Effects of preoperative parenteral nutrition on cell-mediated immunity in malnourished patients

Cell-mediated immunity was studied in 19 malnourished patients admitted for major abdominal surgery. Nine of them received total parenteral nutrition (TPN) before operation (the TPN group), while ten (the control group) were operated on without a period of TPN. In vitro lymphocyte proliferative responses to phytohaemagglutinin (PHA), concanavalin A (Con A) and purified protein derivative of tuberculin (PPD), were measured in whole blood cultures preoperatively, at the end of surgery and 5 days after operation. In vivo delayed skin hypersensitivity to candida, mumps, streptokinase-streptodornase and PPD was studied preoperatively and 5 days after operation. Complications in both groups were observed and recorded. Nutritional assessment was carried out by evaluating the extent of recent weight loss, the weight for height index and by measuring the arm muscle circumference (AMC), triceps skinfold thickness (TSF), the creatinine-height index (CHI) and serum albumin and prealbumin concentrations. The patient was considered to be malnourished and was included in the study, if at least three of these criteria were abnormal. In the TPN group changes in mitogen induced lymphocyte proliferative responses caused by surgery were not significant. By contrast, responses in the control group decreased significantly (P < 0.01) during surgery and most of these responses differed from the preoperative values even at the fifth postoperative day. Anergy was equally common in both groups before and after surgery. The number of infectious complications was lower in the TPN group.     

Prognostic role of preoperative nutritional and immunological assessment in the surgical patient

The utilization of delayed hypersensitivity response (DHR) for the identification of high-risk patients with regard to postoperative septic complications is still discussed. The aim of this study was to clarify how much DHR may improve the prognostic capacity of nutritional assessment (NA). Nutritional and immunological evaluations were performed at admission on 405 patients undergoing elective general surgical procedures. Subjects with serum albumin less than or equal to 3.0 g/dl or total iron-binding capacity less than or equal to 220 micrograms/dl or weight loss greater than or equal to 10% with respect to usual body weight were classified as malnourished. DHR was assessed by performing skin tests with four recall antigens: PPD, candida, trichophyton, sk-sd. The incidence of postoperative complications resulted higher among the 187 malnourished patients (31.0%) than in the 218 well-nourished ones (14.2%) (p less than 0.001), and among the 213 anergic patients (29.6%) than in the 192 normal responders (13.5%) (p less than 0.001). To determine how much skin tests may improve the prognostic ability of NA, the relationship between DHR and postoperative complications was also studied in the malnourished and in the well-nourished patients, separately. In the malnourished group, the patients with an impairment of DHR had a higher incidence of postoperative infections than normal responders (p less than 0.05). In the well-nourished group, no significant differences were found between anergic patients and normal responders. In our study, DHR slightly improved the prognostic capacity of NA. Therefore, the first approach to identify the high-risk patients seems to be the unexpensive, quick and available determination of nutritional status.     

肠内免疫营养对胃癌手术病人免疫功能和急性炎性反应的调理作用

目的 :观察胃癌病人围手术期使用肿瘤特异性肠内免疫营养物 Supportan对病人的营养、免疫和急性炎性反应的调理作用。　方法 :本研究是一个前瞻、随机、单盲、对照的临床研究。30例营养不良择期手术的胃癌病人 ,随机分为两组 :1、免疫营养组 (Supportan,n=15 ) ,2、标准营养组 (能全素 Nutrison,n=15 )。两组使用等热量肠内营养 ,12 5 k J(30 kcal) / (kg· d)。术前置鼻胃管 ,使用 7天。术中均行空肠造口 ,术后 12小时开始空肠输注肠内营养 ,连续 7天。术前第 8、1天 ;术后第 1、8天抽取静脉血 ,检测血清白蛋白、前白蛋白、转铁蛋白、T淋巴细胞亚群、血清免疫球蛋白、血清 IL - 6、CRP、PGE2 浓度。　结果 :两组病人术后均有急性炎性反应的发生和免疫功能的降低。但免疫营养组比标准营养组的术后第 1、8天的 CD4/ CD8比值、血清 Ig G水平有显著增加 ;血清 IL- 6、CRP、PGE2 有显著下降 ;术后第 8天血清前白蛋白浓度有显著增加。　结论 :胃癌合并营养不良的病人围手术期使用肠内免疫营养物 Supportan可以改善手术后免疫功能的低下 ,缓解急性相炎性反应和增加内脏蛋白的合成。     

