Nutritional and immune impairments and their effects on outcomes in early pancreatic cancer patients undergoing pancreatoduodenectomy

Using Data to Improve Healthcare: A Case Study of Pancreatic Enzyme Replacement in Pancreatic Cancer

OBJECTIVES

In the UK, guidelines recommend pancreatic enzyme replacement therapy (PERT) to all people with unresectable pancreatic cancer. In 2023, we published a national audit of PERT which showed suboptimal prescribing and wide regional variation in England. The aim of this manuscript was to describe how we used the PERT audit to drive improvements in healthcare.

METHODS

Building on the PERT audit, we deployed an online dashboard which will deliver ongoing updates of the PERT audit. We developed a collaborative intervention with cancer nurse specialists (CNS) to improve care delivered to people with pancreatic cancer. The intervention called Creating a natiOnAL CNS pancrEatic cancer network to Standardise and improve CarE (COALESCE) will use the dashboard to evaluate improvements in prescribing of PERT.

RESULTS

We demonstrated how large databases of electronic healthcare records (EHRs) can be used to improve cancer care. The PERT audit was implemented into a dashboard for tracking the progress of COALESCE. We will measure improvements in PERT prescribing as the intervention with CNS progresses.

CONCLUSIONS

Improving healthcare is an ongoing and iterative process. By implementing the PERT dashboard, we created a resource-efficient, automated evaluation method enabling COALESCE to deliver a sustainable change. National-scale databases of EHRs enable rapid cycles of audits, providing regular feedback to interventions, working systematically to deliver change. Here, the focus is on pancreatic cancer. However, this methodology is transferable to other areas of healthcare.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a key role in collecting good quality data which are needed in clinical audits to identify shortcomings in healthcare. Nurse-driven interventions can be designed to improve healthcare. In this study, we capitalize on the unique role of CNS coordinating care for every patient with cancer. COALESCE is the first national collaborative study which uses CNS as researchers and change agents.

The Impact of Body Mass Index on Multiple Complications, Respiratory Complications, Failure to Rescue and In-hospital Mortality After Laparoscopic Pancreaticoduodenectomy: A Single-Center Retrospective Study

Background: Pancreaticoduodenectomy serves as the standard surgical treatment for periampullary tumors. Previous studies have suggested that high body mass index (BMI) is associated with an unfavorable prognosis following laparoscopic pancreaticoduodenectomy (LPD). However, the relationship between low BMI and postoperative complications remains unclear. Materials and Methods: A retrospective analysis of clinical data from 1130 patients who underwent LPD between April 2014 and December 2022 was conducted. Multivariate regression and restricted cubic spline analyses were utilized to explore the correlations between BMI and short-term outcomes, with adjustments for potential confounders. Results: Multivariable logistic regression revealed that overweight, obese, or severely underweight patients had an elevated risk of postoperative pancreatic fistula (POPF) compared to those with a normal BMI. Moreover, obesity was significantly correlated with a higher proportion of "failure to rescue." BMI exhibited a J-shaped relationship with respiratory complications and in-hospital mortality, a W-shaped relationship with multiple complications and anastomotic leakage (pancreatic fistula), and a U-shaped association with "failure to rescue" rates. The lowest risk was observed at BMI levels of 20 and 25 kg/m2 for multiple complications and pancreatic fistula, respectively. Conclusion: Both high and low BMI are identified as risk factors for the occurrence of postoperative POPF and in-hospital mortality following LPD. Notably, patients with higher BMI and severe underweight conditions are associated with an increased likelihood of "failure to rescue."

Phase I/IIa Trial in Advanced Pancreatic Ductal Adenocarcinoma Treated with Cytotoxic Drug-Packaged, EGFR-Targeted Nanocells and Glycolipid-Packaged Nanocells

PURPOSE

We assessed the safety and efficacy of an EGFR-targeted, super-cytotoxic drug, PNU-159682-packaged nanocells with α-galactosyl ceramide-packaged nanocells (E-EDV-D682/GC) in patients with advanced pancreatic ductal adenocarcinoma (PDAC) who had exhausted all treatment options.

