TGF-β2, EGF, and FGF21 Growth Factors Present in Breast Milk Promote Mesenteric Lymph Node Lymphocytes Maturation in Suckling Rats

Breast milk, due to its large number of nutrients and bioactive factors, contributes to optimal development and immune maturation in early life. In this study, we aimed to assess the influence of some growth factors present in breast milk, such as transforming growth factor-β2 (TGF-β2), epidermal growth factor (EGF), and fibroblast growth factor 21 (FGF21), on the immune response development. Newborn Wistar rats were supplemented daily with TGF-β2, EGF, or FGF21, throughout the suckling period. At day 14 and 21 of life, lymphocytes from mesenteric lymph nodes (MLNs) were isolated, immunophenotyped, and cultured to evaluate their ability to proliferate and release cytokines. The main results demonstrated that supplementation with TGF-β2, EGF, or FGF21 modified the lymphocyte composition in MLNs. At day 14, all supplementations were able to induce a lower percentage of natural killer (NK) cells with the immature phenotype (CD8⁺), and they reduced the CD8αα/CD8αβ ratio at day 21. Moreover, the cytokine pattern was modified by the three treatments, with a down regulation of interleukin (IL)-13 secretion. These results showed the contribution of these growth factors in the lymphocytes MLNs immune maturation during the neonatal period.

Inflammatory bowel disease and immunonutrition: novel therapeutic approaches through modulation of diet and the gut microbiome

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract, thought to at least in part reflect an aberrant immune response to gut bacteria. IBD is increasing in incidence, particularly in populations that have recently immigrated to western countries. This suggests that environmental factors are involved in its pathogenesis. We hypothesize that the increase in IBD rates might reflect the consumption of an unhealthy Western diet, containing excess calories and lacking in key nutritional factors, such as fibre and vitamin D. Several recent studies have determined that dietary factors can dramatically influence the activation of immune cells and the mediators they release through a process called immunonutrition. Moreover, dietary changes can profoundly affect the balance of beneficial versus pathogenic bacteria in the gut. This microbial imbalance can alter levels of microbiota-derived metabolites that in turn can influence innate and adaptive intestinal immune responses. If the diet-gut microbiome disease axis does indeed underpin much of the 'western' influence on the onset and progression of IBD, then tremendous opportunity exists for therapeutic changes in lifestyle, to modulate the gut microbiome and to correct immune imbalances in individuals with IBD. This review highlights four such therapeutic strategies - probiotics, prebiotics, vitamin D and caloric restriction - that have the potential to improve and add to current IBD treatment regimens.

Influence of nutritional status on postoperative outcome in patients with colorectal cancer - the emerging role of the microbiome

Many patients with colorectal cancer are overweight. Even then, nutritional status is a frequently underestimated risk factor for perioperative complications. Enhanced Recovery after Surgery is the goal for perioperative management, and preoperative nutritional risk screening should be a standard. In case of nutritional risk, perioperative nutrition therapy should be started without delay and should follow recent guideline recommendations. The preservation of the microbiome has an emerging role in preventing postoperative anastomotic leakage and septic complications. The time window for recovery after neoadjuvant treatment for rectal cancer may be used for conditioning appropriate-risk patients in a “prehabilitation” program. In order to assess metabolic recovery and the prognosis for long-term survival, C-reactive protein/albumin ratio may be a promising parameter, which has to be validated in the future. This narrative review summarizes recent strategies and guideline recommendations.

Immune-Enhancing Formulas for Patients With Cancer Undergoing Esophagectomy: Systematic Review Protocol

BACKGROUND

Adult patients with an esophageal cancer can potentially be compromised with postoperative leaks or fistulae if patients' nutritional status is in a vulnerable stage. Currently in Australia, there is a growing need for clinicians to know whether use of immune-enhancing formulas (IEFs) containing Arg, omega-3, and RNA are a cost-effective approach compared with isonitrogenous-isocaloric formulas to reduce postoperative infectious complications in esophagectomy patients. Since IEFs may carry higher costs, this has led to inconsistencies in practice among clinicians and hospitals.

OBJECTIVE

Our aim is to compile and present the most up-to-date nutrition evidence available regarding the provision of IEFs containing Arg, omega-3, and RNA to help clinicians develop an evidence-based nutrition care plan; identify available evidence of whether an esophagectomy patient should receive IEF; determine the cost-effectiveness and safety of such nutrition; and determine appropriate administration quantity and timing (pre-, peri-, or postesophagectomy).

METHODS

This review will include RCTs involving the use of IEFs enriched with Arg, omega-3 polyunsaturated fatty acids, and RNA in the pre-, peri-, or postoperative period (for at least 5-7 days) given orally or via enteral feeding tube, in adult cancer patients undergoing esophageal resection. Lower gastrointestinal, gastric, or head cancer surgery with parenteral nutrition or non-IEF or use of isolated immunonutrient (Arg vs omega-3 vs RNA) will be excluded. Primary outcome comprises postoperative infectious complications. Secondary outcomes (pre/postoperatively) consist of cost-effectiveness, length of stay, survival/mortality, quality of life, nutritional status, percentage of weight loss, and biochemical changes. The risk of bias will be independently assessed by the reviewers, using a domain-based evaluation tool. Blinding will be assessed for subjective and objective outcome measures. Publication bias will be visually assessed by funnel plots. A meta-analysis will be generated by the Review Manager 5.3 software and represented in forest plots.

