Wang L S, Lin H Y, Chang C J, Fahn H J, Huang M H, Lin C F
Department of Surgery, Veterans General Hospital and National Yang-Ming Medical University, Taipei, Taiwan, Republic of China.
J Surg Oncol. 1998 Feb;67(2):90-8. doi: 10.1002/(sici)1096-9098(199802)67:2<90::aid-jso4>3.0.co;2-g.
En bloc esophagectomy has been established as the treatment of choice for patients with resectable esophageal carcinoma. However, an extensive surgical procedure may result in further impairment of the patient's nutritional status and immune system. Thus a prospective study was undertaken to evaluate the perioperative sequential changes in patients' nutritional and immune status and the timing to institute postoperative adjuvant therapy.
Thirty-seven patients (34 male, 3 female) who had undergone en bloc esophagectomy with gastric institution for epidermoid carcinoma of the esophagus were studied. The mean age was 62.3 years. The nutritional and immune assessments were performed preoperatively, on the third postoperative day, in the first week, second week, third week, and at the end of the first and third month. The biochemical studies for nutritional evaluation included serum albumin, cholesterol, iron, transferrin, magnesium, zinc, total iron binding capacity (TIBC), and nitrogen balance. Evaluation of the immune status consisted of: (1) total lymphocyte count, (2) lymphocyte subpopulation, (3) immunoglobulins, (4) complements (C3 and C4), (5) lymphocyte blastogenic responses, (6) tumor necrosis factor-alpha and interleukin-2 secretion activity from mononuclear cells, and (7) C-reactive protein (CRP) level.
All the parameters in nutritional assessment declined profoundly by the third postoperative day (P < 0.05). The most severe deterioration was in serum iron, followed by transferrin, TIBC, cholesterol, and zinc. Most of them returned to the preoperative levels within 2-3 weeks after surgery. However, the serum levels of iron, transferrin, and TIBC required a longer period of time (> 1 month) to return to normal. A remarkable increase of serum CRP was detected in the first postoperative week (P < 0.05), but immunoglobulins and complements decreased significantly yet variably (P < 0.05) in the second or third postoperative week before gradually returning to preoperative levels. Moreover, during the first week after surgery, CD3 and CD8 diminished following esophageal surgery, whereas CD20, CD4/CD8 ratio, and lymphocyte blastogenic responses increased significantly (P < 0.05).
Except for iron-related parameters, all the other nutritional parameters returned to the preoperative level by the third postoperative week. An adequate supplementation of iron and protein for 1-3 months after surgery is needed. En bloc esophagectomy might have only a mild and temporarily adverse effect on the host immune defense. Regarding the postoperative recovery of a patient's nutritional and immune status, postoperative chemo-radiotherapy is optimally instituted after the third postoperative week, instead of within 2 weeks of surgery.
整块食管切除术已被确立为可切除食管癌患者的首选治疗方法。然而，广泛的外科手术可能会进一步损害患者的营养状况和免疫系统。因此，开展了一项前瞻性研究，以评估患者营养和免疫状态的围手术期序贯变化以及术后辅助治疗的时机。
对37例（男34例，女3例）因食管表皮样癌接受整块食管切除术并胃代食管术的患者进行研究。平均年龄为62.3岁。在术前、术后第3天、第1周、第2周、第3周以及第1和第3个月末进行营养和免疫评估。用于营养评估的生化研究包括血清白蛋白、胆固醇、铁、转铁蛋白、镁、锌、总铁结合力（TIBC）和氮平衡。免疫状态评估包括：（1）总淋巴细胞计数，（2）淋巴细胞亚群，（3）免疫球蛋白，（4）补体（C3和C4），（5）淋巴细胞增殖反应，（6）单核细胞分泌肿瘤坏死因子-α和白细胞介素-2的活性，以及（7）C反应蛋白（CRP）水平。
术后第3天，营养评估中的所有参数均显著下降（P<0.05）。最严重的恶化是血清铁，其次是转铁蛋白、TIBC、胆固醇和锌。其中大多数在术后2 - 3周内恢复到术前水平。然而，血清铁、转铁蛋白和TIBC水平需要更长时间（>1个月）才能恢复正常。术后第1周检测到血清CRP显著升高（P<0.05），但免疫球蛋白和补体在术后第2或第3周显著下降且变化不定（P<）0.05），然后逐渐恢复到术前水平。此外，在术后第1周，食管手术后CD3和CD8减少，而CD20、CD4/CD8比值和淋巴细胞增殖反应显著增加（P<0.05）。
除与铁相关的参数外，所有其他营养参数在术后第3周恢复到术前水平。术后需要补充1 - 3个月的铁和蛋白质。整块食管切除术可能仅对宿主免疫防御有轻微和暂时的不利影响。关于患者营养和免疫状态的术后恢复，术后放化疗最好在术后第3周后进行，而不是在术后2周内。
