1
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Huang K, Qian T, Chen W, Bai X, Gao S, Shen Y, Zhang M, Ma T, Liang T. Clinical Significance and Risk Factors of Nonalcoholic Fatty Liver Diseases After Whipple Procedure. J Surg Res 2024; 302:706-714. [PMID: 39214062 DOI: 10.1016/j.jss.2024.07.013] [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: 02/04/2024] [Revised: 05/30/2024] [Accepted: 07/01/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION The etiology and management of nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD) remain unclear. This study aimed to investigate the risk factors and outcomes of NAFLD after PD (PD-NAFLD). METHODS Patients who underwent PD at our institution between June 2019 and September 2021 were enrolled in the study. The clinical manifestations and outcomes of the patients with PD-NAFLD were evaluated. Multivariable analysis was used to identify risk factors for PD-NAFLD. RESULTS Of the 407 patients enrolled, PD-NAFLD was identified in 54 (13.2%). The median time of onset of PD-NAFLD was 72.5 (51.5-171.25) d postoperatively. Twenty-four patients (44.4%) recovered completely within 36 mo postoperatively. Adjuvant chemotherapy was administered in 147 malignant cases, and patients with PD-NAFLD encountered delay or discontinuation of chemotherapy more frequently than those without PD-NAFLD (55.9% versus 30.1%, P = 0.006). Multivariable analysis identified female sex, high body mass index, and neoadjuvant chemotherapy as independent risk factors for PD-NAFLD. CONCLUSIONS PD-NAFLD is a common complication of PD. Female sex, high body mass index, and neoadjuvant chemotherapy may be associated with the development of PD-NAFLD. PD-NAFLD may interrupt the delivery of adjuvant chemotherapy in patients with malignant tumors.
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Affiliation(s)
- Kaiquan Huang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Qian
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yan Shen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China.
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China; Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China; Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China; Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China; Cancer Center, Zhejiang University, Hangzhou, China.
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Ohta M, Kanba R, Fukushima K, Takahashi K, Nishimaki H, Sasaki T, Fujita A, Kanno M, Ogasawara Y, Namiki K. Rapid deterioration of steatotic liver disease due to portal vein stenosis after pancreaticoduodenectomy. Clin J Gastroenterol 2024:10.1007/s12328-024-02027-5. [PMID: 39147944 DOI: 10.1007/s12328-024-02027-5] [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: 05/19/2024] [Accepted: 07/23/2024] [Indexed: 08/17/2024]
Abstract
Steatotic liver disease after pancreatoduodenectomy occurs due to various factors, such as exocrine pancreatic insufficiency, impaired intestinal absorption, and malnutrition. The mechanism of steatogenesis differs to that of conventional steatotic liver disease associated with obesity and insulin resistance. We experienced a rare case of rapidly progressive steatotic liver disease accompanied by portal vein stenosis in the early postoperative period after subtotal stomach-preserving pancreaticoduodenectomy for distal cholangiocarcinoma. Although there was a complication due to postoperative drain infection, the patient was discharged from hospital with no nutritional problems. Two months postoperatively, the patient presented to the emergency room with dyspnea. CT showed a markedly steatotic liver, ascites, and portal vein stenosis. A portal vein stent was inserted transhepatically and the steatotic liver disease gradually improved. During the postoperative course, there were no problems indicated by nutritional markers; although the patient had diarrhea associated with postoperative pancreatic exocrine insufficiency, the symptoms were mild and improved after administration of oral pancrelipase. Before the intervention, the patient had intestinal edema, exacerbation of diarrhea, and a low serum zinc concentration, suggesting that impaired absorption caused by intestinal blood stasis and gut barrier dysfunction contributed to the development of steatotic liver disease.
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Affiliation(s)
- Mineto Ohta
- Department of Surgery, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan.
- Department of General Medicine, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan.
| | - Rikiya Kanba
- Department of Surgery, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
- Department of General Medicine, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
| | - Keisuke Fukushima
- Department of Surgery, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
| | - Kazutomi Takahashi
- Department of Surgery, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
| | - Hiroyasu Nishimaki
- Department of Surgery, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
| | - Tatsuya Sasaki
- Department of Nutrition, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
| | - Ai Fujita
- Department of Nutrition, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
| | - Maika Kanno
- Department of Nutrition, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
| | - Yuki Ogasawara
- Department of Nutrition, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
| | - Kenji Namiki
- Department of Surgery, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
- Department of General Medicine, Osaki Citizen Hospital, 3-8-1 Honami, Osaki, Miyagi, 989-6183, Japan
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3
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Su R, Liu HN, Wang YB, Bai Y. Cirrhosis after pancreaticoduodenectomy for pancreatic cancer. Hepatobiliary Pancreat Dis Int 2024:S1499-3872(24)00107-3. [PMID: 39129077 DOI: 10.1016/j.hbpd.2024.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 07/29/2024] [Indexed: 08/13/2024]
Affiliation(s)
- Rui Su
- Graduate Academy, Hebei Medical University, Shijiazhuang 050017, China; Department of Geriatric Gastroenterology, Hebei General Hospital, Shijiazhuang 050000, China
| | - Hong-Na Liu
- Department of Geriatric Gastroenterology, Hebei General Hospital, Shijiazhuang 050000, China
| | - Yu-Bo Wang
- Department of Geriatric Gastroenterology, Hebei General Hospital, Shijiazhuang 050000, China; Graduate Academy, North China University of Science and Technology, Tangshan 063000, China
| | - Yun Bai
- Department of Geriatric Gastroenterology, Hebei General Hospital, Shijiazhuang 050000, China.
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4
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Fujii T, Iizawa Y, Kobayashi T, Hayasaki A, Ito T, Murata Y, Tanemura A, Ichikawa Y, Kuriyama N, Kishiwada M, Sakuma H, Mizuno S. Radiomics-based prediction of nonalcoholic fatty liver disease following pancreatoduodenectomy. Surg Today 2024; 54:953-963. [PMID: 38581555 DOI: 10.1007/s00595-024-02822-0] [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: 12/18/2023] [Accepted: 01/09/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE Predicting nonalcoholic fatty liver disease (NAFLD) following pancreaticoduodenectomy (PD) is challenging, which delays therapeutic intervention and makes its prevention difficult. We conducted this study to assess the potential application of preoperative computed tomography (CT) radiomics for predicting NAFLD. METHODS The subjects of this retrospective study were 186 patients with PD from a single institution. We extracted the predictors of NAFLD after PD statistically from conventional clinical and radiomic features of the estimated remnant pancreas and whole liver region on preoperative nonenhanced CT images. Based on these predictors, we developed a machine-learning predictive model, which integrated clinical and radiomic features. A comparative model used only clinical features as predictors. RESULTS The incidence of NAFLD after PD was 43.5%. The variables of the clinicoradiomic model included one shape feature of the pancreas, two texture features of the liver, and sex; the variables of the clinical model were age, sex, and chemoradiotherapy. The accuracy%, precision%, recall%, F1 score, and area under the curve of the two models were 75.0, 72.7, 66.7, 69.6, and 0.80; and 69.6, 68.4, 54.2, 60.5, and 0.69, respectively. CONCLUSIONS Preoperative CT-derived radiomic features from the pancreatic and liver regions are promising for the prediction of NAFLD post-PD. Using these features enhances the predictive model, enabling earlier intervention for high-risk patients.
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Affiliation(s)
- Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takumi Kobayashi
- School of Medicine, Faculty of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasutaka Ichikawa
- Department of Radiology, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hajime Sakuma
- Department of Radiology, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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5
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Ali FEM, Abdel-Reheim MA, Hassanein EHM, Abd El-Aziz MK, Althagafy HS, Badran KSA. Exploring the potential of drug repurposing for liver diseases: A comprehensive study. Life Sci 2024; 347:122642. [PMID: 38641047 DOI: 10.1016/j.lfs.2024.122642] [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: 02/09/2024] [Revised: 03/24/2024] [Accepted: 04/10/2024] [Indexed: 04/21/2024]
Abstract
Drug repurposing involves the investigation of existing drugs for new indications. It offers a great opportunity to quickly identify a new drug candidate at a lower cost than novel discovery and development. Despite the importance and potential role of drug repurposing, there is no specific definition that healthcare providers and the World Health Organization credit. Unfortunately, many similar and interchangeable concepts are being used in the literature, making it difficult to collect and analyze uniform data on repurposed drugs. This research was conducted based on understanding general criteria for drug repurposing, concentrating on liver diseases. Many drugs have been investigated for their effect on liver diseases even though they were originally approved (or on their way to being approved) for other diseases. Some of the hypotheses for drug repurposing were first captured from the literature and then processed further to test the hypothesis. Recently, with the revolution in bioinformatics techniques, scientists have started to use drug libraries and computer systems that can analyze hundreds of drugs to give a short list of candidates to be analyzed pharmacologically. However, this study revealed that drug repurposing is a potential aid that may help deal with liver diseases. It provides available or under-investigated drugs that could help treat hepatitis, liver cirrhosis, Wilson disease, liver cancer, and fatty liver. However, many further studies are needed to ensure the efficacy of these drugs on a large scale.
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Affiliation(s)
- Fares E M Ali
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut 71524, Egypt; Michael Sayegh, Faculty of Pharmacy, Aqaba University of Technology, Aqaba 77110, Jordan
| | - Mustafa Ahmed Abdel-Reheim
- Department of Pharmaceutical Sciences, College of Pharmacy, Shaqra University, Shaqra 11961, Saudi Arabia; Department of Pharmacology and Toxicology, Faculty of Pharmacy, Beni-Suef University, Beni Suef 62521, Egypt.
| | - Emad H M Hassanein
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut 71524, Egypt.
| | - Mostafa K Abd El-Aziz
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut 71524, Egypt
| | - Hanan S Althagafy
- Department of Biochemistry, Faculty of Science, University of Jeddah, Jeddah, Saudi Arabia
| | - Khalid S A Badran
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut 71524, Egypt
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6
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Maino C, Cereda M, Franco PN, Boraschi P, Cannella R, Gianotti LV, Zamboni G, Vernuccio F, Ippolito D. Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon. Eur J Radiol Open 2024; 12:100544. [PMID: 38304573 PMCID: PMC10831502 DOI: 10.1016/j.ejro.2023.100544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 02/03/2024] Open
Abstract
Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.
