Ann Hepatobiliary Pancreat Surg.  2020 Nov;24(4):396-414. 10.14701/ahbps.2020.24.4.396.

Perioperative immunonutrition in hepatectomy: A systematic review and meta-analysis

• Wong CS
• Praseedom R
• Liau SS

• KMID: 2508848
• DOI: http://doi.org/10.14701/ahbps.2020.24.4.396

Abstract

Backgrounds/Aims
The role of immunonutrition (IMN) after liver resections or hepatectomies remains unclear and controversial. We undertook a systematic review to evaluate the effects of IMN on clinical outcomes of patients undergoing hepatectomy.
Methods
Main electronic databases were searched for randomised trials reported clinical outcomes or effects of IMN. The systematic review was conducted in accordance with the PRISMA guideline and meta-analysis was analysed using fixed or random-effects models.
Results
Eleven RCTs were identified. A total of 1084 patients (529 IMN and 555 Control) were included in the final pooled analysis. Of these patients, 43% (440/1016) underwent major hepatectomies and the majority are for hepatocellular carcinoma (90%, 956/1055) with Child-Pugh A disease (89%, 793/894). IMN significantly reduced post-operative wound infection (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.43 to 0.96; p=0.03). IMN also had a shorter hospital stay (MD −4.97 days, 95% CI −8.23 to −1.72; p=0.003). There was no statistically significant in other post-operative morbidities and mortality.
Conclusions
Wound infection rate was not significantly different between oral and parenteral IMN group. The length of hospital stay was significantly lower in parenteral IMN group than in oral IMN group. The mortality rates were not affected. Immunonutrition should be recommended routinely as part of the nutritional support in the Enhanced Recovery after Surgery (ERAS) protocol for hepatectomy.

Keyword

Immunonutrition; Hepatectomy; Complication; Liver resection

Figure

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  Fig. 1 PRISMA flow diagram. RCT, randomised controlled trial.

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  Fig. 2 (A) Histogram depicts the proportion or number of male and female patients in both IMN and control group. (B) Histogram depicts the number of major and minor liver resection in both IMN and control group. (C) Histogram depicts the proportion on Child-Pugh A, B, and C in both IMN and control group. IMN, immunonutrition.

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  Fig. 3 Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.

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  Fig. 4 Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.

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  Fig. 5 Test of heterogeneity of selected randomized controlled trials on clinical impact of perioperative immunonutrition in hepatectomy. Funnel plots of comparison: immunonutrition versus controlled group for outcomes based on overall pooled data for (A) wound infection (B) length of hospital stay (C) bile leak (D) liver failure (E) mortality.

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  Fig. 6 Comparison IMN Vs control group. Outcome: wound infection.

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  Fig. 7 Comparison IMN Vs control group. Outcome: LOS.

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  Fig. 8 Comparison IMN Vs control group. Outcome: bile leak.

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  Fig. 9 Comparison IMN Vs control group. Outcome: liver failure.

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  Fig. 10 Comparison IMN Vs control group. Outcome: ascites.

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  Fig. 11 Comparison IMN Vs control group. Outcome: ileus.

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  Fig. 12 Comparison IMN Vs control group. Outcome: mortality.

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  Fig. 13 Effect of preoperative and post-operative oral IMN on wound infection.

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  Fig. 14 Effect of preoperative and post-operative parenteral IMN on wound infection.

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  Fig. 15 Effect of preoperative and post-operative oral IMN on LOS.

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  Fig. 16 Effect of preoperative and post-operative parenteral IMN on LOS.

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  Fig. 17 Sensitivity analysis on primary outcome, wound infection.

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  Fig. 18 Sensitivity analysis on primary outcome, LOS.

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