Immune-enhancing Nutrition Research Articles

Perioperative nutrition optimization: a review of the current literature†

Abstract Objective This article aims to elaborate the recent research status of perioperative nutrition optimization, in order to help clinical practice. Methods This study employed a comprehensive and systematic method to search prominent databases, including PubMed and Web of Science, using carefully selected keywords. Following meticulous screening, the inclusion of high-quality studies was prioritized, and a thorough review of the references was conducted to comprehensively analyze the latest evidence on perioperative nutrition optimization. Results The main contents include preoperative nutritional risk screening and assessment, nutritional support pathway, immune enhancing nutrition, preoperative and postoperative nutritional management, as well as personalized nutrition optimization strategies for specific populations (such as children, bariatric surgery patients, and cancer patients). Conclusions In clinical practice, the importance of perioperative nutrition should be emphasized, and personalized nutrition management plans should be developed based on the characteristics and needs of patients. Further research and promotion of perioperative nutrition optimization strategies will help improve the overall prognosis and quality of life of surgical patients.

Effects of immune-enhancing nutrition on radical cystectomy outcomes: Primary results from the randomized phase III double-blind clinical trial (S1600).

4501 Background: SWOG S1600 was a randomized, double-blind, phase III trial comparing the impact of consuming Specialized IMmunonutrition (SIM) to oral nutritional support (ONS) on postoperative complications following radical cystectomy (RC). SIM is fortified with nutrients: L-arginine; omega-3 fatty acids; and dietary nucleotides. Methods: Patients with bladder carcinoma planning to undergo RC were enrolled and randomized 1:1 to SIM vs. ONS. The primary endpoint was any (≥Grade I) postoperative complication assessed by the Clavien-Dindo (CD) scale at Day 30 after RC. Multivariable logistic regression was used, adjusted for the stratification factors: diversion type (neobladder vs. ileal conduit), prior neoadjuvant chemotherapy (any vs. none), and baseline nutrition status (well-nourished vs. moderate malnutrition). Additional outcomes included 90-day complications and high-grade (CD ≥Grade III) complications. Two-year progression-free survival (PFS) and overall survival (OS) were assessed; differences by arm were reported using Log-rank test statistics. Protocol-specified intention-to-treat (ITT) analyses based on all randomized patients and 1-sided alpha=.05 tests were performed. Results: Among N=203 enrolled patients (99 on SIM, 104 on ONS), median age was 68.8 years, 20% were female and 5% were Black. Five patients did not meet eligibility criteria (1 on SIM, 4 on ONS) but were included under the ITT design. Seventeen patients withdrew consent prior to their Day 30 assessment, and 8 patients were not assessed; thus, n=178 (90 on SIM, 88 on ONS) were evaluable at Day 30. The proportion of patients experiencing CD Grade ≥1 complications was 62.2% for SIM and 58.0% for ONS; in multivariable regression, there was no difference in Grade ≥1 complications by arm (OR=1.18, 95% CI, 0.64-2.18, 1-sided p=.71). There were no differences by arm in high-grade complications at Day 30, in any or high-grade complications at Day 90 or overall. To date, among all 203 patients, 17 on SIM and 26 on ONS have progressed or died, with 2-year PFS estimates of 77.2% and 68.3%, respectively (1-sided p=.16). Nine patients on SIM and 17 on ONS have died, with 2-year OS estimates of 87.4% and 78.2%, respectively (1-sided p=.07). Conclusions: There was no difference in any grade CD complications by type of nutritional supplement for patients with bladder cancer undergoing RC. Fewer patients on the SIM arm have progressed or died, although differences were not statistically significant; follow-up for survival will continue through 3-years after enrollment. Future work to understand the interaction of diet on cancers sensitive to immune modulation is needed. Clinical trial information: NCT03757949 .

Dynamic changes in practical inflammation and immunity markers in cancer patients receiving immune-enhancing nutritional supplementation during concurrent chemoradiotherapy.

