Impact of a designed dietary protocol, with specially tailored total parenteral nutrition, on post-gastrectomy dumping syndrome and patient outcome

Peer review under responsibility of Egyptian Society of Anesthesiologists.

Figures & data

Table 1 Frequency distribution of the two studied groups as regards socio-demographic characteristics (n = 30 in each group) expressed as number of patients in each group.

Group	Study	Control
Age (mean ± SD)	45.4 ± 9.4	50 ± 8.8
Gender (number of patients)
Male	16	21
Female	14	9
Marital status (number of patients)
Single	2	2
Married	28	28
Type of Gastrectomy (number of patients)
Total	10	8
Partial	20	22
Education (number of patients)
Illiterate	15	15
Read and write	8	8
Secondary school	3	4
Higher education	4	3
Residence (number of patients)
Urban	13	10
Rural	17	20
Length of hospital stay (mean ± SD)	17.6 ± 6.2	20.1 ± 8.1

Table 2 Comparison between the two studied groups as regards anthropometric measurements throughout the assessment periods (n = 30 in each group).

Frequency:		On admission		During hospitalization		After one month (Follow up 1)		After two month (Follow up 2)		After three months (Follow up 3)
Groups:		Study	Control	Study	Control	Study	Control	Study	Control	Study	Control
Body weight
Mean		62.0	59.9	60.2	49.4^∗∗	56.7	51.2^∗	56.9	50.4^∗∗	57.3	49.4^∗∗
±SD		10.6	11.4	10.5	10.3	9.9	8.9	10.3	8.5	10.0	8.2
BMI
Mean		23.7	22.5	23.0	20.6^∗	22.2	19.4^∗	21.9	19.1^∗∗	22.1	18.8^∗∗
±SD		4.5	4.3	4.3	3.9	4.2	3.8	4.1	3.6	3.9	3.4
% Weight change
Mean		19.0	14.3^∗	3.0	8.4^∗∗	7.3	13.4^∗∗	8.3	14.9^∗∗	7.9	16.3^∗∗
±SD		6.3	6.1	1.0	5.5	2.8	7.4	3.6	7.0	3.9	7.1
TSF
Mean		14.4	10.8	14.5	10.4^∗	13.4	10.6	13.1	10.2	13.0	10.2
SD		6.2	8.1	6.2	8. 2	6.2	8	6.1	7.8	6.0	7.8
MAMC
Mean		21.5	20.4	21.4	2 0.	21.2	20.1^∗	20.8	19.5^∗	20.8	19.4^∗∗
±SD		3.01	1.9	3.01	1.6	2.9	2.7	2.9	1.87	2.9	1.8

BMI: Body Mass Index, TSF: Triceps Skin Fold, MAMC: Mid Arm Muscle Circumference.

∗ p < 0.05 compared to the other group.

∗∗ p < 0.01 compared to the other group.

Table 3 Comparison between the two studied groups as regards laboratory investigations (n = 30 in each group).

Frequency:		On admission		During hospitalization		After one month (Follow up 1)		After two month (Follow up 2)		After three months (Follow up 3)
Lab. data:		Study	Control	Study	Control	Study	Control	Study	Control	Study	Control
Hemoglobin (g dl^−1)	Mean	11.3	11.1	10.0	9.8	9.5^∗	7.4	10^∗∗	8.2	10.5^∗∗	7.9
	SD	2.2	2.1	1.3	1.3	1.0	3.8	1.0	2.6	1.1	2.5
Serum albumin (g dl^−1)	Mean	3.6	33.7	3.2	2.9	3.4^∗	2.7	3.5^∗	3.0	3.7^∗	2.9
	SD	0.5	0.6	0.5	0.5	0.2	1.2	0.2	0.9	0.2	1.3
Total protein (g dl^−1)	Mean	6.7^∗	6.4	6.0^∗∗	5.5	6.2^∗∗	5.3	6.5^∗∗	5.5	6.4^∗∗	4.9
	SD	0.7	0.5	0.6	0.6	0.6	0.5	0.5	0.6	0.5	0.5
Serum cholesterol (mg dl^−1)	Mean	144.9^∗∗	179.4	136^∗∗	171.5	142	157	137	150	140^∗	155
	SD	38.9	25.3	40	18.3	41.7	16.1	40.2	18.2	40.2	17.4
Serum sodium (mmol l^−1)	Mean	135.9	137.9	135.8^∗	132.4	135.2	133.5	135	134	137^∗	133
	SD	4.0	3.9	5.3	4.8	4.8	4.8	5.9	4.8	5.9	4.7
Serum potassium (mmol l^−1)	Mean	3.7	3.8	3.6^∗∗	3.4	3.4	3.4	3.6	3.4	3.5	3.3
	SD	0.6	0.3	0.3	0.3	0.3	0.3	0.2	0.3	0.3	0.2

