Nutritional Support in Pancreatic Diseases

Fat malabsorption in pancreatic cancer: Pathophysiology and management

Exocrine pancreatic insufficiency (EPI) is common in pancreatic ductal adenocarcinoma (PDAC) and may lead to significant nutrition compromise. In the setting of cancer cachexia and gastrointestinal toxicities of cancer treatments, untreated (or undertreated) EPI exacerbates weight loss, sarcopenia, micronutrient deficiencies, and malnutrition. Together, these complications contribute to poor tolerance of oncologic therapies and negatively impact survival. Treatment of EPI in PDAC involves the addition of pancreatic enzyme replacement therapy, with titration to improve gastrointestinal symptoms. Medical nutrition therapies may also be applicable and may include fat-soluble vitamin replacement, medium-chain triglycerides, and, in some cases, enteral nutrition. Optimizing nutrition status is an important adjunct treatment approach to improve quality of life and may also improve overall survival.

Rational Prescribing of Pancreatic Enzymes for Patients with Pancreatic Cancer

Most patients with pancreatic cancer at some point present with symptoms related to exocrine pancreatic insufficiency (EPI). These include diarrhea, abdominal bloating, indigestion, steatorrhea, weight loss, and anorexia. Even though up to 80% of pancreatic cancer patients eventually present with symptoms related to exocrine pancreatic insufficiency, only 21% are prescribed pancreatic enzyme replacement therapy (PERT). Its effectiveness is also highly dependent on its proper timing of administration, and patients must be thoroughly educated about this. The impact of symptoms of EPI can lead to poorer overall well-being. Pharmacists play a crucial role in properly educating patients on the correct use of pancreatic enzyme replacement therapy. PERT is a key strategy in managing the symptoms of EPI and can improve quality of life, which is a central focus in palliative care. This treatment is profoundly underutilized in the palliative care of these patients. The objective of this review is to discuss the pharmacology, pharmacokinetics, side effects, available evidence of the effectiveness of pancreatic enzyme use for patients with pancreatic cancer, and challenges, along with proposed solutions regarding its use.

Influence of standardized nursing intervention combined with mindfulness stress reduction training on the curative effect in patients with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common inflammatory disease of the pancreas with high mortality rates. It is of great significance to take scientific intervention measures for patients with AP in time.

AIM

To explore the effect of standardized nursing combined with mindfulness stress reduction training on the curative effect, negative emotion, and quality of life in patients with acute pancreatitis.

METHODS

A total of 80 patients with acute pancreatitis admitted to The First People's Hospital of Jiangxia District Hospital from May 2021 to May 2023 were randomly divided into control group and observation group (n = 40). Patients in control group were given the standardized nursing intervention, and the observation group were given standardized nursing plus mindfulness stress reduction training intervention. The time of clinical symptom disappeared or improved, complication occurrence rate, emotional state, and quality of life score of the two groups were observed and compared.

RESULTS

In comparison with the control group, the bowel sound recovery time, ventosity and abdominal pain improvement time, and venting and cacation time in observation group were shorter, and the total incidence rate of complications was reduced, showing statistically significant difference (P < 0.05). The scores of anxiety and depression in observation group were lower than those in control group (P < 0.05). Serum levels of tumour necrosis factor alpha, interleukin (IL)-6, IL-1β and IL-8 in observation group were lower than those in control group (P < 0.05). The scores of life quality in physiology, psychology, environment and social relations in observation group were higher than those in control group, and the differences were statistically significant (P < 0.05).

CONCLUSION

The application of standardized nursing intervention combined with mindfulness stress reduction training in patients with acute pancreatitis has a definite effect, which can help to ameliorate the clinical symptoms, anxiety and depression of patients, reduce the incidence rate of complications, and improve the prognosis of patients.

Pancreatic Ductal Adenocarcinoma and Nutrition: Exploring the Role of Diet and Gut Health

