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

INTRODUCTION: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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. REGISTRATION IN PROSPERO: CRD42021255177.

Six-month outcomes of teduglutide treatment in adult patients with short bowel syndrome with chronic intestinal failure: A real-world French observational cohort study.

BACKGROUND & AIMS: Teduglutide, a GLP-2-analog, has proven effective in two placebo-controlled studies in reducing parenteral support (PS) in patients with short bowel syndrome-associated intestinal failure (SBS-IF) after 24 weeks. The aim of this study was to describe in a real-life situation the effects of teduglutide treatment and their predictive factors. METHODS: We included 54 consecutive SBS-IF patients treated with teduglutide in France for at least 6 months from 10 expert centers. Small bowel length was 62 ± 6 cm and 65% had colon in continuity. PS was 4.4 ±0 .2 infusions per week, started 9.8 ± 1.2 years before. Response (PS reduction ≥ 20%) and PS discontinuation rates were assessed at week 24. Adjusted p values of factors associated with response and weaning were calculated using a multivariate logistic regression model. RESULTS: At week 24, 85% of patients were responders and 24% had been weaned off PS, with a 51% reduction of PS needs and 1.5 ± 0.2 days off PS per week. Response to teduglutide was influenced by a higher baseline oral intake (p = 0.02). Weaning off PS was influenced by the presence of colon (p = 0.04), a lower PS volume (p = 0.03) and a higher oral intake (p = 0.01). There were no differences based on age, bowel length or SBS-IF causes. CONCLUSIONS: Our study confirms the effectiveness of teduglutide in reducing PS needs in SBS-IF patients. We associated reduced parenteral support volume with baseline parenteral volume support, bowel anatomy, and oral intake. These findings underline the role of nutritional optimization when starting the treatment.

Home parenteral nutrition (HPN) in patients with post-bariatric surgery complications.

BACKGROUND & AIMS: Obesity is a worldwide health problem. Bariatric surgery (BS) is becoming one of the most commonly used methods for fighting obesity and its associated comorbidities. However, current BS techniques can be associated with early or late complications that may require nutritional support. The aim of this retrospective observational study was to determine the indications and outcomes for patients on Home parenteral nutrition (HPN) due to post-bariatric surgery complications. METHODS: A specific questionnaire was designed by the ESPEN HAN/CIF working group and submitted to HPN centers. This questionnaire included: patient demographics, type of surgery, BMI before surgery and at start of HPN, indications for HPN including technical and nutritional complications (early within 2 months after surgery or late), outcome, PN regimen, and HPN complications. Patients were retrospectively included from January 2008 to June 2014. RESULTS: Eighteen HPN centers responded to the survey. A total of 2880 HPN patients were treated during the study period, 77 of whom had BS (65 females; mean age 51 ± 7 years); gastric bypass was performed in 69% of the patients; mean BMI was 44.4 before surgery and 23.2 at the start of HPN. Indications for HPN were early complications in 17 cases and late complications in 60 cases. Early complications were mostly anastomotic leakage/fistula; late complications were hypoalbuminemia, and vitamin and trace element deficiencies. Out of 77 patients, 16 needed a surgical re-intervention, 29 were weaned off HPN, and 6 died (no HPN-related deaths). During the HPN period, 58% of the patients were re-hospitalized and central venous complications were observed in 41%. Diabetes mellitus was described in 17/77 patients. HPN was supportive in 60 patients and exclusive in 17 patients (mean caloric intake: 23 ± 6 kcal/k BW/day and 1.2 g/kBW/day). Only 7/77 patients resumed their professional activities on HPN. CONCLUSIONS: This is the largest observational multicenter study describing the use of HPN in patients with post-BS complications. Severe hypoalbuminemia is a major late complication. Rates of re-hospitalization and CVC infection were high. HPN may be a "bridge therapy" before surgical revision after BS. The high mortality rate reflects the complexity of these cases.

Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study.

