Perioperative Alanyl-Glutamine–Supplemented Parenteral Nutrition in Chronic Radiation Enteritis Patients With Surgical Intestinal Obstruction

Abstract

Background: A prospective, randomized, controlled study was performed to evaluate the effects of perioperative alanyl-glutamine–supplemented parenteral nutrition (PN) support on the immunologic function, intestinal permeability, and nutrition status of surgical patients with chronic radiation enteritis (CRE)–induced intestinal obstruction. Methods: Patients who received 0.4 g/kg/d alanyl-glutamine and isonitrogenous PN were assigned to an alanyl-glutamine–supplemented PN (Gln-PN) group and a control group, respectively. Serum levels of alanine aminotransferase and glutamine, body fat mass (FM), immunologic function, and intestinal permeability were measured before and after surgery. Results: Serum glutamine levels of the Gln-PN group significantly exceeded that of the control group (P < .001; Gln-PN, baseline 460.7 ± 42.5 vs 523.3 ± 48.6 µmol/L on postoperative day 14 [POD14], P < .001; control, baseline 451.9 ± 44.0 vs 453.8 ± 42.3 µmol/L on POD14, P = .708). Lactulose/mannitol ratios of both groups decreased over time (Gln-PN, baseline 0.129 ± 0.0403 vs 0.024 ± 0.0107 on POD1 4; control, baseline 0.125 ± 0.0378 vs 0.044 ± 0.0126 on POD14, P < .001 in both groups). CD4/CD8-positive T-lymphocyte ratios significantly rose in both groups, with significant intergroup difference (P < .001; Gln-PN, baseline 1.36 ± 0.32 vs 1.82 ± 0.30 on POD14, P < .001; control, baseline 1.37 ± 0.25 vs 1.63 ± 0.31 on POD14, P < .001). In the Gln-PN group, FM increased from 3.68 ± 1.68 kg at baseline to 5.22 ± 1.42 kg on POD14 (P < .001). FM of control group increased from 3.84 ± 1.57 kg at baseline to 5.40 ± 1.54 kg on POD14 (P < .001). However, there were no significant intergroup differences (P = .614). Conclusion: Gln-PN significantly boosted the immune state and decreased the intestinal permeability of CRE patients. However, Gln-PN was not superior to standard PN in improving the nutrition state and intestinal motility of surgical patients with CRE-induced intestinal obstruction.

Keywords

radiation injuries glutamine immune system chronic radiation enteritis parenteral nutrition alanyl-glutamine intestinal obstruction immunologic function intestinal permeability

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References

Gami

Harrington

Blake

. How patients manage gastrointestinal symptoms after pelvic radiotherapy. Aliment Pharmacol Ther. 2003;18:987-994.

Theis

Sripadam

Ramani

Lal

. Chronic radiation enteritis. Clin Oncol (R Coll Radiol). 2010;22:70-83.

Regimbeau

Panis

Gouzi

Fagniez

. Operative and long term results after surgery for chronic radiation enteritis. Am J Surg. 2001;182:237-242.

Braga

Ljungqvist

Soeters

Fearon

Weimann

Bozzetti

. ESPEN guidelines on parenteral nutrition: surgery. Clin Nutr. 2009;28:378-386.

Zheng

Zhang

. Glutamine dipeptide for parenteral nutrition in abdominal surgery: a meta-analysis of randomized controlled trials. World J Gastroenterol. 2006;12:7537-7541.

Roth

. Nonnutritive effects of glutamine. J Nutr. 2008;138:2025S-2031S.

Estívariz

Griffith

Luo

. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill surgical patients. JPEN J Parenter Enteral Nutr. 2008;32:389-402.

Pérez-Bárcena

Regueiro

Marsé

. Glutamine as a modulator of the immune system of critical care patients: effect on Toll-like receptor expression. A preliminary study. Nutrition. 2008;24:522-527.

Asprer

Llido

Sinamban

Schlotzer

Kulkarni

. Effect on immune indices of preoperative intravenous glutamine dipeptide supplementation in malnourished abdominal surgery patients in the preoperative and postoperative periods. Nutrition. 2009;25:920-925.

10.

Lin

Kung

Yeh

. The effect of glutamine-supplemented total parenteral nutrition on nitrogen economy depends on severity of diseases in surgical patients. Clin Nutr. 2002;21:213-218.

11.

Han

Cai

Zhong

Geng

. Effects of glutamine-supplemented enteral or parenteral nutrition on apoptosis of intestinal mucosal cells in rats with severe acute pancreatitis. Eur Rev Med Pharmacol Sci. 2013;17:1529-1535.

12.

Leite

Lima

Leite

Farhat

Guerrant

Lima

. Improvement of intestinal permeability with alanyl-glutamine in HIV patients: a randomized, double blinded, placebo-controlled clinical trial. Arq Gastroenterol. 2013;50:56-63.

13.

Miller

O’Grady

. Guidelines for the prevention of intravascular catheter-related infections: recommendations relevant to interventional radiology for venous catheter placement and maintenance. J Vasc Interv Radiol. 2012;23:997-1007.

14.

Wernerman

. Clinical use of glutamine supplementation. J Nutr. 2008;138:2040S-2044S.

15.

Roth

Funovics

Mühlbacher

. Metabolic disorders in severe abdominal sepsis: glutamine deficiency in skeletal muscle. Clin Nutr. 1982;1:25-41.

16.

Vanek

Matarese

Robinson

Sacks

Young

Kochevar

. A.S.P.E.N. position paper: parenteral nutrition glutamine supplementation. Nutr Clin Pract. 2011;26:479-494.

17.

Chambrier

Sztark

. French clinical guidelines on perioperative nutrition: update of the 1994 consensus conference on perioperative artificial nutrition for elective surgery in adults. J Visc Surg. 2012;149:e325-e336.

18.

Membrive Conejo

Reig Castillejo

Rodríguez de Dios

. Prevention of acute radiation enteritis: efficacy and tolerance of glutamine. Clin Transl Oncol. 2011;13:760-763.

19.

Vidal-Casariego

Calleja-Fernandez

de Urbina-Gonzalez

Cano-Rodriguez

Cordido

Ballesteros-Pomar

. Efficacy of glutamine in the prevention of acute radiation enteritis: a randomized controlled trial. JPEN J Parenter Enteral Nutr. 2014;38(2):205-213.

20.

Kucuktulu

Guner

Kahraman

Topbas

Kucuktulu

. The protective effects of glutamine on radiation-induced diarrhea. Support Care Cancer. 2013;21:1071-1075.

21.

Oliveira

Dias

Pelosi

Rocco

. Understanding the mechanisms of glutamine action in critically ill patients. An Acad Bras Cienc. 2010;82:417-430.

22.

Windle

. Glutamine supplementation in critical illness: evidence, recommendations, and implications for clinical practice in burn care. J Burn Care Res. 2006;27:764-772.

23.

Viana Lde

Burgos

Silva Rde

. Refeeding syndrome: clinical and nutritional relevance. Arq Bras Cir Dig. 2012;25:56-59.

24.

Sion-Sarid

Cohen

Houri

Singer

. Indirect calorimetry: a guide for optimizing nutritional support in the critically ill child. Nutrition. 2013;29:1094-1099.