PATIENTS AND METHODS

ENG9 was a first-in-man, single-arm, open-label, phase I/IIa, dose-escalation clinical trial. Eligible patients had advanced PDAC, Eastern Cooperative Oncology Group status 0 to 1, and failed all treatments. Primary endpoints were safety and overall survival (OS).

RESULTS

Of 25 enrolled patients, seven were withdrawn due to rapidly progressive disease and one patient withdrew consent. All 25 patients were assessed for toxicity, 24 patients were assessed for OS, which was also assessed for 17 patients completing one treatment cycle [evaluable subset (ES)]. Nineteen patients (76.0%) experienced at least one treatment-related adverse event (graded 1 to 2) resolving within hours. There were no safety concerns, dose reductions, patient withdrawal, or treatment-related deaths.

Median OS (mOS) was 4.4 months; however, mOS of the 17 ES patients was 6.9 months [208 days; range, 83-591 days; 95.0% confidence interval (CI), 5.6-10.3 months] and mOS of seven patients who did not complete one cycle was 1.8 months (54 days; range, 21-72; 95.0% CI, 1.2-2.2 months). Of the ES, 47.1% achieved stable disease and one partial response. Ten subjects in the ES survived over 6 months, the longest 19.7 months. During treatments, 82.0% of the ES maintained stable weight.

CONCLUSIONS

E-EDV-D682/GC provided significant OS, minimal side effects, and weight stabilization in patients with advanced PDAC. Advanced PDAC can be safely treated with super-cytotoxic drugs via EnGeneIC Dream Vectors to overcome multidrug resistance.

Phase Angle and Postoperative Complications in a Model of Immunonutrition in Patients with Pancreatic Cancer

BACKGROUND

The aim of this study was to determine the influence of our own model of immunonutrition on phase angle and postoperative complications. Our goal was to establish modern prehabilitation procedures for patients operated on for pancreatic cancer.

METHODS

Patients with pancreatic cancer who qualified for surgical treatment were divided into two groups. Group I (20 patients; 12 with pancreatic head cancer, 8 with pancreatic tail/body cancer) was given immunonutrition (Impact Oral 3× a day, 237 mL, for 5 days before surgery, and after surgery for an average of 3.5 days). Group II (20 patients; 12 with pancreatic head cancer, 8 with pancreatic tail/body cancer) did not receive immunonutrition. Body weight, body mass index and phase angle were assessed on admission to the hospital, after preoperative immunonutrition, on the third and eighth postoperative days. C-reactive protein and Interleukin-1 α were measured on admission to the hospital, after preoperative immunonutrition, on the eighth postoperative day. Postsurgical complications were assessed via Clavien-Dindo classification.

RESULTS

On admission to the hospital, the phase angle was 5.0° (4.70-5.85) in Group I and 5.1° (5.00-6.25) in Group II. After 5 days of using preoperative immunonutrition, it increased statistically significantly (p < 0.02) to 5.35°. In Group I, on the third day after surgery, it decreased statistically significantly (p < 0.001) to 4.65°, and then, increased to 4.85° on the eighth day. In Group II, statistically significant decreases in the phase angle were observed on the third (4.5°; p < 0.002) and eighth (4.55°; p < 0.008) days after surgery. A statistically significant increase in CRP (86.6 mg/dL; p < 0.02) and IL-1α (18.5 pg/mL; p < 0.03) levels was observed on the eighth day after surgery in this group. In Group I, a statistically significant negative correlation (R -0.501106; p < 0.002) of the phase angle after 5 days of preoperative immunonutrition with postoperative complications was observed.

