Effect of route of delivery and formulation of postoperative nutritional support in patients undergoing major operations for malignant neoplasms
L. Gianotti, M. Braga, A. Vignali, G. Balzano, A. Zerbi, P. Bisagni and V. Di Carlo
Department of Surgery, Scientific Institute San Raffaele, University of Milan, Italy.
OBJECTIVE: To study the effect of the route of delivery and formulation of
postoperative nutritional support on host defense, protein metabolism,
infectious complications, and outcome. DESIGN: Prospective, randomized,
clinical trial. SETTING: Department of Surgery at a university hospital.
PATIENTS: Two hundred sixty candidates for pancreaticoduodenectomy or
gastrectomy for cancer. INTERVENTIONS: Patients were randomly allocated
into 3 groups during surgery. Starting 6 hours after operation, the first
group received a standard enteral formula (standard group; n = 87); the
second, the same enteral formula enriched with arginine, omega-3 fatty
acids, and RNA (immunonutrition group; n = 87); and the third, total
parenteral nutrition (parenteral group; n = 86). The 3 regimens were
isocaloric and isonitrogenous. The nutritional goal was 105 kJ/kg per day.
MAIN OUTCOME MEASURES: Immune response by phagocytosis ability of
polymorphonuclear cells, interleukin (IL)-2 receptor levels, and delayed
hypersensitivity response; protein synthesis by IL-6 and prealbumin;
tolerance of enteral feeding; incidence of postoperative complications; and
length of hospital stay. RESULTS: The immunonutrition group had a
significantly better recovery of the immune parameters on postoperative day
8 compared with the other groups. Linear regression analysis showed an
inverse correlation between IL-6 and preambulin levels (r = 0.766) only in
the immunonutrition group. Only 11 patients (6.3%) in both enteral groups
did not reach the nutritional goal. Postoperative infection rate was 14.9%
(13/87) in the immunonutrition group, 22.9% (20/87) in the standard group,
and 27.9% (24/86) in the parenteral group (P = .06). Mean +/- SD length of
hospital stay was 16.1 +/- 6.2, 19.2 +/- 7.9, and 21.6 +/- 8.9 days in the
immunonutrition, standard, and parenteral groups, respectively (P = .01 vs
standard group; P = .004 vs parenteral group). CONCLUSIONS: Early
postoperative enteral feeding is a valid alternative to parenteral feeding
in patients undergoing major surgery. Immunonutrition enhances the host
response, induces a switch from acute-phase to constitutive proteins, and
improves outcome.