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Bar N, Abdelgani S, Lal S, Deutsch L. A look inside the gut as a clue to nutritional status. Curr Opin Clin Nutr Metab Care 2024:00075197-990000000-00157. [PMID: 38837038 DOI: 10.1097/mco.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
PURPOSE OF REVIEW Malabsorption and malnutrition are common gastrointestinal manifestations clinicians face, requiring diagnostic workup for effective diagnosis and management of the underlying cause. This review discusses recent advances in diagnostic approaches to malabsorption and maldigestion of macronutrients - lipids, proteins, and carbohydrates. We highlight underrecognized causes, available testing modalities, and ongoing diagnostic unmet needs. RECENT FINDINGS Innovations in the diagnostic landscape are enhancing our understanding of malabsorption syndromes. Stool collection and handling is uncomfortable and commonly avoided. The objective quantification of stool lipids, bile acids, and gut enzymes is therefore underused in the diagnosis and management of common disorders such as exocrine pancreatic insufficiency, bile acid diarrhea, protein-losing enteropathy, and more. We review the recent advancements in spot quantification of stool fat and bile acid content, endoscopic imaging techniques such as endocytoscopy, confocal laser endomicroscopy, and optical coherence tomography and the future place in clinical practice. SUMMARY Malabsorption and maldigestion represent significant challenges in clinical nutrition and gastroenterology. Through the integration of advanced diagnostic techniques, clinicians will be better equipped to tailor therapy and monitor treatment response, ultimately improving patient health outcomes. This review underscores the critical role of innovative diagnostic tools in accurately detecting and effectively managing gastrointestinal disorders linked to nutritional status.
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Affiliation(s)
- Nir Bar
- Department of Gastroenterology and Liver diseases, Tel-Aviv Sourasky Medical Center
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Siham Abdelgani
- Department of Gastroenterology and Liver diseases, Tel-Aviv Sourasky Medical Center
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford
- Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Liat Deutsch
- Department of Gastroenterology and Liver diseases, Tel-Aviv Sourasky Medical Center
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Balaban DV, Coman LI, Balaban M, Costache RS, Jinga M. Novel Insights into Postoperative Surveillance in Resected Pancreatic Cystic Neoplasms-A Review. Diagnostics (Basel) 2024; 14:1056. [PMID: 38786354 PMCID: PMC11119521 DOI: 10.3390/diagnostics14101056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/11/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Pancreatic cystic lesions (PCL) are frequently encountered in clinical practice and some are referred to surgery due to their neoplastic risk or malignant transformation. The management of PCL involves complex decision-making, with postoperative surveillance being a key component for long-term outcomes, due to the potential for recurrence and postoperative morbidity. Unfortunately, the follow-up of resected patients is far from being optimal and there is a lack of consensus on recommendations with regard to timing and methods of surveillance. Here, we summarize the current knowledge on the postoperative surveillance of neoplastic pancreatic cysts, focusing on the mechanisms and risk factors for recurrence, the recurrence rates according to the initial indication for surgery, the final result of the surgical specimen and neoplastic risk in the remaining pancreas, as well as the postsurgical morbidity comprising pancreatic exocrine insufficiency, metabolic dysfunction and diabetes after resection, according to the type of surgery performed. We analyze postsurgical recurrence rates and morbidity profiles, as influenced by different surgical techniques, to better delineate at-risk patients, and highlight the need for tailored surveillance strategies adapted to preoperative and operative factors with an impact on outcomes.
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Affiliation(s)
- Daniel Vasile Balaban
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Laura-Ioana Coman
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Marina Balaban
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Raluca Simona Costache
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
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Alexandre-Heymann L, Yaker F, Lassen PB, Dubois-Laforgue D, Larger E. Pancreatic enzyme replacement therapy in subjects with exocrine pancreatic insufficiency and diabetes mellitus: a real-life, case-control study. Diabetol Metab Syndr 2024; 16:39. [PMID: 38331895 PMCID: PMC10854028 DOI: 10.1186/s13098-024-01265-4] [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: 12/08/2023] [Accepted: 01/10/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Exocrine pancreatic insufficiency (EPI) can be associated with all types of diabetes. Pancreatic enzyme replacement therapy (PERT) has short and long-term benefits in subjects with EPI, but its effects on diabetes control are uncertain. We aimed to study the effects of PERT initiation on glycemic control in subjects with diabetes and EPI from any cause. METHODS In this retrospective study, we compared subjects with EPI and diabetes who were prescribed PERT with subjects with diabetes who had a fecal elastase-1 concentration dosage, but did not receive PERT. The primary outcome was the effect of PERT on hypoglycemia frequency and severity. The secondary outcomes were the effects of PERT on gastro-intestinal disorders, HbA1c and body mass index (BMI). RESULTS 48 subjects were included in each group. Overall, PERT did not have any significant effect on hypoglycemia frequency or severity, but hypoglycemia frequency tended to decrease in subjects with chronic pancreatitis. While 19% of subjects experienced mild hyperglycemia after PERT initiation, we did not report any keto-acidosis or any other severe adverse event. Gastro-intestinal disorders improved in 80% of subjects treated with PERT, versus in 20% of control subjects (p = 0.02). Gastro-intestinal disorders improved in 87% of subjects with recommended dosage of PERT, versus in 50% of subjects with underdosage (NS). HbA1c and BMI evolution did not differ between the groups. CONCLUSIONS PERT initiation is safe in subjects with diabetes and EPI. It does not globally decrease hypoglycemia severity of frequency, but is associated with a decrease in gastro-intestinal disorders. Trial registration Retrospectively registered. The database was registered with the Commission Nationale Informatique et Libertés (CNIL), registration number: 2203351v0. The study was approved by the local ethics committee CLEP, registration number: AAA-2023-09047.
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Affiliation(s)
- Laure Alexandre-Heymann
- Service de Diabétologie, AP-HP, Hôpital Cochin, 123 boulevard de Port-Royal, 75014, Paris, France.
- Institut Cochin, INSERM, CNRS, Université Paris Cité, Paris, France.
| | - Fetta Yaker
- Service de Diabétologie, AP-HP, Hôpital Cochin, 123 boulevard de Port-Royal, 75014, Paris, France
| | - Pierre Bel Lassen
- Sorbonne Université, INSERM, Nutrition and Obesities: Systemic approaches (NutriOmics), Paris, France
- Service de Nutrition, AP-HP, Hôpital Pitié-Salpétrière, Paris, France
| | - Danièle Dubois-Laforgue
- Service de Diabétologie, AP-HP, Hôpital Cochin, 123 boulevard de Port-Royal, 75014, Paris, France
- Institut Cochin, INSERM, CNRS, Université Paris Cité, Paris, France
| | - Etienne Larger
- Service de Diabétologie, AP-HP, Hôpital Cochin, 123 boulevard de Port-Royal, 75014, Paris, France
- Institut Cochin, INSERM, CNRS, Université Paris Cité, Paris, France
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Wilschanski M, Munck A, Carrion E, Cipolli M, Collins S, Colombo C, Declercq D, Hatziagorou E, Hulst J, Kalnins D, Katsagoni CN, Mainz JG, Ribes-Koninckx C, Smith C, Smith T, Van Biervliet S, Chourdakis M. ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clin Nutr 2024; 43:413-445. [PMID: 38169175 DOI: 10.1016/j.clnu.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented. METHODS The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members. RESULTS The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Anne Munck
- Cystic Fibrosis Centre, Hopital Necker-Enfants Malades, AP-HP, Paris, France
| | - Estefania Carrion
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sarah Collins
- CF Therapies Team, Royal Brompton & Harefield Hospital, London, UK
| | - Carla Colombo
- University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitri Declercq
- Cystic Fibrosis Reference Centre, Ghent University Hospital and Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Elpis Hatziagorou
- Cystic Fibrosis Unit, 3rd Pediatric Dept, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics and Department of Nutritional Sciences, The University of Toronto, Toronto, Canada
| | - Daina Kalnins
- Department of Clinical Dietetics, The Hospital for Sick Children, Toronto, Canada
| | - Christina N Katsagoni
- Department of Clinical Nutrition, Agia Sofia Children's Hospital, Athens, Greece; EFAD, European Specialist Dietetic Networks (ESDN) for Gastroenterology, Denmark
| | - Jochen G Mainz
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterology and Paediatric Cystic Fibrosis Unit. La Fe Hospital & La Fe Research Institute, Valencia, Spain
| | - Chris Smith
- Department of Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Thomas Smith
- Independent Patient Consultant Working at Above-disease Level, UK
| | | | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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Hall LA, Powell-Brett S, Halle-Smith J, Ward L, Wiggins T, Markar SR, Roberts KJ. Pancreatic exocrine insufficiency after non-pancreatic upper gastrointestinal surgery: meta-analysis. Br J Surg 2024; 111:znad369. [PMID: 38064682 DOI: 10.1093/bjs/znad369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/12/2023] [Accepted: 10/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Untreated pancreatic exocrine insufficiency (PEI) results in substantial patient harm. Upper gastrointestinal surgery (bariatric metabolic surgery and oesophagogastric resection) affects the delicate physiology of pancreatic exocrine function and may result in PEI. The aim of this study was to assimilate the literature on incidence, diagnosis, and management of PEI after bariatric metabolic surgery and oesophagogastric resection. METHODS A systematic review of PubMed, MEDLINE, and Embase databases identified studies investigating PEI after non-pancreatic upper gastrointestinal surgery. Meta-analyses were undertaken for incidence of PEI and benefit of pancreatic enzyme replacement therapy. RESULTS Among 1620 patients from 24 studies included in quantitative synthesis, 36.0% developed PEI. The incidence of PEI was 23.0 and 50.4% after bariatric metabolic surgery and oesophagogastric resection respectively. Notably, the incidence of PEI was 44% after biliopancreatic diversion with duodenal switch and 66.2% after total gastrectomy. The most common diagnostic test used was faecal elastase 1 (15 of 31 studies), with less than 200 µg/g being diagnostic of PEI. A total of 11 studies considered the management of pancreatic exocrine insufficiency, with 78.6% of patients responding positively to pancreatic enzyme replacement when it was prescribed. CONCLUSION PEI is common after non-pancreatic upper gastrointestinal surgery and patients may benefit from enzyme replacement therapy.
