Nutritional Status Of Patients Research Articles

Malnutrition among Patients with Chronic Liver Disease Admitted to the Department of Gastroenterology and Hepatology in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction: Protein-calorie malnutrition is a transversal condition to all stages of chronic liver disease. It is considered an independent predictor of mortality that leads to an increased number of complications. The aim of this study was to find out the prevalence of malnutrition among patients with chronic liver disease admitted to the Department of Gastroenterology and Hepatology in a tertiary care centre. Methods: This descriptive cross-sectional study was done among patients with chronic liver disease admitted to the Department of Gastroenterology and Hepatology in a tertiary care centre between 10 January 2021 to 15 February 2022 after receiving ethical approval from the Institutional Review Committee (Reference number: 394/077/078-IRC). The nutritional status of patients was assessed by subjective global assessment. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 110 patients with chronic liver disease, malnutrition was seen in 91 (82.72%) (75.65-89.79, 95% Confidence Interval). Out of 91 patients who were malnourished, 56 (61.53%) had moderate malnutrition whereas 35 (38.46%) had severe malnutrition. Seventy-six (83.51%) suffered from alcoholic cirrhosis. Conclusions: The prevalence of malnutrition among patients with chronic liver disease was higher than in other studies done in similar settings.

Case Report on Hypophosphatemic Rickets

In children with rickets, osteoid fails to mineralize. This condition is sometimes accompanied by a vitamin D deficiency or a drop in blood phosphate levels, which causes hypophosphatemia. This case report describes a 4-year-old youngster with persistent respiratory conditions since he was nine months old. At an outpatient tubulopathies clinic, throughout a 24-month study, information on the patient's metabolic profile, creatinine clearance, nutritional status, weight, and body composition was gathered. Clinical and laboratory evidence of hypophosphatemia rickets was present in the patient. The patient's bone metabolism had changed. He had been bedridden for some time and was mechanically ventilated. Our case improved after receiving phosphate, calcium, and calcitriol multiple as treatment. The patient improved, eventually walking alone and breathing on his own. Additionally, weight and structural development are enhanced with transient gallstones. The clearance of creatinine was constant. The medication improved his test results and nutritional status. Following two years of treatment, he fully recovered. Early detection can help kids receive additional support earlier and prevent them from falling behind. All age groups can benefit from multimodality treatment, which is essential for managing the condition. The current example is presented since it is so uncommon.

Amyotrophic lateral sclerosis with respiratory failure and dysautonomia: a case report.

A 58-year-old male presented with left lower limb limping, difficulty climbing stairs, and left foot weakness, followed by right upper limb weakness and was diagnosed with ALS and received edaravone and riluzole treatment. He presented again with right lower limb weakness, shortness of breath, and wide fluctuations in blood pressure, leading to ICU admission with new diagnosis of ALS with dysautonomia with respiratory failure and was managed with non-invasive ventilation, physiotherapy, and gait training exercises. ALS is a progressive neurodegenerative disease affecting motor neurons but non-motor symptoms can also occur, including dysautonomia, which can result in blood pressure fluctuations. Dysautonomia in ALS is caused by several mechanisms such as severe muscle atrophy, prolonged ventilatory support, and upper and lower motor neuron lesions. Management of ALS involves giving a definitive diagnosis, providing nutritional support, using disease-modifying drugs such as riluzole and non-invasive ventilation to improve survival and quality of life. Early diagnosis is essential for effective management of the disease. Early diagnosis, use of disease-modifying drugs, non-invasive ventilation, and maintaining the patient's nutritional status are crucial for managing ALS which can have non-motor symptoms as well.

