Perioperative Immunonutrition Research Articles

Impact of Immunonutrition on Nutritional Status in Patients Undergoing Colorectal Cancer Surgery: A Randomized Controlled Clinical Trial

This study aimed to investigate the additional effects of perioperative immunonutrition (IMN) compared with preoperative immunonutrition (IMN) on anthropometric, nutritional, and biochemical parameters, hospital stay and postoperative complications in patients with colorectal cancer. Oral supplementation enriched with arginine, omega-3 fatty acids, and dietary nucleotides was given to 25 patients before and after the operation (Group 2); 25 patients received the same formula before surgery and standard isocaloric nutrition following the operation (Group 1). Postoperative body weight, body mass index (BMI), and middle upper arm circumference (MUAC) of Group 1 decreased more than Group 2 during follow-up (p < 0.05). The biochemical parameters, C-reactive protein (CRP), aspartate aminotransferase (AST) and fasting plasma glucose (FPG) were higher, and albumin was lower than the baseline in Group 1 compared to Group 2 (p < 0.05). There was a negative correlation between CRP and Nutrition Risk Screening (NRS) 2002 scores, and prealbumin and NRS 2002 scores had a positive correlation (p = 0.007, r = 0.384; p = 0.012, r = 0.352). There was no difference in hospital stay and postoperative complications between the groups (p > 0.05). Perioperative immunonutrition, compared to preoperative immunonutrition, can be used as a positive and effective approach in improving some anthropometric measurements and biochemical parameters in patients undergoing colorectal cancer surgery.

Hepatopancreaticobiliary Resection Arginine Immunomodulation (PRIMe) trial: protocol for a randomised phase II trial of the impact of perioperative immunomodulation on immune function following resection for hepatopancreaticobiliary malignancy

IntroductionSurgical stress results in immune dysfunction, predisposing patients to infections in the postoperative period and potentially increasing the risk of cancer recurrence. Perioperative immunonutrition with arginine-enhanced diets has been found...

Impact of Perioperative Immunonutrition on Postoperative Outcomes in Patients with Upper Gastrointestinal Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

There is no consensus on the efficacy of perioperative immunonutrition in patients with upper gastrointestinal (GI) cancer surgery. We clarified the impact of perioperative immunonutrition on postoperative outcomes in patients with upper GI cancers. We searched MEDLINE (PubMed), MEDLINE (OVID), EMBASE, Cochrane Central Register of Controlled Trials, Web of Science Core Selection, and Emcare from 1981-2022 using search terms related to immunonutrition and upper GI cancer. We included randomized controlled trials. Intervention was defined as immunonutritional therapy, including arginine, n-3 omega fatty acids, or glutamine during the perioperative period. The control was defined as standard nutritional therapy. The primary outcomes were infectious complications, defined as events with a Clavien-Dindo classification grade ≥ II that occurred within 30 days after surgery. After screening, 23 studies were included in the qualitative synthesis and in the quantitative synthesis. The meta-analysis showed that immunonutrition reduced infectious complications (relative risk ratio: 0.72; 95% confidence interval: 0.57-0.92; certainty of evidence: Moderate) compared with standard nutritional therapy. In conclusion, nutritional intervention with perioperative immunonutrition in patients with upper GI cancers significantly reduced infectious complications. The effect of immunonutrition for upper GI cancers in reducing the risk of infectious complications was about 30%.

EFFECTS OF NUTRITION STATUS AND PERIOPERATIVE NUTRITION SUPPLEMENT COMPLETION ON POSTOPERATIVE OUTCOMES IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE UNDERGOING SURGERY