PURPOSE: Malnutrition is a predictor of poor outcomes in patients with cancer. Little is known about the benefit of nutritional support in these patients. The purpose of this study was to assess the impact of home parenteral nutrition (HPN) on quality of life (Qol) in cancer patients. METHODS: We performed an observational prospective study to determine the impact of HPN on Qol in a population of patients with heterogeneous cancer. Physicians, patients and family members had to complete a questionnaire before HPN administration and 28 days after the course of HPN. Qol was evaluated using the self-administered questionnaire FACT-G. RESULTS: We included 767 patients with cancer of whom 437 ended the study. Mean patient age was 63±11.4 years and 60.5% were men. Primary gastrointestinal cancer was reported in 50% of patients and 65.3% were presenting metastases. Malnutrition was reported in 98.3%. After 28 days of HPN intake, significant improvement was observed in the Qol (49.95±5.82 vs. 48.35±5.01 at baseline, p<0.0001). The mean weight, serum albumin and the nutrition risk index had also improved significantly. Most patients (78%) had perceived a positive impact of the HPN. A significant improvement in patient's well-being was perceived also by family members and physicians. CONCLUSIONS: Our data suggest that preventing and correcting malnutrition using HPN in patients with cancer might have a significant benefit on their well-being. Randomized controlled studies are required to confirm this finding.

Is diabetes a risk factor for central venous access port-related bloodstream infection in oncological patients?

It was a dogma that patients with diabetes mellitus (DM) are at increased risk of infection or death associated with an infection. However, in cancer patients, this has not been well investigated. The aim was to investigate whether diabetic patients with cancer are at high risk of central venous access port (CVAP)-related bloodstream infection (BSI), and to analyse mortality after CVAP-BSI. A total of 17 patients with type 1 DM (T1DM), 66 with type 2 DM (T2DM) and 307 non-diabetic patients were included. Each patient was followed up until the first late CVAP-BSI or for a maximum for 1 year in the absence of a CVAP-BSI. Fifty-three CVAP-BSIs occurred in 66,528 catheter-days. The cumulative incidence of CVAP-BSI was not higher in T1DM (5.9 %; p = 0.17) and T2DM (19.7 %; p = 0.70) compared with the non-diabetic patients (12.7 %). However, in patients with CVAP-BSI, the 1-month crude mortality rate was higher in DM patients (42.9 % vs. 15.4 %; p = 0.04), whereas the mortality in patients without CVAP-BSI was similar in both groups of patients (19.8 % vs. 17.1 %; p = 0.58). Of the 12 deaths that occurred within 1 month of CVAP-BSI, 16.66 % was attributable to CVAP-BSI. The predictive factor of 1-month mortality was DM (p = 0.04). Parenteral nutrition (PN) was independently associated with CVAP-BSI in diabetic patients (p = 0.001). In this study, diabetes did not increase the risk of CVAP-BSI, but mortality was higher in diabetic patients who had a CVAP-BSI. This suggests, in addition to medical treatment, CVAP should be withdrawn after infection onset.

French clinical guidelines on perioperative nutrition. Update of the 1994 consensus conference on perioperative artificial nutrition for elective surgery in adults.

Surgical patient is a stressed patient. Aggression is more intense and prolonged as surgery is important. Surgery induces secretion of stress hormones, inflammatory mediators and metabolic changes resulting in significant catabolic phenomena. The presence of malnutrition is an independent risk factor for postoperative complications. Malnutrition increases morbidity (infections, delayed healing), mortality, length of stay and costs and impacts human quality of life for patients. It has been shown that the management of perioperative malnutrition reduces the additional risk generated by it. Perioperative nutritional support should not be systematically provided. Since 1994, recommendations on perioperative nutrition, the care of patients and the available resources have changed dramatically. An update of these recommendations was needed. In 2010, an expert panel of the French society of Anesthesiology (SFAR) and the French-speaking society of Clinical Nutrition and Metabolism (SFNEP) has made recommendations for good clinical practice of perioperative nutrition. They are presented. Thus, the perioperative nutritional management must be integrated in a process to reduce the operative risk: risk reduction due to preoperative malnutrition, reduced risk of postoperative malnutrition which may compromise the following treatments, reduction of postoperative metabolic complications, reducing the postoperative morbidity, especially infectious, through the use of pharmaconutrients either preoperatively or postoperatively in some patients.