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Affiliation(s)
- Cesare Maino
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Marco Cereda
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Paolo Niccolò Franco
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Piero Boraschi
- Radiology Unit, Azienda Ospedaliero-Universitaria Pisana, 56124 Pisa, Italy
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Luca Vittorio Gianotti
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
| | - Giulia Zamboni
- Institute of Radiology, Department of Diagnostics and Public Health, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Federica Vernuccio
- University Hospital of Padova, Institute of Radiology, 35128 Padova, Italy
| | - Davide Ippolito
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
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7
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Mori T, Ozawa E, Sasaki R, Shimakura A, Takahashi K, Kido Y, Kanda Y, Matsuo S, Tajima K, Beppu A, Nakao Y, Fukushima M, Haraguchi M, Miuma S, Miyaaki H, Adachi T, Eguchi S, Okano S, Nakao K. Are transmembrane 6 superfamily member 2 gene polymorphisms associated with steatohepatitis after pancreaticoduodenectomy? JGH Open 2024; 8:e13113. [PMID: 38919271 PMCID: PMC11197035 DOI: 10.1002/jgh3.13113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/29/2024] [Accepted: 06/09/2024] [Indexed: 06/27/2024]
Abstract
Aim After pancreaticoduodenectomy, 20-40% of patients develop steatotic liver disease (SLD), and steatohepatitis can be a problem. Although patatin-like phospholipase domain-containing 3 protein (PNPLA3) and transmembrane 6 superfamily member 2 (TM6SF2) polymorphisms are involved in SLD and steatohepatitis development, whether this is the case after pancreaticoduodenectomy is unclear. Methods and Results Forty-three patients with pancreatic cancer who underwent pancreaticoduodenectomy at our hospital between April 1, 2018, and March 31, 2021, were included. We extracted DNA from noncancerous areas of residual specimens after pancreaticoduodenectomy and determined PNPLA3 and TM6SF2 gene polymorphisms using real-time polymerase chain reaction. SLD was defined as a liver with an attenuation value of ≤40 HU or a liver-to-spleen ratio of ≤0.9 on computed tomography. We defined high hepatic fibrosis indexes (HFI) instead of steatohepatitis as a Fibrosis-4 index of ≥2.67 or nonalcoholic fatty liver disease fibrosis score of ≥0.675 in patients with SLD. The cumulative incidence of SLD (P = 0.299) and high HFI (P = 0.987) after pancreaticoduodenectomy were not significantly different between the PNPLA3 homozygous and minor allele groups. The incidences of high HFI at 1 year after pancreaticoduodenectomy were 16.8% and 27.0% in the TM6SF2 major homozygous and minor allele groups, respectively, with a significant difference in the cumulative incidence (P = 0.046). Conclusion The TM6SF2 minor allele may contribute to steatohepatitis development after pancreaticoduodenectomy.
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Affiliation(s)
- Tomotaka Mori
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
- Department of Gastroenterology and HepatologyJapanese Red Cross Nagasaki Genbaku HospitalNagasakiJapan
| | - Eisuke Ozawa
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ryu Sasaki
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Akane Shimakura
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kosuke Takahashi
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Yoko Kido
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Yasuko Kanda
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Satoshi Matsuo
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kazuaki Tajima
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Asami Beppu
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Yasuhiko Nakao
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Masanori Fukushima
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Masafumi Haraguchi
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Satoshi Miuma
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Tomohiko Adachi
- Department of SurgeryNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Susumu Eguchi
- Department of SurgeryNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Shinji Okano
- Department of PathologyNagasaki University HospitalNagasakiJapan
| | - Kazuhiko Nakao
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
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8
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Sugumar K, Naik L, Hue JJ, Ammori JB, Hardacre JM, Ocuin LM, Winter JM. Risk factors of developing nonalcoholic fatty liver disease after pancreatic resection: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:983-992. [PMID: 38552899 DOI: 10.1016/j.gassur.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/19/2024] [Accepted: 03/22/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) occurs in 10% to 40% of patients after pancreatic resection. Pancreatic exocrine insufficiency (PEI) is thought to be closely associated with NAFLD; however, the mechanism of NAFLD is not clearly understood. We perform a systematic review and meta-analysis to better understand the risk factors of NAFLD. METHODS A systematic literature search was performed in the MEDLINE database. Studies focused on the risk factors associated with NAFLD in patients undergoing pancreatectomy. The odds ratios (ORs) denoting the association of risk factors with NAFLD after resection were curated. RESULTS Of 814 published articles, 26 studies met the inclusion criteria. Combined, these studies included clinical data on 4055 patients. The pooled incidence of NAFLD was 29% (23%-35%). Among the various risk factors analyzed, the following had a significant likelihood of NAFLD on forest plot analysis: female gender (OR, 2.44), pancreatic ductal adenocarcinoma (OR, 2.11), portal vein or superior mesenteric vein resection (OR, 1.99), dissection of nerve plexus around the superior mesenteric artery (OR, 1.93), and adjuvant chemotherapy (OR, 1.58). Only 2 studies investigated 2 different measurements of quantitative PEI, which could not be used for analysis. Owing to heterogeneity of studies, pancreatic remanent volume, which is considered a marker for PEI could not be evaluated. Pancreatic enzyme replacement therapy (PERT) was not associated with NAFLD. CONCLUSION Numerous factors are associated with NAFLD after pancreatectomy. Previous research shows that PEI may be associated with NAFLD; however, this could not be compared in our meta-analysis. Further research is required to study the role of PERT in NAFLD.
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Affiliation(s)
- Kavin Sugumar
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Lora Naik
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
| | - Jonathan J Hue
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - John B Ammori
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Jeffrey M Hardacre
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Lee M Ocuin
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Jordan M Winter
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States.
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9
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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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10
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Zhao P, Yang W, Xiao H, Zhang S, Gao C, Piao H, Liu L, Li S. Vitamin K2 protects mice against non-alcoholic fatty liver disease induced by high-fat diet. Sci Rep 2024; 14:3075. [PMID: 38321064 PMCID: PMC10847165 DOI: 10.1038/s41598-024-53644-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/03/2024] [Indexed: 02/08/2024] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is one of the most common liver diseases worldwide and there is a huge unmet need to find safer and more effective drugs. Vitamin K has been found to regulate lipid metabolism in the liver. However, the effects of vitamin K2 on NAFLD is unclear. This study aims to evaluate the preventive and therapeutic effects of vitamin K2 in the process of fatty liver formation and to explore molecular mechanisms the associated with lipid metabolism. A non-alcoholic fatty liver model was established by high-fat diet administration for three months. Vitamin K2 significantly reduced the body weight, abdominal circumference and body fat percentage of NAFLD mice. Vitamin K2 also showed histological benefits in reducing hepatic steatosis. NAFLD mice induced by high-fat diet showed increased HMGR while vitamin K2 intervention could reverse the pathological lterations. Adiponectin (APN) is an endogenous bioactive polypeptide or protein secreted by adipocytes. We detected APN, SOD, AlaDH and other indicators that may affect the state of high-fat diet mice, but the experimental results showed that the above indicators did not change significantly. It is worth noting that the effect of vitamin K2 supplementation on the lipid-lowering effect of uc OC in vivo needs to be further explored. This study first reported the protective effect of vitamin K2 on high-fat diet-induced NAFLD in mice. The protective effect of vitamin K2 may be related to the improvement of lipid metabolism disorder in NAFLD.
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Affiliation(s)
- Peizuo Zhao
- Department of Physiology, Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Weidong Yang
- Department of Physiology, Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Huiyu Xiao
- Department of Physiology, Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Shuaishuai Zhang
- Department of Physiology, Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Chuanzhou Gao
- Central Laboratory, Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Hua Piao
- Department of Physiology, Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Lihong Liu
- Department of Physiology, Dalian Medical University, Dalian, Liaoning, People's Republic of China.
| | - Shuzhuang Li
- Department of Physiology, Dalian Medical University, Dalian, Liaoning, People's Republic of China.
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11
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Li Z, Weinstein J, Redstone E, Mitchell DG. Hepatic Steatosis After Partial Pancreatectomy in a Cohort of Patients with Intraductal Papillary Mucinous Neoplasm. J Clin Exp Hepatol 2023; 13:955-961. [PMID: 37975040 PMCID: PMC10643521 DOI: 10.1016/j.jceh.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/13/2023] [Indexed: 11/19/2023] Open
Abstract
Background/Aims Nonalcoholic fatty liver disease (NAFLD) has been observed in patients after partial pancreatectomy. Previous studies have been performed on oncologic patients who underwent partial pancreatectomy and received adjuvant chemotherapy. By studying a cohort of patients with intraductal papillary mucinous neoplasms (IPMNs) who did not receive chemotherapy, the authors investigate the isolated effect of partial pancreatectomy on the development of fatty liver. Methods A retrospective search for patients with pancreatic IPMNs who underwent partial pancreatectomy at an academic center from 2006 to 2014 identified 63 patients, including 42 who had pancreaticoduodenectomy (PD) and 21 who had distal pancreatectomy (DP). Fourteen patients with preoperative hepatic steatosis, diabetes, obesity, on steroid therapy, history of malignancy, or incomplete data were excluded. No patient received chemotherapy. Liver fat signal fraction (LFSF) was computed by the Dixon method using pre- and postoperative in- and out-of-phase MRI. Results Of the 49 patients included in the study, 29 (59%) underwent PD and 20 (41%) underwent DP. A total of 17 patients (34%) developed fatty liver after surgery. The entire cohort developed significant weight loss, 72.1 versus 69.4 kg (P < 0.01). Postoperatively, there was significant increase in LFSF, 1.3% versus 9.6% following PD (P < 0.01), and 2.1% versus 9.4% following DP (P = 0.01). Conclusion Partial pancreatectomy increases the risk of NAFLD independent of chemotherapy-induced hepatotoxicity. The underlying mechanism remains unclear and possibly related to pancreatic exocrine insufficiency and malnutrition.
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Affiliation(s)
- Zhenteng Li
- Department of Radiology, St. Luke's University Health Network, Bethlehem, PA, USA
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jonathan Weinstein
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Ellen Redstone
- Department of Radiology, St. Luke's University Health Network, Bethlehem, PA, USA
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Donald G. Mitchell
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
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12
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Takata K, Nagata T, Matsumoto K, Miyayama T, Shibata K, Fukuda H, Yamauchi R, Fukunaga A, Tanaka T, Yokoyama K, Shakado S, Sakisaka S, Hirai F. Two Cases of Rapidly Progressive Fatty Liver Disease due to Pancreatic Exocrine Insufficiency without a History of Surgery. Intern Med 2023; 62:2667-2673. [PMID: 36754408 PMCID: PMC10569931 DOI: 10.2169/internalmedicine.0775-22] [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: 08/01/2022] [Accepted: 12/26/2022] [Indexed: 02/10/2023] Open
Abstract
We herein report two cases of rapidly progressive fatty liver (FL) disease due to pancreatic exocrine insufficiency (PEI) without a surgical history. Two women, 59 and 72 years old, with no history of abdominal surgery presented to our hospital with severe anorexia and nausea persisting for one week. Examinations revealed progressive, marked FL disease with hepatomegaly and PEI, for which pancreatic enzyme replacement therapy was effective. Commonly known causes of PEI include chronic pancreatitis, abdominal surgery (e.g. pancreaticoduodenectomy), pancreatic cancer, and obstruction of the pancreatic duct, none of which were present in either of these two cases.
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Affiliation(s)
- Kazuhide Takata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takahiro Nagata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Keisuke Matsumoto
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takashi Miyayama
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Kumiko Shibata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Hiromi Fukuda
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Ryo Yamauchi
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Atsushi Fukunaga
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takashi Tanaka
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Keiji Yokoyama
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Satoshi Shakado
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Shotaro Sakisaka
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
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13
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Izumi H, Yoshii H, Fujino R, Takeo S, Nomura E, Mukai M, Makuuchi H. Factors contributing to nonalcoholic fatty liver disease (NAFLD) and fat deposition after pancreaticoduodenectomy: A retrospective analysis. Ann Gastroenterol Surg 2023; 7:793-799. [PMID: 37663962 PMCID: PMC10472401 DOI: 10.1002/ags3.12673] [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: 12/28/2022] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 09/05/2023] Open
Abstract
Aim Nonalcoholic fatty liver disease (NAFLD) can occur due to various reasons after pancreaticoduodenectomy (PD). This study examined the risk and perioperative determinants of NAFLD and fat deposition after PD. Methods A total of 101 patients who had undergone computed tomography 6 months after PD were included. We compared perioperative factors between patients who developed NAFLD and those who developed fatty deposits after PD. Results In the NAFLD group, pancreatic cancer was significantly more prevalent among patients who developed postoperative NAFLD (p = 0.024) and had a lower postoperative body mass index (BMI; p = 0.008). Multivariate analysis revealed that pancreatic carcinoma (hazard ratio [HR] 4.42, 95% confidence interval [CI] 1.118-17.442, p = 0.034) and lower postoperative BMI (HR 0.51, 95% CI 0.274-0.954, p = 0.0355) were risk factors for fatty liver. Pancreatic leakage (p = 0.024) and postoperative BMI (p = 0.002) were significantly lower in the fat deposition group than those in the NAFLD group. Multivariate analysis also revealed that a lower postoperative BMI was a risk factor for fat deposition (HR 0.56, 95% CI 0.523-0.982, p = 0.042). Moreover, multivariate analysis revealed that the fat deposition group had significantly lower pancreatic leakage than the NAFLD group (HR 7.944, 95% CI 1.993-63.562, p = 0.049). Conclusion The findings of this study suggest that postoperative BMI and pancreatic cancer are associated with a higher risk of NAFLD after PD, possibly because of pancreatic exocrine insufficiency and impaired fat absorption.
