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Sugumar K, Naik L, Hue JJ, Ammori JB, Hardacre JM, Ocuin LM, Winter JM. Risk factors of developing nonalcoholic fatty liver disease after pancreatic resection: a systematic review and meta-analysis. J Gastrointest Surg 2024:S1091-255X(24)00379-2. [PMID: 38552899 DOI: 10.1016/j.gassur.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/19/2024] [Accepted: 03/22/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) occurs in 10% to 40% of patients after pancreatic resection. Pancreatic exocrine insufficiency (PEI) is thought to be closely associated with NAFLD; however, the mechanism of NAFLD is not clearly understood. We perform a systematic review and meta-analysis to better understand the risk factors of NAFLD. METHODS A systematic literature search was performed in the MEDLINE database. Studies focused on the risk factors associated with NAFLD in patients undergoing pancreatectomy. The odds ratios (ORs) denoting the association of risk factors with NAFLD after resection were curated. RESULTS Of 814 published articles, 26 studies met the inclusion criteria. Combined, these studies included clinical data on 4055 patients. The pooled incidence of NAFLD was 29% (23%-35%). Among the various risk factors analyzed, the following had a significant likelihood of NAFLD on forest plot analysis: female gender (OR, 2.44), pancreatic ductal adenocarcinoma (OR, 2.11), portal vein or superior mesenteric vein resection (OR, 1.99), dissection of nerve plexus around the superior mesenteric artery (OR, 1.93), and adjuvant chemotherapy (OR, 1.58). Only 2 studies investigated 2 different measurements of quantitative PEI, which could not be used for analysis. Owing to heterogeneity of studies, pancreatic remanent volume, which is considered a marker for PEI could not be evaluated. Pancreatic enzyme replacement therapy (PERT) was not associated with NAFLD. CONCLUSION Numerous factors are associated with NAFLD after pancreatectomy. Previous research shows that PEI may be associated with NAFLD; however, this could not be compared in our meta-analysis. Further research is required to study the role of PERT in NAFLD.
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Affiliation(s)
- Kavin Sugumar
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Lora Naik
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
| | - Jonathan J Hue
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - John B Ammori
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Jeffrey M Hardacre
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Lee M Ocuin
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Jordan M Winter
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States.
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2
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Yaceczko S, Baltz J. Evaluation of nutrition components within prehabilitation programs in gastrointestinal cancers: Is prehab worth the hype? Nutr Clin Pract 2024; 39:117-128. [PMID: 37772471 DOI: 10.1002/ncp.11079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/01/2023] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
Nutrition impact symptoms and unintended weight loss are prevalent in patients with gastrointestinal cancers, especially during the perioperative period or while prescribed anticancer treatments. Because patients may experience loss of lean body mass and malnutrition, aggressive nutrition intervention prior to surgery should be considered. Cancer prehabilitation is a process spanning the care continuum from diagnosis to the time of surgery encompassing nutrition support, psychological and physical assessment, and targeted interventions. Thirteen studies published between 2013 and 2023 were included in this review and evaluated prehabilitation programs' impact on postoperative outcomes in patients with gastrointestinal cancers. Literature continues to emerge supporting the integration of nutrition into a prehabilitation program because of its potential to contribute to improved clinical outcomes, quality of life, and cost-effectiveness, but considerable variation exists with respect to the specific recommendations provided by current prehabilitation programs.
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Affiliation(s)
- Shelby Yaceczko
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Jami Baltz
- Stanford Health Care, Comprehensive Cancer Center, Stanford, California, USA
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3
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Garay MB, Carbajal-Maldonado ÁL, Rodriguez-Ortiz-DE-Rozas R, Guilabert L, DE-Madaria E. Post-surgical exocrine pancreatic insufficiency. Minerva Surg 2023; 78:671-683. [PMID: 38059441 DOI: 10.23736/s2724-5691.23.10125-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Being an underdiagnosed and under or insufficiently treated condition, surgical pancreatic exocrine insufficiency (PSP) is the condition in which pancreatic enzymes are insufficient for digestion because of gastrointestinal (GI) surgery involving the upper GI tract, biliary ducts, or the pancreas, and and leading to potential malnutrition and deterioration in quality of life. Age, obesity, history of tobacco use, family history of diabetes, surgery due to a malignant tumor, presence of steatorrhea, jaundice, weight loss, and intraoperative findings of hard pancreatic texture have been associated with a higher risk of PSP. Pancreatoduodectomy (PD) has demonstrated an increased risk of developing PSP, with a prevalence between 19-100%. Distal pancreatectomy (DP) and central pancreatectomy (CenP) are associated with less risk of PSP, with a prevalence of 0-82% and 3.66-8.7%, respectively. In patients with chronic pancreatitis (CP), PSP was associated with 80% in Partington-Rochelle procedure, 86% in Frey procedure, 80% in duodenum preserving pancreatic head procedure, >60% in PD and 27.5-63% in DP. Fecal elastase-1 (FE-1) is a generally accepted tool for diagnosis. Treatment is recommended to start as soon as a diagnosis is achieved, or clinical suspicion is high. Pancreatic enzyme replacement therapy improves symptoms of malabsorption, facilitates weight gain, and ultimately improves patients' quality of life. Starting dosage is between 10,000-50,000 units in snacks and 50,000-75,000 units in main meals, administered throughout food intake, though further data specifically on PSP are needed. Follow-up in PSP is recommended on an on-demand basis, where malnutrition should be assessed.
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Affiliation(s)
- Maria B Garay
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Ángela L Carbajal-Maldonado
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Rosario Rodriguez-Ortiz-DE-Rozas
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Lucia Guilabert
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Enrique DE-Madaria
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain -
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4
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Hartman V, Roeyen E, Bracke B, Huysentruyt F, De Gendt S, Chapelle T, Ysebaert D, Hendrikx B, Roeyen G. Prevalence of pancreatic exocrine insufficiency after pancreatic surgery measured by 13C mixed triglyceride breath test: A prospective cohort study. Pancreatology 2023; 23:563-568. [PMID: 37301695 DOI: 10.1016/j.pan.2023.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/04/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Patients undergoing pancreatic surgery are at risk of pancreatic exocrine insufficiency (PEI) and needing pancreatic enzyme replacement therapy (PERT). METHODS This study included 254 patients undergoing pancreatic surgery for oncologic indications. A13C mixed triglyceride breath test was performed immediately preoperative and postoperative. This test analyzes the pancreatic remnant lipase activity measuring 13CO2 in breath samples after a test meal with 1.3-distearyl-(13C-Carboxyl)octanol-glycerol. Cumulative percent dose recovery after 6 h of less than 23% confirms PEI. In addition, PEI was compared between pathology subgroups. RESULTS In 197 patients undergoing pancreaticoduodenectomy, cPDR-6h decreased significantly from a median of 32.84% before to 15.80% after surgery (p < 0.0001). This decrease in exocrine function was significant in all pathology subgroups except in pancreatic neuroendocrine tumors. Exocrine function decreased most in pancreatic ductal adenocarcinoma (PDAC). In addition, the percentage of patients needing PERT because of PEI increased from 25.9% to 68.0% postoperative (p < 0.001). Overall, patients with an MPD diameter of more than 3 mm had a higher risk of developing postoperative PEI: 62.7% compared to 37.3% (p = 0.009), OR = 3.11. In contrast, the majority of the 57 patients undergoing a distal pancreatectomy did not experience any significant change in exocrine function. CONCLUSIONS The vast majority of patients undergoing pancreaticoduodenectomy for oncologic indications experience a significant drop in exocrine function, are at high risk of developing pancreatic exocrine insufficiency and consequently need to be treated with pancreatic enzyme replacement therapy. Therefore, systematic screening for pancreatic exocrine insufficiency is needed after pancreaticoduodenectomy.
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Affiliation(s)
- V Hartman
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium; University of Antwerp, Belgium.
| | - E Roeyen
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - B Bracke
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - F Huysentruyt
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - S De Gendt
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - T Chapelle
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium; University of Antwerp, Belgium
| | - D Ysebaert
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium; University of Antwerp, Belgium
| | - B Hendrikx
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - G Roeyen
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium; University of Antwerp, Belgium
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Phillips ME, Hart KH, Frampton AE, Robertson MD. Do Patients Benefit from Micronutrient Supplementation following Pancreatico-Duodenectomy? Nutrients 2023; 15:2804. [PMID: 37375707 DOI: 10.3390/nu15122804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/06/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Pancreatico-duodenectomy (PD) includes resection of the duodenum and use of the proximal jejunum in a blind loop, thus reducing the absorptive capacity for vitamins and minerals. Several studies have analysed the frequency of micronutrient deficiencies, but there is a paucity of data on those taking routine supplements. A retrospective review of medical notes was undertaken on 548 patients under long-term follow-up following PD in a tertiary hepato-pancreatico-biliary centre. Data were available on 205 patients from 1-14 years following PD, and deficiencies were identified as follows: vitamin A (3%), vitamin D (46%), vitamin E (2%), iron (42%), iron-deficiency anaemia (21%), selenium (3%), magnesium (6%), copper (1%), and zinc (44%). Elevated parathyroid hormone was present in 11% of cases. There was no significant difference over time (p > 0.05). Routine supplementation with a vitamin and mineral supplement did appear to reduce the incidence of biochemical deficiency in vitamin A, vitamin E, and selenium compared to published data. However, iron, vitamin D, and zinc deficiencies were prevalent despite supplementation and require surveillance.
