Nutrition périopératoire chez la personne âgée. Cas particulier de la fracture de l’extrémité supérieure du col du fémur

Emergency surgery is associated with an increase in the risk of malnutrition in the elderly. Thirty to fifty percent of elderly persons admitted to in surgery are malnourished. In patients for which nutritional status is threatened by both the aging process and comorbidities, the surgical intervention represents an additional stress that will induce or worsen malnutrition. Nutritional care must no be delayed. First choice is the oral route, including protein and energy rich nutritional supplements, and must be a part of multidimensional perioperative care It is recommended to reach 30 to 40 kcal tot/kg/day and 1.2 to 1.5 g of proteins/kg/day. It is recommended to prescribe, during the stay in rehabilitation wards after surgery, oral nutritional supplements. This oral supplementation has been shown to be efficacious in malnourished elderly patients: there is weight gain, a lower risk for complications and a lower mortality rate. However, compliance may be reduced in elderly patients with low appetite, especially in case of dementia, or early medical complications. In order to prevent other falls and fractures, it is recommended to look for vitamin D deficiency and to prescribe vitamin D 800–1200 UI/day.     

Connaître les pièges du suivi après by-pass gastrique pour obésité

During the follow-up of obese patients operated for gastric surgery, practitioners must be vigilant for several reasons. The semiology of the surgical complications is often misleading. Physicians may consider that because of weight loss and comorbidities improvement, the patient is cured. Moreover, the positive situation created by weight loss leads the patient to minimize symptoms and difficulties. Several clinical situations require attention and rigorous evaluation. Abdominal pain should be a warning sign of surgical complications, requiring urgent response (intestinal obstruction, internal hernia, cholecystitis). Pain semiology can guide complementary investigations such as oesogastroduodenal fibroscopy useful to diagnose anastomotic ulcers occasionally resulting in anemia. Recurrent postprandial pain evokes an internal hernia, for which exploratory laparoscopy should be discussed. Faintness is particularly frequent after gastric bypass and most often associated with postprandial hypoglycemia. Practitioners should have a higher awareness of symptoms consistent with neuroglycopenia in patients with a history of bariatric surgery. First of all, uptake of hypoglycemic drugs and neurological and cardiological causes should be eliminated. Furthermore, in the presence of fasting neuroglycopenic signs, an insulinoma must be eliminated. In the presence of hypoglycemic faintness, dietary measures (fractionated meals, low glycemic index) are necessary but not always sufficient. Treatment (acarbose, calcium channel blockers, diazoxide or octreotide) could be discussed although their effectiveness is not clearly demonstrated. Occasionally, some teams suggest surgery of the gastric pouch or distal pancreatectomy. After gastric surgery, nutritional deficiencies are common (iron and vitamin D especially). Neurological complications are rare but potentially serious such as Gayet-Wernicke encephalopathy or neuropathy, most often related to deficiencies in vitamins B1, B12 or B6. Physicians must be vigilant in case of rapid weight loss, surgical complications, intercurrent diseases, vomiting or protein malnutrition. Recent appearance of neurological signs should be treated promptly without waiting for laboratory confirmation of vitamin deficiency. The infusion of glucose after surgery must always be accompanied by a parenteral supplementation of B1 vitamin. Finally, weight curve must be carefully monitored. An unusual weight loss leads to search intercurrent diseases such as surgical complications or neoplasia and psychological disturbance.     

La nutrition artificielle en periopératoire chez le patient diabétique

The diabetic patients are at high risk of malnutrition. One recommends seeking specific deficiencies (zinc, selenium, vitamins C and E) for malnourished diabetic patients. For the perioperative cares, one recommends to cover their protein needs and their caloric needs and to accordingly optimize the antidiabetic treatment. One should probably use oral supplements or enteral nutrition products with a low glycemic index. The presence of diabetic gastroparesis can make it difficult or dissuade enteral nutrition. The incidence of gastroparesis justifies gastric residue control, the use of prokinetic, and nutrition in postpyloric site. An equivalent parenteral carbohydrate intake has a hyperglycaemic effect more important than with the oral or enteral way. It is recommended to use an infusion pump in diabetic patients to administer parenteral nutrition. Daily use of lipid emulsions is recommended in this context.     

Grossesse après bypass : quels problèmes ?

