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

Kylie Russell; Han-Guang Zhang; Lyn K Gillanders; Adam Sjr Bartlett; Helena L Fisk; Philip C Calder; Peter J Swan; Lindsay D Plank

doi:10.4254/wjh.v11.i3.305

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

World J Hepatol. 2019 Mar 27;11(3):305-317. doi: 10.4254/wjh.v11.i3.305.

Authors

Kylie Russell¹, Han-Guang Zhang², Lyn K Gillanders¹, Adam Sjr Bartlett², Helena L Fisk³, Philip C Calder³, Peter J Swan², Lindsay D Plank⁴

Affiliations

¹ Nutrition Services, Auckland City Hospital, Auckland 1023, New Zealand.
² Department of Surgery, University of Auckland, Auckland 1023, New Zealand.
³ Human Development and Health, Faculty of Medicine, University of Southampton, Southampton SO171BJ, United Kingdom.
⁴ Department of Surgery, University of Auckland, Auckland 1023, New Zealand. l.plank@auckland.ac.nz.

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.

Keywords: Arginine; Fish oil; Inflammation; Liver cancer; Nutritional status; Partial hepatectomy.