The effect of nutritional status on morbidity after elective surgery for benign gastrointestinal disease

The effect of nutritional status on the morbidity and mortality of major gastrointestinal surgery for benign disease was studied in 32 patients. Malnutrition was defined as a serum albumin less than 3.5 g/dl and a recent weight loss greater than 10%, in addition to any two of the following: weight for height, midarm circumference or triceps skin-fold thickness less than 10th percentile. The morbidity and mortality in the 17 malnourished patients was 59% and 29%, respectively, compared with 20% and 7% in 15 well-nourished patients matched for age and operative procedure (p less than 0.05). After operation, the mean duration of inadequate oral nutritional intake period (IONIP, defined as a caloric intake greater than 60% requirement) was 11.9 days +/- 2.9 (SEM) in well-nourished patients compared with 30.5 days +/- 3.7 in the malnourished group. The longer IONIP in malnourished patients was a consequence of the higher morbidity in this group, thus warranting the consideration of supportive (postoperative) parenteral nutrition in malnourished patients who undergo major gastrointestinal surgery for benign disease.     

Nutritional status of preoperative colorectal cancer patients

Background: The present study aimed to determine the extent of malnutrition in preoperative colorectal cancer patients. Malnutrition has been shown to affect post‐operative outcome, so it would be beneficial to identify those who are malnourished or who are at risk of becoming so preoperatively. We examine whether weight loss is related to the length of stay or changes in fat free mass. Methods: Patients were enrolled consecutively from outpatients 2–4 weeks prior to surgery. Assessments included body mass index, percentage weight loss, dynamometry, Malnutrition Universal Screening Tool, Subjective Global Assessment and bioelectrical impedance. Cancer staging and hospital length of stay were recorded. Results: One hundred and thirty‐two patients were eligible and 87 enrolled. Sixty‐seven patients were weight losing and 20% had lost >10% of their usual body weight. Handgrip strength was lower in malnourished patients compared to those who had not lost weight (mean 19.4 and 27.3 kg, respectively, P = 0.013). Mean (SD) fat free mass in patients with a weight loss >10% was 39.7 (13.5) kg and, in those with <10% weight loss, was 51.9 (12.0) kg (P = 0.001). This difference was not demonstrated for fat. Conclusions: Over half of these patients had lost weight prior to surgery and one in five were malnourished. Body composition measurements demonstrated that malnourished patients had significantly less fat free mass compared to patients who were not clinically malnourished. Nutritional screening would be beneficial in this group preoperatively to identify weight‐losing patients at an early stage in the care pathway when they initially enter the secondary care system.     

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

BACKGROUND: Malnourished head and neck cancer patients are at increased risk of postoperative complications. OBJECTIVE: We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss >10% of body weight) head and neck cancer patients undergoing major surgery. DESIGN: Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding. RESULTS: Patients in both prefed groups received approximately 9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1, 2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor alpha and P = 0.042 for interleukin 6) at the start of the study than did patients who died. CONCLUSIONS: Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses.     

围手术期联合应用四君子汤和大黄的早期肠内营养对胃癌术后近期免疫功能的影响

目的评价在围手术期应用中药大黄的基础上,术后早期联合应用四君子汤和肠内营养对胃癌患者免疫功能的影响。方法将40例胃癌手术患者随机分为常规肠内营养组(对照组)和大黄、四君子汤干预肠内营养组(研究组)。研究组术前1天、术后18、36小时,经鼻饲管给予中药大黄,对照组给予相同剂量的生理盐水;两组患者均于术后第36小时开始给予等热量、等氮肠内营养支持至术后第10天,研究组在予以肠内营养的同时,经鼻肠管予以四君子汤治疗,并持续应用至术后第10天,对照组经鼻肠管予以相同剂量的生理盐水。两组分别于术前1天,术后第1、10天检测外周血T淋巴细胞亚群(CD3、CD4、CD8及CD4/CD8),免疫球蛋白(IgA、IgG、IgM)浓度。结果研究组术后10天CD3、CD4、CD4/CD8及IgG水平均显著高于对照组(P<0.05)。结论同手术后单独应用肠内营养相比,围手术期联合应用中药的肠内营养具有显著的细胞免疫增强作用,可有效纠正胃癌患者术后细胞免疫抑制状态。     