The first available data suggest that rates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having a gastric bypass compared with rates in pregnant women who are obese, and with rates in these women before surgery (reduction in gestational diabetes, preeclampsia, low birth weight or macrosomia). In spite of these positive results, there are potential complications during pregnancy directly related to the surgical procedure of gastric bypass. Usual intestinal symptoms of pregnancy (nausea and vomiting during the first trimester, acid reflux, constipation, food intolerance) need to be distinguished from surgical complication, particularly occlusive syndrome. This is a rare event but it could be very serious. In case of abdominal pain, women need to be examined by a digestive surgeon if there is no obstetrical problem. In addition, gastric bypass may result in nutritional deficiencies, in particular iron, vitamin B12, calcium, folic acid, vitamin D and protein deficiencies, because of malabsorption and low food intake. These deficiencies may be pronounced due to food intolerance and increase of physiologic nutritional needs in pregnancy. The frequency of severe deficiencies is limited in women taking vitamin supplements, but their consequences affect both mothers and neonates (such as congenital vitamin B12 deficiency in breastfed infant, or neural tube defect). Folic acid intake should be systematic before pregnancy. Recent recommendations suggest to avoid any pregnancy until weight stabilization (12 to 18 months) after gastric bypass, to screen pregnancy before surgical intervention, to prescribe folic acid supplementation and an efficient contraception right after gastric bypass, to provide support and counseling about diet before or just at the beginning of the pregnancy, to give supplements in iron, folic acid, vitamin B12, calcium and vitamin D. A follow-up on nutrition, if possible with a dietitian in a multidisciplinary team, should be organized once every trimester and in the post-partum period.     

Carences en vitamines,minéraux et éléments traces,et dénutrition après chirurgie de l’obésité

Obese patient is at risk of undernutrition, due to specific deficiencies or sarcopenia. After bariatric surgery, the risk of nutritional deficiency depends on the weight loss and the type of surgery; restrictive procedures (as gastric banding) can induce digestive disorders, food intolerance and inappropriate dietary behaviors related to pre- or postoperative eating disorders. Low micronutrient intake during weight loss justifies a systematic supplementation with multivitamins with trace elements. Gastric bypass causes micronutrients. Sleeve gastrectomy leads to a lower risk of deficiency than gastric bypass but significant in the short term, justifying regular screening and supplementation. Iron deficiency is frequent after these three interventions and especially in non-menopausal women. Gastric bypass increases the risk of iron deficiency. Supplementation is not systematic but may be discussed in women before menopause. After gastric bypass, the malabsorption of calcium and vitamin D leads to a risk of accelerated osteoporosis, especially in women at the time of menopause. The risk of vitamin B12 deficiency is extremely high after gastric bypass and justifies systematic supplementation. Gayet-Wernicke encephalopathy is not uncommon, particularly in cases of food intolerance and prolonged vomiting. Regardless of the surgical technique, nutritional monitoring, appropriate supplementation and monitoring of patient adherence to these measures are required. These patients should therefore be monitored regularly and over the long term.     

Stratégie de prise en charge nutritionnelle de l'enfant et de l'adolescent (Nutrition orale, entérale, parentérale)

Children are especially threatened by malnutrition, because of the high protein-energy cost of growth. Any nutritional deficiency is the source of protein energy malnutrition, which compounds the problems of underlying disease. The protein-energy cost of catch-up growth is particularly high, and should lead to a rigorous adjustment of nutritional supply to prevent metabolic disorders associated with refeeding syndrome (directly related to the homeostatic change secondary to severe protein energy malnutrition). If the gastrointestinal tract can be used for refeeding, it should be used (oral or enteral nutrition). When the gastrointestinal tract is unable to meet the protein and energy requirements, parenteral nutrition is required. Catch-up growth may be achieved by using appropriate nutritional support.     

Place de la pharmaconutrition en périopératoire

Since 20 years, data from high quality studies have demonstrated that perioperative immunonutrition is able, even in well-nourished patients, to reduce septic complications, length of stay and costs, in elective digestive cancer surgery. Then update of recommendations for clinical practice has been proposed. As this treatment is effective, French system reimburses the cost of treatment since 2006. Educational programme is now necessary to diffuse state of art.     

Nutrient deficiencies secondary to bariatric surgery

PURPOSE OF REVIEW: The number of adolescent and adult patients submitting to bariatric surgery is increasing rapidly around the world. This review describes the literature published in the last few years concerning nutritional deficiencies after bariatric surgery as well as their etiology, incidence, treatment and prevention. RECENT FINDINGS: Although bariatric surgery was first introduced in the 1950s, safe and successful surgical management has progressed over the last two decades and longer post-surgical follow-up data are now available. Most of the patients undergoing malabsorptive procedures will develop some nutritional deficiency, justifying mineral and multivitamin supplementation to all postoperatively. Nutrient deficiency is proportional to the length of absorptive area and to the percentage of weight loss. Low levels of iron, vitamin B12, vitamin D and calcium are predominant after Roux-en-Y gastric bypass. Protein and fat-soluble vitamin deficiencies are mainly detected after biliopancreatic diversion. Thiamine deficiency is common in patients with frequent vomiting. As the incidence of these deficiencies progresses with time, the patients should be monitored frequently and regularly to prevent malnutrition. SUMMARY: Nutritional deficiencies can be prevented if a multidisciplinary team regularly assists the patient. Malnutrition is generally reverted with nutrient supplementation, once it is promptly diagnosed. Especial attention should be given to adolescents, mainly girls at reproductive age who have a substantial risk of developing iron deficiency. Future studies are necessary to detect nutrient abnormalities after new procedures and to evaluate the safety of bariatric surgery in younger obese patients.     

