Perioperative Immunonutrition: Good Idea or More Hype?From the UMKC Department of Surgery, Kansas City, Missouri Correspondence: Charles W. Van Way III, MD, UMKC Department of Surgery, 2301 Holmes Street, Kansas City, MO 64108. Electronic mail may be sent to charles.vanway{at}tmc.med.org.
It's back. Just when you thought it was safe to go in the ICU. Yes, as the
swallows return to Capistrano, as the wild geese go back to the Arctic in
summer, immunonutrition has returned to nutrition support. By
"immunonutrition," I refer to the use of enteral formulas that
have been supplemented by some combination of glutamine, arginine,
Three recent examples will suffice to illustrate. A recent article in the
World Journal of Surgery, by Xuet
al1 from Shanghai,
studied 60 patients who had gastrointestinal cancer, then preoperatively and
postoperatively fed half with an enteral regimen enriched with glutamine,
arginine, and
Immunonutrition was first introduced 10–15 years ago. The premise was
that using certain nutrients known or thought to enhance the immune system
could lower complications in surgical patients and in the critically ill. The
usual added components were glutamine, arginine,
A somewhat more specific study was done by McClave et
al,6 in which a
systematic review was done on studies of nutrition support in pancreatitis. A
major question was the relative merits of parenteral (PN) vs enteral
nutrition. Enteral nutrition was found to be superior. Regarding
immunonutrition, however, they looked at supplementation of PN using glutamine
and at multiple-component supplementation of enteral nutrition using
glutamine, arginine, There are 3 major problems with the use of peri-operative immunonutrition. First, it is unclear just which components should be included. The list of possible supplements is long, as noted in the first paragraph of this editorial, and specific commercial products often seem to have been compounded almost arbitrarily (this essay has studiously avoided any trade names). Second, although there have been studies showing very suggestively positive results, many good studies have shown no benefit. Finally, there is confusion in the literature over what the desired outcome should be. Suppression of cytokine response suggests modulation of the inflammatory system, which may certainly be beneficial. But that's not the same as enhancement of the immune system, as shown (for example) by increased immunoglobulin levels or changes in the composition of the CD4-positive T-cell population. So... do we want to suppress systemic inflammation? Do we want to increase cellular immunity? Do we want to do both? Most of the papers on this subject tend to treat all such indicators as working toward the same goal, an assumption that is questionable at best. My own feeling is that the primary gain from such nutrition manipulation will be in blunting the excesses of the systemic inflammatory reaction. But that's an educated guess at best, and I may well be wrong. The answer, then, to the question in the title is an unequivocal maybe. We just don't know enough. It would be very nice if the money spent on advertising of immunonutrition were to be diverted into adequate scientific studies. Shucks, I'd settle for a tenth of it. But (sigh) such is not to be. Meanwhile, let us keep an open mind. And remember what they said in ancient Rome: caveat emptor. Received for publication August 8, 2006. Accepted for publication August 8, 2006.
Journal of Parenteral and Enteral Nutrition, Vol. 30, No. 6,
539-540 (2006)
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fatty acids, ribonucleic acids, antioxidant vitamins (C, E, β-carotene),
or micronutrients (zinc, selenium, chromium). And I suppose, to be fair, it
never really went away. Still, there has been a recent increase in activity,
and one can already detect early marketing efforts. 
) were lower after 7 days in the enriched regimen, whereas
immunoglobulins, DC4 counts, and IL-2 were
higher.