EARLY POSTOPERATIVE ENTERAL IMMUNONUTRITION - CLINICAL OUTCOME AND COST-COMPARISON ANALYSIS IN SURGICAL PATIENTS

Objective: To determine if early postoperative feeding of patients wit h upper gastrointestinal malignancy, using an enteral diet supplemente d with arginine, dietary nucleotides, and omega-3 fatty acids (IMPACT( R), Sandoz Nutrition, Bern, Switzerland) results in an improved clinic al outcome, i.e., reduced infectious and wound complications and decre ased treatment costs when compared with an isocaloric, isonitrogenous control diet. Design: A prospective, randomized, placebo-controlled, d ouble-blind, multicenter trial of the clinical outcome and a retrospec tive cost comparison analysis.Setting: Surgical intensive care units i n three different German university hospitals. Patients: Of 164 patien ts enrolled in the study, 154 patients were eligible for analysis, The y were admitted to the intensive care unit after upper gastrointestina l surgery for cancer and they received an enteral diet via needle cath eter jejunostomy, Infectious complications were defined as sepsis or s ystemic inflammatory response syndrome, pneumonia, urinary tract infec tion, central venous catheter sepsis, wound infection, and anastomotic leakage, The complication events were prospectively divided into two groups: early (postoperative days 1 to 5) and late (after the fifth po stoperative day) postoperative complications, The treatment costs of e ach complication were analyzed and compared in both groups. Interventi ons: Patients were randomized to receive either the immunonutritional diet (n = 77) or an isocaloric and isonitrogenous placebo diet (n = 77 ). Enteral feeding was initiated 12 to 24 hrs after surgery, starting with 20 mL/hr and advanced to a target volume of 80 mL/hr by postopera tive day 5. Measurements and Main Results: Clinical examination and ad verse gastrointestinal symptoms were recorded on a daily basis, Both g roups tolerated early enteral feeding well, and the rate of tube feedi ng-related complications was low. Postoperative complications occurred in 17 patients in the immunonutrition group vs, 24 patients in the co ntrol group (NS), Further, in the early phase (postoperative day 1 to 5), complications occurred to a similar extent in both groups (12 pati ents in the immunonutritional group vs, 11 patients in the control gro up). However, in the late phase (after postoperative day 5), considera bly fewer patients in the experimental diet group experienced complica tions compared with the control group (5 vs, 13, p <.05), In addition, the frequency rate of complicating events were recorded in each group , In the experimental diet group, a total of 22 complicating events we re recorded vs. a total of 32 events in the placebo diet group (NS), H owever, the occurrence of late complicating events, i.e., complicating events after the fifth postoperative day, was significantly reduced i n the immunonutrition group when compared with the control group (8 vs . 17 events, p <.05). The total costs for the treatment of the complic ations were 83,563 German marks in the experimental diet group vs, 122 ,430 German marks in the control group, resulting in a cost-reduction of 38,867 German marks, (At the end of December 1995, the conversion r ate from German marks to U.S. dollars was 1.4365 German marks to $1.00 .) Conclusions: Early enteral feeding with an arginine, dietary nucleo tides, and omega-3 fatty acids supplemented diet, as well as an isonit rogenous, isocaloric control diet (placebo) were well tolerated in pat ients who underwent upper gastrointestinal surgery. In patients who re ceived the supplemented diet, a significant reduction in the frequency rate of late postoperative infectious and wound complications was obs erved. Thereby, the treatment costs were substantially reduced in the immunonutrition group as compared with the control group.