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Affiliation(s)
- Lewis A Hall
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Scientists, University of Birmingham, Birmingham, UK
| | - Sarah Powell-Brett
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - James Halle-Smith
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - Liz Ward
- Department Therapies and Dietetics, Churchill Hospital, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - Tom Wiggins
- Department of Bariatric Surgery and Upper Gastrointestinal Surgery, Birmingham Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sheraz R Markar
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Keith J Roberts
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Scientists, University of Birmingham, Birmingham, UK
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Croagh D, Michalski CW, van Berge Henegouwen MI, Alfieri S. Diagnosis and management of pancreatic insufficiency in patients with gastrectomy due to cancer or gastric ulcers: a virtual roundtable expert discussion. Expert Rev Gastroenterol Hepatol 2023; 17:1313-1319. [PMID: 38108090 DOI: 10.1080/17474124.2023.2296762] [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: 05/30/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Pancreatic exocrine insufficiency (PEI) is common after gastric resection for cancer or ulcers but is under-recognized and undertreated. Although pancreatic enzyme replacement therapy (PERT) is the mainstay of PEI management, robust evidence supporting its use after gastric surgery is limited. AREAS COVERED In the absence of guideline recommendations specific for patients with pancreatic insufficiency after gastrectomy, a panel of experts from different geographical regions convened in a virtual meeting to discuss their approach to patient management. EXPERT OPINION Pancreatic insufficiency after gastrointestinal surgery is not a simple post-surgical complication as several factors contribute to its development. Although the pancreas is unimpaired after gastrectomy, it cannot function normally in the altered environment. Pancreatic insufficiency can be challenging to diagnose in gastrectomy patients due to nonspecific symptoms and the absence of a simple diagnostic test. Fecal elastase appears to be the default test, although it is not sufficiently sensitive nor reliable for diagnosing or monitoring PEI. Patients with maldigestion symptoms after gastrectomy are treated pragmatically: those with clinical suspicion of pancreatic insufficiency receive a trial of PERT and are monitored for symptom improvement. There is a clear need for high-quality evidence from clinical trials to guide the management of this patient population.
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Affiliation(s)
- Daniel Croagh
- Department of General Surgery, Monash Health, Melbourne, Victoria, Australia; School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | | | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Sergio Alfieri
- Divisione di Chirurgia Digestiva, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
- CRMPG (Advanced Pancreatic Research Center), Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Rome, Italy
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7
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Kumar P, Chander A, Chittajallu V, Grewal US. Underutilization of pancreatic enzyme replacement therapy in pancreatic cancer and chronic pancreatitis. J Intern Med 2023; 294:679-681. [PMID: 37264522 DOI: 10.1111/joim.13671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Prabhat Kumar
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Cleveland, Ohio, USA
| | - Apoorva Chander
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Vibhu Chittajallu
- Department of Gastroenterology and Hepatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Udhayvir Singh Grewal
- Division of Hematology, Oncology, Bone and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Holden Comprehensive Cancer Center, Iowa City, Iowa, USA
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8
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Whitcomb DC, Buchner AM, Forsmark CE. AGA Clinical Practice Update on the Epidemiology, Evaluation, and Management of Exocrine Pancreatic Insufficiency: Expert Review. Gastroenterology 2023; 165:1292-1301. [PMID: 37737818 DOI: 10.1053/j.gastro.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/18/2023] [Accepted: 07/04/2023] [Indexed: 09/23/2023]
Abstract
DESCRIPTION Exocrine pancreatic insufficiency (EPI) is a disorder caused by the failure of the pancreas to deliver a minimum/threshold level of specific pancreatic digestive enzymes to the intestine, leading to the maldigestion of nutrients and macronutrients, resulting in their variable deficiencies. EPI is frequently underdiagnosed and, as a result, patients are often not treated appropriately. There is an urgent need to increase awareness of and treatment for this condition. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review was to provide Best Practice Advice on the epidemiology, evaluation, and management of EPI. METHODS This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: EPI should be suspected in patients with high-risk clinical conditions, such as chronic pancreatitis, relapsing acute pancreatitis, pancreatic ductal adenocarcinoma, cystic fibrosis, and previous pancreatic surgery. BEST PRACTICE ADVICE 2: EPI should be considered in patients with moderate-risk clinical conditions, such as duodenal diseases, including celiac and Crohn's disease; previous intestinal surgery; longstanding diabetes mellitus; and hypersecretory states (eg, Zollinger-Ellison syndrome). BEST PRACTICE ADVICE 3: Clinical features of EPI include steatorrhea with or without diarrhea, weight loss, bloating, excessive flatulence, fat-soluble vitamin deficiencies, and protein-calorie malnutrition. BEST PRACTICE ADVICE 4: Fecal elastase test is the most appropriate initial test and must be performed on a semi-solid or solid stool specimen. A fecal elastase level <100 μg/g of stool provides good evidence of EPI, and levels of 100-200 μg/g are indeterminate for EPI. BEST PRACTICE ADVICE 5: Fecal elastase testing can be performed while on pancreatic enzyme replacement therapy. BEST PRACTICE ADVICE 6: Fecal fat testing is rarely needed and must be performed when on a high-fat diet. Quantitative testing is generally not practical for routine clinical use. BEST PRACTICE ADVICE 7: Response to a therapeutic trial of pancreatic enzymes is unreliable for EPI diagnosis. BEST PRACTICE ADVICE 8: Cross-sectional imaging methods (computed tomography scan, magnetic resonance imaging, and endoscopic ultrasound) cannot identify EPI, although they play an important role in the diagnosis of benign and malignant pancreatic disease. BEST PRACTICE ADVICE 9: Breath tests and direct pancreatic function tests hold promise, but are not widely available in the United States. BEST PRACTICE ADVICE 10: Once EPI is diagnosed, treatment with pancreatic enzyme replacement therapy (PERT) is required. If EPI is left untreated, it will result in complications related to fat malabsorption and malnutrition, having a negative impact on quality of life. BEST PRACTICE ADVICE 11: PERT formulations are all derived from porcine sources and are equally effective at equivalent doses. There is a need for H2 or proton pump inhibitor therapy with non-enteric-coated preparations. BEST PRACTICE ADVICE 12: PERT should be taken during the meal, with the initial treatment of at least 40,000 USP units of lipase during each meal in adults and one-half of that with snacks. The subsequent dosage can be adjusted based on the meal size and fat content. BEST PRACTICE ADVICE 13: Routine supplementation and monitoring of fat-soluble vitamin levels are appropriate. Dietary modifications include a low-moderate fat diet with frequent smaller meals and avoiding very-low-fat diets. BEST PRACTICE ADVICE 14: Measures of successful treatment with PERT include reduction in steatorrhea and associated gastrointestinal symptoms; a gain of weight, muscle mass, and muscle function; and improvement in fat-soluble vitamin levels. BEST PRACTICE ADVICE 15: EPI should be monitored and baseline measurements of nutritional status should be obtained (body mass index, quality-of-life measure, and fat-soluble vitamin levels). A baseline dual-energy x-ray absorptiometry scan should be obtained and repeated every 1-2 years.