CONCLUSIONS

This study used our own model of immunonutrition in patients undergoing surgery for pancreatic cancer. The applied model of perioperative IN improved the postoperative course of patients operated on due to pancreatic cancer. Fewer complications were observed in patients in the group receiving IN. Also, the PA value increased after the 5-day preoperative IN, and the use of perioperative IN improved the PA value on the eighth postoperative day compared to the group that did not receive IN. On this day, an increase in inflammatory parameters was also observed in the group that did not receive IN. In addition, PA correlated negatively with complications. The PA can be a useful tool to assess the effectiveness of the applied IN, and thus, to predict the occurrence of postoperative complications. Therefore, there is a further need for studies on larger groups of patients.

Prevalence of Malnutrition and the Value of Predicting Pancreatic Fistula in Patients with Laparoscopic Pancreatoduodenectomy

Background: Pancreatoduodenectomy is a standard surgical procedure for periampullary tumors. With recent improvements in perioperative management, postoperative mortality has decreased significantly in recent years; however, postoperative pancreatic fistula (POPF) is still one of the most prevalent and dangerous complications. The purpose of this study was to analyze the prevalence of malnutrition and the value of predicting POPF in patients with laparoscopic pancreatoduodenectomy (LPD). Methods: We retrospectively analyzed the perioperative data of 747 patients undergoing LPD in the Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, China. Simultaneously, we analyzed the prevalence rate of malnutrition with three different nutritional assessment scores and explored the independent risk variables for POPF to identify potential predictive value. Results: Malnutrition was observed in 20.1% of patients with the prognostic nutritional index (PNI), 85.0% of patients with the controlling nutritional status (CONUT) score, and 73.1% of patients with the NRI score. Univariate and multivariate analyses all showed that the risk factors for POPF were pancreatic texture, pancreatic duct diameter, abdominal infection, body mass index (BMI), nomogram-revised risk index (NRI), and PNI. The receiver operating characteristic curve indicated that the BMI/PNI ratio was capable of predicting the occurrence of clinical POPF following LPD, with an area under the curve of 0.708. Conclusions: Compared with no malnourished patients, malnutrition is associated with a higher risk of POPF among patients with LPD. In addition, the BMI/PNI ratio has some predictive value in the development of POPF following LPD.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

The Effect of immunonutrition in patients undergoing pancreaticoduodenectomy: a systematic review and meta-analysis

BACKGROUND

Pancreaticoduodenectomy (PD) is a complex and traumatic abdominal surgery with a high risk of postoperative complications. Nutritional support, including immunonutrition (IMN) with added glutamine, arginine, and ω-3 polyunsaturated fatty acids, can improve patients' prognosis by regulating postoperative inflammatory response. However, the effects of IMN on PD patients' outcomes require further investigation.

METHODS

PMC, EMbase, web of science databases were used to search literatures related to IMN and PD. Data such as length of hospital stay, infectious complications, non-infectious complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), mortality, systemic inflammatory response syndrome (SIRS) duration, IL-6, and C-reactive protein (CRP) were extracted, and meta-analyses were performed on these data to study their pooled results, heterogeneity, and publication bias.

RESULTS

This meta-analysis involved 10 studies and a total of 572 patients. The results showed that the use of IMN significantly reduced the length of hospital stay for PD patients (MD = -2.31; 95% CI = -4.43, -0.18; P = 0.03) with low heterogeneity. Additionally, the incidence of infectious complications was significantly reduced (MD = 0.42; 95% CI = 0.18, 1.00, P = 0.05), with low heterogeneity after excluding one study. However, there was no significant impact on non-infectious complications, the incidence of POPF and DGE, mortality rates, duration of SIRS, levels of IL-6 and CRP.

CONCLUSION

The use of IMN has been shown to significantly shorten hospital stays and decrease the frequency of infectious complications in PD patients. Early implementation of IMN is recommended for those undergoing PD. However, further research is needed to fully assess the impact of IMN on PD patients through larger and higher-quality studies.

