Assessment of structured triglyceride emulsion in parenteral nutrition for abdominal surgery patients: A systematic review and network meta-analysis

Abstract

Background:Structured triglyceride (STG) is an emulsion synthesized from long and medium-chain triglycerides. It is a widely accepted lipid component of clinical parenteral nutrition treatment. However, conflict evidence observed for its safety and efficacy with the abdominal surgery patients.
Objective:We conducted a systematic review and network meta-analysis to systematically summarize the evidence for STG emulsions compared with physically mixed medium-chain/long-chain triglycerides (MCT/LCT) or long-chain triglycerides (LCT) in short-term abdominal surgery parenteral nutrition treatment.
Methods:We conducted a systematic search of PubMed, Cochrane Library, Web of Science, EMBASE and China National Knowledge Infrastructure (CNKI) to identify qualified studies published in English or Chinese. The search period ranged from the inception of each database to Oct 21, 2024. Eligible studies included trials of hospitalized patients aged 18 or older required parenteral nutrition therapy during short-term hospitalization following abdominal surgery, comparing STG with physically mixed MCT/LCT or LCT. Two independent reviewers extracted data via standardized methods and assessed the risk of bias using the Jadad score. Publication bias was evaluated via funnel plots and Egger's test.
Results:A total of 34 randomized controlled trials and controlled clinical trials involving 2154 participants were included. These studies showed high level of accountability, as demonstrated by a Jadad score of 3.29 out of 3.5. Significant heterogeneity was detected in studies reporting aspartate aminotransferase (AST), alanine aminotransferase, and triglyceride (TG) levels. The meta-analysis revealed better performance of STG in higher prealbumin (PA) levels weighted mean difference [WMD]: 1.49; 95 % confidence interval [CI]: 0.56 to 2.43), lower AST (WMD: − 12.49; 95 % CI: − 22.58 to − 2.40) and TG (WMD: − 0.30; 95 % CI: − 0.42 to − 0.18) levels compared to physically mixed MCT/LCT or LCT, but no significant difference for other factors.
Conclusion:This analysis demonstrated that STG has more positive effects for the patient nutritional level and lower level of liver harm, whereas MCT/LCT outperformed LCT in reducing AST levels as well. These findings suggest that STG is at least as safe and effective for hospitalized patients undergoing abdominal surgery, especially patients with hepatic insufficiency, as other lipids. However, further research is needed to confirm its advantages for each subgroup.

Keywords

Abdominal surgery / Lipid emulsion / Network meta-analysis / Parenteral nutrition

CRediT authorship contribution statement

Yashuang Luo: Search planning and key words drafting, data extraction Investigation. Yuen Chen: Writing -original draft, Formal analysis, Project administration, Data curation, Conceptualization, Methodology, Validation, Writing -review & editing. Haode Wang: Visualization, Project administration, Methodology, Data curation, Conceptualization, Project administration. Wendi Chen: Searching and data extraction, Data curation. Hui Sun: Supervision, Software, Investigation. Haiyin Wang: Conceptualization, Supervision, Funding acquisition. Yuyan Fu: Visualization, Data curation. All the authors have read and approved the final version of this manuscript.

Ethics approval

Not applicable (systematic review of published studies).

Funding information

None.

Data availability

The datasets of the study are available from the corresponding author on reasonable request.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

None.

Appendix A. Supplementary material

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.hcr.2025.100040.