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Affiliation(s)
- David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anna M Buchner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
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Lewis DM, Shahid A. Survey of Pancreatic Enzyme Replacement Therapy Dosing Experiences in Adults with Exocrine Pancreatic Insufficiency. Healthcare (Basel) 2023; 11:2316. [PMID: 37628514 PMCID: PMC10454644 DOI: 10.3390/healthcare11162316] [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: 07/07/2023] [Revised: 08/12/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVES Pancreatic enzyme replacement therapy (PERT) is essential for treating exocrine pancreatic insufficiency (EPI), a condition where the pancreas does not produce adequate enzymes for digestion. This study delves into the real-world experiences of individuals with EPI regarding their PERT usage. METHODS A study was executed using a tailored survey targeting individuals with EPI. Quantitative data analysis assessed factors such as age, duration of EPI, elastase levels, choice of PERT, perceived effectiveness of titration, and the time taken for effective titration. RESULTS The study comprised 111 participants, predominantly female (93%) and hailing from North America (79%). Of these, 36.7% had been diagnosed with EPI for 3 or more years. A significant 72% felt they were not consistently consuming adequate enzymes, with only 22% believing their intake was sufficient. There were 44 participants (42%) still in the process of adjusting their enzyme doses. In contrast, 17 participants (16%) took a few weeks, 21 (20%) a few months, 11 (10%) over six months, 10 (9%) more than a year, and 3 (3%) several years for dose adjustment. Regarding enzyme titration advice, 30 participants (29%) received vague guidance, while 22 (21%) found the advice beneficial. CONCLUSIONS This study underscores the pressing need for enhanced PERT dosing guidance. The insights gleaned spotlight the prevalent undertreatment across the entire EPI demographic, including in those with lesser-studied co-conditions.
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Affiliation(s)
| | - Arsalan Shahid
- CeADAR—Ireland’s Centre for Applied AI, University College Dublin, D04 V2N9 Dublin, Ireland
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10
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Błachnio K, Szymocha A, Kovalsky M, Pawlak A, Juzwiszyn J, Chabowski M. Quality of Life and Pain in Patients With Chronic Pancreatitis. Pancreas 2023; 52:e321-e327. [PMID: 38127316 DOI: 10.1097/mpa.0000000000002262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
INTRODUCTION The quality of life (QoL) of patients with chronic conditions is a function of factors associated with the illness, its natural course, and treatment as well as those related to the patient. Chronic pancreatitis (CP) is a critical public health problem. Chronic pancreatitis patients can experience chronic pain with different mechanisms, malabsorption, diabetes, and cachexia. OBJECTIVE Chronic pancreatitis (CP) is a critical public health problem. CP patients can experience chronic pain with different mechanisms, malabsorption, diabetes, and cachexia. The aim of the study was to assess the Quality of Life (QoL) of patients with CP and identify factors affecting QoL. METHODS 104 patients diagnosed with CP from the hospital in Wrocław, Poland, were included. The study was conducted using our own questionnaire, the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale, the 36-Item Short Form Health Survey (SF-36), and the Visual Analog Scale (VAS). RESULTS The mean total SF-36 score was 47.7, with the highest mean rating for the physical functioning domain. The mean VAS pain score was 5.13. Pain intensity was significantly correlated with impairments in activities of daily living (P = 0.001), the need to reduce their duration (P = 0.001), and the performance of physical activity (P = 0.003). Comorbidities, education, and age have a significant relationship with only some domains of SF-36. CONCLUSIONS One aspect that has an impact on QoL impairment is pain which perception is governed by the same brain regions in which abnormalities result in depression and anxiety. QoL in CP patients also depends on the patient's age, comorbidities, and level of education.
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Affiliation(s)
| | | | - Maryan Kovalsky
- Division of Anaesthesiological and Surgical Nursing, Department of Nursing and Obstetrics, Faculty of Health Science, Wrocław Medical University
| | - Andrzej Pawlak
- Division of Anaesthesiological and Surgical Nursing, Department of Nursing and Obstetrics, Faculty of Health Science, Wrocław Medical University
| | - Jan Juzwiszyn
- Division of Anaesthesiological and Surgical Nursing, Department of Nursing and Obstetrics, Faculty of Health Science, Wrocław Medical University
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Shestakova MV, Maev IV, Ametov AS, Antsiferov MB, Bordin DS, Galstyan GR, Dzgoeva FK, Kucheryavyy YA, Mkrtumyan AM, Nikonova TV, Pashkova EY. Pancreatic exocrine insufficiency in diabetes mellitus. DIABETES MELLITUS 2023; 26. [DOI: 10.14341/dm13027] [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
Diabetes is disease of both the endo- and exocrine parts of the pancreas. Pancreatic exocrine insufficiency (PEI) can occur in every 2–3 patients with diabetes and affect not only the quality, but also life expectancy. At the same time, the diagnosis and treatment of PEI is not getting enough attention. The endocrinologist, as the main specialist leading patients with diabetes, can diagnose and treat patients with pancreatic exocrine insufficiency and diabetes using adequate doses of pancreatic enzyme replacement therapy (PERT).
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Affiliation(s)
| | - I. V. Maev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - A. S. Ametov
- Russian Medical Academy of Continuous Professional Education
| | - M. B. Antsiferov
- Endocrinological Dispensary of the Moscow City Health Department
| | - D. S. Bordin
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry; A.S. Loginov Moscow Clinical Scientific Centre; Tver State Medical University
| | | | | | | | - A. M. Mkrtumyan
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry; A.S. Loginov Moscow Clinical Scientific Centre
| | | | - E. Y. Pashkova
- Russian Medical Academy of Continuous Professional Education; Botkin Hospital
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12
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Shestakova MV, Maev IV, Ametov AS, Antsiferov MB, Bordin DS, Galstyan GR, Dzgoeva FK, Kucheryavyy YA, Mkrtumyan AM, Nikonova TV, Pashkova EY. Pancreatic exocrine insufficiency in diabetes mellitus. DIABETES MELLITUS 2023; 26. [DOI: https:/doi.org/10.14341/dm13027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Diabetes is disease of both the endo- and exocrine parts of the pancreas. Pancreatic exocrine insufficiency (PEI) can occur in every 2–3 patients with diabetes and affect not only the quality, but also life expectancy. At the same time, the diagnosis and treatment of PEI is not getting enough attention. The endocrinologist, as the main specialist leading patients with diabetes, can diagnose and treat patients with pancreatic exocrine insufficiency and diabetes using adequate doses of pancreatic enzyme replacement therapy (PERT).
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Affiliation(s)
| | - I. V. Maev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - A. S. Ametov
- Russian Medical Academy of Continuous Professional Education
| | - M. B. Antsiferov
- Endocrinological Dispensary of the Moscow City Health Department
| | - D. S. Bordin
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry; A.S. Loginov Moscow Clinical Scientific Centre; Tver State Medical University
| | | | | | | | - A. M. Mkrtumyan
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry; A.S. Loginov Moscow Clinical Scientific Centre
| | | | - E. Y. Pashkova
- Russian Medical Academy of Continuous Professional Education; Botkin Hospital
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13
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Hall LA, Powell-Brett S, Thompson O, Smith D, Bradley E, Smith S, Vickrage S, Kemp-Blake J, Roberts KJ, Shah T. Casting a Wider NET: Pancreatic Exocrine Insufficiency Induced by Somatostatin Analogues among Patients with Neuroendocrine Tumours? Cancers (Basel) 2023; 15:cancers15071933. [PMID: 37046594 PMCID: PMC10093494 DOI: 10.3390/cancers15071933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
Somatostatin-analogues (SSAs) are a first-line treatment of unresectable neuroendocrine tumours (NETs). However, SSAs inhibit pancreatic secretions, which could lead to pancreatic exocrine insufficiency (PEI). PEI is known to be detrimental to patient quality of life and nutritional status. This study aimed to evaluate the effect of SSAs on pancreatic exocrine function in patients with NETs, using the 13C-mixed triglyceride breath test (13C-MTGT). Exocrine function was assessed using the 13C-MTGT at baseline and after a third SSA injection (two months). A quotient of 13CO2/12CO2 was measured by mass spectrometry, and the cumulative percent dose recovered at 6 h (cPDR) is reported. The secondary endpoints investigated were change in weight, HbA1C, and vitamin D levels. Ten patients completed the study. Exocrine function reduced in all patients (n = 10) following SSA therapy (median reduction from baseline: -23.4% (range: -42.1-0.5%, p = 0.005)). vitamin D levels decreased in all but one patient (median decrease from baseline: -26.5%, (-44.7-10%; p = 0.038)), and median HbA1C levels increased by 8.0% (0-59.3%; p = 0.008). Change in weight was not significant (median decrease from baseline: -0.21% (-4.5-3.5%, p = 1.000)). SSA therapy has a consistent impact on exocrine function from early in the treatment course, but the long-term clinical effects of this remain to be defined. Further studies are required to determine the clinical relevance of this observation and optimise the management of PEI in this cohort.
