NUTRITION AND THE GASTROINTESTINAL TRACT: Edited by M. Isabel T.D. Correia and Alastair Forbes
The 2018 issue of the Journal again includes a series of reviews addressing the interface between nutrition, gastroenterology/hepatology and surgery, aiming to include areas which are novel, previously neglected or both. It was also the editors’ goal to give authors the opportunity to cover these topics from their respective evidence-based opinions, even if controversial, in approaching updated topics. A focus is placed on the underlying mechanisms wherever possible. Therefore, in the current issue, we have a broad range of themes from taste perception, through eating attitudes to postoperative adverse events and, finally into the new arena of faecal transplantation.
Korczak and Slavin (pp. 377–380) address the important question of fructan and related fibres with regard to their effects on satiety, given thoughts that they might have an important role to play in combating the obesity epidemic. From a formal literature review, they conclude that the quantities likely to form part of an ordinary diet are unlikely to have any meaningful effect on appetite, satiety or their consequences. In this regard, it is important to assess other factors associated with the obesity, both in the general population and in those suffering with chronic diseases, highlighting the relevant role of the interdisciplinary approach to obesity.
Anastácio and Ferreira (pp. 381–387), then, develop the theme of appetite and satiety in a review of nutrition and eating behaviour after liver transplantation, noting first that the almost universal default position of malnutrition at the time of transplantation is said to be largely reversed by a year after successful surgery. A continuing trend towards obesity is also well documented. Body composition studies have suggested, but not confirmed, that muscle mass recovery is incomplete even when weight gain appears good. Our authors identify a major lack of information on underlying eating behaviours but postulate that excessive postoperative weight gain is prompted by food deprivation in the pretransplant period as well as by continuing psychological factors.
In line with the previous authors, Montastier et al. (pp. 388–393) review some of the difficulties in managing the extremely obese patient who has had bariatric surgery. They consider some of the long-term complications, including not only osteoporosis, neurological and psychological complications but also the risk of Barrett's oesophagus after sleeve gastrectomy. There is a general recognition that clinical protocols for long-term follow-up and management do not yet exist, but that the need for this follow-up is paramount if comprehensively good care is to be offered.
Another important topic related to one of the most commonly seen postoperative adverse events, independently of the surgical procedure and which negatively impacts patients’ outcomes, length of hospital stay and costs, is postoperative dysmotility or ileus (POI). This is covered by Smeets and Luyer who advocate the use of lipid-enriched early enteral nutrition as a means of reducing POI. Their recommendation is undoubtedly a controversial issue in times of multimodal surgical approaches such as those proposed in the Enhancing Recovery After Surgery (ERAS) protocols. ERAS advocates defend, among the many other initiatives, the proposition that the early initiation of oral diets is feasible after the majority of operations, while at the same time controlling for ileus-related risk factors such as fluid overload and opiate use, providing motility stimulants and good analgesia with NSAIDs [1–4]. Smeets and Luyer (pp. 394–398) discuss the role of the vagus nerve in postoperative ileus and its stimulation by lipid-enriched enteral nutrition as means of decreasing the problem. Also, according to the authors, lipid-enriched formula has been shown to decrease plasma tumour necrosis factor-alpha (TNF-α) and interleukin (IL)-6 in a model of haemorrhagic shock, which indicates its potential role as an anti-inflammatory pathway in POI, via stimulation of cholecystokinin receptors on vagal afferents. This is indeed a challenging approach in the time of ERAS.
The following two articles address the role of the microbiota in two different scenarios: cancer mucositis and gastrointestinal disorders. Caccialanza et al. (pp. 399–404) describe the association between the oral and intestinal microbiota as agents related to mucositis development and treatment. Despite the increasing interest in the use of probiotics as adjuvant care therapy, there is limited evidence supporting specific recommendations. However, it seems that Lactobacillus species, particularly Lactobacillus reuteri and Lactobacillus brevi CD2, may be useful in the treatment of oral mucositis. The authors pinpoint the relevance of identifying high-risk patients who could benefit from the use of probiotics, as their prescription seems to be ell tolerated and their various mechanisms of action might well improve patient care.
Bouri and Hart (pp. 405–410) provide an update on the status of intestinal microbiological transplantation (or faecal transplantation). This has now become an accepted treatment for recurrent Clostridium difficile infection and is beginning to find a place in the management of patients with more refractory infection. Our authors explore its future role in ulcerative colitis (probable) and Crohn's disease, hepatic encephalopathy, irritable bowel syndrome and the metabolic syndrome (at least possible). They also give something of a practical guide to the implementation of faecal transplantation with explanations of the underlying requirements for its success.
Finally, Khan et al. (pp. 411–415) address the interesting and relatively unexplored area of taste perception in children. Their assessment of the impact of (in particular) salt and fats on the interaction with bitter tastes may prove to have important implications on overall eating patterns and perhaps especially to future obesity.
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Conflicts of interest
There are no conflicts of interest.
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