The incidence of pancreatic cancer is increasing worldwide. The most common form is represented by pancreatic ductal adenocarcinoma (PDAC) which has been shown to be linked to chronic inflammation. Notably, the gut microbiota has emerged as a critical player in regulating immune responses and inflammation. Indeed, intestinal dysbiosis, characterized by an imbalance in the gut microbiota composition, can contribute to the initiation of chronic inflammation. Sterile chronic inflammation can occur, probably activated by the translocation of bacterial components, such as lipopolysaccharide (LPS), the major component of Gram-negative microbiota, with the consequent induction of innate mucosal immunity, through the activation of Toll-like receptors (TLRs). Furthermore, the interaction between LPS and TLRs could enhance cancer progression. Recent research has shed light on the pivotal role of nutrition, as a modifiable risk factor, in PDAC immunological processes, particularly focusing on the immuno-modulatory effects of the gut microbiota. Different dietary regimens, fiber intake, immunonutrients, and antioxidants have the potential to either exacerbate or mitigate chronic inflammation, thereby influencing the pathogenesis and natural history of PDAC. These dietary components may affect the gut microbiota composition and, consequently, the level of inflammation, either promoting or protecting against PDAC. In this review of reviews, we discuss the modulatory role of nutrition and the gut microbiota in PDAC's immunological processes to explore a translational therapeutic approach that could improve the survival and quality of life of these patients.

Evaluation of Nutritional Status and the Impact of Nutritional Treatment in Patients with Pancreatic Cancer

Patients with pancreatic cancer who develop irreversible cancer cachexia have a life expectancy of less than 3 months. Therefore, it is extremely important to evaluate the patient's nutritional status as early as possible and to implement an appropriate nutritional intervention in order to reduce the risk of further weight loss and/or muscle loss, which affect the outcomes of cancer treatment and the correct nutritional treatment in patients with pancreatic cancer. A literature review was performed by using the PubMed and Cochrane quick search methodology. The main purpose of this review was to present the current approach to nutritional treatment in pancreatic cancer. The review included publications, most of which concerned clinical nutrition as part of the phase of treatment of patients with pancreatic cancer, nutritional and metabolic disorders in pancreatic cancer, and the period after pancreatic resection. Some of the publications concerned various nutritional interventions in patients with pancreatic cancer undergoing chemotherapy or surgical treatment (nutritional support before surgery, after surgery, or during palliative treatment). There is an unmet need for integrated nutritional therapy as a key part of the comprehensive care process for PC patients. Nutritional counseling is the first line of nutritional treatment for malnourished cancer patients, but pancreatic enzyme replacement therapy also constitutes the cornerstone of nutritional treatment for relieving symptoms of indigestion and maintaining or improving nutritional status.

Cutoff Value of Psoas Muscle Area as Reduced Muscle Mass and Its Association with Acute Pancreatitis in China

Objective

The Global Leadership Initiative on Malnutrition (GLIM) has proposed criteria for the diagnosis of malnutrition, one of which is reduced muscle mass. Computed tomography (CT) assessment of psoas muscle area (PMA) has been used to estimate muscle mass in patients, including those with acute pancreatitis (AP). The present study aimed to define the cutoff value of PMA indicative of reduced muscle mass in patients with AP and to assess the impact of reduced muscle mass on the severity and early complications of AP.

Methods

Clinical data of 269 patients with AP were analyzed retrospectively. The severity of AP was determined according to the revised Atlanta classification. PMA was evaluated by CT and used to calculate the psoas muscle index (PMI). Cutoff values for reduced muscle mass were calculated and validated. Logistic regression analysis was performed to assess the relationship between PMA and the severity of AP.

Results

PMA was a better indicator of reduced muscle mass than PMI, with cutoff values of 11.50 cm² for men and 8.22 cm² for women. Rates of local complications, splenic vein thrombosis, and organ failure were significantly higher in AP patients with low than high PMA (all p < 0.05). PMA showed good ability to predict splenic vein thrombosis in women, with an area under the receiver operating characteristic curve of 0.848 (95% confidence interval 0.768-0.909, sensitivity 100%, specificity 83.64%). Multivariate logistic regression revealed that PMA was an independent risk factor for moderately severe plus severe AP (odds ratio 5.639, p = 0.001) and severe AP (odds ratio 3.995, p = 0.038).

Conclusion

PMA is a good predictor of the severity and complications of AP. The PMA cutoff value is a good indicator of reduced muscle mass.

Physiological stress level and screening for malnutrition as preoperative predictors of postoperative complications in pancreatic surgery: a retrospective study

BACKGROUND

Assessment of 'physiological stress levels' and 'nutritional status' before surgery is important for predicting complications and indirect interventions on the pancreas. The aim of this study was to determine neutrophil-lymphocyte ratio (NLR) and nutritional risk index (NRI) indicators before surgery to predict 90-day complications and mortality in a cohort of patients with complicated chronic pancreatitis and cancer of the head of the pancreas.