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Affiliation(s)
- Hideki Izumi
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Hisamichi Yoshii
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Rika Fujino
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Shigeya Takeo
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Eiji Nomura
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Masaya Mukai
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Hiroyasu Makuuchi
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
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14
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Zheng Q, Kawaguchi M, Mikami H, Diao P, Zhang X, Zhang Z, Nakajima T, Iwadare T, Kimura T, Nakayama J, Tanaka N. Establishment of Novel Mouse Model of Dietary NASH Rapidly Progressing into Liver Cirrhosis and Tumors. Cancers (Basel) 2023; 15:3744. [PMID: 37509405 PMCID: PMC10378543 DOI: 10.3390/cancers15143744] [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: 04/30/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH), which is the most severe manifestation of non-alcoholic fatty liver disease (NAFLD), has been recognized as a major hepatocellular carcinoma (HCC) catalyst. However, the molecular mechanism of NASH-liver fibrosis-HCC sequence remains unclear and a specific and effective treatment for NASH has not yet been established. The progress in this field depends on the availability of reliable preclinical models which show the steady progression to NASH, liver cirrhosis, and HCC. However, most of the NASH mouse models that have been described to date develop NASH generally for more than 24 weeks and there is an uncertainty of HCC development. To overcome such shortcomings of experimental NASH studies, we established a novel NASH-HCC mouse model with very high reproducibility, generality, and convenience. We treated male C57BL/6J mice with a newly developed choline-deficient and methionine-restricted high-fat diet, named OYC-NASH2 diet, for 60 weeks. Treatment of OYC-NASH2 diet for 3 weeks revealed marked steatosis, lobular inflammation, and fibrosis, histologically diagnosed as NASH. Liver cirrhosis was observed in all mice with 48-week treatment. Liver nodules emerged at 12 weeks of the treatment, > 2 mm diameter liver tumors developed in all mice at 24 weeks of the treatment and HCC appeared after 36-week treatment. In conclusion, our rapidly progressive and highly reproducible NASH-liver cirrhosis-HCC model is helpful for preclinical development and research on the pathogenesis of human NAFLD-NASH-HCC. Our mouse model would be useful for the development of novel chemicals for NASH-HCC-targeted therapies.
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Affiliation(s)
- Qianqian Zheng
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | | | - Hayato Mikami
- Oriental Yeast Co., Ltd., Itabashi, Tokyo 174-8505, Japan
| | - Pan Diao
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Xuguang Zhang
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Zhe Zhang
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Takero Nakajima
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Takanobu Iwadare
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Takefumi Kimura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Jun Nakayama
- Department of Molecular Pathology, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Naoki Tanaka
- Department of Global Medical Research Promotion, Shinshu University Graduate School of Medicine, Matsumoto 390-8621, Japan
- International Relations Office, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
- Research Center for Social Systems, Shinshu University, Matsumoto 390-8621, Japan
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15
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Song Q, Wang J, Griffiths A, Lee SM, Iyamu ID, Huang R, Cordoba-Chacon J, Song Z. Nicotinamide N-methyltransferase upregulation contributes to palmitate-elicited peroxisome proliferator-activated receptor transactivation in hepatocytes. Am J Physiol Cell Physiol 2023; 325:C29-C41. [PMID: 37212549 PMCID: PMC10259858 DOI: 10.1152/ajpcell.00010.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
Peroxisome proliferator-activated receptor γ (PPARγ) plays a pivotal role in regulating lipid metabolism and hepatic PPARγ transactivation contributes to fatty liver development. Fatty acids (FAs) are well-known endogenous ligands for PPARγ. Palmitate, a 16-C saturated FA (SFA) and the most abundant SFA in human circulation, is a strong inducer of hepatic lipotoxicity, a central pathogenic factor for various fatty liver diseases. In this study, using both alpha mouse liver 12 (AML12) and primary mouse hepatocytes, we investigated the effects of palmitate on hepatic PPARγ transactivation and underlying mechanisms, as well as the role of PPARγ transactivation in palmitate-induced hepatic lipotoxicity, all of which remain ambiguous currently. Our data revealed that palmitate exposure was concomitant with both PPARγ transactivation and upregulation of nicotinamide N-methyltransferase (NNMT), a methyltransferase catalyzing the degradation of nicotinamide, the predominant precursor for cellular NAD+ biosynthesis. Importantly, we discovered that PPARγ transactivation by palmitate was blunted by NNMT inhibition, suggesting that NNMT upregulation plays a mechanistic role in PPARγ transactivation. Further investigations uncovered that palmitate exposure is associated with intracellular NAD+ decline and NAD+ replenishment with NAD+-enhancing agents, nicotinamide and nicotinamide riboside, obstructed palmitate-induced PPARγ transactivation, implying that cellular NAD+ decline resulted from NNMT upregulation represents a potential mechanism behind palmitate-elicited PPARγ transactivation. At last, our data showed that the PPARγ transactivation marginally ameliorated palmitate-induced intracellular triacylglycerol accumulation and cell death. Collectively, our data provided the first-line evidence supporting that NNMT upregulation plays a mechanistic role in palmitate-elicited PPARγ transactivation, potentially through reducing cellular NAD+ contents.NEW & NOTEWORTHY Hepatic PPARγ transactivation contributes to fatty liver development. Saturated fatty acids (SFAs) induce hepatic lipotoxicity. Here, we investigated whether and how palmitate, the most abundant SFA in the human blood, affects PPARγ transactivation in hepatocytes. We reported for the first time that upregulation of nicotinamide N-methyltransferase (NNMT), a methyltransferase catalyzing the degradation of nicotinamide, the predominant precursor for cellular NAD+ biosynthesis, plays a mechanistic role in regulating palmitate-elicited PPARγ transactivation through reducing intracellular NAD+ contents.
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Affiliation(s)
- Qing Song
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Jun Wang
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Alexandra Griffiths
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Samuel Man Lee
- Division of Endocrinology/Diabetes & Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Iredia D Iyamu
- Department of Medicinal Chemistry and Molecular Pharmacology, Institute for Drug Discovery, Purdue University, West Lafayette, Indiana, United States
| | - Rong Huang
- Department of Medicinal Chemistry and Molecular Pharmacology, Institute for Drug Discovery, Purdue University, West Lafayette, Indiana, United States
| | - Jose Cordoba-Chacon
- Division of Endocrinology/Diabetes & Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Zhenyuan Song
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, United States
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16
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Portincasa P. NAFLD, MAFLD, and beyond: one or several acronyms for better comprehension and patient care. Intern Emerg Med 2023; 18:993-1006. [PMID: 36807050 PMCID: PMC10326150 DOI: 10.1007/s11739-023-03203-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/09/2023] [Indexed: 02/19/2023]
Abstract
The term non-alcoholic fatty liver disease (NAFLD) has rapidly become the most common type of chronic liver disease. NAFLD points to excessive hepatic fat storage and no evidence of secondary hepatic fat accumulation in patients with "no or little alcohol consumption". Both the etiology and pathogenesis of NAFLD are largely unknown, and a definitive therapy is lacking. Since NAFLD is very often and closely associated with metabolic dysfunctions, a consensus process is ongoing to shift the acronym NAFLD to MAFLD, i.e., metabolic-associated fatty liver disease. The change in terminology is likely to improve the classification of affected individuals, the disease awareness, the comprehension of the terminology and pathophysiological aspects involved, and the choice of more personalized therapeutic approaches while avoiding the intrinsic stigmatization due to the term "non-alcoholic". Even more recently, other sub-classifications have been proposed to concentrate the heterogeneous causes of fatty liver disease under one umbrella. While awaiting additional validation studies in this field, we discuss the main reasons underlying this important shift of paradigm.
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Affiliation(s)
- Piero Portincasa
- Clinica Medica "A. Murri", Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124, Bari, Italy.
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17
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Mangieri CW, Strode MA, Valenzuela CD, Erali RA, Shen P, Howerton R, Clark CJ. High-risk liver patients are not associated with adverse events following pancreaticoduodenectomy. Am J Surg 2023; 225:735-739. [PMID: 36428108 DOI: 10.1016/j.amjsurg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/26/2022] [Accepted: 11/07/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Pancreaticoduodenectomy performed with underlying hepatic disease has been reported to have increased adverse events postoperatively. This study aimed to further evaluate that association. METHODS Retrospective review of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) main and targeted pancreatectomy registries for 2014-2016. High-risk liver patients were defined by MELD scores, received neoadjuvant chemotherapy, and had hepatosteatosis; two separate subgroups of MELD ≥9 and ≥ 11. High-risk liver patients were then compared to control cases via propensity score matching. RESULTS There were 156 and 132 cases that met the high-risk liver criteria for the MELD cutoffs of ≥9 and ≥ 11 respectively. Propensity score matching left 2527 cases for final adjusted analysis. On both univariate and multivariate analysis high-risk liver patients were not associated with increased adverse events following Whipple resection. Lack of association with increased adverse events held for both the ≥9 and ≥ 11 MELD score cohorts. CONCLUSION High-risk liver patients defined by MELD scores, neoadjuvant chemotherapy utilization, and hepatosteatosis were not associated with any increased incidence of adverse events following pancreaticoduodenectomy. Patients with underlying high-risk liver disease in this study did not appear to pose as a contraindication for oncologic resection of pancreatic adenocarcinoma.
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Affiliation(s)
- Christopher W Mangieri
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States.
| | - Matthew A Strode
- Womack Army Medical Center, Department of General Surgery, United States
| | - Cristian D Valenzuela
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
| | - Richard A Erali
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
| | - Perry Shen
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
| | - Russell Howerton
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
| | - Clancy J Clark
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
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18
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Patel V, Shah P, Ludwig DR, Hammill CW, Ashkar M. Development of de novo nonalcoholic fatty liver disease following pancreatectomy. Medicine (Baltimore) 2023; 102:e32782. [PMID: 36705353 PMCID: PMC9875952 DOI: 10.1097/md.0000000000032782] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
De novo non-alcoholic fatty liver disease (NAFLD) after pancreatectomy is a recognized phenomenon; however, its pathophysiology is poorly understood. This study aimed to determine the incidence and identify peri-operative risk factors for the development of de novo NAFLD within various pancreatectomy groups. This single-center retrospective cohort study included patients who underwent pancreatectomy between 2000 and 2020. The incidence rate of de novo NAFLD and time to diagnosis were recorded across patients with malignant versus benign indications for pancreatectomy. The overall incidence of de novo NAFLD after pancreatectomy was 17.5% (24/136). Twenty-one percent (20/94) of patients with malignant indications for surgery developed NAFLD compared to 9.5% (4/42) with benign indications (P = .09). Time to development of hepatic steatosis in the malignant group was 26.4 months and was significantly shorter by an average of 6 months when compared to the benign group (32.8 months, P = .03). Higher pre-operative body mass index was associated with new-onset NAFLD (P = .03). Pre-operative body mass index is a significant predictor for de novo NAFLD and highlights a group that should be closely monitored post-operatively, especially after resections for pancreatic malignancy.