RESULTS

The first results are expected in 2018. Outlining the protocol will ensure transparency for the completed review.

CONCLUSIONS

This protocol for a systematic review and meta-analysis will enable a comprehensive appraisal of the literature to help determine whether overall institutional savings are associated with this approach. Findings will form a knowledge base relevant to stakeholders across the health system and researchers who are involved in decision making on evidence-based nutrition care plan pathways for patients undergoing esophagectomy, as well as the use of IEF, timing, and administration quantity.

TRIAL REGISTRATION

PROSPERO Registration Number: CRD42017056908; http://www.crd.york.ac.uk/PROSPERO/ display_record.asp? ID=CRD42017056908 (Archived by WebCite at http://www.webcitation.org/6rLyeqaD6).

Nutritional Therapy in Liver Transplantation

Protein-energy malnourishment is commonly encountered in patients with end-stage liver disease who undergo liver transplantation. Malnutrition may further increase morbidity, mortality and costs in the post-transplantation setting. The importance of carefully assessing the nutritional status during the work-up of patients who are candidates for liver replacement is widely recognized. The metabolic abnormalities induced by liver failure render the conventional assessment of nutritional status to be challenging. Preoperative loss of skeletal muscle mass, namely, sarcopenia, has a significant detrimental impact on post-transplant outcomes. It is essential to provide sufficient nutritional support during all phases of liver transplantation. Oral nutrition is preferred, but tube enteral nutrition may be required to provide the needed energy intake. Herein, the latest currently employed perioperative nutritional interventions in liver transplant recipients are thoroughly illustrated including synbiotics, micronutrients, branched-chain amino acid supplementation, immunonutrition formulas, fluid and electrolyte balance, the offering of nocturnal meals, dietary counselling, exercise and rehabilitation.

Preoperative immunonutrition regulates tumor infiltrative lymphocytes and increases tumor angiogenesis in gastric cancer patients

INTRODUCTION

An increased number of tumor infiltrative lymphocytes (TILs) is considered a favorable prognostic factor in various cancers because it is a marker of antitumoral activity of the immune system. In this prospective, non-randomized clinical trial, we evaluated the impact of preoperative immunonutrition on tumor infiltrative lymphocytes and neoangiogenesis in cancerous tissue in patients with locoregional and resectable gastric adenocarcinoma.

MATERIAL AND METHODS

Patients with locoregional and resectable gastric adenocarcinoma were divided non-randomly into two study groups. The first (control) group included patients who had standard nutrition, and the second group included those who had immunonutrition for 7 days before surgery. The biopsy samples taken endoscopically in the preoperative period, as well as the gastrectomy samples, were subjected to immunohistochemical staining for quantitative analysis of CD4, CD8, CD16, CD56, CD31 and CD105 antibodies. Main outcome measures were CD4-to-CD8 ratio and CD105 levels.

RESULTS

Fifty patients were included in the study between January 2013 and December 2014. Twenty-five patients were assigned to each of the first and second group. The CD4-to-CD8 ratio and CD105 levels determined in endoscopic biopsy samples were similar in both groups. The CD4-to-CD8 ratio in gastrectomy samples was significantly higher in the first group (p = 0.0001). The CD105 levels in gastrectomy samples were significantly lower in the first group (p = 0.01).

CONCLUSIONS

Seven-day preoperative immunonutrition use regulates TILs in gastric cancer patients, but prolonged use increases tumor angiogenesis.

The benefit of immunonutrition in patients undergoing hepatectomy: a systematic review and meta-analysis

Perioperative immunonutrition in liver resection remains doubtful. A systematic review and meta-analysis was conducted to compare postoperative outcomes between patients undergoing hepatectomy who received perioperative immunonutrition and those who did not.A PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Knowledge database search was performed to retrieve all of the randomized controlled trials (RCTs) evaluating the value of perioperative immunonutrition in patients undergoing hepatectomy until the end of September 2016. Data extraction and quality assessment of RCTs were performed in accordance with PRISMA guidelines. The quality of evidence for each postoperative outcome was assessed using the GRADEpro analysis. A random-effects model was used to conduct a meta-analysis with RevMan 5.3.5 software. Eight RCTs including 805 patients (402 with and 403 without immunonutrition) were identified. Immunonutrition, mainly ω-3 fatty acids, significantly reduced the incidence of postoperative total complications (risk ratio [RR] = 0.59; 95% confidence interval [CI], 0.46-0.75; p < 0.0001) and infectious complications (RR = 0.46; 95% CI, 0.32-0.68; p < 0.0001), and shortened the length of hospital stay (standardized mean difference, -0.49; 95% CI, -0.81 to -0.16; p = 0.0004). There was no significant between-group difference in postoperative mortality (RR = 0.46; 95% CI, 0.16-1.31; p = 0.15). Immunonutrition, mainly ω-3 fatty acids, is potentially beneficial in reducing overall and infectious postoperative complications and in shortening the hospital stay for patients undergoing hepatectomy.