Abstract BACKGROUND Malnutrition is common in inflammatory bowel disease, (IBD) and is associated with poor disease activity, greater hospital length of stay (LOS), higher 30-day readmission rates, and increased risk of postoperative complications. Structured, multimodal prehabilitation including nutrition counseling improves various outcomes after elective cancer and orthopedic surgeries. We examined the effects of malnutrition and perioperative nutrition supplementation on surgical outcomes in IBD patients participating in a multimodal prehabilitation program. METHODS This was a retrospective study of patients aged 18-80 enrolled in a 10-week prehabilitation program undergoing surgery for IBD. Beginning 4 weeks prior to surgery, patients met with a multidisciplinary team including a nurse practitioner, physical therapist and registered dietitian. Patients were provided 3 preoperative carbohydrate loading oral nutrition supplements (ONS) 48 hours prior to surgery, and 20 perioperative immunonutrition ONS. Malnutrition was defined using the Global Leadership in Malnutrition criteria as moderate or severe. We used Fisher’s exact test to determine associations between malnutrition, ONS use, and postoperative complications (defined by the comprehensive complication index (CCI, with CCI scores &amp;gt;20 classified as severe)), and 30-day readmission. Logistic and linear regression were used to analyze length of stay (LOS), opioid use (defined as morphine milligram equivalents, MME), nutrition status, and ONS completion. RESULTS 25 patients (48% female, mean age 44, 18 (72%) with Crohn’s disease) completed the prehabilitation program between 05/2022 and 10/2023. 10 patients (40%) met criteria for malnutrition (of these, 50% were moderate and 50% severe). Malnutrition was not significantly associated with CCI severity (p=0.07), LOS (p =0.07), opioid use (p=0.07) or 30 day readmission rates (0.06). Higher ONS use for carbohydrate loading and immunonutrition were more likely to have a LOS&amp;lt;5 days (p=0.05 and p=0.03 respectively). CONCLUSION ONS for preoperative carbohydrate loading and perioperative immunonutrition may shorten LOS after surgery among patients with IBD. In our study, higher amounts of ONS consumption led to a shorter LOS. Larger, controlled studies will help to further clarify the effects of malnutrition, carbohydrate loading, and immunonutrition among patients with IBD preparing for surgery.

MULTIMODAL PREHABILITATION MAY IMPROVE SURGICAL OUTCOMES FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract BACKGROUND Surgery is associated with loss of lean body mass and physical deconditioning, which can delay healing and lead to complications. Multimodal prehabilitation (PH) with nutrition optimization and physical therapy improves outcomes after cancer surgery. However, the effects of prehabilitation for inflammatory bowel disease (IBD) surgery are not established. We aimed to assess surgical outcomes among IBD patients exposed to prehabilitation relative to no prehabilitation. METHODS We conducted a case-controlled study of the impact of prehabilitation in patients with IBD who underwent major abdominal surgery for Crohn’s disease (CD) or ulcerative colitis (UC) between May 1st, 2022 and June 6th, 2023 at a tertiary care center. Cases were defined as those who participated in a multimodal PH program that included nutrition counseling (weight optimization, preoperative carbohydrate loading and perioperative immunonutrition), medication management, physical therapy, and psychosocial evaluation beginning 4 weeks prior to surgery; controls received standard of care (SOC) written preoperative surgical instructions without PH. We assessed postoperative complications (defined by the comprehensive complications index (CCI)), severe complications (CCI&amp;gt;20), reoperation rate, 30-day readmission, post operative length of stay (LOS) and post-operative opioid use (defined by daily morphine milligram equivalents (MME)). Statistical tests included linear and logistic regression, Mann-Whitney U test, Chi-Square test, and Fisher’s exact test, as appropriate. RESULTS A total of 68 patients were identified, including 20 PH (cases) and 48 SOC (controls). Among PH, 75% had CD with the remainder UC; surgeries included ileocecal resection (45%), colectomy with ileostomy (25%), ileal pouch-anal anastomosis (25%), and small bowel resection (5%). Among SOC, 31% had CD with the remainder UC, and surgeries included colectomy with ileostomy (60%), stage 2 IPAA (29%), and small bowel (6%) or ileal (4%) resections. Age, sex, race, and ethnicity was similar between groups. Overall and severe complication rates were similar between PH and SOC (mean CCI scores 13.42 PH vs 11.25 SOC (p = 0.58), and CCI &amp;gt; 20 in 40% PH patients vs 29% SOC (p = 0.56)). Median post-operative LOS was shorter among PH vs SOC (3.0 vs 3.5d, p=0.02), and median post-operative opioid use was lower among PH vs SOC (19.5 vs 20.8 MME, p = 0.04). Readmission within 30 days occurred in 30% of PH and 17% of SOC (p = 0.22). Reoperation within 30 days occurred in 5% of PH and 17% of SOC (p = 0.37). CONCLUSION: Multimodal prehabilitation may improve select surgical outcomes in IBD, including length of stay and opioid use after surgery. Larger, prospective, controlled studies may help to further clarify the impact of PH on surgical outcomes for IBD, including complications, readmissions, and functional status. Table 1. Patient Characteristics and Outcomes by Prehabilitation Exposure Status