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Affiliation(s)
- Lewis A Hall
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sarah Powell-Brett
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- The Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Oscar Thompson
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Daniel Smith
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Elizabeth Bradley
- Department of Nutrition and Dietetics, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Stacey Smith
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Suzanne Vickrage
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Joanne Kemp-Blake
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Keith J Roberts
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- The Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Tahir Shah
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
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14
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Mathew A, Fernandes D, Andreyev HJN. What is the significance of a faecal elastase-1 level between 200 and 500μg/g? Frontline Gastroenterol 2023; 14:371-376. [PMID: 37581180 PMCID: PMC10423608 DOI: 10.1136/flgastro-2022-102271] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 01/26/2023] [Indexed: 08/16/2023] Open
Abstract
Background Pancreatic exocrine insufficiency is a cause of malabsorption. It is generally diagnosed if faecal elastase-1 (FE-1) levels are below 200 µg/g. Pancreatic function is assumed to be normal when faecal elastase levels are >500 µg/g. The significance of faecal elastase levels above 200 µg/g but less than 500 µg/g is unclear. Methods This retrospective study reports the response to treatment in patients who had an FE-1 level between 200 and 500 µg/g. Results Of these 82 patients, 28 were offered pancreatic enzyme replacement therapy (PERT). A clinical response, defined as an improvement in their initial symptoms after commencing PERT, was seen in 20 patients (71%), 7 with potentially predisposing conditions and 13 with functional diarrhoea. PERT particularly abolished or improved diarrhoea, steatorrhoea and flatulence. Conclusion Clinicians should, therefore, be aware that a trial of PERT given to patients with FE-1 levels between 200 and 500 µg/g may lead to improvement in gastrointestinal symptoms.
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Affiliation(s)
| | - Darren Fernandes
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln, UK
- School of Health and Social Care, Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - H Jervoise N Andreyev
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln, UK
- The Biomedical Research Centre, Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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15
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Roberts DA, Watson E, Macdonald C, Khan Y, Prideaux S, Puthiyakunnel Saji A, Postaleniec E, Selvakumar J, Haghighat Ghahfarokhi M, Davidson B, Gurusamy K. Management of pain and cachexia in pancreatic cancer: Protocol for two systematic reviews, network meta-analysis, surveys and focus groups (Preprint). JMIR Res Protoc 2023; 12:e46335. [PMID: 37014692 PMCID: PMC10139686 DOI: 10.2196/46335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/26/2023] [Accepted: 02/26/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Approximately 75% of people with pancreatic cancer experience pain, and >50% of them have cachexia (weakness and wasting of the body). However, there is considerable uncertainty regarding the management of these distressing symptoms. OBJECTIVE Our primary objectives are to compare the relative benefits and harms of different interventions for pain in people with unresectable pancreatic cancer and for prevention and treatment of cachexia due to pancreatic cancer, through systematic reviews and network meta-analysis. Our secondary objectives are to develop an evidence-based clinical care pathway to manage pain and prevent and treat cachexia in people with pancreatic cancer through surveys and focus groups involving patients, carers, and health care professionals. METHODS We will perform 2 systematic reviews of the literature related to pain and cachexia in people with pancreatic cancer using searches from Cochrane Library, MEDLINE, Embase, Science Citation Index, and trial registries. Two researchers will independently screen for eligibility and identify randomized controlled trials (no language or publication status restriction), comparing interventions for pain or cachexia based on full-texts for articles shortlisted during screening. We will assess risk of bias in the trials using the Cochrane risk of bias tool (version 2.0) and obtain data related to baseline prognostic characteristics, potential effect modifiers and outcome data related to overall survival, health-related quality of life, treatment-related complications, and resource utilisation. We aim to conduct network meta-analysis on outcomes with multiple treatment comparisons where possible, otherwise, meta-analysis with direct comparisons, or narrative synthesis. We will perform various subgroup and sensitivity analyses. Using information obtained from both systematic reviews, we will conduct 2 surveys: one directed to patients or carers to assess acceptability of interventions, and the other to health care professionals to assess feasibility of delivery in the National Health Service. Four mixed focus groups will be conducted to evaluate findings and foster consensus in the development of the care pathway. RESULTS Funding was awarded from April 2022 (NIHR202727). Both systematic review protocols were prospectively registered on PROSPERO in May 2022. Formal searches began thereafter. Approval by the University College London Research Ethics Committee (23563/001) was received in December 2022. Data collection began in January 2023; data analysis will begin in May 2023 (completion expected by October 2023). CONCLUSIONS This study will comprehensively encompass major interventions for management of pain in people with unresectable pancreatic cancer, and prevention and treatment of cachexia in people with pancreatic cancer. Key stakeholders will facilitate the development of an evidence-based care pathway, ensuring both acceptability and feasibility. The project ends in April 2024 and published results are expected within 12 months of completion. We aim to present the findings through patient group websites, conferences, and publications, irrespective of the findings, in a peer-reviewed journal. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46335.
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Affiliation(s)
- Danielle Amanda Roberts
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, London, United Kingdom
| | - Eila Watson
- Supportive Cancer Care Research Group, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom
| | | | | | - Sarah Prideaux
- Patient and Public Involvement Representative, England, United Kingdom
| | | | - Emilia Postaleniec
- Leicester Medical School, The University of Leicester, Leicester, United Kingdom
| | - Jashan Selvakumar
- St George's, University of London Medical School, London, United Kingdom
| | | | - Brian Davidson
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, London, United Kingdom
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, London, United Kingdom
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Cintoni M, Grassi F, Palombaro M, Rinninella E, Pulcini G, Di Donato A, Salvatore L, Quero G, Tortora G, Alfieri S, Gasbarrini A, Mele MC. Nutritional Interventions during Chemotherapy for Pancreatic Cancer: A Systematic Review of Prospective Studies. Nutrients 2023; 15:nu15030727. [PMID: 36771433 PMCID: PMC9920549 DOI: 10.3390/nu15030727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/19/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Marco Cintoni
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Futura Grassi
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Marta Palombaro
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-06-3015-3410
| | - Emanuele Rinninella
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gabriele Pulcini
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Agnese Di Donato
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Lisa Salvatore
- Comprehensive Cancer Center, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Giuseppe Quero
- Digestive Surgery Unit, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Giampaolo Tortora
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Comprehensive Cancer Center, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Sergio Alfieri
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Digestive Surgery Unit, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Maria Cristina Mele
- UOC di Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Rosenberg J, Reddy MN, Seelam P, Li O, Twal J, Pack J. A Retrospective Real-World Evidence Evaluation of the Characteristics of Exocrine Pancreatic Insufficiency in Patients With Chronic Pancreatitis and Type 2 Diabetes Treated With Pancrelipase in the United States. Pancreas 2022; 51:1308-1314. [PMID: 37099771 PMCID: PMC10184798 DOI: 10.1097/mpa.0000000000002203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
OBJECTIVES This retrospective real-world data analysis assessed clinical/health care professional characteristics of gastrointestinal symptom profiles in pancrelipase-treated patients with exocrine pancreatic insufficiency symptoms and chronic pancreatitis (CP) or type 2 diabetes (T2D). METHODS Data were from the Decision Resources Group Real-World Evidence Data Repository US database. Patients 18 years and older receiving pancrelipase (Zenpep) between index dates August 2015 and June 2020 were included. Gastrointestinal symptoms were assessed 6, 12, and 18 months post-index versus baseline. RESULTS A total of 10,656 pancrelipase-treated patients with CP (n = 3215) or T2D (n = 7441) were identified. Significant/sustained reductions in gastrointestinal symptoms were observed in both cohorts after pancrelipase treatment (P < 0.001) versus baseline. Significantly fewer patients with CP compliant with treatment for more than 270 days (n = 1553) reported abdominal pain (P < 0.001) and nausea/vomiting (P < 0.05) versus those compliant for less than 90 days (n = 1115). Significantly fewer patients with T2D compliant with treatment for more than 270 days (n = 2964) reported abdominal pain (P < 0.001) and diarrhea/steatorrhea (P < 0.05) versus those compliant for less than 90 days (n = 2959). CONCLUSIONS Pancrelipase reduced exocrine pancreatic insufficiency symptoms in patients with CP or T2D, with greater treatment compliance associated with improved gastrointestinal symptom profiles.