∗ p < 0.05 compared to the other group.

∗∗ p < 0.01 compared to the other group.

Table 4 Comparison between the studied groups as regards dumping syndrome symptoms (n = 30 in each group) expressed as number of patients in each group.

Frequency:	During hospitalization		Follow up 1		Follow up 1I		Follow up III
Variables:	Study	Control	Study	Control	Study	Control	Study	Control
Cramping abdominal pain	10	0	6	0	6	0	8	8
Cramping abdominal pain & diarrhea	4	6	5	9	4	13	9	14
Dizziness, palpitation, diaphoresis	5	9	3	6	5	9	0	8
Headache, thirst diaphoresis & dry mouth	0	3	0	3	0	4	0	0
Nausea & Vomiting	5	12	5	12	0	4	0	0
χ^2 & P	15.815^∗∗		11.25^∗∗		14.93^∗∗		5.8	N.S

N.S: Not significant, p ⩾ 0.05

∗∗ Significant at p ⩽ 0.01.

Table 5 Timing of dumping syndrome symptoms among the two studied groups (n = 30 in each group) expressed as number of patients in each group.

Frequency & time:	During hospitalization		Follow up I		Follow up 1I		Follow up III
Variables:	Study	Control	Study	Control	Study	Control	Study	Control
Immediately after eating & drinking	9	12	7	10	2	4	0	7
15 min later	11	10	1	14	0	0	4	5
15–30 min later	1	8	3	6	5	0	6	8
30–45 min later	3	0	8	0	6	12	4	1
1 h later	0	0	0	0	2	14	3	9
χ^2 & P	6.25		19.36^∗∗∗		12.7^∗∗		9.275^∗

∗ Significant at p ⩽ 0.05.

∗∗ Significant at p ⩽ 0.01.

∗∗∗ Significant at p ⩽ 0.0001.

Table 6 Comparison between the study and control group subjects as regards wound assessment, on the fifth post-operative day and before discharge (n = 30 in each group).

Frequency & groups:	In the 5th post. operative day			Before discharge
	Number of patients		χ^2 & P	Number of patients		χ^2 & P
	Study	Control		Study	Control
Extent of inflammation			8.44^∗∗
1-Very slight (<0.5wide) & Slight (0.5 – <1 cm wide)	10	2		18	7	12^∗∗
2-Moderate (1–2 cm width)	9	18		6	19
3- Extensive (3 cm wide or more)	11	10		6	4
The inflammation area			2.58			8.28^∗∗
1. Surrounding half of the sutures	14	8	N.S	23	12
2. Surrounding all of the suture	16	22		7	18
3. At the drain site only	30	30		30	30
Type of wound exudates	18	20		9	10	1.33
1. Purulent	0	2	2.91	16	12	N.S
2. Non-purulent	12	8	N.S	5	8
3. Purulent & Non-purulent
Site of exudates:	4	7		4	5	1.46
At the drain site only			0.49			N.S
At sutures & incision	7	8	N.S	7	5
Sutures, incision & the drain site	7	7		7	7

N.S: Not significant, p ⩾ 0.05.