Impact of Perioperative Immunonutrition on Postoperative Outcomes for Patients Undergoing Head and Neck or Gastrointestinal Cancer Surgeries: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

To clarify whether perioperative immunonutrition is effective in adult patients with or without malnutrition undergoing elective surgery for head and neck (HAN) or gastrointestinal (GI) cancers. It is important to avoid postoperative complications in patients with cancer as they can compromise clinical outcomes. There is no consensus on the efficacy of perioperative immunonutrition in patients with or without malnutrition undergoing HAN or GI cancer surgery. We searched MEDLINE (PubMed), MEDLINE (OVID), EMBASE, Cochrane Central Register of Controlled Trials, Web of Science Core Selection, and Emcare from 1981 to 2022 using search terms related to immunonutrition and HAN or GI cancer. We included randomized controlled trials. Intervention was defined as immunonutritional therapy including arginine, n-3 omega fatty acids, or glutamine during the perioperative period. The control was defined as standard nutritional therapy. The primary outcomes were total postoperative and infectious complications, defined as events with a Clavien-Dindo classification grade ≥ II that occurred within 30 days after surgery. Of the 4825 patients from 48 included studies, 19 had upper GI cancer, 9 had lower, and 8 had mixed cancer, whereas 12 had HAN cancers. Immunonutrition reduced the total postoperative complications (relative risk ratio: 0.78; 95% CI, 0.66-0.93; certainty of evidence: high) and infectious complications (relative risk ratio: 0.71; 95% CI, 0.61-0.82; certainty of evidence: high) compared with standard nutritional therapy. Nutritional intervention with perioperative immunonutrition in patients with HAN and GI cancers significantly reduced total postoperative complications and infectious complications.

The Impact of Peri-operative Enteral Immunonutrition on Post-operative Complications in Gastrointestinal Cancer Surgery: A Meta-Analysis.

Immunonutrition (IMN) in gastrointestinal (GI) cancer surgery remains under-utilised and contentious. Despite previous meta-analysis reporting benefit, most recent randomised control trials (RCTs) have failed to demonstrate this and have recommended against its routine use. A contemporary meta-analysis may contribute to the recommendations for immunonutrition use and help select which patients may benefit. The objective of this study was to review IMN and its impact on post-operative outcomes in GI cancer surgery, exploring its role in both malnourished and non-malnourished populations, the optimal dose to use, cancer type of patients using IMN and the timing of IMN relative to the peri-operative period. The EMBASE and Medline databases were searched from 2000 to 2022 for RCTs evaluating IMN in adults undergoing GI cancer surgery. Thirty-seven studies were included (22 pre-operative IMN studies, 11 peri-operative IMN trials and 9 post-operative IMN trials; 4 trials had multiple IMN protocols) that reported on 3793 patients. The main outcome of post-operative infectious complications was reduced with IMN [odds ratio (OR) 0.58, 95% confidence interval (CI) 0.47-0.72]. This association was significant in subgroup analysis only with pre-operative and peri-operative administration and in trials including upper GI cancers, colorectal cancer and 'mixed GI' cancer populations, and significance was independent of nutritional status. IMN in pooled analysis reduced surgical site infection (SSI) (OR 0.65, 95% CI 0.52-0.81), anastomotic leak (OR 0.67, 95% CI 0.47-0.93) and length of stay (LOS) by 1.94 days (95% CI -3 to -0.87). Immunonutrition was associated with reduced post-operative complications. Peri-operative administration may be the preferred strategy in reducing infectious complications, anastomotic leak, SSI and LOS.

Impact of Preoperative Immunonutrition on Oxidative Stress and Gut Barrier Function in Surgical Patients with Crohn's Disease.