[Nutritional assessment of patients before surgery]. / Évaluation nutritionnelle à la consultation d'anesthésie.

The identification of nutritional status is one of the objectives of the anaesthesia consultation often difficult to achieve routinely. It usually requires the use of multiple indicators, which are complex for a non-nutrition specialist. In preoperative period, nutritional assessment should be easy to do in order to identify patients who are malnourished or at risk of malnutrition and relevant information about nutritional risk should be registered in the patient chart. To facilitate this evaluation, we propose a stratification of nutritional risk in four grades (NG) using three types of simple and validated parameters: preoperative nutritional status (BMI, weight loss, eventually serum albumin), comorbidities and kind of surgery. This stratification can develop a tailored nutritional care for each patient.

Crohn's disease patients with chronic intestinal failure receiving long-term parenteral nutrition: a cross-national adult study.

BACKGROUND: Chronic intestinal failure (CIF) is a very rare Crohn's disease (CD) complication. AIM: To determine incidence of CIF treated with home parenteral nutrition (HPN) in adult CD patients and to isolate factors associated with severe CIF. METHODS: This retrospective multicentre study included 38 patients with CD-related CIF treated with HPN for at least 12 months in French HPN centres. Severe CIF was defined by a length of remnant small bowel of less than 100 cm or CIF occurrence within the 15 years following CD diagnosis. RESULTS: Median delay between CD diagnosis and CIF was 15 years. CIF incidence did not decrease over time (1.4/year before 1995 vs. 2.2/year after). Median number of small bowel resections per patient was three (range 1-8). Median small bowel resection, remnant and initial lengths were 160, 80 and 260 cm, respectively. Twenty-four per cent of patients developed stenosis within 1 year after CD diagnosis and 76% developed perforative complications within 2 years. In multivariate analysis, severe CIF, defined as CIF onset <15 years after CD diagnosis, was associated with a more recent CD diagnosis (odds ratio, 0.785; 95% confidence interval, 0.623-0.989). CIF occurred despite frequent use of immunosuppressants. Course of CD remained severe during HPN: immunosuppressants prescription occurred in 11 patients, surgery in six. Six patients died from CD (n = 2), HPN complications (n = 2) or other causes (n = 2). CONCLUSIONS: Chronic intestinal failure requiring HPN is rare during CD. Incidence remained stable over time. Surgical procedures play a minor role in the occurrence of severe chronic intestinal failure compared to CD severity.

[From the creation to the appreciation of a personal digital assistant-based clinical decision-support system for the management of artificial nutrition]. / De la conception à l'évaluation d'un programme d'aide à la prescription en nutrition artificielle sous Palm OS.

OBJECTIVES: The aim of our study was to assess the effect of NutriPDA, a personal digital assistant (PDA)-based clinical decision-support system (CDSS) for the management of artificial nutrition. A CDSS was developed and implemented on a handheld computer for use in the ICU after cardiovascular and thoracic surgery. STUDY DESIGN: System impact was assessed in a prospective "before/after" cohort trial. METHODS: After informed consent we studied 61 patients in the postcardiovascular and thoracic surgery ICU (age > 17 years, duration of artificial nutrition > 3 days, length of stay > 8 days). Patients were divided into two groups (before and after the use of NutriPDA: Group A: 32 patients (4-month period in 2005); group B: 29 patients (4-month period in 2006). RESULTS: There were no significant differences in anthropometric and clinical parameters between the 2 groups. Energetic intakes were < 80% of basal energetic expenditures in 21% and 1% of patients, respectively (P < 0.01). Caloric and nitrogen intakes were below international recommendation in Group A: 20+/-4 kcal/kg/d (mean+/-SD), 104+/-30 mg/kg/d, but not in Group B: 26+/-5 kcal/kg/d, 196+/-41 mg/kg/d (P < 0.01). CONCLUSION: NutriPDA was found to be able to optimize artificial nutrition by improving caloric intake in ICU. This new software has potential clinical applications.

