Perioperative Immunonutrition Modulates Inflammatory Response after Radical Cystectomy: Results of a Pilot Randomized Controlled Clinical Trial

Hamilton-Reeves, Jill; Stanley, Abigail; Bechtel, Misty; Yankee, Thomas M.; Chalise, Prabhakar; Hand, Lauren; Lee, Eugene K.; Smelser, Woodson; Mirza, Moben; Wyre, Hadley; Hull, Holly R.; Carlson, Susan E.; Holzbeierlein, Jeffrey M.

doi:10.1016/j.juro.2018.03.001

Cited by 46 publications

(73 citation statements)

References 30 publications

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“…Both groups of patients received 5 days of their supplement before and after surgery. Patients receiving the arginine-containing supplement experienced a 39% reduction in late postoperative infections ( p = 0.027) [20••]. …”

Section: Preoperative Immunonutritionmentioning

confidence: 99%

“…In the patients that received the arginine-containing supplement, the balance of Th1-Th2 T cells was maintained at the time of surgery, and for those who received the non-arginine-containing supplement, it was not maintained (p = 0.027). In addition, the plasma concentration of IL-6 was significantly lower in patients receiving immunonutrition supplementation ( p = 0.020), suggesting that this intervention counteracts the disrupted Th1-Th2 balance and pro-inflammatory response after radical cystectomy [20••, 22••].…”

Section: Preoperative Immunonutritionmentioning

confidence: 99%

“…This inhibited T cell response lowers resistance to infection by depleting serum arginine through arginase-1, which is found within MDSCs [23]. Furthermore, T lymphocytes are dependent on arginine for their proliferation, so these findings suggest that there are multiple mechanisms for infection prevention when patients receive supplemental arginine [20••, 24]. …”

Section: Preoperative Immunonutritionmentioning

confidence: 99%

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Optimizing Nutrition Prior to Radical Cystectomy

et al. 2018

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Purpose of Review Malnutrition in a prevalent problem in patients undergoing radical cystectomy. Preoperative malnutrition has been shown to contribute to increased rates of postoperative complications. Given the significant morbidity and mortality of the procedure of radical cystectomy, there is potential for improvement in patient outcomes by nutritional intervention. Recent Findings Prospective studies have demonstrated a reduction in postoperative infection rates in patients who receive supplemental immunonutrition prior to major surgery including radical cystectomy. These initial evaluations of nutritional optimization show significant potential for improved outcomes. Additionally, several studies using enhanced recovery after surgery protocols, which include a preoperative nutritional component, have shown a benefit in reducing length of stay. Summary Emerging literature has shown the benefits of preoperative immunonutrition in improving postoperative outcomes of radical cystectomy. However, further work is needed to determine the best mechanism to optimize nutrition prior to radical cystectomy.

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Section: Preoperative Immunonutritionmentioning

confidence: 99%

Section: Preoperative Immunonutritionmentioning

confidence: 99%

Section: Preoperative Immunonutritionmentioning

confidence: 99%

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Optimizing Nutrition Prior to Radical Cystectomy

et al. 2018

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“…According to a meta‐analysis by Tyson and Chang, ERAS protocols have reduced lengths of stay, improved postoperative bowel function, and reduced some (low‐grade) complications, but they have not reduced readmission rates; this confirms the findings of many published single‐institution series around the world. On the heels of ERAS, an explosion of interventions to further reduce complications and prevent readmission have followed: identifying and reducing malnutrition, improving fitness through exercise, targeting mental health and anxiety, and comprehensive programs that target multiple domains (prehabilitation) . Unfortunately, each of these interventions (including ERAS) entail additional information and education on top of an overload of preoperative education that Smith et al have identified as overwhelming for patients.…”

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confidence: 99%

Optimizing cystectomy outcomes

Porten

Master

2019

Cancer

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In this month's issue of Cancer, Smith et al 1 from the University of North Carolina at Chapel Hill present a unique patient-centered perspective and identify potential solutions for reducing complications and subsequent readmissions after radical cystectomy. Through semistructured interviews of readmitted patients, their caregivers, and health care providers, they have identified a critical lack of knowledge regarding normal and abnormal symptoms after discharge that is not mitigated by the standard preoperative education that many of us provide before a surgery of this magnitude.Radical cystectomy with pelvic lymphadenectomy and intestinal urinary diversion is the mainstay of treatment for invasive bladder cancer. It is a complex and morbid operation often performed in frail patients with significant comorbid conditions. Postoperatively, patients can experience long length of stays, high complication rates (35%-65%), and one of the highest readmission rates among surgical procedures (25%-30%). 2,3 This is most often related to urinary tract infections, bowel complications such as ileus, a failure to thrive, dehydration, or wound complications. 4 As with many other complex surgeries, a shift to perioperative management incorporating enhanced recovery after surgery (ERAS) pathways has improved some of these outcomes. According to a meta-analysis by Tyson and Chang, 5 ERAS protocols have reduced lengths of stay, improved postoperative bowel function, and reduced some (low-grade) complications, but they have not reduced readmission rates; this confirms the findings of many published single-institution series around the world. On the heels of ERAS, an explosion of interventions to further reduce complications and prevent readmission have followed: identifying and reducing malnutrition, improving fitness through exercise, targeting mental health and anxiety, and comprehensive programs that target multiple domains (prehabilitation). 6,7 Unfortunately, each of these interventions (including ERAS) entail additional information and education on top of an overload of preoperative education that Smith et al 1 have identified as overwhelming for patients. One patient's quotation sums it best: "It's like drinking water from a fire hydrant."Using a variety of statistical modeling methods on nationwide and institutional data sets, Hu et al 8 and Krishnan et al 9,10 at the University of Michigan have provided insight into the causes, timing, and associated symptoms of readmission. In summary, they found that the majority of patients (67%) were readmitted in the first 2 weeks after their discharge, with infection (51%) and a failure to thrive (36%) being the most common diagnoses. Standard clinicodemographic factors did not identify patients at risk of readmission. However, patients who experienced a complication during their initial postoperative stay and those who were discharged to a skilled nursing facility were at the highest risk for readmission. As expected, patients who reported symptoms of infection or a failure to thri...

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“…In a recent issue of the Journal of Urology , Hamilton-Reeves et al ( 1 ) reported interesting results of a prospective, randomized study that sought to compare the effects of a short-term specialized immunonutrition (SIM) with those of a standard oral nutrition supplement (ONS) on the acute inflammatory response and arginine status in patients with bladder cancer undergoing radical cystectomy (RC). RC involves several invasive procedures and is associated with high rates of complications and morbidity, partly due to extensive lymph node dissection and urinary diversions using intestinal segments, for example, orthotopic neobladders and ileal conduits.…”

mentioning

confidence: 99%