Enteral immunonutrition versus enteral nutrition for patients undergoing oesophagectomy: a systematic review and meta-analysis

Abstract

OBJECTIVES According to retrospective studies, oesophageal carcinoma is the second deadliest gastrointestinal cancer after gastric cancer. Enteral immunonutrition (EIN) has been increasingly used to enhance host immunity and relieve the inflammatory response of patients undergoing oesophagectomy; however, conclusions across studies remain unclear. We aimed to evaluate the effect of EIN on the clinical and immunological outcomes of patients undergoing oesophagectomy. METHODS Four electronic databases (MEDLINE, Embase, Web of Science and Cochrane Library) were used to search articles in peer-reviewed, English-language journals. The mean difference, relative risk or standard mean difference with 95% confidence interval were calculated. Heterogeneity was assessed by the Cochran’s Q test and I2 statistic combined with the corresponding P-value. The analysis was carried out with RevMan 5.3. RESULTS Six articles were finally included, with a total of 320 patients with oesophageal cancer. The meta-analysis results showed that EIN did not improve clinical outcomes (such as infectious complications, pneumonia, surgical site infection, anastomotic leak and postoperative hospital stay) or immune indices [referring to C-reactive protein, interleukin (IL)-6, IL-8, tumour necrosis factor-α]. Descriptive analysis suggested that EIN also increased the serum concentrations of IgG and the percentage of the B-cell fraction. Thus, its impact on IL-8 and IL-6 remains inconsistent. CONCLUSIONS The early-stage impact of EIN on immunological status in patients undergoing oesophagectomy is still unclear. According to the results of this meta-analysis, whether EIN could improve the clinical outcomes or biological status after oesophagectomy compared to standard enteral nutrition is uncertain. Since the impact of EIN is unclear, current guidelines that strongly advise the use of EIN should be changed, as the utility of EIN is very uncertain. More appropriately powered clinical studies are warranted to confirm its effectiveness.

Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction

“…Correspondingly, perioperative immunonutrition was found to reduce postoperative morbidity in gastrointestinal cancer surgery in a systematic review of randomized controlled trials (RCTs) [37]. However, another recent metaanalysis of RCTs with a specific focus on esophagectomy did not confirm a positive effect of immunonutrition on AL, overall morbidity, postoperative hospital stay, or immune indices such as C-reactive protein, interleukin-6, IL-8, and tumor necrosis factor-α [38]. Therefore, immunonutrition prior to esophageal cancer surgery remains a controversial issue.…”

The Optimal Time of Applying Enteral Immunonutrition in Esophageal Cancer Patients Receiving Esophagectomy: A Network Meta-Analysis of Randomized Clinical Trials

“…However, patients will experience a series of serious complications after surgery such as infection and anastomotic leakage due to immunosuppression and in ammatory response (8,10). Therefore, it is critically important to supply immune-modulating substances such as arginine and omega-3-fatty acids to SEN, which was de ned as EIN (7,17). Although the effectiveness of EIN in patients receiving gastrointestinal surgery has been established (8)(9)(10), the role of EIN in EC patients undergoing esophagectomy remains controversial.…”

“…To date, two meta-analyses (17,18) investigating the effectiveness of EIN for treating EC patients receiving esophagectomy have been published. Li and colleagues performed a meta-analysis of six articles to compare the effectiveness between EIN and SEN in patients receiving oesophagectomy, and found that impact of EIN on immunological status, biological status or clinical outcomes remains unclear (17). However, this nding must be cautiously interpreted because this meta-analysis missed four eligible studies (37,39,43,44).…”

“…To date, several meta-analyses have determined the effectiveness of EIN in patients undergoing gastrointestinal surgery (8,10,15,16). Meanwhile, there are two meta-analyses also investigated the role of EIN in treating EC patients receiving esophagectomy (17,18) and do not obtain a de nitive conclusion.…”

“…However, conclusions from previous two meta-analyses must be cautiously interpreted because several limitations can not be ignored, such as incomplete inclusion of eligible studies (17) and incorrect inclusion of an study (18). Moreover, several factors such as the time of applying EIN (10) and formula of containing different substances (11) were directly associated with the effectiveness of EIN.…”