Re-assessing the role of peri-operative nutritional therapy in patients with pancreatic cancer undergoing surgery: a narrative review

Pancreatic cancer is the most common medical condition that requires pancreatic resection. Over the last three decades, significant improvements have been made in the conditions and procedures related to pancreatic surgery, resulting in mortality rates lower than 5%. However, it is important to note that the morbidity in pancreatic surgery remains r latively high, with a percentage range of 30-60%. Pre-operative malnutrition is considered to be an independent risk factor for post-operative complications in pancreatic surgery, such as impaired wound healing, higher infection rates, prolonged hospital stay, hospital readmission, poor prognosis, and increased morbidity and mortality. Regarding the post-operative period, it is crucial to provide the best possible management of gastrointestinal dysfunction and to handle the consequences of alterations in food digestion and nutrient absorption for those undergoing pancreatic surgery. The European Society for Clinical Nutrition and Metabolism (ESPEN) suggests that early oral feeding should be the preferred way to initiate nourishing surgical patients as it is associated with lower rates of complications. However, there is ongoing debate about the optimal post-operative feeding approach. Several studies have shown that enteral nutrition is associated with a shorter time to recovery, superior clinical outcomes and biomarkers. On the other hand, recent data suggest that nutritional goals are better achieved with parenteral feeding, either exclusively or as a supplement. The current review highlights recommendations from existing evidence, including nutritional screening and assessment and pre/post-operative nutrition support fundamentals to improve patient outcomes. Key areas for improvement and opportunities to enhance guideline implementation are also highlighted.

Primary breast lymphoma in a male patient

Primary lymphoma of the male breast is extremely rare. We report a case of a diffuse large B-cell lymphoma in a male patient. A 67-year-old man presented with a palpable mass in the right breast and ipsilateral axillary lymphadenopathy. At operation a 6 x 5 x 4-cm mass was excised, and a frozen section demonstrated malignancy. A modified radical mastectomy was then performed, together with axillary lymph node clearance. Histological examination established the diagnosis of a primary non-Hodgkin's lymphoma of the breast. The patient was referred for chemotherapy and died a year later from systemic disease involving the adrenals. The importance of early diagnosis is emphasized; this should be based on an excisional biopsy or aspiration cytology. As patients with primary breast lymphoma (PBL) have a better prognosis than those with carcinoma of the breast or patients with extranodal lymphomas, a multidisciplinary approach including surgery, radiotherapy, and chemotherapy when needed would result in a more favorable outcome.

Albendazole in the conservative management of multiple hydatid disease

Hydatid disease is quite common in Greece and is routinely treated by surgery. Nevertheless, multiple cysts constitute a difficult problem for treatment. Patients with multiple cysts have already undergone several operations, and their general condition may be poor. We investigated the effect of albendazole [a drug not FDA approved in the US], in the conservative management of multiple hydatid disease in 44 patients with a high antiechinococcal antibody titer who had already undergone two or three operations for the disease (21 men, mean age 51.05; 24 women, mean age 53.42). Albendazole was administered daily in a 10 mg/kg dose for 5 months to 33 patients and for 2 months to 11 patients. Cysts disappeared in 5 patients and decreased in size in 12 patients. Side effects included allergic shock (1 patient), reversible increase in SGOT and SGPT (3 patients), reversible fever and fall in leukocyte number (1 patient). We conclude that surgery remains the treatment of choice for this condition and that albendazole may have a place in the elimination of recurrence of the disease.

Studies in gastric carcinogenesis. II. Absence of elevated concentrations of N-nitroso compounds in the gastric juice of Greek hypochlorhydric individuals

The concentrations of nitrate, nitrite, N-nitroso compounds and bacteria were measured in 96 samples of fasting gastric juice, pH 0.90-8.50, obtained from 56 individuals just before or at various times (8 days - 1 year) after gastric operation. The mean pH of the post-operative samples [4.66 +/- 0.39 (SEM)] was significantly higher than that of the pre-operative ones [3.29 +/- 0.33 (SEM)]. A positive correlation with pH was observed for the concentrations of total and nitrate-reducing bacteria (median values 5.0 X 10(5) organisms/ml and 9.2 X 10(4) organisms/ml, respectively, for samples with pH greater than or equal to 1.2 X 10(3) organisms/ml and 0 organisms/ml, respectively, for samples with pH less than or equal to 2.5) and nitrite [mean values 22.5 +/- 3.1 (SEM) microM and 3.20 +/- 0.5 (SEM) microM for samples with pH greater than or equal to 6.5 and pH less than or equal to 2.5, respectively]. No correlation with pH was seen for the concentrations of nitrate [mean value 0.48 +/- 0.06 (SEM) mM] or N-nitroso compounds [mean value 0.30 +/- 0.06 (SEM) microM]. The concentrations of bacteria and nitrite, although increased in hypochlorhydric individuals, were lower than those reported for corresponding individuals in other, primarily British, studies. It is suggested that the relatively low concentrations of nitrite observed in our hypochlorhydric population may account for the absence of elevated concentrations of N-nitroso compounds and that the latter phenomenon may be related to the relatively low frequency of gastric cancer in Greece.

O6-Methylguanine-DNA transmethylase activity in extracts of human gastric mucosa

In view of the possible involvement of N-nitroso compounds in the etiology of gastric carcinoma in man, we have examined the abilities of extracts of human gastric mucosa for the removal from DNA of O6-methylguanine, the primary precarcinogenic lesion induced in DNA by methylating carcinogenic N-nitroso compounds. We find that all 20 specimens examined (including 14 non-neoplastic and 6 neoplastic) possess significant activity, removing on average 0.73 +/- 0.06 (s.e.m.) pmol O6-methylguanine per mg protein in the extract. This activity, which has the characteristics of an O6-methylguanine-DNA-transmethylase, while exhibiting wide interindividual variations, shows no significant differences between the groups of normal and of neoplastic tissues or between the groups of non-neoplastic tissues obtained from individuals with benign or with malignant gastric disease. It is estimated that the average O6-methylguanine-removing capacity of the cells of normal gastric mucosa (calculated as 166 000 +/- 26 000 (s.e.m.) molecules per cell) greatly exceeds the extent of DNA damage likely to be caused by gastric-juice N-nitroso compounds.