BACKGROUND: Immune-enhancing nutrition (IMN) strengthens the systematic inflammatory response and the immune system. Neutrophil to lymphocyte ratio (NLR) and absolute lymphocyte count (ALC) are affected during cancer therapies.OBJECTIVE: We carried out an analysis of the dynamic changes in NLR and ALC over time in cancer patients with or without IMN supplementation.METHODS: 88 cancer patients receiving concurrent chemoradiotherapy (CCRT) were randomized into regular diet group, and regular diet and IMN group.Generalized estimation equation models were used to assess associations between patient’s characteristics, IMN, and dynamic changes in NLR and ALC over time.RESULTS: NLR and ALC at pre-CCRT were significantly associated with dynamic changes in NLR (adjusted 1.08, 95% confidence interval [CI]: 0.64–1.52) and ALC (adjusted 0.41, 95% CI: 0.36–0.46). The magnitudes of the NLR and ALC changes through CCRT were lower in patients receiving IMN, although the differences were not statistically significant except ALC at the end of CCRT in head and neck cancer patients ( 0.023).CONCLUSION: Dynamic negative changes in both markers were demonstrated throughout CCRT. There were non-significant trend in promising changes in both NLR and ALC values in the whole group in IMN supplementation.

Effects of preoperative nutrition on postoperative outcomes in esophageal cancer: a systematic review and meta-analysis.

Postoperative enteral nutrition has been widely implemented in esophageal cancer, but the efficacy and safety of preoperative nutrition, particularly immune-enhancing nutrition (IEN), remain controversial. This meta-analysis aims to provide a quantitative synthesis of whether preoperative nutrition improves postoperative morbidity and mortality in patients with resectable esophageal cancer. A systematic search was conducted in Medline, Embase, Cochrane, and databases of clinical trials dated up to December 2019. Randomized controlled trials and observational studies comparing postoperative outcomes between esophageal cancer patients with and without preoperative nutritional support were included. Random-effects model was applied in the meta-analysis of primary outcomes (overall complication rate, in-hospital mortality) and secondary outcomes (infectious complication rate, anastomotic leak rate, length of postoperative hospital stay). Complications of feeding tube access and perioperative weight loss were evaluated by qualitative synthesis. Subgroup analyses were performed by stratifying immunonutrition and standard nutrition before surgery. Subgroup analysis of randomized controlled trials alone was also done. A total of 15 studies enrolling 1864 participants were included. The overall meta-analysis found that preoperative nutrition could reduce infectious complications (odds ratio [OR] = 0.51, 95% confidence interval [CI] [0.26, 0.98]; I2= 48%) and length of hospital stay (mean difference = -2.10day, 95% CI [-3.72, -0.47]; I2= 78%) after esophagectomy, whereas no significant difference was revealed in the incidence of overall complications (OR = 0.76, 95% CI [0.52, 1.11]; I2= 32%), in-hospital mortality (OR = 1.03, 95% CI [0.41, 2.61]; I2= 12%), and anastomotic leak (OR = 1.05, 95% CI [0.69, 1.58]; I2= 0%). Subgroup of preoperative immunonutrition showed more prominent benefits. The complication rate of feeding tube access was low (1.6-16%). In conclusion, preoperative nutrition is safe in esophageal cancer, but benefits are observed in infectious complication rate and length of stay on a limited scale. IEN holds more advantages over standard nutrition. Randomized trials in the context of nutritional support during neoadjuvant therapy are in demand.

1318: Immune-Enhancing Nutrition in Traumatic Brain Injury: A Blinded Prospective Randomized Pilot Study

Semon, Gregory1; Miner, Jason2; DaSilva, Joshua3; Malik, Rema2; Bruun, John2; Gossett, Holly4; Young, Lisa4; Herzing, Karen5; Ekeh, Akpofure2; Hardman, Claire5 Author Information

Immunonutrition for traumatic brain injury in children and adolescents: protocol for a systematic review and meta-analysis

IntroductionTraumatic brain injury (TBI) is the leading cause of paediatric trauma death and disability worldwide. The ‘Guidelines for the Management of Severe Traumatic Brain Injury (Fourth Edition)’ recommend that nutritional...

Preoperative immunonutrition in frail patients with colorectal cancer: an intervention to improve postoperative outcomes.