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Affiliation(s)
- Mary E Phillips
- Department of Nutrition and Dietetics, Royal Surrey Hospital, Guildford GU2 7XX, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7NX, UK
| | - Kathryn H Hart
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7NX, UK
| | - Adam E Frampton
- Oncology Section, Surrey Cancer Research Institute, Department of Clinical and Experimental Medicine, FHMS, University of Surrey, The Leggett Building, Daphne Jackson Road, Guildford GU2 7WG, UK
- Department of HPB Surgery, Royal Surrey Hospital, Guildford GU2 7XX, UK
| | - M Denise Robertson
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7NX, UK
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6
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Lemanska A, Andrews C, Fisher L, Butler-Cole B, Mehrkar A, Roberts KJ, Goldacre B, Walker AJ, MacKenna B. A National Audit of Pancreatic Enzyme Prescribing in Pancreatic Cancer from 2015 to 2023 in England Using OpenSAFELY-TPP. Semin Oncol Nurs 2023; 39:151439. [PMID: 37142468 DOI: 10.1016/j.soncn.2023.151439] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Cancer treatments were variably disrupted during the coronavirus disease 2019 (COVID-19) pandemic. UK guidelines recommend pancreatic enzyme replacement therapy (PERT) to all people with unresectable pancreatic cancer. The aim was to investigate the impact of the COVID-19 pandemic on PERT prescribing to people with unresectable pancreatic cancer and to investigate the national and regional rates from January 2015 to January 2023. DATA SOURCES With the approval of NHS England, we conducted this study using 24 million electronic health records of people within the OpenSAFELY-TPP research platform. There were 22,860 people diagnosed with pancreatic cancer in the study cohort. We visualized the trends over time and modeled the effect of the COVID-19 pandemic with the interrupted time-series analysis. CONCLUSION In contrast to many other treatments, prescribing of PERT was not affected during the pandemic. Overall, since 2015, the rates increased steadily over time by 1% every year. The national rates ranged from 41% in 2015 to 48% in early 2023. There was substantial regional variation, with the highest rates of 50% to 60% in West Midlands. IMPLICATIONS FOR NURSING PRACTICE In pancreatic cancer, if PERT is prescribed, it is usually initiated in hospitals by clinical nurse specialists and continued after discharge by primary care practitioners. At just under 50% in early 2023, the rates were still below the recommended 100% standard. More research is needed to understand barriers to prescribing of PERT and geographic variation to improve quality of care. Prior work relied on manual audits. With OpenSAFELY, we developed an automated audit that allows for regular updates (https://doi.org/10.53764/rpt.a0b1b51c7a).
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Affiliation(s)
- Agnieszka Lemanska
- Senior Lecturer in Health Data Science, School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.
| | - Colm Andrews
- Data scientist, Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louis Fisher
- Epidemiologist & Health Data Scientist, Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ben Butler-Cole
- Director of Engineering, Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- Senior Clinical Researcher, Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Keith J Roberts
- Consultant Liver Transplant, Hepatobiliary and Pancreatic Surgeon & Honorary Professor, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Ben Goldacre
- Director & Bennett Professor of Evidence-Based Medicine, Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alex J Walker
- Epidemiologist, Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian MacKenna
- Director of NHS Service Analytics, Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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7
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Lemanska A, Andrews C, Fisher L, Butler-Cole B, Mehrkar A, Roberts KJ, Goldacre B, Walker AJ, MacKenna B. A national audit of pancreatic enzyme prescribing in pancreatic cancer from 2015 to 2023 in England using OpenSAFELY-TPP. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2022.07.08.22277317. [PMID: 36093352 PMCID: PMC9460968 DOI: 10.1101/2022.07.08.22277317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objectives Cancer treatments were variably disrupted during the COVID-19 pandemic. UK guidelines recommend pancreatic enzyme replacement therapy (PERT) to all people with unresectable pancreatic cancer. The aim was to investigate the impact of COVID-19 on PERT prescribing to people with unresectable pancreatic cancer and to investigate the national and regional rates from January 2015 to January 2023. Data sources With the approval of NHS England, we conducted this study using 24 million electronic healthcare records of people within the OpenSAFELY-TPP research platform. There were 22,860 people diagnosed with pancreatic cancer in the study cohort. We visualised the trends over time and modelled the effect of COVID-19 with the interrupted time series analysis. Conclusions In contrast to many other treatments, prescribing of PERT was not affected during the pandemic. Overall, since 2015, the rates increased steadily over time by 1% every year. The national rates ranged from 41% in 2015 to 48% in early 2023. There was substantial regional variation with the highest rates of 50% to 60% in West Midlands. Implications for Nursing Practice In pancreatic cancer, if PERT is prescribed, it is usually initiated in hospitals by clinical nurse specialists and continued after discharge by primary care. At just under 50% in early 2023, the rates were still below the recommended 100% standard. More research is needed to understand barriers to prescribing of PERT and geographic variation to improve quality of care. Prior work relied on manual audits. With OpenSAFELY, we developed an automated audit allowing for regular updates.
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Affiliation(s)
- Agnieszka Lemanska
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Colm Andrews
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louis Fisher
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ben Butler-Cole
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Keith J Roberts
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alex J Walker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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8
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Kroon VJ, Daamen LA, Tseng DSJ, de Vreugd AR, Brada LJH, Busch OR, Derksen TC, Gerritsen A, Rombouts SJE, Smits FJ, Walma MS, Wennink RAW, Besselink MG, van Santvoort HC, Molenaar IQ. Pancreatic exocrine insufficiency following pancreatoduodenectomy: A prospective bi-center study. Pancreatology 2022; 22:1020-1027. [PMID: 35961936 DOI: 10.1016/j.pan.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 06/06/2022] [Accepted: 08/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Pancreatic exocrine insufficiency (PEI) is a common complication following pancreatoduodenectomy (PD) leading to malnutrition. The course of PEI and related symptoms and vitamin deficiencies is unknown. This study aimed to assess the (long-term) incidence of PEI and vitamin deficiencies after PD. METHODS A bi-centre prospective observational cohort study was performed, including patients who underwent PD for mainly pancreatic and periampullary (pre)malignancies (2014-2018). Two cohorts were formed to evaluate short and long-term results. Patients were followed for 18 months and clinical symptoms were evaluated by questionnaire. PEI was based on faecal elastase-1 (FE-1) levels and/or clinical symptoms. RESULTS In total, 95 patients were included. After three months, all but three patients had developed PEI and 27/29 (93%) patients of whom stool samples were available showed abnormal FE-1 levels, which did not improve during follow-up. After six months, all patients had developed PEI. During follow-up, symptoms resolved in 35%-70% of patients. Vitamin D and K deficiencies were observed in 48%-79% of patients, depending on the moment of follow-up; 0%-50% of the patients with deficiencies received vitamin supplementation. DISCUSSION This prospective study found a high incidence of PEI after PD with persisting symptoms in one-to two thirds of all patients. Limited attention was paid to vitamin deficiencies. Improved screening and treatment strategies for PEI and vitamins need to be designed.
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Affiliation(s)
- V J Kroon
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - L A Daamen
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands; Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - D S J Tseng
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - A Roele- de Vreugd
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - L J H Brada
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - O R Busch
- Dept. of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - T C Derksen
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - A Gerritsen
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - S J E Rombouts
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - F J Smits
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - M S Walma
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - R A W Wennink
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - M G Besselink
- Dept. of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - H C van Santvoort
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - I Q Molenaar
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands.
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Crowder SL, Playdon MC, Gudenkauf LM, Ose J, Gigic B, Greathouse L, Peoples AR, Sleight AG, Jim HSL, Figueiredo JC. A Molecular Approach to Understanding the Role of Diet in Cancer-Related Fatigue: Challenges and Future Opportunities. Nutrients 2022; 14:nu14071496. [PMID: 35406105 PMCID: PMC9003400 DOI: 10.3390/nu14071496] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/27/2022] [Accepted: 03/31/2022] [Indexed: 02/04/2023] Open
Abstract
Cancer-related fatigue (CRF) is considered one of the most frequent and distressing symptoms for cancer survivors. Despite its high prevalence, factors that predispose, precipitate, and perpetuate CRF are poorly understood. Emerging research focuses on cancer and treatment-related nutritional complications, changes in body composition, and nutritional deficiencies that can compound CRF. Nutritional metabolomics, the novel study of diet-related metabolites in cells, tissues, and biofluids, offers a promising tool to further address these research gaps. In this position paper, we examine CRF risk factors, summarize metabolomics studies of CRF, outline dietary recommendations for the prevention and management of CRF in cancer survivorship, and identify knowledge gaps and challenges in applying nutritional metabolomics to understand dietary contributions to CRF over the cancer survivorship trajectory.
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Affiliation(s)
- Sylvia L. Crowder
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL 33617, USA; (S.L.C.); (L.M.G.); (H.S.L.J.)
| | - Mary C. Playdon
- Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA;
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, UT 84112, USA
| | - Lisa M. Gudenkauf
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL 33617, USA; (S.L.C.); (L.M.G.); (H.S.L.J.)
| | - Jennifer Ose
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA; (J.O.); (A.R.P.)
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA
| | - Biljana Gigic
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69047 Heidelberg, Germany;
| | - Leigh Greathouse
- Human Science and Design, Robbins College of Health and Human Sciences, Baylor University, Waco, TX 76798, USA;
| | - Anita R. Peoples
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA; (J.O.); (A.R.P.)
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA
| | - Alix G. Sleight
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
- Center for Integrated Research in Cancer and Lifestyle, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Heather S. L. Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL 33617, USA; (S.L.C.); (L.M.G.); (H.S.L.J.)
| | - Jane C. Figueiredo
- Center for Integrated Research in Cancer and Lifestyle, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Correspondence:
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10
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Hata H, Ota Y, Uesaka K, Yamazaki Y, Murata T, Murai C, Yoshikawa K, Imamachi K, Yurikusa T, Kitagawa Y. Oral adverse events due to zinc deficiency after pancreaticoduodenectomy requiring continuous intravenous zinc supplementation: a case report and literature review. BMC Oral Health 2022; 22:52. [PMID: 35241043 PMCID: PMC8895859 DOI: 10.1186/s12903-022-02088-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/22/2022] [Indexed: 11/30/2022] Open
Abstract
Background Zinc is mainly absorbed in the duodenum and proximal jejunum, which are removed during pancreaticoduodenectomy (PD). Little is known about the adverse oral events and skin disorders caused by zinc deficiency after PD. Herein, we reviewed studies on the development of zinc deficiency after PD and reported about a patient with zinc deficiency after PD who required home intravenous zinc replacement.
Case presentation A 73-year-old woman with glossitis, taste disorder, and acrodermatitis enteropathica-like eruption on her fingers presented to the Division of Dentistry and Oral Surgery 69 days after PD. Her serum zinc level markedly decreased to 30 μg/dL. Oral zinc administration was inadequate to treat hypozincemia after PD; therefore, multi-trace elements were injected intravenously during readmission. Her serum zinc levels recovered, and her lesions gradually improved. Furthermore, a central venous port was implanted to maintain normal serum zinc levels, and she continued self-injecting zinc at home. Conclusions Zinc deficiency after PD rarely occurs. The clinical oncologist community, including dentists responsible for the oral care of cancer patients, should be aware of the oral adverse events, such as dysgeusia, glossitis, and oral pain, associated with zinc deficiency after cancer surgery and that induced by chemotherapy or head and neck radiation therapy.