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Affiliation(s)
- Vanisha Patel
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Parth Shah
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - Daniel R. Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Chet W. Hammill
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Motaz Ashkar
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
- * Correspondence: Motaz Ashkar, Division of Gastroenterology, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110 (e-mail: )
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19
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Shah P, Patel V, Ashkar M. De novo non-alcoholic fatty liver disease after pancreatectomy: A systematic review. World J Clin Cases 2022; 10:12946-12958. [PMID: 36569000 PMCID: PMC9782952 DOI: 10.12998/wjcc.v10.i35.12946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/10/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As operative techniques and mortality rates of pancreatectomy have improved, there has been a shift in focus to maintaining and improving the nutritional status of these patients as we continue to learn more about post-operative complications. Although pancreatic endocrine and exocrine insufficiencies are known complications of pancreatectomy, increased longevity of these patients has also led to a higher incidence of de novo fatty liver disease which differs from traditional fatty liver disease given the lack of metabolic syndrome. AIM To identify and summarize patterns and risk factors of post-pancreatectomy de novo fatty liver disease to guide future management. METHODS We performed a database search on PubMed selecting papers published between 2001 and 2022 in the English language. PubMed was last accessed 1 June 2022. RESULTS Various factors influence the development of de novo fatty liver including indication for surgery (benign vs malignant), type of pancreatectomy, amount of pancreas remnant, and peri-operative nutritional status. With an incidence rate up to 75%, de novo non-alcoholic fatty liver disease (NAFLD) can develop within 12 mo after pancreatectomy and various risk factors have been established including pancreatic resection line and remnant pancreas volume, peri-operative malnutrition and weight loss, pancreatic exocrine insufficiency (EPI), malignancy as the indication for surgery, and postmenopausal status. CONCLUSION Since majority of risk factors leads to EPI and malnutrition, peri-operative focus on nutrition and enzymes replacement is key in preventing and treating de novo NAFLD after pancreatectomy.
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Affiliation(s)
- Parth Shah
- Gastroenterology, Washington University in Saint Louis, Saint Louis, MO 63110, United States
| | - Vanisha Patel
- Internal Medicine, Washington University in Saint Louis, Saint Louis, MO 63110, United States
| | - Motaz Ashkar
- Gastroenterology, Washington University in Saint Louis, Saint Louis, MO 63110, United States
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20
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Saluja SS, Varshney VK, Kumar A, Sugumaran K, Aravinda PS, Mishra PK. Histopathological Changes in Liver of Patients With Chronic Pancreatitis Requiring Surgical Intervention and Their Clinical Significance. Pancreas 2022; 51:1320-1326. [PMID: 37099773 DOI: 10.1097/mpa.0000000000002181] [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 The histopathological changes in the liver and their clinical implication in chronic pancreatitis (CP) have not been studied well. We analyzed the incidence, risk factors, and long-term outcomes of these changes in CP. METHODS Chronic pancreatitis patients who underwent surgery with intraoperative liver biopsy from 2012 to 2018 formed the study group. Based on liver histopathology, 3 groups were formed: normal liver, group NL; fatty liver, group FL; and inflammation/fibrosis, group FS. The risk factors and long-term outcomes, including mortality, were evaluated. RESULTS Among 73 patients, 39 (53.4%) had idiopathic, and 34 (46.6%) had alcoholic CP. The median age was 32 years, 52 (71.2%) were males and comprised NL, n = 40 (55%); FL, n = 22 (30%); and FS, n = 11 (15%). The preoperative risk factors were comparable among NL and FL groups. Overall 14 of 73 patients (19.2%) (NL, 5 of 40; FL, 5 of 22; FS, 4 of 11 [P = 0.82]) had died at median follow-up of 36 months (range, 25-85 months). The main causes of mortality were tuberculosis and severe malnutrition secondary to pancreatic insufficiency. CONCLUSIONS The mortality is higher in patients with inflammation/fibrosis or steatosis in liver biopsy, and such patients need monitoring for progression of liver disease and pancreatic insufficiency.
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Affiliation(s)
| | | | - Ajay Kumar
- Gastroenterology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | | | - P S Aravinda
- From the Departments of Gastrointestinal Surgery
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21
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Tsunematsu M, Gocho T, Yanagaki M, Shirai Y, Haruki K, Furukawa K, Yasuda J, Onda S, Sakamoto T, Ikegami T. The impact of postoperative exocrine index on non-alcoholic fatty liver disease following pancreaticoduodenectomy. Ann Gastroenterol Surg 2022; 6:704-711. [PMID: 36091315 PMCID: PMC9444855 DOI: 10.1002/ags3.12572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/22/2022] [Indexed: 11/07/2022] Open
Abstract
Background To study exocrine function of the remnant pancreas after pancreatoduodenectomy (PD), we propose the use of an exocrine index (PEI) that combines the volume of the remnant pancreas and the intraoperative amylase activity of the pancreatic juice. Here, we aimed to determine whether the PEI can predict non-alcoholic fatty liver disease (NAFLD) following PD. Methods Fifty-seven patients for whom pancreatic juice amylase activity was measured during PD were enrolled. NAFLD was defined as a liver-to-spleen attenuation ratio of <0.9 on plain CT 1 year following surgery. We retrospectively evaluated clinical parameters, including the PEI, to identify predictors of NAFLD. Results Fifty-four patients (95%) were regularly administered 1200 mg of pancreatic lipase. NAFLD was diagnosed in 13 participants (23%) 1 year following surgery. NAFLD was associated with pancreatic ductal adenocarcinoma (P = .006), soft pancreas (P = .001), small main pancreatic duct (P = 0008), low remnant pancreatic volume (P < .001), low intraoperative amylase activity in the pancreatic juice (P = .001), high pancreatic fibrosis (P = .032), and large body weight loss (P = .015). The PEI was significantly lower in the participants with NAFLD than in those without (P < .001). The participants were then classified into tertiles of PEI: <5 × 106, 5-25 × 106, and >25 × 106. The prevalence of NAFLD in these groups was 53% (10/19), 11% (2/19), and 5% (1/19), respectively. In multivariable analyses, there was a significant association between NAFLD and the PEI (P value for trend = .042). Conclusion The PEI, calculated using the remnant pancreatic volume and the intraoperative pancreatic juice amylase activity, predicts NAFLD development following PD.
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Affiliation(s)
| | - Takeshi Gocho
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Mitsuru Yanagaki
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Yoshihiro Shirai
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Koichiro Haruki
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Kenei Furukawa
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Jungo Yasuda
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Shinji Onda
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Taro Sakamoto
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Toru Ikegami
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
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22
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Hong AS, Sarwar N, Goldin RD, Dhar A, Possamai LA. Pembrolizumab-Induced Pancreatic Exocrine Insufficiency Complicated by Severe Hepatic Steatosis. Cureus 2022; 14:e26596. [PMID: 35936135 PMCID: PMC9354921 DOI: 10.7759/cureus.26596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/25/2022] Open
Abstract
Anti-programmed death receptor-1 (anti-PD-1) monoclonal antibodies (mAbs) are used to treat an increasing range of cancers. However, the distinct toxicity profile of immune-related adverse events (irAEs) is a frequent drawback of their clinical application. Among the more common irAEs are hepatitis and colitis, which are diagnosed and graded in patients based on elevated serum liver enzyme levels and increased stool frequency, respectively, and both of which often require treatment with high-dose corticosteroids. Herein, we describe the case of a patient who developed severe transaminase elevation and diarrhoea due to an unusual irAE, which was successfully treated without corticosteroids.
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Affiliation(s)
- Alex S Hong
- Gastroenterology and Hepatology, Imperial College School of Medicine, London, GBR
| | - Naveed Sarwar
- Medical Oncology, Department of Oncology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, GBR
| | - Robert D Goldin
- Section for Pathology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, GBR
| | - Ameet Dhar
- Gastroenterology and Hepatology, Department of Hepatology, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, GBR
| | - Lucia A Possamai
- Gastroenterology and Hepatology, Department of Hepatology, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, GBR
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23
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Yamamura K, Yamashita Y, Yamao T, Kitano Y, Arima K, Miyata T, Higashi T, Hayashi H, Beppu T, Baba H. Clinical impact of atrophic changes in remnant pancreas on the development of nonalcoholic fatty liver disease after pancreaticoduodenectomy. Ann Gastroenterol Surg 2022; 6:555-561. [PMID: 35847431 PMCID: PMC9271020 DOI: 10.1002/ags3.12554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/13/2022] [Accepted: 01/30/2022] [Indexed: 11/21/2022] Open
Abstract
Aim The aim of this study was to evaluate risk factors for nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD), with a special focus on remnant pancreatic volume (RPV) as assessed using computed tomography (CT). Methods From February 2004 to June 2017, 101 patients who underwent PD in our institution were enrolled. We defined a CT attenuation value of less than 40 HU as hepatic steatosis and measured RPV at 7 days, 3 months, and 1 year after PD using the SYNAPSE VINCENT system. The incidence of NAFLD and RPV were compared between the two groups according to reconstruction with pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ). Results The incidence of NAFLD at 3 months after PD was 39.6% (40/101). The RPV ratio (RPV at 3 months or 1 year divided by RPV at 7 days after PD) at both 3 months and 1 year was significantly smaller in the PG group than in the PJ group (59% vs 73%, P < .001 and 53% vs 67% P < .01, respectively). A positive correlation between the RPV ratio and liver CT value at 3 months was found. The multivariate analysis identified three independent risk factors for NAFLD: female sex (odds ratio [OR] 8.16, 95% confidence interval [95% CI] 2.27-35.9, P < .001), PG reconstruction (OR 3.87, 95% CI 1.04-15.6, P = .04), and RPV ratio ≤60% (OR 3.44, 95% CI 1.06-11.8, P = .001). Conclusion Atrophic change in the remnant pancreas is significantly associated with the development of NAFLD, and PJ reconstruction may be superior to PG from the viewpoint of NAFLD development.
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Affiliation(s)
- Kensuke Yamamura
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
- Department of SurgeryYamaga City Medical CenterKumamotoJapan
| | - Yo‐ichi Yamashita
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Takanobu Yamao
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Yuki Kitano
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Kota Arima
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Tatsunori Miyata
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Takaaki Higashi
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Hiromitsu Hayashi
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Toru Beppu
- Department of SurgeryYamaga City Medical CenterKumamotoJapan
| | - Hideo Baba
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
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24
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Kawaguchi T, Tsutsumi T, Nakano D, Torimura T. MAFLD: Renovation of clinical practice and disease awareness of fatty liver. Hepatol Res 2022; 52:422-432. [PMID: 34472683 DOI: 10.1111/hepr.13706] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/15/2021] [Accepted: 08/17/2021] [Indexed: 12/11/2022]
Abstract
Recently, international expert panels have proposed a new definition of fatty liver: metabolic dysfunction-associated fatty liver disease (MAFLD). MAFLD is not just a simple renaming of non-alcoholic fatty liver disease (NAFLD). The unique feature of MAFLD is the inclusion of metabolic dysfunctions, which are high-risk factors for events. In addition, MAFLD is independent of alcohol intake and the co-existing causes of liver disease. This new concept of MAFLD may have a widespread impact on patients, medical doctors, medical staff, and various stakeholders regarding fatty liver. Thus, MAFLD may renovate clinical practice and disease awareness of fatty liver. In this review, we introduce the definition of and rationale for MAFLD. We further describe representative cases showing how the diagnostic processes differ between MAFLD and NAFLD. We also summarize recent studies comparing MAFLD with NAFLD and discuss the impact of MAFLD on clinical trials, Japanese populations, and disease awareness.
