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Using Anthropometric and Demographic Factors to Predict Small Bowel Length to Prevent Malnutrition in Bariatric Surgery
Masoud Sayadishahraki1, Mohsen Mahmoudieh2, Behrooz Keleidari1, Hamid Melali3, Mahmood Heidary4, Sayed Mohsen Hosseini5, Mohamad Davud Qane6
1 Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Isfahan Minimally Invasive Surgery and Obesity Research Center, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Surgery, Amin Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Surgery, School of Medicine, Qom University of Medical Sciences, Qom, Iran
5 Department of Epidemiology and Biostatistics, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
6 Department of Surgery, School of Medicine, Isfahan University of Medical Sciences; Isfahan Minimally Invasive Surgery and Obesity Research Center, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| Date of Submission | 16-Apr-2021 |
| Date of Acceptance | 31-May-2021 |
| Date of Web Publication | 31-Aug-2023 |
Correspondence Address:
Mohamad Davud Qane
Isfahan Minimally Invasive Surgery and Obesity Research Center, Alzahra University Hospital, Isfahan University of Medicine Sciences, Isfahan
Iran
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/abr.abr_83_21
Background: Small bowel length measurements and estimation have high clinical importance, especially in bariatric surgeries to prevent postoperation malnutrition. This study aimed to investigate the possible correlation between demographic and anthropometric factors with small bowel length.
Materials and Methods: This cross-sectional study was performed on 150 patients that were candidates of abdominal surgeries. Anthropometric factors including age, gender, weight, height, body mass index, right wrist and waist circumstance, length of the right hand 2nd and 4th fingers and 2nd to 4th finger ratio, and length of the right hemithorax were obtained. Whole length of the small bowel was measured during surgery from the ligament of Treitz to the ileocecal junction between the mesenteric and antimesenteric border of the intestine.
Results: The mean small bowel length was 5.45 ± 1.62 meters and significantly lower in women compared to men (P = 0.003) and had a significant direct relationship with height (r = 0.3, P < 0.001), an inverse relationship to 2nd to 4th finger ratio (= −0.34, P < 0.001). There were the same correlations between small intestine length with height and the 2nd to 4th finger ratio in open surgeries (P < 0.05). There was a correlation between age (r = 0.33, P = 0.032), weight (r= −0.60, P, 0.001), waist circumstance (r = −0.43, P = 0.004), and length of the right hemithorax (r = −0.47, P = 0.001).
Conclusions: Using demographic and anthropometric factors, we could predict the small bowel length. These results could be further used in bariatric surgeries to avoid possible malnutrition.
Keywords: Anthropometry, bariatric surgery, malnutrition
How to cite this article:
Sayadishahraki M, Mahmoudieh M, Keleidari B, Melali H, Heidary M, Hosseini SM, Qane MD. Using Anthropometric and Demographic Factors to Predict Small Bowel Length to Prevent Malnutrition in Bariatric Surgery. Adv Biomed Res 2023;12:209 |
How to cite this URL:
Sayadishahraki M, Mahmoudieh M, Keleidari B, Melali H, Heidary M, Hosseini SM, Qane MD. Using Anthropometric and Demographic Factors to Predict Small Bowel Length to Prevent Malnutrition in Bariatric Surgery. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 28];12:209. Available from: https://www.advbiores.net/text.asp?2023/12/1/209/384886 |
| Introduction | |  |
Overweight/obesity which is defined as body mass index (BMI) equal to or above 25 kg/m2 has increasingly become a major problem among adults. The prevalence of obesity has been amazingly increased over the past three decades mostly due to lifestyle changes.[1] Surgical procedures for the treatment of obesity are mostly recommended when BMI is >35–40 kg/m2. One of the best weight loss methods for people who are obese (and have not been able to lose a lot of weight with the usual weight loss methods) is laparoscopic surgery.[2],[3]
During bariatric surgeries, an amount of small bowel is bypassed to add a malabsorptive characteristic to bariatric surgery. During these surgical procedures, 150–200 cm of the small bowel is diverted.[4],[5] One of the considerable bariatric surgery complications is malnutrition and it occurs more in malabsorptive methods. On the other hand failure of bariatric surgery in weight loss could also be common. Studies have reported that variations in bowel length are one of the most important factors that may influence malnutrition and weight loss after bariatric surgeries.[6] Considering the difficulty of small bowel length measurements in bariatric surgery and risk of bowel damage, and the fact that whole bowel length is not measured during bariatric surgery, finding a way to predict bowel length may prevent probable bowel damage and also prevent malnutrition or help in preventing the failure of surgery.[7],[8]
It is also a hypothesis that demographic and anthropometric factors could be related to body structures and also correlated to small bowel length.[9] These demographic and anthropometric factors are available and could be easily measured. One of these anthropometric factors is finger length measurements. It has been estimated that this factor could predict small bowel length, but further research is required.[10] This study intends to evaluate the correlation between demographic and anthropometric factors of patients and small bowel length to achieve this purpose.
