The effect of enteral immunonutrition in upper gastrointestinalsurgery for cancer: a prospective study

The effect of enteral immunonutrition in upper gastrointestinalsurgery for cancer: a prospective study

Background/aim: Enteral feeding and immunonutrition (ImN) have been shown to be associated with a number of favorable effects in patients undergoing cancer surgery. In this prospective study, we aimed to assess the perioperative use of enteral immunonutrition in patients undergoing radical gastrointestinal surgery for malignancy. Materials and methods: Forty-one patients with malignancy were included in this study and were randomized into one of the two following nutritional strategies: enteral only (EN) or enteral with enteral immunonutrition (ENIN). These regimens were followed for 7 days perioperatively by all patients. Nutritional parameters and postoperative morbidity, mortality, and length of hospital stay (LHS) were assessed. Results: Serum prealbumin levels increased significantly in the ENIN group (P = 0.033). Moreover, patients in the ENIN group showed a more marked decrease in the rate of postoperative infections (P = 0.021) and anastomotic leakage (P = 0.018) than patients fed with EN. In the EN group, LHS was significantly longer than that in the ENIN group (18 vs. 12 days) (P = 0.032). Rates of overall morbidity and mortality were similar in the two groups (P > 0.05). Conclusion: ENIN was found to have a favorable effect on the outcome of radical gastrointestinal surgery for malignancy. Meticulous preoperative assessment of malnutrition and at least a 7-day perioperative enteral use can increase the effectiveness of immunonutrition.

___

  • 1. Pisters PW, Pearlstone DB. Protein and amino acid metabolism in cancer cachexia: investigative techniques and therapeutic interventions. Crit Rev Clin Lab Sci 1993; 30: 223–272.
  • 2. Nitenberg G, Raynard B. Nutritional support of the cancer patient: issues and dilemmas. Crit Rev Oncol Hematol 2000; 34: 137–168.
  • 3. Dewys WD, Begg C, Lavin PT,  Band PR, Bennett JM, Bertino JR, Cohen MH, Douglass HO Jr, Engstrom PF, Ezdinli EZ et al. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med 1980; 69: 491–497.
  • 4. Tang R, Chen HH, Wang YL, Changchien CR, Chen JS, Hsu KC, Chiang JM, Wang JY. Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2,809 consecutive patients. Ann Surg 2001; 234: 181–189.
  • 5. Rosa F,  Bossola M,  Pacelli F,  Alfieri S,  Doglietto GB. Malnutrition and postoperative complications in abdominal surgery. Ann Surg 2011; 254: 666.
  • 6. Falewee MN,  Schilf A,  Boufflers E,  Cartier C,  Bachmann P,  Pressoir M,  Banal A,  Michel C,  Ettaiche M. Reduced infections with perioperative immunonutrition in head and neck cancer: exploratory results of a multicenter, prospective, randomized, double-blind study. Clin Nutr 2014; 33: 776–784.
  • 7. Buzby GP, Knox LS, Crosby LO, Eisenberg JM,  Haakenson CM,  McNeal GE,  Page CP,  Peterson OL,  Reinhardt GF, Williford WO. Study protocol: a randomized clinical trial of total parenteral nutrition in malnourished surgical patients. Am J Clin Nutr 1988; 47: 366–381.
  • 8. Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 2001; 74: 534–542.
  • 9. Peter JV, Moran JL, Philips-Hughes J. A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med 2005; 33: 213–220.
  • 10. Bulus N, Cersosimo E, Ghishan F, Abumrad NN. Physiologic importance of glutamine. Metabolism 1989; 38: 1–5.
  • 11. Kudsk KA, Minard G, Croce MA, Brown RO,  Lowrey TS,  Pritchard FE,  Dickerson RN,  Fabian TC. A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications. Ann Surg 1996; 224: 531–540.
  • 12. Xu J,  Zhong Y,  Jing D,  Wu Z. Preoperative enteral immunonutrition improves postoperative outcome in patients with gastrointestinal cancer. World J Surg 2006; 30: 1284–1289.
  • 13. Bozzetti F, Braga M, Gianotti L, Gavazzi C,  Mariani L. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet 2001; 358: 1487–1492.
  • 14. Gianotti L, Braga M, Nespoli L, Radaelli G, Beneduce A, Di Carlo V. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology 2002; 122: 1763– 1770.