The aim of this study is to evaluate whether preoperative immunonutrition can shorten length of stay and improve postoperative outcomes in frail patients who are candidates for major oncologic colorectal surgery. A single center retrospective analysis of a prospectively collected database of frail patients, who underwent surgery with curative intent for colorectal cancer between January 2014 and December 2017, was performed. From March 2016, frail oncological patients undergoing major surgery were recommended to receive preoperative immunonutrition; their postoperative outcomes were compared to those of patients not treated with any preoperative nutritional support. Propensity score matching in a 1:1 ratio was used to balance patient characteristics. Overall, 175 patients were included in the study. Of 74 patients receiving immunonutrition, 65 were matched with the group not treated with immunonutrition (n = 101). Baseline characteristics were comparable after matching. Although differences in postoperative length of stay were nonsignificant (p = 0.38), patients who received immunonutrition showed a shorter gastrointestinal (GI) recovery time (3.00 [2.00-4.00] versus 4.00 [2.00-5.00], p = 0.04), a lower rate of situs site infections complications (0.31 [0.10, 0.94], p = 0.04) and less need of antibiotic treatment (0.19 [0.06, 0.64], p = 0.01). Preoperative immunonutrition was found to reduce both postoperative situs site infections and need of antibiotic treatment during the postoperative course. This study encourages the use of preoperative immune-enhancing nutrition as a part of multimodal prehabilitation programs in the management of frail colorectal cancer patients.

Randomized controlled study of immune nutrition in patients with acute stress

Objective To explore the effects of immune-enhanced enteral nutrition support on the clinical outcome and nutritional status of patients with acute stress. Methods From December 2014 to August 2015, 120 patients with acute stress were enrolled in this study in the First Affiliated Hospital of Zhengzhou University. The patients were randomly divided into the control group and the experimental group, 60 cases in each group. Besides of medical treatment, the control group received routine enteral nutrition, while the experimental group received immune-enhanced nutrition for 8 days. The main parameters related to nutritional status, immune function, blood glucose, infection control of patients were collected. Results No significance of parameters listed above were observed between patients in the two groups at baseline. After intervention, the levels of prealbumin and lymphocyte counts in the experimental group were higher than those in the control group [(162.5±29.7) mg/L and (136.6±15.1) mg/L, (1.86±0.9) ×109/L and (1.45±0.710) ×109/L, P=0.021 and P=0.012]. The levels of C-reactive protein in the experimental group were lower than those in the control group [ (47.2±22.1) mg/L and (82.6±13.4) mg/L, P=0.043]. Moreover, the level of blood glucose in the experimental group was lower than that in the control group [(5.4±1.7) mmol/L and (6.6±3.5) mmol/L, P=0.009]. The patients in the experimental group had better intestinal tolerance (8.3% vs 25%, P=0.014) but lower mortality (6.7% vs 20%, P=0.032) than those in the control group. Conclusions Immune-enhanced enteral nutrition can reduce level of blood glucose and alleviate inflammatory responses of patients with acute stress, thus improving intestinal tolerance, and reducing mortality. Key words: Immune-enhanced enteral nutrition; Acute stress; Inflammation

Prognostic Factors Influencing Infectious Complications after Cytoreductive Surgery and HIPEC: Results from a Tertiary Referral Center.

Background Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) showed promising results in selected patients. High morbidity restrains its wide application. The aim of this study was to report postoperative infectious complications and investigate possible correlations with the preoperative nutritional status and other prognostic factors in patients with peritoneal metastases treated with CRS and HIPEC. Methods For the study, we reviewed the clinical records of all patients with peritoneal metastases from different primary cancers treated with CRS and HIPEC in our Institution from November 2000 to December 2017. Patients were divided according to their nutritional status (SGA) into groups A (well-nourished) and B/C (mild or severely malnourished, respectively). Possible statistical correlations between risk factors and postoperative complication rates have been investigated by univariate and multivariate analysis. Results Two hundred patients were selected and underwent CRS and HIPEC during the study period. Postoperative complications occurred in 44% of the patients, 35.3% in SGA-A patients, and 53% in SGA-B/C patients. Cause of complications was infective in 42, noninfective in 37, and HIPEC related in 9 patients. Infectious complications occurred more frequently in SGA-B/C patients (32.6% vs. 9.8% of SGA-A patients). The most frequent sites of infection were surgical site infections (SSI, 35.7%) and central line-associated bloodstream infections (CLABSI, 26.2%). The most frequent isolated species was Candida (22.8%). ASA score, blood loss, performance status, PCI, large bowel resection, postoperative serum albumin levels, and nutritional status correlated with higher risk for postoperative infectious complications. Conclusions Malnourished patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are more prone to postoperative infectious complications, and adequate perioperative nutritional support should be considered, including immune-enhancing nutrition. Sequential monitoring of common sites of infection, antifungal prevention of candidiasis, and careful patient selection should be implemented to reduce the complication rate.

