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This study is a randomised control trial comparing the effects of a pre-operative very low calorie diet (VLCD) on wound healing in the morbidly obese patients undergoing bariatric surgery.
The benefits and disadvantages of a very low calorie pre-operative diet are not clear. Some centres ask their patients to take a VLCD 2-6 weeks before bariatric surgery with the aim of shrinking the liver to make surgery easier. Studies have shown that after this diet the liver does shrink and therefore operating may be easier but this did not necessary translate into significant lesser operative times. The effects of operating during a catabolic phase have not been evaluated. Theoretically a low calorie diet before surgery is similar to starving a patient and can potentially create a state of malnutrition. This is rarely advisable before surgery and can lead to poor wound healing and poor healing of bowel anastomosis.
This study will ascertain if there is any difference in wound healing rates in these morbidly obese patients (BMI>40kg/m2)undergoing a Laparoscopic Roux en Y gastric by pass in groups who have taken the preoperative diet compared to those who were not on a special diet. Skin wounds will be evaluated. This will potentially reflect the general state of healing of the patient which includes the healing of bowel anastomosis. Surrogate markers will be employed to evaluate the pre-morbid nutritional state, effectiveness of dieting, subsequent wound healing (collagen production, markers for the different aspects of wound healing) and impact on liver cell death .This study will be able to tell us how safe this calorie deficient diet is in these morbidly obese patients before surgery.
Full description
Study Design:
Prospective single blinded randomised controlled study
Null hypothesis: There is no difference in wound healing between patients on a very low calorie diet and those not on a diet prior to a Laparoscopic Roux en Y gastric bypass (LRYGB)
Participants:
All patients referred to King's College Hospital for weight loss surgery who are morbidly obese (BMI>40) who undergo LRYGB will be eligible. All patients undergo an introductory group education session after which they are counselled one to one where the patient and the clinician decide on the most appropriate bariatric procedure. Only those who will undergo a laparoscopic roux en y gastric bypass will be offered the opportunity to participate in the study by a member of the research team. The study is open to all irrespective of age, sex, ethnicity and religion.
Written information will be given in the appropriate language.
Interventions:
Diet:
Patients who meet the eligibility criteria will be placed in 2 broad groups based on whether they smoke or not. In each group, patients will be randomly chosen in two subgroups:
Group I:taking the pre operative diet Group II:no special diet. A preoperative, low energy diet will be used for 4 weeks. The diet contains 3 pints of semiskimmed milk. This is equivalent to 1704 ml and provides a total intake of 800kcal, 82 g carbohydrate, 61 g protein and 30g fat in a day. Each patient will also take multivitamin and mineral supplementation. This will further be supplemented with a minimum of 2 litres of energy free liquids (water, diet fizzy drinks, mineral water, black tea / coffee or squash (no added sugar)) per day. The longterm safety and success of VLCD has been demonstrated.It does cause shrinkage of the liver and can decrease the patients weight prior to surgery.
Data collection:
Patient characteristics and medical history will be taken
Pre diet, post diet and prior to surgery:
Anthropometric measurements:
Height, Weight, BMI, Hip:Waist ratio
Routine prediet blood tests and for routine preoperative evaluation:
This includes full blood count,Lipid profile,Renal profile,Bone profile,Liver Function Tests
Serum CK 18 (M30 and M65) levels before and after the diet, which is a marker of liver apoptosis.
Imaging:
The length and breadth of the liver will be measured, which will allow an estimate of the cross-section of the liver at a well defined constant point on each patient
Two punch biopsies (4mm) from the abdominal wall where the patient is likely to have a laparoscopic port, before start of the diet
Per operatively:
Post operatively:
Follow up:
Patient will be followed at 1 week, 8 weeks, 3 months and then will continue to be followed according to our usual bariatric protocol.
Wound Healing Assessment:
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20 participants in 2 patient groups
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Data sourced from clinicaltrials.gov
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