Intervention Review

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Perioperative nutrition interventions for women with ovarian cancer

  1. Hazel A Billson1,*,
  2. Cathrine Holland2,
  3. Janet Curwell1,
  4. Valerie L Davey1,
  5. Laura Kinsey1,
  6. Lianna J Lawton1,
  7. Alison J Whitworth1,
  8. Sorrel Burden3

Editorial Group: Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group

Published Online: 11 SEP 2013

Assessed as up-to-date: 31 JUL 2013

DOI: 10.1002/14651858.CD009884.pub2


How to Cite

Billson HA, Holland C, Curwell J, Davey VL, Kinsey L, Lawton LJ, Whitworth AJ, Burden S. Perioperative nutrition interventions for women with ovarian cancer. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009884. DOI: 10.1002/14651858.CD009884.pub2.

Author Information

  1. 1

    Manchester Royal Infirmary, Dietetic Department, Platt 2 Rehabilitation, Manchester, UK

  2. 2

    Central Manchester NHS Trust, Gynaecological Oncology, Manchester, UK

  3. 3

    University of Manchester, School of Nursing, Midwifery and Social Work, Manchester, UK

*Hazel A Billson, Dietetic Department, Platt 2 Rehabilitation, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK. Hazel@billson.org. Hazel.Billson@cmft.nhs.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 11 SEP 2013

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Characteristics of included studies [ordered by study ID]
Minig 2009a

MethodsRandomised controlled trial


ParticipantsWomen aged 18 to 75 with preoperative diagnosis of gynaecological malignancy undergoing laparotomy with associated intestinal resection, at the European Institute of Oncology, Milan, Italy between 2007 to 2008. 18/22 women in the intervention group had ovarian cancer (82%) in comparison with 17/18 women (94%) in the control group. Other women in the study had either cancer of the endometrium or fallopian tube; FIGO staging was not reported. The median age of the women in the intervention group was 54 and in the control group was 58 (not significantly different). Sixty-two per cent of the women had undergone previous unspecified surgery while a smaller number (17%) had been given preoperative chemotherapy in the preceding six months. The women in the study underwent a variety of surgical procedures, the most frequent of which included rectosigmoid (large bowel) resection (75% of women), 70% had hysterectomy (removal of womb) and/or adnexectomy (removal of fallopian tubes and/or ovaries) and the same number had omentectomy (removal of the abdominal lining). Upper abdominal surgery occurred in 38% of the women, there were no significant differences between the intervention and control group in the types of surgery that occurred, in the median operative time or in intraoperative complications, which occurred in 35% of the patients. Perioperative care was standardised during the study and included preoperative bowel preparation, naso-gastric tube insertion for the duration of surgery and pharmacological regimes for pain, nausea and vomiting. Discharge from hospital occurred when regular diet had been tolerated for at least 24 hours with the resumption of bowel function and when normal clinical measures and physical examination were satisfactory.


InterventionsNutrition status was evaluated using subjective global assessment and a standardised questionnaire to categorise women as well nourished, moderately nourished or severely malnourished, patients categorised as severely malnourished were excluded from the trial. Postoperatively, early oral feeding (EOF) was compared with a "traditional" postoperative feeding regimen (TOF). Patients in the EOF were offered liquids (mineral water, tea, chamomile infusion or apple juice) during the first 24 hours postoperatively; after 24 hours, if liquids were well tolerated, the women commenced on a regular diet of beef, chicken or fish for the duration of hospital stay. Patients allocated to the TOF regimen remained 'nil by mouth' until there was evidence of bowel sounds and passage of flatus, after which, if they did not have nausea and emesis, they were switched to an oral liquid diet for 24 hours, provided this was well tolerated, they were placed on a semi-solid diet for a further 24 hours and again if this was well tolerated, they were then prescribed the regular diet.


OutcomesThe primary outcome was length of hospital stay. Other outcome measures examined were recovery of intestinal activity, intensity of abdominal pain, presence of nausea and vomiting, postoperative complications, analgesic and antiemetic drug requirements, patient satisfaction level and QoL (assessed by standard questionnaires EORTC QLQ-C30 and EORTC QLQ-OV28). Following discharge from hospital, outcomes continued to be assessed with weekly telephone calls for the subsequent 30 days.


NotesExclusions preoperatively were for any of: infection, intestinal obstruction, severe malnutrition, ASA score ≥ 4 or planned pelvic exenteration; postoperative exclusion from the study was made if admission to ICU ≥ 24 hours or if the malignancy was found to be non-gynaecologic.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer web-based randomisation (TENALEA 2013).

