M. C. Terroba

Micronutrient status in morbidly obese women before bariatric surgery

BACKGROUND A high prevalence of micronutrient deficiencies in obese subjects has been reported. Bariatric surgery is the most effective long-term treatment of morbid obesity, but this treatment can result in secondary micronutrient deficiencies. The aim of our work was to describe the micronutrient status in obese women before surgery at a university hospital. METHODS We analyzed a consecutive series of 115 women who were referred to our unit for evaluation for bariatric surgery. Their weight, height, body mass index, and waist circumference were measured. The basal hemoglobin, albumin, prealbumin, ferritin, copper, zinc, calcium, phosphorus, parathyroid hormone, and vitamin (A, D, E, K, B12, and folic) blood levels were also determined. RESULTS Deficiencies were found in 6.1% of the subjects for albumin, 21.7% for prealbumin, 2.6% for hemoglobin, and 5.2% for ferritin. In the vitamin analysis, no deficiencies were found in the patients for vitamins A, E, or K, but 71.3% had a moderate deficiency of vitamin D and 26.1% a severe deficiency of vitamin D (<15 ng/mL). In concorndance with the high prevalence of 25-OH vitamin D deficiency, 22.6% of the patients had secondary hyperparathyroidism with intact parathyroid hormone levels >72 pg/mL. Deficiencies were found in 9.5% for vitamin B12, 25.2% for folic acid, 67.8% for copper, and 73.9% for zinc. CONCLUSION Our study has demonstrated a high prevalence of micronutrient deficiencies in morbidly obese women seeking obesity surgery.

Clinical Results and Nutritional Consequences of Biliopancreatic Diversion: Three Years of Follow-Up

Background: Bariatric surgery is the most effective long-term treatment for morbid obesity, reducing obesity-associated comorbidities. The aim of our work was to describe clinical results and nutritional complications in morbidly obese patients with biliopancreatic diversion. Methods: We have analyzed a consecutive series of 64 patients who have been followed up for 3 years after undergoing open biliopancreatic diversion by the Scopinaro technique. Results: Initial excess weight loss was 29.3% at 6 months and 61.5% at 3 years. A significant improvement of body mass index, weight, waist circumference, fat mass, glucose level, total cholesterol, uric acid and triglycerides levels was detected. Ferritin, vitamin A, vitamin D, vitamin B12, zinc and copper levels showed a low percentage of deficiency at basal time, but during the follow-up, the percentage of deficiency increased. Vitamin E and K did not show basal deficiency. However, after surgery, a moderate deficiency of both vitamins was detected (vitamin E 7.1% and vitamin K 8.3%). Folic acid deficiency was observed in 54.3% of the subjects at basal time, but decreased during the study. Conclusion: Biliopancreatic diversion is an effective method of sustainable weight loss. However, micronutrient deficiencies can occur.

Postsurgery enteral nutrition in head and neck cancer patients

Objective: Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients, using an arginine-enriched diet, could improve nutritional variables as well as clinical outcomes.Design: Randomized clinical trial.Setting: Tertiary care.Subjects: A population of 47 patients with oral and laryngeal cancer were enrolled.Interventions: At surgery patients were randomly allocated to two groups: (a) patients receiving an enteral diet supplemented with arginine and fiber (group I); (b) patients receiving an isocaloric, isonitrogenous enteral formula (group II).Results: No significant intergroup differences in the trend of the three plasma proteins and lymphocytes were detected. Gastrointestinal tolerance (diarrhea) of both formulas was good (17.4% group I and 8.3% group II; NS). During the 3 months after hospital discharge five patients died; no diferences were detected between groups (13% group I and 8.3% group II; NS). The incidences postoperative infection complications were similar (nine patients) in both groups (21.7% group I and 16.7% group II; NS). Fistula were less frequent in enriched nutrition group (0% group I and 20.8% group II; P<0.05); wound infection was more frequent in group II, but without statistical difference (4.3% group I and 12.5% group II; NS). The length of postoperative stay was 22.8±11.8 days in the enriched group and 31.2±19.1 days in the control group (P=0.07).Conclusions: In conclusion, enriched formula improves local wound complications in postoperative head and neck cancer patients. Our results suggest that these patients could benefit from an immunonutrient-enhanced enteral formula.

