Perioperative Immunonutrition

Dear Editor:

We have read the systematic review of the literature by Morán López et al. with interest. Throughout the article, the authors emphasize the importance of perioperative nutritional support and its proven beneficial impact on the incidence of infectious complications and, especially, hospital stay.¹ They also insist on some basic concepts that were scientifically proven years ago (such as the greater efficacy of enteral over parenteral nutrition, or the need for preoperative immunonutrition in patients scheduled for major gastrointestinal surgery). Nonetheless, these practices have not become generalized among surgeons.

In 2005, after a systematic review on perioperative management of surgical patients, the Société Française de Chirurgie Digestive (SFCD) published very specific clinical practice guidelines in which they insisted on the importance of systematic nutritional status assessment and perioperative nutritional support.² Specifically, in accordance with the high-level of scientific evidence that existed at that time, the administration of preoperative immunonutrition was recommended for 5–7 days in all patients scheduled for digestive tract cancer surgery (not only upper digestive tract surgery, but also colorectal procedures), even in well-nourished patients. Immunonutrition is then continued during the postoperative period only in those patients who presented malnutrition before surgery. This explicit and formal recommendation “obligated” the Health Ministry to assume the cost of preoperative immunonutrition (approximately 175€ for one week of preoperative treatment) in a decree one year later, providing the product was prescribed by a surgeon, oncologist or anesthetist for a patient undergoing gastrointestinal cancer surgery.³

The recommendations made by the SFCD in 2005 were then re-examined and confirmed by the corresponding nutrition (SFNEP) and anesthesia-reanimation (SFAR) scientific societies.⁴ This process meant that, in just 5 years, these practices went from total unawareness in the world of surgery to a level of prescription of 65% in oncological patients; today, this percentage is certainly higher thanks to the many communications on this subject.⁵

Therefore, the reason for this letter is to encourage the Spanish Association of Surgeons (Asociación Española de Cirujanos) to initiate a similar process to transmit to surgeons, responsible health care administrators and ministries that these practices are not only in the patients’ best interest, but also result in proven medical and economic benefits.^6–8 The French situation in this matter is a clear example of how scientific evidence can come to influence clinical practice.