Evaluation of Proteolytic Enzyme on Hemodialysis Patients with Protein–Energy Wasting and Associated Variables

Introduction: Protein–energy wasting (PEW) is very commonly seen among hemodialysis (HD) patients. This study was carried out to estimate the nutrition status of HD patients receiving aminase tablets, a proteolytic enzyme with a high-protein diet, for reducing PEW. Methods and Materials: The outpatients who visited the HD unit were nutritionally assessed using the Subjective Global Assessment (SGA). Malnourished patients were selected for the study. Diet advice was given on a high-protein diet as per the standard renal guidelines. They were nutritionally assessed pre- and postsupplementation at 0–6 months gap using SGA, malnutrition-inflammation score (MIS), bioelectrical impedance analysis, hand grip dynamometer, C-reactive protein (CRP), serum albumin, and total iron-binding capacity. Patients were given proteolytic enzyme 2 capsules daily after food (morning and night) for 6 months and high-protein diet. Results: A significant improvement (P < 0.05) was seen in the intracellular water, body cell mass, skeletal muscle mass, and protein mass. An improvement in the mean hand grip strength and mean reduction of CRP, SGA, and MIS scores were observed. Conclusion: Proteolytic enzyme along with a high-protein diet could be recommended for better clinical outcomes in dialysis patients.

Geriatric Nutritional Risk Index and the Survival of Patients with Hepatocellular Carcinoma: A Meta-Analysis.

Malnutrition is a risk factor of adverse clinical outcome in patients with cancer. Recent studies suggest that geriatric nutritional risk index (GNRI) could reflect the nutritional status in patients with various clinical conditions. The aim of the systematic review and meta-analysis was to evaluate the association between GNRI and survival of patients with hepatocellular carcinoma (HCC). Observational studies evaluating the association between pretreatment GNRI and survival of patients with HCC were obtained by search of PubMed, Web of Science, Embase, Wanfang, and CNKI databases. A random-effects model was used to pool the results after incorporating the potential influence of heterogeneity. Seven cohort studies including 2636 patients with HCC contributed to the meta-analysis. Pooled results showed that HCC patients with low pretreatment GNRI were associated with poor overall survival [hazard ratio (HR): 1.77, 95% confidence interval (CI): 1.32 to 2.37, p<0.001; I2=66%) and progression-free survival (HR: 1.62, 95% CI: 1.39 to 1.89, p<0.001; I2=0%) as compared to those with normal GNRI. Sensitivity analyses by excluding one study at a time showed similar results (p all<0.05). Subgroup analyses showed that the association between low pretreatment GNRI and poor survival of patients with HCC was not significantly affected by age of the patients, main treatment, cutoff of GNRI, or the follow-up durations. In conclusion, malnutrition indicated by a low pretreatment GNRI may be a risk factor of poor survival of patients with HCC.

145: Nutrition status in adult patients with advanced and recurrent non-resectable pseudomyxoma peritonei who undergo intestinal transplantation surgery

145: Nutrition status in adult patients with advanced and recurrent non-resectable pseudomyxoma peritonei who undergo intestinal transplantation surgery

Intraoperative complications during total hip arthroplasty: a very uncommon intraoperative femur fracture occurred in a malnourished osteoporotic patient.

Intraoperative femoral fracture is a rare but growing complication of primary total hip arthroplasty. We aimed to present an uncommon related case, assessing also the role of malnutrition and osteoporosis. We discuss the case of a 49 years old male patient, malnourished and osteoporotic, with an intertrochanteric, multifragmentary, inveterate fracture, that happened three months before. During the prosthetic surgery, a supracondylar fracture occurred. We synthesized it with a 13 holes LISS plate, 7 distal screws and 3 proximal cerclage wires. The leg was immobilized to 0° for 3 weeks and the load forbidden for 3 months. Calcium, Albumine, Total Proteins, Osteocalcin and Vitamin-D levels were below the normal range. Teriparatide was administered for 6 months. Global investigation of the patient's nutritional status is recommended before joint replacement and preoperative planning is mandatory to choose the adequate implant. Osteoanabolic therapy could be advisable to favor fracture healing.

From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients.

Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.