Nutritional Care for Patients With Esophageal Cancer

Esophageal cancer (EC) is frequently associated with gastrointestinal side effects that contribute to high rates of malnutrition. The objective of this review was to summarize the research on nutritional interventions during EC treatment and formulate recommendations for nutrition care. Recommendations include (1) nutritional assessment using screening tools, (2) dietitian-driven interventions using nutrition protocols, (3) immune-enhanced nutrition administered perioperatively, (4) parenteral nutrition administered concurrently with enteral nutrition and lipid emulsions containing omega-3 fatty acids, and (5) dietitian-driven nutrition therapy until intake meets nutritional goals. Patient outcomes are improved when dietitians plan and implement nutritional interventions throughout EC treatment.

AHNS Series - Do you know your guidelines?: Assessment and management of malnutrition in patients with head and neck cancer: Review of the NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines).

This article is a part of the "Do you know your guidelines" series by the Education Committee of the American Head and Neck Society. The aim is to summarize the core principles outlined by the NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines® ) on management of malnutrition in patients with head and neck cancer. We outline the current recommendations from the National Comprehensive Cancer Network® (NCCN® ) for the screening and management of malnutrition, including indications for nutritional supplementation and placement of a nasogastric or gastrostomy tube. We also include a brief review of the available literature on additional screening tools, alternative guidelines, as well as an update on the emerging data surrounding the use of immune-enhancing nutrition.

Survey of nutritional practices in total gastrectomy and oesophagectomy procedures

Total gastrectomy and Ivor Lewis oesophagectomy procedures are the mainstay of upper gastrointestinal cancer management. Maintenance of adequate nutritional intake is essential for positive patient outcomes. Although numerous nutritional support options exist, clear evidence-based guidelines on the optimal means and duration of nutritional support are lacking. The aim of this study is to establish preliminary data on the current perioperative nutritional practices of upper gastrointestinal surgeons performing these procedures across Australia and New Zealand. It is hoped this will help provide the platform for future research towards establishing evidence-based guidelines in upper gastrointestinal surgery. A questionnaire exploring the nutritional practices and considerations of surgeons was developed and emailed to the members of the Australia & New Zealand Gastric & Oesophageal Surgery Association. A total of 27.4% of Australia & New Zealand Gastric & Oesophageal Surgery Association members completed the questionnaire. Surgeons reported inserting a jejunostomy feeding tube intraoperatively in Ivor Lewis oesophagectomy procedures 80-100% of the time, compared to only 20-39% of the time in total gastrectomy procedures. For both procedures, surgeons often refer their patients to a dietitian preoperatively, and always postoperatively. Preoperative immune-enhancing nutrition is rarely administered. Patient age and BMI are deemed to be of low importance when determining the means of nutritional support. This study has demonstrated the current nutritional practices employed in Australia and New Zealand for patients undergoing major upper gastrointestinal surgery. Questions remain regarding the noted differences between procedures as well as the optimal means and duration of perioperative nutritional support.

A randomized phase III double-blind clinical trial (S1600) evaluating the effect of immune-enhancing nutrition on radical cystectomy outcomes.

TPS529 Background: This phase III trial will compare the impact of consuming Specialized IMmunonutrition (SIM) to oral nutritional support on postoperative complications after radical cystectomy. Specialized IMmunonutrition is fortified with nutrients (L-arginine, omega-3 fatty acids, dietary nucleotides, and vitamin A) that have immediate effects on immune and inflammatory responses, muscle sparing, and wound healing after surgery. Methods: Two hundred patients will be randomized in a 1:1 fashion to one of two arms. Subjects will be stratified by diversion type (neobladder vs. ileal conduit) and whether the patient had neoadjuvant chemotherapy (any vs. none) to balance the intervention assignment according to important prognostic factors. Nutrition drinks are given three times a day for 5 days before and 5 days after surgery. The primary endpoint is 30 day overall complication rate. Two hundred patients gives 80% power to detect an absolute reduction of 23% in the 30 day overall complication rate (from 65% down to 42%). Secondary endpoints will assess infections, muscle mass, readmissions, quality of life, recurrence, DFS, OS, immune response, cytokines, amino acids, and fatty acids. The trial is testing a high yield, low-risk, low-cost strategy to improve the outcome of patients with bladder cancer who undergo cystectomy. Funding: NIH/NCI/DCP grant award UG1CA189974. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Randomized study of nutritional status and treatment toxicities of oral arginine, glutamine, and Omega-3 fatty acids during concurrent chemoradiotherapy for head and neck cancer patients