References

[1] Berlana D.Parenteral nutrition overview. Nutrients. 2022; 14(21):4480. https://doi.org/10.3390/nu14214480

[2] Williams DGA, Molinger J, Wischmeyer PE. The malnourished surgery patient: a silent epidemic in perioperative outcomes? Curr Opin Anaesthesiol. 2019; 32(3):405-411. https://doi.org/10.1097/ACO.0000000000000722

[3] Vest MT, Papas MA, Shapero M, McGraw P, Capizzi A, Jurkovitz C. Characteristics and outcomes of adult inpatients with malnutrition. JPEN J Parenter Enter Nutr. 2018; 42(6):1009-1016. https://doi.org/10.1002/jpen.1042

[4] Cass AR, Charlton KE. Prevalence of hospital‐acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: a systematic review of the evidence. J Hum Nutr Diet. 2022; 35(6):1043-1058. https://doi.org/10.1111/jhn.13009

[5] Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F. ESPEN guidelines on parenteral nutrition: surgery. Clin Nutr. 2009; 28(4):378-386. https://doi.org/10.1016/j.clnu.2009.04.002

[6] Zhu M, Li X. Meta-analysis of structured triglyceride versus other lipid emulsions for parenteral nutrition. Nutrition. 2013; 29(6):833-840. https://doi.org/10.1016/j.nut.2012.11.014

[7] Mundi MS, Martindale RG, Hurt RT. Emergence of mixed‐oil fat emulsions for use in parenteral nutrition. JPEN J Parenter Enteral Nutr. 2017; 41(1S):3S-13S. https://doi.org/10.1177/0148607117742595

[8] Babayan VK. Medium chain triglycerides and structured lipids. Lipids. 1987; 22(6):417-420. https://doi.org/10.1007/BF02537271

[9] Kruimel JW, Naber TH, van der Vliet JA, Carneheim C, Katan MB, Jansen JB. Parenteral structured triglyceride emulsion improves nitrogen balance and is cleared faster from the blood in moderately catabolic patients. JPEN J Parenter Enteral Nutr. 2001; 25(5):237-244. https://doi.org/10.1177/0148607101025005237

[10] Wu GH, Zaniolo O, Schuster H, Schlotzer E, Pradelli L. Structured triglycerides versus physical mixtures of medium-and long-chain triglycerides for parenteral nutrition in surgical or critically ill adult patients: systematic review and meta-analysis. Clin Nutr. 2017; 36(1):150-161. https://doi.org/10.1016/j.clnu.2016.01.004

[11] Zhu M, Li X. Meta-analysis of structured triglyceride versus other lipid emulsions for parenteral nutrition. Nutrition. 2013; 29(6):833-840. https://doi.org/10.1016/j.nut.2012.11.014

[12] Li C, Ni Q, Pei Y, Ren Y, Feng Y. Meta-analysis of the efficacy and safety of structured triglyceride lipid emulsions in parenteral nutrition therapy in China. Clin Nutr. 2019; 38(4):1524-1535. https://doi.org/10.1016/j.clnu.2018.07.013

[13] Petropoulou M, Nikolakopoulou A, Veroniki AA, et al.Bibliographic study showed improving statistical methodology of network meta-analyses published between 1999 and 2015. J Clin Epidemiol. 2017; 82:20-28. https://doi.org/10.1016/j.jclinepi.2016.11.002

[14] Hutton B, Catalá-López F, Moher D. The PRISMA statement extension for systematic reviews incorporating network meta-analysis: PRISMA-NMA. Med Clin (Barc). 2016; 147(6):262-266. https://doi.org/10.1016/j.medcli.2016.02.025

[15] Tugwell P, Tovey D. PRISMA 2020. J Clin Epidemiol. 2021;134:A5-A6. https://doi.org/10.1016/j.jclinepi.2021.04.008

[16] Mirtallo JM, Ayers P, Boullata J, et al. ASPEN lipid injectable emulsion safety recommendations, Part 1: background and adult considerations. Nutr Clin Pract. 2020; 35(5):769-782. https://doi.org/10.1002/ncp.10496

[17] Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996; 17(1):1-12. https://doi.org/10.1016/0197-2456(95)00134-4

[18] Alam M, Rauf M, Ali S, Nodzenski M, Minkis K. A systematic review of reporting in randomized controlled trials in Dermatologic Surgery: jadad scores, power analysis, and sample size determination. Dermatol Surg. 2014; 40(12):1299-1305. https://doi.org/10.1097/DSS.0000000000000166

[19] White I. MVMETA: Stata module to perform multivariate random-effects meta-analysis. Accessed 20 Jan 2007.https://econpapers.repec.org/software/bocbocode/s456970.htm.

