Advertisement

World Journal of Surgery

, Volume 33, Issue 9, pp 1815–1821 | Cite as

Attenuation of the Systemic Inflammatory Response and Infectious Complications After Gastrectomy with Preoperative Oral Arginine and ω-3 Fatty Acids Supplemented Immunonutrition

  • Yoshiki Okamoto
  • Keiichi Okano
  • Kunihiko Izuishi
  • Hisashi Usuki
  • Hisao Wakabayashi
  • Yasuyuki Suzuki
Article

Abstract

Background

Past trials have shown perioperative immunonutrition to improve the outcome for patients with gastric cancer. The present study was designed to evaluate the effect of preoperative oral immunonutrition on cellular immunity, the duration of the systemic inflammatory response syndrome (SIRS), and detailed postoperative complications in patients with gastric cancer.

Methods

Sixty patients with gastric cancer were randomly assigned to two groups: one group received immune-enhanced formulas supplemented with arginine and ω-3 fatty acids (immune-enhancing diet (ID) group, n = 30); the other received standard formulas (conventional diet (CD) group, n = 30) for 7 days before the operation. These groups were well matched in terms of age, sex, operations, cancer stages, and intraoperative variables. The postoperative outcome was evaluated based on clinical variables, including postoperative infectious complications, noninfectious complications, and SIRS duration. In addition, the perioperative state of cellular immunity was evaluated and compared between the two groups.

Results

The incidence of postoperative infectious complications in the ID group (6%) was significantly (p < 0.05) lower than that of the CD group (28%). The duration of SIRS in the ID group (0.77 ± 0.9 days) was significantly (p < 0.05) shorter than that in the CD group (1.34 ± 1.45 days). The postoperative lymphocyte and CD4+T-cell counts significantly decreased (p < 0.05) in both groups. However, the number of CD4+T-cells on preoperative day 1 and postoperative day 7 was significantly (p < 0.05) higher in the ID group than in the CD group.

Conclusions

Preoperative oral immune-enhanced formulas supplemented with arginine and ω-3 fatty acids enhanced the immune status of the patients, reduced the duration of SIRS, and decreased the incidence of postoperative infectious complications. CD4+T-cell immunity likely played an important role in the modulation of the postoperative immune and inflammatory response after gastrectomy.