METHODS

We evaluated preoperative levels of NLR and NRI among 225 subjects treated at different centres located in three countries. Short-term outcomes included length of hospital stay, postoperative complications, and mortality at 90 days and were appreciated based on NLR and NRI. The level of physiological stress was divided according by the formulas: neutrophil-lymphocyte ratio (NLR) = (neutrophil count, %)/(lymphocyte count, %). The nutritional state of the patients was divided according to the INR: NRI = (1.519 × serum albumin, g/L) + (41.7 × present weight, kg / usual weight, kg)].

RESULTS

All patients were operated. An analysis of the operations performed in three institutions demonstrated mortality in chronic pancreatitis and pancreatic pseudocysts in 1.4%, in chronic pancreatitis and the presence of an inflammatory mass mainly in the pancreatic head in 1.2%, and in cancer of the pancreatic head in 5.9%. The mean preoperative NLR was normal in 33.8% of the patients, the mild physiologic stress level was 54.7%, and the moderate was 11.5% before surgery. 10.2% of patients had a normal nutritional status, 20% had mild, 19.6% had moderate, and 50.2% had severe malnutrition. In a univariate analysis, at the cutoff of NLR ≥ 9.5 (AUC = 0.803) and the cutoff of NRI ≤ 98.5 (AUC = 0.801), increasing the risk of complications was observed (hazard ratio, 2.01; 95% CI, 1.247-3.250, p = 0.006), but at the cutoff of NRI ≤ 83.55 (AUC = 0.81), we observed a survival difference in operated patients (hazard ratio, 2.15; 95% CI, 1.334-3.477, p = 0.0025).

CONCLUSIONS

Our study demonstrated that NLR and NRI were predictors of postoperative complications, but only NRI was a predictor of 90-day mortality in patients after surgery.

Nutritional Interventions during Chemotherapy for Pancreatic Cancer: A Systematic Review of Prospective Studies

BACKGROUND

Pancreatic cancer incidence is growing, but the prognosis for survival is still poor. Patients with pancreatic cancer often suffer from malnutrition and sarcopenia, two clinical conditions that negatively impact oncological clinical outcomes. The aim of this systematic review was to analyze the impact of different nutritional interventions on clinical outcomes in patients with pancreatic cancer during chemotherapy.

METHODS

A systematic review of MedLine, EMBASE, and Web of Science was carried out in December 2022, identifying 5704 articles. Titles and abstracts of all records were screened for eligibility based on inclusion criteria, and nine articles were included.

RESULTS

All nine articles included were prospective studies, but a meta-analysis could not be performed due to heterogenicity in nutritional intervention. This Systematic Review shows an improvement in Quality of Life, nutritional status, body composition, oral intake, and Karnofsky Performance Status, following nutritional interventions.

CONCLUSIONS

This Systematic Review in pancreatic cancer patients during chemotherapies does not allow one to draw firm conclusions. However, nutritional support in pancreatic cancer patients is advisable to ameliorate oncological care. Further well-designed prospective studies are needed to identify nutritional support's real impact and to establish a reliable way to improve nutritional status of pancreatic cancer patients during chemotherapy.

CONUT score is associated with short-term prognosis in patients with severe acute pancreatitis: a propensity score matching cohort study

Background

The Controlling Nutritional Status (CONUT) score was designed to assess the immune-nutritional status in patients. This study aimed to investigate the role of the CONUT score in the short-term prognosis of severe acute pancreatitis.

Methods

This was a retrospective cohort study. 488 patients with severe acute pancreatitis at the Department of Critical Care Medicine of the West China Hospital of Sichuan University (Chengdu, China) were enrolled in the study. Baseline data were collected from the West China Hospital of Sichuan University database. The primary outcome during follow-up was all-cause mortality. The secondary outcomes were 28 day mortality, renal insufficiency, length of stay (LOS) in the ICU, and length of stay (LOS) in the hospital. Patients were divided into two groups based on a median CONUT score of 7, and baseline differences between the two groups were eliminated by propensity matching. Univariate Cox regression analyses were performed to estimate the association between CONUT score and outcomes. The Kaplan-Meier method was used to estimate the survival rate of patients.

Results

CONUT score was an independent predictor of all-cause mortality (hazard ratio [HR]:2.093; 95%CI: 1.342-3.263; p < 0.001) and 28 day mortality (hazard ratio [HR]:1.813; 95%CI: 1.135-2.896; p < 0.013). CONUT score was not statistically significant in predicting the incidence of renal insufficiency. The high CONUT group had significantly higher all-cause mortality (p < 0.001), and 28 day mortality (p < 0.011) than the low CONUT group.

Conclusion

The CONUT score is an independent predictor of short-term prognosis in patients with severe acute pancreatitis, and timely nutritional support is required to reduce mortality in patients with severe acute pancreatitis.