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Luca Gianotti, MD, ScD; Marco Braga, MD; Andrea Vignali, MD; Gianpaolo Balzano, MD; Alessandro Zerbi, MD; Pietro Bisagni, MD; Valerio Di Carlo, MD

Arch Surg. 1997;132(11):1222-1230.

Abstract
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, -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.

Arch Surg. 1997;132:1222-1230

Author Affiliations
From the Department of Surgery, Scientific Institute San Raffaele, University of Milan, Milan, Italy.

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