Standard and Immunostimulating Enteral Nutrition in Surgical Patients (ImmuniEteral)

• length of hospital stay [ Time Frame: length of hospital stay ] [ Designated as safety issue: No ]
• function of immune system [ Time Frame: function of immune system ] [ Designated as safety issue: No ]
• assessment of liver and kidney function [ Time Frame: assessment of liver and kidney function ] [ Designated as safety issue: Yes ]
• determination of the treatment tolerance [ Time Frame: determination of the treatment tolerance ] [ Designated as safety issue: Yes ]
• assessment of visceral protein turnover [ Time Frame: assessment of visceral protein turnover ] [ Designated as safety issue: No ]

The aim of the study was to assess the clinical effect of immunomodulating enteral nutrition in patients undergoing resection for gastrointestinal cancer. 196 subjects were randomly assigned into two study groups: standard and immunostimulating. The study failed to demonstrate any clear advantage of routine postoperative immunonutrition in patients undergoing elective upper gastrointestinal surgery

Background&Aim: The administration of immunomodulating enteral diets during postoperative period in patients after major gastrointestinal surgery is intended to reduce the number of postoperative complications and to shorten the hospital stay. The aim of the study was to assess the clinical effect of enteral immunostimulatory nutrition in surgical patients.

Material and Methods: 196 patients undergoing resection for pancreatic and gastric cancer were randomized in double-blind manner to receive early postoperative enteral nutrition with immunostimulating diet (IMEN group: formula supplemented with arginine, glutamine, omega-3 fatty acids) or oligopeptic control (SEN group) between June 2004 and September 2007. Enteral nutrition was started 6 hours after surgery and continued for 7 days, up to target volume of 100 ml/h. All malnourished patients requiring preoperative nutritional therapy were excluded for the study and treated preoperatively. Outcome measures were: number and type of complications, length of hospital stay, mortality, treatment tolerance, liver and kidney function.

Results: One hundred eighty-three patients (91 in SEN, 92 in IMEN group, 69 F, 114 M, mean age 61.2) of 196 initially enrolled were analyzed. There were 2 deaths in both groups. Median postoperative hospital stay was 12.4 days (SD 5.9) in SEN group and 12.9 days (SD 8.0) in IMEN group (p=0.42). Complications were observed in 21 patients (23.1%) in SEN and 23 (25.2%) in IMEN group (p>0.05). 4 (4.4%) patients in SEN group and 4 (4.4%) in IMEN had surgical complications (p>0.05). There were no differences in liver and kidney function, visceral protein concentration and treatment tolerance.

Conclusion: Clinical and laboratory parameters show no benefit of immunomodulating enteral nutrition over standard enteral nutrition in patients after major gastrointestinal surgery as far as complications, hospital stay, mortality and treatment tolerance and safety are considered.

• Gastric Cancer
• Pancreatic Cancer

• Drug: Reconvan
  isocaloric, immunomodulating entral diet
  Other Name: oligopeptic immunostimulatory diet
• Drug: Peptisorb
  isocaloric, isopeptic standard diet
  Other Name: standard enetral diet

• Experimental: IMEN: 1
  Enteral nutrition with immunostimulating diet (IMEN group: formula supplemented with arginine, glutamine, omega-3 fatty acids)
  Intervention: Drug: Reconvan
• Active Comparator: SEN
  postoperative enteral nutrition - standard oligopeptic diet
  Intervention: Drug: Peptisorb

• Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V. Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg. 2002 Feb;137(2):174-80.
• Klek S, Sierzega M, Szybinski P, Szczepanek K, Scislo L, Walewska E, Kulig J. The immunomodulating enteral nutrition in malnourished surgical patients - a prospective, randomized, double-blind clinical trial. Clin Nutr. 2011 Jun;30(3):282-8. Epub 2010 Nov 13.
• Klek S, Kulig J, Sierzega M, Szczepanek K, Szybiński P, Scislo L, Walewska E, Kubisz A, Szczepanik AM. Standard and immunomodulating enteral nutrition in patients after extended gastrointestinal surgery--a prospective, randomized, controlled clinical trial. Clin Nutr. 2008 Aug;27(4):504-12. Epub 2008 Jun 20.

Inclusion Criteria:

• Adults aged 18-80 years undergoing subtotal and total gastric resection with lymphadenectomy and pancreatoduodenectomy/ total pancreatectomy with lymphadenectomy, in good general status (Karnofsky > 80, Eastern Cooperative Oncology Group (ECOG) grade 0 or 1); with no confirmed neoplastic dissemination nor distant metastases
• No severe concomitant disease (heart failure, chronic obstructive pulmonary disease [COPD], coronary aortic bypass graft [CABG], etc.)
• No history of known allergies or drug intolerance

Exclusion Criteria:

• Patients with metastatic or unresectable disease
• Pregnant
• In poor general status (Karnofsky <80, Eastern Cooperative Oncology Group (ECOG) > 1)
• With recent history of severe heart, lung, kidney or liver failure
• With history of allergies or drug intolerance