Francesco Chiappelli Ph.D
Although the length of hospital stay reduced, the underlying mechanism for beneficial effects of immunonutrition in patients treated surgically for head and neck cancer remain unclear.
This conclusion is based on six studies that addressed length of hospital stay as the outcome, none of which addressed key variables that would have directly affected this outcome.
In patients with head and neck cancer, does perioperative standard polymeric nutrition reduce length of hospital stay as compared to no nutritional supplementation with immunonutrition?
The authors searched PubMed, Embase, and Cochrane databases using the following MeSH terms: head and neck neoplasms, enteral nutrition, immune, arginine, immunonutrition, surgery, and jaw. They contacted pharmaceutical companies and trial authors for additional unpublished data. The authors assessed four aspects of trial quality: 1) generation of the allocation sequence; 2) concealment of allocation; 3) masking of outcome assessors and participants to treatment allocation during the trial; and 4) intention-to-treat (ITT) analysis. Data were expressed as odds ratio (OR) and a confidence interval of 95 percent at a level of significance a = 0.05. Data were pooled and interpreted using a random model of meta-analysis inference.
The authors identified 4,121 studies. After applying inclusion and exclusion criteria, the authors selected 10 trials for review. Six of the ten trials met all the criteria for quality assessment. There was some heterogeneity among the studies. Overall, pooled estimates showed a reduction in length of hospital stay by 3.5 days (95 percent CI, 0.7 to 63). The data failed to show reductions in any of the tested clinical complication outcomes, primarily because the clinical trials were small and had incomplete reporting of outcomes.
Nutritional supplementation with immunonutrition may reduce hospital stay, but the underlying mechanism remains unclear because no reductions were noted in associated clinical complications (e.g., wound infections, fistula formation) or death.
Source of Funding:
Unrestricted education grant, Numico research, Wageningen, The Netherlands
Importance and Context:
Patients with head and neck cancer often are malnourished. This patient population tends to have a high incidence of postoperative complications, a decreased quality of life and increased treatment costs. During a patient's perioperative period, immunotrition may be beneficial, but the evidence to support its benefit is inconclusive.
Strengths and Weaknesses of the Systematic Review:
The authors used accepted methods to identify and appraise the selected studies. They combined the data using a meta-analysis.
Strengths and Weaknesses of the Evidence:
The authors included 10 randomized controlled trials, six of which reported the outcome of interest (length of hospital stay). The studies inconsistently addressed clinical complications, which precluded the authors from making inferences about the possible effects of these complications on the observed result. The trials were small with incomplete reporting of outcomes.
Implications for Dental Practice:
The large expenditure on immuno-feeding and other supplements for dental patients with head and neck cancer demonstrates the urgency to improve treatment modalities. Adequately powered clinical trials should evaluate the possible physiological and economic benefits of immunonutrition.