[20] Shim S, Yoon BH, Shin IS, Bae JM. Network meta-analysis: application and practice using Stata. Epidemiol Health. 2017;39:e2017047. https://doi.org/10.4178/epih.e2017047

[21] Watt J, Del Giovane C. Network meta-analysis. Methods Mol Biol. 2022; 2345:187-201. https://doi.org/10.1007/978-1-0716-1566-9_12

[22] Delgado-Rodríguez M, Sillero-Arenas M.Systematic review and meta-analysis. Med Intensiva (Engl Ed). 2018; 42(7):444-453. https://doi.org/10.1016/j.medine.2017.10.012

[23] Page MJ, McKenzie JE, Bossuyt PM, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372:n71. https://doi.org/10.1136/bmj.n71

[24] Sun ZJ, Liu ZY, Yao YC. Effects of structured lipid emulsion on postoperative metabolism and immune function in elderly patients with gastrointestinal malignant tumors. Clinical Medicine. 2021; 41(1):113-115. https://doi.org/10.19528/j.issn.1003-3548.2021.01.048

[25] Li CM, Cao YJ, Geng SP, Xu XX. Comparison of the effects of medium/long-chain triglyceride emulsion and long-chain triglyceride emulsion on postoperative patients with colorectal cancer. Medical Journal of Chinese People's Health. 2021; 33(8):129-131. https://doi.org/10.3969/j.issn.1672-0369.2021.08.052

[26] Chen JY, Liu Z, Zhong Y, Xie L, Chen H, Li JS. Application of structured lipid emulsion or medium/long-chain triglyceride emulsion in preoperative nutritional support for liver cancer and its impact on clinical outcomes. Modern Interventional Diagnosis and Treatment in Gastroenterology. 2020; 25(7):932-936. https://doi.org/10.3969/j.issn.1672-2159.2020.07.023

[27] Wang K, Dong GN, Yang YP. The effect of structural triglyceride on nutrition and immuno-globulin concentration of elderly rectal carcinoma patients. The Practical Journal of Cancer. 2019; 34(9):1435-1437. https://doi.org/10.3969/j.issn.1001-5930.2019.09.013

[28] Li YQ, Li F, Luan XR. Clinical effect and significance of adding structural fat emulsion to parenteral nutrition after radical gastrectomy for gastric cancer. Chinese Journal of Current Advances in General Surgery. 2019; 22(2):146-148. https://doi.org/10.3969/j.issn.1009-9905.2019.02.018

[29] Shi WZ, Song JH, Niu XJ, Li Z, Wei JM. Effect of Structured Triglycerides on Liver Function,Immune Function and Liver Regeneration Related Factors in Post-Operation Patients with Liver Cancer. Journal of Medical Research. 2019; 48(12):115-118,123. https://doi.org/10.11969/j.issn.1673-548X.2019.12.029

[30] Du LJ, Xing Y, Zhang B, Li X, Zhao J, Tian YH. Effect of medium and long chain fatty emulsion on gastrointestinal function,serum protein and cytokine levels in patients with colorectal cancer after operation. Laboratory Medicine and Clinic. 2018; 15(11):1579-1582,1586. https://doi.org/10.3969/j.issn.1672-9455.2018.11.013

[31] Peng N, Lyu F, Guo QX. Efficacy comparison of structured fat emulsion and medium/ long chain fat emulsion for nutritional support in liver carcinoma patients after hepatectomy. China Pharmacy. 2017; 28(2):250-253. https://doi.org/10.6039/j.issn.1001-0408.2017.02.30

