25/11/23, 07:20 Immunonutrition in gastric cancer surgical patients - ScienceDirect

Nutrition
Volume 14, Issues 11–12, November–December 1998, Pages 831-835

Original Articles

Immunonutrition in gastric cancer surgical patients

Marco Braga MD a , Luca Gianotti MD (ScD) a, Andrea Vignali MD a, Valerio Di Carlo MD a

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https://doi.org/10.1016/S0899-9007(98)00103-8
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Abstract

The aim of this study was to evaluate the potential advantages of perioperative versus postoperative administration of
an enteral immune-enhancing diet on host defense and protein metabolism. Thirty subjects, candidates for
gastrectomy for cancer, were randomly allocated into two groups. The first group (n = 15) received an enteral formula
enriched with arginine, ω-3 fatty acids, and RNA 7 d before and 7 d after surgery; the second group (n = 15) received
the same diet but only 7 d after surgery. Postoperative immune and inflammatory responses were investigated by
phagocytosis ability of polymorphonuclear cells, interleukin-2 receptors (IL-2R), lymphocyte subsets, interleukin-6 (IL-
6), and delayed hypersensitivity response (DHR). Prealbumin (PA), retinol binding protein, albumin, and transferrin
were determined as protein synthesis indicators. Perioperative immunonutrition prevented the early postoperative
impairment of phagocytosis, DHR, total number of lymphocytes, and CD4/CD8 ratio (P < 0.05 versus postoperative
group). The IL-2R levels were significantly higher in the perioperative group (P < 0.05 versus postoperative on
postoperative day [POD] 4 and 8). Perioperative group also showed lower levels of IL-6 (P < 0.05 versus postoperative
on POD 1, 4, and 8) and higher levels of PA (P = 0.04 versus postoperative on POD 8). The perioperative administration
of immunonutrition ameliorated the host defense mechanisms, controlled the inflammatory response, and improved
the synthesis of short half-life constitutive proteins.

Introduction

In the last decade several clinical and experimental studies have shown the beneficial effects of early enteral feeding
over parenteral or delayed enteral nutrition during critical conditions.1, 2, 3, 4, 5, 6, 7

Promising experimental results on outcome were obtained by adding specific nutritional substrates to standard enteral
or parenteral formulas. The mechanisms of host protection are mediated by the ability of immunonutrients to
modulate immune defense mechanisms, inflammatory response, intestinal barrier function, tissue oxygenation,
nitrogen metabolism, and ischemia/reperfusion injury.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18

Clinical trials showed that despite enriched enteral diets given early after operation, the recovery of both cell-mediated
and humoral responses occurred late.19, 20, 21, 22, 23, 24 Because the alterations of immune parameters are detectable
immediately after surgery,19, 20, 21, 22, 23, 24, 25 the delayed recovery of the host defense mechanisms might be only
partially effective in improving outcome.19, 22, 26, 27

https://www.sciencedirect.com/science/article/abs/pii/S0899900798001038 1/4
25/11/23, 07:20 Immunonutrition in gastric cancer surgical patients - ScienceDirect

Recently, we reported that the perioperative administration of an enriched enteral formula significantly improved gut
function and positively modulated postsurgical immunosuppressive and inflammatory responses.28 Based on these
previous experiences21, 28 we prospectively evaluated the possible metabolic advantages of the perioperative versus
postoperative administration of an immune-enhancing enteral diet in patients undergoing curative surgery for gastric
cancer.

Section snippets

Patients and methods

Thirty consecutive patients, male and female, ages 18–75 y, with histologically documented adenocarcinoma of the
stomach and candidate for curative surgery were prospectively enrolled. History of renal, hepatic, or cardiopulmonary
dysfunction, ongoing infection, and immune disorders were exclusion criteria. Patients were required to sign a written
informed consent once the protocol was explained. Patients were then randomized into two groups. The first group (n
= 15) received 1 L/d of an…

Results

Table I summarizes the characteristics of the two groups. As far as baseline age, sex, weight, albumin, hemoglobin,
performance status, weight loss, surgical parameters, and blood transfusions the two groups were comparable. No
patient underwent splenectomy.

The baseline arginine level was 62.5 ± 18.3 (μmol/L) in the perioperative group and 66.9 ± 17.8 in the postoperative
group (P = NS). The day before surgery, arginine rose to 104.9 ± 38.7 in the perioperative group (P < 0.05) and
remained…

Discussion

The results of this trial confirmed that the early postoperative jejunal infusion of nutrients is safe and well tolerated,
even if the diet is given proximally to a “fresh” intestinal anastomosis.

In the last few years, standard enteral and parenteral preparations have been modified by adding “immunonutrients.”
This new category of dietary compounds have been shown to have several peculiar properties. Among the most
interesting and carefully investigated are arginine, which improves immune-cell…

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