| Materials and Methods | | |
This is a cross-sectional study that was performed in 2020 in Kashani, Al-Zahra, and Amin hospitals affiliated to Isfahan University of Medical Sciences. The current study was conducted on all patients that were candidates of any types of abdominal surgeries such as bariatric, gynecologic, or colorectal using the census method. The study protocol was approved by the Research Committee of Isfahan University of Medical Sciences and the Ethics committee has confirmed it (Ethics code: IR.MUI.MED.REC.1399.1041).
The inclusion criteria were being a candidate for abdominal surgeries of any kind that made the intestinal length measurements possible and signing the written informed consent to participate in this study. The exclusion criteria had Crohn's disease or severe adhesion or history of previous intestinal surgery and unstable hemodynamics during surgery or inability to measure any factors or small bowel accurately.
We should note that we did not have any age range and included patients of any age. The reason for this issue was that it has been indicated that bowel length is not affected by the age of individuals.[11]
Demographic data and anthropometric factors of all patients including age, gender, weight, height, BMI, right wrist and waist circumstance, length of the right hand 2nd and 4th fingers and 2nd to 4th finger ratio, and length of the right hemithorax were obtained.[12],[13],[14] The anthropometric factors were measured by a measuring tape with a millimeter scale and recorded for each patient in a form.
We hypothized that there is relation between these factors and bowel length; so the study was aimed to find and prove the relation. However, some of these factors were evaluated for other patients in the literature finger lengths were measured from the metacarpophalangeal joint to the tip of the finger in millimeters.[15] Hemithoracic length was measured from clavicle to costal margin at the midclavicular line in centimeters.[16] Furthermore, height, waist, and wrist circumstances were recorded in centimeters. All the measurements and evaluations were performed by a single researcher and the same device.
The underwent a surgical procedure. During the surgery by the attendance of the same researcher whole length of the small bowel was measured from the ligament of Treitz to the ileocecal junction between the mesenteric and antimesenteric border of the intestine with minimal traction of intestinal loops in open surgeries. In open surgeries, a 10 cm silk string marked at the mid part by a knot was used as a guide. In laparoscopic surgeries, bowel length was measured by a small bowel clamp marked at 5 and 10 cm with normal and minimal traction. Then, the length of the small bowel was recorded in the same form.
The obtained data were entered into the Statistical Package for the Social Sciences (SPSS) (SPSS Inc., 233 South Wacker Drive, 11th Floor, Chicago, IL.version 23). We used the Pearson correlation test, Student's t-test, and linear regression test. Based on the Kolmogorov-Smirnov normality test, data have normal distribution so the analysis was performed based on the parametric models. P < 0.05 was considered as a significance threshold.
| Results | | |
The study population consisted of 211 patients undergoing abdominal surgery using open or laparoscopic procedures. During operations, 16 patients were excluded from the study due to having characteristic features of Crohn's disease (N = 2) and severe adhesion (N = 14) which impeded measurement of small bowel length. Furthermore, 45 other cases were excluded due to the inability of the surgeon to measure the small bowel length. Data of 150 cases were analyzed.
We showed that the study population consisted of 94 females (62.6%) and 56 males (37.4%). In this study, 108 cases (72%) underwent open surgery and 42 patients (28%) were operated using the laparoscopic method. Descriptive data of the patients are summarized in [Table 1].
In statistical analysis of bowel length in categorizing by gender, the average intestinal length was 518.83 in women versus 598.04 in men, respectively. Statistical significance was proven by Student's t-test (P = 0.003).