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Affiliation(s)
- Jonathan Rosenberg
- From the Department of Gastroenterology, Illinois Gastroenterology Group, GI Alliance, Gurnee, IL
| | | | | | - Olivia Li
- RWE Analytics, Clarivate Analytics, Toronto, Canada
| | - Janine Twal
- Medical Science Liaison, Aimmune Therapeutics, a Nestlé Health Science company, Bridgewater Township, NJ
| | - Jennifer Pack
- Medical Science Liaison, Aimmune Therapeutics, a Nestlé Health Science company, Bridgewater Township, NJ
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18
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Clinical Course of Medically Managed Patients With Large and Small Duct Chronic Pancreatitis. Clin Transl Gastroenterol 2022; 14:e00537. [PMID: 36205696 PMCID: PMC9875973 DOI: 10.14309/ctg.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/21/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Pancreatic duct obstruction is the primary indication for endoscopic and/or surgical therapy in patients with chronic pancreatitis (CP). However, the clinical course of medically managed patients in relation to pancreatic duct obstruction is largely unknown. METHODS This was a retrospective cohort study of medically managed patients with CP. We classified patients based on pancreatic duct obstruction from a stricture or stone using cross-sectional imaging (i.e., large vs small duct CP). We compared prevalence of diabetes and exocrine insufficiency (EPI) between subgroups at inclusion and investigated risk of new-onset diabetes, EPI, and all-cause mortality over a follow-up period of 5 years. Changes in pancreatic morphology were studied in patients who underwent follow-up imaging. RESULTS A total of 198 patients (mean age 58 ± 12 years, 70% male, 60% alcoholic etiology, 38% large duct CP) were evaluated. At inclusion, patients with large vs small duct CP had a higher prevalence of both diabetes (43% vs 24%, P = 0.004) and EPI (47% vs 28%, P = 0.007). There was an increased risk of new-onset EPI in patients with large duct CP (hazard ratio 1.72; 95% confidence interval [1.05-2.80], P = 0.031) and higher rates of pancreatic atrophy ( P < 0.001). No differences between groups were observed for new-onset diabetes and all-cause mortality. Conversion from small to large duct CP or vice versa during follow-up was observed in 14% of patients. DISCUSSION In a medically managed cohort of patients, large duct CP was associated with increased risk of EPI and pancreatic atrophy compared with small duct CP.
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19
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Johnston PC, Thompson J, Roberts B, McKee A, Taylor M, Ellison V. Faecal elastase testing and factors linked with development of pancreatic exocrine insufficiency in diabetes: the Belfast Trust experience. PRACTICAL DIABETES 2022. [DOI: 10.1002/pdi.2409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Philip C Johnston
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast Northern Ireland, UK
- Department of Diabetes and Endocrinology, Belfast City Hospital, Belfast Northern Ireland, UK
| | - Judith Thompson
- Department of Diabetes and Endocrinology, Belfast City Hospital, Belfast Northern Ireland, UK
| | - Brona Roberts
- Department of Chemical Pathology, Belfast City Hospital, Belfast Northern Ireland, UK
| | - Allison McKee
- Department of Diabetes and Endocrinology, Belfast City Hospital, Belfast Northern Ireland, UK
| | - Mark Taylor
- Department of Hepatobiliary Surgery, Mater Hospital, Belfast Northern Ireland, UK
| | - Victoria Ellison
- Department of Diabetes and Endocrinology, Belfast City Hospital, Belfast Northern Ireland, UK
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20
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Tanaka E, Ogawa T, Tsutsumi K, Kobayashi S, Nawa T, Ueki T, Okada H. Pancreatic Exocrine Insufficiency in Intraductal Papillary Mucinous Carcinoma Presenting with Leg Edema Treated with Pancreatic Exocrine Replacement Therapy. Intern Med 2022; 61:1963-1967. [PMID: 34840231 PMCID: PMC9334247 DOI: 10.2169/internalmedicine.8611-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
An 89-year-old woman underwent examinations for leg edema. Blood tests indicated low nutrition and low pancreatic enzymes, and a stool examination indicated fatty stool. Computed tomography showed pleural effusion, ascites, and cystic lesions in the pancreatic head and mural nodules within the cysts. Pancreatic juice cytology revealed adenocarcinoma. The diagnosis was pancreatic exocrine insufficiency caused by intraductal papillary mucinous carcinoma. The patient did not wish to undergo surgery. Therefore, diuretics, component nutrients, and pancreatic exocrine replacement therapy using pancrelipase were initiated. After starting treatment, her leg edema, pleural effusion, and ascites disappeared, and her activities of daily living improved markedly.
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Affiliation(s)
- Emi Tanaka
- Department of Internal Medicine, Fukuyama City Hospital, Japan
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | | | - Koichiro Tsutsumi
- Department of Internal Medicine, Fukuyama City Hospital, Japan
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Sayo Kobayashi
- Department of Internal Medicine, Fukuyama City Hospital, Japan
| | - Toru Nawa
- Department of Internal Medicine, Fukuyama City Hospital, Japan
| | - Toru Ueki
- Department of Internal Medicine, Fukuyama City Hospital, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
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21
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de Rijk FEM, van Veldhuisen CL, Besselink MG, van Hooft JE, van Santvoort HC, van Geenen EJM, Hegyi P, Löhr JM, Dominguez-Munoz JE, de Jonge PJF, Bruno MJ, Verdonk RC. Diagnosis and treatment of exocrine pancreatic insufficiency in chronic pancreatitis: An international expert survey and case vignette study. Pancreatology 2022; 22:457-465. [PMID: 35346599 DOI: 10.1016/j.pan.2022.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Despite evidence-based guidelines, exocrine pancreatic insufficiency is frequently underdiagnosed and undertreated in patients with chronic pancreatitis. Therefore, the aim of this study is to provide insight into the current opinion and clinical decision-making of international pancreatologists regarding the management of exocrine pancreatic insufficiency. METHODS An online survey and case vignette study was sent to experts in chronic pancreatitis and members of various pancreatic associations: EPC, E-AHPBA and DPSG. Experts were selected based on publication record from the past 5 years. RESULTS Overall, 252 pancreatologists participated of whom 44% had ≥ 15 years of experience and 35% treated ≥ 50 patients with chronic pancreatitis per year. Screening for exocrine pancreatic insufficiency as part of the diagnostic work-up for chronic pancreatitis is performed by 69% and repeated annually by 21%. About 74% considers nutritional assessment to be part of the standard work-up. Patients are most frequently screened for deficiencies of calcium (47%), iron (42%), vitamin D (61%) and albumin (59%). In case of clinically steatorrhea, 71% prescribes enzyme supplementation. Of all pancreatologists, 40% refers more than half of their patients to a dietician. Despite existing guidelines, 97% supports the need for more specific and tailored instructions regarding the management of exocrine pancreatic insufficiency. CONCLUSION This survey identified a lack of consensus and substantial practice variation among international pancreatologists regarding guidelines pertaining the management of exocrine pancreatic insufficiency. These results highlight the need for further adaptation of these guidelines according to current expert opinion and the level of available scientific evidence.
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Affiliation(s)
- Florence E M de Rijk
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands.
| | - Charlotte L van Veldhuisen
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter Hegyi
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - J-Matthias Löhr
- Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Juan E Dominguez-Munoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
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Roeyen G, Berrevoet F, Borbath I, Geboes K, Peeters M, Topal B, Van Cutsem E, Van Laethem JL. Expert opinion on management of pancreatic exocrine insufficiency in pancreatic cancer. ESMO Open 2022; 7:100386. [PMID: 35124465 PMCID: PMC8819032 DOI: 10.1016/j.esmoop.2022.100386] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/23/2021] [Accepted: 12/23/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- G Roeyen
- Department of Hepatobiliary Transplantation and Endocrine Surgery, Antwerp University Hospital and University of Antwerp, Edegem.