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Affiliation(s)
- Hironobu Hata
- Division of Dentistry and Oral Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan. .,Department of Dentistry and Oral Surgery, National Hospital Organization Hokkaido Cancer Center Hospital, Sapporo, Japan.
| | - Yojiro Ota
- Division of Dentistry and Oral Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yutaka Yamazaki
- Gerodontology, Department of Oral Health Science, Faculty of Dental Medicine, Hokkaido University, Sapporo, Japan
| | - Tsubasa Murata
- Department of Dental and Oral Surgery, Tomakomai City Hospital, Tomakomai, Japan
| | - Chika Murai
- Faculty of Dental Medicine, Oral Diagnosis and Medicine, Hokkaido University, Sapporo, Japan
| | - Kazuhito Yoshikawa
- Faculty of Dental Medicine, Oral Diagnosis and Medicine, Hokkaido University, Sapporo, Japan
| | - Kenji Imamachi
- Department of Dentistry and Oral Surgery, National Hospital Organization Hokkaido Cancer Center Hospital, Sapporo, Japan
| | - Takashi Yurikusa
- Division of Dentistry and Oral Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yoshimasa Kitagawa
- Faculty of Dental Medicine, Oral Diagnosis and Medicine, Hokkaido University, Sapporo, Japan
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11
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Kumar TK, Tewari M, Shukla SK, Mishra SP. Pancreatic exocrine insufficiency occurs in most patients following pancreaticoduodenectomy. Indian J Cancer 2022; 58:511-517. [PMID: 34975096 DOI: 10.4103/ijc.ijc_764_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Pancreatic exocrine insufficiency (PEI) is a well-defined complication of malignant diseases and pancreatic resection; however, study results of PEI are less consistent. Assessment of PEI by estimation of fecal elastase (FE)-1 in stool by enzyme-linked immunosorbent essay (ELISA) is a relatively inexpensive, noninvasive, and simple test. This study assessed exocrine function of pancreas following pancreaticoduodenectomy (PD) by estimating FE-1. Methods This prospective hospital-based study involved 30 patients who had undergone PD for malignancy. All 30 patients had an uneventful postoperative period under the unit's enhanced recovery after surgery (ERAS) protocol with no Grade B, C postoperative pancreatic fistula/postpancreatectomy hemorrhage as per the International Study Group of Pancreatic Surgery (ISGPS) definitions. Stool samples were collected postoperatively 3 months after surgery from all patients irrespective of clinical symptoms. The analysis was based on a solid phase ELISA used for the quantitative determination of human elastase 1 in feces. Fecal elastase was considered normal if >200 μg/gm stool, moderately reduced if 100-200 μg/gm stool, and severely reduced if <100 μg/gm stool. Results Among 30 patients included, fecal elastase levels were moderately reduced in 10 (33.33%) and severely reduced in 20 (66.67%) patients (P <0.0001). Mean (± standard deviation) of fecal elastase was 87.12 ± 38.76 with median of 74.6 μg/gm stool. There was no significant difference in the fecal elastase levels between men and women (P = 0.057), age (P = 0.48), pancreatic duct diameter (P = 0.609), pancreatic texture (P = 0.286), and presence or absence of clinical symptoms (P = 0.181). Conclusions PD was frequently associated with PEI. Unfortunately PEI is an under recognized and under treated long-term sequel of PD. Fecal elastase 1 should be performed routinely in both symptomatic and asymptomatic patients. Pancreatic enzyme replacement therapy should be considered in every patient after PD.
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Affiliation(s)
- Thogari K Kumar
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Mallika Tewari
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S K Shukla
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S P Mishra
- Department of Biochemistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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12
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Estes-Doetsch H, Ganzer H, Roberts K, Brody RA. Risk factors and assessment considerations for essential fatty acid deficiency in nonparenterally fed patients using a case example. Nutr Clin Pract 2022; 37:843-851. [PMID: 34978102 DOI: 10.1002/ncp.10822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Essential fatty acid deficiency (EFAD) has most commonly been reported in parenterally fed individuals but may also present in patients receiving fat-restricted diets and in patients with fat-malabsorption disorders. This article reviews the physical and biochemical assessment for EFAD in clinical practice and disorders of fat malabsorption as potential risk factors for EFAD. A case report is included to describe the fatty acid profile of a patient with exocrine pancreatic insufficiency receiving low-dose pancreatic enzyme replacement therapy after a self-imposed fat-restricted diet. The current challenges with laboratory interpretation of essential fatty acid status are also discussed.
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Affiliation(s)
- Holly Estes-Doetsch
- Medical Dietetics Division, College of Medicine, The Ohio State University, Columbus, Ohio, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Heidi Ganzer
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, Newark, New Jersey, USA
| | - Kristen Roberts
- Medical Dietetics Division, College of Medicine, The Ohio State University, Columbus, Ohio, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Rebecca A Brody
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, Newark, New Jersey, USA
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13
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Malykh MV, Dubtsova EA, Vinokurova LV, Kiryukova MA, Bordin DS. Nutritional status of patients undergoing pancreatic resection. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2022:60-65. [DOI: 10.31146/1682-8658-ecg-195-11-60-65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Changes in the exocrine function of the pancreas often develops after proximal and distal resections. Exocrine pancreatic insufficiency (EPI) is characterized by a reduced secretion of pancreatic enzymes, because of which the digestion and absorption of nutrients is impaired. Clinical manifestations of EPI and, as a consequence, changes in nutritional status significantly affect the quality of life of patients.
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Affiliation(s)
- M. V. Malykh
- Moscow Clinical Research Center named after A. S. Loginov
| | - E. A. Dubtsova
- Moscow Clinical Research Center named after A. S. Loginov
| | | | | | - D. S. Bordin
- Moscow Clinical Research Center named after A. S. Loginov; Moscow State University of Medicine and Dentistry named after A. I. Yevdokimov; Tver State Medical University
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14
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Blonk L, Wierdsma NJ, Jansma EP, Kazemier G, van der Peet DL, Straatman J. Exocrine pancreatic insufficiency after esophagectomy: a systematic review of literature. Dis Esophagus 2021; 34:6131382. [PMID: 33558869 DOI: 10.1093/dote/doab003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/18/2020] [Accepted: 12/14/2020] [Indexed: 12/26/2022]
Abstract
Complaints of maldigestion, malabsorption, and unintended weight loss after esophagectomy are often attributed to an impaired exocrine pancreatic function. This review systematically summarizes all literature reporting on the presence of exocrine pancreatic insufficiency (EPI) after esophagectomy and the effect of treatment with pancreatic enzymes on gastrointestinal complaints, body weight, and quality of life. Databases of PubMed, Embase, and Wiley/Cochrane Library were searched systematically until July 2020. Studies reporting on EPI and pancreatic enzyme replacement therapy after esophagectomy were included. The Newcastle-Ottawa scale was used to assess study quality. Four studies, including 158 patients, were selected. The maximum score for study quality was six (range 4-6). Exocrine pancreatic function was investigated in three studies, measured by fecal elastase-1 and 72-hour fecal fat excretion. Fecal elastase-1 levels <200 μg/g were reported in 16% of patients at 4 months, 18% at 6 months, and 31% at 18-24 months postoperatively. A decreased fecal fat absorption was noticed in 57% 1 month postoperatively. Treatment with pancreatic enzymes was reported in two studies. In patients with fecal elastase-1 levels <200 μg/g, 90% of patients reported improvement in symptoms and 70% reported improvement in weight. In patients with complaints of steatorrhea, 87% noticed settlement of symptoms. Based on current literature, complaints of maldigestion, malabsorption, and unintended weight loss after esophagectomy are common and can be related to an impaired exocrine pancreatic function. High-quality studies evaluating the presence of EPI and the effect of treatment with pancreatic enzymes after esophagectomy are needed to verify this conclusion.
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Affiliation(s)
- L Blonk
- Amsterdam UMC, Cancer Center Amsterdam, Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Amsterdam UMC, Department of Nutrition and Dietetics, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - N J Wierdsma
- Amsterdam UMC, Department of Nutrition and Dietetics, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - E P Jansma
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - G Kazemier
- Amsterdam UMC, Cancer Center Amsterdam, Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - D L van der Peet
- Amsterdam UMC, Cancer Center Amsterdam, Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J Straatman
- Amsterdam UMC, Cancer Center Amsterdam, Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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15
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McKee AM, McGill JB. Letter to the Editor from McKee and McGill: "Glycemic Control and Variability of Diabetes Secondary to Total Pancreatectomy Assessed by Continuous Glucose Monitoring". J Clin Endocrinol Metab 2021; 106:e4298-e4299. [PMID: 33822983 DOI: 10.1210/clinem/dgab220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Alexis M McKee
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO, USA
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16
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Micronutritional status after pylorus preserving duodenopancreatectomy: analysis of data from a randomized controlled trial. Sci Rep 2021; 11:18475. [PMID: 34531424 PMCID: PMC8445937 DOI: 10.1038/s41598-021-97438-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/11/2021] [Indexed: 12/30/2022] Open
Abstract
Physical frailty and nutritional malassimilation are often observed after pancreaticoduodenectomy for pancreatic cancer. But long-term data concerning the course of micronutrient status is still missing. Micronutrient status after pylorus preserving pancreaticoduodenectomy with a follow-up of 12 months was evaluated using data of a randomized controlled trial. 47 patients were randomized with respect to the physiotherapy regimen they received (intensified physiotherapy: n = 22; standard physiotherapy: n = 25). Nutritional status was recorded preoperatively and postoperatively after one week, 3, 6 and 12 months. BMI, body fat measurement and albumin, lipid, iron and bone metabolism parameters, vitamins A, B1 B6 and B12, homocysteine, folic acid, and trace elements were measured. Laboratory values were analyzed descriptively. Differences between the groups were analyzed using the t-test in SPSS. For vitamin D, B1, B6 and iron a deficiency over time could be demonstrated with 50% of all patients or more being below normal range. The other laboratory values were in low normal range after 3 months and later. Significant differences between groups were found in cholesterol, HDL and selenium levels (corrected p-values < 0.033 in all cases). Vitamin D and iron should be supplemented postoperatively in the long term, and vitamin B1 and B6 substitution should be considered in symptomatic patients. Levels of malnutrition induced fatigue should be comparable between both groups. However, the role of nutritional status on other health-related aspects such as quality of life should be the focus of further studies.Trial Registration Number in the German Registry for Clinical Studies: DRKS00006786; Date of Registration: 01.10.2014.
