Malnourished (42%) and well-nourished children randomized to the late PN group (42%) started PN on the fourth versus seventh day after admission, respectively. Mechanical ventilation (MV) was the primary outcome, while PICU length of stay and mortality were secondary outcomes. Patients who received early PN started enteral feeding significantly earlier (median, 6 days; interquartile range, 2-20 days) than those not provided early PN (median, 12 days; interquartile range, 3-30 days; P<0.001) and had a significantly lower risk of feeding intolerance (5.6% vs.18.8%, P=0.035). The median time required to obtain full calories enterally was shorter in the early versus late PN group (P=0.004). Furthermore, patients in the early versus late PN group had a significantly shorter median PICU stay (P<0.001) and were less likely to require MV (P=0.018). Patients who received early PN had a lower MV need and duration than those who received later PN and had more favorable clinical outcomes in terms of morbidity.