Preoperative oral immunonutrition therapy on postoperative outcomes in gastrointestinal surgery

1
Pre-operative oral immunonutrition therapy on
postoperative outcomes in gastrointestinal surgery
Pre-operative oral immunonutrition therapy on
postoperative outcomes in gastrointestinal
surgery

• Lisa Barker
• Senior Clinician, Dietitian
• Gastrointestinal Surgery and Critical Care

Lisa Barker Senior Clinician, Dietitian Gastrointe
stinal Surgery and Critical Care
2
Background

• 40 of hospitalised patients are malnourished
• Many hospitalised patients experience nutrition
  depletion during their surgical hospital
  admission
• Fasting post op
• Nausea / vomiting
• Poor appetite

3
Background

• Surgery is an insult, leading to
• Increased sympathetic activity
• Rise in catecholamine secretion
• Hypermetabolic state
• This in turn causes
• skeletal muscle proteolysis and depression of
  metabolism
• Increased intestinal permeability and risk of
  bacterial translocation

Ward. Nutrition Journal 2003
4
Background

• Much published evidence to support malnourished
  patients have poorer surgical outcomes
• Higher rates of
• Infection
• Risk of anastomotic breakdown
• Mortality
• Slower recovery
• Longer convalescence
• Cardio-respiratory impairment
• Increased length of stay
• Greater hospital costs

5
Nutrition and Surgery

• Pre Operative Nutrition
• Two weeks prior until 24 hours prior
• Peri Operative Nutrition
• 24 hours pre until after operation complete
• Post Operative Nutrition
• After anesthetic has warn off until return of
  usual appetite

6
Evidence

• Immuno-modulating supplements
• High energy, high protein, nutrient dense
• Alter biochemical pathways and decrease immune
  impairment after surgery
• Arginine increases protein synthesis and immune
  function
• Fatty acids regulate eicosanoid production and
  immune function
• Dietary nucleotides support T-cell development
  and immune function

Senkal et al, Arch Surg, 1999
7
Immunonutrition

• Impact Advanced Recovery
• Dose
• 3 x 220ml/day for 5 days pre-op
• Has been shown to
• Decreased LOS
• Decreased infection rate and post-operative
  complication
• No change in mortality

Waitzburg et al, World J Surg, 2006, Tepaske et
al, Lancet (2001), Braga et al, Surgery, (2002)
8
Meta Analysis
Waitzburg et al, World J Surg, 2006

• 17 Studies, 2305 patients
• Randomised clinical trials
• Pre-op and post-op IMPACT supplementation
• GI surgery, cardiac and head and neck patients
• 14/17 trials on GI surgery patients
• Enteral and oral IMPACT
• Multilingual
• 1985 - 2003

9
Meta Analysis
Waitzburg et al, World J Surg, 2006

• Main outcome measures
• Post-operative complications
• Mortality
• Length of hospital stay
• Costs of treatment
• IMPACT V Placebo V Standard Care
• Sub-group analysis

10
Meta Analysis

• Results (Pre-operative IMPACT)
• 39-61 reduction in infective complications (
  p lt 0.0001)
• Average decrease in length of stay by 2 days
  ( p lt 0.0001)
• Decrease in anastomotic leaks by 46
  (p 0.034) (post-op IMPACT)
• No change in mortality (p 0.98)
• Greatest improvement appeared with pre-op IMPACT
  support

11
Issues with Current Literature

• No local studies
• Most out of Italy
• Studies often combine pre-and post-op nutrition
  support
• Hard to standardise for post-op nutrition support
• Most compare to a placebo (isonitrogenous,
  isocaloric)
• Cost and compliance

12
Our Proposal

• Compare immunonutrition to standard practice (no
  placebo)
• Impact Advanced Recovery
• GI surgery patients
• HB and CR
• Pre-op only
• Easy to implement if trial successful

13
Hypothesis

• Oral Impact Advanced Recovery taken three times a
  day for five days prior to major surgery will
  decrease length of stay and post-operative
  complications in elective upper and lower
  gastrointestinal surgical patients

14
Aims

• Show that the provision of a hospital funded
  immunoenhancing supplement to patients
  pre-operatively is practical and viable
• Measure the success of the nutrition intervention
  by collecting data on length of stay, rates of
  infection and non-infective complications
• A cost / benefit analysis will also be performed
  to justify use of the product in the hospital

15
Methods

• Elective GI surgery patients
• Randomised into two groups
• Treatment (Impact Advanced Recovery tds for 5
  days pre-operatively)
• Control (no intervention)
• Surgery and post op care as normal

16
Outcome Measures

• Primary
• LOS
• Secondary
• Infectious complications
• Non-infectious complications
• ICU admission
• Mortality
• Cost benefit analysis

17
Current progress

• Ethics approval granted this week
• Awaiting confirmation of Deakin University
  Honours Student to assist
• Likely start January
• Likely 8-12 months data collection
• ? Extend trial to Peter MacCallum
• Aim for publication early 2009

18
Other progress

• Looking at reviewing anaesthetic fasting
  guidelines
• In line with American and Australian standards
• Commencement of Fast Track feeding trial with CR
  unit
• Multidisciplinary
• Oral nutrition 4h post op for lower GI cases

19
Acknowledgements

• Mr Ben Thompson
• General Surgeon, Hepatobiliary, RMH
• Professor Ian Jones
• Head of Colorectal Surgery, RMH
• Ms Lisa Wilson
• Colorectal Outpatient Nurse, RMH
• Dr Tim Crowe
• Senior Lecturer (Nutrition), Deakin University
• Ms Michele Hughes
• Manager, Clinical Nutrition, RMH