
==== Front
Discov Oncol
Discov Oncol
Discover Oncology
2730-6011
Springer US New York

39225821
1288
10.1007/s12672-024-01288-3
Research
The effect of preoperative supplementary parenteral nutrition on nutrition and inflammation in gastric cancer patients
Huang Xiaoyan 1
Cui Changxing 1
Wang Jing 2
Kong Dongchi 3
Cui Yuanqing shandong667788@126.com

2
Huang Peng dapeng19837@163.com

4
Li Xuelong dragon.ghost@163.com

3
1 https://ror.org/05vawe413 grid.440323.2 0000 0004 1757 3171 Department of Nursing, Yantai Yuhuangding Hospital, Shandong, 264000 China
2 https://ror.org/05vawe413 grid.440323.2 0000 0004 1757 3171 Department of Surgery, Yantai Yuhuangding Hospital, Shandong, 264000 China
3 https://ror.org/05vawe413 grid.440323.2 0000 0004 1757 3171 Department of Clinical Nutrition, Yantai Yuhuangding Hospital, Shandong, 264000 China
4 https://ror.org/05vawe413 grid.440323.2 0000 0004 1757 3171 Department of Internal Medicine, Yantai Yuhuangding Hospital, Shandong, 264000 China
3 9 2024
3 9 2024
12 2024
15 40030 4 2024
29 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Objectives

Supplemental parenteral nutrition (SPN) is recommended to add when enteral nutrition alone is not sufficient. This research aims to evaluate the effect of preoperative SPN in patients with gastric cancer.

Methods

A total of 180 patients with gastric cancer were divided into three groups (60 patients per group) according to different nutritional support scheme. The primary endpoint was the changes in nutrition and inflammatory, while the secondary endpoint included the changes in prognosis.

Results

Compared with the control group, there were significant differences in nutrition and inflammation related indicators in the oral nutrition supplement (ONS) group and the SPN + ONS group (P < 0.05). Compared with the ONS group, the SPN + ONS group showed significant differences in the above indicators (P < 0.05). However, no significant changes were observed in the incidence of complications, the postoperative exhaust time, and the hospitalization time.

Conclusions

Preoperative SPN had a positive effect on nutrition and inflammation of gastric cancer patients undergoing surgery, but had no significant effect on their prognosis.

Keywords

Supplemental parenteral nutrition
Gastric cancer
Nutritional support
Prognosis
issue-copyright-statement© Springer Science+Business Media, LLC 2024
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pmcIntroduction

Nutritional support for the malnourished cancer patients can be performed by enteral and parenteral route. Oral nutritional supplements (ONS) had shown great potentials in managing malnutrition condition [1]. However, the implementation of enteral nutrition is often limited by the adverse effects such as gastrointestinal complications. The nutritional support, including supplemental parenteral nutrition (SPN), has been recommended as early as possible in malnourished cancer patients [2]. SPN is recommended for use in cancer patients who have oral nutritional supplements but have insufficient oral food intake [3].

The effectiveness of supplementary parenteral nutrition is a key issue. However, there is no consensus on the impact of SPN on the outcomes, and further research is wanted [4]. Previous studies about SPN have mostly focused on ICU patients [5, 6], while there have been few studies targeting cancer patients. SPN are not discussed in detail in the ESPEN guidelines [3]. In the oncology nutrition landscape, this is a major unmet need. Thus, the aim of this study is to evaluate and compare the clinical outcomes of the use of SPN as an adjunct to ONS compared to ONS alone in patients with cancer.

