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Garay MB, Carbajal-Maldonado ÁL, Rodriguez-Ortiz-DE-Rozas R, Guilabert L, DE-Madaria E. Post-surgical exocrine pancreatic insufficiency. Minerva Surg 2023; 78:671-683. [PMID: 38059441 DOI: 10.23736/s2724-5691.23.10125-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Being an underdiagnosed and under or insufficiently treated condition, surgical pancreatic exocrine insufficiency (PSP) is the condition in which pancreatic enzymes are insufficient for digestion because of gastrointestinal (GI) surgery involving the upper GI tract, biliary ducts, or the pancreas, and and leading to potential malnutrition and deterioration in quality of life. Age, obesity, history of tobacco use, family history of diabetes, surgery due to a malignant tumor, presence of steatorrhea, jaundice, weight loss, and intraoperative findings of hard pancreatic texture have been associated with a higher risk of PSP. Pancreatoduodectomy (PD) has demonstrated an increased risk of developing PSP, with a prevalence between 19-100%. Distal pancreatectomy (DP) and central pancreatectomy (CenP) are associated with less risk of PSP, with a prevalence of 0-82% and 3.66-8.7%, respectively. In patients with chronic pancreatitis (CP), PSP was associated with 80% in Partington-Rochelle procedure, 86% in Frey procedure, 80% in duodenum preserving pancreatic head procedure, >60% in PD and 27.5-63% in DP. Fecal elastase-1 (FE-1) is a generally accepted tool for diagnosis. Treatment is recommended to start as soon as a diagnosis is achieved, or clinical suspicion is high. Pancreatic enzyme replacement therapy improves symptoms of malabsorption, facilitates weight gain, and ultimately improves patients' quality of life. Starting dosage is between 10,000-50,000 units in snacks and 50,000-75,000 units in main meals, administered throughout food intake, though further data specifically on PSP are needed. Follow-up in PSP is recommended on an on-demand basis, where malnutrition should be assessed.
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Affiliation(s)
- Maria B Garay
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Ángela L Carbajal-Maldonado
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Rosario Rodriguez-Ortiz-DE-Rozas
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Lucia Guilabert
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Enrique DE-Madaria
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain -
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Lan X, Robin G, Kasnik J, Wong G, Abdel-Rahman O. Challenges in Diagnosis and Treatment of Pancreatic Exocrine Insufficiency among Patients with Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2023; 15:1331. [PMID: 36831673 PMCID: PMC9953920 DOI: 10.3390/cancers15041331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most common malignancy of the pancreas and is associated with an extremely poor prognosis. Many PDAC patients suffer from profound nutritional complications such as nutrient deficiencies, weight loss, malnutrition, and cancer cachexia. These complications cause barriers to effective anticancer treatments, gravely influence their quality of life, and decrease their overall survival. Pancreatic exocrine insufficiency (PEI) is defined as impaired digestion due to inadequate secretion of pancreatic enzymes and is a common cause of malnutrition in PDAC. This review first summarizes the existing literature around malnutrition in PDAC, with a particular focus on PEI and its management with pancreatic enzyme replacement therapy (PERT). Second, we summarize existing guidelines and recommendations for the management of PEI among patients with PDAC. Lastly, we highlight potential gaps of knowledge of PEI among healthcare providers resulting in underdiagnosis and treatment, which may have implications for the quality of life and overall survival of PDAC patients.
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Affiliation(s)
- Xiaoyang Lan
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Gabrielle Robin
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Jessica Kasnik
- Nutrition Services, Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada
| | - Grace Wong
- Pharmacy Department, Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada
| | - Omar Abdel-Rahman
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB T6G 1Z2, Canada
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Johansen K, Ghorbani P, Lundgren L, Gilg S, Sandström P, Sparrelid E, Björnsson B, Drott J. Symptoms and life changes after total pancreatectomy: a qualitative study. HPB (Oxford) 2023; 25:269-277. [PMID: 36526539 DOI: 10.1016/j.hpb.2022.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 10/11/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Total pancreatectomy (TP) is a major surgical procedure that involves lifelong exocrine and endocrine pancreatic insufficiency. Qualitative evidence is sparse regarding patients' experiences after the operation. The aim of this study was to explore patients' experiences of symptoms that occur after TP and how these symptoms affect their health and life situations. METHODS A qualitative design with prospective consecutive sampling and an inductive thematic analysis was used. Semistructured interviews were postoperatively performed at 6-9 months with 20 patients undergoing TP in two university hospitals in Sweden. RESULTS Two main themes emerged from the analysis: "Changes in everyday life" and "Psychological journey". Patients experienced symptoms related to diabetes as the major life change after the operation, and they were also limited by symptoms of exocrine insufficiency, difficulties with food intake and physical weakness. In the psychological journey that patients underwent, the support received from family, friends and the health care system was important. Moreover, patients experienced a general need for more extensive information, especially regarding diabetes. CONCLUSION Patients experience a lack of sufficient support and education after TP, particularly concerning their diabetes. Further efforts should be undertaken to improve information and the organization of diabetes care for this patient group.
