Stellenwert der perioperativen Immunonutrition

Zusammenfassung

Die perioperative Immunonutrition moduliert die im Zusammenhang mit großen operativen Eingriffen stattfindenden pathophysiologischen Veränderungen von Immun- und Stoffwechselfunktionen durch die gezielte Zufuhr von konstitutionell essentiellen Substraten wie Glutamin, Arginin, Omega-3-Fettsäuren oder Nukleotiden. Empfohlen wird die Anwendung bei Patienten mit großen abdominalchirurgischen Eingriffen und bei Tumoroperationen im Kopf-Hals-Bereich jeweils 5–7 Tage vor und nach dem Eingriff.

Abstract

Perioperative immunonutrition is aiming at modulating altered immunological and metabolic functions in the context of major surgery. It is defined as the supplementation of constitutionally essential substrates such as glutamine, arginine, omega-3-fatty acids or nucleotides. The application of such formula is recommended for patients undergoing major abdominal-surgical procedures and tumour surgery in the head neck area. The substitution should be given 5–7 days before and after the intervention.

Schlüsselwörter

Immunonutrition - Arginin - Glutamin - Omega-3-Fettsäuren - Chirurgie - postoperative Komplikationen

Key words

immunonutrition - arginine - glutamine - omega-3 fatty acids - surgery - postoperative complications

