Message to surgeons: the expected norm in elective complex GI cancer surgery is use of perioperative immunonutritional therapy that also saves hospital costs!

Acurious headline of a column in the January 2, 2007 issue of USA Today read: “Omega-3 pours into cereal, orange juice, eggs, and pet food. ” It stated that ‘Omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), found in fish, some nuts, and oils were the hottest food additive in 2007, because of their health and immuno-modulating effects in reducing inflammation, and thus thought to prevent heart disease, cancer, and arthritis. So, if our dogs are getting ‘Omega-3 fatty acids’ in their food, why not give it to our upper GI cancer patients, the majority of who suffer from debilitating cancer cachexia-anorexia syndrome and are at high risk of operative complications? Thus we read with enthusiasm in this issue of Annals, the paper by Ryan et al of a well designed controlled clinical study in patients undergoing esophagectomy to examine the effects of perioperative EPA-enriched enteral nutrition therapy on the nutritional, metabolic, and immunoinflammatory response and on postoperative complications. 1 The enthusiasm emanates, in part, from the success of demonstrating EPA’s anticatabolic properties. This achievement reflects the culmination of a long and tortuous journey of nutritional support in cachectic cancer patients in an attempt to decrease their perioperative morbidity. Warren in 1932 documented that cancer cachexia was a common cause of death in patients with cancer. 2 Studley in 1936 made the crucial observation in his gastrectomized patients, that the greater the preoperative weight loss in his patients, the higher the complication and mortality rate. 3 This seminal observation clearly linked nutritional status to postoperative outcome. Patients with upper gastrointestinal (GI) tumors have among the highest incidence of malnutrition, which correlates positively with high postoperative complication rates. 4 These complications are similar to those described by Studley 70 years ago: wound dehiscence, ileus, sepsis, pneumonia, prolonged hospital stays, poor quality of life and death. In the intervening years, numerous studies examined the effects of both pre- and postoperative nutrition therapy, either parenteral or enteral, to decrease surgery related complications. Initially, these studies focused on providing supraphysiological concentrations of different substrates to induce positive nitrogen balance postoperatively. In many of these studies, the observed reversal of weight loss was due to an increase in fat mass and in total body water (TBW). Our concepts in clinical nutrition evolved to include the understanding that specific nutrients had immunologic effects, particularly when given in pharmacological amounts. Thus began the ‘trial and error era’ of immunonutrition, not only in cancer patients and high risk elective surgical patients, but also in critically ill postoperative patients. The ‘immunonutritional mixtures’ that were added to conventional substrates known to improve metabolic processes included arginine, glutamine, nucleotides, antioxidants, and omega-3 fatty acids, often in different permutations. It required meta-analysis of many studies to conclude that immunonutrition improved clinical outcomes. 5 In retrospect, it may seem curious that for almost 20 years, studies were done in which different experimental compounds were administered simultaneously in an effort to determine the nebulous postoperative beneficial metabolic effects. But such was our knowledge base and the sense of frustration and urgency of the times, underpinning the need to address the ongoing critical issues as to which ‘immune compounds’ and to what amounts were needed to reverse the processes of cancer cachexia. The importance of Ryan et al’s study is its simplicity in examining the effects of one compound, EPA, in an ‘exemplar model of complex major surgery’ that often includes patients who also require neoadjuvant combined chemo- and radiotherapy. 1 This is an ideal model for testing the stated primary end-point of exploring the anticatabolic effect of EPA by preserving lean body mass (LBM). The protocol is user friendly, and when applied to our patients, in consultation with a