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P.O.Box 2345, Beijing 100023,China World J Gastroenterol 2002;8(6):1149-1152Fax: +86-10-85381893 World Journal of GastroenterologyE-mail: Copyright 2002 by The WJG Press ISSN 1007-9327 Sequential changes of body composition in patients with
enterocutaneous fistula during the 10 days after admission

Xin-Bo Wang, Jian-An Ren, Jie-Shou Li, Clinical School of
nutritional stability[1]. Unfortunately, accurate nutritional Medical College, Nanjing University, Research Institute of General assessment is difficult in patients with enterocutaneous fistula Surgery, Nanjing General Hospital, People’s Liberation Army, because standard laboratory methods are inaccurate and the techniques used to precisely assess metabolic compartments Correspondence to: Dr. Xin-Bo Wang, Research Institute of General
are complex, expensive, and of limited availability, especially Surgery, Nanjing General Hospital, People’s Liberation Army, 305 in China. Assessment of body composition may provide East Zhongshan Road, Nanjing 210002, Jiangsu Province, China. important information about the nutritional status[2] .The Fax: +86-25-4803956
applicability of one safe and convenient methods for body Received 2002-06-01 Accepted 2002-07-22
composition analysis, multiple-frequency bioelectricalimpedance analysis (MFBIA) in malnourished patients withenterocutaneous fistula has been sparsely elucidated[3] .
Thus, the aim of the present study is to investigate thesequential changes of body composition in the metabolic AIM: To investigate the sequential changes of body
resp onse th at occu rred in a grou p of patients with composition in the metabolic response that occurred in a enterocutaneous fistula after admission to the hospital.
group of patients with enterocutaneous fistula after MATERIALS AND METHODS
METHODS: Sixty-one patients with enterocutaneous fistula
admitted to our hospital had measurements of body composition by multiple-frequency bioelectrical impedance Between December 1, 2000, and November 30, 2001, 86 patients analysis after admission and 5, 10 days later. Sequential suffering from enterocutaneous fistula (EF) were admitted to measurements of plasma constitutive proteins were also made.
the EF Treatment Group of Institute of General Surgery at JinlingHospital, Nanjing, China. All of these patients wholly recruitedfrom other inpatient clinic were included in the study. EF care RESULTS: The body weight, fat-free mass, body mass
index, and body cel mass were initial y wel below the normal at our hospital took place more than thirty years ago in a well range, especial y the body mass index and body cel mass.
coordinated system of pre-hospital and in-hospital care that And al the data gradual y moved up over the 10-day study includes good co-operation with other hospitals, radio-telephone period, only a highly significant difference was found in body communication, and a high-level, in-hospital EF team response cel mass. Once the patients received nutrition supplement, and experience, which includes rapid assessment, resuscitation, ECW began to return to normal range slowly as wel as ICW stabilization, and sequential therapeusis according to well- and TBW began to rise up, and ECW/TBW significantly declined to near normal level by day 10 in either male or At the time of admission, all patients studied were able to female patients. There was a reprioritization of plasma accomplish the analysis of body composition in standing constitutive protein synthesis that was obligatory and position for 3 minutes. None of the patients were treated with diuretics and prednisolone and they had exclusion of anymetabolic disease. For each patient, diagnosis was made onclinical presentation: definite history of operation, temperature CONCLUSION: Serial measurements can quantify the
disturbance of body composition in enterocutaneous fistula spikes, elevated white cell counts, increasing abdominal patients. The early nutritional intervention rapidly ameliorates tenderness, wound infection, and drainage of succus entericus the abnormal distribution of body water while the state-of- from intraperitonal drains. Initial management of the patients the-art surgical management prevents the further invariably involved fluid resuscitation, repletion of depleted deterioration in cel ular composition.
electrolytes, maintenance of systemic and multi-organicfunction, active suction drainage of succus entericus, Wang XB, Ren JA, Li JS. Sequential changes of body composition appropriate broad-spectrum antibiotic therapy to control sepsis, in patients with enterocutaneous fistula during the 10 days after pharmacological approaches including H2 antagonists, admission. World J Gastroenterol 2002; 8(6):1149-1152 somatostatin and growth hormone if needed[5] ,and nutritionalsupplementation. Some patients who needed promptexploration of the abdominal cavity to control generalized INTRODUCTION
peritonitis or definitive pus were excluded from the study.