#5285 SERUM IRON AND NUTRITIONAL STATUS ARE ASSOCIATED IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Abstract Background and Aims Both anemia and malnutrition are highly prevalent in patients with chronic kidney disease (CKD). Iron deficiency plays a significant role in anemia of CKD. However, whether iron deficiency contributes to malnutrition in CKD is unclear. Method We examined the association of iron status with nutritional status among patients with CKD stages 3–5 not yet on dialysis. The iron indices for assessing iron status included serum iron, serum ferritin, and transferrin saturation. Nutritional status was determined using body composition assessed by anthropometric measures and multi-frequency bioelectrical impedance, serum albumin, handgrip strength, Malnutrition Inflammation Score (MIS), and dietary protein and energy intake. We performed linear regression analyses to explore the cross-sectional association between iron status and different nutritional assessment tools. Results A total of 157 patients (age 64 ± 12 years; 93 men and 64 women; diabetes 39%) with CKD [estimated glomerular filtration rate (eGFR) 24.4 ± 13.4 ml/min/1.73 m2] were included. Patients were stratified as low (&amp;lt;70 μg/dL) or high (≥70 μg/dL) serum iron. Compared with patients with high serum iron (n = 104), patients with low serum iron (n = 53) were more likely to be female and had a significantly lower eGFR, hemoglobin, lean tissue index, serum albumin, handgrip strength, and dietary protein intake but a significantly higher MIS. In adjusted linear regression analyses, there was a significant association of serum iron with serum albumin, handgrip strength, and MIS (all adjusted P &amp;lt; 0.05). Serum ferritin was not associated with nutritional status, while the association between transferrin saturation and handgrip strength was only marginal (adjusted P = 0.044). Conclusion Higher serum iron is associated with better nutritional status in patients with CKD. Serum iron may be considered a complementary tool to assess nutritional status in CKD.

Dietary Intake and Nutritional Status in Diabetic and Nondiabetic Patients With Chronic Kidney Disease Stage 4-5 (NutriDiab Study)

The aim of the present study was to assess the dietary intake and nutritional status of patients with chronic kidney disease (CKD) stage 4-5 according to the presence of diabetes. This observational and cross-sectional study included adult patients with CKD stage 4-5 referred to a nephrology unit, between October 2018 and March 2019. Daily dietary intake was evaluated by 24-hour dietary inquiry and urine excretion. Nutritional status was assessed by measuring body composition using bioimpedance analysis and muscle function using handgrip strength. Undernutrition was considered using the protein energy wasting score. A total of 75 CKD patients were included, 36 (48%) of whom had diabetes; median age (interquartile range) was 71 (60-80) years. The median weight-adjusted dietary energy intake (DEI) was 22.6 (19.1-28.2) kcal/kg/day and the mean weight-adjusted dietary protein intake (DPI) was 0.86±0.19g/kg/day. There was no significant difference in DEI and DPI between patients with diabetes and those without, except for weight-adjusted DPI which was significantly lower in diabetic patients (P=.022). In univariate analysis, diabetes was associated with weight-adjusted DPI (coefficient [95% confidence interval] -0.237 [-0.446; -0.004] kcal/kg/day; P=.040), but this association did not remain significant in multivariate analysis. Nutritional status did not differ significantly between diabetic and nondiabetic patients except for lean tissue mass, which was lower in diabetic patients (P=.046). The proportion of patients with protein energy wasting was not significantly different between diabetic and nondiabetic patients (13.9% vs. 10.2%, respectively). In the present cohort, DPI and DEI were not significantly different between diabetic and nondiabetic CKD patients. Diabetes was not found to be associated with dietary intakes in CKD stage 4-5 patients.

Nutritional Status of People with Schizophrenia in Sidoarjo District and its review according to Islamic View

Schizophrenia is a psychiatric illness that affects the brain and causes strange thoughts, perceptions, emotions, movements and behaviors. Schizophrenia is associated with many health problems that will increase morbidity and mortality due to changes in body weight. Lack of nutrition will make the body more susceptible to infection, while excess nutrition can trigger degenerative diseases. Decreased ability to care for oneself in schizophrenic patients can cause the patient's nutritional status to become malnourished or even malnourished. The purpose of this study was to determine the demographics and nutritional status of people with schizophrenia in Sidoarjo Regency. The method used in this research is descriptive quantitative method. The type of analysis used in this research is univariate data analysis. The results showed that people with schizophrenia in Sidoarjo district, especially in Wonoayu, Krian, and Tarik sub-districts, as many as 30 people (17.6%) were included in the Underweight category, 62 people (36.5%) were included in the Normal Weight category. 29 people (17.1%) were included in the overweight category with Risk, 38 people (22.4%) were included in the Obesity I category, 11 people (6.5%) were included in the obesity category II.

