• Lucas W Thornblade, Thomas K Varghese, Xu Shi, Eric K Johnson, Amir Bastawrous, Richard P Billingham, Richard Thirlby, Alessandro Fichera, and David R Flum.
• 1 Department of Surgery, University of Washington, Seattle, Washington 2 Department of Surgery, University of Utah, Salt Lake City, Utah 3 Department of Biostatistics, University of Washington, Seattle, Washington 4 Department of Surgery, Madigan Army Medical Center, Tacoma, Washington 5 Colon and Rectal Surgery, Swedish Medical Center, Seattle, Washington 6 General Surgery, Virginia Mason Medical Center, Seattle, Washington.
• Dis. Colon Rectum. 2017 Jan 1; 60 (1): 68-75.

BackgroundRandomized controlled trials demonstrate the efficacy of arginine-enriched nutritional supplements (immunonutrition) in reducing complications after surgery. The effectiveness of preoperative immunonutrition has not been evaluated in a community setting.ObjectiveThis study aims to determine whether immunonutrition before elective colorectal surgery improves outcomes in the community at large.DesignThis is a prospective cohort study with a propensity score-matched comparative effectiveness evaluation.SettingsThis study was conducted in Washington State hospitals in the Surgical Care Outcomes Assessment Program from 2012 to 2015.PatientsAdults undergoing elective colorectal surgery were selected.InterventionsSurgeons used a preoperative checklist that recommended that patients take oral immunonutrition (237 mL, 3 times daily) for 5 days before elective colorectal resection.Main Outcome MeasuresSerious adverse events (infection, anastomotic leak, reoperation, and death) and prolonged length of stay were the primary outcomes measured.ResultsThree thousand three hundred seventy-five patients (mean age 59.9 ± 15.2 years, 56% female) underwent elective colorectal surgery. Patients receiving immunonutrition more commonly were in a higher ASA class (III-V, 44% vs 38%; p = 0.01) or required an ostomy (18% vs 14%; p = 0.02). The rate of serious adverse events was 6.8% vs 8.3% (p = 0.25) and the rate of prolonged length of stay was 13.8% vs 17.3% (p = 0.04) in those who did and did not receive immunonutrition. After propensity score matching, covariates were similar among 960 patients. Although differences in serious adverse events were nonsignificant (relative risk, 0.76; 95% CI, 0.49-1.16), prolonged length of stay (relative risk, 0.77; 95% CI, 0.58-1.01 p = 0.05) was lower in those receiving immunonutrition.LimitationsPatient compliance with the intervention was not measured. Residual confounding, including surgeon-level heterogeneity, may influence estimates of the effect of immunonutrition.ConclusionsReductions in prolonged length of stay, likely related to fewer complications, support the use of immunonutrition in quality improvement initiatives related to elective colorectal surgery. This population-based study supports previous trials of immunonutrition, but shows a lower magnitude of benefit, perhaps related to compliance or a lower rate of adverse events, highlighting the value of community-based assessments of comparative effectiveness.

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