The prognostic value of severe malnutrition in the development of nonthyroidal illness in head and neck cancer patients

BACKGROUND: Thyroid hormone metabolism is modulated by starvation and overfeeding but also by dietary composition. Unfortunately, little is known about the effect of malnutrition on disease-induced nonthyroidal illness (NTI). In this study, we investigated whether the degree of NTI after surgery differed between severely malnourished and well-fed patients with head and neck cancer. METHODS: Plasma levels of the thyroid hormones 3',5-triiodothyronine (T(3)), reverse T(3) (rT(3)), free T(4) (FT(4)), and thyrotropin (TSH) were measured on the first day before the operation and on the first, fourth, and seventh day after the operation in 16 malnourished patients who were admitted for intentional curative surgery of T1-T4 carcinomas of the head and neck. Six well-fed head and neck cancer patients eligible for surgical treatment served as a control group. RESULTS: In the malnourished group, rT(3) showed a significant increase, whereas T(3) and FT(4) decreased significantly due to the operation. TSH showed no significant change. During the postoperative course, it took 7 days until rT(3) and 4 days until T(3) and FT(4) were restored to their preoperative value. In contrast, well-fed patients did not develop NTI. CONCLUSIONS: This study shows that peri- and postoperative rT(3), T(3), and FT(4) levels change significantly in malnourished patients compared with well-fed patients. Therefore, it can be concluded that nutrition status of patients undergoing major head and neck surgery should be optimized in order to prevent the development of NTI.     

Nutritional status of surgical patients and the relationship of nutrition to postoperative outcome.

A preoperative nutritional assessment including anthropometry, biochemical indices and global subjective assessment was performed for 127 patients admitted for elective gastrointestinal surgery. Of these, 24 were subjected to minor surgery, 65 to intermediate surgery and 38 to major procedures. Patients were followed postoperatively, recording complications or mortality. Intermediate and major surgery patients had lower triceps skinfold thickness and mid-arm circumference and greater weight loss than did minor surgery patients. Thirty-six percent of the patients suffered complications. No association was found between preoperative nutritional status and incidence of postoperative complications. Six patients died and they showed greater preoperative weight loss (21 +/? 6.5 vs 12 +/? 1.4%) and lower serum albumin levels (25 +/? 4 vs 35 +/? 1 g/l) than patients who survived complications. Global subjective assessment classified 43% of survivors as malnourished, compared to 100% of patients who died.     

Nutritional status of surgical patients and the relationship of nutrition to postoperative outcome.

A preoperative nutritional assessment including anthropometry, biochemical indices and global subjective assessment was performed for 127 patients admitted for elective gastrointestinal surgery. Of these, 24 were subjected to minor surgery, 65 to intermediate surgery and 38 to major procedures. Patients were followed postoperatively, recording complications or mortality. Intermediate and major surgery patients had lower triceps skinfold thickness and mid-arm circumference and greater weight loss than did minor surgery patients. Thirty-six percent of the patients suffered complications. No association was found between preoperative nutritional status and incidence of postoperative complications. Six patients died and they showed greater preoperative weight loss (21 +/- 6.5 vs 12 +/- 1.4%) and lower serum albumin levels (25 +/- 4 vs 35 +/- 1 g/l) than patients who survived complications. Global subjective assessment classified 43% of survivors as malnourished, compared to 100% of patients who died.     

Assessing the Effect of Preoperative Nutrition on Upper Body Function in Elderly Patients Undergoing Elective Abdominal Surgery

Background: Malnutrition among elderly surgical patients has been associated with poor postoperative outcomes and reduced functional status. Although previous studies have shown that nutrition contributes to patient outcomes, its long‐term impact on functional status requires better characterization. This study examines the effect of nutrition on postoperative upper body function over time in elderly patients undergoing elective surgery. Methods: This is a 2‐year prospective study of elderly patients (≥70 years) undergoing elective abdominal surgery. Preoperative nutrition status was determined with the Subjective Global Assessment (SGA). The primary outcome was handgrip strength (HGS) at 1, 4, 12, and 24 weeks postsurgery. Repeated measures analysis was used to determine whether SGA status affects the trajectory of postoperative HGS. Results: The cohort included 144 patients with a mean age of 77.8 ± 5.0 years and a mean body mass index of 27.7 ± 5.1 kg/m². The median (interquartile range) Charlson Comorbidity Index was 3 (2–6). Participants were categorized as well‐nourished (86%) and mildly to moderately malnourished (14%), with mean preoperative HGS of 25.8 ± 9.2 kg and 19.6 ± 7.0 kg, respectively. At 24 weeks, 64% of well‐nourished patients had recovered to baseline HGS, compared with 44% of mildly to moderately malnourished patients. Controlling for relevant covariates, SGA did not significantly affect the trajectory of postoperative HGS. Conclusion: While HGS values over the 24 weeks were consistently higher in the well‐nourished SGA group than the mildly to moderately malnourished SGA group, no difference in the trajectories of HGS was detected between the groups.     

