Perioperative Weight Loss Research Articles

Endoscopic Intragastric Injection of Botulinum Toxin A in Obese Patients Accelerates Weight Loss after Bariatric Surgery: Follow-Up of a Randomised Controlled Trial (IntraTox Study).

Background: Intragastric injection of botulinum toxin A (BT-A) has been shown to be effective for weight loss up to six months after administration, according to previous studies. Our objective was to determine, in patients on bariatric surgery waiting lists, the effect of BT-A on weight loss in the pre- and postoperative period and to analyse if there are different responses based on Body Mass Index (BMI). Methods: We performed a follow-up analysis of the IntraTox study, which included 46 patients on bariatric surgery waiting lists in a single-centre, randomised, double-blind, placebo-controlled clinical trial. The treatment group received intragastric BT-A, whereas the control group received physiological saline solution. The one-time procedure was performed at the time of diagnostic endoscopy 7–8 months before surgery. Weight loss was evaluated at admission and after 4 and 12 weeks from the bariatric surgery. Our analysis was stratified by BMI at randomisation. Results: weight loss percentage on the day of surgery, with respect to the initial visit, was −4.5 ± 3.9% for the control group vs. −7.6 ± 4.2%, for the treatment group (p = 0.013). Weight loss percentage tended to remain greater in the treatment group one month after the intervention (−12.7 ± 4.7% vs. −15.2 ± 4.6%, p = 0.07) and become similar three months after (−21.6 ± 4.7% vs. −21.6 ± 4.6%). After stratifying by BMI, only patients with BMI over 50 kg/m2 allocated to the treatment group obtained a greater weight loss at the end of the trial, the day of surgery, and one month after, compared with the placebo group (−4.9 ± 4.9%, −10.8 ± 5.3% and −17.1 ± 3.8% vs. −0.1 ± 2.6%, −4.3 ± 3.2% and −12.8 ± 4.1%, respectively (p < 0.05). Conclusions: intragastric injection of BT-A is effective to achieve significant weight loss, especially in extreme obesity. Its use before bariatric surgery enhances perioperative weight loss.

Nutritional Status Indicators Affecting the Tolerability of Postoperative Chemotherapy After Total Gastrectomy in Patients With Gastric Cancer.

PurposeNutritional problems after gastrectomy affect continuation of postoperative chemotherapy. There have been no studies limited to total gastrectomy, which is particularly prone to nutritional problems. In this study, we aimed to investigate the factors that predict the continuation of postoperative chemotherapy.Materials and MethodsWe included 101 patients who underwent curative total gastrectomy and postoperative chemotherapy at Hiroshima Memorial Hospital. The effects of 37 factors, including perioperative inflammatory, nutritional, and tumor status, on the persistence of postoperative chemotherapy were analyzed.ResultsIn univariate analysis of preoperative factors, age, carbohydrate antigen 19-9, platelet-to-neutrophil ratio, Onodera's prognostic nutritional index (PNI), controlling nutritional status score, and nutritional risk screening (NRS-2002) score were significantly associated with the duration of postoperative chemotherapy. In multivariate analysis of preoperative factors, age (≥74 years) was an independent factor for a shorter duration of postoperative chemotherapy (hazard ratio [HR], 5.24; 95% confidence interval [CI], 2.19–12.96; P<0.01). In univariate analysis of factors before postoperative chemotherapy, intraoperative blood loss, perioperative weight loss rate, postoperative performance status, PNI, albumin-to-bilirubin index, and NRS-2002 score were significantly associated with the duration of postoperative chemotherapy. In multivariate analysis of factors before postoperative therapy, age (≥74 years) (HR, 5.75; 95% CI, 1.90–19.49; P<0.01) and PNI (<39) (HR, 3.29; 95% CI, 1.26–8.56; P=0.02) were independent factors for a shorter duration of postoperative chemotherapy.ConclusionsAge and PNI are useful predictors of postoperative chemotherapy intolerance after total gastrectomy and may determine the treatment strategy and timing of chemotherapy initiation.

Effects of preoperative nutrition on postoperative outcomes in esophageal cancer: a systematic review and meta-analysis.