Preventive Effect of Cow's Milk Fermented with Lactobacillus paracasei CBA L74 on Common Infectious Diseases in Children: A Multicenter Randomized Controlled Trial

Background: Fermented foods have been proposed to prevent common infectious diseases (CIDs) in children attending day care or preschool. Objectives: To investigate the efficacy of dietary supplementation with cow’s skim milk fermented with the probiotic Lactobacillus paracasei CBA L74 in reducing CIDs in children attending day care or preschool. Methods: Multicenter, randomized, double-blind, placebo-controlled trial on healthy children (aged 12–48 months) consuming daily 7 grams of cow’s skim milk fermented with L. paracasei CBA L74 (group A), or placebo (maltodextrins group B) attending day care or preschool during the winter season. The main outcome was the proportion of children who experienced ≥1 episode of CID during a 3-month follow-up. Fecal biomarkers of innate (α- and β-defensins, cathelicidin) and acquired immunity (secretory IgA) were also monitored. Results: A total of 126 children (71 males, 56%) with a mean (SD) age of 33 (9) months completed the study, 66 in group A and 60 in group B. At intention to treat analysis, the proportion of children presenting ≥1 CID was 60% in group A vs. 83% in group B, corresponding to an absolute risk difference (ARD) of −23% (95% CI: −37% to −9%, p < 0.01). At per-protocol-analysis (PPA), the proportion of children presenting ≥1 CID was 18% in group A vs. 40% in group B, corresponding to an absolute risk difference (ARD) of −22% (95% CI: −37% to −6%, p < 0.01). PPA showed that the proportion of children presenting ≥1 acute gastroenteritis (AGE) was significantly lower in group A (18% vs. 40%, p < 0.05). The ARD for the occurrence of ≥1 AGE was −22% (95% CI: −37% to −6%, p < 0.01) in group A. Similar findings were obtained at PPA regarding the proportion of children presenting ≥1 upper respiratory tract infection (URTI), which was significantly lower in group A (51% vs. 74%, p < 0.05), corresponding to an ARD of −23% (95% CI: −40% to −7%, p < 0.01). Significant changes in innate and acquired immunity biomarkers were observed only in subjects in group A. Conclusions: Dietary supplementation with cow’s skim milk fermented with L. paracasei CBA L74 is an efficient strategy in preventing CIDs in children.

Nutrition Support for Critically Ill Patients With Cancer

Oncology patients often experience the classic signs of malnutrition-weight loss as well as fat and muscle wasting, which have been associated with poor tolerance to treatment and increased morbidity and mortality. Nutrition status may be an important factor in determining tolerance to treatment and outcomes associated with it. Thus, identification of those with preexisting malnutrition or who are at risk for developing malnutrition is crucial not only at time of cancer diagnosis but also throughout the treatment course so that nutrition interventions may be implemented to prevent development or worsening of malnutrition in this high-risk population. These patients often have extremely complicated hospital courses due to the aggressive nature of the disease and treatment, leading to intensive care unit admission and periods of critical illness. Critical illness is associated with catabolism, extreme stress on the body, and a state of systemic inflammation. During critical illness, it is important to provide adequate nutrition to prevent further break down of lean muscle mass and oxidative cellular injury and to regulate favorable immune responses. The purpose of this review is to discuss the importance of nutrition screening and assessment for the critically ill patient with cancer; to appropriately identify those at risk for, or who have developed, malnutrition; and to provide appropriate interventions to optimize nutrition status. This review also discusses the complications and difficulties associated with feeding this patient population and offers nutrition support recommendations.

Immunonutrition in patients with cyctic fibrosis leads to drop of serum amyloid A and increase of oxidative stress

The aim of the present study is to evaluate of the impact of immunonutrition on parameters of oxidative stress and inflammation in patients with cystic fibrosis and malnutrition. In the 30 patients with cystic fibrosis and long-term enteral nutrition support for malnutrition the effect of standard and immunonutrion sipping on oxidative stress and inflammatory activity parameters was compared. Malonyldialdehyde (MDA) as parameter of oxidative stress and serum amyloid A (SAA), interleukin 1 and 6, hsCRP, IgM, IgA, IgG as parameters of inflammatory activity were examined. Immunonutrition decreased SAA to 17.6 mg/L comparing to 25.6 mg/L when standard nutrition was given (p = 0.014). MDA was 0.66 µM on standard and 0.96 µM on immunonutrition support (p<0.01). The significant negative correlation was recorded between MDA and SAA, hs-CRP, interleukin 6, IgA and IgG. In conclusion, the application of immunonutrition in patients with cystic fibrosis and malnutrition is associated with drop of SAA but with the rise of MDA.