Background: Patients with head and neck cancer (HNC) undergoing concurrent chemoradiotherapy (CCRT) are at high risk of dysphagia, malnutrition, and immunosuppression. Arginine, glutamine, and Omega-3 fatty acidsare immune-enhanced nutrition that can promote cellular immunity.We aimed to examine the impact of immunonutrition diet on nutritional status, and CCRT toxicities, in this group of patients.Methods: Forty patients with HNC who treated with curative CCRT were randomized to: group A (n = 20), patients who received a regular diet and dietary counselingby a protocol dietician; group B (n = 20), patients who received a regular diet plus immune-enhanced nutrition supplements and dietary counseling by the same protocol dietician. Outcome measures were weight loss, protein and energy intake, serum pre-albumin and albumin, and toxicities of CCRT were evaluated at baseline, weekly and at the end of treatment.Results:Both groups were well balanced at baseline.One patient from group A (1/20) withdrew consent. Seven patients from group B (7/20) withdrew from the study; 1 patient could not tolerate the side effect of chemotherapy and 6 patients could not tolerate the taste of oral immune-enhanced nutrition.A significant loss in total body weight was observed in group A patients (p<0.001), whereas not significant loss in group B (p=0.109). Median percentage change from baseline of energy intake was 19.6%, and 22.9% at the end of treatment for group A, and B, respectively. The circulating levels of nutritional markers, pre-albumin and albumin decreased after CCRT in both groups. There was a significantly decreased level of albumin in group A more than group B, at the end of treatment. During CCRT; 4 patients (20%) in group A and 1 patient(5%) in group B developed grade 3 mucositis, respectively. One patient (5%) in group A had grade 3 radiation dermatitis. Grade 3 – 4 hematologic toxicities, mainly in absolute neutrophil count (ANC) were significant higher in group A than group B; 20% versus 0% (p=0.035).Over the 7-week period of CCRT, both intention to treat analysis and per protocol analysis revealed similar in scaled for all endpoints.Conclusions: Nutritional counseling and immuno-nutrition can reduce the deterioration of nutrition status and also significantly reduced hematologic and non-hematologic toxicity of CCRT in head and neck cancer.Keywords : immune-enhanced nutrition, concurrent chemoradiotherapy, head and neck cancer

The recovery effects of Perinereis aibuhitensis Grube added to enteral immune-enhancing nutrition in severely burned mice

The recovery effects ofPerinereis aibuhitensisGrube added to early enteral nutrition (EEN) were investigated.

Immune enhancing nutrition in traumatic brain injury – A preliminary study

Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Certain patients appear to benefit when they receive immune enhancing additives, such as glutamine, arginine, and omega-3 fatty acids. We hypothesized that TBI patients given enteral feedings containing these supplements may have improved nutrition measures and infection rates when compared to standard tube feedings.This is a retrospective review of patients from a Level-One trauma center from July 2009 to July 2013. A total of 240 TBI patients received either an immune enhancing nutrition (IEN) formula (n = 126), or a standard formula (SF) (n = 114) based on the attending surgeon's preference. Data collected included demographic information, infection information and outcome measures.Patients were similar in terms of age, ISS, head AIS, and initial prealbumin level. Patients receiving IEN were found to have lower rates of blood stream infections (10.3% vs 19.3%, p < 0.05), whereas pneumonia and UTI rates were similar between groups. In addition, both groups had similar rates of all-cause mortality and hospital length of stay, however IEN patients spent longer in the ICU and on ventilators. In TBI patients receiving IEN, prealbumin levels were higher at the second, third, and fourth week of admission (week 2 – 22.2 vs 17.4, p = 0.006; week 3 – 24.6 vs 20.1, p = 0.04; week 4 – 26.3 vs 22.1, p = 0.19; week 5 – 25.8 vs 20.3, p = 0.21).This study suggests that patients with traumatic brain injury who receive IEN are more likely to have increased prealbumin levels perhaps reflecting improved nutrition throughout their hospital stay and may show some benefit in rates of infections, particularly in bacteremia.

