Effect of Route of Delivery and Formulation of Postoperative Nutritional Support in Patients Undergoing Major Operations for Malignant Neoplasms

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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, ω-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