Surgery for Obesity - An Update of a Randomized Trial

Background: A prospective, randomized trial comparing vertical banded gastroplasty (VBG) and gastric bypass (GB) was performed on 106 patients between 1987 and 1990. Methods and Results: Failures of these two operations (manifested by failure to lose weight, late weight gain or intolerance of adequate oral intake) were treated by means of a third operation, isolated gastric bypass (IGB), in which the small gastric pouch was isolated from the gastric fundus. The latter operation was significantly better than VBG or GB and achieved a 63% success rate, i.e. body mass index (BMI) < 35 kg m⁻² and less than 50% excess weight. During the year following this trial an additional 54 patients underwent IGB. When this operation was performed for morbid obesity and was the initial procedure, 96% of the patients achieved a successful result. If IGB was performed as a revision procedure or for super obesity (BMI > 50 kg m⁻²), the success rate was 63% with 100% follow-up at 40 months. Major morbidity occurred in six of the 160 patients who underwent 195 operations (the trial period and subsequent year). There were no deaths and follow-up was 98%. Conclusions: The ideal gastric operation based on this study emphasizes the following requirements: a small pouch (< 15ml) totally separated from the stomach, a pouch not dependent on staples, placed in the dependent position to prevent stasis, constructed without foreign material and with an anastomosis which permits ingestion of solid food.     

Calcium requirements for the athlete

There is oftentimes a notion of "the more, the better" with regard to vitamin and mineral intake among individuals, and especially among athletes. Although adequate calcium intake is necessary to promote bone health and prevent osteoporosis, increased physical activity alone does not necessarily demand an increased intake of dietary calcium or other micronutrients. Athletes may lose calcium via sweat, in which case replenishment is advocated either via dietary intake of calcium-rich foods or a commercial calcium supplement. The important message to athletes is to consume a diet adequate in energy, protein, fat, vitamins, minerals, and fluids to support the physical demands and replenish the physiologic losses incurred with physical training.     

Recent developments in home total parenteral nutrition

Home parenteral nutrition (HPN) support has been an advancing therapy in the past 30 years. Patients who previously had no options to sustain their lives are now able to live at home, maintain employment, and continue with most daily activities. Although this therapy has been innovative and successful, it requires great financial and professional resources. The expense of HPN makes most patients dependent on third-party payment, and the complications can result in frequent hospitalizations and may be life-threatening. For these reasons, extensive training of the patient and caregivers is necessary. Thorough and time-consuming monitoring by a multidisciplinary team of professionals is also essential. Home care and supply companies offer services that make the process of home TPN easier for the patient and the healthcare team. Advances in the area of home nutrition support are expected to continue as the demand for this therapy rises.     

Small bowel transplantation

Until very recently, outcomes from small bowel transplantation (SBTx) lagged behind those in liver, heart, and kidney transplantation because of the magnitude of the immunologic burden; the strong expression of histocompatibility antigens; and the contamination in grafts by bacterial organisms. With novel techniques of immune-induction therapies, such as recipient "preconditioning" with lymphocyte reduction, followed by the more subtle use of immunosuppression-based singleagent tacrolimus, graft and host 1-year survival is now over 90% in the most active US centers, a finding that parallels the outcomes in liver and kidney transplantation. In contrast to the alternative therapy for permanent intestinal failure, home total parenteral nutrition (TPN), SBTx improves quality of life and restores digestive and absorptive function, making patients nutritionally autonomous. With survival beyond 1 to 3 years, the procedure is cost-effective. Current results support expansion of the indications for SBTx from use as salvage therapy for patients with TPN failure to preemptive therapy for patients at risk of developing TPN failure.     

Impact of Varying Levels of Protein Intake on Protein Status Indicators after Gastric Bypass in Patients with Multiple Complications Requiring Nutritional Support

Background: <6% of patients who undergo Roux-en-Y gastric bypass (RYGBP) for morbid obesity require nutritional support after surgery. Protein and caloric needs have been estimated as 14-21 kcal, 1.2 g protein/kg/current body weight/day in uncomplicated morbidly obese patients. This study assesses the effect of varying protein-calorie intake in complicated patients after RYGBP on two markers of protein status: thyroxine-binding prealbumin (TBPA) and serum albumin. Methods: This 25-month retrospective study consisted of 22 patients with postoperative complications. Serum albumin, TBPA, medical nutrition care-plans, laboratory data and history were reviewed. These post-RYGBP patients who had BMI >35 and no multi-system organ failure or fistulas, had complications after surgery requiring nutrition support services (NSS). Serum albumin and TBPA were matched to fed levels of protein using random coefficient regression analysis. Results: Mean incremental increases of 2.34 mg/dl (TBPA, P=0.0113) and 0.11 g/dl (serum albumin, P=0.0272) were found with each 0.5 g protein intake increase/kg ideal body weight/day (kg/IBW/day). Patients required NSS for 23 ± 21 (mean ± SD) days, with 15 ±19 days fed at goal rate. Initial serum albumin was 2.3 ± 0.5, with a final measure of 2.7 ± 0.5 g/dl. Goal protein and calorie intake were 2.1 g and 17 kcal/kg IBW/day versus actual intake of 1.6 g and 13 kcal/kg IBW/day. Conclusion: Morbidly obese patients requiring NSS following RYGBP risk iatrogenic protein malnutrition. There was a positive linear relationship between protein status and protein intake that warrants further study of higher protein feeding in complicated post-RYGBP patients.     

Comparison of Resting Energy Expenditure Prediction Methods With Measured Resting Energy Expenditure in Obese,Hospitalized Adults

Background: Several methods are available to estimate caloric needs in hospitalized, obese patients who require specialized nutrition support; however, it is unclear which of these strategies most accurately approximates the caloric needs of this patient population. The purpose of this study was to determine which strategy most accurately predicts resting energy expenditure in this subset of patients. Methods: Patients assessed at high nutrition risk who required specialized nutrition support and met inclusion and exclusion criteria were enrolled in this observational study. Adult patients were included if they were admitted to a medical or surgical service with a body mass index ≥ 30 kg/m². Criteria excluding patient enrollment were pregnancy and intolerance or contraindication to indirect calorimetry procedures. Investigators calculated estimations of resting energy expenditure for each patient using variations on the following equations: Harris‐Benedict, Mifflin–St. Jeor, Ireton‐Jones, 21 kcal/kg body weight, and 25 kcal/kg body weight. For nonventilated patients, the MedGem handheld indirect calorimeter was used. For ventilated patients, the metabolic cart was used. The primary endpoint was to identify which estimation strategy calculated energy expenditures to within 10% of measured energy expenditures. Results: The Harris‐Benedict equation, using adjusted body weight with a stress factor, most frequently estimated resting energy expenditure to within 10% measured resting energy expenditure at 50% of patients. Conclusion: Measured energy expenditure with indirect calorimetry should be employed when developing nutrition support regimens in obese, hospitalized patients, as estimation strategies are inconsistent and lead to inaccurate predictions of energy expenditure in this patient population.