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17
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Pancreatic resection in the pediatric, adolescent and young adult population: nationwide analysis on complications. HPB (Oxford) 2021; 23:1175-1184. [PMID: 33281080 DOI: 10.1016/j.hpb.2020.10.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to determine pancreatic surgery specific short- and long-term complications of pediatric, adolescent and young adult (PAYA) patients who underwent pancreatic resection, as compared to a comparator cohort of adults. METHODS A nationwide retrospective cohort study was performed in PAYA patients who underwent pancreatic resection between 2007 and 2016. PAYA was defined as all patients <40 years at time of surgery. Pancreatic surgery-specific complications were assessed according to international definitions and textbook outcome was determined. RESULTS A total of 230 patients were included in the PAYA cohort (112 distal pancreatectomies, 99 pancreatoduodenectomies), and 2526 patients in the comparator cohort. For pancreatoduodenectomy, severe morbidity (29.3% vs. 28.6%; P = 0.881), in-hospital mortality (1% vs. 4%; P = 0.179) and textbook outcome (62% vs. 58%; P = 0.572) were comparable between the PAYA and the comparator cohort. These outcomes were also similar for distal pancreatectomy. After pancreatoduodenectomy, new-onset diabetes mellitus (8% vs. 16%) and exocrine pancreatic insufficiency (27% vs. 73%) were lower in the PAYA cohort when compared to adult literature. CONCLUSION Pancreatic surgery-specific complications were comparable with patients ≥40 years. Development of endocrine and exocrine insufficiency in PAYA patients who underwent pancreatoduodenectomy, however, was substantially lower compared to adult literature.
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18
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Phillips ME, Hopper AD, Leeds JS, Roberts KJ, McGeeney L, Duggan SN, Kumar R. Consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000643. [PMID: 34140324 PMCID: PMC8212181 DOI: 10.1136/bmjgast-2021-000643] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/08/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Pancreatic exocrine insufficiency is a finding in many conditions, predominantly affecting those with chronic pancreatitis, pancreatic cancer and acute necrotising pancreatitis. Patients with pancreatic exocrine insufficiency can experience gastrointestinal symptoms, maldigestion, malnutrition and adverse effects on quality of life and even survival.There is a need for readily accessible, pragmatic advice for healthcare professionals on the management of pancreatic exocrine insufficiency. METHODS AND ANALYSIS A review of the literature was conducted by a multidisciplinary panel of experts in pancreatology, and recommendations for clinical practice were produced and the strength of the evidence graded. Consensus voting by 48 pancreatic specialists from across the UK took place at the 2019 Annual Meeting of the Pancreatic Society of Great Britain and Ireland annual scientific meeting. RESULTS Recommendations for clinical practice in the diagnosis, initial management, patient education and long term follow up were developed. All recommendations achieved over 85% consensus and are included within these comprehensive guidelines.
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Affiliation(s)
- Mary E Phillips
- Nutrition and Dietetics, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Andrew D Hopper
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John S Leeds
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Keith J Roberts
- HPB Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Laura McGeeney
- Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sinead N Duggan
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - Rajesh Kumar
- HPB Surgery, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
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19
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Latenstein AEJ, van Gerven R, Grevers F, Pek CJ, Groot Koerkamp B, Hartog H, de van der Schueren MAE, Besselink MG, van Eijck CHJ. Micronutrient deficiencies and anaemia in patients after pancreatoduodenectomy. Br J Surg 2021; 108:e74-e75. [PMID: 33711142 DOI: 10.1093/bjs/znaa092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 10/23/2020] [Indexed: 11/14/2022]
Abstract
In patients >4 months after PD, deficiencies of iron, ferritin, vitamin A, and vitamin D, and anaemia were common. Future, prospective studies should study determine the impact of standardized laboratory assessments during follow-up and supplementation of deficiencies.
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Affiliation(s)
- A E J Latenstein
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - R van Gerven
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands (e-mail: )
| | - F Grevers
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands (e-mail: )
| | - C J Pek
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands (e-mail: )
| | - B Groot Koerkamp
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands (e-mail: )
| | - H Hartog
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands (e-mail: )
| | - M A E de van der Schueren
- Department of Nutrition and Health, School of Allied Health, HAN University of Applied Sciences, Nijmegen, the Netherlands.,Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, the Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands (e-mail: )
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20
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Murphy DP, Kanwar MA, Stell MD, Briggs MC, Bowles MM, Aroori MS. The prevalence of micronutrient deficiency in patients with suspected pancreatico-biliary malignancy: Results from a specialist Hepato-Biliary and Pancreatic unit. Eur J Surg Oncol 2021; 47:1750-1755. [PMID: 33775486 DOI: 10.1016/j.ejso.2021.03.227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/16/2021] [Accepted: 03/03/2021] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION There is a paucity of information on micronutrient status in patients with pancreatico-biliary malignancies referred for surgery. Deficiency states could impact recovery from surgery. The purpose of this study was to investigate the frequency of deficiency states in our specialist Hepato-Biliary and Pancreatic (HPB) unit. METHODS Patients with suspected pancreatico-biliary malignancies referred to our surgical team between October 2019 and July 2020, and seen by a dietitian were included in the study. Serum levels of vitamins A, D, E, B12, and folate, and minerals zinc, selenium, copper and iron were obtained. RESULTS Forty-eight patients were eligible for inclusion, 28 males and 20 females with a median age of 68 years. Pancreatic cancer was suspected in 40 patients, bile duct cancer in four patients, and duodenal cancer in four patients. Zinc, vitamin D, selenium and iron were the most frequently occurring micronutrient deficiencies. Zinc deficiency was found in 83% patients and vitamin D insufficiency in 57%. Selenium deficiency was less frequent but found in 24% cases, while iron deficiency suggested by low transferrin saturation was found in 23% patients. CONCLUSIONS Micronutrient deficiencies and borderline status may be more frequent in this patient group than generally acknowledged. Routine analysis of specific vitamins and minerals may be useful to identify deficiency/sub-clinical deficiency states. Further more extensive studies are needed to inform practice and enable guideline development.
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Affiliation(s)
- Dr Paula Murphy
- Professional Lead Dietitian, Department of Dietetics, Department of Nutrition and Dietetics, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr Aditya Kanwar
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr David Stell
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr Christopher Briggs
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr Matthew Bowles
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr Somaiah Aroori
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK.
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21
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Beger HG, Mayer B, Poch B. Resection of the duodenum causes long-term endocrine and exocrine dysfunction after Whipple procedure for benign tumors - Results of a systematic review and meta-analysis. HPB (Oxford) 2020; 22:809-820. [PMID: 31983660 DOI: 10.1016/j.hpb.2019.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/23/2019] [Accepted: 12/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Metabolic dysfunctions after pancreatoduodenectomy (PD) need to be considered when pancreatic head resection is likely to lead to long-term survival. METHODS Medline, Embase and Cochrane Library were searched for studies reporting measured data of metabolic function after PD and duodenum-sparing total pancreatic head resection (DPPHR). Data from 23 cohort studies comprising 1019 patients were eligible; 594 and 910 patients were involved in systematic review and meta-analysis, respectively. RESULTS The cumulative incidence of postoperative new onset of diabetes mellitus (pNODM) after PD for benign tumors was 46 of 321 patients (14%) measured after follow-up of in mean 36 months postoperatively. New onset of postoperative exocrine insufficiency (PEI) was exhibited by 91 of 209 patients (44%) after PD for benign tumors measured in mean 23 months postoperatively. The meta-analysis indicated pNODM after PD for benign tumor in 32 of 208 patients (15%) and in 10 of 178 patients (6%) after DPPHR (p = 0.007; OR 3.01; (95%CI:1.39-6.49)). PEI was exhibited by 80 of 178 patients (45%) after PD and by 6 of 88 patients (7%) after DPPHR (p < 0.001). GI hormones measured in 194 patients revealed postoperatively a significant impairment of integrated responses of gastrin, motilin, insulin, secretin, PP and GIP (p < 0.050-0.001) after PD. Fasting and stimulated levels of GLP-1 and glucagon levels displayed a significant increase (p < 0.020/p < 0.030). Following DPPHR, responses of gastrin, motilin, secretin and CCK displayed no change compared to preoperative levels. CONCLUSIONS After PD, duodenectomy, rather than pancreatic head resection is the main cause for long-term persisting, postoperative new onset of DM and PEI.
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Affiliation(s)
- Hans G Beger
- c/o University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany; Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donauklinikum Neu-Ulm, Germany.
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Germany
| | - Bertram Poch
- Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donauklinikum Neu-Ulm, Germany
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22
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Pancreatic Enzyme Replacement Therapy in Pancreatic Cancer. Cancers (Basel) 2020; 12:cancers12020275. [PMID: 31979186 PMCID: PMC7073203 DOI: 10.3390/cancers12020275] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/14/2020] [Accepted: 01/20/2020] [Indexed: 12/19/2022] Open
Abstract
Pancreatic cancer is an aggressive malignancy and the seventh leading cause of global cancer deaths in industrialised countries. More than 80% of patients suffer from significant weight loss at diagnosis and over time tend to develop severe cachexia. A major cause of weight loss is malnutrition. Patients may experience pancreatic exocrine insufficiency (PEI) before diagnosis, during nonsurgical treatment, and/or following surgery. PEI is difficult to diagnose because testing is cumbersome. Consequently, PEI is often detected clinically, especially in non-specialised centres, and treated empirically. In this position paper, we review the current literature on nutritional support and pancreatic enzyme replacement therapy (PERT) in patients with operable and non-operable pancreatic cancer. To increase awareness on the importance of PERT in pancreatic patients, we provide recommendations based on literature evidence, and when data were lacking, based on our own clinical experience.