Nutrition dans la période postopératoire (dont urgence)

Policies which tend to reduce surgical stress and therefore decrease catabolism and to improve anabolism could allow patients to recover more quickly and efficiently even after major surgery. In most instances, interruption of nutritional intake is not necessary after surgery. Oral intake can be started as soon as possible within the first 24 hours unless surgical contra-indication. Oral intake should be adjusted according to patient's tolerance. In patients without overt under-nutrition, postoperative nutritional support for periods of less than 7 days is not indicated. However, nutritional support is recommended when postoperative food intakes reach less than 60% of daily needs for 7 days. Moreover, early nutritional support should probably be administered if expected postoperative food intake will be less than 60% of daily needs for more than 7 days. In malnourished patients, nutritional support (using enteral rather than parenteral route) is strongly recommended within the first postoperative 24 hours regardless of preoperative nutritional support.     

Évaluation de l’état nutritionnel péri-opératoire

In surgical patients, malnutrition is associated with an increase in morbidity, mortality, length of stay and health care costs, and has an impact on quality of life. Before surgery, the risk of malnutrition is depending on patient-related factors (age, associated diseases, on-going symptoms, duration of pre-operative hospital stay), surgical procedure, and medical treatment (radiotherapy, chemotherapy, corticoid treatment). The early screening and management of malnutrition are mandatory during the peri-operative period, with the aim to improve post-operative prognosis and clinical outcome. The nutritional assessment is based on the research of weight loss, the calculation of body mass index and the research of an hypoalbuminemia, all of them having a negative impact on postoperative prognosis. The Nutritional Risk Index (NRI) is also of strong prognostic value. We propose a stratification of the nutritional risk indicating several levels of surgical risk. The organization, the planning and the traceability in the medical record of the nutritional assessment should allow optimizing the management and the clinical outcome of surgical patients. The pre-operative consultation of anaesthesia could be the privileged time to perform the screening of malnutrition and to plan its management, if they were not previously performed by the medico-surgical team.     

Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpitalBio-impedance analysis: Screening of denutrition in hospitalized patients

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

Prise en charge nutritionnelle préopératoire

Undernutrition is an independent factor of postoperative morbidity and mortality. The aim of a preoperative nutritional support is to enhance immune, muscular and cognitive functions, and to support wound healing. This nutritional support (e.g. dietary management, enteral or parenteral nutrition) should be limited to high-risk situations with a beneficial effect of nutrition for the patient: undernutrition, major surgery and elderly. Preoperative nutritional support should be scheduled for at least 7 to 10 days before the surgery. During the preoperative period, the type and route of an eventual postoperative nutritional assistance should be anticipated. In the case of emergency surgery, nutritional assessment of the patient should be done as soon as possible before surgery or in the 48-h postoperative period. Finally, in elective surgery, preoperative fasting should be limited to 2–3 hours for clear liquids and 6 hours for solids.     

Déficits en micronutriments dans le surpoids et l’obésité : conséquences métaboliques et cliniques

Due to deleterious dietary habits, micronutrient deficiencies occur frequently in overweight or obesity. These deficiencies are involved in obesity-induced metabolic alterations such as insulinresistance (zinc, selenium, chromium, vitamin C, vitamin D), inflammation (zinc, selenium, iron, vitamin D), oxidative stress (zinc, selenium, vitamin C, vitamin E, carotenoids) while vitamin B, vitamin D and iron deficiencies result in decreased energetic rate and vitamin B9 and B12 low status in altered methyl cycle. Consequently, the risk of diabetes type 2, cardiovascular or inflammatory or neurodegenerative diseases is increased. To identify and take in charge micronutrient deficiencies in obese or overweight patients should be systematic despite the lack of specific nutritional recommendations for obese individuals who represent an increasing segment of the general population, with a special focus on bariatric surgery candidates.     

Nutrition périopératoire : protocoles de soins

Based on texts written by experts, the objective of this paper is to propose a practical approach to nutrition for clinicians, according to the nutritional status of patients and the evaluation of surgical risk. Any patient with a nutritional grade greater than or equal to 2 should benefit from nutritional support. Indeed, current data confirm that preoperative and early nutritional support in surgery at risk can reduce significantly postoperative morbidity for patients with non-malnourished (immunonutrition in cancer surgery GI), and the morbidity and mortality in malnourished patients (enteral nutrition when possible). A preoperative oral intake is recommended 2 to 3 hours before elective surgery for clear fluids and 6 hours for a light meal. Moreover, a preoperative oral intake of carbohydrates (maltodextrin 12.5%) is recommended (except in diabetic patients). Postoperatively, early oral feeding (within 24 hours) is recommended in the absence of cons to surgery. Glutamine is recommended in case of postoperative complications.     