Phase Angle, Handgrip Strength, and Other Indicators of Nutritional Status in Cancer Patients Undergoing Different Nutritional Strategies: A Systematic Review and Meta-Analysis

Malnutrition in cancer patients is one of the most influential factors in the evolution and mortality of such patients. To reduce the incidence of malnutrition, it is necessary to establish a correct nutritional intervention. For this purpose, precise tools and indicators must be developed to determine the patient’s condition. The main objective of this systematic review and meta-analysis was to analyze the relationship between different nutritional strategies, phase angle (PA), and handgrip strength in patients with cancer, with the secondary objectives being the modification of other indicators of nutritional status, such as weight and body mass index (BMI). A systematic review of randomized clinical trials was carried out in March 2023 in the databases PubMed, Web of Science, Cochrane, and Scopus. As a risk-of-bias tool, RoB 2.0 was utilized. A total of 8 studies with a total of 606 participants were included in the analysis. A significant increase in PA was observed after the different nutritional strategies (SMD: 0.43; 95% CI: 0.10 to 0.77; p = 0.01; I2 = 65.63%), also detecting a significant increase in handgrip strength (SMD: 0.27, 95% CI: 0.08 to 0.47; p = 0.01; I2 = 30.70%). A significant increase in PA and handgrip were observed in cancer patients subjected to different nutritional strategies. These results suggest that these indicators could be used in the nutritional and functional assessment of the patients.

GLIM criteria as a valid tool for nutrition assessment and mortality prediction in treatment-naïve patients with cancer

BACKGROUND

Clinical care of patients with cancer mostly focuses on medical management with less attention on disease-related malnutrition. The Global Leadership Initiative on Malnutrition (GLIM) released new criteria for diagnosing malnutrition, but the validation of these criteria in treatment-naïve patients with cancer is not well documented. This study aimed to investigate the application of the GLIM criteria in nutrition assessment and mortality prediction in treatment-naïve patients with cancer.

METHODS

A total of 267 patients newly diagnosed with different types of cancer were enrolled. Nutrition status was assessed with the Patient-Generated Subjective Global Assessment (PG-SGA) at outpatient clinic admission during the data collection period. Furthermore, after the GLIM criteria publication, nutrition status was assessed retrospectively using the GLIM criteria in the same cohort to assess validity. The agreement between the tools was calculated using kappa statistics, and the association of malnutrition according to each tool and mortality was analyzed using logistic regression analysis.

RESULTS

The mean age of the patients was 58.06 ± 12.6 years, and 42.7% were women. The prevalence of malnutrition was 60.3% with GLIM criteria and 53.6% with PG-SGA. Agreement between tools was moderate (κ = 0.483, P < 0.001). During a median follow-up period of 23.6 months, 99 deaths occurred. Both GLIM-defined and PG-SGA-defined malnutrition was independently associated with 2-year mortality after adjusting for age, sex, presence of comorbidities, and stage of cancer.

CONCLUSIONS

Our findings support the validation of GLIM in diagnosing malnutrition and predicting 2-year mortality among treatment-naïve patients with cancer.

Comprehensive multimodal management of borderline resectable pancreatic cancer: Current status and progress

Borderline resectable pancreatic cancer (BRPC) is a complex clinical entity with specific biological features. Criteria for resectability need to be assessed in combination with tumor anatomy and oncology. Neoadjuvant therapy (NAT) for BRPC patients is associated with additional survival benefits. Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT. More attention to management standards during NAT, including biliary drainage and nutritional support, is needed. Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period, including NAT responsiveness and the selection of surgical timing.

