ESPEN Guideline: Clinical Nutrition in inflammatory bowel disease

Introduction: The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD). Methodology: The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required. Results: IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD – especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnu-trition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative man-agement of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is mod-erately well supported in Crohn's disease, especially in children where the adverse conse-quences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed. Conclusions: Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recom-mendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP)

Impact of body composition and physical strength changes during chemoradiotherapy on complications and survival after oesophagectomy

Background: The aim of this study was to assess body composition and physical strength changes during neoadjuvant chemoradiotherapy (nCRT) and assess their predictive value for (severe) postoperative complications and overall survival in patients who underwent oesophagectomy for oesophageal cancer. Methods: Consecutive patients who underwent nCRT and oesophagectomy with curative intent in a tertiary referral center were included in the study. Perioperative data were collected in a prospectively maintained database. The CT images before and after nCRT were used to assess skeletal muscle index (SMI), subcutaneous fat index (SFI), and visceral fat index (VFI). To assess physical strength, handgrip strength (HGS) and the exercise capacity of the steep ramp test (SRT Wpeak) were acquired before and after nCRT. Results: Between 2015 and 2020, 126 patients were included. SMI increased in female subgroups and decreased in male subgroups (35.38 to35.60 cm 2/m 2 for females, P value 0.048, 46.89 to 45.34 cm 2/m 2 for males, P value < 0.001). No significant changes in SFI, VFI, HGS, and SRT Wpeak were observed. No predictive value of changes in SMI, HGS, and SRT Wpeak was shown for (severe) postoperative complications and overall survival. Conclusions: A significant but minimal decrease in SMI during nCRT was observed for males only, it was not associated with postoperative complications or overall survival. Physical strength measurements did not decrease significantly over the course of nCRT. No associations with postoperative complications or overall survival were observed

Impact of feeding strategy after pancreatoduodenectomy on delayed gastric emptying and hospital stay:Nationwide study

Background:Delayed gastric emptying is a major contributor to prolonged hospital stay following pancreatoduodenectomy. Although enhanced recovery after surgery guidelines recommend unrestricted feeding after pancreatoduodenectomy, nationwide studies evaluating the impact of different feeding strategies after surgery on delayed gastric emptying and length of hospital stay are limited. This study aimed to identify the use and impact of different feeding strategies after pancreatoduodenectomy on delayed gastric emptying and length of hospital stay. Methods: This nationwide cohort study included consecutive patients after pancreatoduodenectomy from the Dutch Pancreatic Cancer Audit (2021-2023). Primary endpoints were delayed gastric emptying grade B/C and length of hospital stay. Feeding strategies were categorized based on structured interviews with representatives from 15 centres. Multilevel analysis was used to assess associations between feeding strategy, delayed gastric emptying, and length of hospital stay. Predictors of delayed gastric emptying were determined. Results: Overall, 2354 patients undergoing pancreatoduodenectomy were included, of whom 526 (23%) developed delayed gastric emptying grade B/C. Median length of hospital stay was 13 days longer in patients with delayed gastric emptying (23 versus 10 days; P &lt; 0.001). Feeding strategies were: unrestricted feeding (3 centres, 637 patients; delayed gastric emptying 18%); step-up feeding (9 centres, 1462 patients; delayed gastric emptying 24%); and artificial feeding (3 centres, 255 patients; delayed gastric emptying 25%). No association was observed between feeding strategy and delayed gastric emptying: step-up versus unrestricted feeding (odds ratio 1.14, 95% confidence interval 0.53 to 2.47) and artificial versus unrestricted feeding (odds ratio 1.76, 0.65 to 4.73). Similarly, no association was found between feeding strategy and length of hospital stay. The strongest predictor of delayed gastric emptying was pancreatic fistula after surgery (odds ratio 3.16, 2.47 to 4.05). Conclusion: This study found no significant association between feeding strategy and incidence of delayed gastric emptying or length of hospital stay after pancreatoduodenectomy. Efforts to reduce delayed gastric emptying should focus on reducing pancreatic fistula after surgery.</p

