Impact of Preoperative Immunonutrition on Perioperative Outcomes following Cystectomy

Abstract

Study Need and Importance: Radical cystectomy (RC) for the management of muscle-invasive bladder cancer remains a morbid procedure with high rates of perioperative complications. 1,2 The role of preoperative immunonutritional supplementation (pre-INS) in improving post-RC outcomes is promising and needs further validation. 3e5 What We Found: We performed a retrospective review of 204 patients who underwent RC for bladder cancer at a single institution, comparing patients who received oral L-arginine-based pre-INS and those who did not. Preoperative features, postoperative complications, and readmission data were collected. Outcomes of interest included development of high-grade (Clavien-Dindo IIIeV) complications, readmission within 30 days, ileus, total parenteral nutrition requirement, postoperative infection, and length of stay (see table ). Multivariable logistic regression (MLoR) analysis was used to identify predictive factors for our outcomes. On MLoR, adjusting for age, gender, body mass index (BMI), Charlson comorbidity index, undergoing neoadjuvant chemotherapy, and operative features, pre-INS was a significant predictor of postoperative infection (Fisher p[0.02; OR[0.35), but not for other outcomes of interest. Limitations: Limitations of this study include its retrospective nature and its reliance on the presumption that all patients given pre-INS were fully compliant with taking the supplement. Furthermore, while preoperative albumin levels and BMI were not significantly different between the 2 patient groups, we were unable to directly assess patient perioperative nutritional status and sarcopenia, 2 increasingly recognized independent predictors of perioperative morbidity. Finally, enhanced recovery after surgery (ERAS) protocol implementation rates were high in both pre-INS and control groups (100% vs 72%, respectively), potentially confounding our findings, although pre-INS remained a significant predictor for postoperative infection after accounting for ERAS in our MLoR models. Interpretation for Patient Care: A short course of preoperative immunonutrition with an inexpensive Larginine-based supplement prior to RC is associated with significant reduction in postoperative infection, one of the most common complications of RC.

Effects of preoperative immunonutrition with surgical site infection after radical cystectomy and ileal conduit for muscle invasive bladder cancer

“…[7][8][9][10] In 2021, Khaleel et al reported in a relatively large number of cases (n = 204) that intake of IMPACT for 5 days before surgery signi cantly reduced postoperative infectious complications after radical cystectomy and urinary diversion. 11 Our study also showed that preoperative intake of IMPACT signi cantly reduced the incidence of SSI.…”

Hemoglobin, Albumin, Lymphocyte, and Platelet Count is a Significant Biomarker Surrogate for Nutritional Status to Predict Overall Survival in Patients Post–radical Cystectomy

“…28 Preoperative immunonutrition has also been shown to promote a lower overall inflammatory state by correcting the Th1-Th2 balance, as well as decreasing the need for postoperative total parenteral nutrition. 29,30 Understanding when to give immunonutritional therapy in the context of RC is yet to be answered and requires further investigation.…”

What is hemoglobin, albumin, lymphocyte, platelet (HALP) score? A comprehensive literature review of HALP’s prognostic ability in different cancer types

“…Furthermore, preoperative oral arginine and n-3 fatty acid supplementation has been shown to improve the immunometabolic host response and outcome after colorectal resection for cancer, showing decreased infection rate, and improved gut oxygenation and microperfusion [ 101 ]. L-arginine supplementation and other immunonutritional support has also been shown to decrease infection rates and lower inflammatory response in radical cystectomy patients [ 102 , 103 ]. As of now, there is no defined standard of care for immune-nutritional supplementation during cancer treatment.…”