Drain fluid biomarkers for prediction and diagnosis of clinically relevant postoperative pancreatic fistula: A narrative review

Clinically relevant postoperative pancreatic fistula (CR-POPF) has continued to compromise patient recovery post-pancreatectomy despite decades of research seeking to improve risk prediction and diagnosis. The current diagnostic criteria for CR-POPF requires elevated drain fluid amylase to present alongside POPF-related complications including infection, haemorrhage and organ failure. These worrying sequelae necessitate earlier and easily obtainable biomarkers capable of reflecting evolving CR-POPF. Drain fluid has recently emerged as a promising source of biomarkers as it is derived from the pancreas and hence, capable of reflecting its postoperative condition. The present review aims to summarise the current knowledge of CR-POPF drain fluid biomarkers and identify gaps in the field to invigorate future research in this critical area of clinical need. These findings may provide robust diagnostic alternatives for CR-POPF and hence, to clarify their clinical utility require further reports detailing their diagnostic and/or predictive accuracy.

Preoperative Nutritional Optimization of the Oncology Patient: A Scoping Review

BACKGROUND

Malnutrition is common among patients with cancer and is a known risk factor for poor postoperative outcomes; however, preoperative nutritional optimization guidelines are lacking in this high-risk population. The objective of this study was to review the evidence regarding preoperative nutritional optimization of patients undergoing general surgical operations for the treatment of cancer.

METHODS

A literature search was performed across the Ovid (MEDLINE), Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCOhost), and Web of Science (Clarivate) databases. Eligible studies included randomized clinical trials, observational studies, reviews, and meta-analyses published between 2010 and 2020. Included studies evaluated clinical outcomes after preoperative nutritional interventions among adult patients undergoing surgery for gastrointestinal cancer. Data extraction was performed using a template developed and tested by the study team.

RESULTS

A total of 5,505 publications were identified, of which 69 studies were included for data synthesis after screening and full text review. These studies evaluated preoperative nutritional counseling, protein-calorie supplementation, immunonutrition supplementation, and probiotic or symbiotic supplementation.

CONCLUSIONS

Preoperative nutritional counseling and immunonutrition supplementation should be considered for patients undergoing surgical treatment of gastrointestinal malignancy. For malnourished patients, protein-calorie supplementation should be considered, and for patients undergoing colorectal cancer surgery, probiotics or symbiotic supplementation should be considered.

The Relationship between Nutritional Status and Body Composition with Clinical Parameters, Tumor Stage, CA19-9, CEA Levels in Patients with Pancreatic and Periampullary Tumors

Recent studies have obtained inadequate data on the association between nutritional status, body composition, clinical parameters and tumor stage in patients withpancreatic and periampullary tumors. The purpose of this study was to assess the relationship between nutritional status (NS), body composition (BC) and selected clinical parameters in patients with pancreatic and periampullary cancer, as well as describe the differences between resection and non-resection groups. This is a prospective study of 76 patients with pancreatic and periampullary tumors. We evaluated NS, BMI, body mass loss (BML) and albumin, total protein, CRP, CEA, CA19-9, lipase, amylase, tumor stage, and BC using bioelectrical impedance (BIA). All subjects were divided into resection (n = 59) and non-resection (n = 17) groups. The non-resection group had a worse NS, as well as increased amylase and WBC, compared to the resection. The selected parameters of BC corresponded to BML albumin, TP, NS, age, BMI, Karnofsky, RBC, HCT and HGB. No associations were found between BC with tumor size, CRP, CA19-9, and CEA. We recorded the relationship between metastasis and NRS, as well as tumor size with SGA. The percentage of BML was positively correlated with age and CRP but negatively correlated with RBC, HGB, HCT and anthropometric measurements. We found many statistical correlations with NS and selected parameters, as well as differences between the resection and non-resection group. The detection of early prognostic factors of nutritional impairments would improve the quality of life and reduce the rate of postoperative complications.