∗∗ Significant at p < 0.01.

Figure 1 Comparison between the percent of subjects with significant (rapid) weight loss in both studied Groups (n  = 30 in each group). On Ad. = On hospital admission F.up I–III  = Follow up I–III, respectively. P < 0.01 between both groups on hospital, Follow up I—III assessments.

Figure 2 Percentage of Nutritional Status Alteration (Malnutrition) among the Two Studied Groups (n = 30 in each group). F.up I–III = Follow up I–III, respectively. P < 0.01 between both groups on hospital, Follow up I–III assessments.

Figure 3 Percentage distribution of dumping syndrome among the studied groups all through the assessment periods (n = 30 in each group). F.up I–III  = Follow up I–III, respectively. P < 0.01 between both groups on hospital, Follow up I–III assessments.

Table 7 Studied groups’ anthropometric measurements in relation to age all through the assessment periods (n = 30 in each group).

Measure	Study					Control
	Adm.	Hosp.	F1	F2	F3	Adm.	Hosp.	F1	F2	F3
BMI
r	0.08	0.01	0.1	0.13	0.11	0.054	0.056	0.11	0.097	0.086
P	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S
Wt. change
r	0.06	0.035	−0.047	−0.04	−0.041	−0.243	−0.096	−0.04	−0.021	−0.049
P	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S
TSF
r	0.082	0.11	0.092	0.12	− 0.094	−0.17	− 0.16	−0.29	− 0.305	− 0.312
P	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S
MAMC
r	− 0.163	− 0.17	− 0.24	− 0.19	− 0.17	0.45	0.425	0.28	0.431	0.532
P	N.S	N.S	N.S	N.S	N.S	^∗∗	^∗∗	N.S	^∗∗	^∗∗

BMI: Body Mass Index, TSF: Triceps Skin Fold, MAMC: Mid Arm Muscle Circumference, Wt. change: weight change, Adm: on hospital admission, Hosp: During hospitalization, F1, F2 and F3: Follow up I–III, respectively, N.S: Not significant, p ⩾ 0.05.

∗∗ Significant at p < 0.01.

Table 8 Correlation between the studied groups’ laboratory investigations and age (n = 30 in each group).

Lab. data	Study					Control
	Adm.	Hosp.	F1	F2	F3	Adm.	Hosp.	F1	F2	F3
Hemoglobin (g dl^−1)
r	0.019	0.203	0.046	0.19	0.202	−0.19	−0.004	−0.068	−0.232	−0.068
P	NS	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S
Albumin (g dl^−1)
r	0.177	0.279	−0.045	−0.06	−0.08	−0.01	−0.234	−0.001	−0.218	−0.003
P	N S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S
Cholesterol (mg dl^−1)
r	−0.11	0.393	0.42	0.41	0.38	−0.14	0.045	0.032	0.065	0.037
P	N.S	^∗	^∗∗	^∗∗	^∗	N.S	N.S	N.S	N.S	N.S
Total. protein (g dl^−1)
r	0.33	0.28	0.006	0.04	0.09	−0.21	−0.26	−0.243	0.33	0.35
P	N S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S
Serum sodium (mmol l^−1)
r	0.05	0.19	0.161	0.18	0.24	−0.09	−0.103	−0.11	−0.23	−0.14
P	N S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S	N.S
Serum potassium (mmol l^−1)
r	0.154	0.046	0.21	0.17	0.43	−0.03	0.28	0.22	0.094	0.27
P	N S	N S	N S	N S	N S	N S	N S	N S	N S	N S

BMI: Body Mass Index, TSF: Triceps Skin Fold, MAMC: Mid Arm Muscle Circumference, Adm: on hospital admission, Hosp: During hospitalization, F1, F2 and F3: Follow up I–III, respectively, N.S: Not significant, p ⩾ 0.05.

∗ Significant at p ⩽ 0.05.