Potential Impact of Nutrition on Immune System Recovery from Heavy Exertion: A Metabolomics Perspective

This review describes effective and ineffective immunonutrition support strategies for the athlete, with a focus on the benefits of carbohydrates and polyphenols as determined from metabolomics-based procedures. Athletes experience regular cycles of physiological stress accompanied by transient inflammation, oxidative stress, and immune perturbations, and there are increasing data indicating that these are sensitive to nutritional influences. The most effective nutritional countermeasures, especially when considered from a metabolomics perspective, include acute and chronic increases in dietary carbohydrate and polyphenols. Carbohydrate supplementation reduces post-exercise stress hormone levels, inflammation, and fatty acid mobilization and oxidation. Ingestion of fruits high in carbohydrates, polyphenols, and metabolites effectively supports performance, with added benefits including enhancement of oxidative and anti-viral capacity through fruit metabolites, and increased plasma levels of gut-derived phenolics. Metabolomics and lipidomics data indicate that intensive and prolonged exercise is associated with extensive lipid mobilization and oxidation, including many components of the linoleic acid conversion pathway and related oxidized derivatives called oxylipins. Many of the oxylipins are elevated with increased adiposity, and although low in resting athletes, rise to high levels during recovery. Future targeted lipidomics-based studies will help discover whether n-3-polyunsaturated fatty acid (n-3-PUFA) supplementation enhances inflammation resolution in athletes post-exercise.

Systematic review with network meta-analysis: comparative efficacy of different enteral immunonutrition formulas in patients underwent gastrectomy

OBJECTIVES

Optimal enteral immunonutrition (EIN) regime for gastric cancer (GC) patients underwent gastrectomy remains uncertainty. To assess comparative efficacy of different EIN formulas in GC patients underwent gastrectomy, we performed network meta-analysis.

RESULTS

We included 11 RCTs enrolling 840 patients. Pairwise meta-analysis indicated that EIN (RR 0.56, 95% CI 0.36-0.86; MD -0.42, 95% CI -0.74-0.10), Arg+RNA+ω-3-FAs (RR 0.37, 95% CI 0.22-0.63; MD -0.42, 95% CI -0.75-0.07), Arg+Gln+ω-3-FAs (RR 0.22, 95% CI 0.05-0.94; MD -0.69, 95% CI -1.22-1.07) reduced ICs and LOS. Network meta-analysis confirmed the potential of Arg+RNA+ω-3-FAs for ICs (OR 0.27, 95% Crl 0.12-0.49) and Arg+Gln+ω-3-FAs for CIs (OR 0.22, 95% Crl 0.02-0.84) and LOS (SMD -0.63, 95% Crl -1.07-0.13), and indicated that Arg+RNA+ω-3-FAs was superior to Arg+RNA and Arg+Gln for ICs as well.

MATERIALS AND METHODS

We performed direct and network meta-analyses for randomized controlled trials comparing EIN formulas with each other or standard enteral nutrition (SEN) in reducing infectious complications (ICs), noninfectious complications (NICs) and length of hospital stay (LOS), through January 2016. The surface under the cumulative ranking curve (SCURA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used to rank regimes and rate qualities of evidences respectively.

CONCLUSIONS

As for GC patients underwent gastrectomy, Arg+RNA+ω-3-FAs and Arg+Gln+ω-3-FAs are the optimal regimes of reducing ICs and LOS.

Preoperative Immunonutrition and Elective Colorectal Resection Outcomes

BACKGROUND

Randomized controlled trials demonstrate the efficacy of arginine-enriched nutritional supplements (immunonutrition) in reducing complications after surgery. The effectiveness of preoperative immunonutrition has not been evaluated in a community setting.

OBJECTIVE

This study aims to determine whether immunonutrition before elective colorectal surgery improves outcomes in the community at large.

DESIGN

This is a prospective cohort study with a propensity score-matched comparative effectiveness evaluation.

SETTINGS

This study was conducted in Washington State hospitals in the Surgical Care Outcomes Assessment Program from 2012 to 2015.

PATIENTS

Adults undergoing elective colorectal surgery were selected.

INTERVENTIONS

Surgeons used a preoperative checklist that recommended that patients take oral immunonutrition (237 mL, 3 times daily) for 5 days before elective colorectal resection.

MAIN OUTCOME MEASURES

Serious adverse events (infection, anastomotic leak, reoperation, and death) and prolonged length of stay were the primary outcomes measured.

RESULTS

Three thousand three hundred seventy-five patients (mean age 59.9 ± 15.2 years, 56% female) underwent elective colorectal surgery. Patients receiving immunonutrition more commonly were in a higher ASA class (III-V, 44% vs 38%; p = 0.01) or required an ostomy (18% vs 14%; p = 0.02). The rate of serious adverse events was 6.8% vs 8.3% (p = 0.25) and the rate of prolonged length of stay was 13.8% vs 17.3% (p = 0.04) in those who did and did not receive immunonutrition. After propensity score matching, covariates were similar among 960 patients. Although differences in serious adverse events were nonsignificant (relative risk, 0.76; 95% CI, 0.49-1.16), prolonged length of stay (relative risk, 0.77; 95% CI, 0.58-1.01 p = 0.05) was lower in those receiving immunonutrition.

