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

Body composition, injury, and wound healing in surgery

Surgical Nutrition Training ModuleLevel 1

Philippine Society of General SurgeonsCommittee 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

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

radicals

Body composition, all ages

Muscle and fat mass, all ages

BODY COMPOSITION IN HEALTH AND DISEASE

Body compartments in health and disease

WATER (60%)

FAT (25%)

PROTEIN (14%)

WATER (72%)

FAT (15%)

PROTEIN (12%)

WATER (70%)

FAT (23%)

PROTEIN (6%)

CARBO + OTHER (1%)

NORMAL STARVATION CRITICAL CARE

WATER (55%)

FAT (30%)

PROTEIN (14%)

OBESE

Energy utilization

POST-PRANDIAL Glucose

POST-PRANDIAL: within 24 hours Glycogen

Glycogen

FASTING: within 24 to 72 hours

Gluconeogenesis

Fatty acid: lipolysis(minimal)

Lipogenesis

FASTING: beyond 5 days Fatty acid: lipolysis(full blast)

Note: Cardiac and skeletal muscle (slow) are mainly dependent on fatty acid for energy source

(preserving protein)

No food intake: glucose utilization

Surgery, wound healing, and nutritional status

SURGERY

INFLAMMATION

↑WBC + ↑ENERGY

↑CELL MULTIPLICATION + ↑NUTRIENT NEEDS

WOUND HEALING

NORMAL POOR ± COMPLICATIONS

No Malnutrition Malnutrition

• Catecholamines• Glucagon• Thyroid hormones• Cortisol

Loss of lean body mass = ↑mortality

Loss of Total LBM

Complications Associated Mortality

10% Decreased immunityIncreased infections

10%

20% Decrease in healing, increaseIn weakness, infection

30%

30% Too weak to sit, pressure ulcers,Pneumonia, lack of healing

50%

40% Death, usually from pneumonia 100%

Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9.

LBM=Lean Body Mass

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

malnutritionScheduled• esophageal resection• gastrectomy• pancreaticoduodenectomy

Enteral nutrition for 10-14 days

oral immunonutrition for 6-7 days

Early oral feeding within 7 days

yes no

within 4 days

yes

“Fast Track”

no

Parenteral hypocaloric

Adequate calorie intake within 14 days

Enteral access (NCJ)

yes no

enteral nutrition immunonutrition for 6-7 days

Oral intake of energy requirements

yes no

combined enteral / parenteral

no slight, moderate severe

SURGERY

PRE-OPERATIVE PHASE

POST-OP

EARLY DAY 1 - 14

LATE DAY 14

Oral intake of energy requirements

yesnosupplemental enteral diet

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

Angiogenesis

Stages of wound healing and repair

Reference: Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.

Basement membrane:1.Cell support2.Exchange 3.Transport4.Development5.Repair6.Defense7.Integrity of structure and environment

Intercellular environment1.Tissue support/shape2.Exchange3.Growth4.Repair5.Defense6.Movement

Wound healing: molecular environment

Wound healing

Robbins Basic Pathology 7th 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

McFie et al

Do lipids matter?

LCT = mostly ω6FA (arachdionic acid) content = proinflammatory

MCT = reduces ω6FA (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

Glutathione reductase

Glutathione peroxidase

Glutathione peroxidase

Superoxide dismutase

• Munoz C. Trace elements and immunity: Nutrition, immune functions and health; Euroconferences, Paris; June 9-10, 2005;

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

Oxygen radicalsO•2

Hydrogen peroxideH2O2

ONOO-

ZnCu

2H2O

ONO- + H2O

Glutathione reductase

Se

2GSH

2GSH

GSSG

GSSG

Vitamin C

Vitamin C

Catalase

2H2O

Antioxidants

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.

1. α-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.

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