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Affiliation(s)
- Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Tsubasa Tsutsumi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Dan Nakano
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Takuji Torimura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
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25
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Jeon D, Park BH, Lee HC, Park Y, Lee W, Lee JH, Song KB, Hwang DW, Kim SC, Choi J. The Impact of Pylorus Preservation on the Development of Nonalcoholic Fatty Liver Disease after Pancreaticoduodenectomy: A Historical Cohort Study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:863-873. [DOI: 10.1002/jhbp.1150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 02/05/2022] [Accepted: 02/08/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Dongsub Jeon
- Department of Gastroenterology, Liver Center, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | | | - Han Chu Lee
- Department of Gastroenterology, Liver Center, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Jonggi Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
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26
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Estes-Doetsch H, Ganzer H, Roberts K, Brody RA. Risk factors and assessment considerations for essential fatty acid deficiency in nonparenterally fed patients using a case example. Nutr Clin Pract 2022; 37:843-851. [PMID: 34978102 DOI: 10.1002/ncp.10822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Essential fatty acid deficiency (EFAD) has most commonly been reported in parenterally fed individuals but may also present in patients receiving fat-restricted diets and in patients with fat-malabsorption disorders. This article reviews the physical and biochemical assessment for EFAD in clinical practice and disorders of fat malabsorption as potential risk factors for EFAD. A case report is included to describe the fatty acid profile of a patient with exocrine pancreatic insufficiency receiving low-dose pancreatic enzyme replacement therapy after a self-imposed fat-restricted diet. The current challenges with laboratory interpretation of essential fatty acid status are also discussed.
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Affiliation(s)
- Holly Estes-Doetsch
- Medical Dietetics Division, College of Medicine, The Ohio State University, Columbus, Ohio, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Heidi Ganzer
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, Newark, New Jersey, USA
| | - Kristen Roberts
- Medical Dietetics Division, College of Medicine, The Ohio State University, Columbus, Ohio, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Rebecca A Brody
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, Newark, New Jersey, USA
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27
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Beger HG, Mayer B, Vasilescu C, Poch B. Long-term Metabolic Morbidity and Steatohepatosis Following Standard Pancreatic Resections and Parenchyma-sparing, Local Extirpations for Benign Tumor: A Systematic Review and Meta-analysis. Ann Surg 2022; 275:54-66. [PMID: 33630451 DOI: 10.1097/sla.0000000000004757] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess metabolic dysfunctions and steatohepatosis after standard and local pancreatic resections for benign and premalignant neoplasms. SUMMARY OF BACKGROUND DATA Duodenopancreatectomy, hemipancreatectomy, and parenchyma-sparing, limited pancreatic resections are currently in use for nonmalignant tumors. METHODS Medline, Embase, and Cochrane libraries were searched for studies reporting measured data of metabolic functions following PD, pancreatic left resection (PLR), duodenum-sparing pancreatic head resection (DPPHR), pancreatic middle segment resection (PMSR), and tumor enucleation (TEN). Forty cohort studies comprising data of 2729 patients were eligible. RESULTS PD for benign tumor was associated in 46 of 327 patients (14.1%) with postoperative new onset of diabetes mellitus (pNODM) and in 109 of 243 patients (44.9%) with postoperative new onset of pancreatic exocrine insufficiency measured after a mean follow-up of 32 months. The meta-analysis displayed pNODM following PD in 32 of 204 patients (15.7%) and in 10 of 200 patients (5%) after DPPHR [P < 0.01; OR: 0.33; (95%-CI: 0.15-0.22)]. PEI was found in 77 of 174 patients following PD (44.3%) and in 7 of 104 patients (6.7%) following DPPHR (P < 0.01;OR: 0.15; 95%-CI: 0.07-0.32). pNODM following PLR was reported in 107 of 459 patients (23.3%) and following PMSR 23 of 412 patients (5.6%) (P < 0.01; OR: 0.20; 95%-CI: 0.12-0.32). Postoperative new onset of pancreatic exocrine insufficiency was found in 17% following PLR and in 8% following PMSR (P < 0.01). pNODM following PPPD and tumor enucleation was observed in 19.7% and 5.7% (P < 0.03) of patients, respectively. Following PD/PPPD, 145 of 608 patients (23.8%) developed a nonalcoholic fatty liver disease after a mean follow-up of 30.4 months. Steatohepatosis following DPPHR developed in 2 of 66 (3%) significantly lower than following PPPD (P < 0.01). CONCLUSION Standard pancreatic resections for benign tumor carry a considerable high risk for a new onset of diabetes, pancreatic exocrine insufficiency and following PD for steatohepatosis. Parenchyma-sparing, local resections are associated with low grade metabolic dysfunctions.
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Affiliation(s)
- Hans G Beger
- c/o University of Ulm, Ulm, Germany
- Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum, Neu-Ulm, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Germany
| | - Catalin Vasilescu
- Fundeni Clinical Institute; Department of General Surgery, Bucharest, Romania
| | - Bertram Poch
- Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum, Neu-Ulm, Germany
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28
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Nakamura N, Kinami S, Fujita J, Kaida D, Tomita Y, Miyata T, Miyashita T, Fujita H, Ueda N, Takamura H. Relationship between fatty liver change and nutritional status after total gastrectomy in gastric cancer patients: a retrospective study. BMC Surg 2021; 21:325. [PMID: 34391390 PMCID: PMC8364078 DOI: 10.1186/s12893-021-01324-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 08/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The relationship between chronological nutritional changes and development of fatty liver after total gastrectomy (TG) in gastric cancer (GC) patients is still unclear. This study aimed to evaluate relationship between development of fatty liver and chronological changes of nutritional parameters during 12 months after TG. METHODS We retrospectively analyzed medical records of 59 patients with GC who underwent TG at the Kanazawa Medical University Hospital between January 2009 and December 2017. We defined fatty liver change as a mean liver-to-spleen attenuation ratio (L/S ratio) of less than 1.2 in the computed tomography images at 12 months after TG and divided the patients into fatty liver (FL) and non-FL groups from the L/S ratio. We analyzed serum levels of total protein and albumin, and psoas muscle index (PMI) before TG and at 6 and 12 months after TG in the non-FL and FL groups. RESULTS Six patients showed an L/S ratio of less than 1.2 at 12 months after TG and were included into FL group. There was no significant difference between the groups in serum parameters, L/S ratio, and PMI before TG. In the FL group, the mean levels of total protein and albumin decreased after TG and were significant lower at 6 months, compared with the non-FL group. And then, these levels in the FL group recovered at 12 months. In contrast, the mean levels of total protein and albumin in the non-FL group did not decrease below the preoperative levels throughout the year after surgery. As with laboratory parameters, all patients in the FL group showed decrease of PMI at 6 months after TG. This proportion was significantly higher than that in the non-FL group (100% vs. 40.8%, P = 0.006). CONCLUSIONS We evaluated that the patients with fatty liver occurring after TG had significantly lower levels of serum nutritional parameters and skeletal muscle index at 6 months, not but 12 months, after TG.
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Affiliation(s)
- Naohiko Nakamura
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Shinichi Kinami
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Jun Fujita
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Daisuke Kaida
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Yasuto Tomita
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Takashi Miyata
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Tomoharu Miyashita
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Hideto Fujita
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Nobuhiko Ueda
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Hiroyuki Takamura
- Department of Surgical Oncology, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
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29
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Maehira H, Iida H, Maekawa T, Yasukawa D, Mori H, Takebayashi K, Kaida S, Miyake T, Matsubara A, Tani M. Estimated functional remnant pancreatic volume predicts nonalcoholic fatty liver disease after pancreaticoduodenectomy: use of computed tomography attenuation value of the pancreas. HPB (Oxford) 2021; 23:802-811. [PMID: 33046368 DOI: 10.1016/j.hpb.2020.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/18/2020] [Accepted: 08/25/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is a late complication of pancreaticoduodenectomy (PD). However, this complication is difficult to predict preoperatively. This study aimed to assess the association between NAFLD and preoperative computed tomography (CT) findings. METHODS Medical records of 112 patients who had undergone PD and had CT scans preoperatively and 6 months postoperatively were retrospectively reviewed. We evaluated several CT findings, including the CT attenuation value of the remnant pancreas, remnant pancreatic volume (RPV), and the estimated functional remnant pancreatic volume (eFRPV) on preoperative CT. The variables, including the CT findings and histopathological findings, were compared between the patients with and without NAFLD after PD. RESULTS The NAFLD group included 21 patients (18.8%). The CT attenuation value of the remnant pancreas was correlated with the pancreatic acinar cell density (r = 0.537), and was lower in the NAFLD group than in the non-NAFLD group (p = 0.007). The eFRPV was lower in the NAFLD group than in the non-NAFLD group (p = 0.002). An eFRPV ≤47 mL·HU was an independent predictive factor for NAFLD (p = 0.007; odds ratio: 6.73; 95% confidence interval: 1.70-26.70). CONCLUSION The eFRPV can be used to preoperatively predict NAFLD after PD.
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Affiliation(s)
- Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan.
| | - Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Takeru Maekawa
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Daiki Yasukawa
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | | | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Akiko Matsubara
- Division of Diagnostic Pathology, Shiga University of Medical Science Hospital, Shiga, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
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30
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McGhee-Jez AE, Chervoneva I, Yi M, Ahuja A, Nahar R, Shah S, Loh R, Houtmann S, Shah R, Yeo CJ, Lavu H, Cohen SJ, Halegoua-DeMarzio D, Basu Mallick A. Nonalcoholic Fatty Liver Disease After Pancreaticoduodenectomy for a Cancer Diagnosis. J Pancreat Cancer 2021; 7:23-30. [PMID: 34095739 PMCID: PMC8175252 DOI: 10.1089/pancan.2020.0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose: Current literature reports increased incidence of postpancreaticoduodenectomy (PD) nonalcoholic fatty liver disease (NAFLD), a precursor for nonalcoholic steatohepatitis and cirrhosis. The incidence of and risk factors (RFs) for NAFLD in the PD population, however, are not well elucidated. Methods: A cohort of 421 patients from a single institution who underwent PD for carcinoma and followed for at least 6 months were assessed retrospectively for age, gender, pathology, surgical complications (operative blood loss and length of stay [LOS]), comorbidities (diabetes, hypertension, hyperlipidemia, obesity), tobacco use, pre- and postoperative nutritional status (albumin and body mass index [BMI]), use of pancreatic enzyme replacement, and perioperative laboratory values (hemoglobin and liver function test). Cox proportional hazards model was used to examine these potential RFs as predictors of time to development of post-PD NAFLD. Results: Sixty (14.3%) patients developed post-PD NAFLD. Patients with NAFLD were younger (61.10 vs. 65.01 years old) and had higher preoperative BMI (28.92 vs. 26.61). Multivariate Cox proportional hazard model identified higher preoperative BMI, shorter postoperative LOS, and female gender as RFs for post-PD NAFLD. After excluding 12 patients with rare histology, there was a lower unadjusted hazard of developing NAFLD (p-value = 0.018) in the adenocarcinoma group than in the neuroendocrine and periampullary tumor groups. There was no statistically significant association between post-PD NAFLD and other characteristics. Conclusion: Female gender, higher preoperative BMI, and shorter LOS deserve closer monitoring for earlier detection and management of NAFLD.