LIMITATIONS

Patient compliance with the intervention was not measured. Residual confounding, including surgeon-level heterogeneity, may influence estimates of the effect of immunonutrition.

CONCLUSIONS

Reductions in prolonged length of stay, likely related to fewer complications, support the use of immunonutrition in quality improvement initiatives related to elective colorectal surgery. This population-based study supports previous trials of immunonutrition, but shows a lower magnitude of benefit, perhaps related to compliance or a lower rate of adverse events, highlighting the value of community-based assessments of comparative effectiveness.

Parenteral or Enteral Arginine Supplementation Safety and Efficacy

Arginine supplementation has the potential to improve the health of patients. Its use in hospitalized patients has been a controversial topic in the nutrition literature, especially concerning supplementation of septic patients. In this article, we review the relevant literature both for and against the use of arginine in critically ill, surgical, and hospitalized patients. The effect of critical illness on arginine metabolism is reviewed, as is its use in septic and critically ill patients. Although mounting evidence supports immunonutrition, there are only a few studies that suggest that this is safe in patients with severe sepsis. The use of arginine has been shown to benefit a variety of critically ill patients. It should be considered for inclusion in combinations of immunonutrients or commercial formulations for groups in whom its benefit has been reported consistently, such as those who have suffered trauma and those in acute surgical settings. The aims of this review are to discuss the role of arginine in health, the controversy surrounding arginine supplementation of septic patients, and the use of arginine in critically ill patients.

Arginine-Dual roles as an onconutrient and immunonutrient

Arginine is an important player in numerous biologic processes and studies have demonstrated its importance for cellular growth that becomes limiting in states of rapid turnover (e.g., malignancy). Thus, arginine deprivation therapy is being examined as an adjuvant cancer therapy, however, arginine is also necessary for immune destruction of malignant cells. Herein we review the data supporting arginine deprivation or supplementation in cancer treatment and the currently registered trials aimed at understanding these divergent strategies. J. Surg. Oncol. 2017;115:273-280. © 2016 Wiley Periodicals, Inc.

Nutrition and Immune-Modulatory Intervention in Surgical Patients With Gastric Cancer

This study evaluated the effect of an immune-modulatory diet on patients with gastric cancer and identified the parameters associated with postoperative outcomes. This was a single-arm prospective intervention study. At baseline, patients were assessed for nutrition (Patient-Generated Subjective Global Assessment), inflammatory markers (albumin, C-reactive protein, and interleukin 6 [IL-6]), and immune markers (percentage NK, CD4, CD8, and CD4:CD8 ratio); they also received nutrition counseling and high-calorie/protein supplement. A week before surgery, they were assessed for nutrition and inflammatory/immune markers and started on an immune-modulatory supplement until the day before surgery, when they were evaluated again. On the second postoperative day, patients were assessed for inflammatory/immune parameters, and a final nutrition evaluation was performed until the day of discharge. Complications were recorded daily and up to 30 days after discharge. Thirty-seven patients (60 ± 10 years old) were included, and 57% were classified as malnourished. Maintenance of nutrition and immune parameters occurred throughout the study period, but we found a preoperative increase in C-reactive protein (0.1-1.5 mg/dL) and IL-6 (2.0-14.2 pg/mL) and a postoperative increase in the CD4:CD8 ratio (2.3 ± 1.0). Complications and death were seen in 35%, especially patients with higher preoperative IL-6 (2.2-46 pg/mL), lower CD4:CD8 ratio (1.7 ± 0.5), and lower protein (1.2 ± 0.5 g/kg/d) and calorie intake (1552 ± 584 kcal/kg/d). The high-calorie/protein supplementation with the immune-modulating diet was able to maintain the nutrition and immune status of patients with gastric cancer.

Should Immune-Enhancing Formulations Be Used for Patients With Acute Respiratory Distress Syndrome?

The potential for regulating immune function in acute respiratory distress syndrome (ARDS) through enteral-administered anti-inflammatory lipids has generated much interest over the past 20 years. Yet recommendations remain inconclusive regarding the utilization of ω-3 fatty acids in patients with ARDS and acute lung injury (ALI). Studies are limited in number, with differing methods, small sample sizes, and conflicting results, making recommendations difficult to interpret.

Should perioperative immunonutrition for elective surgery be the current standard of care?

