Explain this table (shown in picture) from a study with the help of the information below and additional information from the article (shown in picture):
Explain this table (shown in picture) from a study with the help of the information below and additional information from the article (shown in picture):
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Explain this table (shown in picture) from a study with the help of the information below and additional information from the article (shown in picture):
Primary liver cancer is one of the most prevalent life- threating diseases in China, and liver resection is the major therapy for this malignancy. Recently, various methods have been advocated perioperatively to maintain liver function and promote liver regener- ation after liver resections. These include systemic interventions such as antibiotics in perioperative period and methods to improve general health and the immunity of the individual such as prebiotics and probiotics. Among them, nutritional support is also a vital approach to protect liver function. It has been demonstrated that a good preoperative nutri- tional status could reduce the postoperative morbidity or mortality and consequently the costs of care after surgery. Moreover, malnutrition is frequent in patients suffering from malignant liver disease. Optimization of nutritional status may improve hepatic function, and preoperative nutritional status is one of the key points for success of liver resection. Enteral nutrition was suggested by the ESPEN as the first choice for liver cancer patients and should be initiated within 12–24 h postoperatively to reduce infection rate. Whole protein formulae and concentrated high-energy formulae are generally recommended as enteral nutrition for patients following liver resection. As a renewed EN, TP-MCT contains 20% and 30% of total energy from protein and fat, respectively. Total protein effectively improve the level of albumin in patients. The fat contains 60% MCT in the enriched nutrition in order to supply energy quickly, promote fat digestion and absorption, and also reduce fat diarrhea. The postoperative patients were in a status of high catabolism and negative nitrogen balance. Intervention with enteral nutrition of different composition improves calorie supply as well as protein intake for patients after major operations. Meanwhile, MCT hydrolyzes faster in the gut. Although median duration of hospital stay and length of postoperative hospital stay were shorter in the treatment group, the difference were not signifi- cant (P 1⁄4 0.484 and P 1⁄4 0.514) (Table 2). In contrast to hospital stay, we found a significant reduction in the time to first flatus in the treatment group, when compared with control group (1.0 (1.0–2.0) d vs. 2.0 (2.0–2.0) d; P 1⁄4 0.001). Consistent with this, the time to first defecation was significantly shorter in the treatment group. The median time to first defecation was 3.0 (2.0–4.0) d in the control group and 2.0 (2.0–3.0) d in the treatment group (P < 0.001) (Table 2).
The intraoperative characteristics, including type of hepatectomy, blood loss and blood transfusion, did not show any significant difference between the control group and the treatment group (Table 1). It showed a significantly reduced surgery time in the treatment group compared with that in the control group (P 1⁄4 0.029). The value of Pringle maneuver time was significantly lower in the treat- ment group than that in the control group (P1⁄40.016).
The decrease of carnitine production in patients with liver dysfunction directly affects the oxi- dation and energy supply of LCFA. MCT oxidation process is short and can provide energy for human body quickly. This is also the reason why the state of negative nitrogen balance can be quickly corrected, and protein decomposition can be reduced in the treatment group in this study.
There are several limitations in this study which need further discussion and exploration. First, limited number of patients were included in outcome analysis although this is a multicenter, prospective, randomized controlled trial. In addition, our results might have been confounded by the absence of standardiza- tion and supervision among the participating centers. Study protocols were compared before the start of the study, and most protocol components were applied similarly in all hospitals. However, adherence to the protocol was not monitored continuously during the trial, leading to possible bias. Finally, our trial did not have a group to assess the impact of a placebo, but as appreciated it is impossible for our study to compose a placebo group.
In conclusion, this study provided evidence that protein-enriched enteral nutrition (TP-MCT) improves postoperative recovery for patients with pri- mary liver cancer following hepatectomy.
Transcribed Image Text:There was significant reduction in serum TBil at
day 1 and 7 in the treatment group when compared
with control group (P=0.022 and 0.042, respectively).
The level of Alb and at day 1 in the treatment group
was higher than that in the control group (P=0.040).
The level of prealbumin at day 7 in the treatment
group was higher than that in the control group
(P=0.044). The value of prothrombin time (PT) at
day 1, 4, and 7 were significantly lower in the treat-
ment group than that in the control group (P=0.002,
0.012, and 0.018, respectively). The value of INR at
day 1 and 4 were significantly higher in the control
group than that in the treatment group (P=0.008 and
0.014, respectively). The value of variation of the
sebum thickness was significantly higher in the treat-
ment group than that in the control group (P=0.028)
(Table 2).
