Skip to main content
SpringerLink
Log in

Preoperative immunonutrition in frail patients with colorectal cancer: an intervention to improve postoperative outcomes

  • Original Article
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

The aim of this study is to evaluate whether preoperative immunonutrition can shorten length of stay and improve postoperative outcomes in frail patients who are candidates for major oncologic colorectal surgery.

Methods

A single center retrospective analysis of a prospectively collected database of frail patients, who underwent surgery with curative intent for colorectal cancer between January 2014 and December 2017, was performed. From March 2016, frail oncological patients undergoing major surgery were recommended to receive preoperative immunonutrition; their postoperative outcomes were compared to those of patients not treated with any preoperative nutritional support. Propensity score matching in a 1:1 ratio was used to balance patient characteristics.

Results

Overall, 175 patients were included in the study. Of 74 patients receiving immunonutrition, 65 were matched with the group not treated with immunonutrition (n = 101). Baseline characteristics were comparable after matching. Although differences in postoperative length of stay were nonsignificant (p = 0.38), patients who received immunonutrition showed a shorter gastrointestinal (GI) recovery time (3.00 [2.00–4.00] versus 4.00 [2.00–5.00], p = 0.04), a lower rate of situs site infections complications (0.31 [0.10, 0.94], p = 0.04) and less need of antibiotic treatment (0.19 [0.06, 0.64], p = 0.01).

Conclusion

Preoperative immunonutrition was found to reduce both postoperative situs site infections and need of antibiotic treatment during the postoperative course. This study encourages the use of preoperative immune-enhancing nutrition as a part of multimodal prehabilitation programs in the management of frail colorectal cancer patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K (2013) Frailty in elderly people. Lancet 381(9868):752–762. https://doi.org/10.1016/S0140-6736(12)62167-9

    Article  PubMed  Google Scholar 

  2. Ethun CG, Bilen MA, Jani AB, Maithel SK, Ogan K, Master VA (2017) Frailty and cancer: implications for oncology surgery, medical oncology, and radiation oncology. CA Cancer J Clin 67(5):362–377. https://doi.org/10.3322/caac.21406

    Article  PubMed  Google Scholar 

  3. Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M (2009) Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr 48(1):78–83. https://doi.org/10.1016/j.archger.2007.10.007

    Article  PubMed  Google Scholar 

  4. Lee DH, Buth KJ, Martin BJ, Yip AM, Hirsch GM (2010) Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation 121(8):973–978. https://doi.org/10.1161/CIRCULATIONAHA.108.841437

    Article  PubMed  Google Scholar 

  5. Drover JW, Dhaliwal R, Weitzel L, Wischmeyer PE, Ochoa JB, Heyland DK (2011) Perioperative use of arginine-supplemented diets: A systematic review of the evidence. J Am Coll Surg 212(3):385–399.e1. https://doi.org/10.1016/j.jamcollsurg.2010.10.016

    Article  PubMed  Google Scholar 

  6. Braga M, Gianotti L, Vignali A, Di Carlo V (2002) Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer. Surgery 132(5):805–814. https://doi.org/10.1067/msy.2002.128350

    Article  PubMed  Google Scholar 

  7. Thornblade LW, Varghese TK, Shi X et al (2017) Preoperative Immunonutrition and elective colorectal resection outcomes. Dis Colon Rectum 60(1):68–75. https://doi.org/10.1097/DCR.0000000000000740

    Article  PubMed  PubMed Central  Google Scholar 

  8. Mazzola M, Bertoglio C, Boniardi M et al (2017) Frailty in major oncologic surgery of upper gastrointestinal tract: how to improve postoperative outcomes. Eur J Surg Oncol 43(8):1566–1571. https://doi.org/10.1016/j.ejso.2017.06.006

    Article  CAS  PubMed  Google Scholar 

  9. Ommundsen N, Wyller TB, Nesbakken A et al (2018) Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomized controlled trial. Color Dis 20(1):16–25. https://doi.org/10.1111/codi.13785

    Article  CAS  Google Scholar 

  10. Charlson M, Pompei PL, Ales K, Mackenzie C (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 40:373–383. https://doi.org/10.1016/0021-9681(87)90171-8

    Article  CAS  PubMed  Google Scholar 

  11. Robinson TN, Wu DS, Stiegmann GV, Moss M (2011) Frailty predicts increased hospital and six-month healthcare cost following colorectal surgery in older adults. Am J Surg 202(5):511–514. https://doi.org/10.1016/j.amjsurg.2011.06.017

    Article  PubMed  PubMed Central  Google Scholar 

  12. Edge SB, Compton CC (2010) The american joint committee on cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol. https://doi.org/10.1245/s10434-010-0985-4

    Article  PubMed  Google Scholar 

  13. Fitz-Henry J (2011) The ASA classification and peri-operative risk. Ann R Coll Surg Engl. https://doi.org/10.1308/rcsann.2011.93.3.185a

    Article  PubMed  Google Scholar 

  14. Gustafsson UO, Scott MJ, Schwenk W et al (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS®) society recommendations. World J Surg. https://doi.org/10.1007/s00268-012-1772-0

    Article  Google Scholar 

  15. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae

    Article  PubMed  PubMed Central  Google Scholar 

  16. Davis CL, Pierce JR, Henderson W et al (2007) Assessment of the reliability of data collected for the Department of Veterans Affairs National Surgical Quality Improvement Program. J Am Coll Surg 204(4):550–560. https://doi.org/10.1016/j.jamcollsurg.2007.01.012