Several international guidelines recommend a peri-operative immunonutrition (IN) support for patients care in elective colorectal surgery, to reduce postoperative complications, particularly infections. In Crohn's patients, is also used to mitigate the severity of the disease. We performed a pilot study on 16 Crohn's patients undergoing intestinal surgery for active disease, not responsive to pharmacological treatment; half of them received an oral nutritional supplement enriched with immunonutrients (IN patients) for 7 days prior to surgery, in addition to normal food intake. Markers of oxidative stress (Advanced Glycated End-products (AGEs) and Advanced Oxidation Protein Products (AOPPs) were measured both in plasma and tissue samples wherein the Receptor for Advanced Glycation End products (RAGE) and Tight Junction Protein 1 (TJP1) gene expression were also determined. Plasma AGEs were significantly and positively correlated with tissue levels of AGEs (p = 0.0354) and AOPPs (p = 0.0043) while they were negatively correlated with TJP1 expression (p = 0.0159). The expression of RAGE was also negatively correlated with that of TJP1 gene (p = 0.0146). IN patients exhibited significantly lower AGEs plasma levels (p = 0.0321) and a higher mucosal TJP1 expression (p = 0.0182). No patient had postoperative complications and the length of hospital stay was similar in the two groups, but IN patients, showed a significantly shorter time to resume fluid and solid diet. These preliminary data suggest that IN might support patient's recovery by improving intestinal mucosa barrier function through the regulation of AGEs/RAGE signaling.

Perioperative Nutritional Considerations in Colon and Rectal Surgery.

Malnutrition is common in surgical patients and is associated with substantially increased morbidity and mortality. Dedicated assessment of nutritional status is advised by major nutrition and surgical societies. Assessment may utilize comprehensive and validated nutritional assessment tools or targeted history, physical examination with accompanying serologic markers to identify nutritional risk preoperatively. Emergent surgery in malnourished patients should proceed as the clinical situation dictates with consideration of ostomy or primary anastomosis with proximal fecal diversion to mitigate postoperative infectious complications. Nonemergent surgery should be delayed to facilitate nutritional optimization via oral nutritional supplementation preferably and total parenteral nutrition if necessary for at least 7 to 14 days. Exclusive enteral nutrition may be considered to optimize nutritional status and inflammation in patients with Crohn's disease. Immunonutrition use in the preoperative setting is not supported by evidence. Perioperative and postoperative immunonutrition may be of benefit but requires dedicated study in the contemporary era. Close attention to preoperative nutritional status and optimization represents a critical opportunity to improve outcomes in patients undergoing colorectal surgery.

Immunonutrition of perioperative therapy for colorectal cancer

Abstract Immunonutrition, a modified nutritional formula that involves the addition of glutamine, arginine, omega-3 fatty acids, nucleotides, and other potential compounds to the diet, has proven its potential for use in immunomodulation and protein metabolism improvement. Its clinical benefits include shortening hospital stays and lowering surgical infectious complications in upper gastrointestinal surgery. However, the use of perioperative immunonutrition is rare among colorectal cancer patients undergoing surgical intervention. Colorectal cancer is one of the most common cancers around the world, but its malnutrition rate is not high in comparison with other cancers (eg, gastric cancer or esophageal cancer). Furthermore, the surgical modality for the majority of colorectal cancer patients involves minimal invasive surgery (MIS), which enhances recovery speed. It is an interesting clinical question whether or not perioperative immunonutrition supplementation for colorectal cancer patients undergoing MIS causes extraclinical impacts. The immunomodulation effect of CD4+ T cells has been proven in colorectal patients undergoing elective surgery. In recent years, there have been several prospective randomized studies elucidating the clinical effects of immunonutrition on colorectal cancer patients undergoing surgery in Western countries. These studies have generally found that perioperative immunonutrition was associated with a lower rate of surgical infectious complications even in normo-nourished patients undergoing MIS. The use of perioperative immunonutrition provides clinical benefits according to high-quality studies. However, most results come from Western countries, and its effect needs to be validated in Asian countries.

