Annals of Clinical Nutrition and Metabolism

Volume 11 (2); December 2020

Review Article

Muscle Protein Metabolism in Critically Illness: Min Chang Kang; Surg Metab Nutr 2020;11(2):35-39. Published online December 30, 2020; DOI: https://doi.org/10.18858/smn.2020.11.2.35

Abstract PDF: Most patients experience a considerable amount of muscle wasting during critical care. A decrease in muscle mass causes weakness which inevitably leads to delayed recovery. Since muscle also plays an important role in protein metabolism, metabolic instability increases as muscle mass decreases. Accordingly, various treatments have been attempted to maintain muscle mass and function in critically ill patients; however, it is still difficult to prevent muscle loss. It is known that muscle wasting in critical illness is primarily due to increased muscle protein breakdown rather than a decrease in muscle protein synthesis. Nutritional therapy and rehabilitation are fundamentally important, but additional anabolic agents may be needed to overcome anabolic resistance. In this review, we will learn about muscle protein metabolism in critically ill patients and how various treatments affect muscle protein metabolism.

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Original Articles

Clinical Impact of Preoperative Sarcopenia to Postoperative Prognosis in Patients with Periampullary Malignancy: Retrospective Multicenter Study: Jee Hyun Park, Youngju Ryu, So Hee Song, Naru Kim, Sang Hyun Shin, Jin Seok Heo, Dong Wook Choi, Woo Kyoung Jeong, Woo Hyun Jung, Yong Chan Shin, Chang-Sup Lim, In Woong Han; Surg Metab Nutr 2020;11(2):40-45. Published online December 30, 2020; DOI: https://doi.org/10.18858/smn.2020.11.2.40

Abstract PDF: Purpose: This study compared the preoperative nutritional status between sarcopenic and non-sarcopenic patients and examined the effects of sarcopenia on the prognosis after a pancreatoduodenectomy (PD).
Materials and Methods: From 2015 to 2016, 480 patients who underwent PD with periampullary cancer at Samsung Medical Center, Seoul National University Boramae Medical Center, Ilsan Paik Hospital, and Ajou University Hospital were analyzed retrospectively. Sarcopenia was measured from the cross-sectional visceral fat and muscle area on CT imaging using an automatic calculation program. The dysnutritional grade was assessed according to Controlling Nutritional Status (CONUT) score system.
Results: Preoperative serum albumin (3.9 g/dl) and cholesterol levels (161.7 mg/dl) of sarcopenic patients were significantly lower than those of the non-sarcopenia patients (4.0 g/dl, P=0.024; 176.1 mg/dl, P=0.005). The proportion of moderate-to-severe dysnutritional grade in sarcopenic patients was significantly higher than in the non-sarcopenic patients (20.0 vs. 8.1%, P=0.004). A comparison of the changes in albumin between before and after PD showed a decrease in sarcopenic patients (0.06 vs. 0.05, P=0.024). Sarcopenia itself was not a factor affecting the overall survival (OS) negatively, but moderate-to-severe dysnutritional grade was an independent risk factor for OS (HR 2.418, CI 1.424~4.107, P=0.001).
Conclusion: Patients with sarcopenia showed poorer preoperative nutritional status than those without sarcopenia, and the sarcopenia affected the postoperative nutritional status negatively. No direct correlation was observed between sarcopenia and OS, but the dysnutritional grade was an independent risk factor that affects OS. As a result, patients with sarcopenia could be affected indirectly for survival because of their poor nutritional status.

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Nutritional Status of Patients with Hepatobiliary-Pancreatic Surgical Disease: Sang Soo Eom, Yong Chan Shin, Chang-Sup Lim, In Woong Han, Woohyun Jung, Yoonhyeong Byun, Dong Wook Choi, Jin Seok Heo, Hongbeom Kim; Surg Metab Nutr 2020;11(2):46-52. Published online December 30, 2020; DOI: https://doi.org/10.18858/smn.2020.11.2.46

Abstract PDF: Purpose: This study examined the nutritional status of patients with hepatobiliary-pancreatic diseases before surgery to establish basic reference data.
Materials and Methods: This study evaluated retrospectively 2,322 patients admitted for hepatobiliary-pancreatic surgery between 2014 and 2016 at four Korean medical institutions using the body mass index (BMI) score. The prognostic nutrition index (PNI) was calculated in patients diagnosed with malignant diseases.
Results: The mean BMI was 24.0 kg/m² (range, 13.2~39.1 kg/m²). The patients were classified as low BMI (<21.5 kg/ m², below 25 percentile), intermediate BMI (21.5~25.5 kg/m²), and high BMI (>25.5 kg/m², above 75 percentile). There were significant differences in the age, sex distribution, ASA classification, type of hospitalization, biliary drainage, organ, and pathology diagnosis between the pairs among the low, intermediate, and high BMI groups. Among the three BMI groups, the complication rate of the low BMI group was highest (34.4% vs. 29.7% vs. 25.8% P=0.005). The median lengths of hospital stay in the low, intermediate, and high BMI groups were 9, 9, and 7 days, respectively (P<0.001). Multivariate analysis revealed the risk factors of the low BMI group to be a higher ASA classification, biliary drainage, pancreatic disease, and malignant disease. The group with PNI<45 had significantly longer hospital stays than the group with PNI≥45 (P<0.001).
Conclusion: Patients with a low BMI had a higher ASA classification, preoperative biliary drainage, pancreatic disease, and malignant disease. The low PNI group had significantly longer hospital stays than the high PNI group. Screening of the preoperative nutritional status is necessary for assessing the risk of malnutrition and its treatment.

