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Original Article |
1 Department of Surgery, Hôpital Cantonal Fribourg, Fribourg, Switzerland
2 Department of Visceral & Transplantation Surgery, University of Berne, Berne, Switzerland
3 Department of General Surgery, University of Heidelberg, Heidelberg, Germany
4 Department of Visceral and Vascular Surgery, Stadtklinik, Baden-Baden, Germany
5 Department of Mathematical Statistics, University of Berne, Berne, Switzerland
6 HealthEcon AG, Health Service Consultant, Basel, Switzerland
7 Clinical Pharmacology and Toxicology, University Hospital, Basel, Switzerland
Correspondence: Address correspondence and reprint requests to: Urs Giger, MD; E-mail: ungiger{at}hotmail.com
Background/Aim: Perioperative administration of immunoenriched diets attenuates the perioperative inflammatory response and reduces postoperative infection complications. However, many questions still remain unresolved in this area, such as the length of diet administration, diet composition, and the mechanisms involved. We performed an open, randomized, triple-arm study comparing the effect of two perioperative feeding regimens with a postoperative one.
Methods: 46 candidates for major elective surgery for malignancy in the upper gastrointestinal tract were randomized to drink preoperatively either 1 L of an immunoenriched formula (Impact) for 5 days (IEF group) or 1 L of Impact plus (Impact enriched with glycine) for 2 days (IEF plus group). The same product as the patient received preoperatively was given to both groups for 7 days postoperatively. In the control group (CON group), patients only received Impact for 7 days postoperatively; there was no preoperative treatment. The main outcome measures were postoperative C-reactive protein (CRP) serum levels.
Results: In the two preoperatively supplemented groups (treatment groups), perioperative endotoxin levels, CRP (postoperative day 7), and TNF-
(postoperative days 1 and 3) levels were significantly lower compared to the CON group (p < .01). Furthermore, the length of postoperative IMU/ICU stay (Impact 1.9 ± 1.3 days; Impact plus 2.2 ± 1.1 days; control group 5.9 ± 0.8 days) and length of hospital stay (Impact 19.7 ± 2.3 days; Impact plus 20.1 ± 1.3 days; control group 29.1 ± 3.6 days) were both reduced in the treatment groups compared to the control group. Infectious complications (Impact 2/14 (14%); Impact plus 5/17 (29%); control group 10/15 (67%)) also showed a trend toward reduction in the treatment groups.
Conclusions: Perioperative administration of an immunoenriched diet significantly reduces systemic perioperative inflammation and postoperative complications in patients undergoing major abdominal cancer surgery, when compared with postoperative diet administration alone. A shortened preoperative feeding regimen of 2 days with Impact enriched with glycine (Impact plus) was as effective as Impact administered for 5 days preoperatively.
Key Words: Immunonutrition • Perioperative inflammatory response • Endotoxin • Cytokines • C-reactive protein (CRP) • Postoperative complication
Abbreviations: ASA, American Society of Anesthesiologists • CON group, Control group • CRP, C-reactive protein • ELISA, Enzyme-linked immunosorbent assay • ICU, Intensive care unit • IEF group, Immunoenriched formula group • IEF plus group, Immunoenriched formula plus glycine group • IL-6/8, Interleukin 6/8 • IMC, Intermediate care unit • IV, Intravenous • LOS, Length of hospital stay • MODS, Multiorgan dysfunction syndrome • POD, Postoperative day • RNA, Ribonucleic acid • SD, Standard deviation • SIRS, Systemic inflammatory response syndrome • TNF-, Tumor necrosis factor alpha • WBC, White blood count
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