Impact of Perioperative Enteral Immunonutrition on Infectious Complications After Major Gastrointestinal Surgery

Objective: To study the impact of perioperative, enterally administered whey protein concentrate on infectious complications after major elective gastrointestinal surgery in a tertiary care hospital. Materials and Methods: Prospective non-randomized study conducted from June 2008–April 2010, which included 50 consecutive patients who underwent major elective gastrointestinal surgery for benign and malignant diseases. The primary outcome measured was the rate of infectious complications, and the secondary outcome was length of postoperative stay. Results: 50 patients were divided into two equal groups: Group 1 and Group 2 (n=25 each). One group received immune-enhanced enteral nutrition (IMEN) perioperatively, and the control group received standard enteral nutrition (SEN) during the same period. There were no significant differences between the two groups with regard to complications (P=0.26), either infective (P=0.76) or non-infective (P=0.65). There was no significant difference in the duration of postoperative stay (P=0.25) between the two groups. There was also no significant difference in the pre- and postoperative White Blood Cell (WBC) count, C-Reactive Protein (CRP), and albumin levels. However, a subgroup analysis carried out to identify malnourished patients in the immunonutrition group revealed significant reduction in the length of postoperative stay (P=0.03) but not the rate of infectious complications (P=0.20). Conclusion: Perioperatively administered immunonutrition did not decrease the incidence of postoperative infectious complications and the duration of postoperative stay. Malnourished patients given immunonutrition in the perioperative period showed a significant reduction in the length of postoperative hospital stay but not the incidence of infective complications.

Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial

Invasive procedures such as surgery cause immunosuppression, leading to increased risk of complications, infections and extended hospital stay. Emerging research around immune-enhancing nutrition supplements and their ability to reduce postoperative complications and reduce treatment costs is promising. This randomised controlled trial aims to examine the effect of preoperative immunonutrition supplementation on length of hospital stay (LOS), complications and treatment costs in both well-nourished and malnourished gastrointestinal surgery patients. Ninety-five patients undergoing elective upper and lower gastrointestinal surgery were recruited. The treatment group (n=46) received a commercial immuno-enhancing supplement 5 days preoperatively. The control group (n=49) received no supplements. The primary outcome measure was LOS, and secondary outcome measures included complications and cost. A nonsignificant trend towards a shorter LOS within the treatment group was observed (7.1 ± 4.1 compared with 8.8 ± 6.5 days; P=0.11). For malnourished patients, this trend was greater with hospital stay reduced by 4 days (8.3 ± 3.5 vs 12.3 ± 9.5 days; P=0.21). Complications and unplanned intensive care admission rates were very low in both the groups. The average admission cost was reduced by AUD1576 in the treatment group compared with the control group (P=0.37). Preoperative immunonutrition therapy in gastrointestinal surgery has the potential to reduce the LOS and cost, with greater treatment benefit seen in malnourished patients; however, there is a need for additional research with greater patient numbers.

Effect of postoperative immune-enhanced enteral nutrition on immune function in gastrointestinal cancer patients with radical resection

Objective To evaluate the effect of postoperative immune-enhanced enteral nutrition on host immune function in gastrointestinal cancer patients with radical resection.Methods 58 patients of radical resection of gastrointestinal carcinoma were randomly divided into the immune-enhanced enteral nutrition group(IEDs group)and the regular enteral nutrition group(EN group)with 29 cases in each group.Patients in the IEDs group received immune enhanced nutrition,containing glutamine,arginine ω-3 polyunsaturated fatty acids,while Nutrison Fibre was given to the EN group.T-lymphocyte subsets (CD3+,CD4+,CD8+,CD4+/CD8+),NK cells,immunoglobulin (IgA,IgM,IgG)were measured respectively on preoperative day 1,and postoperative day 1 and day 9.Results No severe adverse effects of those two formulas were recorded.Postoperative procedures went smoothly in two groups.There were no significant differences in immune parameters between two groups on preoperative day 1 and postoperative day 1.The immune indicators were decreased on postoperative day 1 while increased on postoperative day 9 in both two groups.The level of CD3+,CD4+,CD4+/CD8+,NK,IgA,IgM in the IEDs group on postoperative day 9 were higher than those on postoperative day 1 while all relevant parameters of the EN group showed no significant difference except CD3+ and immunoglobulin.The level of CD3+,CD4+,CD4+/CD8+,NK,IgA,IgM in the IEDs group on postoperative day 9 had increased significantly in comparison with those of the EN group.Conclusions The postoperative immune-enhanced enteral nutrition in gastrointestinal cancer patients with radical resection is superior to regular enteral nutrition in improving immune function. Key words: Enteral nutrition; Immune-enhanced; Gastrointestinal cancer, Immune function