Randomized Controlled Trial Investigating Perioperative Immunonutrition for Patients Undergoing Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Immunonutrition has been shown to reduce hospital stay and postoperative morbidity in patients undergoing gastrointestinal, and head and neck surgery. However, its use has not been demonstrated in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). This study aims to determine the effectiveness of perioperative immunonutrition on patients undergoing CRS-HIPEC in reducing length of hospitalization and postoperative complications. From April 2017 to December 2018, patients undergoing CRS-HIPEC for peritoneal metastases in a single center were enrolled in a randomized controlled trial. Patients with evidence of intestinal obstruction or with diabetes mellitus were excluded. Patients were randomly assigned in a 1:1 fashion to receive perioperative oral immunonutrition or standard nutritional feeds. Length of hospital stay and rates of wound infection and complications were recorded and compared between the two groups in an intention-to-treat manner. A total of 62 patients were recruited and randomized into two groups. Compliance to nutritional feeds in the preoperative period was significantly higher in the standard nutrition group (95.2% versus 75.4%, p = 0.004). There was no difference in postoperative compliance rates. Length of hospital stay and rates of wound infection and postoperative complications were higher in the standard nutrition group when compared with patients on immunonutrition (15.5 versus 11.1 days, p = 0.186; 19% versus 9.7%, p = 0.473; 16% versus 9.7%, p = 0.653; respectively). Patients undergoing CRS-HIPEC who received perioperative immunonutrition had shorter hospitalization and less wound infections and postoperative complications, although the differences with the standard nutrition group were not statistically significant. Potential benefits of perioperative immunonutrition need to be further evaluated in larger studies.

SP5.2.9 Perioperative immunonutrition in reducing the infectious complications in patients undergoing colorectal cancer resections: a meta-analysis of randomized controlled trials

Abstract Objective Perioperative nutritional interventions have been reported to improve colorectal rectal cancer surgery outcomes. The objective of this article is to assess the influences of immunonutrition intervention during perioperative period in patients undergoing colorectal cancer resections. Method Meta-analysis was conducted according to the PRISMA guidelines. Systematic search of medical databases like MEBASE, MEDLINE and pubmed was performed to find studies exclusively reporting the perioperative use of immunonutrition in patients undergoing colorectal cancer resections and relevant published randomized, controlled trials (RCT) were shortlisted according to the inclusion criteria. The analysis of the pooled data was done using the RevMan statistical software. Result Ten RCTs on 1218 patients with colorectal cancer fulfilled the inclusion criteria. In the random effects model analysis, the use of perioperative immunonutrition in patients undergoing colorectal cancer resections statistically reduced the risk [odds ratio 0.59, 95% CI (0.35–1.0), z= 1.96, p=0.05] of infectious complications. However, there was significant heterogeneity [Tau2 = 0.35; Chi2= 19.11, df = 9 (P &amp;lt; 0.02; I2 = 53%)] among included studies. The variables of postoperative mortality [odds ratio 2.1, 95% CI (0.33–12.36), z= 0.75, p=0.45] and length of hospitalization [standardized mean difference 0.16, 95% CI (-0.08–0.39), z= 1.31, p=0.19] were statistically similar in patients using immunonutrition or standard conventional perioperative nutrition. Conclusion Perioperative immunonutrition in patients undergoing colorectal resections seems to reduce infectious complications but this study failed to demonstrate its role in reducing the postoperative mortality and length of hospitalization.

Immunonutrition reduces complications rate and length of stay after laparoscopic total gastrectomy: a single unit retrospective study

BackgroundPreoperative immunonutrition (IN) reduces the incidence of postoperative complications in malnourished patients undergoing upper gastrointestinal surgery. However, its effect in norm-nourished patients remains unclear. Furthermore, patients with gastric cancer undergoing laparoscopic total gastrectomy (LTG) are not routinely included in protocols of enhanced recovery after surgery (ERAS).ObjectiveThe aim of this study was to investigate the effects of perioperative IN in patients undergoing laparoscopic total gastrectomy (LTG) within an established ERAS pathway.MethodsA comparative retrospective study of patients undergoing LTG, receiving an immune-enhancing feed plus maltodextrin load the day of surgery (Group A) versus patients who had the same operation but no IN nor fast track management (group B).ResultsThere were no significant differences in patient demographic characteristics between the two groups but the medium age of patients in group A was older. Thirty-days postoperative complications were respectively 8.7% in Group A and 33.3% in Group B (p 0.04). Mean and median LOS for Group A and B were also significantly different: 7.2 ± 4.4 vs 10.3 ± 5.4 and 7 vs 10 days respectively.ConclusionPreoperative IN associated with ERAS protocol in normo-nourished patient undergoing LTG seems to reduce postoperative complications. Reduction in LOS is possibly associated to the ERAS protocol.Clinical trial registration Clinical trials.gov: NCT05259488

The impact of immunomodulatory enteral nutrition on patients submitted to elective gastrointestinal cancer surgery: integrative review