[32] Cai JP, Wang YD, Zhang X, Xue HZ. Effect of structured fat emulsion and medium and long chain fat emulsion on liver function,protein metabolism,immunologic function and side effects in patients with pancreaticoduodenectomy. Journal of Clinical Surgery. 2017; 25(10):781-784. https://doi.org/10.3969/j.issn.1005-6483.2017.10.022

[33] Yu J, Wu G, Tang Y, Ye Y, Zhang Z. Efficacy, safety, and preparation of standardized parenteral nutrition regimens: three-chamber bags vs compounded monobags—a prospective, multicenter, randomized, single-blind clinical trial. Nutr Clin Pract. 2017; 32(4):545-551. https://doi.org/10.1177/0884533617701883

[34] Jiang N. Study on medium and long chain fat emulsion to improve immune function and nutritional status in gastric cancer patients. Chinese Archives of General Surgery (Electronic Edition). 2015; 9(5):30-33.

[35] Shi XL, Wang S, Wu YF, Tang N, Zhang WW, Ding YT. Effects of structured triglyceride on postoperative recovery of patients with primary liver cancer after hepatectomy:a prospective study. Chinese Journal of Digestive Surgery. 2015; 14(5):370-375. https://doi.org/10.3760/cma.j.issn.1673-9752.2015.05.005

[36] Ma CJ, Wu JM, Tsai HL, et al. Prospective double-blind randomized study on the efficacy and safety of an n-3 fatty acid enriched intravenous fat emulsion in postsurgical gastric and colorectal cancer patients. Nutr J. 2015;14:9. https://doi.org/10.1186/1475-2891-14-9

[37] Cao YQ, Feng WM. Application of structured triglyceride in alleviative treatment of malignant obstructive jaundice. Parenteral & Enteral Nutrition. 2014; 21(2):87-90.

[38] Chen HZ, Cai L, Zhang X. Comparison of the effects of structured triglyceride and medium/long chain triglycerides on liver function and serum lipid in critical patients. China Pharmacy. 2013; 24(24):2238-2240.

[39] Wu ZS, Zhang F, Wu XF. Effects of structured lipid emulsion on protein metabolism and immunologic function in patients with liver cancer. Jiangsu Medical Journal. 2013; 39(6):693-695.

[40] Lu M, Ye HW, Yu S, Feng YF, Zheng F. Clinical application of the structured triglyceride and physical mixed MCT/LCT in critically ill patients. Modern Medicine Journal of China. 2012; 14(7):8-10. https://doi.org/10.3969/j.issn.1672-9463.2012.07.003

[41] Su MS, He L, Liu ZW, Ma HX, Zhao QH, Zhang WZ. Applied studies of structured triglycerides for parenteral nutrition in severe hemorrhagic shock patients after resuscitation. National Medical Journal of China. 2012; 92(12):827-830. https://doi.org/10.3760/cma.j.issn.0376-2491.2012.12.010

[42] Yuan Y, Xu JM. Effects of structured triglycerides on nitrogen balance and protein metabolism in liver cirrhosis patients. Medical Journal of Chinese People's Liberation Army. 2012; 37(4):357-359.

[43] Kang HJ, Song Q, Zhou FH. Safety of structured triglyceride used in treatment of hyperbilirubinemia patients:A comparative study. Journal of Chinese PLA Postgraduate Medical School. 2011; 32(12):1235-1236, 1244.

[44] Luo HL, Luo Z. Effects of three different triglycerides on hepatic function in parenteral nutrition patients. Chinese General Practice. 2011; 14(10):1104-1106. https://doi.org/10.3969/j.issn.1007-9572.2011.10.017

[45] Mao XL, Mao HB, Liu QY, Chen JW. Effect of structured lipid emulsion on protein metabolism and immunologic function in gastrointestinal cancer. Medical Journal of Wuhan University. 2010; 31(4):495-498.