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Affiliation(s)
- Karin Johansen
- Department of Surgery, Linköping University Hospital, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Linda Lundgren
- Department of Surgery, Linköping University Hospital, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Per Sandström
- Department of Surgery, Linköping University Hospital, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Bergthor Björnsson
- Department of Surgery, Linköping University Hospital, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Jenny Drott
- Department of Surgery, Linköping University Hospital, Linköping, Sweden; Division of Nursing Science, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
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Allenson K, Turner K, Gonzalez BD, Gurd E, Zhu S, Misner N, Chin A, Adams M, Cooper L, Nguyen D, Naffouje S, Castillo DL, Kocab M, James B, Denbo J, Pimiento JM, Malafa M, Powers BD, Fleming JB, Anaya DA, Hodul PJ. Pilot trial of remote monitoring to prevent malnutrition after hepatopancreatobiliary surgery. BMC Nutr 2021; 7:82. [PMID: 34886909 PMCID: PMC8656101 DOI: 10.1186/s40795-021-00487-3] [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: 09/05/2021] [Accepted: 11/25/2021] [Indexed: 11/24/2022] Open
Abstract
Background Patients undergoing hepatopancreatobiliary (HPB) surgery, such patients with pancreatic, periampullary, and liver cancer, are at high risk for malnutrition. Malnutrition increases surgical complications and reduces overall survival. Despite its severity, there are limited interventions addressing malnutrition after HPB surgery. The aim of this pilot trial was to examine feasibility, acceptability, usability, and preliminary efficacy of a remote nutrition monitoring intervention after HPB surgery. Methods Participants received tailored nutritional counseling before and after surgery at 2 and 4 weeks after hospital discharge. Participants also recorded nutritional intake daily for 30 days, and these data were reviewed remotely by registered dietitians before nutritional counseling visits. Descriptive statistics were used to describe study outcomes. Results All 26 patients approached to participate consented to the trial before HPB surgery. Seven were excluded after consent for failing to meet eligibility criteria (e.g., did not receive surgery). Nineteen participants (52.6% female, median age = 65 years) remained eligible for remote monitoring post-surgery. Nineteen used the mobile app food diary, 79% of participants recorded food intake for greater than 80% of study days, 95% met with the dietitian for all visits, and 89% were highly satisfied with the intervention. Among participants with complete data, the average percent caloric goal obtained was 82.4% (IQR: 21.7). Conclusions This intervention was feasible and acceptable to patients undergoing HPB surgery. Preliminary efficacy data showed most participants were able to meet calorie intake goals. Future studies should examine intervention efficacy in a larger, randomized controlled trial. Trial registration Clinicaltrials.gov. Registered 16 September 2019, https://clinicaltrials.gov/ct2/show/NCT04091165.
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Affiliation(s)
- Kelvin Allenson
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA. .,University of South Florida Morsani College of Medicine, Tampa, Fl, USA.
| | - Brian D Gonzalez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA.,University of South Florida Morsani College of Medicine, Tampa, Fl, USA
| | - Erin Gurd
- Department of Nutrition Therapy, Moffitt Cancer Center, Tampa, Fl, USA
| | - Sarah Zhu
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Nicole Misner
- Department of Nutrition Therapy, Moffitt Cancer Center, Tampa, Fl, USA
| | - Alicia Chin
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Melissa Adams
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Laura Cooper
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Diana Nguyen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Samer Naffouje
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Diana L Castillo
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Maria Kocab
- University of South Florida Morsani College of Medicine, Tampa, Fl, USA
| | - Brian James
- University of South Florida Morsani College of Medicine, Tampa, Fl, USA
| | - Jason Denbo
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Jose M Pimiento
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Benjamin D Powers
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA.,Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Jason B Fleming
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Daniel A Anaya
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
| | - Pamela J Hodul
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Fl, USA
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Phillips ME, Hopper AD, Leeds JS, Roberts KJ, McGeeney L, Duggan SN, Kumar R. Consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000643. [PMID: 34140324 PMCID: PMC8212181 DOI: 10.1136/bmjgast-2021-000643] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/08/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Pancreatic exocrine insufficiency is a finding in many conditions, predominantly affecting those with chronic pancreatitis, pancreatic cancer and acute necrotising pancreatitis. Patients with pancreatic exocrine insufficiency can experience gastrointestinal symptoms, maldigestion, malnutrition and adverse effects on quality of life and even survival.There is a need for readily accessible, pragmatic advice for healthcare professionals on the management of pancreatic exocrine insufficiency. METHODS AND ANALYSIS A review of the literature was conducted by a multidisciplinary panel of experts in pancreatology, and recommendations for clinical practice were produced and the strength of the evidence graded. Consensus voting by 48 pancreatic specialists from across the UK took place at the 2019 Annual Meeting of the Pancreatic Society of Great Britain and Ireland annual scientific meeting. RESULTS Recommendations for clinical practice in the diagnosis, initial management, patient education and long term follow up were developed. All recommendations achieved over 85% consensus and are included within these comprehensive guidelines.
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Affiliation(s)
- Mary E Phillips
- Nutrition and Dietetics, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Andrew D Hopper
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John S Leeds
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Keith J Roberts
- HPB Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Laura McGeeney
- Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sinead N Duggan
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - Rajesh Kumar
- HPB Surgery, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
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