Objective: To carry out a review about the use of enteral nutrition composed of immunonutrients in cancer patients undergoing elective surgery in the gastrointestinal tract on surgical outcomes. Methods: The research was carried out in the Medline, Lilacs and Pubmed databases. Results: The administration of enteral diet in both groups was well tolerated, there was no significant difference in the mortality rate and in the Intensive Care Unit or postoperative hospital stay. The immunomodulatory nutritional therapy was favorable to decrease the TNFα values and increase the total lymphocyte count in the postoperative period. Perioperative enteral immunonutrition has no significant effects on mortality rate, length of hospital stay and complications in gastrointestinal tract surgeries. Final considerations: Immunonutrition appears to be promising in terms of modulating the immune response. More randomized studies are needed regarding the effects of immunonutrients on abdominal surgical cancer patients.

Umbrella review of the efficacy of perioperative immunonutrition in visceral surgery.

Immunonutrition (IN) is used in major visceral surgery to reduce postoperative complications. This umbrella review (review of reviews) collects and analyses data on the efficacy of perioperative IN. The review was conducted in accordance with PRISMA 2020 guidelines. Inclusion criteria were meta-analyses comparing IN with normal diet or isocaloric isonitrogenous feeding. The primary outcome was infectious complications. Secondary outcomes were overall morbidity, hospital length of stay and mortality. Methodological quality was evaluated using AMSTAR-2. Overlap and certainty of evidence (GRADE) were assessed. Twenty meta-analyses (MAs) were included in the umbrella review: eleven on various abdominal surgeries (one MA was considered twice) and eight on pancreatic, oesophageal, hepatic, or colorectal surgeries. Overall, IN was associated with significantly fewer postoperative infectious complications (OR 0.60 [0.54-0.65], random effect model) but with substantial heterogeneity (I2=64%), and less postoperative morbidity (OR 0.78 [0.74-0.81], I2=30.3%). Excluding three MAs with heterogeneity did not alter the results. The overlap between the MAs was slight, with a corrected covered area of 0.13. There was no significant difference in the timing of IN (preoperative, postoperative or perioperative). This umbrella review confirms the beneficial effect of IN in visceral surgery. Some practical questions remain unanswered: optimal timing of IN, in which surgical speciality it is best used, and its utility in enhanced recovery programmes. CRD42021255177.

Perioperative enteral immunonutrition with probiotics favors the nutritional, inflammatory, and functional statuses in digestive system surgery.

This study aimed to evaluate the effects of enteral immunonutrition (EIN) on the nutritional status of patients during the perioperative period of digestive system surgery. The clinical data of 102 patients who underwent gastrointestinal surgery between August 2017 and February 2021 were retrospectively analyzed. According to the nutritional support regimen, the patients were divided into an enteral nutrition (EN) group (50 patients) and an EIN group (52 patients). The times (in hours) to return of the first bowel sound, first postoperative flatus, and first bowel movement, as well as the length of postoperative hospital stay were shorter in the EIN group than in the EN group (p<0.05). The concentrations of hemoglobin, prealbumin, albumin, and transferrin, as well as the concentrations of immunoglobulin A (IgA), immunoglobulin G (IgG), immunoglobulin M (IgM), complement C3, and complement C4 were higher in the EIN group than in the EN group at 1 and 7 days after surgery (p<0.05). The concentrations of endotoxins, D-lactic acid, and diamine oxidase were lower in the EIN group than in the EN group (p<0.05). The tolerance to enteral feeding was better in the EIN group than in the EN group (p<0.05). The incidence of complications was lower in the EIN group (5.77%) than in the EN group (10.0%) (p>0.05). EIN can promote gastrointestinal function recovery, improve the nutritional status, enhance the humoral immune function, regulate intestinal flora balance, improve intestinal permeability, prevent enteral feeding intolerance, and reduce complications in patients undergoing surgery for digestive system diseases.

Impact of perioperative enteral immunonutrition in patients with gastrointestinal cancer undergoing elective surgery: a randomized controlled trial

Rationale: Major cancer surgery poses a significant risk to patient’s nutritional intake, especially among gastrointestinal cancer patients. Patients are often at high risk of a remarkable weight loss and impaired functional capacity after surgery. The aim of our study is to investigate the effects of two immune-modulating formulas on nutritional status and functional capacities in patients undergoing elective surgery.