Materials and methods

Study population

We retrospectively studied 386 patients with GC who underwent surgical treatment at the Yantai Yuhuangding Hospital from March 2009 to October 2012. All data in this study was obtained from our institution's database and electronic medical record system. In total, 180 patients (NRS-2002 ≥ 3) were included in this study. The flowchart of the present trial is shown in Fig. 1. The patients rejected the nasogastric tube or nasointestinal tube, and were divided into 3 groups based on the patient's wishes and different nutritional support methods. The control group (n = 60) received basic diet without any other nutritional support. The oral nutrition supplement (ONS) group (n = 60) received oral nutritional supplements on the basis of a basic diet. The third group was provided supplemental parenteral nutrition based on the ONS group (SPN + ONS, n = 60). All patients received radical gastrectomy. The preoperative nutritional support lasted for 5 days. For comparison purposes, all patients were case matched regarding tumor location, tumor stage, demographics, and procedure performed were used. The study was approved by the ethics committee of the Yantai Yuhuangding Hospital. The study was conducted according to the principles of the Declaration of Helsinki. The informed consent was waived by the committee because of the retrospective nature of the study.Fig. 1 The flowchart of the present trial. The control group: received basic diet without any other nutritional support; The oral nutrition supplement (ONS) group: received oral nutritional supplements on the basis of a basic diet; The SPN + ONS group: was provided supplemental parenteral nutrition based on the ONS group (SPN + ONS)

Preoperative nutritional protocol

Hospitalization diet

The hospital canteen prepared and distributed a uniform diet. The recommended calorie intake was set at 25 kcal/kg and protein at 1.0 g/kg [7].

Oral nutrition supplement

The ONS used in this study was the “Sainte Food”, which contains 250 kcal of energy, 34.0 g of carbohydrates, 10.1 g of protein and 7.8 g of fat per pack. The ONS group took two packs orally daily.

Supplemental parenteral nutrition

Calvin: 1440 ml/day, 1000 kcal, 11% Glucose solution 885 ml; 11.5% Amino acid solution 300 ml; 20% Fat emulsion injection 255 ml.

Postoperative nutritional protocol

The protocol for the three groups of patients was the same.

Data collection

The blood samples were collected from patients at different time points, including 1 day before surgery, 1 day after surgery and before discharge. These laboratory data included total protein (TP), albumin (ALB), prealbumin (PA), total lymphocyte count (TLC) and C-reactive protein (CRP). Besides that, the postoperative exhaust time, the hospitalization time and the incidence of complications were also needed to be collected to reflect the effectiveness of different nutritional support methods.

All complications and events were recorded (infectious, sepsis, pneumonia, water retention and respiratory, renal, cardiac, and metabolic complications).

Statistical analysis

We conducted the statistical analyses in SPSS 22.0. All data values are expressed as mean ± standard deviation. One-way analysis of variance was used to compare multiple groups. Time since baseline randomization was included in the model as a categorical variable, and the group × time interaction was treated as the fixed effect in the model and was the primary effect of interest. Other potential confounders included in the model as fixed effects were age and sex. P < 0.05 was deemed statistically.

Results

At baseline, there were no significant differences in the baseline characteristics of the three groups (P > 0.05) (Table 1).Table 1 Baseline data of patients with gastric cancer

	Control group (n = 60)	ONS group
(n = 60)	SPN + ONS group (n = 60)	P	
Age	60.3 ± 12.2	62.8 ± 13.6	59.1 ± 9.0	0.294	
Gender (male)	32 (53.3%)	32 (53.3%)	34 (56.7%)	0.162	
Height (cm)	167.4 ± 7.5	169.5 ± 6.3	168.3 ± 6.5	0.372	
Weight (kg)	52.3 ± 12.4	53.8 ± 12.3	54.6 ± 10.8	0.240	
BMI (kg/m2)	21.2 ± 3.4	20.9 ± 4.0	21.7 ± 3.1	0.221	
TP (g/L)	50.8 ± 5.7	52.4 ± 5.8	51.2 ± 5.3	0.623	
ALB(g/L)	31.3 ± 3.8	32.4 ± 5.1	31.5 ± 3.2	0.137	
PA (mg/L)	134 ± 16.1	129 ± 18.5	131 ± 17.4	0.279	
TLC(× 109/L)	1.1 ± 0.4	1.2 ± 0.3	1.2 ± 0.4	0.304	
CRP (mg/L)	4.8 ± 0.8	5.1 ± 0.9	4.7 ± 0.7	0.216	
Values are presented as mean ± SD