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Usefulness of Bioelectrical Impedance Analysis as a Guidance of Fluid Management in Critically Ill Patients after Major Abdomen Surgery; a Single Center, Prospective Cohort Study: Yoon Ji Chung, Eun Young Kim; Surg Metab Nutr 2020;11(2):53-60. Published online December 30, 2020; DOI: https://doi.org/10.18858/smn.2020.11.2.53

Abstract PDF: Purpose: We evaluated the patterns and changes in bioelectrical impedance analysis parameters of patient who underwent abdominal surgery throughout the early period in surgical intensive care unit stay.
Materials and Methods: From May 2019 to April 2020, patients admitted to surgical intensive care unit for more than 48 hours after surgery were enrolled. Body composition and volume status of patients were measured prospectively using portable bioelectrical impedance analysis device every morning for three days from the day of intensive care unit admission. Overhydration was defined as the case where the value of extracellular water ratio is above 0.390, and the participants were daily classified into overhydration or normohydration group. Relationship between daily volume status measured by bioelectrical impedance analysis and outcomes was assessed.
Results: 107 patients who underwent abdominal surgery and 26 patients who underwent endovascular surgery were reviewed as control group. During the first postoperative 48 hours, most of them showed overhydration status, while the rate of overhydaration was significantly lower in the control group. Overhydration status on day 3 was significant predictors of postoperative morbidities (OR 5.709, 95% CI 2.199~14.819, P<0.001) and in-hospital mortality (OR 4.244, 95% CI 1.398~12.883, P<0.001).
Conclusion: Overhydration status by extracellular water ratio on postoperative day 3 needs careful monitoring and appropriate interventions to improve the postoperative morbidities and in-hospital mortality. Bioelectrical impedance analysis could be a simple, easy and useful tool to monitor the volume status of patients who requiring intensive fluid resuscitation after abdominal surgery.

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Efficacy of Intravenous Ferric Carboxymaltose in Patients with Acute Post-Operative Anemia after Colorectal Cancer Surgery: Young Ju Oh, Dae Hee Pyo, Jung Kyong Shin, Yoon Ah Park, Jung Wook Huh, Hee Cheol Kim, Seong Hyeon Yun, Woo Yong Lee, Yong Beom Cho; Surg Metab Nutr 2020;11(2):61-65. Published online December 30, 2020; DOI: https://doi.org/10.18858/smn.2020.11.2.61

Abstract PDF: Purpose: This study evaluated the efficacy of administering intravenous ferric carboxymaltose (Ferinject^®) in patients with acute post-operative anemia after colorectal surgery.
Materials and Methods: Patients with colorectal cancer, who underwent colectomy from January 2017 to July 2019 at the Samsung Medical Center, were retrospectively reviewed. Depending on their body weight, patients were administered 500 mg or 1000 mg of ferric carboxymaltose (ferric carboxymaltose group, 92 patients). The primary outcome evaluated was serum hemoglobin level on post-operative day 21. The secondary outcome was the number of hemoglobin responders, defined as the proportion of patients with normalized serum hemoglobin on post-operative day 21 (hemoglobin level of 12 g/dL or more for male, 11 g/dL or more for female), and a serum hemoglobin increase of 2 g/dL or more from baseline (day 0).
Results: Of the 560 patients who underwent colectomy, 92 patients (median age, 67 years; women 59.8%; mean baseline hemoglobin level 10.7 g/dL) received intravenous ferric carboxymaltose. Compared with the no-ferric carboxymaltose group, patients in the ferric carboxymaltose group experienced significantly greater improvement in serum hemoglobin level (post-operative day 5: 8.9 g/dL, P=0.09; post-operative day 21: 11.7 g/dL, P=0.006). The increase in hemoglobin levels was significantly greater in the ferric carboxymaltose group (2.7 g/dL) than the no-ferric carboxymaltose group (2.1 g/dL) (P=0.002).
Conclusion: Findings of this study indicate a better outcome after administering intravenous ferric carboxymaltose, which results in continuous increase in the levels of hemoglobin during the early post-operative period after colorectal cancer surgery.

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Preoperative Neutrophil to Lymphocyte Ratio and Albumin Level as Predictors for Postoperative Complication in Patients with Colorectal Cancer: Kyung Pil Kang, Young Hun Kim, Kyung Jong Kim PhD.; Surg Metab Nutr 2020;11(2):66-72. Published online December 30, 2020; DOI: https://doi.org/10.18858/smn.2020.11.2.66

Abstract PDF: Purpose: Systematic inflammatory response biomarkers are recognized as potential prognostic factors for colorectal cancer (CRC). Recently, the neutrophil-to-lymphocyte ratio (NLR) has emerged as a possible marker for predicting the outcomes of patients with CRC. The purpose of the current study was to determine if NLR could function as a predictive marker of postoperative complications in patients with colorectal cancer who were treated surgically.
Materials and Methods: One hundred and seven patients who underwent radical surgery for colorectal cancer were enrolled in the study. The NLR values were determined from the complete blood counts within one month before surgery. Values of less than or greater than 3 were defined as low (NLR-low) or high (NLR-high), respectively. Statistical comparisons were made between the NLR and the clinical-pathological variables.
Results: Sixty-eight patients met the criteria of NLR-low, and 39 patients were categorized as NLR-high. The NLR status was significantly correlated with T-stage, perineural invasion, and an increased likelihood of complications. Univariate analysis indicated that both low albumin and meeting the criteria for the NLR-high group correlated with an increased occurrence of complications (P=0.004, P=0.004, respectively). Multivariate analysis identified NLR-high and low albumin levels as independent predictors for complications (P=0.007, odd ratio=6.405, P=0.016, odd ratio=9.641, respectively)
Conclusion: The current results suggest that the preoperative NLR levels could be useful tools for predicting the occurrence of postoperative complications.

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