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Affiliation(s)
- Amy E McGhee-Jez
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Inna Chervoneva
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Misung Yi
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Amisha Ahuja
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ritu Nahar
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Samik Shah
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rebecca Loh
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sarah Houtmann
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rashesh Shah
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Charles J Yeo
- Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Harish Lavu
- Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Steven J Cohen
- Division of Hematology/Medical Oncology, Abington/Jefferson Health, Department of Medical Oncology, Thomas Jefferson University Hospital, Willow Grove, Pennsylvania, USA
| | - Dina Halegoua-DeMarzio
- Division of Gastroenterology and Hepatology, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Atrayee Basu Mallick
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Tanaka N, Kimura T, Fujimori N, Ichise Y, Sano K, Horiuchi A. Non-alcoholic fatty liver disease later diagnosed as myotonic dystrophy. World J Hepatol 2020; 12:685-692. [PMID: 33033573 PMCID: PMC7522559 DOI: 10.4254/wjh.v12.i9.685] [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: 04/22/2020] [Revised: 07/24/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Myotonic dystrophy (MD) is sometimes accompanied by metabolic/endocrine disorders, including dyslipidemia, central obesity, and hypogonadism. Due to considerable individual differences in the severity and progression of myopathy, MD patients with minimal-to-mild muscle symptoms might be followed as having other diseases, such as non-alcoholic fatty liver disease (NAFLD).
CASE SUMMARY A 40-year-old non-obese man without a history of regular ethanol consumption was referred to our hospital due to persistent liver dysfunction and hyperlipidemia. His body mass index was 23.4 kg/m2. Liver histology demonstrated macrovesicular steatosis, ballooned hepatocytes with eosinophilic inclusion bodies, and perisinusoidal fibrosis, leading to the diagnosis of non-alcoholic steatohepatitis (NASH). Although he had no discernable muscle pain or weakness, persistently high serum creatine kinase (CK) and myoglobin levels as well as the presence of frontal baldness, a hatched face, history of cataract surgery, and grip myotonia indicated the possibility of MD. Southern blotting of the patient’s DNA revealed the presence of CTG repeats, confirming the diagnosis.
CONCLUSION When gastroenterologists encounter NAFLD/NASH patients, serum CK should be verified. If hyperCKemia, frontal baldness, a hatched face, history of cataract surgery, and grip myotonia are noted, the possibility of MD may be considered.
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Affiliation(s)
- Naoki Tanaka
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Takefumi Kimura
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Naoyuki Fujimori
- Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Yasuyuki Ichise
- Digestive Disease Center, Showa Inan General Hospital, Komagane 399-4117, Japan
| | - Kenji Sano
- Department of Pathology, Iida Municipal Hospital, Iida 395-8502, Japan
| | - Akira Horiuchi
- Digestive Disease Center, Showa Inan General Hospital, Komagane 399-4117, Japan
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Yasukawa K, Shimizu A, Yokoyama T, Kubota K, Notake T, Seki H, Kobayashi A, Soejima Y. Preventive Effect of High-Dose Digestive Enzyme Management on Development of Nonalcoholic Fatty Liver Disease after Pancreaticoduodenectomy: A Randomized Controlled Clinical Trial. J Am Coll Surg 2020; 231:658-669. [PMID: 32927075 DOI: 10.1016/j.jamcollsurg.2020.08.761] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/27/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is a complication of pancreaticoduodenectomy (PD). We conducted a randomized clinical trial to determine if high-dose digestive enzymes prevented the development of NAFLD after PD. STUDY DESIGN This parallel-group, nonblinded, multicenter study enrolled patients undergoing elective PD at Shinshu University School of Medicine, from June 2011 to April 2017. Patients were randomly assigned to receive normal-dose (Excelase: 3.0 g/day [Meiji Seika Pharma Holdings Co, Ltd]) or high-dose digestive enzyme treatment (Excelase: 3.0 g/day; Pancreatin [Tokyo Chemical Industry Co Ltd]: 3.0 g/day; Berizym [Kyowa Pharmaceutical Industry Co Ltd]: 3.0 g/day; and Toughmac-E [Ono Pharmaceutical Co, Ltd]: 3.0 g/day) within 1 week after surgery. Because patients in the control group switched interventions upon receiving a diagnosis of NAFLD, intention-to-treat analysis was used. The primary endpoint was incidence of NAFLD within 1 year, and the secondary endpoints were the incidences of NAFLD at 1, 3, 6, and 12 months and the rate of improvement in NAFLD with high-dose transfer in the control group. The secondary analysis comprised assessment of risk factors for the development of NAFLD. RESULTS Eighty-four patients were randomly assigned (42 per group), 80 of whom were finally analyzed (39 normal-dose, 41 high-dose). The incidence of NAFLD was significantly lower in the high-dose (8 of 41) compared with the normal-dose (25 of 39) patients (p < 0.001). Multivariate analysis identified normal-dose (odds ratio [OR] 14.65, p < 0.001), total protein ≤ 6.5g/dL (OR 9.01, p = 0.018), pre-albumin ≤ 22.0 mg/dL (OR 7.71, p = 0.018), and pancreatic function diagnostic test ≤ 70% (OR 6.66, p = 0.009) as independent risk factors. There were no adverse effects. The model was accurate (c-index = 0.92) and reliable (Hosmer-Lemeshow test p = 0.32). CONCLUSIONS High-dose administration of digestive enzymes significantly reduced the onset of NAFLD after PD compared with normal-dose administration. Registration number: UMIN000005595 (http://www.umin.ac.jp/ctr/).
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Affiliation(s)
- Koya Yasukawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation, and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Akira Shimizu
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation, and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takahide Yokoyama
- Gastroenterological Surgery, National Hospital Organization Shinshu Ueda Medical Center, Ueda, Japan
| | - Koji Kubota
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation, and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tsuyoshi Notake
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation, and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hitoshi Seki
- Gastroenterological Surgery, Nagano Municipal Hospital, Nagano, Japan
| | - Akira Kobayashi
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation, and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuji Soejima
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation, and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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Kaufmann B, Reca A, Wang B, Friess H, Feldstein AE, Hartmann D. Mechanisms of nonalcoholic fatty liver disease and implications for surgery. Langenbecks Arch Surg 2020; 406:1-17. [PMID: 32833053 PMCID: PMC7870612 DOI: 10.1007/s00423-020-01965-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/09/2020] [Indexed: 02/08/2023]
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) has become the most common form of chronic liver disease in both adults and children worldwide. Understanding the pathogenic mechanisms behind NAFLD provides the basis for identifying risk factors, such as metabolic syndrome, pancreatoduodenectomy, and host genetics, that lead to the onset and progression of the disease. The progression from steatosis to more severe forms, such as steatohepatitis, fibrosis, and cirrhosis, leads to an increased number of liver and non-liver complications. Purpose NAFLD-associated end-stage liver disease (ESLD) and hepatocellular carcinoma (HCC) often require surgery as the only curative treatment. In particular, the presence of NAFLD together with the coexisting metabolic comorbidities that usually occur in these patients requires careful preoperative diagnosis and peri-/postoperative management. Bariatric surgery, liver resection, and liver transplantation (LT) have shown favorable results for weight loss, HCC, and ESLD in patients with NAFLD. The LT demand and the increasing spread of NAFLD in the donor pool reinforce the already existing lack of donor organs. Conclusion In this review, we will discuss the diverse mechanisms underlying NAFLD, its implications for surgery, and the challenges for patient management.
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Affiliation(s)
- Benedikt Kaufmann
- Department of Pediatric Gastroenterology, University of California San Diego (UCSD), La Jolla, CA, USA.,Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675, Munich, Germany
| | - Agustina Reca
- Department of Pediatric Gastroenterology, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Baocai Wang
- Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675, Munich, Germany
| | - Helmut Friess
- Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675, Munich, Germany
| | - Ariel E Feldstein
- Department of Pediatric Gastroenterology, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Daniel Hartmann
- Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675, Munich, Germany.
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Shah N, Rocha JP, Bhutiani N, Endashaw O. Nonalcoholic Fatty Pancreas Disease. Nutr Clin Pract 2020; 34 Suppl 1:S49-S56. [PMID: 31535735 DOI: 10.1002/ncp.10397] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Nonalcoholic fatty pancreas disease (NAFPD) describes a phenotype of pancreatic steatosis (PS) that is not caused by alcohol consumption, viral infections, toxins, or congenital metabolic syndromes but is associated with insulin resistance, malnutrition, obesity, metabolic syndrome, or increasing age. NAFPD is a relatively new disease entity, as the clinical significance of fatty infiltration of pancreas has gained attention recently. Clinical consequences of NAFPD remain largely unknown despite clinical associations. This review aims to study similarities and differences between hepatic and PS and explore recent advances in NAFPD.
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Affiliation(s)
- Nihar Shah
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Jason P Rocha
- Division of Gastroenterology and Nutrition, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Neal Bhutiani
- Department of Surgery and Department of Microbiology and Immunology, University of Louisville, Louisville, Kentucky, USA
| | - Omer Endashaw
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA
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Miyamoto R, Inagaki Y, Ikeda N, Oda T. Three-dimensional remnant pancreatic volume ratio indicates postoperative pancreatic exocrine insufficiency in pancreatic cancer patients after distal pancreatectomy. Pancreatology 2020; 20:867-874. [PMID: 32654989 DOI: 10.1016/j.pan.2020.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/26/2020] [Accepted: 06/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatectomy may cause serious pancreatic exocrine insufficiency (PEI), which can lead to some nutritional problems, including new-onset diabetes mellitus (DM) or non-alcoholic fatty liver disease (NAFLD). Recent studies have reported that remnant pancreatic volume (RPV) significantly influences postoperative PEI. However, the specific correlation between RPV and postoperative PEI remains unclear. Here, we compare various pre-, peri-, and postoperative risk factors in a retrospective cohort to address whether preoperatively measured RPV is a predictor of postoperative PEI in pancreatic cancer patients after distal pancreatectomy (DP). METHODS Sixty-one pancreatic cancer patients who underwent DP were retrospectively enrolled. Pancreatic volume was measured using preoperative 3D images, which simulated the actual intraoperative pancreatic parenchymal volume. We obtained the 3D-measured RPV and resected pancreatic volume. We calculated the ratio of the RPV to the total pancreatic volume and then divided the cohort into high- and low-RPV ratio groups based on a cut-off value (>0.35, n = 37 and ≤ 0.35, n = 24). Using multivariate analysis, the RPV ratio as well as pre-, peri- and postoperative PEI risk factors were independently assessed. RESULTS The multivariate analysis revealed that a low RPV ratio (odds ratio [OR], 5.911; p = 0.001), a hard pancreatic texture (OR, 3.313; p = 0.023) and TNM stage III/IV (OR, 3.515; p = 0.031) were strong predictors of the incidence of PEI. CONCLUSIONS The present study indicates that the RPV ratio is an additional useful predictor of postoperative nutrition status in pancreatic cancer patients.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan.
| | - Yuki Inagaki
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Naoya Ikeda
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Tatsuya Oda
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Beger HG, Mayer B, Poch B. Resection of the duodenum causes long-term endocrine and exocrine dysfunction after Whipple procedure for benign tumors - Results of a systematic review and meta-analysis. HPB (Oxford) 2020; 22:809-820. [PMID: 31983660 DOI: 10.1016/j.hpb.2019.12.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/23/2019] [Accepted: 12/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Metabolic dysfunctions after pancreatoduodenectomy (PD) need to be considered when pancreatic head resection is likely to lead to long-term survival. METHODS Medline, Embase and Cochrane Library were searched for studies reporting measured data of metabolic function after PD and duodenum-sparing total pancreatic head resection (DPPHR). Data from 23 cohort studies comprising 1019 patients were eligible; 594 and 910 patients were involved in systematic review and meta-analysis, respectively. RESULTS The cumulative incidence of postoperative new onset of diabetes mellitus (pNODM) after PD for benign tumors was 46 of 321 patients (14%) measured after follow-up of in mean 36 months postoperatively. New onset of postoperative exocrine insufficiency (PEI) was exhibited by 91 of 209 patients (44%) after PD for benign tumors measured in mean 23 months postoperatively. The meta-analysis indicated pNODM after PD for benign tumor in 32 of 208 patients (15%) and in 10 of 178 patients (6%) after DPPHR (p = 0.007; OR 3.01; (95%CI:1.39-6.49)). PEI was exhibited by 80 of 178 patients (45%) after PD and by 6 of 88 patients (7%) after DPPHR (p < 0.001). GI hormones measured in 194 patients revealed postoperatively a significant impairment of integrated responses of gastrin, motilin, insulin, secretin, PP and GIP (p < 0.050-0.001) after PD. Fasting and stimulated levels of GLP-1 and glucagon levels displayed a significant increase (p < 0.020/p < 0.030). Following DPPHR, responses of gastrin, motilin, secretin and CCK displayed no change compared to preoperative levels. CONCLUSIONS After PD, duodenectomy, rather than pancreatic head resection is the main cause for long-term persisting, postoperative new onset of DM and PEI.