[46] Zhuo DQ, Qi P. Influence of structured triglyceride on the surgical patients with liver disease. Chinese Journal of Experimental Surgery. 2010; 27(12):1930-1932. https://doi.org/10.3760/cma.j.issn.1001-9030.2010.12.058

[47] Puiggròs C, Sánchez J, Chacón P, et al. Evolution of lipid profile, liver function, and pattern of plasma fatty acids according to the type of lipid emulsion administered in parenteral nutrition in the early postoperative period after digestive surgery. JPEN J Parenter Enter Nutr. 2009; 33(5):501-512. https://doi.org/10.1177/0148607109333001

[48] Yu YH, Yang JX. Comparison of clinical side effects of structured lipid and MCT/LCT. Journal of Clinical Surgery. 2008; 16(12):811-812. https://doi.org/10.3969/j.issn.1005-6483.2008.12.011

[49] Shi YM, Fei XF, Jiang YM, Wang Y, Shang J, Cao WX. Effects of structured lipid emulsion on protein and lipid metabolism. Shanghai Medical Journal. 2006; 29(8):534-537. https://doi.org/10.3969/j.issn.0253-9934.2006.08.007

[50] Chen FM, Wang JY, Sun LC, Juang RF, Huang TJ, Hsieh JS. Efficacy of medium‐chain triglycerides compared with long‐chain triglycerides in total parenteral nutrition in patients with digestive tract cancer undergoing surgery. Kaohsiung J Med Sci. 2005; 21(11):487-494. https://doi.org/10.1016/S1607-551X(09)70156-1

[51] Zhu MW, Wei JM, Cao JD, Zhao X, Tang DN, Chen Y. Comparison of nutrition treatment between MCT and LCT in postoperative elderly patients with gastrointestinal tumor. Chinese Journal of Gastrointestinal Surgery. 2002; 5(3):180-182. https://doi.org/10.3760/cma.j.issn.1671-0274.2002.03.005

[52] Garnacho-Montero J, Ortiz-Leyba C, Jiménez-Jiménez FJ, et al. Clinical and metabolic effects of two lipid emulsions on the parenteral nutrition of septic patients. Nutrition. 2002; 18(2):134-138. https://doi.org/10.1016/S0899-9007(01)00716-X

[53] Lindgren BF, Ruokonen E, Magnusson-Borg K, Takala J. Nitrogen sparing effect of structured triglycerides containing both medium-and long-chain fatty acids in critically ill patients; a double blind randomized controlled trial. Clin Nutr. 2001; 20(1):43-48. https://doi.org/10.1054/clnu.2000.0156

[54] Demirer S, Aydintuğ S, Üstün C, et al. Comparison of the efficacy of medium chain triglycerides with long chain triglycerides in total parenteral nutrition in patients with hematologic malignancies undergoing peripheral blood stem cell transplantation. Clin Nutr. 2000; 19(4):253-258. https://doi.org/10.1054/clnu.2000.0101

[55] Chambrier C, Guiraud M, Gibault JP, Labrosse H, Boulétreau P. Medium-and long-chain triacylglycerols in postoperative patients: structured lipids versus a physical mixture. Nutrition. 1999; 15(4):274-277. https://doi.org/10.1016/S0899-9007(99)00006-4

[56] Qin HL, Wu ZH. Influence of Lipofundin vs Intralipid on the surgical patients with liver disease. Chinese Journal of Practical Surgery. 1998; 18(12):742-745.

[57] Ball MJ. Parenteral nutrition in the critically ill: use of a medium chain triglyceride emulsion. Intensive Care Med. 1993; 19(2):89-95. https://doi.org/10.1007/BF01708368

[58] Russell MK, Wischmeyer PE. Supplemental parenteral nutrition: review of the literature and current nutrition guidelines. Nutr Clin Pract. 2018; 33(3):359-369. https://doi.org/10.1002/ncp.10096

[59] Rücker G, Schwarzer G. Ranking treatments in frequentist network meta-analysis works without resampling methods. BMC Med Res Methodol. 2015;15:58. https://doi.org/10.1186/s12874-015-0060-8