Allocation concealment (selection bias)Low riskWeb-based randomisation was used prior to commencement of intervention.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskMore than 20% of patients (22%) were randomised but then excluded from the trial and the analysis, however post-intervention exclusion was for pre-determined reasons (admission to ICU for ≥ 24 hours, non-gynaecologic malignancy).

Selective reporting (reporting bias)Unclear riskPrimary and secondary end-points were reported. Trial protocol was not seen.

Other biasLow riskAlthough there was an significant imbalance in the groups for estimated blood loss (EBL) and FIGO stage and volume of ascites were not reported, the authors report that these factors did not have a significant impact on either nutritional group in terms of length of hospital stay.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskInsufficient information to assess risk of bias.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information to assess risk of bias.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Celik 2009Fewer than 75% of the women in this RCT had ovarian cancer (32%). The study is a comparison of two types of enteral feeding given perioperatively to women with gynaecological malignancies.

Cutillo 1999Fewer than 75% of the women in this RCT had ovarian cancer (48%). The study examined early postoperative oral feeding in comparison with nasogastric decompression and delayed feeding in women who had major surgery for gynaecological cancer.

Feng 2008Fewer than 75% of the women in this RCT had ovarian cancer (18%). This study evaluated the introduction of a semi-liquid diet in comparison with clear fluids, 6 hours after major abdominal surgery for gynaecological cancer.

Gerardi 2008Not a RCT (prospective and retrospective comparison). The study is an evaluation of a clinical pathway which included rapid diet advancement following cytoreductive surgery with intestinal resection.

Marx 2006Not a RCT (prospective and retrospective comparison). The study evaluated the introduction of a multi-modal rehabilitation programme including early oral feeding in comparison with conventional care in women undergoing surgery for ovarian cancer.

Minig 2009bFewer than 75% of the women in this RCT had ovarian cancer (58%). This study compared early oral feeding and traditional oral feeding in women following major abdominal surgery for gynaecological cancer.

Nuutinen 1982RCT was not undertaken in the perioperative phase of treatment for ovarian cancer. A study of nutrition support during chemotherapy for gynaecological cancer.

Pearl 1998Fewer than 100% of the women in this RCT had cancer (75%) Fewer than 75% of the women in this RCT had ovarian cancer (32%). This study compared the early introduction of a liquid diet in comparison with delayed postoperative feeding in women undergoing gynaecological intra-abdominal surgery.

Pearl 2002Fewer than 100% of the women in this RCT had cancer (79%) Fewer than 75% of the women in this RCT had ovarian cancer (33%). This study compared the effect of introducing a normal diet in comparison with clear liquids one day after intraabdominal gynaecological surgery.

Schilder 1997Fewer than 100% of the women in this RCT were diagnosed with cancer (55%). An evaluation of early postoperative oral feeding in women following major gynaecological surgery.

Spirtos 1988Fewer than 75% of the women in this RCT had ovarian cancer (49%). An evaluation of postoperative feeding of an elemental diet via jejunostomy tube in comparison with a control group given IV fluids.

Steed 2002Fewer than 100% of the women in this RCT were diagnosed with cancer (58%). This study examined early postoperative oral feeding in comparison with delayed feeding in 96 women undergoing major abdominal gynaecological cancer.

Tan 2002No indication in the text (translated from Chinese) that randomisation had been used to allocate the women to the intervention and control groups.

 
Characteristics of ongoing studies [ordered by study ID]
QCGC OPEN study

Trial name or titlePost-operative enteral nutrition in patients with epithelial ovarian cancer (OPEN)

MethodsInterventional randomised controlled trial

ParticipantsWomen aged over 18 undergoing planned cytoreductive surgery for ovarian, primary peritoneal or fallopian tube cancer who have been identified as having signs of moderate or severe malnutrition using the Patient-Generated Subjective Global Assessment method..

InterventionsWomen will be randomised to commence enteral (tube) feeding directly into the small bowel, commencing 4 hours postoperatively, after 24 hours feeds will be gradually increased to an individualised goal rate, this will be in addition to standard post-surgery care. Women randomised to standard postoperative diet will be given intravenous fluids and increasing oral diet as tolerated.

OutcomesLength of stay in hospital and related costings, length of stay in intensive care unit or high dependency unit, Quality of life measured preoperatively, 6 weeks after surgery and following the 3rd course of postoperative chemotherapy, use of inotropic medication to support blood pressure and kidney function, using standardised questionnaire, intravenous treatment requirements, treatment-related adverse events, delay and dose reductions of chemotherapy administered postoperatively.

Starting dateFebruary 2009

Contact informationDana Middleton, Queensland Centre for Gynaecological Cancer, Level 6 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Herston Qld 4029, Australia Email: dana_middleton@health.qld.gov.au

Progress of studyCurrently recruiting

NotesClinicalTrials.gov Identification: NCT00850772