Keywords

Gastric Cancer Systemic Inflammatory Response Syndrome Retinol Binding Protein Postoperative Infectious Complication Conventional Liquid Diet 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Chang HR, Bistrian B (1998) The role of cytokines in the catabolic consequences of infection and injury. JPEN J Parenter Enteral Nutr 22:156–166PubMedCrossRefGoogle Scholar
  2. 2.
    Bistrian BR, Blackburn GL, Hallowell E, Heddle R (1974) Protein status of general surgical patients. JAMA 230:858–860PubMedCrossRefGoogle Scholar
  3. 3.
    Nixon DW, Heymsfield SB, Cohell AE, Kutner MH, Anslev J, Lawson DH et al (1980) Protein-calorice undernutrition in hospitalized cancer patients. Am J Med 68:683–690PubMedCrossRefGoogle Scholar
  4. 4.
    Meakins JL (1989) Host defense mechanisms in surgical patients: effect of surgery and trauma. Acta Chir Scand Suppl 550:43–53PubMedGoogle Scholar
  5. 5.
    Decker D, Schoendorf M, Bidlingmaier F, Himer A, von Ruecker AA (1996) Surgical stress induces a shift in the type-1/type-2 T-helper cell balance, suggesting down-regulation of cell-mediated and up-regulation of antibody-mediated immunity commensurate to the trauma. Surgery 119:316–325PubMedCrossRefGoogle Scholar
  6. 6.
    Weiss G, Meyer F, Matthies B, Pross M, Koenig W, Lippert H (2002) Immunomodulation by perioperative administration of n-3 fatty acids. Br J Nutr 87:S89–S94PubMedCrossRefGoogle Scholar
  7. 7.
    Braga M, Gianotti L, Vignali A, Carlo VD (1998) Immunonutrition in gastric cancer surgical patients. Nutrition 14:831–835PubMedCrossRefGoogle Scholar
  8. 8.
    Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V (2002) Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg 137:174–180PubMedCrossRefGoogle Scholar
  9. 9.
    Daly JM, Weintraub FN, Shou J, Rosato EF, Lucia M (1995) Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Ann Surg 221:327–338PubMedCrossRefGoogle Scholar
  10. 10.
    Senkal M, Zumtobel V, Bauer K-H, Marpe B, Wolfram G, Frei A et al (1999) Outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery. Arch Surg 134:1309–1316PubMedCrossRefGoogle Scholar
  11. 11.
    Farreras N, Artigas V, Cardona D, Rius X, Trias M, Gonzalez JA (2005) Effect of early postoperative enteral immunonutrition on wound healing in patients undergoing surgery for gastric cancer. Clin Nutr 24:55–65PubMedCrossRefGoogle Scholar
  12. 12.
    Gianotti L, Braga M, Neapoli L, Radaelli G, Beneduce A, Carlo VD (2002) A randomized controlled trial on preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology 122:1763–170Google Scholar
  13. 13.
    Braga M, Gianotti L, Radaelli G, Vignali A, Mari G, Gentilini O et al (1999) Perioperative immunonutrition in patients undergoing cancer surgery: results of a randomized double-blind phase 3 trial. Arch Surg 134:428–433PubMedCrossRefGoogle Scholar
  14. 14.
    Japan Gastric Cancer Association (1999) Japanese classification of gastric carcinoma, 13th edn. Japan Gastric Cancer Association, TokyoGoogle Scholar
  15. 15.
    Bone RC, Balk RA, Cerra FB, Dellinqer RP, Fein AM, Knaus WA et al (1992) ACCP/SCCM Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 101:1644–1655PubMedCrossRefGoogle Scholar
  16. 16.
    Xu J, Zhong Y, Jing D, Wu Z (2006) Preoperative enteral immunonutrition improves postoperative outcome in patients with gastrointestinal cancer. World J Surg 30:1284–1289PubMedCrossRefGoogle Scholar
  17. 17.
    Christou NV, Meakins JL, Gordon J, Yee J, Hassan-Zahraee M, Nohr CW et al (1995) The delayed hypersensitivity response and host resistance in surgical patients. 20 years later. Ann Surg 222:534–546PubMedCrossRefGoogle Scholar
  18. 18.
    Lundy J, Lovett EJIII, Wolinsky SM, Conran P (1979) Immune impairment and metastatic tumor growth: the need for an immunorestorative drug as an adjunct to surgery. Cancer 43:945–951PubMedCrossRefGoogle Scholar
  19. 19.
    Atkinson S, Sieffiert E, Bihari D (1998) A prospective, randomized, double-blind, controlled clinical trial of enteral immunonutrition in the critically ill. Guy’s Hospital Intensive Care Group. Crit Care Med 26:1164–1172PubMedCrossRefGoogle Scholar
  20. 20.
    Daly JM, Lieberman MD, Goldfine J, Shou J, Weintraub F, Rosato EF (1992) Enteral nutrition with supplemental arginine, RNA, and omega-3 fatty acids in patients after operation: immunologic, metabolic and clinical outcome. Surgery 112:56–67PubMedGoogle Scholar
  21. 21.