TP: total protein, ALB: albumin, PA: prealbumin, TLC: total lymphocyte count; CRP: C-reactive protein

Comparison of nutritional and inflammatory status

As shown in Table 2, compared with the control group, there were differences in ALB before discharge, in PA on the first day before surgery, and in CRP and TLC on the first day after surgery in the ONS group and the SPN + ONS group (P < 0.05). Compared with the ONS group, the SPN + ONS group showed differences in the above indicators (P < 0.05).Table 2 Comparison of relevant indicators among the three groups

	Time	Control group (n = 60)	ONS group
(n = 60)	SPN + ONS group (n = 60)	P-time	P-group	P-time × group interaction	
TP

(g/L)

	1st day before surgery	51.6 ± 6.1	52.1 ± 7.2	51.5 ± 5.5	0.426	0.242	0.268	
1st day after surgery	50.1 ± 6.3	51.2 ± 6.9	50.7 ± 5.3				
Before discharge	52.4 ± 5.9	52.8 ± 5.7	51.9 ± 4.7				
ALB

(g/L)

	1st day before surgery	30.8 ± 4.1	33.6 ± 6.1	32.9 ± 4.0	0.267	0.043	0.327	
1st day after surgery	27.9 ± 4.5	27.4 ± 4.4	28.9 ± 2.9				
Before discharge	29.2 ± 3.7a	31.8 ± 4.1b	34.5 ± 3.2ab				
PA

(mg/L)

	1st day before surgery	149.2 ± 18.9a	164.2 ± 19.8b	185.4 ± 19.9ab	0.353	0.035	0.361	
1st day after surgery	140.1 ± 16.2	151.1 ± 20.3	157.3 ± 18.1				
Before discharge	173.4 ± 15.7	177.5 ± 20.5	188.3 ± 16.0				
CRP

(mg/L)

	1st day before surgery	4.8 ± 0.8	5.1 ± 0.9	4.7 ± 0.7	0.132	0.028	0.276	
1st day after surgery	16.7 ± 1.3a	12.3 ± 1.1b	6.8 ± 1.2ab				
Before discharge	4.5 ± 0.5	4.3 ± 0.6	5.1 ± 0.4				
TLC

(mg/L)

	1st day before surgery	1.1 ± 0.2	1.2 ± 0.3	1.0 ± 0.2	0.115	0.025	0.214	
1st day after surgery	0.54 ± 0.2a	1.18 ± 0.2b	2.73 ± 0.1ab				
Before discharge	1.5 ± 0.3	1.4 ± 0.2	1.3 ± 0.2				
Values are presented as mean ± SD

TP: total protein, ALB: albumin, PA: prealbumin; CRP: C-reactive protein; TLC: total lymphocyte count

Groups sharing the same superscript (a or b) have no significant difference from each other in the post hoc analysis (p ≥ 0.05)

Comparison of prognosis

As shown in Table 3, there was no significant difference in the postoperative exhaust time, hospital stay and incidence of complications (P > 0.05).Table 3 Comparisons of prognosis among the three groups

	Control group (n = 60)	ONS group
(n = 60)	SPN + ONS group (n = 60)	P	
Postoperative exhaust time (days)	2.7 ± 0.4	2.4 ± 0.5	2.6 ± 0.3	0.157	
Hospital stay (days)	17.0 ± 6.4	17.8 ± 8.4	16.4 ± 7.8	0.629	
Infection	6	7	5		
Anastomotic fistula	1	0	1		
Obstruction	1	1	1		
Gastric evacuation disorders					
Abdominal distention	3	3	4		
Vomiting	3	4	2		
Complications

N (%)

	14 (23.3)	15 (25.0)	13 (21.7)	0.524	
Values are presented as mean ± SD or percentages

Discussion

In recent years, the impact of nutritional support on nutritional and clinical outcomes has been evaluated in a growing number of studies. However, the effect of different nutritional protocols is still controversial, especially SPN. This research aims to assess the effects of the preoperative SPN in gastric cancer patients.