Enhanced Recovery After Surgery: It's Time to Change Practice

Perioperative surgical care is undergoing a paradigm shift. Traditional practices such as prolonged preoperative fasting (nil by mouth from midnight), bowel cleaning, and reintroduction of oral nutrition 3-5 days after surgery are being shunned. These and other similar changes have been formulated into a protocol called Enhanced Recovery After Surgery (ERAS) pathway. It is a multimodal perioperative care pathway designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of an ERAS protocol include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimes, and early mobilization. The recent literature is heavily influenced by colorectal surgery, but the principles are now being applied to a wide range of disciplines. As they challenge traditional surgical doctrine, the implementation of ERAS guidelines has been slow, despite the significant body of evidence indicating that ERAS guidelines may lead to improved outcomes

Enhanced Recovery After Surgery: It's Time to Change Practice

Perioperative surgical care is undergoing a paradigm shift. Traditional practices such as prolonged preoperative fasting (nil by mouth from midnight), bowel cleaning, and reintroduction of oral nutrition 3-5 days after surgery are being shunned. These and other similar changes have been formulated into a protocol called Enhanced Recovery After Surgery (ERAS) pathway. It is a multimodal perioperative care pathway designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of an ERAS protocol include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimes, and early mobilization. The recent literature is heavily influenced by colorectal surgery, but the principles are now being applied to a wide range of disciplines. As they challenge traditional surgical doctrine, the implementation of ERAS guidelines has been slow, despite the significant body of evidence indicating that ERAS guidelines may lead to improved outcomes

Physical ExeRcise Following Esophageal Cancer Treatment (PERFECT) study: design of a randomized controlled trial

Contains fulltext : 177177.pdf (publisher's version ) (Open Access)BACKGROUND: Following esophagectomy, esophageal cancer patients experience a clinically relevant deterioration of health-related quality of life, both on the short- and long-term. With the currently growing number of esophageal cancer survivors, the burden of disease- and treatment-related complaints and symptoms becomes more relevant. This emphasizes the need for interventions aimed at improving quality of life. Beneficial effects of post-operative physical exercise have been reported in several cancer types, but so far comparable evidence in esophageal cancer patients is lacking. The aim of this study is to investigate effects of physical exercise on health-related quality of life in esophageal cancer patients following surgery. METHODS: The Physical ExeRcise Following Esophageal Cancer Treatment (PERFECT) study is a multicenter randomized controlled trial including 150 esophageal cancer patients after surgery with curative intent. Patients are randomly allocated to an exercise group or usual care group. The exercise group participates in a 12-week combined aerobic and resistance exercise program, supervised by a physiotherapist near the patient's home-address. In addition, participants in the exercise group are requested to be physically active for at least 30 min per day, every day of the week. Participants allocated to the usual care group are asked to maintain their habitual physical activity pattern. The primary outcome is health-related quality of life (EORTC-QLQ-C30). Secondary outcomes include esophageal cancer specific quality of life, fatigue, anxiety and depression, sleep quality, work-related factors, cardiorespiratory fitness (VO2peak), muscle strength, physical activity, malnutrition risk, anthropometry, blood markers, recurrence of disease and survival. All questionnaire outcomes, diaries and accelerometers are assessed at baseline, post-intervention (12 weeks post-baseline) and 24 weeks post-baseline. Physical fitness, anthropometry and blood markers are assessed at baseline and post-intervention. In addition, adherence and safety are monitored throughout the exercise program. DISCUSSION: This randomized controlled trial investigates effects of physical exercise versus usual care in esophageal cancer patients after surgery. As the design of the exercise program closely resembles daily practice, this study can contribute both to evidence on effects of exercise in esophageal cancer patients, and to potential implementation strategies. TRIAL REGISTRATION: Trial registration:Netherlands Trial Registry NTR5045 Date of trial registration: January 19th, 2015 Date and version study protocol: February 2017, version 1