Facteurs lipolytiques et protéolytiques de la cachexie cancéreuseLipolytic and proteolytic factors in cancer cachexia

Patients with cancer cachexia experience a profound loss of both adipose tissue and skeletal muscle mass. Depletion of adipose tissue arises primarily from an increased hydrolysis of triglycerides mediated by a tumour factor, lipid mobilizing factor (LMF). LMF induces stimulation of adipocyte adenylate cyclase in a GTP-dependent process through binding to a β-adrenergic receptor, as for lipolytic hormones, resulting in specific depletion of carcass fat. Loss of muscle mass results from a decrease in protein synthesis and an increase in protein degradation, the latter being mediated through an increased expression of the components of the ubiquitin-proteasome pathway. Both murine and human cachexia-inducing tumours have been shown to secrete a proteolysis-inducing factor (PIF), a 24 kDa sulphated glycoprotein capable of inducing catabolism of skeletal muscle proteins both in vitro and in vivo. PIF initiates muscle protein catabolism by upregulation of the expression of the ubiquitin-proteasome pathway, possibly through the mediation of 15-hydroxyeicosatetraenoic acid (15-HETE). This process is attenuated by the polyunsaturated fatty acid, eicosapentaenoic acid (EPA), which has also been shown to completely stabilize weight loss in patients with unresectable pancreatic carcinoma. This suggests that knowledge of the catabolic mediators involved in cancer cachexia well lead to effective therapeutic intervention.     

Dénutrition chez l’enfant et l’adolescent obèse

Recently, childhood obesity, defined by an excessive fat mass, has become a major public health problem due to its steady increased prevalence over the last thirty years and its long-term complications if it persists during adulthood. Although malnutrition is rare in obese children, this population is at risk for iron and vitamin deficiencies. Hypovitaminosis D affects more than one in three children and requires systematic supplementation per 100,000 IU of vitamin D every three months. Iron deficiency is common as described in the pediatric population and must be detected. Specific vitamin of group B deficiencies is also described but is more rare. In addition, with the emergence of bariatric surgery in teenagers with sleeve gastrectomy or gastric by-pass, the risk of malnutrition will increase throughout life, especially in the case of poor compliance with vitaminic supplements as observed in adults.     

减重手术患者的营养缺乏及管理现状

近年来全球肥胖、超重的发病率不断增高,超重或肥胖是多种慢性代谢性疾病的主要危险因素之一,减重手术是目前实现长期减重的有效方法之一.然而,国内外针对减重术前是否应该进行减重管理尚无明确定论.此外,手术改变了正常消化道解剖和功能,使胃容量减少、肠道吸收面积减少或胃酸分泌减少,减重手术在使患者获得满意的减重效果的同时也伴随着...     

Aspects métaboliques de la dénutrition au cours de la maladie VIH

The Wasting Syndrome (WS) is one of the major aspects of the acquired immunodeficiency syndrome (AIDS). Fat free mass, the amount of functionnal protoplasm in non adipose tissue is an independent predictor of death in AIDS patients.The deficit of the energy balance could be the result of decreased caloric intake and/or increased energy expenditure. Elevated Resting Energy Expenditure (REE) has been reported in the early stage of the HIV infection. Patients with AIDS who had active secondary infection had a striking average weight loss resulting of the combination of anorexia and dramatic elevated REE. The role of cytokines in the WS was proposed in reason of the in vitro and in vivo metabolic disturbances induced by these cytokines. The difference studies suggest that synergistic interactions between cytokines may be necessary for developping the WS.     

Évaluation de l'état nutritionnel et des besoins de l'enfant et de l'adolescent

Ten to fifteen percent of hospitalized children suffer from malnutrition. Children suffering from chronic diseases are at particularly high risk for malnutrition. A systematic screening for malnutrition and nutritional risk can improve nutritional care in this population. Simple measures (weight and height at admission) can be used to calculate nutritional indices (weight for height ratio or body mass index). Nutritional risk depends on: 1) the severety of the principal diagnosis, 2) the ability to feed oneself, and 3) the pain intensity. The oral or enteral route is preferred when the gut is functional. In all cases nutritional status must be followed throughout hospitalisation. Furthermore, it is preferable to begin nutritional care before malnutrition sets in. Nutritional care can improve the outcome and well-being of hospitalized children.