When bowel length was classified and assessed according to the type of surgery (open or laparoscopic), the average intestinal length in open surgeries was 496.39 cm and in laparoscopic operations was 670.95 cm but not statistically significant analyzed by Student's t-test (P = 0.11).
In an assessment of all patients with Pearson's correlation test, it was shown that the bowel length had a significant direct relationship with height and an inverse relationship to the 2nd to 4th finger ratio. Age, weight, waist and wrist circumstance, and hemithoracic length did not have any significant correlation with bowel length. Due to the colinearity of BMI with height and weight, BMI was not assessed. These results are shown in [Table 2]. | Table 2: Correlation of small bowel length with anthropometric and demographic factors
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With classifying based on the method of surgery and repeating the Pearson's correlation test, the relation of bowel length in laparoscopic surgeries is revealed with age, weight, and waist circumstance, and hemithoracic length with reciprocal effect for three letters. In open surgeries, the correlation of bowel length with height with positive effect and 2nd to 4th finger ratio with reciprocal effect was concluded [Table 3]. | Table 3: Correlation of small bowel length with anthropometric and demographic factors with consideration of type of surgery
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To detect a model for prediction of small bowel length, a linear regression test was performed and with attention to the fact that there is a difference in technique of measurement of bowel length according to the type of surgery, it revealed for laparoscopic surgeries age, height, and weight can be predictors. In open surgeries, the wrist and fingers ratio may help predict bowel length [Table 4]. In linear regression test for open surgery adjusted R-squared was 0.13 and for the laparoscopic model was 0.42 that shows the model is stronger for prediction of small bowel length in laparoscopic surgeries.
Complications
Small partial thickness damage to the small bowel wall occurred in one case, which was sutured by prolene 4_0. In addition, in another patient bowel obstruction was reported 3 weeks after a laparoscopic sigmoidectomy due to the adenocarcinoma, in which the small bowel was herniated under mesocolon and adhered to the abdominal wall. The patient's symptoms were started 5 days after surgery with abdominal pain and nausea and revealed soon and repeated with complete obstruction features 3 weeks later. All patients were, at last, recovered and discharged from the hospital.
Accidental findings
One accidental case of Meckel's diverticulum was seen in laparoscopic surgery that was managed by the abandoned method so it was not inflamed or did not have palpable mass and had a large noninflamed base.
| Discussion | | |
Evaluation and prediction of small intestine length in bariatric surgery have great importance. In the present study, we measured the small intestine length during open and laparoscopic abdominal surgeries of any kind and evaluated the relationship between small intestine length and demographic and anthropometric factors. The results of our study could be very effective and useful for bariatric surgical operations when the small intestine length matters most to prevent malabsorption.
Bariatric surgery is developing worldwide and its complications such as malnutrition or failure to adequate weight loss will be a future concern for the health system. One of the reasons may explain the possibility of such complications, especially in surgeries with the malabsorptive component, is different small bowel length. Hence, the detection of a method to predict small bowel length before the operation may help prevent such events.
The results of our study showed that the mean small bowel length was 5.45 ± 1.62 meters and significantly lower in women compared to men and had a significant direct relationship with height, and inverse relationship to the 2nd to 4th finger ratio. We also showed the same correlations between small intestine length with height and the 2nd to 4th finger ratio in open surgeries. In laparoscopic surgeries, we observed a correlation between age, weight, and length of the right hemithorax. It should also be noted that small intestine length measurements in open and laparoscopic surgeries may have small variations. In this study, we tried to measure the small intestine length with the least tissue tension, but we also should mention that during laparoscopic surgeries, small intestinal tension could be made.
The present study shows that height, male gender, age, and length of the right hemithorax have direct relationships to the small intestinal length, while the 2nd to 4th finger ratio have an inverse relation to this object. Based on previous data, bypassing up to 40% of small bowel length is a good formula to achieve acceptable weight loss meanwhile prevents malnutrition and some others have reported that at least 2.5 meters and up to 4 meters of small intestine should remain after bypass surgeries to avoid malnutrition.[17] Estimating the small intestinal length by demographic and anthropometric factors is feasible and has no costs and therefore, useful. Some previous studies on alive patients and cadaver have also investigated the associating factors related to small intestinal length.