Postoperative infectious complications are independently associated with increased hospital length of stay (LOS) and cost and contribute to significant inpatient morbidity. Many strategies such as avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, metabolic control and early mobilization have been used to either prevent or reduce the incidence of postoperative infections. Despite these efforts, it remains a big challenge to our current healthcare system to mitigate the cost of postoperative morbidity. Furthermore, preoperative nutritional status has also been implicated as an independent risk factor for postoperative morbidity. Perioperative nutritional support using enteral and parenteral routes has been shown to decrease postoperative morbidity, especially in high-risk patients. Recently, the role of immunonutrition (IMN) in postoperative infectious complications has been studied extensively. These substrates have been found to positively modulate postsurgical immunosuppression and inflammatory responses. They have also been shown to be cost-effective by decreasing both tpostoperative infectious complications and hospital LOS. In this review, we discuss the postoperative positive outcomes associated with the use of perioperative IMN, their cost-effectiveness, current guidelines and future clinical implications.

COST-EFFECTIVENESS OF PERIOPERATIVE IMMUNONUTRITION IN GASTROINTESTINAL ONCOLOGIC SURGERY: A SYSTEMATIC REVIEW

INTRODUCTION

Costs, length of hospital staying and morbidity are frequently and significantly increased as a result of infections and other complications following surgical procedure for gastrointestinal tract cancer. Recently, improving host defence mechanisms have become a target of interest. Immunonutrition aims at improving immunity, most likely providing key nutrients to maintain T-lymphocyte and other host defence.

AIM

To evaluate the immunonutrition in cancer patients who are operated by digestive diseases and assess the cost-effectiveness of this supplementation.

METHODS

This study consisted of a systematic review of the literature based on reference analyses retrieved from current databases such as PubMed, Lilacs and SciELO. The search strategy was defined by terms related to immunonutrition [immunonutrition, arginine, omega-3 and nucleotides] in combination with [costs, cost-effective and cost-effectiveness] as well as [gastrointestinal cancer surgery, oesophageal, gastric or pancreatic surgery] in English, Portuguese or Spanish language. For cost analyses, currencies used in the manuscripts were all converted to American dollars (US$) in order to uniform and facilitate comparison. Six prospective randomized studies were included in this review.

CONCLUSION

The cost-effectiveness was positive in most of studies, demonstrating that this diet can significantly reduce hospital costs in the North hemisphere. However, similar studies needed to be carried to determine such results among us.

Nutrition chez le brûlé

Nutrition is a challenge for burn patients. Emphasized points are early enteral amounts by means of a naso-gastric tube, semi-recumbent position > 30°, gastro-intestinal survey improved by kinetics, weight evolution, nutritional amounts assessment to prevent proteino-energetic deficiency. Feeding is difficult with children, as with seniors often associating a preexisting starvation. Nutritional supplements are useful in medium severity patients. For overweight patients, hypo caloric and hyperprotidic diet is the better choice. Non hemodialysed kidney failure patients need potassium limitation. In case of perineal burns, short constipation or faecal collector rather than colostomy prevent local contamination. Enteral amounts are difficult to administrate in prone position following ARDS (recumbent, post pyloric tube). In extensive burns, quality of nutrients is more suitable than quantity. Old caloric formulas lead to badly tolerated over-nutrition, while indirect calorimetry or Toronto formula allow a better assessment. Immunonutrition (supplementation with trace elements, glutamine, arginine, omega 3 fatty acids, and rational control of blood glucose) could reduce oxidative stress and hyper metabolism induced by burn trauma.

Biomarkers in immunonutrition programme, is there still a need for new ones? A brief review

BACKGROUND AND AIMS

Pre-existing malnutrition is one the most important factors affecting postsurgical complications, especially in cancer patients. The consequences of this on the immune function as well as on outcome could be reversed by immunonutrition. To help the clinician as a researcher, a routinely available biomarker (derived from clinical or biological data) would be of great importance.

METHODS

We reviewed the potential markers that may routinely be used in perioperative immunonutrition programmes. A comprehensive approach was used to identify and discuss the potential markers, focusing on body mass and serum biomarkers.

RESULTS

Body mass (including weight loss and body mass index) are predictive of complications, but not specifically to malnutrition. Serum markers, such as albumin, transthyretin, white blood cells counts, and C-reactive protein are not more specific. Composite scores, including the Nutritional Risk Index (NRI), the Prognostic Inflammatory and Nutritional Index (PINI), the modified Glasgow Prognostic Score (mGPS), the neutrophil-to-lymphocyte ratio (NLR), CD4 and CD8 lymphocytes counts, the platelet-to-lymphocyte ratio (PLR), the Prognostic Index (PI), and the Prognostic Nutritional Index (PNI) are prognostic factors of outcome, but are not always correlated to immunonutrition effect.

CONCLUSIONS

In conclusion, there remains a lack of efficient and widely available monitoring of the effects of immunonutrition. To predict and monitor the effect of immunonutrition on immunity, efforts should be directed to the validation of routinely available tools to aid the implementation of advanced immune monitoring (like lymphocytes subpopulations counts) in clinical practices.

Gut failure in critical care: old school versus new school

The concept of bacterial translocation and gut-origin sepsis as causes of systemic infectious complications and multiple organ deficiency syndrome in surgical and critically ill patients has been a recurring issue over the last decades attracting the scientific interest. Although gastrointestinal dysfunction seemingly arises frequently in intensive care unit patients, it is usually underdiagnosed or underestimated, because the pathophysiology involved is incompletely understood and its exact clinical relevance still remains controversial with an unknown yet probably adverse impact on the patients' outcome. The purpose of this review is to define gut-origin sepsis and related terms, to describe the mechanisms leading to gut-derived complications, and to illustrate the therapeutic options to prevent or limit these untoward processes.