Nutrition was given enterally (Peptide, Nutricia, Dutch) Malnutrition is common in patients with enterocutaneous when possible[4]. The caloric distribution of the formula was fistula, over a period of time, giving rise to alterations in body 16.5 % protein, 22.7 % fat, and 60.8 % carbohydrate co mp o si ti o n , as w ell a s s y s tem ic an d m u l tio rg an administered by the nasogastric, nasojejunal, gastrostomic, manifestations. Malnutrition is also associated with adverse jejunostomic, or any available intestinal route[4, 6] . Nutritional outcomes, whereas clinical stability is associated with intake was increased up to 2000Kcal/d according a standard 1150 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol December 15, 2002 Volume 8 Number 6 protocol. Patients with contraindications to enteral feeding were patients who did not complete the protocol, 11 underwent prompt given parenteral nutrition by dedicated single-lumen central laparotomy exploration to control sepsis, the remaining 14 were venous catheters. The initial daily prescription of 17 g nitrogen, too weakness to stand up to complete the body composition 1000Kcal from glucose, and 500Kcal from fat was modified measurement. The 61 enterocutaneous fistula patients were all on the basis of size, renal function, and indirect calorimetry.
secondary to alimentary tract operation, 18 secondary to cancer,10 secondary to inflammatory bowel diseases, 2 secondary to Study protocol
pancreatitis, 5 secondary to digestive ulcer, 26 secondary to Patients underwent serial measurements of plasma protein trauma, intestinal obstruction, and cholelithiasis.
concentrations and body composition during a period of 10 days.
Of the 51 male patients, 24 received total parenteral nutrition, The first studies were performed as soon as hemodynamic the remaining 27 received enteral nutrition with or without stability was achieved without either colloid infusion or parenteral feeding. Of the 10 female patients, 3 received TPN, increasing inotropic support (day 0). The body composition and the remaining 7 received total or partial enteral feeding.
measurements were repeated 5, 10 after admission in the Nutrition was administered continuously. There was no apparent Department of General Surgery by one medician. Measurements clinical manifestation of peripheral extremity edema, ascites, or of the plasma protein were also made 10 days later.
other intra-abdominal fluid collections just before bodycomposition measurement. The median time from admission to Techniques of body composition analysis
receiving the nutritional support was 2 days (range 1 to 3 days).
Body composition measurements were made in all subjectsusing an multiple-frequency bioelectrical impedance (MFBIA) Table 1 Clinical data of patients recruited for the study
model InBody 3.0 (Biospace, Seoul, Korea). As one of thelatest impedance analyzers, InBody 3.0 uses state-of-the-art technology, an 8-point tactile electrode system that measuresthe total and segmental impedance and phase angle of alternating electric current at four different frequencies (5 kHz, Impedance measurements were made with the subjectstanding in an upright position, on foot electrodes in the platform of the instrument, with the legs not touching the thighs and the arms not touching the torso. The subject stood on the four foot electrodes: two oval shape electrodes and two heel shape electrodes, and gripped the two Palm-and-Thumbelectrodes in order to yield two thumb electrodes and two palm electrodes, without shoes or excess clothing (coats, sweaters, Some patients had multiple-origin enterocutaneous fistulas.
vests). The skin and the electrodes were precleaned using thespecific electrolyte tissue according to the manufacturer’s Body composition measurements
instructions. Prior to this, height (stadiometry) was recorded The body weight, BMI, FFM, and BCM in the male patients to the nearest 0.1 cm. All the subjects were instructed to fast were initially well below the normal range (in our own data), and to avoid exercise 8 h before measurement and had been especially BMI and BCM, which can be accounted for the resting for at least 30 min before measurement.
severely malnutritional state of these enterocutaneous fistula All the body composition data were performed in the patients. All the data gradually moved up over the 10-day study instrument by inner software and typed in the result sheet period (in Table 2), only a highly significant difference was immediately after measuring. The software performs provides found in BCM. As is also shown in Table 3, except for the a plot of reactive and resistive components of the measured female patients received a significant increase in FFM as well impedance at each frequency, as well as body weight, fat-free as in BCM. As to the differences of FFM in gender-specific, mass (FFM), total body water (TBW), intra-/extra-cellular the causes may be attributed to the small case number, the water (ICW/ECW), segmental fluid distribution, fat mass (FM), gentle state of illness, and the high proportion of enteral feeding body cell mass (BCM) and body mass index (BMI).
of the female patients. The latter intensifies the benefits ofenteral nutrition in the treatment of enterocutaneous fistula in Plasma proteins
early course and needs further refinement in future research.
Fibronectin, transferrin, and prealbumin were measured as Once the patients received nutrition supplement, ECW markers of the constitutive plasma proteins. These were began to return to normal slowly as well as ICW and TBW determined by ELISA assay using kits of Pointe, UK.
began to raise to normal, and ECW/TBW (which should bethe index of edema) significantly declined to near normal by Statistical methods
day 10 in either male or female patients. Finally, TW and TW/ Analyses were performed using SPSS10.0. Paired student’s t TBW in male patients significantly increased on Day 5 and test was used to detect significant changes over time. Values then slowly decreased on Day 10, which may be attributable to excess fluid locating in the trunk for abdominal infection or intolerance to early enteral feeding.