Metabolic Syndrome Screening and Nutritional Status of Patients with Psoriasis: A Scoping Review.

Background: Patients with plaque psoriasis have an increased risk of metabolic syndrome. However, no studies have assessed the nutritional status or screening methods of this population. Aims: This review aimed to identify and summarise metabolic syndrome screening criteria and the tools/methods used in nutrition assessment in patients with plaque psoriasis. Data synthesis: PubMed, Web of Science, Ovid and Scopus were searched from inception to March 2023, following the Arkensey and O'Malley framework, to identify articles that report nutritional assessment methods/tools and metabolic screening criteria. Twenty-one studies were identified. Overall, these studies used four different screening criteria to define metabolic syndrome. Patients with psoriasis had a high prevalence of metabolic syndrome and had a poor nutritional status compared to controls. However, only anthropometric measures such as weight, height and waist circumference were employed to determine the nutritional status. Only two studies assessed the vitamin D status. Conclusions: Patients with psoriasis have a poor nutritional status, and they are at risk of nutrient deficiencies. However, these health aspects are not routinely assessed and may increase the risk of malnutrition among these patients. Therefore, additional assessments, such as body composition and dietary assessment, are needed to determine the nutritional status to provide a suitable intervention.

Geriatric Nutritional Risk Index and Risk of Mortality in Critically Ill Patients With Acute Kidney Injury: A Multicenter Cohort Study

Malnutrition is associated with adverse outcomes in acute or chronic diseases. However, the prediction value of the Geriatric Nutritional Risk Index (GNRI) in critically ill patients with acute kidney injury (AKI) has not been well studied. Data was extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) and the electronic intensive care unit database. We used two nutritional indicators, the GNRI and the modified Nutrition Risk in Critically ill (NUTRIC) score, to evaluate the relationship between the nutritional status of patients with AKI and prognosis. The outcome is in-hospital mortality and 90-day mortality. The prediction accuracy of GNRI was compared with the NUTRIC score. A total of 4,575 participants with AKI were enrolled in this study. The median age of 68 (interquartile range, 56-79) years, and 1,142 (25.0%) patients experienced in-hospital mortality, and 1,238 (27.1%) patients experienced 90-day mortality. Kaplan-Meier survival analysis indicated that lower GNRI levels and high NUTRIC score are associated with lower in-hospital and 90-day survival of patients with AKI (P<.001 by log-rank test). After multivariate adjustment, Cox regression analysis demonstrated a 2-fold increased risk of in-hospital (hazard ratio =2.019, 95% confidence interval: 1.699-2.400, P<.001) and 90-day (hazard ratio =2.023, 95% confidence interval: 1.715-2.387, P<.001) mortality in the low GNRI group. Moreover, the multivariate-adjusted Cox model containing GNRI had higher prediction accuracy for the prognosis of patients with AKI than that with NUTRIC score (AUCGNRI model vs. AUCNUTRIC model for in-hospital mortality=0.738 vs. 0.726, AUCGNRI model vs. AUCNUTRIC model for 90-day mortality=0.748 vs. 0.726). In addition, the prediction value of GNRI was validated by the electronic intensive care unit database (7,881 patients with AKI) with satisfying performance (AUCGNRI model=0.680). Our results demonstrated that GNRI is strongly associated with survival in patients in the intensive care unit coexisting with AKI, and the GNRI has a superior predictive value than the NUTRIC score.

Gut barrier protein levels in serial blood samples from critically ill trauma patients during and after intensive care unit stay.

