Nutritional approach in malnourished surgical patients: a prospective randomized
study
Reference: Arch Surg 2002;137(2):174-80.
HYPOTHESIS: Perioperative administration of a supplemented enteral formula
may decrease
postoperative morbidity. DESIGN: Randomized clinical trial. SETTING: Department
of surgery
at a university hospital. PATIENTS: One hundred ninety-six registered malnourished
patients
(weight loss > or = 10%) who were candidates for major elective surgery
for malignancy of the
gastrointestinal tract. INTERVENTION: After randomization (n = 150), one
group received
postoperative enteral feeding with a standard diet within 12 hours of surgery
(control group; n =
50). Another group orally received 1 L/d for 7 consecutive days of a liquid
diet enriched with
arginine, omega-3 fatty acids, and RNA (preoperative group; n = 50). After
surgery, patients
were given the same standard enteral formula as the control group. A third
group orally received
1 L/d for 7 consecutive days of the enriched liquid diet. After surgery,
patients were given enteral
feeding with the same enriched formula (perioperative group; n = 50). MAIN
OUTCOME
MEASURES: Postoperative complications and length of hospital stay. RESULTS:
The 3 groups
were comparable for baseline demographics, biochemical markers, comorbidity
factors, and
surgical variables. The intent-to-treat analysis showed that the total
number of patients with
complications was 24 in the control group, 14 in the preoperative group,
and 9 in the
perioperative group (P =.02, control group vs perioperative group). Postoperative
length of stay
was significantly shorter in the preoperative (13.2 days) and perioperative
(12.0 days) groups
than in the control group (15.3 days) (P =.01 and P =.001, respectively,
vs the control group).
CONCLUSION: Perioperative immunonutrition seems to be the best approach
to support
malnourished patients with cancer.
Immunonutrition in patients after multiple trauma.
Reference: Br J Nutr 2002;87(S1):S133-4.
Severe trauma threatens the life of the victim, both directly and indirectly
via immunological
dysregulation during the subsequent clinical course. Inflammatory or infectious
episodes may
complicate the clinical course and ultimately result in sepsis and multiple
organ failure, which have
mortality rates of up to 80%. Immunomodulatory intervention aims to ameliorate
the early
hyperinflammatory phase (systemic inflammatory response syndrome, SIRS)
to avoid the
development of sepsis. One of the immunomodulation strategies is enteral
feeding supplemented
with specific nutrients, such as glutamine, n-3-polyunsaturated fatty acids,
and nucleotides
('immunonutrition'), because changes in the GALT (gut-associated lymphoid
tissue) immune
response may contribute to intestinal dysfunction and increase susceptibility
to post injury
gut-derived sepsis. In a prospective, randomized, double-blind, controlled
study in twenty-nine
patients suffering severe trauma we were able to show that immunonutrition
(arginine, n-3-fatty
acids, and nucleotides) significantly reduces the number of SIRS days per
patient, and also
lowers the multiple organ failure (MOF) score on day 3 and days 8-11 (P<0.05).
Other studies
have reported a reduction in septic complications and MOF rates, shortened
hospital stay, and
reduction in the use of antibiotics in patients randomized to the immune-enhancing
diet. This
improved clinical outcome was reflected in a reduction in hospital costs.
In the recovery period
after trauma (1-72 h after injury) a limitation of the inflammatory response
of immunocompetent
cells must be achieved as quickly as possible (<72 h). The only strategy
available to clinicians
caring for trauma patients is immunonutrition, and this should be strongly
considered as a rational
approach improving immune function and reducing septic complications in
critically ill or injured
patients.
Regulatory potential of n-3 fatty acids in immunological and inflammatory
processes.
Reference: Br J Nutr 2002;87(S1):S59-67.
Over the last few years immunonutrition has gained increasing importance.
Among other
compounds lipids, especially n-3 polyunsaturated fatty acids, were shown
to influence the
immune response. The anti-inflammatory effects they exert can be induced
by free fatty acids,
triglyceride fatty acids, after incorporation into the membrane phopspholipid
bilayer or following
metabolism to eicosanoids. n-3 Fatty acids influence inflammatory cell
activation processes from
signal transduction to protein expression even involving effects at the
genomic level. n-3 Fatty
acid-mediated mechanisms decreased cytokine-induced adhesion molecule expression,
thereby
reducing inflammatory leucocyte-endothelium interactions and modified lipid
mediator synthesis,
thus influencing the transendothelial migration of leucocytes and leucocyte
trafficking in general.
Even the metabolic repertoire of specific immunocompetent cells such as
cytokine release or
proliferation is modified by n-3 fatty acids. Beyond this they regulate
lipid homeostasis shifting the
metabolic pathways towards energy supply thus optimizing the function of
immune cells. Due to
the regulatory impact on different processes of inflammatory and immune
cell activation n-3 fatty
acids provide positive effects on various states of immune deficiencies
and diseases with a
hyperinflammatory character, among which selected examples are presented.
Prevention of parenteral nutrition-associated liver disease in children.
Reference: Pediatr Transplant 2002;6(1):37-42.
Liver injury is associated with parenteral nutrition therapy. Severity
of injury varies from minimal
and transient increases in liver-related blood tests to biliary cirrhosis
and liver failure. Severe
parenteral nutrition-related liver disease is usually confined to patients
who have undergone
massive intestinal resection. In these patients, early sepsis appears to
cause initial liver injury, and
recurring sepsis and inflammation, local or systemic, may result in its
perpetuation and
progression. Liver disease associated with parenteral nutrition is not
necessarily related either to
duration of parenteral nutrition or to delayed intestinal feeding. However,
treatment includes
enteral nutrition to promote enterohepatic circulation of bile acids and
management of
inflammation and sepsis, including control of intestinal bacterial overgrowth.
Restriction of
intravenous lipid emulsions may be important. The clinical picture of advanced
liver failure related
to short bowel syndrome differs from liver failure with an anatomically
normal gastrointestinal
tract. In the former, hyperbilirubinemia, hepatosplenomegaly, and functional
hypersplenism
dominate the clinical picture, and severe ascites and esophageal variceal
hemorrhage are unusual.
Early referral of these patients for intestinal and/or liver transplantation
may provide the best
chance for long-term survival.
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