[Impact of the guidelines on clinical practice of artificial nutrition in intensive care unit after cardiovascular and thoracic surgery]. / Impact d'un protocole de nutrition artificielle en réanimation après chirurgie cardiovasculaire et thoracique.

OBJECTIVE: To analyze the impact of an artificial nutrition program in post-anaesthesia intensive care unit. STUDY DESIGN: Observational study. PATIENTS AND METHODS: Patients with length of stay greater than 8 days after cardiovascular and thoracic surgery: Group 1: 34 patients (4-month period in 2000); group 2: 15 patients (2-month period in 2001); group 3: 40 patients (4-month period in 2003). Between these 3 periods, informations of physicians and written protocol in order to improve their nutritional knowledge. After analysis of variance (P<0.05). Newman-Keuls tests to compare themselves each groups. RESULTS: Anthropometric, demographic and clinical parameters were similar in the 3 groups. Energic intakes were less than 80% of basal energetic expenditures in 33%, 33 and 22% of patient, respectively (NS). Caloric and nitrogen intakes were less than recommended, respectively 19+/-6 (mean+/-SD), 21+/-7 and 21+/-8 kcal/kg/24 h and 102+/-32, 111+/-31 and 92+/-40 mg/kg/24 h (NS). However enteral nutrition was administered in 49, 40 and 100% of patients respectively (P<0.001). The glucid/lipid ratio improved from 0.47 in group 1 up to 0.68 in group 3 (P<0.0001). Vitamins, oligoelements and clinical and biological monitoring of artificial nutrition improved (P<0.001). CONCLUSION: A clinical audit demonstrated an improvement in artificial nutrition parameters but no significant change in others.

The expression of the p85alpha subunit of phosphatidylinositol 3-kinase is induced by activation of the peroxisome proliferator-activated receptor gamma in human adipocytes.

AIMS/HYPOTHESIS: Thiazolidinediones are new oral antidiabetic drugs that activate the nuclear receptor PPARgamma. Our aim was to identify potential target genes of PPARgamma in the human adipocyte in order to clarify how thiazolidinediones improve insulin sensitivity. METHODS: The effect of BRL 49653 (Rosiglitazone) on the mRNA expression of insulin receptor, insulin receptor substrate-1, p85alpha, p110alpha and p110beta subunits of phosphatidylinositol 3-kinase, Glut 4 and hormone sensitive lipase was examined in isolated adipocytes. Target mRNA levels were determined by RT-competitive PCR. RESULTS: The BRL 49653 (1 micromol/l) increased the mRNA concentrations of p85alphaPI-3 K (264 +/- 46 vs 161 +/- 31 amol/microg total RNA, p = 0.003) whithout affecting the expression of the other mRNAs of interest. This effect was dose-dependent (K0.5 = 5 nmol/l) and was reproduced by a specific activator of RXR, indicating that it was probably mediated by the PPARgamma/RXR heterodimer. The BRL 49653 also increased the amount of p85alphaPI-3K protein in adipose tissue explants (71 +/- 19%). In addition, BRL 49653 produced a more than twofold increase in insulin stimulation of phosphatidylinositol 3-kinase activity and significantly enhanced the antilipolytic action of insulin. CONCLUSION/INTERPRETATION: This work demonstrates that the gene of p85alphaPI-3K is probably a target of PPARgamma and that thiazolidinediones can improve insulin action in normal human adipocytes. Although the precise mechanism of action of BRL 49653 on PI3-Kinase activity is not completely clear, these findings improve our understanding of the insulin-sensitizing effects of the thiazolidinediones, possible drugs for the treatment of Type II (non-insulin-dependent) diabetes mellitus.

Medium- and long-chain triacylglycerols in postoperative patients: structured lipids versus a physical mixture.