The effect of perioperative immunonutrition on surgical complications and quality of life in patients with head and neck cancer

Rationale: This intervention study, which was planned as a prospective randomized controlled, was conducted to compare the effects of perioperative nutritional support with immunonutrition and standard enteral products on postoperative complications and quality of life in patients with head and neck cancer ( HNC ).

Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States.

Malnutrition, particularly under-nutrition, is highly prevalent among adult patients with a diagnosis of gastrointestinal (GI) cancer and negatively affects patient outcomes. Malnutrition is associated with clinical and surgical complications for patients undergoing therapy for GI cancers and the costs associated with those complications is a high burden for the US health system. Our objective was to identify high-quality evidence for nutrition support interventions associated with cost savings for patient care, followed by a complex economic value analysis to project cost savings for the US health system. A narrative literature search was conducted in which combined keywords in the areas of therapeutic nutrition (nutrition, malnutrition), a specific therapeutic area [GI cancer (esophageal, gastric, gallbladder, pancreatic, liver/hepatic, small and large intestine, colorectal)], and clinical outcomes and healthcare cost, to look for nutrition interventions that could significantly improve clinical outcomes. Medicare claims data were then analyzed using the findings of these identified studies and this modeling exercise supported identifying the cost and healthcare resource utilization implications of specific populations to determine the impact of nutrition support on reducing these costs as reflected in the summary of the evidence. Eight studies were found that provided clinical outcomes and health cost savings data, 2 of those had the strongest level of evidence and were used for Value Analysis calculations. Nutrition interventions such as oral diet modifications, enteral nutrition (EN) supplementation, and parenteral nutrition (PN) have been studied especially in the peri-operative setting. Specifically, peri-operative immunonutrition administration and utilization of enhanced recovery pathways after surgery have been associated with significant improvement in postoperative complications and decreased length of hospital stay (LOS). Utilizing economic modeling of Medicare claims data from GI cancer patients, potential annual cost savings of $242 million were projected by the widespread adoption of these interventions. Clinical outcomes can be improved with the use of nutrition interventions in patients with GI cancers. Healthcare costs can be reduced as a result of fewer in-hospital complications and shorter lengths of hospital stay. The application of nutrition intervention provides a positive clinical and economic value proposition to the healthcare system for patients with GI cancers.

Enteral immunonutrition versus enteral nutrition for patients undergoing esophagectomy: a randomized controlled trial.

In recent years, immunonutrition has been introduced and proposed to have a positive modulatory effect on inflammatory and immune responses and gut function for surgical patients, especially for patients undergoing gastrointestinal cancer resection. We conducted this parallel-group, randomized and double-blind clinical controlled trial to investigate the efficacy of perioperative enteral immunonutrition (EIN) on clinical and immunological outcomes of patients undergoing esophageal resection. A randomized, parallel-group, double-blind, clinical trial was conducted between December 1, 2017 and March 1, 2018. This study enrolled 120 patients with esophageal cancer. And 112 patients were divided into two groups randomly: EIN group and enteral nutrition (EN) group. The EIN contained extra immunonutritional substrates, including a consistent combination of arginine, RNA and the omega-3 fatty acids compared with EN. Immune indicators were measured at preoperative day 7, postoperative day (POD) 1, 3, 7 and post-discharge day (PDD) 30. There were 56 participants randomized to each group. Finally, 53 patients in EIN and 50 patients in EN were analyzed. Immune indicator was the primary outcome in this study. EIN yielded a significantly lower rate of CD8/CD3 (%) at POD 3 compared with EN group (P=0.005). The rate of CD4/CD8 (%) in EIN group was higher than that in EN group at POD3 (P=0.004). The serum levels of IgM at POD 3 and 7 were significantly higher in EN group compared with EIN group (P=0.025 and P=0.009, respectively). The rate of NK (%) and the serum level of IgA were significantly higher in EIN group compared with EN group at PDD 30 (P=0.022 and P=0.041, respectively). No significant differences were found in 2-year progressionfree survival and overall survival. Immunonutrition is a safe and feasible nutritional treatment, which has a positive modulatory impact on immune responses after esophagectomy. Although no significant difference was found in clinical and survival outcomes between EIN and EN groups, immunonutrition could still have a positive effect on immunological function of patients undergoing esophagectomy.