Postoperative enteral immunonutrition in head and neck cancer patients

AIMS: to determine if postoperative feeding of head and neck cancer patients, using an enteral diet supplemented with arginine, improves immunological and nutritional status, and clinical outcome, i.e., reduces postoperative infectious/wound complications and length of stay, when compared with an isocaloric, isonitrogenous control diet. METHODS: at operation 44 patients were randomized into two groups to receive: a) an enriched diet (n=23);b) an isocaloric, isonitrogenous control diet (n=21). Thirteen patients with a history of significant weight loss (> or = 10% over the last 6 months) were considered malnourished. Preoperatively and on postoperative days 1, 4 and 8 the following parameters were evaluated: albumin, prealbumin, transferrin, total number of lymphocytes, lymphocyte subsets (CD3, CD4, CD8 and CD4/CD8 ratio) and immunoglobulins. Postoperative complications and length of stay were recorded. RESULTS: 'visceral' serum proteins and immunological parameters decreased on postoperative day 1 in both groups. However, only the enriched group demonstrated a significant increase (P<0.05) in the total number of lymphocytes, CD4, CD4/CD8 on postoperative day 4, and total number of lymphocytes, CD3, CD4, CD4/CD8 on postoperative day 8. In the malnourished subgroup the administration of the enriched formula significantly reduced both postoperative infectious/wound complications and length of stay compared with the control group (P<0.05). CONCLUSIONS: enteral immunonutrition of head and neck cancer patients improves postoperative immunological response. Significant clinical advantages were observed in malnourished patients.     

In vitro leukocyte endogenous mediator production is not impaired following surgical stress in moderately malnourished patients

Leukocyte endogenous mediator (LEM), a protein produced by phagocytizing cells, plays a critical role in the metabolic response to injury and infection. There is an important interaction between protein-calorie malnutrition and the capacity of cells to produce LEM, since severely malnourished or severely stressed individuals, have a reduced capacity to produce LEM. The leukocytes of 10 mildly to moderately malnourished patients undergoing elective major surgery, a moderate stress, had an intact ability to produce LEM on preoperative assessment. This ability was not affected by a 5-day postoperative period of hypocaloric nutrient intake despite a significant loss of body protein in one-half of the patients and a significant fall in serum protein concentrations. These results suggest a high biologic priority for LEM production during the metabolic response to injury and for infection.     

Survival of malnourished head and neck cancer patients can be predicted by human leukocyte antigen-DR expression and interleukin-6/tumor necrosis factor-alpha response of the monocyte

BACKGROUND: Patients with advanced stages of head and neck cancer are often characterized by malnutrition and by an impaired immune system. Because some of the suppressed immune parameters were shown to be of prognostic importance in trauma and sepsis, we investigated whether these would also correlate with survival in head and neck cancer. METHODS: Severely malnourished head and neck cancer patients undergoing ablative and reconstructive surgery were followed prospectively and their perioperative immune parameters were related to long-term survival. RESULTS: Forty-nine patients with a preoperative weight loss of more than 10% were followed up for a period of at least 16 months after surgery. Analyses of variance revealed that preoperative human leukocyte antigen-DR (HLA-DR) expression on monocytes and endotoxin-induced production of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) were different between patients who survived and patients who died. Proportional hazards identified a weight loss of more than 12%, the presence of coexistent disease, and an HLA-DR expression on monocytes below the cutoff points (mean fluorescence index < 15, peak channel index < 9) to be of significant influence on survival. CONCLUSIONS: In addition to known prognostic parameters such as tumor stage, coexistent disease, and weight loss, the immune parameters HLA-DR expression on monocytes and endotoxin-induced cytokine production may carry prognostic value in cancer patients. Immunomodulating therapies leading to improvement of these parameters might in the future lead to increased options for treatment.     