Forty patients, scheduled for abdominal surgery, were randomized to receive postoperatively either a structured or a physical mixture of long-chain triacylglycerols/medium-chain triacylglycerols (LCT/MCT) emulsions to assess the tolerance and the effectiveness of the structured triacylglycerol emulsion. Total parenteral nutrition started the day after surgery and covered 100% of measured energy expenditure with nitrogen (0.2 g N.kg-1.d-1) and non-protein calories: glucose (50%) and lipids (50%). Blood samples for liver function tests, albumin, transthyretin, and triacylglycerols were checked at 0800 h on the day before surgery and on day 1, day 3, and day 6 after surgery. Urine samples were taken each day from day 1 to day 7 for 3-methylhistidine (3 Me His) and total nitrogen measurements. Aspartate transaminase (ASAT), alanine transaminase (ALAT), and triacylglycerol plasma levels in routine clinical biochemistry increased significantly in the physical mixture group. Nitrogen balance and 3 Me His excretion were not significantly different between groups. Structured triacylglycerol (STG) lipid emulsions are as efficacious as the physical mixture on nitrogen balance in postoperative patients. They could have some advantages: no disturbances were found to occur in liver function tests or plasma triacylglycerol levels.

[Economic impact of the consensus conference guidelines on postoperative artificial nutrition in the Rhone-Alps region]. / Impact économique des recommandations de la conférence de consensus sur la nutrition artificielle postopératoire en région Rhône-Alpes.

OBJECTIVES: To assess the economic impact of the French guidelines produced by the 1994 consensus conference on postoperative artificial nutrition (AN) in elective surgery. STUDY DESIGN: Multicentre before-after study, conducted on a cost-containment model from the hospital perspective. PATIENTS AND METHODS: Ten hospitals were randomly selected in the Rhône-Alpes area, after a stratification of hospital category. Twenty consecutive patients, who underwent upper and lower abdominal surgery in each hospital, were included over each study period. Data were collected on site by investigators from patients' records before (1994) and after (1995) guidelines had been circulated. The calculated costs were direct and partial medical and non medical staff costs of a one-day parenteral nutrition. They included nutrients, disposable devices, staff time and laboratory tests. RESULTS: Between 1994 and 1995, the study showed a 7.4% decrease in the postoperative prescription rate of AN, a 4.7% increase in the duration of AN and a 3.6% (FF 74.07 constant francs per patient) increase in the total cost of AN in surgical patients. Guidelines had mainly a positive impact in patients suffering from denutrition, as the duration of postoperative AN increased by 23.7% in this group, leading to a 65.1% (FF 175.53) increase in cost in 1995. CONCLUSIONS: The cost variable is a valuable indicator of the impact of practice guidelines, as it includes the rate and duration of prescriptions. The consensus conference had a significant impact in patients suffering from denutrition. Conversely, only minor changes in practices concerning patients non suffering from denutrition have been observed, leading to a slight cost increase in AN.

Effects of intraoperative glucose administration on circulating metabolites and nitrogen balance during prolonged surgery.

STUDY OBJECTIVES: To compare the effects of intraoperative administration of 2.5% glucose or Ringer's solution on metabolism during prolonged surgery. DESIGN: Prospective, randomized study. SETTING: Teaching hospital. PATIENTS: 20 ASA physical status I and II adults patients scheduled for thoracic or abdominal surgery lasting at least 3 hours. INTERVENTIONS: Patients received Ringer's solution (Group R) or 2.5% glucose solution (Group G) 10 ml.kg-1.h-1 during surgery and 2 ml.kg-1.h-1 during the first two postoperative hours (Ringer's or glucose), then 40 ml.kg-1.day-1 of 5% intravenous (i.v.) glucose postoperatively. MEASUREMENTS AND MAIN RESULTS: Plasma glucose, free fatty acids, ketone bodies, lactate, insulin, glucagon, cortisol, and growth hormone concentrations were determined after an overnight fast (T0), on induction of anesthesia (T1), at the end of surgery (T2), 2 hours thereafter (T3), and on the following morning (T4). Capillary blood glucose was determined every 30 minutes from T1 to T2. Urinary nitrogen and 3-methylhistidine were measured every day for 5 days. There were no differences between groups in demographic data, anesthesia, or surgical procedures. All data were comparable at baseline and on the following morning. In Group R, no patient experienced hypoglycemia, but plasma fatty acids and ketone bodies increased during surgery. In Group G, glycemia rose to very high levels, with a significant increase in insulin during surgery. Other hormones were the same within the two groups. Urinary nitrogen and 3-methylhistidine were similar in both groups. CONCLUSION: The absence of glucose infusion in prolonged surgery did not cause hypoglycemia, and no increase in protein catabolism was observed.