| | - F Berrevoet
- Department of General and Hepatobiliary Surgery, Ghent University Hospital, Ghent
| | - I Borbath
- Hepato-Gastroenterology Unit, Cliniques Universitaires Saint-Luc, Brussels
| | - K Geboes
- Department of Gastroenterology, Division of Digestive Oncology, Ghent University Hospital, Ghent
| | - M Peeters
- Department of Oncology, Antwerp University Hospital and University of Antwerp, Edegem
| | - B Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Leuven
| | - E Van Cutsem
- Department of Gastroenterology/Digestive Oncology, University Hospital Leuven, University Hospitals Gasthuisberg Leuven and KU Leuven, Leuven
| | - J-L Van Laethem
- Department of Digestive Oncology, University Hospital Erasmus Brussels, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Pancreatogenic Diabetes, 2 Onset Forms and Lack of Metabolic Syndrome Components Differentiate It From Type 2 Diabetes. Pancreas 2021; 50:1376-1381. [PMID: 35041336 DOI: 10.1097/mpa.0000000000001930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES We compared pancreatogenic (DM3c) and type 2 diabetes mellitus. METHODS We compared age-, sex-, and diabetes mellitus duration-matched DM3c cases (n = 142) and type 2 diabetes mellitus (n = 142). Pancreatogenic diabetes was considered when it appeared after the diagnosis of pancreatitis or after pancreatic surgery. RESULTS Pancreatogenic diabetes presented lower body mass index (BMI) [odds ratio (OR), 1.2; 95% confidence interval (CI), 1.13-1.28; P < 0.001], worse glycemic control (OR, 1.196; 95% CI, 1.058-1.35; P = 0.004), required insulin more frequently (OR, 4.21; 95% CI, 2.57-6.93; P = 0.0001), had more hypoglycemic episodes (OR, 3.65; 95% CI, 1.64-8.16; P = 0.001) but lower frequency of dyslipidemia (OR, 0.42; 95% CI, 0.26-0.68; P = 0.001) and arterial hypertension (OR, 0.52; 95% CI, 0.32-0.86; P = 0.01). Pancreatogenic diabetes cases on pancreatic enzyme replacement therapy had lower glycosylated hemoglobin (8.52% vs 9.44%; P = 0.026), serum carotenes (79.1 vs 116.1; P = 0.03), and BMI (23.4 vs 26.1; P = 0.0005) than those not on pancreatic enzyme replacement therapy. Pancreatogenic diabetes onset occurred earlier in necrotizing pancreatitis and after pancreatic surgery. CONCLUSIONS Pancreatogenic diabetes presents with low BMI and lacks metabolic syndrome components. The type of pancreatic disease or surgery defines its onset time.
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Carnie LE, Farrell K, Barratt N, Abraham M, Gillespie L, Satyadas T, McNamara MG, Hubner RA, Geraghty J, Bibby N, Valle JW, Lamarca A. Pancreatic Enzyme Replacement Therapy for Patients Diagnosed With Pancreaticobiliary Cancer: Validation of an Algorithm for Dose Escalation and Management. Pancreas 2021; 50:1254-1259. [PMID: 34860808 DOI: 10.1097/mpa.0000000000001906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE An algorithm was designed aiming to provide consistency of pancreatic enzyme replacement therapy (PERT) dosing/titration across healthcare professionals in pancreaticobiliary cancers (PBCs). This prospective observational study aimed to validate this algorithm. METHODS Consecutive patients with inoperable or postoperative PBC with pancreatic exocrine insufficiency (PEI) symptoms, not taking PERT, or taking below the algorithm "starting dose," were eligible. A dietitian or clinical nurse specialist reviewed patients for up to 3 weeks, titrating PERT as per the algorithm. Feasibility of algorithm deliverability was assessed by the percentage of patients with successful completion (primary objective). RESULTS Twenty-five patients were eligible (N = 25): at baseline, 22 took PERT (100% on suboptimal doses, 54.5% taking incorrectly) and 3 initiated PERT because of PEI symptoms. Algorithm completion (20 of 25, 80%) confirming deliverability by dietitians (11 of 12, 92%) and clinical nurse specialists (9 of 13, 69%). Symptom resolution occurred in 8 of 19 (42%), 3 of 7 (43%), and 1 of 3 (33%) patients at first, second, and third reviews, respectively; advice compliance was between 63% and 86%. CONCLUSIONS This algorithm provides a structured method to titrate PERT. At diagnosis, all patients with PBC should be assessed for PEI and adequate PERT initiated. Regular reviews are required for timely symptom resolution and adequate escalation, facilitating differential diagnosis if refractory symptoms exist.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Neil Bibby
- Dietetics, Manchester Royal Infirmary, Manchester, United Kingdom
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Trestini I, Carbognin L, Peretti U, Sperduti I, Caldart A, Tregnago D, Avancini A, Auriemma A, Orsi G, Pilotto S, Frulloni L, Capurso G, Bria E, Reni M, Tortora G, Milella M. Pancreatic Enzyme Replacement Therapy in Patients Undergoing First-Line Gemcitabine Plus nab-paclitaxel for Advanced Pancreatic Adenocarcinoma. Front Oncol 2021; 11:688889. [PMID: 34568019 PMCID: PMC8458827 DOI: 10.3389/fonc.2021.688889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/17/2021] [Indexed: 01/06/2023] Open
Abstract
Background The clinical consequences of pancreatic exocrine insufficiency and its treatment in advanced pancreatic ductal adenocarcinoma (PDAC) are poorly investigated. This retrospective study aims at investigating the pancreatic enzyme replacement therapy (PERT) use and its impact on survival and maldigestion-related symptoms in advanced PDAC patients undergoing chemotherapy. Methods A retrospective analysis was conducted on advanced PDAC patients, treated with first-line gemcitabine plus nab-paclitaxel at two academic institutions (March 2015-October 2018). Data were correlated with overall survival (OS) using Cox regression model. Kaplan-Meier curves were compared using Log-Rank test. Results Data from 110 patients were gathered. PERT was administered in 55 patients (50%). No significant differences in baseline characteristics with those who did not receive PERT were found. Median OS for the entire group was 12 months (95% CI 9-15). At multivariate analysis, previous surgical resection of the primary tumor, (HR 2.67, p=0.11), weight gain after 3 months (HR 1.68, p=0.07) and PERT (HR 2.85, p ≤ 0.001) were independent predictors of OS. Patients who received PERT reported an improvement of maldigestion-related symptoms at 3 months more frequently than patients who did not (85.2% vs 14.8%, p ≤ 0.0001). Conclusion PERT is associated with significantly prolonged survival and maldigestion-related symptoms alleviation in advanced PDAC patients.
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Affiliation(s)
- Ilaria Trestini
- Section of Oncology, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona, Verona, Italy
| | - Luisa Carbognin
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Biomedical Sciences, Department of Medicine, University of Verona, Verona, Italy
| | - Umberto Peretti
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Isabella Sperduti
- Biostatistics Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alberto Caldart
- Section of Oncology, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona, Verona, Italy
| | - Daniela Tregnago
- Section of Oncology, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona, Verona, Italy
| | - Alice Avancini
- Biomedical Sciences, Department of Medicine, University of Verona, Verona, Italy
| | - Alessandra Auriemma
- Section of Oncology, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona, Verona, Italy
| | - Giulia Orsi
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Pilotto
- Section of Oncology, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona, Verona, Italy
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emilio Bria
- Comprehensive Cancer Center, Unità Operativa Complessa (UOC) Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Michele Reni
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giampaolo Tortora
- Comprehensive Cancer Center, Unità Operativa Complessa (UOC) Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Michele Milella
- Section of Oncology, Department of Medicine, University of Verona, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona, Verona, Italy
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Trestini I, Cintoni M, Rinninella E, Grassi F, Paiella S, Salvia R, Bria E, Pozzo C, Alfieri S, Gasbarrini A, Tortora G, Milella M, Mele MC. Neoadjuvant treatment: A window of opportunity for nutritional prehabilitation in patients with pancreatic ductal adenocarcinoma. World J Gastrointest Surg 2021; 13:885-903. [PMID: 34621468 PMCID: PMC8462076 DOI: 10.4240/wjgs.v13.i9.885] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/28/2021] [Accepted: 07/20/2021] [Indexed: 02/06/2023] Open
Abstract
Patients affected by pancreatic ductal adenocarcinoma (PDAC) frequently present with advanced disease at the time of diagnosis, limiting an upfront surgical approach. Neoadjuvant treatment (NAT) has become the standard of care to downstage non-metastatic locally advanced PDAC. However, this treatment increases the risk of a nutritional status decline, which in turn, may impact therapeutic tolerance, postoperative outcomes, or even prevent the possibility of surgery. Literature on prehabilitation programs on surgical PDAC patients show a reduction of postoperative complications, length of hospital stay, and readmission rate, while data on prehabilitation in NAT patients are scarce and randomized controlled trials are still missing. Particularly, appropriate nutritional management represents an important therapeutic strategy to promote tissue healing and to enhance patient recovery after surgical trauma. In this regard, NAT may represent a new interesting window of opportunity to implement a nutritional prehabilitation program, aiming to increase the PDAC patient's capacity to complete the planned therapy and potentially improve clinical and survival outcomes. Given these perspectives, this review attempts to provide an in-depth view of the nutritional derangements during NAT and nutritional prehabilitation program as well as their impact on PDAC patient outcomes.
