M. Senkal et al., EARLY POSTOPERATIVE ENTERAL IMMUNONUTRITION - CLINICAL OUTCOME AND COST-COMPARISON ANALYSIS IN SURGICAL PATIENTS, Critical care medicine, 25(9), 1997, pp. 1489-1496
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.