Plasma proteins
Twenty of 61 patients at random underwent serial measurement Patients
of plasma protein concentration (Shown in Table 4). We found Sixty-one of the 86 patients who were recruited into the study that fibronectin, transferrin, and prealbumin concentrations, completed the protocol, and their clinical diagnostic details are which were initially well below the normal range increasingly listed in Table 1. During the 10 days after admission, Of the 25 raised up without significance by Day 10 (P>0.05).
Wang XB et al. Body composition on enterocutaneous fistula Table 2 Demographic and body composition data for male (n=51)
and monitoring of enterocutaneous fistula patients.
Enterocutaneous fistula is a condition in which overnutrition, edema, and undernutrition can coexist simultaneously, or successively, over a period of time, giving rise to alterations inbody composition, as well as systemic and multiple-organic manifestations. The development of a noninvasive, inexpensive, and accurate technique to assess body water and nutritionalcompartment would be of great clinical value to identify those patients with impaired morbidity and mortality in enterocutaneous fistula, and enhanced nutritional support is indicated in those patients with persisting nutritional deficits[4, 7].
Bioelectrical impedance analysis is a technique of assessing body composition such as total body water and thus fat-freemass in the healthy population[8]. And in a number of conditions such as hemodialysis[9], pregnancy[10], hepatic cirrhosis[11], after surgery[12], and in critical illness[13], changes in TBW have been shown to be accompanied by changes in impedance. However, in situations where there are clinically important changes in intraceullar and extracellular water distribution, such as ascites[11] and critical illness[14], the value of single-frequency BIA islimited. It is proposed that multiple-frequency BIA (MFBIA) BM I= bod y ma ss in dex , TB W=t ot a l bo dy w a te r , may be of particular use in patients with altered distribution of ECW=extracellular water, ICW=intracellular water, FM=fat body water[2]. At low frequency, the current passes through the mass, FFM=fat-free mass, BCM=body cell mass, TW=trunk extracellular fluids because of the capacitance effect of cell water aP<0.05, bP<0.01 vs Day0.
membranes and tissue interfaces, whereas at high frequencies,the current is conduced through both intra-and extracellular Table 3 Demographic and body composition data for female (n=10)
fluids. The Biospace InBody 3.0 body-composition analyzer isa novel device to estimate body water compartments and body fat. It differs from other impedance systems, which uses an 8- point tactile electrode system that measures the total andsegmental impedance and phase angle of alternating electric current at four different frequencies between 5 and 500 kHz.
BMI was found to be an important predictor of mortality in clinic study, with the association between body mass index and mortality suggesting the U-shaped relation corroborated by many studies[15]. Although BMI in our study was initially well below the normal range, there were no significant differences in BMI over the study period for male and female patients as well as inbody weight and FFM. However, there were highly significant differences in BCM changes over the study period (Table 2 and Table 3). Weight and BMI do not definitely evaluate changes in body compartments and therefore do not reveal if loss of FFM or gain in FM occurs[16]. The keenness and speediness in the response of BCM to medical intervention made a strong impression on us.
BCM provides an ideal reference for metabolic studies inenterocutaneous fistula, while less specific parameters such as body weight, BMI or FFM (which include non-metabolic compart- BM I= bod y ma ss in dex , TB W=t ot a l bo dy w a te r , ments such as ECW) should be interpreted with caution[17].
ECW=extracellular water, ICW=intracellular water, FM=fat Therefore, we emphasize the importance of measurement of the mass, FFM=fat-free mass, BCM=body cell mass, TW=trunk growth of the metabolically active body compartment, the BCM, water, aP<0.05, bP<0.01 vs Day0.
in accurately assessing nutritional status in enterocutaneous fistula.
And it would be useful in future research to investigate whether Table 4 Results of plasma proteins over 10 days
the relation between BCM and mortality is also U-shaped in criticalillness especially in enterocutaneous fistula. This question may be more amenable to investigate in relatively small, short studies,provided that an appropriate tool for assessment of body composition in enterocutaneous fistula patients is used.
Our results show once again that there is a reprioritization of hepatic protein synthesis in enterocutaneous fistula[18] thatis obligatory and independ ent of chang es in FFM.
FN=fibronectin, TF=transferrin, PA=prealbumin aP vs Day0.
Concentrations of the constitutive plasma proteins falleninitially raised up over the study period without significance(P>0.05) because of their well known turnover rates. There DISCUSSION
were no significant correlations between the changes of FFM Estimation of body composition is important in the assessment and those of the constitutive plasma proteins. These obligatory 1152 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol December 15, 2002 Volume 8 Number 6 changes may occur in face of continuing proteolysis and high REFERENCES
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Edited by Ren SY


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