Body composition injury and wound healing in surgery

Body composition, injury, and wound healing in surgery Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training

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

BASICS AND NORMAL BODY COMPOSITION

The cell and its organelles Major: • Cell membrane • Cytoplasm • Mitochondria • Nucleus • Endoplasmic reticulum • Golgi apparatus Illustrations from Guyton’s Textbook of Physiology

Nutrients, structure, function

Human body = 100 trillion cells ENERGY radicals • • • Nervous system Musculoskeletal system Cardiovascular system Respiratory system Gastrointestinal system Genitourinary system Reproductive system Endocrine system Hemopoietic system

Body composition, all ages

Muscle and fat mass, all ages

BODY COMPOSITION IN HEALTH AND DISEASE

Body compartments in health and disease CARBO + OTHER (1%) PROTEIN (14%) FAT (25%) WATER (60%) NORMAL PROTEIN (14%) PROTEIN (12%) PROTEIN (6%) FAT (15%) FAT (23%) WATER (72%) WATER (70%) STARVATION CRITICAL CARE FAT (30%) WATER (55%) OBESE

Energy utilization Lipogenesis POST-PRANDIAL Glucose Glycogen POST-PRANDIAL: within 24 hours Glycogen Gluconeogenesis FASTING: within 24 to 72 hours Fatty acid: lipolysis (minimal) FASTING: beyond 5 days Fatty acid: lipolysis (full blast) (preserving protein) Note: Cardiac and skeletal muscle (slow) are mainly dependent on fatty acid for energy source

No food intake: glucose utilization

Surgery, wound healing, and nutritional status SURGERY INFLAMMATION ↑WBC + ↑ENERGY ↑CELL MULTIPLICATION + ↑NUTRIENT NEEDS WOUND HEALING No Malnutrition NORMAL POOR ± COMPLICATIONS Malnutrition

• • Catecholamines Glucagon Thyroid hormones Cortisol

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 Too weak to sit, pressure ulcers, Pneumonia, lack of healing Death, usually from pneumonia 30% 40% 50% 100% LBM=Lean Body Mass Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009; 9: e 9.

BODY COMPOSITION ANALYSIS

The surgical nutrition process All admitted patients are nutritionally screened All nutritionally at risk patients are assessed All high risk patients are given nutrition care plans Monitoring of the nutrition process is done Nutrition care plan modification / Discharge

Nutritional Assessment and Risk Level Form

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.

SURGICAL DECISION MAKING BASED ON BODY COMPOSITION ANALYSIS

PRE-OPERATIVE PHASE severe Scheduled • esophageal resection • gastrectomy • pancreaticoduodenectomy Enteral nutrition for 10 -14 days oral immunonutrition for 6 -7 days malnutrition no slight, moderate SURGERY Early oral feeding within 7 days POST-OP EARLY DAY 1 - 14 no yes Enteral access (NCJ) within 4 days enteral nutrition yes immunonutrition for 6 -7 days Oral intake of energy requirements no yes “Fast Track” no Parenteral hypocaloric combined enteral / parenteral Adequate calorie intake within 14 days LATE DAY 14 yes no Oral intake of energy requirements supplemental enteral diet no yes

WOUND HEALING ISSUES

Inflammation: part of wound healing • Cell proliferation • ↑ nutrient and energy requirements • Adequacy of response is dependent on the nutrient supply / reserves

Wound healing Stages of wound healing and repair Angiogenesis Reference: Robbins Basic Pathology 7 th edition. Kumar, Cotran, Robbins editors. 2003.

Wound healing: molecular environment Basement membrane: 1. Cell support 2. Exchange 3. Transport 4. Development 5. Repair 6. Defense 7. Integrity of structure and environment Intercellular environment 1. Tissue support/shape 2. Exchange 3. Growth 4. Repair 5. Defense 6. Movement

Wound healing Robbins Basic Pathology 7 th edition. Kumar, Cotran, Robbins editors. 2003.

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

Energy calculations are good enough

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

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

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 Protein: Fat: Glucose caloric ratio should approximate to 20: 30: 50% (Grade C) ESPEN: European Society of Parenteral and Enteral Nutrition

Carbohydrate and fat ratios Stoner et al Mc. Fie et al

Do lipids matter? q LCT = mostly ω6 FA (arachdionic acid) content = proinflammatory q MCT = reduces ω6 FA (arachidonic acid) content + direct utilization in the liver

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

Energy requirements and antioxidants 2 H 2 O Vitamin C Catalase Hydrogen peroxide H 2 O 2 Superoxide dismutase Zn Glutathione peroxidase Cu Glutathione peroxidase ONOO- GSSG Se ONO- + H 2 O GSSG 2 GSH • Glutathione reductase 2 H 2 O Oxygen radicals O • 2 • 2 GSH Vitamin C Glutathione reductase Munoz C. Trace elements and immunity: Nutrition, immune functions and health; Euroconferences, Paris; June 9 -10, 2005; Robbins Basic Pathology 7 th edition 2003. Kumar, Cotran, Robbins editors.

Antioxidants 1. α-tocopherol 1, 000 IU (20 m. L) q 8 h per naso- or orogastric tube 2. ascorbic acid 1, 000 mg given IV in 100 m. L D 5 W q 8 h 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.

Body composition, intake and outcome

CONCLUSION

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