Preoperative immunonutrition in patients undergoing liver resection: A prospective randomized trial

Abstract

BACKGROUND Preoperative supplementation with immunonutrients, including arginine and n-3 fatty acids, has been shown in a number of systematic reviews to reduce infectious complications in patients who have undergone gastrointestinal surgery. Limited information, however, is available on the benefits of nutritional supplementation enriched with arginine and n-3 fatty acids in patients undergoing liver resection. AIM To evaluate the effects of preoperative nutritional supplementation enriched with arginine and n -3 fatty acids on inflammatory and immunologic markers and clinical outcome in patients undergoing liver resection. METHODS Thirty-four patients undergoing liver resection were randomized to either five days of preoperative Impact ® [1020 kcal/d, immunonutrition (IMN) group], or standard care [no supplementation, standard care (STD) group]. Nutritional status was measured at study entry by subjective global assessment (SGA). Functional assessments (grip strength, fatigue and performance status) were carried out at study entry, on the day prior to surgery, and on postoperative day (POD) 7 and 30. Inflammatory and immune markers were measured at study entry, on the day prior to surgery, and POD 1, 3, 5, 7, 10 and 30. Postoperative complications were recorded prospectively until POD30. RESULTS A total of 32 patients (17 IMN and 15 STD) were analysed. All except four patients were SGA class A. The plasma ratio of (eicosapentaenoic acid plus docosahexaenoic acid) to arachidonic acid was higher in IMN patients on the day prior to surgery and POD 1, 3, 5 and 7 ( P < 0.05). Plasma interleukin (IL)-6 concentrations were elevated in the IMN group ( P = 0.017 for POD7). No treatment effect was detected for functional measures, immune response (white cell count and total lymphocytes) or markers of inflammation (C-reactive protein, tumour necrosis factor-α, IL-8, IL-10). There were 10 patients with infectious complications in the IMN group and 4 in the STD group ( P = 0.087). Median hospital stay was 9 (range 4–49) d in the IMN group and 8 (3-34) d in the STD group ( P = 0.476). CONCLUSION In well-nourished patients undergoing elective liver resection, this study failed to show any benefit of preoperative immunonutrition.

Current Knowledge about the Effect of Nutritional Status, Supplemented Nutrition Diet, and Gut Microbiota on Hepatic Ischemia-Reperfusion and Regeneration in Liver Surgery

“…However, these benefits cannot be exclusively attributed to EPA because the oral supplementation was also enriched with arginine and nucleotides. A similar approach but with controversial results was conducted by Russell et al Indeed, any benefit of preoperative immunonutrition was reported with arginine and n-3 fatty acids [69]. In a retrospective study reported by Kamo et al, liver recipients suffering from infection after LT were submitted to enteral immunonutrition enriched with nucleotides, arginine and omega-3 fatty acids, and hydrolyzed whey peptide (HWP) (an immunonutritional liquid).…”

“…In experimental and clinical studies performed in animals and humans, fatty acids, arginine, and nucleotides have shown the ability to modulate immune and inflammatory responses [18,69]. These nutrients, among others, have been labeled as pharmaconutrients [18].…”

Clinical Efficacy of Perioperative Immunonutrition Containing Omega-3-Fatty Acids in Patients Undergoing Hepatectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…Whole 45 studies were eligible for further full-text screening, and 36 studies were excluded because they did not meet the inclusion criteria: 7 were not RCTs, 10 were systematic reviews, 5 were letters, and 14 articles lacked the related data. Finally, 9 articles were included in the analysis [21][22][23][24][25][26][27][28][29]. A flow diagram of the search strategy is presented in Figure 1.…”

“…The bias risk of the included studies was assessed using the Cochrane Collaboration risk of bias tool. Seven articles [22,23,[25][26][27][28][29] reported the methods of random sequence generation, 4 studies [22,23,25,27] performed allocation concealment, 8 studies [22][23][24][25][26][27][28][29] described the blinding of participants and personnel, and 6 studies [22,23,25,[27][28][29] considered blinding of outcome assessment. Seven studies [22][23][24][26][27][28][29] reported incomplete outcome data, while the remaining 2 trials [21,25] were considered to have a high risk of attrition bias because of the high dropout rate.…”

“…However, this study failed to assess clinical outcomes, such as postoperative complications, mortality, and length of hospital stay. In addition, several studies [21][22][23][24][25][26][27][28][29] have been conducted to evaluate the effectiveness of immunonutrition support in patients undergoing liver resection, and they have yielded inconsistent results. Therefore, whether immunonutrition is beneficial and safe for these patients remains undetermined.…”