Postoperative enteral nutrition has been widely implemented in esophageal cancer, but the efficacy and safety of preoperative nutrition, particularly immune-enhancing nutrition (IEN), remain controversial. This meta-analysis aims to provide a quantitative synthesis of whether preoperative nutrition improves postoperative morbidity and mortality in patients with resectable esophageal cancer. A systematic search was conducted in Medline, Embase, Cochrane, and databases of clinical trials dated up to December 2019. Randomized controlled trials and observational studies comparing postoperative outcomes between esophageal cancer patients with and without preoperative nutritional support were included. Random-effects model was applied in the meta-analysis of primary outcomes (overall complication rate, in-hospital mortality) and secondary outcomes (infectious complication rate, anastomotic leak rate, length of postoperative hospital stay). Complications of feeding tube access and perioperative weight loss were evaluated by qualitative synthesis. Subgroup analyses were performed by stratifying immunonutrition and standard nutrition before surgery. Subgroup analysis of randomized controlled trials alone was also done. A total of 15 studies enrolling 1864 participants were included. The overall meta-analysis found that preoperative nutrition could reduce infectious complications (odds ratio [OR] = 0.51, 95% confidence interval [CI] [0.26, 0.98]; I2= 48%) and length of hospital stay (mean difference = -2.10day, 95% CI [-3.72, -0.47]; I2= 78%) after esophagectomy, whereas no significant difference was revealed in the incidence of overall complications (OR = 0.76, 95% CI [0.52, 1.11]; I2= 32%), in-hospital mortality (OR = 1.03, 95% CI [0.41, 2.61]; I2= 12%), and anastomotic leak (OR = 1.05, 95% CI [0.69, 1.58]; I2= 0%). Subgroup of preoperative immunonutrition showed more prominent benefits. The complication rate of feeding tube access was low (1.6-16%). In conclusion, preoperative nutrition is safe in esophageal cancer, but benefits are observed in infectious complication rate and length of stay on a limited scale. IEN holds more advantages over standard nutrition. Randomized trials in the context of nutritional support during neoadjuvant therapy are in demand.

Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period.

The metabolic risk for patients undergoing abdominal cancer resection increases in the perioperative period and malnutrition may be observed. In order to prevent further weight loss, the guidelines recommend for high-risk patients the placement of a needle catheter jejunostomy (NCJ) for supplementing enteral feeding in the early and late postoperative period. Our aim was to evaluate the safety of NCJ placement and its potential benefits regarding the nutritional status in the postoperative course. We retrospectively analyzed patients undergoing surgery for upper gastrointestinal cancer, such as esophageal, gastric, and pancreato-biliary cancer, and NCJ placement during the operation. The nutritional parameters body mass index (BMI), perioperative weight loss, phase angle measured by bioelectrical impedance analysis (BIA) and the clinical outcome were assessed perioperatively and during follow-up visits 1 to 3 months and 4 to 6 months after surgery. In 102 patients a NCJ was placed between January 2006 and December 2016. Follow-up visits 1 to 3 months and 4 to 6 months after surgery were performed in 90 patients and 88 patients, respectively. No severe complications were seen after the NCJ placement. The supplementing enteral nutrition via NCJ did not improve the nutritional status of the patients postoperatively. There was a significant postoperative decline of weight and phase angle, especially in the first to third month after surgery, which could be stabilized until 4–6 months after surgery. Placement of NCJ is safe. In patients with upper gastrointestinal and pancreato-biliary cancer, supplementing enteral nutrition during the postoperative course and continued after discharge may attenuate unavoidable weight loss and a reduction of body cell mass within the first six months.

Plasma metabolomics of early parenteral nutrition followed with enteral nutrition in pancreatic surgery patients

Nutrition support is essential for surgical patients. Patients undergoing pancreaticoduodenectomy (PD) require tremendous nutrient support but also faced with risks of infection and gastrointestinal complications. Early parenteral nutrition has recently shown benefits while limited information provided about the influence on metabolism. This prospective single-center cohort study used plasma metabolomics to clarify metabolic alteration after early parenteral nutrition followed with enteral nutrition. Patients undergoing pancreaticoduodenectomy (n = 52) were enrolled. 36 patients received parenteral nutrition within 3 days postoperatively followed with EN (TPN group), 16 patients received standard fluids followed with EN (GIK group). We found that the weight loss is reduced in TPN group while the other clinical outcomes and inflammatory cytokines showed no statistical significance. The TPN group showed significance in amino acids, lipid, and phospholipids metabolism compared with the GIK group. Moreover, integration analysis indicated that early TPN could promote the metabolism of long-chain fatty acids, phospholipids, ketone bodies, and branched-chain amino acids. We conclude that early TPN support followed with EN for patients undergoing PD reduced the perioperative weight loss and promoted the metabolic transition to anabolic metabolism with the recovery of lipid metabolism, suggesting its benefits for the recovery of patients.

Perioperative weight loss and its influencing factors in patients with colorectal cancer