In 2018, a study was performed by Baud et al., on 200 adults to investigate the anatomical length of the small intestine. It was shown that the length of the small bowel was significantly longer in men and in young patients. It was also correlated with the subject's weight.[18] Hosseinpour and Behdad also showed that the mean small bowel length of 100 patients was 4.59 meters and reported that the measurement of the length of small bowel was more accurate than the estimation given by the classical anatomic books. They also reported no significant correlation between bowel length and age, gender, height, and weight.[19] Teitelbaum and others also showed that the mean small bowel length was 5.06 meters and male sex and height had positive correlations with the length of the small bowel.[20] As observed, various studies have reported different results but the findings of our study were in line with the previous reports regarding the mean small intestinal length. However, the findings of Hosseinpour and Behdad were not consistent with our findings showing no correlations between bowel length and age, gender, height, and weight. We believe that these differences may be due to variations in study populations.
An important aspect of our study was that we divided our measurements into open surgical operations and laparoscopic surgeries to avoid possible errors due to tissue tension during measurements. In 2019, Komaei et al., investigated the Tailored Biliopancreatic limb length formula relative to small bowel length in 64 patients undergoing one anastomosis gastric bypass-mini-gastric bypass surgical procedure. They showed that tailoring biliopancreatic limb length by bypassing about 40% of the small bowel length seems to be safe and effective in preventing malnutrition in patients.[21] In this study, the full length of the small bowel was measured and presented a formula to prevent malnutrition.
Tacchino reported that a positive association between height and small bowel length was found. Sex, age, height, and estimated jejunal length may be strong predictors of weight in 443 patients undergoing laparoscopy and then laparotomy.[22] Measurement with traction and without traction was implied and expressed it is very important to mention the technique of bowel measurement due to the significant difference between the two methods. These data are also in line with our findings showing the positive relationship between height and bowel length. Furthermore, the important point of the current study was that we observed an inverse relationship between small bowel length and 2nd to 4th finger ratio and positive correlation with height in open surgeries and a positive correlation between age and negative relationship with weight, waist circumstance, and length of the right hemithorax in laparoscopic surgeries.
Another study was conducted by Bekheit et al., in 2020 on 606 participants. It was reported that the mean small bowel length was 6.3 m with a range that varies from 2.5 to 13 m. They also reported that the length of the small bowel had no significant correlation to the weight and height of the individual.[23] These results were not in line with the findings of our study and also not in line with the findings of most previous studies. The main reason for these variations could be ethnic differences among populations and also measurement tools. Gazer and others showed that the small bowel length assessment during laparoscopy is inaccurate and associated with substantial variability. There is a need to develop a standardized laparoscopic technique for measuring small bowel length which is simple, reproducible, and easy to learn.[24] These data are also consistent with the mentioned reports.
In this study in opposite to the Tacchino study which only height was the variable for bowel length prediction, in laparoscopic surgeries weight and height and in open surgeries wrist circumstance and fingers ratio were the predictors in the model for bowel length prediction.
We should also note that the number of patients undergoing laparoscopic surgeries was lower than open surgical procedures in our study that could be also mentioned as a limitation. Furthermore, a restricted study population could also be mentioned as another limitation of the present study. However, we observed significant correlations between some demographic and anthropometric factors and small bowel length that could have high clinical and surgical importance. Further studies with more detailed and precise measurements are essential to be conducted to define the efficacy of such anthropometric indices. For future studies, we suggest the size of fingers to be measured by more precise tools such as Collis. Furthermore, a great amount of patients should be entered the study. It is very important to define and accept a similar method for measurement of the small bowel, especially in laparoscopic surgeries which bariatric surgeries are managed in such a way.
| Conclusions | | |
We observed that the mean small bowel length was 5.45 ± 1.62 meters and had a significant direct relationship with height, and inverse relationship to the 2nd to 4th finger ratio. We also showed the same correlations between small intestine length with height and the 2nd to 4th finger ratio in open surgeries. In laparoscopic surgeries, we observed a correlation between age, weight, waist circumstance, and length of right hemithorax.
| Declarations | | |
Ethics approval and consent to participate
The study protocol was approved by the Research Committee of Isfahan University of Medical Sciences and the Ethics committee has confirmed it (Ethics code: IR.MUI.MED.REC.1399.1041). Informed consent was obtained from all patients.
Acknowledgements
The authors gratefully acknowledge all those who help to do this project.
Financial support and sponsorship
This study was granted by Isfahan University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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