Literatur

• 1 McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital.  BMJ. 1994;  308 945-948
• 2 Butters M. et al . Studies on nutritional status in general surgery patients by clinical, anthropometric, and laboratory parameters.  Nutrition. 1996;  12 405-410
• 3 Dannhauser A. Preoperative nutritional status and prognostic nutritional index in patients with benign disease undergoing abdominal operations – Part II.  J Am Coll Nutr. 1995;  14 91-98
• 4 Bozzetti F. Rationale and indications for preoperative feeding of malnourished surgical cancer patients.  Nutrition. 2002;  18 953-959
• 5 Furukawa K. et al . Influences of soybean oil emulsion on stress response and cell-mediated immune function in moderately or severely stressed patients.  Nutrition. 2002;  18 235-240
• 6 Calder PC. N-3 fatty acids, inflammation, and immunity – relevance to postsurgical and critically ill patients.  Lipids. 2004;  39 1147-1161
• 7 Lenssen P. et al . Intravenous lipid dose and incidence of bacteremia and fungemia in patients undergoing bone marrow transplantation.  Am J Clin Nutr. 1998;  67 927-933
• 8 Battistella FD. et al . A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition.  J Trauma. 1997;  43 58-60
• 9 Calder PC. Use of fish oil in parenteral nutrition: Rationale and reality.  Proc Nutr Soc. 2006;  65 264-277
• 10 Koch T, Heller AR. Auswirkungen einer parenteralen Ernährung mit n-3-Fettsäuren auf das Therapieergebnis – Eine multizentrische Analyse bei 661 Patienten Outcome Effects of Parenteral Nutrition with n-3 Fatty Acids-A Multicenter Observation in 661 Patients.  Akt Ernähr Med. 2005;  30 15-22
• 11 Hammarqvist F. et al . Addition of glutamine to total parenteral nutrition after elective abdominal surgery spares free glutamine in muscle, counteracts the fall in muscle protein synthesis, and improves nitrogen balance.  Annals of Surgery. 1989;  209 ▪
• 12 Amores-Sánchez MI, Medina M. Glutamine, as a Precursor of Glutathione, and Oxidative Stress.  Molecular Genetics and Metabolism. 1999;  67 100-105
• 13 Tremel H. et al . Glutamine dipeptide-supplemented parenteral nutrition maintains intestinal function in the critically ill.  Gastroenterology. 1994;  107 1595-1601
• 14 Phanvijhitsiri K. et al . Heat induction of heat shock protein 25 requires cellular glutamine in intestinal epithelial cells.  Am J Physiol Cell Physiol. 2006;  291 290-299
• 15 Parry-Billings M. et al . Effects of major and minor surgery on plasma glutamine and cytokine levels.  Archives of Surgery. 1992;  127 1237-1240
• 16 Oudemans-vanStraaten HM. et al . Plasma glutamine depletion and patient outcome in acute ICU admissions.  Intensive Care Med. 2001;  27 84-90
• 17 Houdijk AP. et al . Randomised trial of glutamine-enriched enteral nutrition on infectious morbidity in patients with multiple trauma.  Lancet. 1998;  352 772-776
• 18 Novak F. et al . Glutamine supplementation in serious illness: A systematic review of the evidence.  Crit Care Med. 2002;  30 2022-2029
• 19 Wischmeyer PE. Glutamine: role in critical illness and ongoing clinical trials.  Curr Opin Gastroenterol. 2008;  24 190-197
• 20 Avenell A. Glutamine in critical care: current evidence from systematic reviews.  Proc Nutr Soc. 2006;  65 236-241
• 21 Tong BC, Barbul A. Cellular and physiological effects of arginine.  Mini Rev Med Chem. 2004;  4 823-832
• 22 Albina JE. Nutrition and wound healing.  JPEN J Parenter Enteral Nutr. 1994;  18 367-376
• 23 Bertolini G. et al . Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial.  Intensive Care Med. 2003;  29 834-840
• 24 Popovic PJ, Zeh 3rd HJ, Ochoa JB. J Nutr. 2007;  137 ▪
• 25 Jones NE, Heyland DK. Pharmaconutrition: a new emerging paradigm.  Curr Opin Gastroenterol. 2008;  24 215-222
• 26 Lee DN. et al . Effects of diets supplemented with organic acids and nucleotides on growth, immune responses and digestive tract development in weaned pigs.  J Anim Physiol Anim Nutr. 2007;  91 508-518
• 27 Braga M. et al . Immune and nutritional effects of early enteral nutrition after major abdominal operations.  Eur J Surg. 1996;  162 105-112
• 28 Heys SD. et al . Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer: a meta-analysis of randomized controlled clinical trials.  Ann Surg. 1999;  229 467-477
• 29 Heyland DK. et al . Should immunonutrition become routine in critically ill patients?: A systematic review of the evidence.  JAMA. 2001;  286 944-953
• 30 Braga M. et al . Perioperative immunonutrition in patients undergoing cancer surgery: results of a randomized double-blind phase 3 trial.  Arch Surg. 1999;  134 428-433
• 31 Braga M. et al . Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer.  Surgery. 2002;  132 ▪
• 32 Braga M. et al . Nutritional Approach in Malnourished Surgical Patients: A Prospective Randomized Study.  Arch Surg. 2002;  137 174-180
• 33 Giger U. et al . Preoperative immunonutrition suppresses perioperative inflammatory response in patients with major abdominal surgery – a randomized controlled pilot study.  Ann Surg Oncol. 2007;  14 2798-2806
• 34 Strickland A. et al . Is the Use of Specialized Nutritional Formulations a Cost-Effective Strategy? A National Database Evaluation.  JPEN J Parenter Enteral Nutr. 2005;  29 81-91
• 35 Heys SD. et al . Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer: a meta-analysis of randomized controlled clinical trials.  Ann Surg. 1999;  229 467-477
• 36 Heyland DK. et al . Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients.  JPEN J Parenter Enteral Nutr. 2003;  27 355-373
• 37 Montejo JC. et al . Immunonutrition in the intensive care unit. A systematic review and consensus statement.  Clinical Nutrition. 2003;  22 221-233
• 38 Dent DL. et al . Immunonutrition may increase mortality in critically ill patients with pneumonia: Results of a randomized trial.  Crit Care Med. 2003;  30 ▪
• 39 Weimann A. et al . Influence of arginine, omega-3 fatty acids and nucleotide-supplemented enteral support on systemic inflammatory response syndrome and multiple organ failure in patients after severe trauma.  Nutrition. 1998;  14 165-172
• 40 De Arruda I, De JE. Aguilar-Nascimento. Benefits of early enteral nutrition with glutamine and probiotics in brain injury patients.  Clinical Science. 2004;  106 287-292
• 41 Zhou YP. et al . The effect of supplemental enteral glutamine on plasma levels, gut function, and outcome in severe burns: a randomized, double-blind, controlled clinical trial.  JPEN J Parenter Enteral Nutr. 2003;  27 241-245
• 42 Weimann A. et al . ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation.  Clin Nutr. 2006;  25 224-244
• 43 Hartl WH, Rittler P, Jauch KW. Immunonutrition.  Intensivmedizin und Notfallmedizin. 2007;  44 64-73