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23
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Hendifar AE, Petzel MQB, Zimmers TA, Denlinger CS, Matrisian LM, Picozzi VJ, Rahib L. Pancreas Cancer-Associated Weight Loss. Oncologist 2019; 24:691-701. [PMID: 30591550 PMCID: PMC6516128 DOI: 10.1634/theoncologist.2018-0266] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/18/2018] [Indexed: 12/17/2022] Open
Abstract
Unintentional weight loss in patients with pancreatic cancer is highly prevalent and contributes to low therapeutic tolerance, reduced quality of life, and overall mortality. Weight loss in pancreatic cancer can be due to anorexia, malabsorption, and/or cachexia. Proper supportive care can stabilize or reverse weight loss in patients and improve outcomes. We review the literature on supportive care relevant to pancreatic cancer patients, and offer evidence-based recommendations that include expert nutritional assessment, counseling, supportive measures to ensure adequate caloric intake, pancreatic enzyme supplementation, nutritional supplement replacement, orexigenic agents, and exercise. Pancreatic Cancer Action Network-supported initiatives will spearhead the dissemination and adoption of these best supportive care practices. IMPLICATIONS FOR PRACTICE: Weight loss in pancreatic cancer patients is endemic, as 85% of pancreatic cancer patients meet the classic definition of cancer cachexia. Despite its significant prevalence and associated morbidity, there is no established approach to this disease entity. It is believed that this is due to an important knowledge gap in understanding the underlying biology and lack of optimal treatment approaches. This article reviews the literature regarding pancreas cancer-associated weight loss and establishes a new framework from which to view this complex clinical problem. An improved approach and understanding will help educate clinicians, improve clinical care, and provide more clarity for future clinical investigation.
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Affiliation(s)
| | | | - Teresa A Zimmers
- Indiana University, Simon Cancer Center, Indianapolis, Indiana, USA
| | | | - Lynn M Matrisian
- Pancreatic Cancer Action Network, Manhattan Beach, California, USA
| | | | - Lola Rahib
- Pancreatic Cancer Action Network, Manhattan Beach, California, USA
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Inglis JE, Lin PJ, Kerns SL, Kleckner IR, Kleckner AS, Castillo DA, Mustian KM, Peppone LJ. Nutritional Interventions for Treating Cancer-Related Fatigue: A Qualitative Review. Nutr Cancer 2019; 71:21-40. [PMID: 30688088 DOI: 10.1080/01635581.2018.1513046] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cancer-related fatigue (CRF) is a debilitating syndrome that persists for many cancer survivors for years after treatment. Symptoms include early and persistent fatigue, functional decline, depression, and cognitive difficulties. Inflammation, assessed using pro-inflammatory biomarkers, is increased in cancer survivors with fatigue and treatments for fatigue are often aimed at reducing inflammation. Additionally, cancer and its treatment lead to nutritional complications, changes in body composition, and nutritional deficiencies that potentially weaken the cancer survivor and impact CRF. We conducted a qualitative review of clinical trials that assessed nutritional interventions for preventing and treating CRF. Further studies were examined that used nutritional interventions to address inflammation and fatigue, due to the dearth of nutrition research directly related to CRF. Dietary intake prior to, during, and after cancer treatment appears to affect fatigue levels. Increased protein intake may help preserve lean mass and body composition. Dietary patterns that reduce inflammation, such as the Mediterranean diet and other plant-based diets, appear tolerable to cancer survivors and may reduce fatigue. Supplementation with ginseng, ginger, or probiotics may improve cancer survivors' energy levels. Nutritional interventions, alone or in combination with other interventions should be considered as therapy for fatigue in cancer survivors.
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Affiliation(s)
- Julia E Inglis
- a Department of Surgery , University of Rochester Medical Center (URMC) , Rochester , New York , USA
| | - Po-Ju Lin
- a Department of Surgery , University of Rochester Medical Center (URMC) , Rochester , New York , USA
| | - Sarah L Kerns
- b Department of Radiation Oncology , University of Rochester Medical Center (URMC) , Rochester , New York , USA
| | - Ian R Kleckner
- a Department of Surgery , University of Rochester Medical Center (URMC) , Rochester , New York , USA
| | - Amber S Kleckner
- a Department of Surgery , University of Rochester Medical Center (URMC) , Rochester , New York , USA
| | - Daniel A Castillo
- c Edward G. Miner Library, University of Rochester Medical Center (URMC) , Rochester , New York , USA
| | - Karen M Mustian
- a Department of Surgery , University of Rochester Medical Center (URMC) , Rochester , New York , USA
| | - Luke J Peppone
- a Department of Surgery , University of Rochester Medical Center (URMC) , Rochester , New York , USA
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Roberts KJ, Bannister CA, Schrem H. Enzyme replacement improves survival among patients with pancreatic cancer: Results of a population based study. Pancreatology 2019; 19:114-121. [PMID: 30385188 DOI: 10.1016/j.pan.2018.10.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) and malnutrition are prevalent among patients with pancreatic adenocarcinoma. Pancreatic enzyme replacement therapy (PERT) can correct PEI but its use among patients with pancreatic cancer is unclear as are effects upon survival. This population-based study sought to address these issues METHODS: Subjects with pancreatic adenocarcinoma were identified from the UK Clinical Practice Research Datalink (CPRD). Propensity score matching generated matched pairs of subjects who did and did not receive PERT. Progression to all-cause mortality was compared using parametric survival models that included a range of relevant co-variables RESULTS: PERT use among the whole cohort (987/4554) was 21.7%. Some 1614 subjects generated 807 matched pairs. This resulted in a total, censored follow-up period of 1643 years. There were 1403 deaths in total, representing unadjusted mortality rates of 748 and 994 deaths per 1000 person-years for PERT-treated cases and their matched non-PERT-treated controls, respectively. With reference to the observed survival in pancreatic adenocarcinoma patients, adjusted median survival time was 262% greater in PERT-treated cases (survival time ratio (STR) = 2.62, 95% CI 2.27-3.02) when compared with matched, non-PERT-treated controls. Survival remained significantly greater among subjects receiving PERT regardless of the studied subgroup with respect to use of surgery or chemotherapy CONCLUSIONS: This population based study observes that the majority of patients with pancreatic adenocarcinoma do not receive PERT. PERT is associated with increased survival among patients with pancreatic adenocarcinoma suggesting a lack of clinical awareness and potential benefit of addressing malnutrition among these patients.
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Affiliation(s)
- K J Roberts
- Honorary Reader and Consultant Surgeon, Institute of Immunology and Immunotherapy, University of Birmingham, UK.
| | | | - H Schrem
- Consultant Surgeon, Dept Visceral, General and Transplant Surgery, Hannover Medical School, Germany
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Systematic review on the impact of pancreatoduodenectomy on quality of life in patients with pancreatic cancer. HPB (Oxford) 2018; 20:204-215. [PMID: 29249649 DOI: 10.1016/j.hpb.2017.11.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/11/2017] [Accepted: 11/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients undergoing pancreatoduodenectomy for pancreatic cancer have a high risk of major postoperative complications and a low survival rate. Insight in the impact of pancreatoduodenectomy on quality of life (QoL) is therefore of great importance. The aim of this systematic review was to assess QoL after pancreatoduodenectomy for pancreatic cancer. METHODS A systematic review of the literature was performed according to the PRISMA guidelines. A systematic search of all the English literature available in PubMed and Medline was performed. All studies assessing QoL with validated questionnaires in pancreatic cancer patients undergoing pancreatoduodenectomy were included. RESULTS After screening a total of 788 articles, the full texts of 36 articles were assessed, and 17 articles were included. QoL of physical and social functioning domains decreased in the first 3 months after surgery. Recovery of physical and social functioning towards baseline values took place after 3-6 months. Pain, fatigue and diarrhoea scores deteriorated postoperatively, but eventually resolved after 3-6 months. CONCLUSION Pancreatoduodenectomy for malignant disease negatively influences QoL in the physical and social domains at short term. It will eventually recover to baseline values after 3-6 months. This information is valuable for counselling and expectation management of patients undergoing pancreatoduodenectomy.
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Nofal YH, Abu Dail Y, Assaf Y, Abo Samra H, Abbas F, Hamzeh A, Alhaj Hasan N. Pancreatic enzyme replacement therapy for steatorrhoea in pancreatic cancer. Cochrane Database Syst Rev 2018; 2018:CD012952. [PMCID: PMC6491113 DOI: 10.1002/14651858.cd012952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To evaluate the efficacy of PERT for the treatment of steatorrhoea in people with pancreatic cancer by accessing whether it: reduces the severity and duration of common symptoms, including fatty (greasy or oily appearance and residue), foul‐smelling, pale‐coloured, and heavy stools (bulky and difficult‐to‐flush), which are usually associated with weight loss and nutritional deficiencies as a result of fat malabsorption and the concomitant malabsorption of amino acids and vitamins, and abdominal pain or cramps (Cheifetz 2011 ; Kasper 2015 ); is an acceptable treatment, as assessed by the number of side effects/adverse events, study dropout rates, and participant satisfaction levels; has an impact on chemotherapy adherence; has an impact on postoperative outcomes.
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Affiliation(s)
- Yazan H Nofal
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Yaser Abu Dail
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Yazan Assaf
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Hayan Abo Samra
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Fatima Abbas
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Ammar Hamzeh
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Nahla Alhaj Hasan
- IRC: International Rescue CommitteeHealth servicesMalikiehSyrian Arab Republic
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Maignan A, Ouaïssi M, Turrini O, Regenet N, Loundou A, Louis G, Moutardier V, Dahan L, Pirrò N, Sastre B, Delpero JR, Sielezneff I. Risk factors of exocrine and endocrine pancreatic insufficiency after pancreatic resection: A multi-center prospective study. J Visc Surg 2018; 155:173-181. [PMID: 29396112 DOI: 10.1016/j.jviscsurg.2017.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Management of functional consequences after pancreatic resection has become a new therapeutic challenge. The goal of our study is to evaluate the risk factors for exocrine (ExoPI) and endocrine (EndoPI) pancreatic insufficiency after pancreatic surgery and to establish a predictive model for their onset. PATIENTS AND METHODS Between January 1, 2014 and June 19, 2015, 91 consecutive patients undergoing pancreatoduodenectomy (PD) or left pancreatectomy (LP) (72% and 28%, respectively) were followed prospectively. ExoPI was defined as fecal elastase content<200μg per gram of feces while EndoPI was defined as fasting glucose>126mg/dL or aggravation of preexisting diabetes. The volume of residual pancreas was measured according to the same principles as liver volumetry. RESULTS The ExoPI and EndoPI rates at 6 months were 75.9% and 30.8%, respectively. The rate of ExoPI after PD was statistically significantly higher than after LP (98% vs. 21%; P<0.001), while the rate of EndoPI was lower after PD vs. LP, but this difference did not reach statistical significance (28% vs. 38.5%; P=0.412). There was no statistically significant difference in ExoPI found between pancreatico-gastrostomy (PG) and pancreatico-jejunostomy (PJ) (100% vs. 98%; P=1.000). Remnant pancreatic volume less than 39.5% was predictive of ExoPI. CONCLUSION ExoPI occurs quasi-systematically after PD irrespective of the reconstruction scheme. The rate of EndoPI did not differ between PD and LP.