Pre-operative nutrition support in patients undergoing gastrointestinal surgery.

Post-operative management in gastrointestinal (GI) surgery is becoming well established with 'Enhanced Recovery After Surgery' protocols starting 24 hours prior to surgery with carbohydrate loading and early oral or enteral feeding given to patients the first day following surgery. However, whether or not nutritional intervention should be initiated earlier in the preoperative period remains unclear. Poor pre-operative nutritional status has been linked consistently to an increase in post-operative complications and poorer surgical outcome. To review the literature on preoperative nutritional support in patients undergoing gastrointestinal surgery (GI). The searches were initially run in March 2011 and subsequently updated in February 2012. Databases including all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA and NHSEED) MEDLINE, EMBASE, AMED, British Nursing Index Archive using OvidSP were included and a search was run on each database separately after which duplicates were excluded. The inclusion criteria were randomised controlled trials that evaluated pre-operative nutritional support in GI surgical participants using a nutritional formula delivered by a parenteral, enteral or oral route. The primary outcomes included post-operative complications and length of hospital stay. Two observers screened the abstracts for inclusion in the review and performed data extraction. Bias was assessed for each of the included studies using the bias assessment tables in the Cochrane Software Review Manager (version 5.1, Cochrane Collaboration). The trials were analysed using risk ratios with Mantel-Haenszel in fixed effects methods displayed with heterogeneity. Meta-analyses were undertaken on trials evaluating immune enhancing (IE) nutrition, standard oral supplements, enteral and parenteral nutrition (PN) which were administered pre-operatively.Study characteristics were summarised in tables. Dichotomous and ratio data were entered into meta-analyses for the primary outcomes. These were then summarised in tables with assumed and corresponding risk with relative effect giving 95% confidence intervals. The searches identified 9900 titles and, after excluding duplicates, 6433 titles were initially screened. After the initial title screen, 6266 were excluded. Abstracts were screened for 167 studies and 33 articles were identified as meeting the inclusion criteria, of which 13 were included in the review after an assessment of the complete manuscripts.Seven trials evaluating IE nutrition were included in the review, of which 6 were combined in a meta-analysis. These studies showed a low to moderate level of heterogeneity and significantly reduced total post-operative complications (risk ratio (RR) 0.67 CI 0.53 to 0.84). Three trials evaluating PN were included in a meta-analysis and a significant reduction in post-operative complications was demonstrated (RR 0.64 95% CI 0.46 to 0.87) with low heterogeneity, in predominantly malnourished participants. Two trials evaluating enteral nutrition (RR 0.79, 95% CI 0.56 to 1.10) and 3 trials evaluating standard oral supplements (RR 1.01 95% CI 0.56 to 1.10) were included, neither of which showed any difference in the primary outcomes. There have been significant benefits demonstrated with pre-operative administration of IE nutrition in some high quality trials. However, bias was identified which may limit the generalizability of these results to all GI surgical candidates and the data needs to be placed in context with other recent innovations in surgical management (eg-ERAS). Some unwanted effects have also been reported with components of IE nutrition in critical care patients and it is unknown whether there would be detrimental effects by administering IE nutrition to patients who could require critical care support after their surgery. The studies evaluating PN demonstrated that the provision of PN to predominantly malnourished surgical candidates reduced post-operative complications; however, these data may not be applicable to current clinical practice, not least because they have involved a high degree of 'hyperalimentation'. Trials evaluating enteral or oral nutrition were inconclusive and further studies are required to select GI surgical patients for these nutritional interventions.