In an effort to better manage critically ill patients hospitalised in the intensive care unit (ICU) after experiencing multiple traumas, the present study aimed to assess whether plasma levels of intestinal epithelial cell barrier proteins, including occludin, claudin-1, junctional adhesion molecule (JAM-1), tricellulin and zonulin, could be used as novel biomarkers. Additional potential markers such as intestinal fatty acid-binding protein (I-FABP), D-lactate, lipopolysaccharide (LPS) and citrulline were also evaluated. We also aimed to determine the possible relationships between the clinical, laboratory, and nutritional status of patients and the measured marker levels. Plasma samples from 29 patients (first, second, fifth and tenth days in the ICU and on days 7, 30 and 60 after hospital discharge) and 23 controls were subjected to commercial enzyme-linked immunosorbent assay (ELISA) testing. On first day (admission) and on the second day, plasma I-FABP, D-lactate, citrulline, occludin, claudin-1, tricellulin and zonulin levels were high in trauma patients and positively correlated with lactate, C-reactive protein (CRP), number of days of ICU hospitalisation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and daily Sequential Organ Failure Assessment (SOFA) scores (P < 0.05-P < 0.01). The results of the present study showed that occludin, claudin-1, tricellulin and zonulin proteins, as well as I-FABP, D-lactate and citrulline, may be used as promising biomarkers for the evaluation of disease severity in critically ill trauma patients, despite the complexity of the analysis of various barrier markers. However, our results should be supported by future studies.

Nutritional status of patients with hepatobiliary-pancreatic surgical disease

Nutritional status of patients with hepatobiliary-pancreatic surgical disease

PERBEDAAN SISA MAKANAN PASIEN BERDASARKAN TINGKAT PENGETAHUAN DIET RENDAH GARAM DAN PERSEPSI CITA RASA DI RSUD WANGAYA KOTA DENPASAR

The remaining food percentage is a simple indicator to evaluate the success of hospital nutritional services. One of the factors influencing is the level of knowledge of low salt diets and the perception of taste. The amount of food remaining will have an impact on patient nutritional status and patient recovery. Based on hospital nutritional guidelines, Standard indicator of food waste ≤ 20%. The purpose of this research is to find out about the Difference Of Patient Food Waste Based On Knowledge Levels Of Low Salt Diets And Flavor Perception At RSUD Wangaya Denpasar City. This research draft is cross sectional with a total of 62 inpatient samples. Food waste data is obtained by food weighing method. The level of knowledge of low salt diets and the perception of taste collected with questionnaires. The results of the research found that the patient's waste were classified as little is about 33 persons (53,2%), the level of knowledge is good which is about 58 persons (93,55%), and the perception of taste is in the good category which is about 56 persons (90,3%). Research results after the chi square test show no significant difference between foods waste with low salt diet knowledge levels (p=0,082). While analyzed difference food leftovers with taste perception showed (p=0,000) that means there is a significant difference.Keywords : Food Waste, Knowledge Levels of Low Salt Diets, Flavour Perception.

WED-374 - Nutritional status of patients with advanced chronic liver disease: descriptive baseline of a prospective study

WED-374 - Nutritional status of patients with advanced chronic liver disease: descriptive baseline of a prospective study

EATING HABITS AND NUTRITIONAL STATUS OF PATIENTS WITH CELIAC DISEASE IN SOUTH BRAZIL.

•Most patients with celiac disease from South Brazil do not consume gluten. •Patients with celiac disease are more careful about gluten cross-contamination in their homes than in restaurants. •Patients with celiac disease from South Brazil have adopted good eating habits with a balanced gluten-free diet. •Nutritional status improved after diagnosis of celiac disease according to body mass index. Background - Celiac disease is defined as a chronic autoimmune disease that affects the small intestine in genetically predisposed people, triggered by exposure to gluten. The only treatment for celiac disease to date is a lifelong gluten-free diet. Eating habits of celiacs play an important role in their nutritional status.Objective - To evaluate the eating habits and nutritional status of patients with celiac disease in Rio Grande do Sul.Methods - This is a cross-sectional study with patients diagnosed with celiac disease residing in Rio Grande do Sul (Brazil) over 18 years of age. An online questionnaire was applied with calls through social networks and also by the Associação dos Celíacos do Brasil - Rio Grande do Sul Section. Sociodemographic data, history of celiac disease, general medical history, reported weight and height and food consumption data (SISVAN food frequency questionnaire and general questions) were collected. Results - The sample consisted of 142 individuals with a mean age of 39.75±11.5 years, 94.4% were women and 93% were white. The patients showed care regarding a gluten-free diet, with the majority not ingesting gluten (82.2%) and being careful regarding cross-contamination by gluten in their homes (85.9%) and in restaurants (62, 4%). Most patients also had good eating habits, with frequent consumption of fruits, vegetables, meats, eggs and low frequency of processed foods and fats. Body weight before and after the diagnosis of celiac disease did not show significant changes (62.3±13.8 versus 63.6±11.7 kg; P=0.147); however, there was an improvement in the classification of nutritional status by body mass index (malnourished: 11.6% before versus 2.3% after; P=0.016). Conclusion - Most celiac disease patients in this study have good eating habits with a balanced gluten-free diet and improved nutritional status after diagnosis according to body mass index classification.