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Affiliation(s)
- A Maignan
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France
| | - M Ouaïssi
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France; CHRU, hôpital de Trousseau, service de chirurgie digestive, oncologique, endocrinienne et de transplantation hépatique, 37170 Chambray-les-Tours, France.
| | - O Turrini
- Institut Paoli-Calmette, service de chirurgie oncologique, 13009 Marseille, France
| | - N Regenet
- Hôpital Hôtel-Dieu, service de chirurgie digestive et endocrinienne, 44000 Nantes, France
| | - A Loundou
- AP-HM, Aix Marseille université, faculté de médecine de Marseille, service de santé publique et biostatistique, 13005 Marseille, France
| | - G Louis
- AP-HM, hôpital de la Timone, service de radiologie, 13005 Marseille, France
| | - V Moutardier
- AP-HM, hôpital Nord, service de chirurgie digestive générale, endocrinienne, 13005 Marseille, France
| | - L Dahan
- AP-HM, hôpital de la Timone, service d'oncologie digestive, 13005 Marseille, France
| | - N Pirrò
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France
| | - B Sastre
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France
| | - J-R Delpero
- Institut Paoli-Calmette, service de chirurgie oncologique, 13009 Marseille, France
| | - I Sielezneff
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France
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Petzel MQB, Hoffman L. Nutrition Implications for Long-Term Survivors of Pancreatic Cancer Surgery. Nutr Clin Pract 2017; 32:588-598. [DOI: 10.1177/0884533617722929] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Maria Q. B. Petzel
- Department of Clinical Nutrition and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Leah Hoffman
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Pancreatic Exocrine Insufficiency in Pancreatic Cancer. Nutrients 2017; 9:nu9030183. [PMID: 28241470 PMCID: PMC5372846 DOI: 10.3390/nu9030183] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/27/2017] [Accepted: 02/17/2017] [Indexed: 12/12/2022] Open
Abstract
Abstract: Cancer patients experience weight loss for a variety of reasons, commencing with the tumor’s metabolism (Warburg effect) and proceeding via cachexia to loss of appetite. In pancreatic cancer, several other factors are involved, including a loss of appetite with a particular aversion to meat and the incapacity of the pancreatic gland to function normally when a tumor is present in the pancreatic head. Pancreatic exocrine insufficiency is characterized by a deficiency of the enzymes secreted from the pancreas due to the obstructive tumor, resulting in maldigestion. This, in turn, contributes to malnutrition, specifically a lack of fat-soluble vitamins, antioxidants, and other micronutrients. Patients with pancreatic cancer and pancreatic exocrine insufficiency have, overall, an extremely poor prognosis with regard to surgical outcome and overall survival. Therefore, it is crucial to be aware of the mechanisms involved in the disease, to be able to diagnose pancreatic exocrine insufficiency early on, and to treat malnutrition appropriately, for example, with pancreatic enzymes.
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Kota J, Hancock J, Kwon J, Korc M. Pancreatic cancer: Stroma and its current and emerging targeted therapies. Cancer Lett 2017; 391:38-49. [PMID: 28093284 DOI: 10.1016/j.canlet.2016.12.035] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 12/20/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal human malignancies with a 5-year survival rate of 8%. Dense, fibrotic stroma associated with pancreatic tumors is a major obstacle for drug delivery to the tumor bed and plays a crucial role in pancreatic cancer progression. Targeting stroma is considered as a potential therapeutic strategy to improve anti-cancer drug efficacy and patient survival. Although numerous stromal depletion therapies have reached the clinic, they add little to overall survival and are often associated with toxicity. Furthermore, increasing evidence suggests the anti-tumor properties of stroma. Its complete ablation enhanced tumor progression and reduced survival. Consequently, efforts are now focused on developing stromal-targeted therapies that normalize the reactive stroma and avoid the extremes: stromal abundance vs. complete depletion. In this review, we summarized the state of current and emerging anti-stromal targeted therapies, with major emphasis on the role of miRNAs in PDAC stroma and their potential use as novel therapeutic agents to modulate PDAC tumor-stromal interactions.
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Affiliation(s)
- Janaiah Kota
- Department of Medical and Molecular Genetics, Indiana University School of Medicine (IUSM), Indianapolis, IN, USA; The Melvin and Bren Simon Cancer Center, IUSM, Indianapolis, IN, USA; Center for Pancreatic Cancer Research, Indiana University and Purdue University-Indianapolis (IUPUI), Indianapolis, IN, USA.
| | - Julie Hancock
- Department of Medical and Molecular Genetics, Indiana University School of Medicine (IUSM), Indianapolis, IN, USA
| | - Jason Kwon
- Department of Medical and Molecular Genetics, Indiana University School of Medicine (IUSM), Indianapolis, IN, USA
| | - Murray Korc
- The Melvin and Bren Simon Cancer Center, IUSM, Indianapolis, IN, USA; Center for Pancreatic Cancer Research, Indiana University and Purdue University-Indianapolis (IUPUI), Indianapolis, IN, USA; Department of Biochemistry and Molecular Biology, IUSM, Indianapolis, IN, USA; Department of Medicine, IUSM, Indianapolis, IN, USA
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Sabater L, Ausania F, Bakker OJ, Boadas J, Domínguez-Muñoz JE, Falconi M, Fernández-Cruz L, Frulloni L, González-Sánchez V, Lariño-Noia J, Lindkvist B, Lluís F, Morera-Ocón F, Martín-Pérez E, Marra-López C, Moya-Herraiz Á, Neoptolemos JP, Pascual I, Pérez-Aisa Á, Pezzilli R, Ramia JM, Sánchez B, Molero X, Ruiz-Montesinos I, Vaquero EC, de-Madaria E. Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery. Ann Surg 2016; 264:949-958. [PMID: 27045859 DOI: 10.1097/sla.0000000000001732] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery. BACKGROUND EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients. METHODS Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement. RESULTS These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement. CONCLUSIONS EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.
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Affiliation(s)
- Luis Sabater
- *Department of Surgery, Hospital Clinico, University of Valencia, Valencia, Spain †Department of Surgery, Complejo Hospitalario Universitario de Vigo, Vigo, Spain ‡Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands §Department of Gastroenterology, Consorci Sanitari de Terrassa, Terrassa, Spain ¶Department of Gastroenterology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain ||Department of Surgery, Università Vita e Salute, Ospedale San Raffaele IRCCS, Milano, Italy **Department of Surgery, Institut de Malalties Digestives I Metabòliques, Hospital Clínic, IDIBAPS, Barcelona, Spain ††Department of Medicine, Pancreas Center, University of Verona, Verona, Italy ‡‡Department of Endocrinology and Nutrition, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. §§Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ¶¶Department of Surgery, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. ||||Department of Surgery, Hospital Universitario de La Princesa, Madrid, Spain ***Department of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain †††Unidad de Cirugía Hepato-bilio-pancreática y Trasplante, Hospital Universitari i Politecnic. La Fe, Valencia, Spain ‡‡‡NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK §§§Department of Gastroenterology, Hospital Clinico, University of Valencia, Valencia, Spain ¶¶¶Unit of Digestive Disease, Agencia Sanitaria Costa del Sol, Marbella, Málaga ||||||Department Digestive System, Sant'Orsola-Malpighi Hospital, Bologna, Italy ****Department of Surgery, Hospital Universitario de Guadalajara, Guadalajara, Spain ††††Department of HPB Surgery and Liver Transplantation, Hospital Carlos Haya, Malaga, Spain ‡‡‡‡Exocrine Pancreas Research Unit, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, CIBEREHD, Barcelona, Spain §§§§Department of Digestive Surgery- Division of HBP Surgery, Hospital Universitario Donostia, San Sebastián, Spain ¶¶¶¶Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, IDIBAPS, CiberEHD, Barcelona, Spain ||||||||Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
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Roeyen G, Jansen M, Ruyssinck L, Chapelle T, Vanlander A, Bracke B, Hartman V, Ysebaert D, Berrevoet F. Pancreatic exocrine insufficiency after pancreaticoduodenectomy is more prevalent with pancreaticogastrostomy than with pancreaticojejunostomy. A retrospective multicentre observational cohort study. HPB (Oxford) 2016; 18:1017-1022. [PMID: 27726974 PMCID: PMC5144554 DOI: 10.1016/j.hpb.2016.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/05/2016] [Accepted: 09/05/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Recently, pancreaticogastrostomy (PG) has attracted renewed interest as a reconstruction technique after pancreaticoduodenectomy (PD), as it may imply a lower risk of clinical pancreatic fistula than reconstruction by pancreaticojejunostomy (PJ). We hypothesise that pancreatic exocrine insufficiency (PEI) is more common during clinical follow-up after PG than it is after PJ. RESEARCH DESIGN AND METHODS This study compares the prevalence of PEI in patients undergoing PD for malignancy with reconstruction by PG versus reconstruction by PJ. PEI during the first year of follow-up was defined as the intake of pancreatic enzyme replacement therapy (PERT) within one year postoperatively and/or an abnormal exocrine function test. RESULTS A total of 186 patients, having undergone surgery at two university hospitals, were included in the study. PEI during the first year postoperatively was present in 75.0% of the patients with PG, compared to 45.7% with PJ (p < 0.001). Intake of PERT within one year after surgery was found to be more prevalent in the PG group, i.e. 75.8% versus 38.5% (p < 0.001). There was a trend towards more disturbed exocrine function tests after PG (p = 0.061). CONCLUSIONS PEI is more common with PG reconstruction than with PJ reconstruction after pancreaticoduodenectomy for malignancy.