肥胖对结直肠癌手术部位感染的影响

目的探讨肥胖对结直肠癌手术部位感染(SSI)的影响。方法回顾性调查2008年1月—2013年12月某院行结直肠癌根治性手术的215例患者,其中100例体重指数(BMI)≥25 kg/m2(肥胖组),115例BMI25 kg/m2(正常体重组),比较两组患者术中情况、术后恢复、手术并发症等指标。结果肥胖患者72例(72.00%)术中出血量60 mL,58例(58.00%)手术持续时间220 min,其中20例(20.00%)发生SSI;正常体重组中仅30例(26.09%)术中出血量60 mL,20例(17.39%)手术持续时间220 min,8例(6.96%)发生SSI。肥胖组患者术中出血量、SSI发病率高于正常体重组,手术持续时间、术后住院时间长于正常体重组,各组比较,差异均有统计学意义(均P0.05)。结论结直肠癌患者SSI发病率较高,肥胖、手术持续时间长、出血量多是结直肠患者SSI的危险因素。     

Perioperative enteral nutrition and quality of life of severely malnourished head and neck cancer patients: a randomized clinical trial

BACKGROUND AND AIMS: This study evaluated the use of perioperative nutritional support on Quality of Life (QOL) in malnourished head and neck cancer patients undergoing surgery. METHODS: 49 Malnourished (weight loss >10%) head and neck cancer patients who were included in a nutrition intervention trial were randomized to receive either no preoperative and standard postoperative tube-feeding (group I), standard preoperative and postoperative tube-feeding (group II) or arginine-supplemented preoperative and postoperative tube-feeding (group III). Of these patients, 31 completed a full QOL assessment on the first day of preoperative nutritional support, one day before surgery, and 6 months after surgery. Both a disease-specific (EORTC QLQ-C30) and a generic questionnaire (COOP-WONCA) were used. One way analysis of variance (ANOVA) and the Kruskal-Wallis test were applied for testing differences in scores between groups. RESULTS: Between baseline and the day before surgery, both preoperatively fed groups revealed a positive change for the dimensions physical and emotional functioning and dyspnea (with significance in group II, P=0.050,0.031,0.045 respectively). Group III showed a negative change in appetite (P=0.049). Between baseline and 6 months after surgery, there were no differences between group I and both pre-fed groups. There were no differences in favour of group III compared to group II. CONCLUSION: Enteral nutrition improves QOL of severely malnourished head and neck cancer patients in the period preceding surgery. No benefit of preoperative enteral feeding on QOL could be demonstrated 6 months after surgery.     

Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ)

OBJECTIVE: For the early detection and treatment of malnourished hospital patients no valid screening instrument for the Dutch language exists. Calculation of percentage weight loss and body mass index (BMI) by the nurse at admission to the hospital appeared to be not feasible. Therefore, the short, nutritional assessment questionnaire (SNAQ), was developed. RESEARCH, DESIGN AND METHODS: Two hundred and ninety one patients on the mixed internal and surgery/oncology wards of the VU University medical center were screened on nutritional status and classified as well nourished (<5% weight loss in the last 6 months and BMI>18.5), moderately malnourished (5-10% weight loss in the last 6 months and BMI>18.5) or severely malnourished (>10% weight loss in the last 6 months or >5% in the last month or BMI<18.5). All patients were asked 26 questions related to eating and drinking difficulties, defecation, condition and pain. Odds ratio, binary and multinomial logistic regression were used to determine the set of questions that best predicts the nutritional status. Based on the regression coefficient a score was composed to detect moderately (2 points) and severely (3 points) malnourished patients. The validity, the nurse-nurse reproducibility and nurse-dietitian reproducibility was tested in another but similar population of 297 patients. RESULTS: The questions 'Did you lose weight unintentionally?'. 'Did you experience a decreased appetite over the last month?' and 'Did you use supplemental drinks or tube feeding over the last month?' were most predictive of malnutrition. The instrument proved to be valid and reproducible. CONCLUSION: SNAQ is an easy, short, valid and reproducible questionnaire for early detection of hospital malnutrition.     