    Article  PubMed  Google Scholar 

  17. Hedrick TL, Harrigan AM, Sawyer RG et al (2015) Defining surgical site infection in colorectal surgery: an objective analysis using serial photographic documentation. Dis Colon Rectum 58(11):1070–1077. https://doi.org/10.1097/DCR.0000000000000466

    Article  PubMed  Google Scholar 

  18. Rahbari NN, Weitz J, Hohenberger W et al (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the international study Group of Rectal Cancer. Surgery. https://doi.org/10.1016/j.surg.2009.10.012

    Article  PubMed  Google Scholar 

  19. Solomkin JS, Mazuski JE, Bradley JS et al (2010) Diagnosis and management of complicated intra-abdominal infection in adults and children : guidelines by the surgical infection society. Clin Infect Dis 50(2):133-164

    Article  PubMed  Google Scholar 

  20. Stevens DL, Bisno AL, Chambers HF et al (2005) Practice guidelines for the diagnosis and Management of Skin and Soft-Tissue Infections. Clin Infect Dis. https://doi.org/10.1086/497143

    Article  PubMed  Google Scholar 

  21. Robinson TN, Wu DS, Pointer L, Dunn CL, Cleveland JC, Moss M (2013) Simple frailty score predicts postoperative complications across surgical specialties. Am J Surg 206(4):544–550. https://doi.org/10.1016/j.amjsurg.2013.03.012

    Article  PubMed  PubMed Central  Google Scholar 

  22. Ochoa JB, Makarenkova V, Bansal V (2004) A rational use of immune enhancing diets: when should we use dietary arginine supplementation? Nutr Clin Pract 19(3):216–225. https://doi.org/10.1177/0115426504019003216

    Article  PubMed  Google Scholar 

  23. Grimble GK, Westwood OM (2001) Nucleotides as immunomodulators in clinical nutrition. Curr Opin Clin Nutr Metab Care 4(1):57–64. https://doi.org/10.1097/00075197-200101000-00011

    Article  CAS  PubMed  Google Scholar 

  24. Bansal V, Syres KM, Makarenkova V et al (2005) Interactions between fatty acids and arginine metabolism: implications for the design of immune-enhancing diets. J Parenter Enter Nutr 29(Suppl 1):S75–S80. https://doi.org/10.1177/01486071050290s1s75

    Article  CAS  Google Scholar 

  25. Finco C, Magnanini P, Sarzo G et al (2007) Prospective randomized study on perioperative enteral immunonutrition in laparoscopic colorectal surgery. Surg Endosc Other Interv Tech 21(7):1175–1179. https://doi.org/10.1007/s00464-007-9238-4

    Article  CAS  Google Scholar 

  26. Burden S, Todd C, Hill J, Lal S (2012) Pre-operative Nutrition Support in Patients Undergoing Gastrointestinal Surgery. Cochrane Database of Systematic Reviews, issue 11, Wiley. https://doi.org/10.1002/14651858.CD008879.pub2

  27. Cerantola Y, Hübner M, Grass F, Demartines N, Schäfer M (2011) Immunonutrition in gastrointestinal surgery. Br J Surg 98(1):37–48. https://doi.org/10.1002/bjs.7273

    Article  CAS  PubMed  Google Scholar 

  28. Hempenius L, Slaets JPJ, van Asselt D, de Bock GH, Wiggers T, van Leeuwen BL (2013) Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly Cancer patients: report on a multicentre, randomized, controlled trial. PLoS One 8(6):1–11. https://doi.org/10.1371/journal.pone.0064834

    Article  CAS  Google Scholar 

  29. Indrakusuma R, Dunker MS, Peetoom JJ, Schreurs WH (2015) Evaluation of preoperative geriatric assessment of elderly patients with colorectal carcinoma. A retrospective study. Eur J Surg Oncol 41(1):21–27. https://doi.org/10.1016/j.ejso.2014.09.005

    Article  CAS  PubMed  Google Scholar 

  30. Barker LA, Gray C, Wilson L, Thomson BNJ, Shedda S, Crowe TC (2013) Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial. Eur J Clin Nutr 67(8):802–807. https://doi.org/10.1038/ejcn.2013.117

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Via Sforza 35, 20122, Milan, MI, Italy

    Pietro Achilli

  2. Department of Oncologic and Minimally Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Michele Mazzola, Camillo Leonardo Bertoglio, Carmelo Magistro, Matteo Origi, Pietro Carnevali & Giovanni Ferrari

  3. Laboratory of Medical Statistics, Biometrics, and Epidemiology “G A Maccacaro”, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy

    Federico Gervasi

  4. Clinical Nutritional Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Carmen Mastellone, Nicoletta Guanziroli & Ettore Corradi

Authors
  1. Pietro Achilli
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michele Mazzola
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Camillo Leonardo Bertoglio
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Carmelo Magistro
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Matteo Origi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Pietro Carnevali
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Federico Gervasi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Carmen Mastellone
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Nicoletta Guanziroli
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ettore Corradi
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Giovanni Ferrari
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Camillo Leonardo Bertoglio, Carmelo Magistro, Matteo Origi, Pietro Carnevali, Federico Gervasi, Nicoletta Guianziroli and Carmen Mastllone. The first draft of the manuscript was written by Pietro Achilli and Michele Mazzola and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Pietro Achilli.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Achilli, P., Mazzola, M., Bertoglio, C.L. et al. Preoperative immunonutrition in frail patients with colorectal cancer: an intervention to improve postoperative outcomes. Int J Colorectal Dis 35, 19–27 (2020). https://doi.org/10.1007/s00384-019-03438-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-019-03438-4

Keywords

Search

Navigation