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Affiliation(s)
- Geert Roeyen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium; Faculty of Medicine, Antwerp University, Belgium.
| | - Miet Jansen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Laure Ruyssinck
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Belgium
| | - Thiery Chapelle
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium; Faculty of Medicine, Antwerp University, Belgium
| | - Aude Vanlander
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Belgium
| | - Bart Bracke
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium; Faculty of Medicine, Antwerp University, Belgium
| | - Vera Hartman
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium; Faculty of Medicine, Antwerp University, Belgium
| | - Dirk Ysebaert
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium; Faculty of Medicine, Antwerp University, Belgium
| | - Frederik Berrevoet
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Belgium
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Abstract
OBJECTIVES The aim of this study was to determine the prevalence of pancreatic exocrine insufficiency in patients with pancreatic or periampullary cancer, both before and after resection. METHODS Systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA guidelines). We included studies reporting on pancreatic exocrine insufficiency in patients with pancreatic or periampullary cancer. Data on patient demographics, type of pancreatic resection, diagnostic test, and occurrence of pancreatic exocrine insufficiency were extracted. Prevalence of pancreatic exocrine insufficiency was calculated before and after pancreatic resections and in patients with locally advanced pancreatic cancer. RESULTS Nine observational cohort studies with 693 patients were included. Median preoperative prevalence of pancreatic exocrine insufficiency was 44% (range, 42%-47%) before pancreatoduodenectomy, 20% (range, 16%-67%) before distal pancreatectomy, 63% before total pancreatectomy, and 25% to 50% in patients with locally advanced pancreatic cancer. The median prevalence of pancreatic exocrine insufficiency at least 6 months after pancreatoduodenectomy was 74% (range, 36%-100%) and 67% to 80% after distal pancreatectomy. CONCLUSION Pancreatic exocrine insufficiency is diagnosed in approximately half of all patients scheduled to undergo resection for pancreatic or periampullary cancer. The prevalence increases markedly after resection. These data highlight the need of pancreatic enzyme suppletion in these patients.
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Abstract
Background The pancreas has a central function in digestion and glucose homeostasis. With regard to the exocrine function, which is responsible for the digestion and absorption of nutrients and vitamins, the most important disturbances of these physiological processes are based on deficiencies in enzyme production and secretion, either due to impaired excretion caused by obstruction of the pancreatic duct or due to loss of pancreatic tissue. Both conditions result in maldigestion, malabsorption, and malnutrition. Methods Systematic literature review. Results Symptoms associated with pancreatic exocrine failure are gastrointestinal discomfort, steatorrhea, and weight loss. Pancreatic exocrine insufficiency caused by ductal obstruction occurs in chronic pancreatitis or with neoplasia of the pancreatic head. Loss of functional parenchyma can be caused either by chronic pancreatitis resulting in fibrotic replacement of the destroyed parenchyma or by a postoperative state of pancreatic resection. Conclusion In patients with chronic pancreatitis, a stage-adapted and timely therapy including conservative as well as surgical measures is essential to prevent functional deterioration and to preserve residual function. In the case of pancreatic resection for chronic pancreatitis, this can be achieved with modern organ-sparing surgery such as the duodenum-preserving pancreatic head resection. In patients requiring more extended pancreatic resections and even total duodenopancreatectomy, regardless of the underlying indication, adequate enzyme replacement and monitoring of the nutritional status is critical to prevent impairment of quality of life as well as detrimental malnutrition in the long term.
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Affiliation(s)
- Thilo Hackert
- Department of General Surgery, University of Heidelberg, Germany
| | - Kerstin Schütte
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University of Magdeburg, Germany
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University of Magdeburg, Germany
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Yasuda H, Fujiwara N, Ishizaki Y, Komatsu N. Anemia attributed to vitamin B6 deficiency in post-pancreaticoduodenectomy patients. Pancreatology 2014; 15:81-3. [PMID: 25543166 DOI: 10.1016/j.pan.2014.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 11/08/2014] [Accepted: 12/08/2014] [Indexed: 12/11/2022]
Abstract
Micronutrient deficiencies such as vitamin A, iron, zinc, and selenium have been known to occur as a consequence of pancreaticoduodenectomy (PD), but vitamin B6 deficiency has not been previously reported. We report two post-PD patients who developed anemias attributed to vitamin B6 deficiency. Oral supplementations of vitamin B6 significantly improved anemias in both cases. Micronutrients including vitamin B6 should be monitored in post-PD patients, and supplementations should be carried out when necessary.
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Affiliation(s)
- Hajime Yasuda
- Division of Hematology, Department of Medicine, Juntendo University School of Medicine, Tokyo, Japan.
| | - Noriko Fujiwara
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoichi Ishizaki
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Norio Komatsu
- Division of Hematology, Department of Medicine, Juntendo University School of Medicine, Tokyo, Japan
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Seguy D. Duodéno-pancréatectomie céphalique : quelle prise en charge en postopératoire ? NUTR CLIN METAB 2014. [DOI: 10.1016/j.nupar.2014.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nutritional status, fecal elastase-1, and 13C-labeled mixed triglyceride breath test in the long-term after pancreaticoduodenectomy. Pancreas 2014; 43:445-50. [PMID: 24622077 DOI: 10.1097/mpa.0000000000000048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study aimed to compare the body composition, dietary intake and serum levels of vitamins and minerals, and exocrine pancreatic function in patients late after pancreaticoduodenectomy (PD) and healthy subjects. METHODS Fifteen patients (PD group) who had undergone PD over 1 year before the study and 15 health volunteers (control group) were included in the study. All volunteers underwent dietary intake evaluation, body composition, laboratory data, exocrine pancreatic function by elastase-1, and carbon (C )-labeled triglycerides in breath tests. The PD group subjects also underwent upper gastrointestinal endoscopy and small intestinal bacterial overgrowth analysis. RESULTS Nutrient intake was adequate, and there were no differences in body mass index and mineral serum levels between the groups. The PD group showed lower serum levels of retinol, α-tocopherol, and ascorbic acid. Small intestinal bacterial overgrowth occurred in 39% of the patients. Fecal elastase-1 was lower in the PD group. The PD group had a higher C peak time; the cumulative label C recovery in 7 hours was similar in both groups. CONCLUSIONS Fecal elastase-1 decreased, and the excretion of C in breath was similar to healthy controls. Although the data point toward an adaptation in the absorptive capacity of fats, A, C, and E hypovitaminosis indicate that some absorptive insufficiency persists late after PD.
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Sikkens ECM, Cahen DL, de Wit J, Looman CWN, van Eijck C, Bruno MJ. Prospective assessment of the influence of pancreatic cancer resection on exocrine pancreatic function. Br J Surg 2013; 101:109-13. [DOI: 10.1002/bjs.9342] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 12/18/2022]
Abstract
Abstract
Background
Exocrine insufficiency frequently develops in patients with pancreatic cancer owing to tumour ingrowth and pancreatic duct obstruction. Surgery might restore this function by removing the primary disease and restoring duct patency, but it may also have the opposite effect, as a result of resection of functional parenchyma and anatomical changes. This study evaluated the course of pancreatic function, before and after pancreatic resection.
Methods
This prospective cohort study included patients with tumours in the pancreatic region requiring pancreatic resection in a tertiary referral centre between March 2010 and August 2012. Starting before surgery, exocrine function was determined monthly by measuring faecal elastase 1 levels (normal value over 0·200 µg per g faeces). Endocrine function, steatorrhoea-related symptoms and bodyweight were also evaluated before and after surgery. Subjects were followed from diagnosis until 6 months after surgery, or until death.
Results
Twenty-nine patients were included, 12 with pancreatic cancer, 14 with ampullary carcinoma and three with bile duct carcinoma (median tumour size 2·6 cm). Twenty-six patients underwent pancreaticoduodenectomy and three distal pancreatectomy. Thirteen patients had exocrine insufficiency at preoperative diagnosis. After a median follow-up of 6 months, this had increased to 24 patients. Diabetes was present in seven patients at diagnosis, and developed in one additional patient within 1 month after surgery.
Conclusion
Most patients with tumours in the pancreatic region requiring pancreatic resection either had exocrine insufficiency at diagnosis or became exocrine-insufficient soon after surgical resection.
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Affiliation(s)
- E C M Sikkens
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J de Wit
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C W N Looman
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C van Eijck
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Yu HJ, Lai HS, Chen KH, Chou HC, Wu JM, Dorjgochoo S, Mendjargal A, Altangerel E, Tien YW, Hsueh CW, Lai F. A sharable cloud-based pancreaticoduodenectomy collaborative database for physicians: emphasis on security and clinical rule supporting. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2013; 111:488-497. [PMID: 23706526 DOI: 10.1016/j.cmpb.2013.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 04/27/2013] [Accepted: 04/29/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a major operation with high complication rate. Thereafter, patients may develop morbidity because of the complex reconstruction and loss of pancreatic parenchyma. A well-designed database is very important to address both the short-term and long-term outcomes after PD. OBJECTIVE The objective of this research was to build an international PD database implemented with security and clinical rule supporting functions, which made the data-sharing easier and improve the accuracy of data. METHODS The proposed system is a cloud-based application. To fulfill its requirements, the system comprises four subsystems: a data management subsystem, a clinical rule supporting subsystem, a short message notification subsystem, and an information security subsystem. After completing the surgery, the physicians input the data retrospectively, which are analyzed to study factors associated with post-PD common complications (delayed gastric emptying and pancreatic fistula) to validate the clinical value of this system. RESULTS Currently, this database contains data from nearly 500 subjects. Five medical centers in Taiwan and two cancer centers in Mongolia are participating in this study. A data mining model of the decision tree analysis showed that elderly patients (>76 years) with pylorus-preserving PD (PPPD) have higher proportion of delayed gastric emptying. About the pancreatic fistula, the data mining model of the decision tree analysis revealed that cases with non-pancreaticogastrostomy (PG) reconstruction - body mass index (BMI)>29.65 or PG reconstruction - BMI>23.7 - non-classic PD have higher proportion of pancreatic fistula after PD. CONCLUSIONS The proposed system allows medical staff to collect and store clinical data in a cloud, sharing the data with other physicians in a secure manner to achieve collaboration in research.
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Affiliation(s)
- Hwan-Jeu Yu
- Department of Computer Science and Information Engineering, National Taiwan University, Taiwan
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41
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Berry AJ. Pancreatic surgery: indications, complications, and implications for nutrition intervention. Nutr Clin Pract 2013; 28:330-57. [PMID: 23609476 DOI: 10.1177/0884533612470845] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.
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Affiliation(s)
- Amy J Berry
- University of Virginia Health System, Surgical Nutrition Support/Nutrition Services, Charlottesville, VA 22908-0673, USA.