Clinical and biochemical outcomes after a randomized trial with a high dose of enteral arginine formula in postsurgical head and neck cancer patients.

Objective:Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients, using a higher dose of arginine-enhanced diet (17 g/day) than previous studies, could improve nutritional variables as well as clinical outcomes, when compared with a control enteral diet.Design:Randomized clinical trial.Setting:Tertiary care.Subjects:A population of 72 patients with oral and laryngeal cancer was enrolled.Interventions:At surgery, patients were randomly allocated to two groups: (a) 35 patients receiving an arginine-enhanced formula with arginine (group I) and (b) 37 patients receiving an isocaloric, isonitrogenous enteral formula (group II).Results:No significant intergroup differences in the trend of the three plasma proteins (albumin, transferrin, prealbumin) and lymphocytes were detected. Episodes of diarrhea rate were equal in both groups (22.8% group I and 21.6% group II: NS). The postoperative infections complications were equal in both groups (5.7% group I and 5.4% group II: NS). Fistula (wound complication) was less frequent in enriched nutrition group (2.8% group I and 18.9% group II: P<0.05), whereas wound infection was similar in both groups. The length of postoperative stay was similar in both (27.9±21 vs 28.2±12 days; NS).Conclusions:At this dose, arginine-enhanced formula improves fistula rates in postoperative head and neck cancer patients without a high rate of diarrhea.

Immunoenhanced enteral nutrition, effect on inflammatory markers in head and neck cancer patients

The aim of our study was to evaluate the effect of enteral nutrition supplemented with arginine in inflammatory markers in surgical head and neck cancer patients. A population of 29 patients with oral and laryngeal cancer were enrolled in a randomized trial. At surgery patients were randomly allocated to two groups: (a) patients receiving an enteral diet supplements with arginine (group I, n=14); (b) patients receiving an isocaloric, isonitrogenous enteral formula (group II, n=15). The mean age was 61.1±10.8 y (five females/24 males). Characteristics of the patients on enrollment were similar for the two groups. Prealbumin and transferrin improved in both groups. c-reactive protein (CRP) levels decreased in both groups, (group I: 134.5±62.5 vs 75.3±51 mg/dl:P<0.05) and (group II: 103.6±62 vs 43.8±34.4 mg/dl:P<0.05). Interleukin-6 (IL-6) improved in both groups (group I: 20.35±11.2 vs 6.7±3.1 pg/ml:P<0.05) and (group II:22.8±40 vs 9.9±17.7 pg/ml:ns). Tumoral necrosis factor alpha and lymphocytes did not change. In conclusion, both formulas improved IL-6 and CRP levels. Further studies are needed to determine whether type of formula is the key in these patients or genetic background play a main role in inflammatory response.

Randomized clinical trial with an enteral arginine-enhanced formula in early postsurgical head and neck cancer patients

Objective: Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients using an arginine-enhanced formula could improve nutritional variables as well as clinical outcomes.Design: Randomized clinical trial.Setting: Tertiary care.Subjects: A population of 90 patients with oral and laryngeal cancer was enrolled.Interventions: At surgery, patients were randomly allocated to two groups: (a) patients receiving an arginine-enhanced formula with arginine and fiber (group I) and (b) patients receiving an isocaloric, isonitrogenous formula with fiber enteral formula (group II).Results: No significant intergroup differences in the trend of the three plasma proteins (albumin, transferrin, prealbumin) and lymphocytes were detected. Gastrointestinal tolerance (diarrhea) was better in group II than I (40% group I and 13% group II: P<0.05). The postoperative complications due to infections were similar in both groups (4% group I and 9% group II: ns). Fistula (wound complication) was less frequent in the enriched nutrition group (5% group I and 11% group II: P<0.05); wound infection was similar in both groups. The length of postoperative stay was better in group I than II (25.8±15 days vs 35±24.6 days; P<0.05).Conclusions: In conclusion, arginine-enhanced formula improves fistula rates in postoperative head and neck cancer patients and decreases length of stay.