Nutritional interventions for brain health in patients with Alzheimer’s disease: An expert consensus

AbstractBackgroundAlzheimer’s disease (AD), the leading cause of dementia in the elderly, is the greatest and sharp increasing challenge for global public health and social care in the 21st century. Being limited options for early diagnosis and the exact pathophysiology of AD, effective therapeutic strategies are still a great challenge. AD is among the least well‐served therapeutic areas for drug treatments. Recently, there has been accumulating evidence that malnutrition and weight loss are frequent and serious presentations of patients with AD, and they also affect the development and progression of this disease, which forms a vicious circle. Accordingly, Mediterranean‐like diet as a protective factor against memory decline and mediotemporal atrophy may be related to a decrease of amyloidosis and tau‐pathology. Moreover, the latest reviews and meta‐analyses have demonstrted that together the modifiable risk factors, including dietary and lifestyle changes, could theoretically prevent or delay 40% of worldwide AD and related dementia. The evidence suggests that nutrition as an important environment factor of AD may participate in the whole stage through multifaceted pathways.It is of further interest how to manage the nutritional status in patients with AD, and whether supplementation of energy and/or specific nutrients could be able to prevent the onset or the development of cognitive decline.MethodWe established a Chinese multidisciplinary working group consistent with officially accepted standards, discussing the nutrition‐related prevention, diagnosis and management in patients with AD based on the international research evidence currently.ResultWe proposed primordial‐primary‐secondary‐tertiary prevention strategies in accordance with the continuous pathological process of AD, and emphasized the important role of nutrition in this new four‐level prevention strategy. Furthermore, we provided the first expert consensus of nutritional interventions for brain health in patients with AD including 26 evidence‐based recommendations, focusing on the nutrition‐related prevention, diagnosis and management.ConclusionThis consensus emphasizes that nutritional intervention should be early, collaborative, holistic and long‐term. Focusing on the social determinants of health in populations, including diet and nutrition, to maintain optimal brain health and reduce the development of risk factors of dementia have great significance.

Value of the Prognostic Nutritional Index in Surgery for Crohn Disease in China and the Effects on Outcome: A Retrospective Study.

To investigate the value of the Prognostic Nutritional Index (PNI) in the surgery of Crohn Disease and examine the ability of PNI to predict poor outcomes with surgery. One hundred fifty-seven patients were divided into a good nutrition group (PNI ≥40) and a poor nutrition group (PNI <40). The retrospective univariate analysis, logistic regression multivariate analysis, and receiver operating characteristic (ROC) curve analysis were used to screen out independent risk factors for postoperative complications and postoperative recurrences that required reoperation. Penetrating behavior was an independent risk factor for postoperative complications. Emergency surgery, penetrating behavior, hypoalbuminemia, and low PNI were independent risk factors for reoperation. By the receiver operating characteristic analysis, low PNI was superior to hypoproteinemia in predicting postsurgical recurrence. PNI is a good marker for predicting surgical recurrence, but it cannot predict postoperative complications. The nutritional status in patients before elective surgery can be modified to improve PNI. It can reduce surgical recurrence to a minimum level.