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PERIOPERATIVE NUTRITION THERAPY TO OPTIMIZE COLORECTAL PATIENT OUTCOMES: A SYSTEMATIC REVIEW AND META-ANALYSIS
Alexander Troester
*, Shelbi Olson, Romil Parikh, Lindsay Welton, Lauren Weaver, Mary Butler, Bronwyn Southwell, Paolo Goffredo
Surgery, University of Minnesota Twin Cities, Minneapolis, MN
Background: Malnutrition is an independent risk factor for multiple postoperative complications and delays in recovery following colorectal surgery (CRS). Appropriate nutritional interventions have the potential to decrease morbidity and improve postsurgical outcomes; however, they are often heterogeneous, poorly defined, and have unaddressed barriers to implementation. In addition, while current guidelines recommend introduction of solid food in the immediate postoperative period, the use of low-fiber diet as opposed to a regular diet is a debated topic with a paucity of supporting data. Therefore, we conducted a comprehensive systematic review and meta-analysis to appraise available evidence regarding perioperative nutritional interventions for CRS.
Methods: We searched Medline®, Embase®, and CENTRAL®, for randomized controlled trials (RCT) and nonrandomized studies of interventions (NRSI) published between January 1, 2000, to November 17, 2023, assessing perioperative protein supplementation, immunonutrition (IMN), carbohydrate loading, and postoperative diet progression. Individual study risk of bias (RoB) and overall strength of evidence (SOE) were evaluated for a prespecified outcome list using standardized methods. We used random effects modeling for meta-analyses of study-level data when 3 or more eligible studies were available for each outcome under each comparison. We calculated the Mantel-Haenszel risk ratio (RR) for count outcomes and the inverse variance-weighted standardized mean difference (SMD) for continuous outcomes. We used funnel plots and the Egger’s test to assess publication bias.
Results: We identified 27 eligible studies and extracted data. Ten were deemed low/moderate RoB. Compared to dietary advice alone, protein supplementation and IMN may show a benefit in lower SSI rates (both low SOE), and carbohydrate loading may result in no difference (low SOE; Table 1). Regarding other postoperative complications, both IMN (RR 0.55, 95% CI 0.24-1.27) and carbohydrate loading (RR 0.55, 95% CI 0.15-2.07) probably do not impact anastomotic leak rates (both moderate SOE; Figure 1A and 1B). Compared to dietary advice alone, IMN (SMD -0.20, 95% CI -1.18-0.79) and carbohydrate loading (SMD -0.79, 95% CI -1.99-0.41) may result in no differences in length of stay (low SOE; Figure 1C and 1D). Evidence was insufficient to recommend the use of low-fiber diet immediately following surgery.
Conclusions: Perioperative colorectal surgery nutrition interventions are heterogeneous with current evidence suggesting small to negligible benefits in terms of postoperative complications. No studies comparing low-fiber diet to regular diet met inclusion criteria. The majority of evidence is insufficient, highlighting research opportunities to further enhance nutritional optimization and limit postsurgical complications.
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