The Role of Immunonutrition in Patients Undergoing Pancreaticoduodenectomy

Abstract

Pancreaticoduodenectomy (PD) is one of the most difficult and complex surgical procedures in abdominal surgery. Malnutrition and immune dysfunction in patients with pancreatic cancer (PC) may lead to a higher risk of postoperative infectious complications. Although immunonutrition (IN) is recommended for enhanced recovery after surgery (ERAS) in patients undergoing PD for 5–7 days perioperatively, its role in patients undergoing pancreatectomy is still unclear and controversial. It is known that the proper surgical technique is very important in order to reduce a risk of postoperative complications, such as a pancreatic fistula, and to improve disease-free survival in patients following PD. However, it has been proven that IN decreases the risk of infectious complications, and shortens hospital stays in patients undergoing PD. This is a result of the impact on altered inflammatory responses in patients with cancer. Both enteral and parenteral, as well as preoperative and postoperative IN, using various nutrients, such as glutamine, arginine, omega-3 fatty acids and nucleotides, is administered. The most frequently used preoperative oral supplementation is recommended. The aim of this paper is to present the indications and benefits of IN in patients undergoing PD.

Nutritional Support in Patients with Severe Acute Pancreatitis-Current Standards

“…Therefore, theoretically, modulation of the altered immune response would be indicated in SAP patients. Immunomodulating nutrition (immunonutrition, IN) involves four main immunonutrients as follows: glutamine (Gln), arginine (Arg), omega-3-unsatturated fat acids (PUFA), and nucleotides [ 68 ]. IN is widely used in surgical and oncological patients and its role in these patient groups has been well documented [ 50 , 51 ].…”

“…It is a substrate in the synthesis of glutathione as well as increases expression of heat shock protein (HSP). Therefore, it is essential for the modulation of altered immune response and gut barrier dysfunction in SAP patients [ 68 ]. Arg, the second immunonutrient, is a semi-essential amino acid which plays an important role in protein synthesis.…”

Nutritional Support in Head and Neck Radiotherapy Patients Considering HPV Status

“…Glutamine is a common nitrogen donor for healing tissues. There are many studies showing benefits of oral or enteral glutamine supplementation in order to improve the quality of life of cancer patients that is associated with better nutrition but also decreased mucosal damage (mucositis, stomatitis, pharyngitis, esophagitis, and enteritis) [ 70 , 71 ]. Additionally, it is a precursor for protein, nucleotide, and nucleic acid synthesis and regulates various cellular pathways and related functions.…”

“…Additionally, it influences lymphocyte activity, such as stimulation of Con-A and PHA-induced proliferation, activation of CD 25, CD 71, CD 45RO expression, stimulation of Interferon (INF)—gamma secretion, stimulation of natural killer (NK) cells, inhibition of apoptosis, stimulation of GALT, and an increase in NK population in the spleen. Also, it influences the activity of monocytes: stimulation of RNA synthesis, an increase of IL-1 secretion, stimulation of phagocytosis, stimulation of antigen presentation, stimulation of monocyte maturation [ 71 , 72 ].…”

“…It has been reported that omega-3 fatty acids decrease excessive inflammatory responses, but they are not immunosuppressive, which is very important in cancer patients in the postoperative course. Nucleotides are necessary for the proliferation of immune cells and cells important for wound healing [ 71 , 72 , 73 , 74 , 75 ].…”