Gastric cancer, as a common digestive system tumor, is often prone to malnutrition, and elective surgery may exacerbate malnutrition [8]. Many gastric cancer patients have significantly reduced oral food intake and changes in nutrition and inflammation may lead to poor prognosis. Assessment of perioperative nutritional and inflammatory status is necessary to optimize treatment of gastric cancer [9]. The current study revealed that the preoperative SPN may improve nutrition and inflammation in patients with gastric cancer undergoing surgery, but has no significant effect on their prognosis. This is consistent with the findings of a meta-analysis [10]. Another meta-analysis showed that the incidence of all complications was comparable for oral feeding with or without ONS and PN [11]. One study clearly showed that SPN did not have any benefit on the quality of life of patients [12]. PN had no significant effect on health-related quality of life or survival in patients with incurable cancer who were randomized to receive optimized nutritional care with or without SPN [13]. The main cause of PN failure was the short survival time of the study population.

However, there were also different research conclusions. For patients with advanced gastrointestinal cancer, SPN not only prevents weight loss, but may also lead to an increase in fat free mass. Although no difference in survival was recorded, the quality of life improved at 12 weeks in the SPN group [14]. This may be due to the relatively long intervention time of this study. A study indicated that SPN can bring important clinical and quality of life benefits to cancer patients [15]. The previous studies on SPN in critically ill patients have shown that adequate levels of protein and energy could improve clinical outcomes [16, 17]. These conclusions are inconsistent with our research findings and that may be related to inconsistent study population, nutritional protocols or intervention time.

A prospective cohort study showed that the predictive factor significantly associated with decreased survival was weight loss (> 15%) in the 3 months before PN start [18]. Unfortunately, we did not pay attention to the patient's previous weight. Body composition changes in cancer patients with SPN have been studied previously. As a supplement to oral diet, early short-term (7 days) SPN could improve muscle strength and body composition in cancer patients [19]. Another study indicated that the advanced cancer patients experienced significantly improved nutritional status, BMI and body weight with SPN [20]. An early 7-day SPN regimen demonstrated improvement in body composition, handgrip strength, and serum pre-albumin levels [19]. However, these studies are limited by the fact that they have been carried out without a control group. As a supplement to ONS, the application of SPN in incurable gastrointestinal cancer patients can prevent loss of fat free mass and even increase fat free mass [14]. However, it failed to distinguish whether this was caused by increased cellular mass or water. We will focus on changes in body composition in future research.

The proper perioperative nutrition support would improve outcomes for patients with cancer [21, 22]. But in this study, we did not observe any differences in other indicators except for nutritional status and inflammation. Enteral nutrition is superior to parenteral nutrition for preoperative nutrition support, and may be performed through a nasogastric or a nasointestinal tube [23]. We speculate that this may be one of the reasons why no differences were observed in the supplementary SPN.

The limitation of the present study was that the sample size was small and that it came from a single center. In addition, it was a retrospective study without the appropriate environmental controls of a randomized control trial. Third, we did not make follow-up after discharge. More research is needed to determine the best nutritional protocols for the cancer patients.

Conclusions

In malnourished patients who are not receiving full nutritional support, SPN should be considered from the time of hospital admission. It helps in increasing energy and protein intakes and improving the nutritional and inflammatory status of cancer patients. Early initiation of SPN may play a “permissive” role in improving cancer treatment compliance and dose maintenance.

Author contributions

Xiaoyan Huang, Changxing Cui and Jing Wang equally contributed to the conception and design of the research; Dongchi Kong contributed to the design of the research; Peng Huang contributed to the acquisition and analysis of the data; Changxing Cui and Yuanqing Cui contributed to the interpretation of the data; Xuelong Li and Xiaoyan Huang drafted the manuscript. All authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Xiaoyan Huang, Changxing Cui, Jing Wang and Dongchi Kong contributed equally to this work.
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