Modulating effects of the feeding route on stress response and endotoxin translocation in severely stressed patients receiving thoracic esophagectomy

Experimental studies have demonstrated that the route of nutritional supply impacts the systemic metabolic responses after surgical injury. Intestinal mucosal atrophy, as induced by total parenteral nutrition (TPN) or prolong ed bowel rest, has been reported to enhance bowel endotoxin translocation. The operative procedure for thoracic esophageal cancer, including thoracoto my, laparotomy, and three-field lymph-node dissection, is a particularly st ressful surgery that requires long-term aggressive nutritional support and often results in the postoperative hypermetabolic state, leading to perturb ation of postoperative immune function. Interleukin-6 (IL-6) plays an impor tant role in host inflammatory responses, whereas IL-10 is linked to suppre ssion of cellular immunity. The aim of this study was to investigate how th e antecedent nutritional routes influence systemic IL-6 and IL-IO responses and endotoxin translocation after an operation for thoracic esophageal can cer. Twenty-nine patients who underwent esophagectomy with three-field lymp hadenectomy were investigated. They were assigned to groups receiving eithe r TPN (n = 18) or enteral nutrition (EN; n = 11) providing 35 kcal . kg(-1) . d(-1) of energy and approximately 1.2-1.5 g . kg(-1) . d(-1) of amino ac ids. These nutritional supports were conducted from 1 wk before the operati on to 14 d after the operation. Serum IL-6, IL-10, and endotoxin concentrat ion were measured before and during the operation and at 2 h and 1, 3, and 7 d after the operation. IL-6 in sera was significantly higher after the op eration in both groups. In the EN group, however, significantly less IL-6 p roduction was observed on the third and seventh postoperative days when com pared with those patients in the TPN group. Similarly, serum IL-IO concentr ation in the TPN group showed a significantly higher level than that in the EN group. Serum IL-6 showed a significant positive correlation with IL-10 at 2 h and at 7 d after the operation, suggesting that the reduced inflamma tory responses were related to the inhibition of the development of postope rative immunosuppression. Endotoxin concentration in sera was significantly lower in the EN group after the operation than in the TPN group. Periopera tive EN provides better regulation of inflammatory cytokine responses and m ay contribute less to immunosuppression after major surgery than parenteral nutrition. The attenuated production of endotoxin induced by EN may play a n important role in these phenomena. (C) Elsevier Science Inc. 2000.