Urinary excretion of deoxypyridinoline increases after gastrointestinal surgery

OBJECTIVES: We investigated the effect of gastrointestinal surgery on bone metabolism with special reference to nutrition status and the systemic inflammatory response (SIR). METHODS: We assessed bone resorption by measuring the urinary excretion of deoxypyridinoline (D-Pyr), a specific marker that reflects the amount of degraded collagen. Twenty patients who underwent gastrectomy or colectomy were enrolled in this study. Daily energy intake, nitrogen, calcium, and phosphate balances, and urinary D-Pyr were examined preoperatively and for 14 days after the operation. The nutritional risk index and prealbumin were measured for nutrition assessment, and SIR was evaluated daily based on scorings of body temperature, pulse rate, respiratory rate, and white blood cell number according to our criteria. RESULTS: Urinary D-Pyr excretion had already increased on postoperative day 1 and continued to increase until postoperative day 14. The amounts of postoperative urinary excretion of D-Pyr correlated positively with the SIR scores and the amount of urinary excretion of cortisol, one of the stress-response hormones, and inversely with pre- and postoperative nutritional risk indices. In addition, the patients who experienced complications during the postoperative period excreted larger amounts of D-Pyr. CONCLUSIONS: Because the amount of excreted D-Pyr reflects the loss of the bone matrix, these results may indicate that bone resorption increases after gastrointestinal surgery. The extent of resorption was parallel to the degree of SIR and nutrition status.     

Differences in immune status between well-nourished and malnourished head and neck cancer patients

Malnutrition is reported to occur in approximately 30% of head and neck cancer patients. Also, impaired immunocompetence is described as a common phenomenon in this patient group. The purpose of this study was to assess the possible relationship between malnutrition and some prognostically important immune parameters in head and neck cancer patients. Thirty-two malnourished (recent weight loss >/= 10%) and 34 well-nourished patients undergoing curative treatment for advanced head and neck cancer were studied prospectively, and six parameters of their immune status (leucocytes, lymphocytes, lymphocyte phenotyping, monocytes, HLA-DR expression on monocytes and serum interleukin-10) were determined on the day of panendoscopy. Reference values for monocytes, HLA-DR expression and interleukin-10 were obtained from 43 healthy controls. Although the number of monocytes was elevated in both patient groups, the HLA-DR expression on these monocytes was significantly lower in the malnourished than in the well-nourished and control groups. Tumor stage, tumor localization, recurrence after initial radiotherapy, age and gender were not correlated to HLA-DR expression. No relationships emerged between nutritional status and lymphocyte subsets. Malnourished head and neck cancer patients show a significantly lower HLA-DR expression on monocytes than well-nourished ones and healthy controls. According to the literature this would imply an increased risk for postoperative complications. Indeed, postoperative complications occur more frequently in malnourished than in well-nourished patients.     

Usefulness of oral mucosal epithelial cell apoptosis rate in nutritional assessment

OBJECTIVE: This preliminary study was designed to explore a new method for nutritional assessment by measuring oral mucosal cell apoptosis or proliferation. METHODS: Forty-two consecutive patients with gastrointestinal malignant tumors were hospitalized on the surgical wards and studied prospectively. Patient-Generated Subjective Global Assessment was used to identify malnourished patients. Anthropometric measurements including weight, body mass index, triceps skinfold thickness, and midarm muscle circumference were recorded. The serum proteins measured were retinol-binding protein (RBP), transferrin, prealbumin (PA), and albumin. Simultaneously, the rates of oral epithelial cell apoptosis and proliferation were measured by flow cytometry. Of the 20 malnourished patients, 14 were followed up in a serial study with a 3-d nutritional support therapy. Nutritional indices and oral epithelial cell apoptosis rate were measured after 3 d of nutritional support. RESULTS: Malnutrition was diagnosed in 20 of 42 patients (47.6%). Oral epithelial apoptosis and proliferation rates were significantly decreased (P < 0.01 and P < 0.05, respectively) in malnourished compared with non-malnourished patients, although there were no significant differences between their anthropometric data. Malnourished patients had lower serum levels of RBP, albumin, and PA and rates of oral epithelial cell apoptosis and proliferation. The rate of oral epithelial cell apoptosis positively correlated with serum RBP (R = 0.32, P < 0.05) and PA (R = 0.33, P < 0.05). The rate of oral epithelial cell apoptosis and serum RBP and PA increased significantly in the malnourished patients who received nutritional support for 3 days. CONCLUSIONS: Measuring the rate of oral epithelial cell apoptosis may be another non-invasive technique to determine nutritional assessment and is worthy of further exploration.