  • 15. Sultan J, Griffin SM, Di Franko F, Kirby JA, Shenton BK, Seal CJ, Davis P, Viswanath YK, Preston SR, Hayes N. Randomized clinical trial of omega-3 fatty acid-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing oesophagogastric cancer surgery. Br J Surg 2012; 99: 346–355.
  • 16. Klek S, Szybinski P, Szczepanek K. Perioperative immunonutrition in surgical cancer patients: a summary of a decade of research. World J Surg 2014; 38: 803–812.
  • 17. Klek S,  Sierzega M,  Szybinski P,  Szczepanek K,  Scislo L, Walewska E, Kulig J. Perioperative nutrition in malnourished surgical cancer patients – a prospective, randomized, controlled clinical trial. Clin Nutr 2011; 30: 708–713.
  • 18. Schiesser M, Müller S, Kirchhoff P, Breitenstein S, Schäfer M, Clavien PA. Assessment of a novel screening score for nutritional risk in predicting complications in gastro-intestinal surgery. Clin Nutr 2008; 27: 565–570.
  • 19. Garth AK, Newsome CM, Simmance N, Crowe TC. Nutritional status, nutrition practices and post-operative complications in patients with gastrointestinal cancer. J Hum Nutr Diet 2010; 23: 393–401.
  • 20. Carr CS, Ling KD, Boulos P, Singer M. Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection. BMJ 1996; 312: 869–871.
  • 21. Ryan AM, Rowley SP, Healy LA, Flood PM, Ravi N, Reynolds JV. Post-oesophagectomy early enteral nutrition via a needle catheter jejunostomy: 8-year experience at a specialist unit. Clin Nutr 2006; 25: 386–393.
  • 22. Harvey RB, Andrews K, Droleskey RE, Kansagra KV,  Stoll B,  Burrin DG,  Sheffield CL,  Anderson RC,  Nisbet DJ. Qualitative and quantitative comparison of gut bacterial colonization in enterally and parenterally fed neonatal pigs. Curr Issues Intest Microbiol 2006; 7: 61–64.
  • 23. Gramlich L, Kichian K, Pinilla J, Rodych NJ,  Dhaliwal R, Heyland DK. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition 2004; 20: 843–848.
  • 24. Madsen H, Frankel EH. The hitchhiker’s guide to parenteral nutrition management for adult patients. Pract Gastroenterol 2006; 40: 46–68.
  • 25. ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 2002; 26: 1–138.
  • 26. Weimann A, Braga M, Harsanyi L, Laviano A,  Ljungqvist O,  Soeters P;  DGEM (German Society for Nutritional Medicine), Jauch KW, Kemen M, Hiesmayr JM et al. ESPEN Guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 2006; 25: 224–244.
  • 27. Braga M, Gianotti L, Nespoli L, Radaelli G,  Di Carlo V. Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg 2002; 137: 174–180.
  • 28. Daly JM, Reynolds J, Thom A, Kinsley L, Dietrick-Gallagher M, Shou J, Ruggieri B. Immune and metabolic effects of arginine in the surgical patient. Ann Surg 1988; 208: 512–523.
  • 29. Zheng Y, Li F, Qi B, Luo B, Sun H, Liu S, Wu X. Application of perioperative immunonutrition for gastrointestinal surgery: a meta-analysis of randomized controlled trials. Asia Pac J Clin Nutr 2007; 16: 253–257.
  • 30. Braga M, Gianotti L, Radaelli G, Vignali A, Mari G, Gentilini O, Di Carlo V. Perioperative immunonutrition in patients undergoing cancer surgery: results of a randomized doubleblind phase 3 trial. Arch Surg 1999; 134: 428–433.
  • 31. Mauskopf JA,  Candrilli SD,  Chevrou-Séverac H,  Ochoa JB. Immunonutrition for patients undergoing elective surgery for gastrointestinal cancer: impact on hospital costs. World J Surg Oncol 2012; 10: 136.
  • 32. Helminen H, Raitanen M, Kellosalo J. Immunonutrition in elective gastrointestinal surgery patients. Scand J Surg 2007; 96: 46–50.
  • 33. Fujitani K,  Tsujinaka T,  Fujita J,  Miyashiro I,  Imamura H,  Kimura Y,  Kobayashi K,  Kurokawa Y,  Shimokawa T,  Furukawa H et al. Prospective randomized trial of preoperative enteral immunonutrition followed by elective total gastrectomy for gastric cancer. Br J Surg 2012; 99: 621– 629.