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Affiliation(s)
- Hans G Beger
- c/o University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany; Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donauklinikum Neu-Ulm, Germany.
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Germany
| | - Bertram Poch
- Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donauklinikum Neu-Ulm, Germany
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Pathanki AM, Attard JA, Bradley E, Powell-Brett S, Dasari BVM, Isaac JR, Roberts KJ, Chatzizacharias NA. Pancreatic exocrine insufficiency after pancreaticoduodenectomy: Current evidence and management. World J Gastrointest Pathophysiol 2020; 11:20-31. [PMID: 32318312 PMCID: PMC7156847 DOI: 10.4291/wjgp.v11.i2.20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/13/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is the commonest procedure performed for pancreatic cancer. Pancreatic exocrine insufficiency (PEI) may be caused or exacerbated by surgery and remains underdiagnosed and undertreated. The aim of this review was to ascertain the incidence of PEI, its consequences and management in the setting of PD for indications other than chronic pancreatitis. A literature search of databases (MEDLINE, EMBASE, Cochrane and Scopus) was carried out with the MeSH terms “pancreatic exocrine insufficiency” and “Pancreaticoduodenectomy”. Studies that analysed PEI and its complications in the setting of PD for malignant and benign disease were included. Studies reporting PEI in the setting of PD for chronic pancreatitis, conference abstracts and reviews were excluded. The incidence of PEI approached 100% following PD in some series. The pre-operative incidence varied depending on the characteristics of the patient cohort and it was higher (46%-93%) in series where pancreatic cancer was the predominant indication for surgery. Variability was also recorded with regards to the method used for the diagnosis and evaluation of pancreatic function and malabsorption. Pancreatic enzyme replacement therapy is the mainstay of the management. PEI is common and remains undertreated after PD. Future studies are required for the identification of a well-tolerated, reliable and reproducible diagnostic test in this setting.
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Affiliation(s)
- Adithya M Pathanki
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Joseph A Attard
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Elizabeth Bradley
- Department of Nutrition and Dietetics, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Sarah Powell-Brett
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Bobby V M Dasari
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - John R Isaac
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Keith J Roberts
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Nikolaos A Chatzizacharias
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
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PPARs as Metabolic Regulators in the Liver: Lessons from Liver-Specific PPAR-Null Mice. Int J Mol Sci 2020; 21:ijms21062061. [PMID: 32192216 PMCID: PMC7139552 DOI: 10.3390/ijms21062061] [Citation(s) in RCA: 267] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/09/2020] [Accepted: 03/09/2020] [Indexed: 12/12/2022] Open
Abstract
Peroxisome proliferator-activated receptor (PPAR) α, β/δ, and γ modulate lipid homeostasis. PPARα regulates lipid metabolism in the liver, the organ that largely controls whole-body nutrient/energy homeostasis, and its abnormalities may lead to hepatic steatosis, steatohepatitis, steatofibrosis, and liver cancer. PPARβ/δ promotes fatty acid β-oxidation largely in extrahepatic organs, and PPARγ stores triacylglycerol in adipocytes. Investigations using liver-specific PPAR-disrupted mice have revealed major but distinct contributions of the three PPARs in the liver. This review summarizes the findings of liver-specific PPAR-null mice and discusses the role of PPARs in the liver.
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Lazar MV, Eapen M, Nair HR, Siyad I, Gopalakrishna R. Correlation between insulin resistance and liver histology in patients with nonalcoholic steatohepatitis with and without obesity. Indian J Gastroenterol 2020; 39:42-49. [PMID: 32222944 DOI: 10.1007/s12664-020-01024-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 02/04/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Insulin resistance (IR) plays a central role in pathogenesis of nonalcoholic steatohepatitis (NASH). The aim of this study was to correlate histopathological grading and IR in overweight/obese patients with NASH as compared with lean NASH. METHODS Patients with NASH who underwent liver biopsy between January 2012 and December 2012 were included. Anthropometric, clinical, and biochemical features, necro-inflammatory grades, and fibrosis stage on liver biopsies were scored according to Brunt and non-alcoholic fatty liver disease (NAFLD) activity score (NAS). RESULTS Of 42 patients, 33 (78.6%) had body mass index (BMI) ≥ 23 kg/m2 (overweight/obese) while 9 had BMI < 23 kg/m2 (lean). Mean fasting blood sugar (FBS) and HbA1c levels in overweight/obese patients with NASH were higher than in lean NASH (p < 0.05). The median homeostatic model assessment-estimated insulin resistance (HOMA-IR) among NASH patients with BMI ≥ 23 kg/m2 was higher than among those with BMI < 23 kg/m2 (3.02 [0.34-17.22] vs. 2 [0.52-5.26]; p = 0.045). However, fasting insulin levels were comparable among lean and overweight/obese patients with NASH. Metabolic syndrome could be predicted with 75% sensitivity and 85.3% specificity at a HOMA-IR cutoff value of 3.9. No significant difference was observed with regard to HOMA-IR levels with Brunt grades, Brunt staging, Brunt grades 1 and 2, Brunt scores < 2 and > 2, and NAS scores, and NAS scores < 4 and > 4. CONCLUSIONS Although IR was significantly higher in overweight/obese patients with NASH as compared with that in lean patients with NASH, there was no difference in the correlation of HOMA-IR with histology between these groups.
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Affiliation(s)
- Mathew Vadukoot Lazar
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, Amrita Vishwa Vidyapeetham, AIMS Ponekkara P.O., Kochi, 682 041, India
| | - Malini Eapen
- Department of Pathology, Amrita Institute of Medical Sciences, Kochi, Amrita Vishwa Vidyapeetham, AIMS Ponekkara P.O., Kochi, 682 041, India
| | - Harikumar R Nair
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, Amrita Vishwa Vidyapeetham, AIMS Ponekkara P.O., Kochi, 682 041, India
| | - Ismail Siyad
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, Amrita Vishwa Vidyapeetham, AIMS Ponekkara P.O., Kochi, 682 041, India
| | - Rajesh Gopalakrishna
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, Amrita Vishwa Vidyapeetham, AIMS Ponekkara P.O., Kochi, 682 041, India.
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Factors Affecting Nonalcoholic Fatty Liver Disease After Pancreatic Head Resection. Pancreas 2019; 48:e75-e77. [PMID: 31609939 DOI: 10.1097/mpa.0000000000001407] [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: 12/10/2022]
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41
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Postoperative nonalcoholic fatty liver disease is correlated with malnutrition leading to an unpreferable clinical course for pancreatic cancer patients undergoing pancreaticoduodenectomy. Surg Today 2019; 50:193-199. [DOI: 10.1007/s00595-019-01866-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/21/2019] [Indexed: 12/28/2022]
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Tanaka N, Kimura T, Fujimori N, Nagaya T, Komatsu M, Tanaka E. Current status, problems, and perspectives of non-alcoholic fatty liver disease research. World J Gastroenterol 2019; 25:163-177. [PMID: 30670907 PMCID: PMC6337019 DOI: 10.3748/wjg.v25.i2.163] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/24/2018] [Accepted: 12/27/2018] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a major chronic liver disease that can lead to liver cirrhosis, liver cancer, and ultimately death. NAFLD is pathologically classified as non-alcoholic fatty liver (NAFL) or non-alcoholic steatohepatitis (NASH) based on the existence of ballooned hepatocytes, although the states have been known to transform into each other. Moreover, since the detection of ballooned hepatocytes may be difficult with limited biopsied specimens, its clinical significance needs reconsideration. Repeated liver biopsy to assess histological NAFLD activity for therapeutic response is also impractical, creating the need for body fluid biomarkers and less invasive imaging modalities. Recent longitudinal observational studies have emphasized the importance of advanced fibrosis as a determinant of NAFLD outcome. Thus, identifying predictors of fibrosis progression and developing better screening methods will enable clinicians to isolate high-risk NAFLD patients requiring early intensive intervention. Despite the considerable heterogeneity of NAFLD with regard to underlying disease, patient age, and fibrosis stage, several clinical trials are underway to develop a first-in-class drug. In this review, we summarize the present status and future direction of NAFLD/NASH research towards solving unmet medical needs.
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Affiliation(s)
- Naoki Tanaka
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
- International Research Center for Agricultural Food Industry, Shinshu University, Matsumoto 390-8621, Japan
| | - Takefumi Kimura
- Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Naoyuki Fujimori
- Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Tadanobu Nagaya
- Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Michiharu Komatsu
- Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Eiji Tanaka
- Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
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Hepatic Steatosis Is Prevalent Following Orthotopic Liver Transplantation in Children With Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2019; 68:96-103. [PMID: 30234762 DOI: 10.1097/mpg.0000000000002154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Systematic study of allograft liver histology in children undergoing orthotopic liver transplantation (LT) for cystic fibrosis-related liver disease (CFLD). METHODS Retrospective clinicopathologic review of explants and allograft liver biopsies from 13 children and adolescents with CFLD. RESULTS In this study, the median age at LT for CFLD was 15.7 years. Notably, 10 of 13 (77%) CF explants had >5% steatosis and 8 of 13 (61.5%) demonstrated variable fibrosis. The median age, sex, type of transplant (liver vs liver-lung), pancreatic insufficiency status, body mass index (BMI) percentile, genotype, and prevalence of diabetes were comparable in those with and without explant steatosis. More than half of allograft biopsies showed significant steatosis (17/31, 54.8%) and lobular inflammation (16/31, 51.6%). Hepatocyte ballooning was less frequent (5/31, 16.1%). Overall, 6 patients (46.2%) had allograft steatosis that worsened over time in 2 patients (33%). None had advanced fibrosis (≥stage 3). Patients with allograft steatosis had significantly more biopsies, were more likely to be "liver only" recipients, had a shorter interval since transplant and higher body mass index percentile (although <85). Patients without explant steatosis never demonstrated allograft steatosis, whereas 60% of patients with explant steatosis (n = 6) developed varying degrees of allograft steatosis. The degree of explant steatosis did not predict its severity in allografts (P = 0.3). CONCLUSION This is the first study highlighting the development of allograft steatosis in CF patients. Our findings suggest that allograft steatosis in patients with CF may be related to pre-existing steatosis in native livers, regardless of other risk factors and may have implications on patient management and long-term graft/patient survival.