A Matter of Fat

Acute respiratory disease syndrome (ARDS) is a common complication of critical illness, associated with significant morbidity, prolonged intensive care unit (ICU) and hospital stay, and increased mortality. Inflammation plays a central role in ARDS, with inflammatory eicosanoid mediators produced from the ω-6 fatty acid arachidonic acid, such as leukotriene B4, being involved. The ω-3 fatty acids found in fish oil exert anti-inflammatory effects, including decreasing production of inflammatory eicosanoids from arachidonic acid. The ω-3 fatty acids are effective in models relevant to ARDS. Several randomized controlled trials of enteral formulas rich in ω-3 fatty acids, often in combination with other bioactive substances, have been conducted in patients with ARDS. Four of these trials reported marked clinical benefits, 2 reported no effect, and 1 reported a negative impact. A systematic review and meta-analysis of these 7 trials identified no overall effect on ventilator-free days or on ICU-free days. There was a small reduction in ICU length of stay and no overall effect on mortality. However, the authors formally identified that trials that used high fat in both treatment and control groups showed a significant reduction in mortality, while trials that used a high, or higher, fat treatment and a low-fat control group showed a trend toward an increase in mortality. It is concluded that differences in outcome reported among these studies largely relate to the relative fat contents of the treatment and control formulas. Further, it is concluded that high-fat enteral formulas should not be used in this patient group.

Innate Mucosal Immune System Response of BALB/c vs C57BL/6 Mice to Injury in the Setting of Enteral and Parenteral Feeding

BACKGROUND

Outbred mice exhibit increased airway and intestinal immunoglobulin A (IgA) following injury when fed normal chow, consistent with humans. Parenteral nutrition (PN) eliminates IgA increases at both sites. Inbred mice are needed for detailed immunological studies; however, specific strains have not been evaluated for this purpose. BALB/c and C57BL/6 are common inbred mouse strains but demonstrate divergent immune responses to analogous stress. This study addressed which inbred mouse strain best replicates the outbred mouse and human immune response to injury.

METHODS

Intravenously cannulated mice received chow or PN for 5 days and then underwent sacrifice at 0 or 8 hours following controlled surgical injury (BALB/c: n = 16-21/group; C57BL/6: n = 12-15/group). Bronchoalveolar lavage (BAL) was analyzed by enzyme-linked immunosorbent assay for IgA, tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, and IL-6, while small intestinal wash fluid (SIWF) was analyzed for IgA.

RESULTS

No significant increase in BAL IgA occurred following injury in chow- or PN-fed BALB/c mice (chow: P = .1; PN: P = .7) despite significant increases in BAL TNF-α and SIWF IgA (chow: 264 ± 28 vs 548 ± 37, P < .0001; PN: 150 ± 12 vs 301 ± 17, P < .0001). Injury significantly increased mucosal IgA in chow-fed C57BL/6 mice (BAL: 149 ± 33 vs 342 ± 87, P = .01; SIWF: 236 ± 28 vs 335 ± 32, P = .006) and BAL cytokines. After injury, PN-fed C57BL/6 mice exhibited no difference in BAL IgA (P = .9), BAL cytokines, or SIWF IgA (P = .1).

CONCLUSIONS

C57BL/6 mice exhibit similar airway responses to injury as outbred mice and humans, providing an appropriate model for studying mucosal responses to injury. The BALB/c mucosal immune system responds differently to injury and does not replicate the human injury response.

Clinical evidence for pharmaconutrition in major elective surgery

In recent years, standard nutrition preparations have been modified by adding specific nutrients, such as arginine, ω-3 fatty acids, glutamine, and others, which have been shown to upregulate host immune response, modulate inflammatory response, and improve protein synthesis after surgery. Most randomized trials and several meta-analyses have shown that perioperative administration of enteral arginine, ω-3 fatty acids, and nucleotides (immunonutrition) reduced infection rate and length of hospital stay in patients with upper and lower gastrointestinal (GI) cancer. The most pronounced benefits of immunonutrition were found in subgroups of high-risk and malnourished patients. Promising but not conclusive results have been found in non-GI surgery, especially in head and neck surgery and in cardiac surgery, but larger trials are required before recommending immunonutrition as a routine practice. Conflicting results on the real benefit of parenteral glutamine supplementation in patients undergoing elective major surgery have been published. In conclusion, enteral diets supplemented with specific nutrients significantly improved short-term outcome in patients with cancer undergoing elective GI surgery. Future research should investigate a molecular signaling pathway and identify specific mechanisms of action of immune-enhancing substrates.

