Book Review

Nutrition and Metabolism in the Surgical Patient

N Engl J Med 1997; 336:738March 6, 1997

Article

Nutrition and Metabolism in the Surgical Patient
Second edition. Edited by Josef E. Fischer. 831 pp., illustrated. Boston, Little, Brown, 1996. $175. ISBN: 0-316-28390-8

Malnutrition is the number-one risk factor for mortality, accounting for 12 percent of deaths worldwide — twice the mortality from tobacco use or hypertension. In the United States, 50 percent of patients are moderately malnourished on admission to the hospital. What is worse, nutritional status deteriorates during hospitalization. This is especially true of patients undergoing surgery, in whom malnutrition is particularly deleterious. Clinical nutrition is neglected in most U.S. medical schools, although annual U.S. costs exceed $4 billion for nutritional therapies, the actual hospital costs of malnourished patients are more than three times those of well-nourished patients, and there is substantial post-hospital morbidity in malnourished patients. Can this neglect be remedied by a postgraduate textbook such as this?

To be competitive or simply justifiable, books like this one should be up to date, comprehensive (within the scope indicated by the title), or educational. Modern techniques of communication, with the real-time on-line dissemination of results, guarantee that new books in rapidly developing fields instantly become obsolete. This book became available in May 1996, at least two years after the completion of the chapters written first and more than one year after those written most recently. The 30 chapters contain a mean of 150 references (range, 2 to 339), with few published later than 1993. Even chapters on “hot” topics, such as arginine, glutamine, growth factors, n-3 fatty acids, and enteral nutrition, written by the leading investigators on each topic, often contain no references whatsoever subsequent to 1993. This explains why there is no mention of apoptosis, cytoprotective trefoil proteins, heat–shock factors, or even intraoperative hypothermia. Thus, the book is neither up to date nor comprehensive. In this computer age, it is also remarkable that the index is as limited as it is, for search words are the lifeblood of a reference work.

This is a revised version of the 1983 book Surgical Nutrition. The new title reflects the editor's objective: to “formulate the best ways to support patients,” providing “a mixture of the theoretical . . . and the practical” for “physicians, nurses, dietitians and pharmacists dealing with nutritional support.” Unfortunately, the book does not meet this objective and does not properly reflect its title. Practical issues of management are not covered: the role (if any) of albumin infusion, “feeding a cancer,” metabolic complications of gastrostomy, patients with acute pancreatitis (who are given less than a quarter of page, with three outdated references), the provision of total parenteral nutrition or enteral nutrition at home, the diagnosis of hypomagnesemia, and peripheral parenteral nutrition (given one half-page), to name a few. None of the otherwise superb chapters on protein requirements, energy metabolism, and nutritional assessment teach how to calculate nitrogen balance. It is an omission not to cover the specific nutritional needs of obese patients: obesity affects more than one third of the U.S. population, with prevalences exceeding 40 percent in blacks and Hispanics. And the epidemic is growing. The excellent final chapter on costs and benefits strongly and appropriately promotes enteral nutrition. Lamentably, the 16-page chapter on this subject is one of the shortest in the book.

A major problem in the field of clinical nutrition, demonstrated in this book, is the inability to translate major advances in basic science, such as the discovery of new fuels (amino acids, “designer lipids,” and the like), cytokine inhibitors and promoters, “nutritional pharmacology,” and immunomodulation into evidence-based clinical practice. However, this is an excellent educational textbook on the foundations of surgical nutrition and metabolism (which would have been a more appropriate title), with several extraordinary chapters. A wealth of tables and diagrams make exemplary teaching tools. Each chapter, besides providing numerous references, suggests selected readings and justifies their selection with scholarly commentary. Throughout the book there are (mostly helpful) editorial clarifications and opinions by the editor, a respected leader in surgical nutrition and critical care, known for his work on amino acid metabolism. These strengths outweigh the book's weaknesses and argue for its place in the libraries of educators and investigators in this field.

John G. Kral, M.D., Ph.D.
State University of New York Health Science Center at Brooklyn, Brooklyn, NY 11203