Sains Malaysiana 49(3)(2020): 625-634

http://dx.doi.org/10.17576/jsm-2020-4903-17

A Systematic Review on the Effectiveness of Enteral Immunonutrition (EIN) on Pre- and Post-Operative Outcomes in Gastric Cancer Patients

(Suatu Ulasan Sistematik tentang Keberkesanan Imunonutrisi Enteral (EIN) kepada Hasil Operatif Pra dan Pos pada Pesakit Kanser Gastrik)

RUTH MERRY PARANJOTHI YANOK¹, IKLIL IMAN MOHD SA’ID¹, SHIN HWA CHAU¹, KAI YEE SENG¹, NIK SHANITA SAFII^1,4 & WEI BOON YAP^2,3

¹Dietetics Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Abdul Aziz, 50300 Kuala Lumpur, Federal Territory, Malaysia

²Biomedical Science Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Abdul Aziz, 50300 Kuala Lumpur, Federal Territory, Malaysia

³Center of Toxicology and Health Risk Studies, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Abdul Aziz, 50300 Kuala Lumpur, Federal Teritory, Malaysia

⁴Center of Community Health, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Abdul Aziz, 50300 Kuala Lumpur, Federal Territory, Malaysia

Received: 13 June 2019/Accepted: 11 November 2019

Abstract

Gastric cancer is one of the most common upper gastrointestinal malignancies. To date, enteral immunonutrition (EIN) has gained increasing attention as it is found to effectively enhance the host’s immunity and improve the metabolic status of gastric cancer patients undergoing gastrectomy. The health-boosting effects of EIN are believed to originate from a number of nutritional elements such as omega-3 fatty acids, glutamine, arginine and nucleic acid precursors that help reduce the incidences of post-operative complications and shorten the length of hospital stay among the aforementioned patients. However, little was known about the consistency of health-boosting benefits conferred by EIN. Hence, according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) protocol, this systematic review was carried out using nine meticulously and specifically selected full-length articles focusing on the pre- and post-operative effects of EIN including physical, biochemical, clinical and immunological outcomes on gastric cancer patients. Among the selected articles, seven of them focused on post-operative EIN while the remaining two concentrated on pre-operative EIN. In most of the selected studies, more than one immunonutritional components (arginine, glutamine, omega-3 fatty acid, RNA) were integrated. Patients receiving EIN showed significantly improved immunity, for example, increase in CD4+ T and NK cell counts that are responsible for fighting pathogens. In addition to that, individuals receiving EIN also showed increased levels of inflammatory biomarkers in their sera such as pre-albumin and transferrin. This results in shorter period of post-operative hospital stay that in turn permits progressive healing process and increases the survival rate due to minimal frequency of post-operative infections. Conclusively, our systematic review acknowledges that regardless of the initiation timing (pre-operative or post-operative) of immunonutrition, EIN can improve the overall health status of gastric cancer patients including infection complications and the length of hospital stay through regulation of immune responses.

Keywords: Arginine; enteral immunonutrition; gastric cancer; glutamine; omega-3 fatty acids; RNA

Abstrak

Kanser gastrik adalah salah satu kanser yang umum di bahagian atas gastroperut. Kini, imunonutrisi enteral (EIN) semakin mendapat perhatian kerana pendekatan ini didapati dapat meningkatkan keimunan tubuh badan dan memperkukuh fungsi metabolik badan bagi pesakit yang menjalani gastrektomi. Kesan peningkatan kesihatan EIN dipercayai berasal daripada unsur pemakanan seperti asid lemak omega-3, glutamin, arginin dan prekursor asid nukleik yang dapat mengurangkan kejadian komplikasi pasca-operasi dan memendekkan tempoh penginapan di hospital dalam kalangan pesakit tersebut. Namun, konsistensi manfaat EIN dalam meningkatkan kesihatan masih kurang perinci. Oleh itu, dengan berpandukan protokol PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), kajian tinjauan sistematik ini telah dijalankan dengan teliti dengan menggunakan sembilan artikel penuh spesifik yang memfokuskan kesan pra- dan pasca-operasi EIN yang merangkumi segi fizikal, biokimia, klinikal dan keimunan dalam kalangan pesakit kanser gastrik. Antara artikel yang terpilih, tujuh daripadanya tertumpu pada kesan pasca-operasi EIN manakala dua artikel lagi menumpu pada kesan pra-operasi EIN. Kebanyakan kajian terpilih menggabungkan lebih daripada sejenis komponen imunonutrisi (arginina, glutamina, asid lemak omega-3, RNA). Pesakit yang menerima EIN menunjukkan peningkatan dalam penanda biologi seperti bilangan sel T CD4+ dan NK yang bertanggungjawab untuk melawan patogen. Tambahan pula, individu yang menerima EIN juga menunjukkan peningkatan dalam aras serum penanda inflamasi seperti pra-albumin and transferrin. Hal ini memendekkan tempoh penginapan pasca-operasi di hospital, seterusnya mempercepat proses penyembuhan dan meningkatkan kadar kemadirian akibat penurunan kebarangkalian jangkitan pasca-operasi. Secara konklusi, ulasan sistematik ini mendapati tanpa kira masa permulaan imunonutrisi (pra-operasi atau pasca-operasi), EIN dapat menambah baik status kesihatan pasakit kanser gastrik secara keseluruhan termasuk komplikasi jangkitan dan tempoh penginapan hospital melalui regulasi tindak balas keimunan.

Kata kunci: Arginina; asid lemak omega-3; glutamina; imunonutrisi enteral; kanser gastrik; RNA

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*Corresponding author; email: yapweiboon@ukm.edu.my