∗∗ Significant at p ⩽ 0.01.

Table 9 Studied groups’ serum albumin level in relation to gender (n = 60).

Groups:	Study		χ^2 & P	Control		χ^2 & P
	Number of patients			Number of patients
	Male	Female		Male	Female
On admission			N.S			N.S
Normal	9	12		17	6
Mild – Moderate.	7	2		4	3
Hospitalization			N.S			N.S
Normal	6	8		4	3
Mild – Moderate	10	6		17	6
Follow up 1			N.S			N.S
Normal	12	10		6	4
Mild – Moderate	4	4		15	5
Follow up II			N.S			5.5
Normal	13	10		3	5
Mild – Moderate	3	4		18	4	^∗
Follow up III			N.S			N.S
Normal	14	13		6	5
Mild – Moderate	2	1		15	4

N.S: Not significant, p ⩾ 0.05.

∗ Significant at p ⩽ 0.05.

Table 10 Correlations between the studied groups’ laboratory investigations and hospital stay (n = 30 in each group).

Hospital. stay:	Study			Control
Lab. data:	Preoperative	Postoperative	Total stay	Preoperative	Postoperative	Total stay
Hemoglobin (g dl^−1)
r	0.182	−0.026	0.089	0.07	−0.141	−0.031
P	N.S	N.S	N.S	N.S	N.S	N.S
Albumin (g dl^−1)
r	0.163	−0.374	−0.207	−0.412	−0.204	− 0.396
P	N.S	N.S	N.S	^∗∗	N.S	^∗
Total protein (g dl^−1)
r	0.174	−0.257	−0.096	0.251	−0.053	0.142
P	N.S	N.S	N.S	N.S	N.S	N.S
Cholesterol (mg dl^−1)
r	0.091	−0.006	0.033	−0.038	−0.553	−0.336
P	N.S	N.S	N.S	N.S	^∗∗	N.S
Serum sodium (mmol l^−1)
r	− 0.096	−0.244	−0.247	0.092	−0.125	−0.007
P	N.S	N.S	N.S	N.S	N.S	N.S
Serum potassium (mmol l^−1)
r	−0.05	−0.351	−0.308	0.049	0.136	0.043
P	N.S	N.S	N.S	N.S	N.S	N.S

N.S: Not significant, p ⩾ 0.05.

∗ Significant at p ⩽ 0.05.

∗∗ Significant at p ⩽ 0.01.

Table 11 Dumping syndrome symptoms in relation to the type of surgery expressed as number of patients in each group (n = 30 in each group).

Type of gastrectomy surgery:	Study		Control
Symptoms:	Total	Partial	Total	Partial
During hospitalization
Cramping pain, diarrhea	4	10	4	2
Dizziness, palpitation, diaphoresis	3	2	3	6
Headache, thirst, dry mouth & diaphoresis	0	0	2	1
Nausea & vomiting	1	4	0	12
χ^2 & P	N.S.		12.4^∗∗
Follow up I
Cramping pain, diarrhea	8	3	3	6
Dizziness, palpitation, diaphoresis	0	3	5	1
Headache, thirst, dry mouth & diaphoresis,	0	0	0	3
Nausea & vomiting	0	5	1	11
χ^2 & P	10.02^∗∗		N.S
Follow up II
Cramping pain, diarrhea	6	4	4	9
Dizziness, palpitation, diaphoresis	2	3	5	4
Headache, thirst, dry mouth & diaphoresis	0	0	0	4
Nausea & vomiting	0	0	0	4
χ^2 & P	N.S		N.S
Follow up III
Cramping pain, diarrhea	7	10	4	9
Dizziness, palpitation, diaphoresis	0	0	5	4
Headache, thirst, dry mouth & diaphoresis	0	0	0	4
Nausea & vomiting	0	0	0	4
χ^2 & P	N.S		N.S

N.S: Not significant, p ⩾ 0.05.

∗∗ Significant at p ⩽ 0.01.