    Gianotti L, Braga M, Gentilini O, Balzano G, Zerbi A, Di Carlo V (2000) Artificial nutrition after pancreaticoduodenectomy. Pancreas 21:344–351PubMedCrossRefGoogle Scholar
  22. 22.
    Braga M, Gianotti L, Vignali A, Carlo VD (2002) Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer. Surgery 132:805–814PubMedCrossRefGoogle Scholar
  23. 23.
    Tujinaka T, Hirao M, Fijitani K, Mishima H, Ikenaga M, Sawamura T et al (2007) Effect of preoperative immunonutrition on body composition in patients undergoing abdominal cancer surgery. Surg Today 37:118–121CrossRefGoogle Scholar
  24. 24.
    Matsuda A, Furukawa K, Takasaki H, Suzuki H, Kan H, Tsuruta H et al (2006) Preoperative oral immune-enhancing nutritional supplementation corrects Th1/Th2 imbalance in patients undergoing elective surgery for colorectal cancer. Dis Colon Rectum 49:507–516PubMedCrossRefGoogle Scholar
  25. 25.
    Kemen M, Senkal M, Homann HH, Mumme A, Dauphin AK, Baier J et al (1995) Early postoperative enteral nutrition with arginine-omega-3 fatty acids and ribonucleic acid: supplemented diet versus placebo in cancer patients: an immunologic evaluation of impact. Crit Care Med 23:652–659PubMedCrossRefGoogle Scholar
  26. 26.
    Senkal M, Kemen M, Homann HH, Eickhoff U, Baier J, Zumtobel V (1995) Modulation of postoperative immune response by enteral nutrition with a diet enriched with arginine, RNA, and omega-3 fatty acids in patients with upper gastrointestinal cancer. Eur J Surg 161:115–122PubMedGoogle Scholar
  27. 27.
    Kinsella JE, Lokesh B, Broughton S, Whelan J (1990) Dietary polyunsaturated fatty acids and eicosanoids: potential effect on the modulation of inflammatory and immune cells: an overview. Nutrition 6:24–44PubMedGoogle Scholar
  28. 28.
    Weinmann A, Bastian L, Bischoff WE, Grotz M, Hansel M, Lotz J et al (1998) Influence of arginine, omega-3 fatty acids and nucleotide-supplemented enteral support on systemic inflammatory response syndrome and multiple organ failure in patients after severe trauma. Nutrition 14:165–172CrossRefGoogle Scholar
  29. 29.
    Takeuchi H, Ikeuchi S, Kawaguchi Y, Kitagawa Y, Isobe Y, Kubochi K et al (2007) Clinical significance of perioperative immunonutrition for patients with esophageal cancer. World J Surg 31:2160–2167PubMedCrossRefGoogle Scholar
  30. 30.
    Morlion BJ, Torwesten E, Lessire H, Sturm G, Peskar BM, Furst P et al (1996) The effect of parenteral fish oil on leukocyte membrane fatty acids composition and leukotriene-synthesizing capacity in patients with postoperative trauma. Metabolism 45:1208–1213PubMedCrossRefGoogle Scholar
  31. 31.
    Swails WS, Kenler AS, Driscoll DF, DeMichele SJ, Babineau TJ, Utsunamiya T et al (1997) Effect of a fish oil structured lipid-based diet on prostaglandin release from mononuclear cells in cancer patients after surgery. JPEN J Parenter Enteral Nutr 21:226–274CrossRefGoogle Scholar
  32. 32.
    Kenler AS, Swails WS, Driscoll DF, DeMichele SJ, Daley B, Barbineau TJ et al (1996) Early enteral feeding in postsurgical cancer patients. Fish oil lipid-based polymeric formula versus a standard polymeric formula. Ann Surg 223:316–333PubMedCrossRefGoogle Scholar
  33. 33.
    Raynold JV, Daly JM, Zhang S, Evabtash E, Shou J, Sigal R et al (1988) Immunomodulatory mechanisms of arginine. Surgery 104:141–151Google Scholar
  34. 34.
    Moncada S, Higgs A (1993) The l-arginine-nitric oxide pathway. N Engl J Med 329:2002–2012PubMedCrossRefGoogle Scholar
  35. 35.
    Gianotti L, Alexander JW, Pyles T, Fukushima R (1993) Arginine-supplemented diet improves survival in gut-derived sepsis and peritonitis by modulating bacterial clearance. The role of nitric oxide. Ann Surg 217:644–653PubMedCrossRefGoogle Scholar
  36. 36.
    Cynober L (2003) Immuno-enhancing diets for stressed patients with a special emphasis on arginine content: analysis of the analysis. Curr Opin Clin Nutr Metab Care 6:189–193PubMedCrossRefGoogle Scholar
  37. 37.
    Kalil AC, Danner RL (2006) l-arginine supplementation in sepsis: beneficial or harmful? Curr Opin Crit Care 12:303–308PubMedCrossRefGoogle Scholar
  38. 38.
    Zhou M, Martindale RG (2007) Arginine in the critical care setting. J Nutr 137:1687S–1692SPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2009

Authors and Affiliations

  • Yoshiki Okamoto
    • 1
  • Keiichi Okano
    • 1
  • Kunihiko Izuishi
    • 1
  • Hisashi Usuki
    • 1
  • Hisao Wakabayashi
    • 1
  • Yasuyuki Suzuki
    • 1
  1. 1.Department of Gastroenterological Surgery, Faculty of MedicineKagawa UniversityKagawaJapan

Personalised recommendations