Discussion
In this multicenter, prospective, randomized con-
trolled trial, protein-enriched enteral nutrition (TP-
MCT) improved postoperative outcomes for patients
with primary liver cancer followed hepatectomy. The
role of enteral nutrition in major surgery is still con-
troversial. In the present study, postoperative MCT
and protein-enriched EN after gastrointestinal surgery
have been shown to improve the prealbumin level and
shortens the length of hospital stay without a high
rate of adverse reaction (13). A program of gastro-
intestinal rehabilitation and early postoperative enteral
nutrition was associated with reduced postoperative
complications and improved clinical outcomes in
patients undergoing gastrointestinal surgery for cancer
(21). Meanwhile, data from patients undergoing major
hepatobiliary resection show evidence that preopera-
tive immunonutrition reduced inflammatory responses
and protected against the aggravation of postoperative
complications in patients undergoing major hepato-
biliary resection (22). However, Emmeline G Peters
et al. (23) observed no advantage of perioperative
lipid-enriched enteral nutrition on postoperative com-
plications in patients undergoing elective colorectal
surgery. Similar results found by Miyauchi et al. (24)
showed that there were no additional effects of peri-
operative, compared with preoperative, immunonutri-
tion on postoperative immunity and infectious
complications in patients undergoing pancreaticoduo-
denectomy. In regards to patients undergoing hepatic
surgery for liver cancer, a prospective, placebo-con-
trolled, randomized, double-blind study demonstrated
that a 10-day perioperative nutritional
supplementation with oral impact does not improve
hepatic function, immune response, and resistance to
infection (25). In this study, we found that protein-
enriched enteral nutrition (TP-MCT) promoted early
recovery of bowel function for patients with primary
liver cancer following hepatectomy, through a reduc-
tion in the time to first flatus and the time to first
defecation. The treatment group was associated with
lower postoperative TBil, lower PT and INR, and
higher Alb and prealbumin, which means that TP-
MCT could also boost liver function recovery.
Our results showed a difference between groups on
the secondary endpoints but not on the main end-
points. This protocol designed to improve outcomes
after liver resection, such as the enhanced recovery
after surgery (ERAS) program. The ERAS program is
widely applied in many countries around the world,
particularly in Europe and United States (26). The
ERAS program has been associated with an acceler-
ated gastrointestinal recovery, lower postoperative
complication rates and a reduction in length of hos-
pital stay (27-31). A recent study also showed that
early enteral nutrition can improve nutritional status
and promote intestinal function recovery for patients
undergoing colorectal cancer surgery (32). In this
study, perioperative enteral nutrition (TP-MCT) is
related with enhanced gastrointestinal function
because MCT in TP-MCT can prevent or alleviate
intestinal damage caused by endotoxin and restore
intestinal function more quickly.
Intestinal congestion, edema and impaired intes-
tinal barrier function were common in patients after
liver resection. In patients with cirrhosis and portal
hypertension, intestinal bacterial translocation and
endotoxemia within portal vein system are more ser-
ious. On the other hand, the structure and function of
hepatocytes were damaged, bile excretion was dis-
turbed, and ability to fat metabolism was reduced
after surgery (25, 33). Therefore, the routine food
intake are not suitable for the special gastrointestinal
status in patients undergoing hepatectomy. At present,
there are many kinds of enteral nutrition formulas
available for clinical use, and the composition and
nutritional value are quite different. In this study, pro-
tein-enriched enteral nutrition (enteral nutritional sus-
pension, TP-MCT, Nutricia, China) was chosen
because it contains a higher proportion of MCT
(MCT/LCT = 1.5:1, three times higher than other
products) and choline. The absorption of MCT is sim-
pler and faster. MCT is absorbed into the body to
form medium-chain fatty acids (MCFA). MCFA can
directly enter the mitochondria of hepatocytes and
Transcribed Image Text:Table 2. Postoperative profiles.