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Komatsu M, Tanaka N, Kimura T, Fujimori N, Sano K, Horiuchi A, Sugiura A, Yamazaki T, Shibata S, Joshita S, Umemura T, Matsumoto A, Tanaka E. Miglitol attenuates non-alcoholic steatohepatitis in diabetic patients. Hepatol Res 2018; 48:1092-1098. [PMID: 29935004 DOI: 10.1111/hepr.13223] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/03/2018] [Accepted: 06/16/2018] [Indexed: 12/13/2022]
Abstract
AIM Postprandial hyperglycemia is frequently accompanied by non-alcoholic fatty liver disease (NAFLD) and steatohepatitis (NASH). Although α-glucosidase inhibitors (αGIs) can slow glucose absorption from the intestine and suppress the surge of circulating glucose concentration after meals, it remains unclear whether αGIs are also beneficial for NASH. The aim of this prospective study was to examine the efficacy and safety of miglitol, a typical αGI, for NASH. METHODS Seventeen patients with histologically confirmed NASH and hemoglobin A1c (HbA1c) >6.5% were treated with miglitol (150 mg/day) for 12 months. The changes in clinical parameters and liver histology were analyzed. RESULTS All patients completed the 12-month miglitol treatment course with no severe adverse events. The treatment significantly decreased body mass index, serum alanine aminotransferase levels, and HbA1c (all P < 0.001). Post-treatment liver biopsy of 11 patients revealed significant improvements in steatosis (from 2.2 ± 0.6 to 1.5 ± 0.7, P = 0.001), lobular inflammation (from 1.8 ± 0.8 to 1.3 ± 0.5, P = 0.014), portal inflammation scores (from 0.6 ± 0.5 to 0.1 ± 0.3, P = 0.025), and NAFLD activity score (from 5.5 ± 1.5 to 3.9 ± 1.4, P = 0.012). Fibrosis and hepatocyte ballooning scores were unchanged. CONCLUSIONS Miglitol appears to safely ameliorate NASH activity by attenuation of steatosis and lobular/portal inflammation. Appropriately powered controlled trials are warranted to validate our results.
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Affiliation(s)
- Michiharu Komatsu
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Naoki Tanaka
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto, Japan.,International Research Center for Agricultural Food Industry, Shinshu University, Matsumoto, Japan
| | - Takefumi Kimura
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Naoyuki Fujimori
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kenji Sano
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Akira Horiuchi
- Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
| | - Ayumi Sugiura
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomoo Yamazaki
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Soichiro Shibata
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoru Joshita
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takeji Umemura
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Akihiro Matsumoto
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Eiji Tanaka
- Department of Internal Medicine, Division of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan
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Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, Griffin O, Fingerhut A, Probst P, Abu Hilal M, Marchegiani G, Nappo G, Zerbi A, Amodio A, Perinel J, Adham M, Raimondo M, Asbun HJ, Sato A, Takaori K, Shrikhande SV, Del Chiaro M, Bockhorn M, Izbicki JR, Dervenis C, Charnley RM, Martignoni ME, Friess H, de Pretis N, Radenkovic D, Montorsi M, Sarr MG, Vollmer CM, Frulloni L, Büchler MW, Bassi C. Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2018; 164:1035-1048. [PMID: 30029989 DOI: 10.1016/j.surg.2018.05.040] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal nutritional therapy in the field of pancreatic surgery is still debated. METHODS An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. RESULTS The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. CONCLUSION The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marta Sandini
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Kevin Conlon
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Arja Gerritsen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Oonagh Griffin
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Abe Fingerhut
- University of Graz Hospital, Surgical Research Unit, Graz, Austria
| | - Pascal Probst
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Antonio Amodio
- Unit of Gastroenterology, University of Verona Hospital Trust, Verona, Italy
| | - Julie Perinel
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Mustapha Adham
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Massimo Raimondo
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Horacio J Asbun
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Asahi Sato
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Marco Del Chiaro
- Pancreatic Surgery Unit - Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) - Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christos Dervenis
- University of Cyprus and Department of Surgical Oncology and HPB Surgery Metropolitan Hospital, Athens, Greece
| | - Richard M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marc E Martignoni
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | | | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Michael G Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Markus W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Mackay TM, Genç CG, Takkenberg RB, Besselink MG, Somers I, Nieveen van Dijkum EJM. New onset non-alcoholic fatty liver disease after resection of pancreatic neuroendocrine tumors. J Surg Oncol 2018; 117:1548-1555. [PMID: 29572825 PMCID: PMC6055648 DOI: 10.1002/jso.25051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/26/2018] [Indexed: 12/11/2022]
Abstract
Background and Objectives Non‐alcoholic fatty liver disease (NAFLD) and non‐alcoholic steatohepatis (NASH) may occur after pancreatic resection due to exocrine pancreatic insufficiency (EPI). Patients with long‐term survival, such as after pancreatic neuroendocrine tumor (pNET) resection, are at risk of NAFLD/NASH. We aimed to determine the incidence and risk factors for new onset NAFLD/NASH and EPI after pNET resection. Methods Retrospective monocenter cohort study. Patients who underwent pNET resection (1992‐2016) were assessed for new onset NAFLD/NASH and EPI. Postoperative NAFLD/NASH was determined by a blinded abdominal radiologist, who compared pre‐ and postoperative imaging. Results Out of 235 patients with pNET, a total of 112 patients underwent resection and were included with a median follow‐up of 54 months. New onset NAFLD/NASH occurred in 20% and EPI in 49% of patients. Multivariate analysis showed that the only risk factor for new onset NAFLD/NASH was recurrent disease (OR 4.4, 95% CI 1.1‐16.8, P = 0.031), but not EPI (OR 0.94, 95% CI 0.3‐2.8, P = 0.911). The only risk factor for EPI was pancreatoduodenectomy (OR 4.3, 95% CI 1.4‐13.7, P = 0.012). Conclusions New onset NAFLD/NASH is occasionally found after pNET resection, especially in patients with recurrent disease, but is not related to EPI.
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Affiliation(s)
- Tara Michella Mackay
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Cansu Güney Genç
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Robert Bart Takkenberg
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc Gerard Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Inne Somers
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
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Neophytou H, Wangermez M, Gand E, Carretier M, Danion J, Richer JP. Predictive factors of endocrine and exocrine insufficiency after resection of a benign tumour of the pancreas. ANNALES D'ENDOCRINOLOGIE 2018. [PMID: 29526248 DOI: 10.1016/j.ando.2017.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of the present study is to evaluate the risk factors of endocrine and exocrine insufficiency occurring few years after pancreatic resections in a consecutive series of patients who underwent pancreatoduodenectomy (PD), left pancreatectomy (LP) or enucleation for benign neoplasms at a referral centre. METHODS Pancreatic exocrine insufficiency (PEI) was defined by the onset of steatorrhea associated with weight loss, and endocrine insufficiency was determinate by fasting plasma glucose. Association between pancreatic insufficiency and clinical, pathological, and perioperative features was studied using univariate and multivariate Cox regression analysis. RESULTS A prospective cohort of 92 patients underwent PD (48%), LP (44%) or enucleation (8%) for benign tumours, from 2005 to 2016 in the University Hospital in Poitiers (France). The median follow-up was 68.6±42.4months. During the following, 54 patients developed exocrine insufficiency whereas 32 patients presented endocrine insufficiency. In the Cox model, a BMI>28kg/m2, being a man and presenting a metabolic syndrome were significantly associated with a higher risk to develop postoperative diabetes. The risks factors for the occurrence of PEI were preoperative chronic pancreatitis, a BMI<18.5kg/m2, tumours located in the pancreatic head, biological markers of chronic obstruction and fibrotic pancreas. Undergoing LP or enucleation were protective factors of PEI. Histological categories such as neuroendocrine tumours and cystadenomas were also associated with a decreased incidence of PEI. CONCLUSION Men with metabolic syndrome and obesity should be closely followed-up for diabetes, and patients with obstructive tumours, pancreatic fibrosis or chronic pancreatitis require a vigilant follow up on their pancreatic exocrine function.
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Affiliation(s)
- Hélène Neophytou
- CHU de Poitiers, service de chirurgie viscérale, 2, rue de la Milétrie, 86000 Poitiers, France.
| | - Marc Wangermez
- CHU de Poitiers, service d'hépato-gastro-entérologie et assistance nutritive, Poitiers, France
| | - Elise Gand
- CHU de Poitiers, pôle DUNE, Poitiers, France
| | - Michel Carretier
- CHU de Poitiers, service de chirurgie viscérale, 2, rue de la Milétrie, 86000 Poitiers, France
| | - Jérôme Danion
- CHU de Poitiers, service de chirurgie viscérale, 2, rue de la Milétrie, 86000 Poitiers, France
| | - Jean-Pierre Richer
- CHU de Poitiers, service de chirurgie viscérale, 2, rue de la Milétrie, 86000 Poitiers, France
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Hafezi-Nejad N, Fishman EK, Zaheer A. Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection. Abdom Radiol (NY) 2018; 43:476-488. [PMID: 29094173 DOI: 10.1007/s00261-017-1378-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths. With surgical resection being the only definitive treatment, improvements in technique has led to an increase in number of candidates undergoing resection by inclusion of borderline resectable disease patients to the clearly resectable group. Post-operative complications associated with pancreaticoduodenectomy and distal pancreatectomy include delayed gastric emptying, anastomotic failures, fistula formation, strictures, abscess, infarction, etc. The utility of dual-phase CT with multiplanar reconstruction and 3D rendering is increasingly recognized as a tool for the assessment of complications associated with vascular resection and reconstruction such as hemorrhage, pseudoaneurysm, vascular thrombosis, and ischemia. Prompt recognition of the complications and distinction from benign post-operative findings such as hepatic steatosis and mesenteric fat necrosis on imaging plays a key role in helping decrease the morbidity and mortality associated with surgery. We discuss, with case examples, some of such common and uncommon findings on imaging to familiarize the abdominal radiologists evaluating post-operative imaging in both acute and chronic post-operative settings.
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Affiliation(s)
- Nima Hafezi-Nejad
- Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Atif Zaheer
- Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
- Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, 600 North Wolfe Street, Hal B164, Baltimore, MD, 21287, USA.
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Association between lower air pressure and the onset of ischemic colitis: a case-control study. Eur J Gastroenterol Hepatol 2017; 29:1071-1078. [PMID: 28562393 DOI: 10.1097/meg.0000000000000913] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Ischemic colitis (IC) often affects the elderly. Proarteriosclerotic factors, such as hypertension and smoking, and cardiovascular disease are considered major contributors to IC. Although a possible link between certain cerebrocardiovascular disorders and meteorological phenomena has been reported, the relationship between IC onset and weather changes remains uninvestigated. This study examined whether specific meteorological factors were associated with the occurrence of IC. PATIENTS AND METHODS We retrospectively enrolled 303 patients who had been diagnosed with IC between January 2003 and June 2010 at Suwa Red Cross Hospital in Nagano Prefecture, Japan. The meteorological data of the days on which IC patients visited the hospital (IC+ days) were compared with those of the days on which IC patients did not (IC- days). RESULTS Univariate analysis indicated that IC+ days had significantly lower air pressure (P<0.001), depressed air pressure from the previous day (P<0.001), and fewer daylight hours (P<0.001), as well as higher air temperature (P=0.017), air humidity (P=0.004), wind velocity (P<0.001), and rainfall (P=0.012) compared with IC- days. Multivariate logistic regression analysis of the meteorological data showed that air pressure (odds ratio: 0.935, P<0.001) and change in air pressure from the previous day (odds ratio: 0.934, P<0.001) were related to onset of IC. CONCLUSION Lower air pressure and decrease in air pressure from the previous day are possible novel factors associated with the development of IC.
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Petzel MQB, Hoffman L. Nutrition Implications for Long-Term Survivors of Pancreatic Cancer Surgery. Nutr Clin Pract 2017; 32:588-598. [DOI: 10.1177/0884533617722929] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Maria Q. B. Petzel
- Department of Clinical Nutrition and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Leah Hoffman
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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