Early Clinical and Surgical Results of Biliopancreatic Diversion

Background: Scopinaro biliopancreatic diversion (BPD) for morbid obesity results in significant longterm weight loss and reduction or resolution of obesity-associated co-morbidities. The aim of our work was to describe the early results after BPD. Methods: 59 morbidly obese patients (BMI >40) underwent open BPD from December 2001 to December 2004. We analyzed a consecutive series of 19 patients who have been followed >4 months. We present the data of basal and early visits (2 and 4 months). Results: Initial excess weight percent loss (IEW%L) was 5.2% at 2 months and 13.7% at 4 months. Glycemia, cholesterol, triglyceride levels and blood pressure improved at each visit. All parameters have significant differences from the basal values. 3 patients had sleep apnea syndrome, and overnight CPAP was able to cease in 2 patients by 4 months. 6 patients (31.5%) had albumin <2.5 g/dl, without clinical findings of malnutrition. Total calorie (857±79.8 cal/day) and protein (59.8±23 g/day) intakes at 4 months were low, with a low intake of multivitamins and oligoelements from food. There was no mortality in this series. Early postoperative morbidity was incisional hernia (21.1%), anastomotic leak (5.2%), wound infection (15.7%), intra-abdominal infection (5.2%), and intestinal obstruction (5.2%). Conclusion: BPD showed early effectiveness in weight loss and co-morbidity improvement. Calorie, protein, oligoelement and vitamin dietary intakes were below recommendations, so that strict multidisciplinary follow-up and supplementation to prevent or treat nutritional deficiencies are mandatory.

A Randomized Clinical Trial with Oral Immunonutrition (ω3-Enhanced Formula vs. Arginine-Enhanced Formula) in Ambulatory Head and Neck Cancer Patients

Objective: The aim of our study was to investigate whether oral ambulatory nutrition of head and neck cancer patients, using an ω3 fatty acid-enhanced diet (low ratio ω6/ω3 fatty acids) versus an arginine-enhanced diet, could improve nutritional variables as well as clinical outcome, postoperative infectious and wound complications. Research Methods: A population of 73 ambulatory postsurgical patients with oral and laryngeal cancer were enrolled. At discharge from hospital the postsurgical head and neck cancer patients were asked to consume two units per day of either a specially designed ω3 fatty acid-enhanced supplement (group 1) or an arginine-enhanced supplement (group 2) for a 12-week period. Results: No significant intergroup differences in the trend of the three serum proteins and lymphocytes were detected. Differences were detected in weight (group 1: 65.5 ± 11.5 kg vs. 70.4 ± 11.1 kg; p < 0.05) with a significant increase in fat mass in group 1 (15.4 ± 6.6 vs. 18.1 ± 8.4 kg; p < 0.05) and in tricipital skinfold. The postoperative infectious complications were similar in both groups (0 in group 1 and 8.57% in group 2; nonsignificant). No local complications were detected in the surgical wound. Gastrointestinal tolerance (diarrhea and vomiting episodes) of both formulas was good. Conclusions: At the dose taken, the ω3-enhanced formula improved fat mass and proteins in ambulatory postoperative head and neck cancer patients. The arginine-enhanced formula improved proteins. Further studies are required to examine the potential role of immune-enhanced supplements.

