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

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

3. BASICS AND NORMAL BODY COMPOSITION

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

5. Nutrients, structure, function

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

7. Body composition, all ages

8. Muscle and fat mass, all ages

9. BODY COMPOSITION IN HEALTH AND DISEASE

10. 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%) NORMALSTARVATIONCRITICAL CARE WATER (55%) FAT (30%) PROTEIN (14%) OBESE

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

12. No food intake: glucose utilization

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

14. Catecholamines Glucagon Thyroid hormones Cortisol

15. Loss of lean body mass = ↑mortality Loss of Total LBM ComplicationsAssociated Mortality 10%Decreased immunity Increased infections 10% 20%Decrease in healing, increase In weakness, infection 30% Too weak to sit, pressure ulcers, Pneumonia, lack of healing 50% 40%Death, usually from pneumonia100% Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9. LBM=Lean Body Mass

16. BODY COMPOSITION ANALYSIS

17. 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

18. Nutritional Assessment and Risk Level Form

19. 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.

20. SURGICAL DECISION MAKING BASED ON BODY COMPOSITION ANALYSIS

21. malnutrition Scheduled 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 yesno combined enteral / parenteral noslight, moderatesevere SURGERY PRE-OPERATIVE PHASE POST-OP EARLY DAY 1 - 14 LATE DAY 14 Oral intake of energy requirements yes no supplemental enteral diet

22. WOUND HEALING ISSUES

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

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

25. 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: molecular environment

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

27. 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

28. Energy calculations are good enough

29. 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

30. 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

31. 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

32. Carbohydrate and fat ratios Stoner et al McFie et al

33. Do lipids matter?  LCT = mostly ω6FA (arachdionic acid) content = proinflammatory  MCT = reduces ω6FA (arachidonic acid) content + direct utilization in the liver  LCT = mostly ω6FA (arachdionic acid) content = proinflammatory  MCT = reduces ω6FA (arachidonic acid) content + direct utilization in the liver

34. 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

35. Energy requirements and antioxidants Glutathione reductase Glutathione peroxidase Superoxide dismutase 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. Oxygen radicals O 2 Hydrogen peroxide H 2 O 2 ONOO - Zn Cu 2H 2 O ONO - + H 2 O Glutathione reductase Se 2GSH GSSG Vitamin C Catalase 2H 2 O

36. 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 D 5 W q 8h for the shorter of the duration of admission to the ICU or 28 days.

37. Body composition, intake and outcome

38. CONCLUSION

39. 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