EFFECT OF ROUTE OF DELIVERY AND FORMULATION OF POSTOPERATIVE NUTRITIONAL SUPPORT IN PATIENTS UNDERGOING MAJOR OPERATIONS FOR MALIGNANT NEOPLASMS

Objective: To study the effect of the route of delivery and formulatio n of postoperative nutritional support on host defense, protein metabo lism infectious complications, and outcome. Design: Prospective, rando mized, clinical trial. Setting: Department of Surgery at a university hospital. Patients: Two hundred sixty candidates for pancreaticoduoden ectomy or gastrectomy for cancer. Interventions: Patients were randoml y allocated into 3 groups during surgery. Starting 6 hours after opera tion, the first group received a standard enteral formula (standard gr oup; n=87); the second, the same enteral formula enriched with arginin e, omega-3 fatty acids, and RNA (immunonutrition group; n=87); and the third, total parenteral nutrition (parenteral group; n=86). The 3 reg imens 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 level s, and delayed hypersensitivity response; protein synthesis by IL-6 an d prealbumin; tolerance of enteral Feeding; incidence of postoperative complications; and length of hospital stay. Results: The immunonutrit ion group had a significantly better recovery of the immune parameters on post operative day 8 compared with the other groups. Linear regres sion analysis showed an inverse correlation between IL-6 and preambuli n levels (r=0.766) only in the immunonutrition group. Only 11 patients (6.3%) in both enteral groups did not reach the nutritional goal. Pos toperative infection rate was 14.9% (13/87) in the immunonutrition gro up, 22.9% (20/87) in the standard group, and 27.9% (24/86) in the pare nteral 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 feedin g is a valid alternative to parenteral feeding in patients undergoing major surgery. Immunonutrition enhances the host response, induces a s witch from acute-phase to constitutive proteins, and improves outcome.