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Affiliation(s)
- Ilaria Trestini
- Section of Oncology, Department of Medicine, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Marco Cintoni
- Scuola di Specializzazione in Scienza dell’Alimentazione, Università di Roma Tor Vergata, Roma 00133, Italy
| | - Emanuele Rinninella
- UOC Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico A. Gemelli IRCCS, Roma 00168, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma 00168, Italy
| | - Futura Grassi
- UOC Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico A. Gemelli IRCCS, Roma 00168, Italy
| | - Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Emilio Bria
- Oncologia Medica Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
- Oncologia Medica Unit, Università Cattolica del Sacro Cuore, Roma 00168, Italy
| | - Carmelo Pozzo
- Oncologia Medica Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
- Oncologia Medica Unit, Università Cattolica del Sacro Cuore, Roma 00168, Italy
| | - Sergio Alfieri
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma 00168, Italy
- Digestive Surgery Unit and Pancreatic Surgery Gemelli Center Director, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
| | - Antonio Gasbarrini
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
| | - Giampaolo Tortora
- Oncologia Medica Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
- Oncologia Medica Unit, Università Cattolica del Sacro Cuore, Roma 00168, Italy
| | - Michele Milella
- Section of Oncology, Department of Medicine, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Maria Cristina Mele
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma 00168, Italy
- UOSD Nutrizione Avanzata in Oncologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
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Molero X, Ayuso JR, Balsells J, Boadas J, Busquets J, Casteràs A, Concepción M, Cuatrecasas M, Fernàndez Esparrach G, Fort E, Garcia Borobia F, Ginès À, Ilzarbe L, Loras C, Masachs M, Merino X, Olsina JJ, Puig-Diví V, Salord S, Serrano T, Vaquero EC. Chronic pancreatitis for the clinician. Part 2: Treatment and follow-up. Interdisciplinary Position Paper of the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:304-314. [PMID: 34171422 DOI: 10.1016/j.gastrohep.2021.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis.
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Affiliation(s)
- Xavier Molero
- Servei d'Aparell Digestiu, Hospital Universitari Vall d'Hebron, Barcelona, España; Exocrine Pancreas Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España; Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; CIBERehd, Instituto de Salud Carlos III, Madrid, España.
| | - Juan Ramon Ayuso
- Servei de Radiologia, Centre de Diagnòstic per la Imatge Clínic, Hospital Clínic, Barcelona, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | - Joaquim Balsells
- Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; Servei de Cirurgia Hepato-Bilio-Pancreàtica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Jaume Boadas
- Servei de Digestologia, Hospital de Terrassa, Consorci Sanitari de Terrassa, Terrassa, Barcelona, España
| | - Juli Busquets
- Unitat de Cirurgia Hepatobiliar i Pancreàtica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Anna Casteràs
- Servei d'Endocrinologia, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Mar Concepción
- Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; Servei de Gastroenterologia, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Míriam Cuatrecasas
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Servei d'Anatomia Patològica, Hospital Clínic, Barcelona, España
| | - Gloria Fernàndez Esparrach
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Unitat d'Endoscòpia, Servei de Gastroenterologia, ICMDiM, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - Esther Fort
- Servei de Gastroenterologia, Hospital Universitari Doctor Josep Trueta, Girona, España; Universitat de Girona (UdG), Girona, España
| | - Francisco Garcia Borobia
- Unitat de Cirurgia Hepatobiliopancreàtica, Servei de Cirurgia General i de l'Aparell Digestiu, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Àngels Ginès
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Servei de Gastroenterologia, Hospital Universitari Doctor Josep Trueta, Girona, España
| | - Lucas Ilzarbe
- Servei de Digestiu, Hospital del Mar Parc Salut Mar, Barcelona, España
| | - Carme Loras
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Servei de Gastroenterologia, Unitat d'Endoscòpia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - Miquel Masachs
- Servei d'Endoscòpia Digestiva, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Xavier Merino
- Unitat d'Imatge Abdominal, Servei de Radiologia, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Jorge J Olsina
- Servei de Cirurgia Gerenal i Aparell Digestiu, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - Valentí Puig-Diví
- Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; Servei de Digestiu, Corporació Sanitària Universitaria Parc Taulí, Sabadell, Barcelona, España
| | - Sílvia Salord
- Servei de Gastroenterologia, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - Teresa Serrano
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Servei d'Anatomia Patològica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Eva Cristina Vaquero
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Servei de Gastroenterologia, ICMDiM, Hospital Clínic, Barcelona, España; Gastrointestinal and Pancreatic Oncology Research Group, Hospital Clínic, Barcelona, España
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Barkin JA, Barkin JS. Effect of Pancrelipase Therapy on Exocrine Pancreatic Insufficiency Symptoms and Coefficient of Fat Absorption Associated With Chronic Pancreatitis. Pancreas 2021; 50:176-182. [PMID: 33560089 DOI: 10.1097/mpa.0000000000001733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate whether improvement in coefficient of fat absorption (CFA) with pancreatic enzyme replacement therapy correlates with clinical symptoms in patients with chronic pancreatitis with moderate to severe exocrine pancreatic insufficiency. METHODS Data were pooled from 2 randomized double-blind trials of the effects of 1 week of pancrelipase (n = 59) versus placebo (n = 57) on CFA and stool frequency, stool consistency, abdominal pain, and flatulence; 1 trial included a 51-week open-label pancrelipase treatment period (n = 34). RESULTS Compared with placebo, significantly more patients receiving pancrelipase reported decreased stool frequency at week 1 (72% vs 38%; P < 0.001). Although 30% of patients receiving pancrelipase and 20% receiving placebo reported improved stool consistency, changes in stool consistency, abdominal pain, and flatulence were not different between groups. Mean CFA absolute change from baseline was significantly greater with pancrelipase versus placebo (24.7% vs 6.4%; P < 0.001). Improvements in stool consistency and frequency correlated with CFA improvement. Symptom improvements persisted or further improved through 52 weeks of treatment. CONCLUSIONS Pancrelipase significantly improved exocrine pancreatic insufficiency maldigestive symptoms. Improvements in objective stool symptoms with pancreatic enzyme replacement therapy correlated with CFA improvement at 1 week.
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Affiliation(s)
- Jodie A Barkin
- From the Division of Gastroenterology, Department of Medicine, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
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You L, Yao L, Mao YS, Zou CF, Jin C, Fu DL. Partial pancreatic tail preserving subtotal pancreatectomy for pancreatic cancer: Improving glycemic control and quality of life without compromising oncological outcomes. World J Gastrointest Surg 2020; 12:491-506. [PMID: 33437401 PMCID: PMC7769744 DOI: 10.4240/wjgs.v12.i12.491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/30/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Total pancreatectomy (TP) is usually considered a therapeutic option for pancreatic cancer in which Whipple surgery and distal pancreatectomy are undesirable, but brittle diabetes and poor quality of life (QoL) remain major concerns. A subset of patients who underwent TP even died due to severe hypoglycemia. For pancreatic cancer involving the pancreatic head and proximal body but without invasion to the pancreatic tail, we performed partial pancreatic tail preserving subtotal pancreatectomy (PPTP-SP) in selected patients, in order to improve postoperative glycemic control and QoL without compromising oncological outcomes.
AIM To evaluate the efficacy of PPTP-SP for patients with pancreatic cancer.
METHODS We retrospectively reviewed 56 patients with pancreatic ductal adenocarcinoma who underwent PPTP-SP (n = 18) or TP (n = 38) at our institution from May 2014 to January 2019. Clinical outcomes were compared between the two groups, with an emphasis on oncological outcomes, postoperative glycemic control, and QoL. QoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30 and EORTC PAN26). All patients were followed until May 2019 or until death.
RESULTS A total of 56 consecutive patients were enrolled in this study. Perioperative outcomes, recurrence-free survival, and overall survival were comparable between the two groups. No patients in the PPTP-SP group developed cancer recurrence in the pancreatic tail stump or splenic hilum, or a clinical pancreatic fistula. Patients who underwent PPTP-SP had significantly better glycemic control, based on their higher rate of insulin-independence (P = 0.014), lower hemoglobin A1c (HbA1c) level (P = 0.046), lower daily insulin dosage (P < 0.001), and less frequent hypoglycemic episodes (P < 0.001). Global health was similar in the two groups, but patients who underwent PPTP-SP had better functional status (P = 0.036), milder symptoms (P = 0.013), less severe diet restriction (P = 0.011), and higher confidence regarding future life (P = 0.035).
CONCLUSION For pancreatic cancer involving the pancreatic head and proximal body, PPTP-SP achieves perioperative and oncological outcomes comparable to TP in selected patients while significantly improving long-term glycemic control and QoL.
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Affiliation(s)
- Li You
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai 200040, China
| | - Lie Yao
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai 200040, China
| | - Yi-Shen Mao
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai 200040, China
| | - Cai-Feng Zou
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - De-Liang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai 200040, China
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Abstract
PURPOSE OF REVIEW The pancreas is highly affected in cystic fibrosis, with complications occurring early in childhood. This review highlights recent research in exocrine pancreatic function in the era of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies and discusses how these are affecting pancreatitis and exocrine pancreatic insufficiency (EPI) in children. Additionally, new research into exocrine--endocrine interactions sheds light on how CFTR dysfunction in ductal cells may affect beta cells. RECENT FINDINGS Ivacaftor has disproved the hypothesis that EPI in children with cystic fibrosis is irreversible. Improvements in pancreatic function have increased pancreatitis episodes in some children and reduced them in others. Imaging advances are providing complementary methods for exocrine pancreatic function testing. New research into the interplay between the exocrine and endocrine components of the pancreas are elucidating the intertwined and complex relationship between the exocrine and endocrine pancreas. SUMMARY Pancreatic complications contribute to the morbidity and mortality of children with cystic fibrosis. Increasing use of highly effective CFTR modulators will not only abrogate these but will also advance our understanding of pancreatic pathophysiology in cystic fibrosis. New frontiers into pancreatic gene therapy and exocrine--endocrine research will help provide new therapeutic opportunities for pancreatitis, EPI, and diabetes in cystic fibrosis.
