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A Meta-Analysis of the Effect of Combinations of Immune Modulating Nutrients on Outcome in Patients Undergoing Major Open Gastrointestinal Surgery

Marimuthu, Kanagaraj MRCS*; Varadhan, Krishna K. MSc, MRCS*; Ljungqvist, Olle MD, PhD; Lobo, Dileep N. MS, DM, FRCS, FACS*

doi: 10.1097/SLA.0b013e318252edf8
Meta-Analysis

Background: Immune modulating nutrition (IMN) has been shown to reduce complications after major surgery, but strong evidence to recommend its routine use is still lacking.

Objective: The aim of this meta-analysis was to evaluate the impact of IMN combinations on postoperative infectious and noninfectious complications, length of hospital stay, and mortality in patients undergoing major open gastrointestinal surgery.

Methods: Randomized controlled trials published between January 1980 and February 2011 comparing isocaloric and isonitrogenous enteral IMN combinations with standard diet in patients undergoing major open gastrointestinal surgery were included. The quality of evidence and strength of recommendation for each postoperative outcome were assessed using the GRADE approach and the outcome measures were analyzed with RevMan 5.1 software (Cochrane Collaboration, Copenhagen, Denmark).

Results: Twenty-six randomized controlled trials enrolling 2496 patients (1252 IMN and 1244 control) were included. The meta-analysis suggests strong evidence in support of decrease in the incidence of postoperative infectious [risk ratio (RR) (95% confidence interval [CI]): 0.64 (0.55, 0.74)] and length of hospital stay [mean difference (95% CI): −1.88 (−2.91, −0.84 days)] in those receiving IMN. Even though significant benefit was observed for noninfectious complications [RR (95% CI): 0.82 (0.71, 0.95)], the quality of evidence was low. There was no statistically significant benefit on mortality [RR (95% CI): 0.83 (0.49, 1.41)].

Conclusions: IMN is beneficial in reducing postoperative infectious and noninfectious complications and shortening hospital stay in patients undergoing major open gastrointestinal surgery.

This meta-analysis of randomized controlled trials on supplementing enteral immune modulating nutrition in patients undergoing major gastrointestinal surgery shows significant reduction in postoperative complications and length of hospital stay when compared with standard enteral nutrition.

*Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, United Kingdom

Department of Surgery, Örebro University Hospital, Örebro, Sweden.

Reprint: Dileep N. Lobo, MS, DM, FRCS, FACS, Division of Gastrointestinal Surgery, E Floor, West Block, Nottingham University Hospitals, Queen's Medical Centre, Nottingham NG7 2UH, United Kingdom. E-mail: Dileep.Lobo@nottingham.ac.uk.

Disclosure: O.L. and D.N.L. have received research funding from Nutricia Clinical Care. K.M. and K.K.V. have no conflicts of interest to declare. K.K.V. was supported by research fellowships from the Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, and the Enhanced Recovery After Surgery Society.

K.M. and K.K.V. contributed equally to this paper. This paper was presented to the European Society for Clinical Nutrition and Metabolism, Gothenburg, September 2011, and was published in abstract form (Clin Nutr Suppl. 2011;6:13–4)

© 2012 Lippincott Williams & Wilkins, Inc.