Mini Nutritional Assessment (MNA) como método de evaluación nutricional en pacientes hospitalizados

OBJECTIVE: The objective of the study was to identified the prevalence of malnutrition in come patients with MNA (Mini Nutritional Assessment) test as a clinical tool. METHODS: A total of 145 patients were studied in Hospital del Rio Hortega (Valladolid), from mars of 2000 till may of 2002. In all patients a MNA test, an anthropometric and biochemical evaluation were performed. RESULTS: Mean age was 57.44 +/- 18.06 years, weight 63.5 +/- 13.7 kg and body mass index 23.4 +/- 4.9 kg/m2. The studied population were 48.6% haematological tumours and other tumours, opposite to the rest of the patients who were presenting cerebro-vascular accidents 2.1%, respiratory problems or infections 16.8%, renal failure 3.5% and neurological diseases or processes of dementia in minor proportion 2.9%. Patients were divided in two groups, malnutrition MNA < 17 (n = 99) (group I) and risk of malnutrition MNA = 17 (n = 43) (group II). The malnutrition prevalence was 68.2% (group I) and risk of malnutrition 29.6% (group II) with test MNA. In biochemical evaluation the malnutrition group I had low levels of albumin (2.9 +/- 0.7 g/dl vs 3.41 +/- 2.71 g/dl; p < 0.05), prealbumin (14.9 +/- 6.2 g/dl vs 17.6 +/- 8.1 g/dl; p < 0.05) and transferrin (152.2 +/- 54.9 g/dl vs 189.9 +/- 32.6 g/dl; p < 0.05. Arm muscular circumference and arm circumference had values under average in patients with malnutrition. On having analyzed the different paragraphs of the test MNA between both groups, it was observed since in the group of undernourished patients the punctuation he was below the average in all the paragraphs. CONCLUSIONS: The risk of malnutrition in hospital was frequent, detected by MNA test.

Effect of c-reactive protein and interleukins blood levels in postsurgery arginine-enhanced enteral nutrition in head and neck cancer patients

Objective: It is known that the immune system is frequently affected in patients with head and neck cancer. Although immune dysfunction could be multifactorial, this immune system may be modulated by specific nutritional substrates, such as arginine. The aim of our study was to evaluate the effect of enteral nutrition supplemented with arginine on c-reactive protein (CRP), interleukin 6 (IL-6) and tumour necrosis factor (TNFα) in surgical head and neck cancer patients.Design: Randomized trial.Setting: Tertiary care.Subjects: A population of 36 patients with oral and laryngeal cancer were enrolled.Interventions: At surgery patients were randomly allocated to two groups: (a) patients receiving an enteral diet supplements with arginine and dietary fibre (group I, n=18); (b) patients receiving an isocaloric, isonitrogenous enteral formula (group II, n=18). Perioperatively and on postoperative day 5 the following parameters were evaluated: serum values of prealbumin, transferrin, albumin, total number of lymphocytes, interleukin 6, tumour necrosis factor α and c-reactive protein.Results: The mean age was 59.6±10.9 y (two females/34 males). No significant intergroup differences in the trend of the three plasma proteins and weight were detected. CRP decreased in both groups (group I: 152.9±76.9 vs 68.9±82.5 mg/dl; P<0.05; and group II: 105.9±92 vs 43.6±59.1 mg/dl; P<0.05). Interleukin 6 did not change (group I: 16.3±12.3 vs 35.6±83.4 pg/ml; NS; and group II: 22.8±40 vs 9.9±17.7 pg/ml; NS). TNFα did not show any differences (group I: 4.6±1.6 vs 5.1±1.5 pg/ml; NS; and group II: 8.8±6.1 vs 5.8±1.7 pg/ml; NS). Lymphocytes increased in both groups (group I: 1405.6±517 vs 1634±529×106/ml; P<0.05; and group II: 1355±696 vs 1561±541×106/ml; P<0.05).Conclusion: Enhanced formula did not change IL6 and TNFα levels. Further studies are needed to determine whether route of nutrition or type of formula is the key in these patients.