New data presented at the recent 16th annual meeting of the Surgical Infection Society Europe (29th-31stMay 2003) in Cernobbio, Italy, Dr Luca Gianotti from the Department of Surgery at the University of Milano-Bicocca, Monza, Italy, showed that major operations for cancer of the gastrointestinal tract are still associated with a high risk of complications and a high consumption of health care resources.
Surgical trauma increases levels of proinflammatory cytokines and lowers host defense mechanisms. But administration of oral IMPACT® an enteral immune-enhancing drink, (supplemented with arginine, n-3 polyunsaturated fatty acids and ribonucleotides) is able to modulate the immune and inflammatory responses altered by surgical trauma, upregulating gut microperfusion and oxygen metabolism. [1]
Randomized trials have shown that preoperatively loading elective surgery patients with immune-enhancing substrates in an oral formula for 5 days and continuing therapy by jejunal infusion for 7 days after surgery results in significant reductions in postoperative infections and length of hospital stay in patients undergoing gastrointestinal surgery for cancer,[2] with a subsequent significant reduction of health care costs.[3]
Post-hoc analysis of these data suggested that even patients who were unable to comply with postoperative immunonutrition benefited from a reduction in complications. So to determine whether preoperative treatment was as effective as perioperative treatment in reducing postoperative complications, Dr Gianotti conducted two trials in patients with gastrointestinal cancer comparing both approaches with control group who received no additional immune-enhancing supplementation to normal diet. One trial enrolled malnourished patients (n=150) [4] the other enrolled well-nourished patients (n=305). [5]
The published results showed that in malnourished patients (those who had lost more than 10% of body weight in the previous 6 months) patients in the control group had significantly more postoperative complications than those treated preoperatively, while those treated before and after surgery even fewer. This was reflected in patients' total length of hospital stay, which was significantly shorter in the preoperative (13.2 days) and perioperative (12.0 days) groups than in the control group (15.3 days).
But in well-nourished patients, oral preoperative supplementation showed similar results to perioperative immune-enhancing supplementation, and both were superior to the control approach:
Dr Gianotti explained: "Preoperative feeding 5 days prior to surgery modulates the host immune defense mechanisms sufficiently to avoid surgical depression of the immune system, and thus to fight off postoperative infections."
"Whether patients are malnourished or well-nourished, preoperative supplementation with an immune-enhancing formula will ensure that patients are fit for surgery," he said. "But in well-nourished patients we can avoid possible side-effects of enteral feeding, such as nasojejunal tube clogging or removal, abdominal cramps and save the costs of providing postoperative immunonutrition."
But the real cost savings from this preoperative immune-enhancing supplementation strategy emerged when he added up the costs of managing postoperative complications (obtained from the Italian Ministry of Health) in this trial.
Unsurprisingly, for patients with no complications the cost was lowest in the control group, but for patients with complications the cost per patient was lowest in the preoperative treatment group.
Adding together the costs of nutrition plus the costs of managing both complicated and uncomplicated patients), Dr Gianotti found the total costs as:
By relating these costs to Diagnosis-Related-Group (DRG) reimbursement rates for the same patients, Dr Gianotti found that costs in the control group accounted for 93% reimbursement of DRG reimbursement while they accounted for just 78% in the preoperative and 86% in the perioperative group, suggesting that hospitals could save money by adopting preoperative immunonutrition.
"The major cost of surgical complications, particularly infectious complications, is the cost of prolonged hospital stays," said Dr Gianotti. "The benefit of immunonutrition is mainly in reducing the rate of infectious complications. The cost of providing preoperative immune-enhancing diet was more than offset by the reduced length of stay from this approach."
He urged surgeons to adopt a strategy of "supporting malnourished patients with a perioperative immune-enhancing supplementation to normal diet and to support well nourished patients with the preoperative approach without postoperative prolongation."
Novartis Medical Nutrition offers a complete range of enteral (tube feeding) and oral nutrition products and devices tailored to the varying needs of patients and healthcare professionals. The product range encompasses supplements, which are taken orally, as well as other products administered through tube feeds and specific medical devices.
Novartis AG (NYSE: NVS) is a world leader in pharmaceuticals and consumer health. In 2002, the Group's businesses achieved sales of USD 20.9 billion and a net income of USD 4.7 billion. The Group invested approximately USD 2.8 billion in R&D. Headquartered in Basel, Switzerland, Novartis Group companies employ about 77 200 people and operate in over 140 countries around the world. For further information please consult http://www.novartis.com.
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References
1. Braga M, Gianotti L, Cestari A, et al. Gut function and immune and inflammatory responses in patients perioperatively fed with supplemented formula. Arch Surg 1996; 131: 1257-65.
2. Braga M, Gianotti l, Radaelli G, et al. Perioperative immunonutrition in patients undergoing cancer surgery: Results of a randomised, double blind phase 3 trial. Arch Surg 1999; 134: 428-33.
3. Gianotti L, Braga M, Frei A, et al. Health care resources consumed to treat postoperative infection: cost saving by perioperative immunonutrition. Shock 2000; 14: 325-30.
4. Braga M, Gianotti L, Nespoli L, et al. Nutritional approach in malnourished surgical patients. Arch Surg 2002; 137: 174-80.
5. Gianotti L, Braga M, Nespoli L, et al. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology 2002; 122: 1763-70.