[A 1993-1995 epidemiological survey of home parenteral nutrition in approved centers for adults in France]. / Données épidémiologiques 1993-1995 de la nutrition parentérale à domicile en centres agréés chez l'adulte en France.

OBJECTIVES: A 1993-1995 three year epidemiological survey of home parenteral nutrition was performed through in France in approved centers for adults. METHODS: Data were retrospectively collected each year on a standardized questionnaire focussing on indications and short term outcome. RESULTS: All centers (n = 14) participated in the study and 524 new adult patients were recruited. The overall incidence was unchanged at 3.75 patients/10(6) adults. Indications for AIDS rose (8 to 18%) whereas other indications were stable. Prevalence increased by 19%: 4.40 adults/10(6) patients at 01.01.1996. At six months, the probability to stay on treatment was 19.5% for AIDS and cancer indications but 52% for others, whereas death rates were 59% and 9% respectively. CONCLUSIONS: For both cancer and AIDS indications, short-term treatment was due to a poor prognosis. For other diagnosis, complicated with a short bowel in 51% of cases, prognosis was excellent but associated with treatment dependency. The latter point focuses on the need for additional treatments in irreversible intestinal failure.

Perioperative artificial nutrition in elective surgery: an impact study of French guidelines.

OBJECTIVE: In France, the consensus conference, held on 16 December 1994, produced guidelines on perioperative artificial nutrition (AN) use in patients undergoing elective surgery. The aim of this study was to assess the impact of these guidelines on practice patterns. METHODS: The study was a practice pattern study with a 'before-after' design and a control group in England. A retrospective cross-sectional sample of adult patients undergoing elective resection of the digestive tract was collected in France and England before and after the consensus conference. RESULTS: Malnourished patients received postoperative AN in 94% of 'before' cases and 82% 'after' but inadequate preoperative AN (40% 'before' and 26% 'after'). Postoperative AN appeared to be over-prescribed in non-malnourished patients without prolonged postoperative fasting (70% 'before' and 65% 'after'). In the English sample there was no significant variation in AN use between 'before' and 'after' periods. CONCLUSION: This study shows that clinical guidelines disseminated by consensus conference had a low impact on practice patterns in France and thus confirms the need to enforce the dissemination of the guidelines.

Energy expenditure during allogeneic and autologous bone marrow transplantation.

Resting energy expenditure (REE) was measured by indirect calorimetry during allogeneic and autologous bone marrow transplantation in order to evaluate the evolution in allogeneic and autologous recipient patients. REE values obtained with indirect calorimetry and compared with values using the Harris-Benedict formula were different. Evolution of REE during aplasia were significantly different in autologous and allogeneic recipients with an increase 11.5 ' 10.8 cent for autologous and a decrease of - 7.3 ' 8.9 cent in allogeneic bone marrow transplantation (BMT) patients. There were no differences in nutritional status and REE before BMT, at discharge and 1 month after discharge between the two groups but all patients had inflicted damage on their nutritional status at discharge from hospital after BMT. However, these patients differed because of the decrease in oral nutritional intake and an increase in the length of aplasia and hospital stay in allogeneic patients. Currently, there is no proof that recommendations for nutritional interventions or results of nutritional investigations in allogeneic BMT can be extrapolated in autologous patients. Harris-Benedict formula does not estimate the energy expenditure of patients submitted to massive chemotherapy and BMT with enough precision because of the great differences in individuals.