Objective To investigate the perioperative weight loss and its influencing factors in patients with colorectal cancer, and to provide evidence for the development and management of perioperative nutritional support strategies. Methods Ninety-one patients with colorectal cancer were enrolled and divided into observation group (n=61) with the degree of weight loss less than 5% of preoperative weight and control group (n=30) with the degree of weight loss more than 5% of preoperative weight. Change of body composition and factors of weight loss in patients with colorectal cancer were compared between the two groups by single factor and multivariate analysis. Results Ninety-one patients with colorectal cancer had the average weight loss of 2.0 kg. Of perioperative changes in body composition, the degree of body fat, muscle mass and protein group decreased statistically (P<0.05). Univariate analysis showed that the age, intraoperative blood loss and postoperative oral nutrition intake compliance were the risk factors for the degree of weight loss in patients with colorectal cancer after the operation. Multivariate logistic regression analysis showed that the intraoperative blood loss was an independent influencing factor for the degree of postoperative weight loss in patients with colorectal cancer (P<0.05). Conclusion Age, intraoperative blood loss and postoperative oral nutritional intake compliance may affect the degree of weight loss during perioperative period. Intraoperative blood loss is an independent risk factor affecting the degree of weight loss during perioperative period. In future clinical research and practice, minimally invasive and accurate surgical treatment should be strengthened, the amount of intraoperative blood loss and surgical trauma should be reduced, and the postoperative oral nutrition intake of patients should be paid attention, especially for elderly patients. Personalized dietary guidance and management for different groups should be conducted, and perioperative nutritional status of patients should be improved. Key words: Colorectal cancer; Weight loss; Body composition; Enhanced recovery after surgery

Unrecognized pregnancy prior to bariatric surgery: case report and review of implications

SummaryA substantial proportion of patients undergoing bariatric surgery are female and of reproductive age. Guidelines suggest that pregnancy should be avoided for 12–18 months following bariatric surgery, and that women be appropriately counselled regarding contraception. We present a case in which a patient underwent a Roux‐en Y gastric bypass while unknowingly in the early stages of pregnancy. After a six‐week period liquid meal replacement for perioperative weight loss, a laparoscopic Roux‐en Y gastric bypass, and a short course of oral antibiotics for a post‐operative wound infection, the patient developed epigastric pain, odynophagia, oesophageal dysphagia, bloating and nausea with oral intake. Only after an abdominal X‐ray, two upper endoscopies and an upper gastrointestinal series was an intrauterine pregnancy seen incidentally on abdominal ultrasound. Ultimately, the patient underwent elective termination of her pregnancy. Patients who are, or are planning to soon become, pregnant should not undergo bariatric surgery. All female patients of reproductive age should be counselled on the importance of effective birth control prior to planning bariatric surgery. Beta‐human chorionic gonadotropin testing should be routinely considered before embarking on meal replacement or surgery.

Need for peri-operative weight loss among obese colorectal cancer patients

Need for peri-operative weight loss among obese colorectal cancer patients

Nutritional Status Deteriorates Postoperatively Despite Preoperative Nutritional Support

Background/Aims: The aim of the current study was to assess the postoperative evolution of nutritional status and to relate it with postoperative outcomes. Methods: Demographic, surgical and nutritional parameters were assessed 10 days preoperatively (d-10) and 30 days postoperatively (d30) in 146 patients. Risk factors responsible for perioperative (>5% between d-10 and d30) weight loss were identified. Overall, severe (Clavien 3-5) and infectious complications were compared in patients with and without perioperative weight loss (>5%). Results: Nutritional status worsened beyond the postoperative period as reflected by decreasing weight (67 ± 13 kg at d-10 vs. 63 ± 13 kg at d30, p < 0.001), body mass index (23.4 ± 4 vs. 22.2 ± 4 kg/m², p < 0.001) and mid upper-arm muscle circumference (MAMC, 241 ± 32 vs. 232 ± 30 mm, p < 0.001). Fifty-two patients (46%) lost >5% of their body weight between d-10 and d30. Patients who presented overall (63 vs. 36%, p = 0.004) and major (27 vs. 10%, p = 0.016) postoperative complications were at significantly higher risk to deteriorate postoperative nutritional status. Multivariate analysis identified low preoperative lean body mass (OR 3.2; 95% CI 1.2-8.9, p = 0.023) and low preoperative MAMC (OR 2.5; 95% CI 0.9-6.8, p = 0.066) as independent risk factors for perioperative weight loss. Conclusions: These data suggest continuing nutritional follow-up after the index hospitalization.

Clinical pathway for esophagectomy improves perioperative nutrition

BackgroundClinical pathways reduce hospitalization and costs in colorectal and pancreatic cancer. We describe creating an esophagectomy pathway and analyze its implementation and effects. MethodsWe documented the process of developing an esophagectomy clinical pathway. We performed a retrospective review of prospectively collected data on 12 patients before pathway implementation and 12 patients after. ResultsPathway Implementation: more patients were presented at tumor board (9 pathway vs. 2 pre-pathway; p=0.012) and chose their postoperative care facility before surgery (8 vs. 0; p=0.0013) Outcomes: There were no changes in mortality (0 vs. 0), major complications (5 vs. 5), hospitalization (median 9.5 vs. 12 days; p=0.82), and total charges ($ 98,395 vs. $ 96,946; p=0.96). Pathway patients lost significantly less weight preoperatively (2.3% vs. 7.6%; p=0.01) and perioperatively (6.3% vs. 12%; p=0.02). ConclusionsThis is the first study to report the process of designing and implementing an esophagectomy pathway. While there was no significant decrease in mortality, complications, hospitalization, or charges, our pathway significantly decreased pre- and perioperative weight loss, which we attribute to coordinated patient education and care.