  • 34. Wischmeyer PE. Glutamine and heat shock protein expression. Nutrition 2002; 18: 225–228.
  • 35. Heyland D,  Muscedere J,  Wischmeyer PE,  Cook D,  Jones G, Albert M, Elke G, Berger MM, Day AG; Canadian Critical Care Trials Group. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med 2013; 368: 1489–1497.
  • 36. van Zanten AR, Sztark F, Kaisers UX, Zielmann S, Felbinger TW, Sablotzki AR, De Waele JJ, Timsit JF, Honing ML, Keh D et al. High-protein enteral nutrition enriched with immunemodulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: a randomized clinical trial. JAMA 2014; 312: 514–524.
  • 37. Braga M, Gianotti L, Vignali A, Carlo VD. Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer. Surgery 2002; 132: 805–814.
  • 38. Lobo DN, Williams RN, Welch NT, Aloysius MM,  Nunes QM, Padmanabhan J, Crowe JR, Iftikhar SY, Parsons SL, Neal KR et al. Early postoperative jejunostomy feeding with an immune modulating diet in patients undergoing resectional surgery for upper gastrointestinal cancer: a prospective, randomized, controlled double-blind study. Clin Nutr 2006; 25: 716–726.
  • 39. Okamoto Y, Okano K, Izuishi K, Usuki H, Wakabayashi H, Suzuki Y. Attenuation of the systemic inflammatory response and infectious complications after gastrectomy with preoperative oral arginine and omega-3 fatty acids supplemented immunonutrition. World J Surg 2009; 33: 1815– 1821.
  • 40. Giger-Pabst U,  Lange J,  Maurer C,  Bucher C,  Schreiber V,  Schlumpf R,  Kocher T,  Schweizer W,  Krähenbühl S, Krähenbühl L. Short-term preoperative supplementation of an immunoenriched diet does not improve clinical outcome in well-nourished patients undergoing abdominal cancer surgery. Nutrition 2013; 29: 724–729.
  • 41. Ryan AM, Reynolds JV, Healy L, Byrne M, Moore J, Brannelly N, McHugh A,  McCormack D,  Flood P. Enteral nutrition enriched with eicosapentaenoic acid (EPA) preserves lean body mass following esophageal cancer surgery: results of a double-blinded randomized controlled trial. Ann Surg 2009; 249: 355–363.
  • 42. May PE, Barber A, D’Olimpio JT, Hourihane A, Abumrad NN. Reversal of cancer-related wasting using oral supplementation with a combination of β-hydroxy-β-methylbutyrate, arginine, and glutamine. Am J Surg 2002; 183: 471–479.
  • 43. Williams JZ, Abumrad N, Barbul A. Effect of a specialized amino acid mixture on human collagen deposition. Ann Surg 2002; 236: 369–375.
  • 44. Sipahi S, Gungor O, Gunduz M, Cilci M, Demirci MC, Tamer A. The effect of oral supplementation with a combination of beta-hydroxy-beta-methylbutyrate, arginine and glutamine on wound healing: a retrospective analysis of diabetic haemodialysis patients. BMC Nephrol 2013; 14: 8.
  • 45. Rathmacher JA, Nissen S, Panton L, Clark RH, Eubanks May PE, Barber AE, D’Olimpio J, Abumrad NN. Supplementation with combination of beta-hydroxy-beta-methylbutyrate (HMB), arginine and glutamine is safe and could improve hematological parameters. JPEN J Parenter Enteral Nutr 2004; 28: 65–75.
  • 46. Shirakawa H,  Kinoshita T,  Gotohda N,  Takahashi S,  Nakagohri T,  Konishi M. Compliance with and effects of preoperative immunonutrition in patients undergoing pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 2012; 19: 249–258.
  • 47. Senkal M, Zumtobel V, Bauer KH, Marpe B, Wolfram G, Frei A, Eickhoff U, Kemen M. Outcome and cost effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: a prospective randomized study. Arch Surg 1999; 134: 1309–1316.
  • 48. Osland E, Hossain MB, Khan S, Memon MA. Effect of timing of pharmaconutrition (immunonutrition) administration on outcomes of elective surgery for gastrointestinal malignancies: a systematic review and meta-analysis. JPEN J Parenter Enteral Nutr 2014; 38: 53–69.
Turkish Journal of Medical Sciences-Cover
  • ISSN: 1300-0144
  • Yayın Aralığı: Yılda 6 Sayı
  • Yayıncı: TÜBİTAK