Q12. What is the nutrition prescription to meet these goals? - Surgery

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Q12. What is the nutrition prescription to meet these goals? - Surgery

Summary

Immunonutrition is a form of oral nutritional supplement or enteral feeding formula which has added nutrients for a proposed immune modulating effect which can then impact upon patients’ clinical outcomes such as reduced infections. The most common types of formula have conditionally essential amino acids arginine and/or glutamine, n-3 fatty acids and/or ribonucleic acids added. The feeds used in the studies have been polymeric formulas (with or without fibre) with the addition of arginine at varying doses. One study has looked at the role of n-3 fatty acids as an immune modulating factor [1]. The European Society of Parenteral and Enteral Nutrition (ESPEN) Guidelines on Enteral Nutrition: Surgery Including Organ Transplantation [2] recommend the use of immunonutrition for 5-7 days after uncomplicated surgery however the majority of the studies undertaken in patients with head and neck cancer have used the feeds for >7-10 days post operatively.

There is one level II positive quality study [3] to determine the effect of fibre versus non fibre feeds, which demonstrates significantly less diarrhoea with fibre feeds.

There are very few studies to provide clear guidelines on calculating energy or protein requirements. One level III-2 neutral quality study (Bruning et al., 1988) which compares energy intakes of 135kJ/kg/day (32kcal/kg/day) with 180kJ/kg/day (43kcal/kg/day) and demonstrated the higher intake maintained weight, fat free mass and fat mass, whereas the lower intake resulted in significant weight loss and loss of fat mass. One level III-2 negative quality study [4] demonstrated that head and neck cancer patients had poorer nutrition outcomes post operatively than maxillofacial trauma patients despite both receiving post operative nasogastric feeding, indicating higher nutritional requirements.

One level III-3 neutral quality study [5] and one level IV neutral quality study [6] investigated different rates of feeding in the early and later post operative phases. The level IV study reported that despite increasing energy and protein intake, there was not an anabolic effect and therefore no weight gain could be achieved. The level III-3 study reported that anabolic effects (positive protein and fat balance) could be achieved with the higher energy and protein intake and should be used if repletion is required. A more recent level IV neutral quality study [7] reported energy intakes of around 125-170kJ/kg/day (30-40kcal/kg/day) and although weight loss still occurred, it was not as severe as other treatment modalities.

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Recommendation Grade
Aim for energy intakes of at least 125kJ/kg/day (30kcal/kg/day). As energy requirements may be elevated post operatively, monitor weight and adjust intake as required.
C
Standard polymeric fibre feed should be used post operatively.
B
If immunonutrition is to be used post operatively, this should be given for a minimum of 7 days.
C

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References

  1. de Luis DA, Izaola O, Aller R, Cuellar L, Terroba MC. A randomized clinical trial with oral Immunonutrition (omega3-enhanced formula vs. arginine-enhanced formula) in ambulatory head and neck cancer patients. Ann Nutr Metab 2005;49(2):95-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15802904.
  2. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, et al. ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation. Clin Nutr 2006 Apr;25(2):224-44 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16698152.
  3. Reese JL, Means ME, Hanrahan K, Clearman B, Colwill M, Dawson C. Diarrhea associated with nasogastric feedings. Oncol Nurs Forum 1996;23(1):59-66; discussion 66-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8628712.
  4. Califano L, Zupi A, Giardino C. Enteral nutrition in maxillo-facial surgery. Rev Stomatol Chir Maxillofac 1992;93(6):388-92 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1475610.
  5. Zurlo F, Schutz Y, Pichard C, Roulet M, Monnier P, Savary M, et al. What energy level is required to avoid nutrient depletion after surgery in oropharyngeal cancer? ORL J Otorhinolaryngol Relat Spec 1988;50(4):236-45 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3140163.
  6. Heber D, Byerley LO, Chi J, Grosvenor M, Bergman RN, Coleman M, et al. Pathophysiology of malnutrition in the adult cancer patient. Cancer 1986 Oct 15;58(8 Suppl):1867-73 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3093049.
  7. van den Berg MG, Rasmussen-Conrad EL, Gwasara GM, Krabbe PF, Naber AH, Merkx MA. A prospective study on weight loss and energy intake in patients with head and neck cancer, during diagnosis, treatment and revalidation. Clin Nutr 2006 Oct;25(5):765-72 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16698130.

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