Duration of hospital stay (d)
Length of postoperative hospital stay (d)
Time to first flatus (d)
Time to first defecation (d)
Time to tracheal extubation (h)
Length of intensive care unit stay (h)
Indwelling time of the catheterization (h)
Indwelling time of the gastric tube (h)
Indwelling time of the abdominal drainage tube (h)
ASebum thickness (cm)
ALT (U/I)
d₁
d₂
d₂
AST (U/I)
d₁
da
d7
Alb (g/l)
d₁
da
d₂
AKP(U/1)
d₁
da
d₂
TBil (μmol/l)
d₁
da
d₂
DBil (μmol/l)
d₁
d₂
d₂
Prealbumin (mg/l)
d₁
d₂
d₂
Lymphocyte (109/1)
d₁
da
d₂
Cr (μmol/l)
d₁
da
d₂
WBC (10/1)
d₁
da
d₂
Hb (g/l)
d₁
d₂
d₂
PLT (10/1)
d₁
da
d₂
PT (s)
d₁
da
d₂
INR
d₁
d₂
d₂
Control group (n=68)
18.00 (16.00-20.00)
10.00 (8.00-13.00)
2.00 (2.00-2.00)
3.00 (2.00-4.00)
2.15 (0.50-4.77)
0.00 (0.00-11.75)
24.00 (18.50-40.00)
0.00 (0.00-0.00)
6.00 (4.00-10.00)
0.10 (0.00-0.20)
188.10 (97.03-307.60)
142.90 (85.52-210.22)
70.50 (44.45-109.45)
188.65 (111.65-288.20)
59.95 (40.00-87.90)
31.55 (22.65-36.72)
32.84 +3.97
33.49±3.93
33.84±4.77
78.90 (60.77-124.50)
81.25 (67.10-103.20)
91.45 (70.97-110.92)
24.29 (15.80-32.12)
23.31 (16.40-31.84)
17.15 (13.32-24.19)
8.05 (5.22-13.23)
8.30 (6.38-12.05)
5.90 (4.52-9.45)
133.34+52.20
95.59 ± 40.82
101.15+41.94
0.75 (0.50-0.99)
1.07 (0.75-1.38)
1.46 (1.02-1.70)
66.00 (56.50-77.22)
59.90 (53.55-68.17)
64.00 (54.70-70.00)
13.35±4.94
7.40 (6.43-9.25)
7.42 (5.96-9.13)
130.84 +17.56
118.61 ±18.99
121.14 ±18.77
140.54 ±56.40
113.00 (90.75-163.30)
157.01 +53.13
13.80 (12.72-14.70)
13.55 (12.60-14.40)
13.55 (13.00-14.45)
1.21 (1.15-1.31)
1.20 (1.14-1.29)
1.20 (1.15-1.28)
Treatment group (n=74)
17.00 (14.75-22.00)
10.00 (8.00-13.00)
1.00 (1.00-2.00)
2.00 (2.00-3.00)
2.00 (0.50-4.08)
0.00 (0.00-0.00)
24.00 (20.75-36.25)
0.00 (0.00-0.00)
5.50 (3.00-8.00)
0.10 (0.08-0.30)
164.00 (105.35-245.83)
128.20 (80.12-207.55)
58.65 (38.40-91.02)
163.40 (97.67-279.02)
55.45 (32.30-96.35)
30.45 (21.27-43.22)
34.16±3.63
33.49 3.10
34.32 ±3.11
85.80 (61.75-124.50)
82.55 (65.15-106.00)
88.00 (69.47-114.00)
19.30 (13.07-29.17)
19.22 (15.45-27.32)
14.80 (10.09-20.80)
6.54 (4.69-9.69)
7.20 (5.29-11.83)
5.53 (4.00-8.67)
140.25 +38.57
105.74±30.81
118.37+45.61
0.68 (0.52-1.00)
1.00 (0.72-1.31)
1.40 (1.00-1.80)
63.15 (52.45-70.40)
57.90 (51.00-69.92)
59.40 (51.82-71.20)
12.61 ±4.71
7.39 (5.27-9.57)
7.80 (5.59-9.26)
127.98 ± 17.98
117.49 +17.37
117.81 +17.58
142.01 +61.74
128.00 (86.50-173.30)
177.52+75.40
12.90 (12.20-13.80)
12.90 (11.97-14.10)
13.15 (12.25-14.12)
1.15 (1.08-1.23)
1.15 (1.06-1.25)
1.17 (1.08-1.27)
P value
0.484
0.514
0.001
<0.001
0.358
0.249
0.847
0.628
0.161
0.028
0.271
0.387
0.120
0.255
0.789
0.984
0.040
0.995
0.484
0.536
0.980
0.870
0.022
0.072
0.042
0.055
0.079
0.397
0.436
0.148
0.044
0.783
0.750
0.814
0.108
0.563
0.341
0.363
0.319
0.810
0.341
0.715
0.278
0.883
0.504
0.062
0.002
0.012
0.018
0.008
0.014
0.081
Alb, Albumin; WBC, White blood cell; Hb, Hemoglobin; PLT, Platelets; ALT, Alanine aminotransferase; AST, Aspartate aminotransferase; AKP, Alkaline phos-
phatase; TBil, Total bilirubin; DBil, Direct bilirubin; Cr, Creatinine; PT, Prothrombin time; INR, International Normalized Ratio. Significant differences of
data between the two groups were shown in bold values. P values <0.05 were considered statistically significant.
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