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De Sutter PJ, Gasthuys E, Van Braeckel E, Schelstraete P, Van Biervliet S, Van Bocxlaer J, Vermeulen A. Pharmacokinetics in Patients with Cystic Fibrosis: A Systematic Review of Data Published Between 1999 and 2019. Clin Pharmacokinet 2020; 59:1551-1573. [DOI: 10.1007/s40262-020-00932-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Rinzivillo M, De Felice I, Magi L, Annibale B, Panzuto F. Occurrence of exocrine pancreatic insufficiency in patients with advanced neuroendocrine tumors treated with somatostatin analogs. Pancreatology 2020; 20:875-879. [PMID: 32684368 DOI: 10.1016/j.pan.2020.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 06/03/2020] [Accepted: 06/09/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although exocrine pancreatic insufficiency (EPI) has been described in patients with neuroendocrine neoplasia (NEN) treated with somatostatin analogs (SSAs), its role in the therapeutic management of these patients is not well established. AIM To determine the frequency of EPI in patients with NEN long-term treated with SSAs. METHODS This is a prospective single-center study evaluating 35 patients treated with SSAs for >12 months due to unresectable/advanced nonpancreatic well-differentiated NEN. Clinical evaluation, biochemical parameters, and fecal elastases 1 (FE-1) were assessed to diagnose EPI. RESULTS A total of 7 patients (20%) had EPI, given the presence of abdominal symptoms and a median FE-1 value of 180 mcg/g stool (150-198). No patient had severe EPI, defined as FE-1 < 100 mcg/g stool. Elevated glycated Hb levels were a significant predictor for developing EPI (OR 4.81, p = 0.01). No significant difference in terms of duration of SSA treatment was observed between patients with or without EPI diagnosed (84 months and 72 months, respectively; p = 0.950). CONCLUSIONS Mild-moderate EPI is a relatively common condition in patients receiving long-term treatment with SSAs. Specific clinical and biochemical evaluations, including FE-1, should be planned in these patients to diagnose this relevant condition early, which may deteriorate quality of life and cause malnutrition.
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Affiliation(s)
- Maria Rinzivillo
- Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Italy
| | - Ilaria De Felice
- Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Italy
| | - Ludovica Magi
- Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Italy
| | - Bruno Annibale
- Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Italy; Dept. of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Italy
| | - Francesco Panzuto
- Digestive Disease Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Italy.
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Abstract
OBJECTIVE Malnutrition is commonly seen in children with exocrine pancreatic insufficiency (EPI). Pancreatic enzyme replacement therapy (PERT) is the mainstay treatment of acute malnutrition in children detected with a disease closely associated with EPI (eg, cystic fibrosis). The effectiveness of PERT in children with malnutrition without any chronic disease, however, remains unclear. The aim of this study was to investigate the effectiveness of PERT on weight gain and EPI in children classified as moderately and severely malnourished according to the World Health Organization (WHO) classification. MATERIALS AND METHODS The study included a total of 40 children aged 2-16 years who were classified as moderately and severely malnourished according to the WHO classification. The patients were randomly divided into 2 groups: PERT group (n = 20) received 2000 U lipase/kg/day (in 4 doses) in addition to hypercaloric enteral supplements and control group received hypercaloric enteral supplements only. In both groups, anthropometric measurements and the assessment of fecal elastase-1 (FE-1) levels were performed both at first admission and at the end of the 8-week treatment period. RESULTS On the basis of WHO classification, 10 (25%) children were classified as severely malnourished and 30 (75%) children as moderately malnourished. EPI was detected in all the patients, among whom 24 (60%) patients had severe EPI. At the end of the treatment, body weight, height, and body mass index (BMI) increased significantly in both groups compared to their pre-treatment values, whereas no significant difference was found with regard to waist circumference (WC) and FE-1 levels. Similarly, no significant difference was found between pre- and posttreatment measurements of PERT and control groups (P > 0.05) and between pre- and posttreatment measurements of patients with moderate and severe malnutrition (P > 0.05). CONCLUSIONS Malnutrition remains a serious public health problem, and thus, the development of novel treatment methods is highly essential. PERT is one of the most commonly considered alternatives, although there is little documentation of PERT in the literature. In the present study, although PERT resulted in higher weight gain, it established no significant difference between the 2 groups.
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Kharbat M, Craig PI. Editorial: management of exocrine pancreatic insufficiency remains a challenge-can we do better? Aliment Pharmacol Ther 2020; 51:1206-1207. [PMID: 32424918 DOI: 10.1111/apt.15755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Mohammad Kharbat
- Department of Gastroenterology & Hepatology, St George Hospital, Sydney, NSW, Australia
| | - Philip I Craig
- Department of Gastroenterology & Hepatology, St George Hospital, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
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Boon M, Calvo-Lerma J, Claes I, Havermans T, Asseiceira I, Bulfamante A, Garriga M, Masip E, van Schijndel BAM, Fornes V, Barreto C, Colombo C, Crespo P, Vicente S, Janssens H, Hulst J, Witters P, Nobili R, Pereira L, Ruperto M, Van der Wiel E, Mainz JG, De Boeck K, Ribes-Koninckx C. Use of a mobile application for self-management of pancreatic enzyme replacement therapy is associated with improved gastro-intestinal related quality of life in children with Cystic Fibrosis. J Cyst Fibros 2020; 19:562-568. [PMID: 32335023 DOI: 10.1016/j.jcf.2020.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most patients with cystic fibrosis (CF) suffer from pancreatic insufficiency (PI), leading to fat malabsorption, malnutrition, abdominal discomfort and impaired growth. Pancreatic enzyme replacement therapy (PERT) is effective, but evidence based guidelines for dose adjustment are lacking. A mobile app for self-management of PERT was developed in the context of the HORIZON 2020 project MyCyFAPP. It contains an algorithm to calculate individual PERT-doses for optimal fat digestion, based on in vitro and in vivo studies carried out in the same project. In addition, the app includes a symptoms diary, educational material, and it is linked to a web tool allowing health care professionals to evaluate patient's data and provide feedback. METHODS A 6-month open label prospective multicenter interventional clinical trial was performed to assess effects of using the app on gastro-intestinal related quality of life (GI QOL), measured by the CF-PedsQL-GI (shortened, CF specific version of the Pediatric Quality of Life Inventory, Gastrointestinal Symptoms Module). RESULTS One hundred and seventy-one patients with CF and PI between 2 and 18 years were recruited at 6 European CF centers. Self-reported CF-PedsQL-GI improved significantly from month 0 (M0) (84.3, 76.4-90.3) to month 6 (M6) (89.4, 80.35-93.5) (p< 0.0001). Similar improvements were reported by parents. Lower baseline CF-PedsQL-GI was associated with a greater improvement at M6 (p < 0.001). CONCLUSIONS The results suggest that the MyCyFAPP may improve GI QOL for children with CF. This tool may help patients to improve self-management of PERT, especially those with considerable GI symptoms.
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Affiliation(s)
- M Boon
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium.
| | - J Calvo-Lerma
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - I Claes
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | - T Havermans
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | - I Asseiceira
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - A Bulfamante
- Università degli Studi di Milano, Fondazione IRCCS Ca" Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - M Garriga
- Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Masip
- Gastroenterology and Pediatric cystic Fibrosis Unit, La Fe Hospital, Valencia, Spain
| | - B A M van Schijndel
- Department of Pediatrics, div of Gastro-Enterology, Erasmus MC- Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - V Fornes
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - C Barreto
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - C Colombo
- Università degli Studi di Milano, Fondazione IRCCS Ca" Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - P Crespo
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - S Vicente
- Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - H Janssens
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - J Hulst
- Department of Pediatrics, div of Gastro-Enterology, Erasmus MC- Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - P Witters
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | - R Nobili
- Università degli Studi di Milano, Fondazione IRCCS Ca" Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - L Pereira
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - M Ruperto
- Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Van der Wiel
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - J G Mainz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Germany; Cystic Fibrosis Center Brandenburg Medical School (MHB), University, Brandenburg an der Havel, Germany
| | - K De Boeck
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
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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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