Body composition, injury, and wound healing in surgery

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Body composition, injury, and wound healing in
surgery

• Surgical Nutrition Training Module
• Level 1
• Philippine Society of General Surgeons
• Committee on Surgical Training

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Objectives

• To discuss the body composition and its key
  components
• To discuss body composition changes in injury
  particularly in surgery

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Basics and normal body composition
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The cell and its organelles

• Major
• Cell membrane
• Cytoplasm
• Mitochondria
• Nucleus
• Endoplasmic reticulum
• Golgi apparatus

Illustrations from Guytons Textbook of Physiology
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Nutrients, structure, function
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Human body 100 trillion cells

• Nervous system
• Musculoskeletal system
• Cardiovascular system
• Respiratory system
• Gastrointestinal system
• Genitourinary system
• Reproductive system
• Endocrine system
• Hemopoietic system

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Body composition, all ages
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Muscle and fat mass, all ages
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Body composition in health and disease
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Body compartments in health and disease
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Energy utilization
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No food intake glucose utilization
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Surgery, wound healing, and nutritional status
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Loss of lean body mass ?mortality
Loss of Total LBM Complications Associated Mortality
10 Decreased immunity Increased infections 10
20 Decrease in healing, increase In weakness, infection 30
30 Too weak to sit, pressure ulcers, Pneumonia, lack of healing 50
40 Death, usually from pneumonia 100
LBMLean Body Mass
Demling RH. Nutrition, anabolism, and the wound
healing process an overview. Eplasty 20099e9.
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Body composition analysis
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The surgical nutrition process
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Nutritional Assessment and Risk Level Form
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Complication(s) prediction
Predicting post-operative complications based on
surgical nutritional risk level using the SNRAF
in colon cancer patients - a Chinese General
Hospital Medical Center experience. Ocampo R B,
Kadatuan Y, Torillo MR, Camarse CM, Malilay RB,
Cheu G, Llido LO, Gilbuena AA. Yr 2007.
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Surgical decision making based on body
composition analysis
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Wound healing issues
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Inflammation part of wound healing

• Cell proliferation
• ? nutrient and energy requirements
• Adequacy of response is dependent on the nutrient
  supply / reserves

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Wound healing
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Wound healing molecular environment
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Wound healing
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Wound healing requirements

• Increased requirements
• Energy and protein
• Electrolytes, vitamins, trace elements
• Oxygen and water
• Addition of
• conditional essential amino acids (glutamine)
• Trace elements (selenium in burns)
• Antioxidants
• Continuous supply of the requirements

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Energy calculations are good enough
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ESPEN Guidelines 2009 Surgery

• Calorie Requirement(s)
• The commonly used formula of 25 kcal/kg ideal
  body weight furnishes an approximate estimate of
  daily energy expenditure and requirements.
• Under conditions of severe stress requirements
  may approach 30 kcal/kg ideal body weight
• (Grade B)

ESPEN European Society of Parenteral and Enteral
Nutrition
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Protein synthesis

• Requirements
• ?Insulin levels induced by adequate glucose
  intake
• ?plasma amino acid levels
• Adequate essential amino acid levels
• Adequate non-protein calories from carbohydrate
  and fat

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ESPEN Guidelines 2009 Surgery

• Protein Requirement(s)
• In illness/stressed conditions a daily nitrogen
  delivery equivalent to a protein intake of 1.5
  g/kg ideal body weight (or approximately 20 of
  total energy requirements) is generally effective
  to limit nitrogen losses. The ProteinFatGlucose
  caloric ratio should approximate to 203050
  (Grade C)

ESPEN European Society of Parenteral and Enteral
Nutrition
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Carbohydrate and fat ratios
Stoner et al
McFie et al
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Do lipids matter?

• LCT mostly ?6FA (arachdionic acid) content
  proinflammatory
• MCT reduces ?6FA (arachidonic acid) content
  direct utilization in the liver

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ESPEN Guidelines 2009 Surgery

• Nitrogen sparing non-protein calories
• Optimal nitrogen sparing has been shown to be
  achieved when all components of the parenteral
  nutrition mix are administered simultaneously
  over 24 hours (Grade A)

ESPEN European Society of Parenteral and Enteral
Nutrition
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Energy requirements and antioxidants
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Antioxidants

1. a-tocopherol 1,000 IU (20 mL) q 8h per naso- or
   orogastric tube
2. ascorbic acid 1,000 mg given IV in 100 mL D5W q
   8h for the shorter of the duration of admission
   to the ICU or 28 days.

Nathens AB, Neff MJ, Jurkovich GJ, Klotz P,
Farver K, Ruzinski JT, Radella F, Garcia I, Maier
RV. Randomized, prospective trial of antioxidant
supplementation in critically ill surgical
patients. Ann Surg. 2002 236(6) 814-22.
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Body composition, intake and outcome
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conclusion
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Body composition

• Body composition changes occur in surgery
• Quality of body composition determines outcome in
  surgery
• Analysis of body composition and correction of
  deficiencies through nutrition improves outcomes
  in surgery