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42
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Zeanandin G, Schneider S, Hébuterne X. Conséquences nutritionnelles de la chirurgie digestive. NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2011.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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43
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Muniz CK, Braga CBM, Kemp R, Santos JSD, Cunha SFDCD. Clinical and nutritional status in the late postoperative of pancreaticoduodenectomy: influence of pylorus preservation procedure. Acta Cir Bras 2012; 27:123-30. [DOI: 10.1590/s0102-86502012000200005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 12/21/2011] [Indexed: 11/21/2022] Open
Abstract
PURPOSE: To evaluate the nutritional status of patients in the late postoperative period of pancreaticoduodenectomy (PD) and compare the long-term outcome according to pylorus-preserving (PPPD) or the standard technique (SPD) in which the pylorus is resected. METHODS: This prospective study was conducted twelve months prior or more in patients who had underwent PD (PD Group, n=15) and health volunteers (Control Group, n=15). At a post hoc analysis, the PD Group was divided in PPPD Subgroup (n=9) and SPD Subgroup (n=6), according to the PD techniques. Gastrointestinal complaints and nutritional status were evaluated, apart from a biochemical assessment; Student t-test or Mann-Whitney test were used. RESULTS: The patients recovered their body weight and the gastrointestinal complaints were uncommon. The PD Group showed higher energy and protein intake even though BMI was lower than in Control Group. There were no differences in laboratorial data, except for higher glycemia, serum alkaline phosfatase and C-reactive protein in PD Group. There was no difference in the various parameters evaluated when the Subgroups (PPPD and SPD) were compared. CONCLUSION: For long-term pancreaticoduodenectomy, the gastrointestinal symptoms are minimal and the patients had the clinical and nutritional status preserved, regardless of pylorus preservation.
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Halloran CM, Cox TF, Chauhan S, Raraty MGT, Sutton R, Neoptolemos JP, Ghaneh P. Partial pancreatic resection for pancreatic malignancy is associated with sustained pancreatic exocrine failure and reduced quality of life: a prospective study. Pancreatology 2011; 11:535-45. [PMID: 22094930 DOI: 10.1159/000333308] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 09/16/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatic resection for cancer may produce pancreatic exocrine insufficiency (PEI), which is poorly understood. This study examined the coefficient of fat absorption (CFA), symptoms, quality of life (QoL) and the accuracy of faecal elastase-1 (FE-1) measurement to predict PEI. METHODS Forty patients were analysed following resection for pancreatic malignancy. The primary endpoint was PEI diagnosis defined by CFA <93%; secondary endpoints were PEI diagnosis using FE-1 <200 μg/g, body mass index (BMI), and symptom and QoL analysis. Interventions were 3-day stool collection, EORTC QLQ-C30 (version 1) questionnaire and patient's diary, at 6 weeks and 3, 6 and 12 months after surgery. RESULTS CFA <93% was present in 67% of patients at 6 weeks and in 55% at 12 months. PEI using FE-1 was present in 77 and 83% of patients, respectively. No significant changes between time-points were observed. Sensitivity, specificity, PPV, NPV and accuracy for FE-1 in detecting CFA <93% were 91, 35, 70, 71 and 70%, respectively. CFA and FE-1 levels were uncorrelated. Overall, QoL increased at 6 (p = 0.0212) and 12 (p < 0.0001) months after surgery, mainly driven by physical, role and social functioning, and by appetite. Importantly, however, BMI and symptoms were unaffected by PEI, which suggests a subclinical presentation; such patients had attributes indicating poorer QoL (notably insomnia, p = 0.0012). CONCLUSIONS PEI was common and sustained following resection and not associated with significant symptoms. These patients had a tendency toward poorer QoL. FE-1 is a poor surrogate for diagnosing impaired fat absorption. Postoperative pancreatic enzyme replacement should be considered more routinely. and IAP.
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Affiliation(s)
- Christopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, and National Institute for Pancreas Biomedical Research Unit, Liverpool, UK
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Zinc Deficiency in Patients Undergoing Pancreatoduodenectomy for Periampullary Tumors Is Associated with Pancreatic Exocrine Insufficiency. World J Surg 2011; 35:2110-7. [DOI: 10.1007/s00268-011-1170-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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46
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Yu HH, Shan YS, Lin PW. Effect of pancreaticoduodenectomy on the course of hepatic steatosis. World J Surg 2010; 34:2122-7. [PMID: 20502896 DOI: 10.1007/s00268-010-0636-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The progression of hepatic steatosis after pancreaticoduodenectomy (PD) is controversial. This study was designed to determine whether PD would influence the course of hepatic steatosis. METHODS Patients admitted for PD and distal pancreatectomy (DP) from January 2004 to January 2008 were enrolled. Exclusion criteria included liver metastasis, severe obesity (body mass index >30), diabetic mellitus, excessive alcohol consumption, and unavailable preoperative and 6-month postoperative unenhanced CT images. The pre-PD and post-PD liver attenuation, ratio, and difference of liver-to-spleen attenuation between liver and spleen attenuation were compared. RESULTS Fifty patients who underwent PD and 20 patients who underwent DP were eligible. The mean follow-up period was 18.2 +/- 1.6 months for the PD group and 19.7 +/- 1.7 months for the DP group. Liver attenuation after PD was significantly decreased from 52.3 +/- 1.1 H. to 47.6 +/- 2 H. (p = 0.044), but no difference was observed in spleen attenuation. The liver-to-spleen attenuation ratio after PD also was significantly decreased: 1.12 +/- 0.02 versus 1.01 +/- 0.04 (p = 0.033). No difference in liver attenuation was found in the DP group. The female gender was a significant risk factor. CONCLUSIONS The liver attenuation of CT images decreases in patients who receive PD, which implicates that hepatic steatosis can develop after PD; however, the mechanism needs to be elucidated.
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Affiliation(s)
- Hsin-Hsien Yu
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
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Siren PMA, Siren MJ. Systemic zinc redistribution and dyshomeostasis in cancer cachexia. J Cachexia Sarcopenia Muscle 2010; 1:23-33. [PMID: 21475700 PMCID: PMC3060652 DOI: 10.1007/s13539-010-0009-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 05/10/2010] [Indexed: 12/20/2022] Open
Abstract
Cachexia affects up to two thirds of all cancer patients and is a significant cause of morbidity and mortality. It is a complex metabolic syndrome associated with the underlying illness and characterized by loss of skeletal muscle tissue with or without loss of fat mass. Cachexia's other prominent clinical symptoms include anorexia, systemic inflammation, pediatric growth failure, and hypogonadism. The relationship between the symptoms of cancer cachexia and the underlying illness is unclear, and there is an urgent need for a better understanding of the pathophysiology of this syndrome. Normal Zn metabolism is often disrupted in cancer patients, but the possible effects of systemic Zn dyshomeostasis in cachexia have not been investigated. We propose that the acute phase response can mediate Zn redistribution and accumulation in skeletal muscle tissue and contribute to the activation of the ubiquitin-proteasome pathway that regulates protein catabolism. This chronic redistribution deprives Zn from other tissues and organs and compromises critical physiological functions in the body. The cardinal symptoms of Zn deficiency are anorexia, systemic inflammation, growth failure in children, and hypogonadism. These symptoms also prominently characterize cancer cachexia suggesting that the role of systemic Zn dyshomeostasis in cachexia should be investigated.
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Affiliation(s)
- Pontus M. A. Siren
- JGK Memorial Research Library, Snellmaninkatu 15, 00170 Helsinki, Finland
- Bioneris Ab, Valbay, Adolf Fredriks Kyrkogatan 13, 11137 Stockholm, Sweden
- Toolon k 19 B, 00260 Helsinki, Finland
| | - Matti J. Siren
- JGK Memorial Research Library, Snellmaninkatu 15, 00170 Helsinki, Finland
- Bioneris Ab, Valbay, Adolf Fredriks Kyrkogatan 13, 11137 Stockholm, Sweden
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Seguy D, Bouteloup C. Suivi nutritionnel après une duodénopancréatectomie céphalique. NUTR CLIN METAB 2010. [DOI: 10.1016/j.nupar.2010.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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49
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Yu HH, Shan YS, Lin PW. Zinc deficiency with acrodermatitis enteropathica-like eruption after pancreaticoduodenectomy. J Formos Med Assoc 2007; 106:864-8. [PMID: 17964967 DOI: 10.1016/s0929-6646(08)60053-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is the standard operation for periampullary lesions. Most reports have focused on the clinical outcome, complications and tumor recurrence after PD. Few studies have focused on the nutritional sequelae that result from the extended resection of the upper gastrointestinal tract and disruption of the normal physiologic process of digestion. Zinc is absorbed mainly in the duodenum and proximal jejunum, which are removed during PD. Herein, we report two patients who experienced zinc deficiency with acrodermatitis enteropathica-like eruption, alopecia, glossitis and nail dystrophy after PD. The lesions improved dramatically after supplementation with zinc sulfate, pancreatic enzyme and diet instructions. No symptoms related to zinc deficiency were noted on follow-up after nutritional instructions had been given to the patients.
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Affiliation(s)
- Hsin-Hsien Yu
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
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50
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Armstrong T, Strommer L, Ruiz-Jasbon F, Shek FW, Harris SF, Permert J, Johnson CD. Pancreaticoduodenectomy for peri-ampullary neoplasia leads to specific micronutrient deficiencies. Pancreatology 2007; 7:37-44. [PMID: 17449964 DOI: 10.1159/000101876] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Accepted: 09/20/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS After pancreaticoduodenectomy (PD) patients may be deficient in essential micronutrients. This study was designed to determine if this is a consequence of surgery. METHODS Long-term survivors (>6 months) of PD for peri-ampullary neoplasia and healthy controls (patients' spouse/partner) were enrolled in the study. Specific clinical parameters were recorded, serum micronutrient levels were measured and subjects completed 7-day food diaries. RESULTS Thirty-seven patients were studied, 25 with paired controls. All were well nourished, as defined by body mass index and food diary analysis. Patients with paired controls were representative of all patients studied. Patients had raised transferrin (median 2.60 vs. 2.16 g/l, p = 0.001) and low ferritin levels (34.9 vs. 119.0 g/l, p < 0.001) indicating relative iron deficiency. Patients also demonstrated lower levels of the anti-oxidants selenium (0.77 vs. 0.93 micromol/l, p < 0.001) and vitamin E (23.2 vs. 35.7 micromol/l, p < 0.001) with 57% of patients having frank selenium deficiencies. Patients had lower levels of vitamin D than controls (15.7 vs. 19.6 micromol/l, p = 0.001) and 30% of patients had a raised parathyroid hormone level, suggesting compensatory mechanisms operate to maintain normocalcaemia. CONCLUSIONS Long-term survivors of PD are relatively deficient in several micronutrients compared to non-operated controls taking the same diet. We recommend that micronutrient status should be regularly checked in these patients and treated where necessary.
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Affiliation(s)
- T Armstrong
- University Department of Surgery, Southampton General Hospital, Southampton, UK.
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