Effect of dietary fat on intestinal inflammatory diseases

Dietary fat has multiple roles on human health, and some dietary fat is used to treat organic diseases because of its anti-inflammatory effect. It is commonly accepted that omega-3 polyunsaturated fatty acid (PUFA) is beneficial on ischemic heart disease or rheumatic arthritis. On the contrary, effect of omega-3-PUFA on Crohn's disease remained controversial. That effect of omega-3 PUFA differs according to the location of inflamed intestine was hypothesized. To elucidate this hypothesis, to investigate the role of dietary fat on disease activity in different kind of murine models of intestinal inflammatory diseases was planned. The effect of omega-3 PUFA on small intestinal Crohn's disease model and large intestinal Crohn's disease model of mice. Chronic colitis model C57BL/6 mice received two cycles of dextran sodium sulfate solution treatment to induce chronic colitis. Feeding of omega-3 fat-rich diets exacerbated colitis with decrease in adiponectin expression. Chronic small intestinal inflammation model: SAMP1/Yit mice showed remarkable inflammation of the terminal ileum spontaneously. Feeding of omega-3 fat-rich diets for 16 weeks significantly ameliorated the inflammation of the terminal ileum. Enhanced infiltration of leukocytes and expression of mucosal addressin cell adhesion molecule-1 in intestinal mucosa was significantly decreased by omega-3 fat-rich diets treatment. Omega-3 PUFA has dual role, pro-/anti-inflammatory, on intestinal inflammatory diseases. The role of omega-3 fat and the potential for immunonutrition in inflammatory conditions of the gastrointestinal tract will be discussed.

The role of the enteral route and the composition of feeds in the nutritional support of malnourished surgical patients

In surgical patients, malnutrition is an important risk factor for post-operative complications. In undernourished patients undergoing major gastrointestinal procedures, preoperative enteral nutrition (EN) should be preferred whenever feasible. It may be given either orally or by feeding tubes, depending on patient compliance. Early oral intake after surgery should be encouraged, but if an insufficient postoperative oral intake is anticipated, tube feeding should be initiated as soon as possible. The use of immunomodulating formulas offers significant advantages when compared to standard feeds and the positive results on postoperative complications seem independent from the baseline nutritional status. In malnourished patients, the optimal timing and dose of immunonutrition is unclear, but consistent data suggest that they should be treated peri-operatively for at least two weeks.

Gender different response to immunonutrition in liver cirrhosis with sepsis in rats

Females with sepsis have a better prognosis than males, while those of both genders with cirrhosis have a high mortality. Impaired immunity accompanies liver cirrhosis. The potential association between sex and immunologic response of cirrhotic rats in sepsis following immunonutrition was investigated. One hundred and forty-three rats were randomly divided into groups. Liver cirrhosis was produced by weekly feeding of CCl(4) for 8 weeks. Among them, 24 male and 19 female underwent castration one month before studying. The rats were fed with either immune enhancing diet or control diet for five days, then sepsis was induced with cecal ligation and two holes puncture. Main outcomes included mortality and serum cytokines (IL-1β, 6, and 10). Comparisons were made both within and between genders. Cirrhotic non-castrated male rats showed a significant decrease in mortality (64.1% vs. 32.1%, p = 0.032) with better survival than control diet following immune enhancing diet. Lower mortality of cirrhotic non-castrated female rats was found after immune enhancing diet (69.6% vs. 52.1%, p = 0.365). Cirrhotic castrated male rats showed a lower mortality (44.4%) following immune enhancing diet, and cirrhotic castrated female rats also showed significantly lower mortality and better survival than control diet after immune enhancing diet (87.5% vs. 33.3%, p = 0.004). Plasma concentrations of IL-1β were higher in non-oophorectomized female rats fed with control diet compared to immune enhancing diet. Non-orchidectomized males and non-oophorectomized females exhibited similar increases in IL-10 after immune enhancing diet. Our results demonstrated that immunonutrition was more beneficial for male than female cirrhotic rats following sepsis. Though orchidectomy was not found to be more advantageous for the normal male rats in sepsis, immunonutrition seemed to be as important as sex hormone for female rats in sepsis.

Immunomodulation in surgical practice

BACKGROUND

Immunomodulation may represent a potential way to improve surgical outcome. These types of interventions should be based on detailed knowledge of the underlying mechanisms involved. The aim of the present review is to summarize some experience on the acute phase response, potential ways of intervention and experiences from critical illness and HPB disease.

DISCUSSION

Mechanisms of the acute phase response are discussed including the individual parameters and local changes that take part. Mechanisms involved in failure of the gut barrier are presented and include changes in gut barrier permeability, effects on gut-associated immunocompetent cells, and systemic implications. As examples of HPB disease, mechanisms of the acute phase response and potential ways of intervention in obstructive jaundice and acute pancreatitis are discussed. Nutritional pharmacology and lessons learned from immunomodulation and immunonutrition in critical illness and major abdominal surgery, including upper GI and HPB surgery, are referred to. Overall, immunomodulation represents a potential tool to improve results but requires a thorough mapping of underlying mechanisms in order to achieve individualized treatment or prevention based on patients' specific needs.