Clinical Implications of Malnutrition in the Management of Patients with Pancreatic Cancer: Introducing the Concept of the Nutritional Oncology Board

Pancreatic cancer represents a very challenging disease, with an increasing incidence and an extremely poor prognosis. Peculiar features of this tumor entity are represented by pancreatic exocrine insufficiency and an early and intense nutritional imbalance, leading to the highly prevalent and multifactorial syndrome known as cancer cachexia. Recently, also the concept of sarcopenic obesity has emerged, making the concept of pancreatic cancer malnutrition even more multifaceted and complex. Overall, these nutritional derangements play a pivotal role in contributing to the dismal course of this malignancy. However, their relevance is often underrated and their assessment is rarely applied in clinical daily practice with relevant negative impact for patients' outcome in neoadjuvant, surgical, and metastatic settings. The proper detection and management of pancreatic cancer-related malnutrition syndromes are of primary importance and deserve a specific and multidisciplinary (clinical nutrition, oncology, etc.) approach to improve survival, but also the quality of life. In this context, the introduction of a "Nutritional Oncology Board" in routine daily practice, aimed at assessing an early systematic screening of patients and at implementing nutritional support from the time of disease diagnosis onward seems to be the right path to take.

Short Nutritional Assessment Questionnaire as a predictor of undernutrition in cancer patients receiving outpatient chemotherapy: A retrospective study

PURPOSE

The purpose of this retrospective study was to verify whether the revised Short Nutritional Assessment Questionnaire© (SNAQ), a simplified nutritional assessment, could be comparable with serum albumin (ALB) levels as a predictor of undernutrition in cancer patients receiving outpatient chemotherapy.

METHODS

Of 111 patients, 79 patients with baseline ALB levels ≥3.5 g/dL were included in the analysis. Patients completed the revised SNAQ, which evaluated items including appetite loss, weight loss, nutritional supplement usage, age, and body mass index, using a maximum of 12 points (a score of ≥3 was marked as severe undernutrition). ALB levels were then monitored for 1 year using patient medical records.

RESULTS

There was a significant difference in event-free survival (EFS) when the SNAQ scores were classified into two groups [i.e., scores of ≤3 (SNAQ3) or scores of ≥4 (SNAQ4)]. The 150-day EFS rate was 86.8% and 57.6% for SNAQ3 and SNAQ4, respectively (hazard ratio: 2.92; 95% confidence interval: 1.31-6.51; p = 0.009). Based on the Cox proportional-hazards analysis, a higher risk of undernutrition was associated with SNAQ4 (compared with SNAQ3), C-reactive protein levels, and serum transthyretin levels.

CONCLUSION

The revised SNAQ is a predictor of undernutrition in cancer patients receiving outpatient chemotherapy. In particular, it is important that patients with a SNAQ score of ≥4 receive dietary guidance at an early stage as they are likely to become undernourished within a year.

Diet and Exercise Interventions in Patients With Pancreatic Cancer: A Scoping Review

Diet and exercise interventions may help reverse malnutrition and muscle wasting common in pancreatic cancer. We performed a scoping review to identify the knowledge gaps surrounding diet and exercise interventions. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Embase, ProQuest Theses and Dissertations, and Google Scholar using the umbrella terms of "pancreatic cancer," "diet/nutrition," and "exercise." Included were articles reporting on ambulatory adults with diagnosed pancreatic cancer. Excluded were studies examining prevention and/or risk, animal, or cell lines. Of the 15,708 articles identified, only 62 met the final inclusion criteria. Almost half of the articles were randomized controlled studies (n = 27). Most studies were from the United States (n = 20). The majority examined dietary interventions (n = 41), with 20 assessing the use of omega-3 fatty acids. Exercise interventions were reported in 13 studies, with 8 examining a diet and exercise intervention. Most studies were small and varied greatly in terms of study design, intervention, and outcomes. We identified 7 research gaps that should be addressed in future studies. This scoping review highlights the limited research examining the effect of diet and exercise interventions in ambulatory patients with pancreatic cancer.

Skeletal muscle depletion and nutrition support affected postoperative complications in patients who underwent pancreatoduodenectomy

BACKGROUND

Body composition has been shown closely related to the outcome in surgical patients. The aim of the present study was to investigate whether preoperative skeletal muscle condition and postoperative nutrition would affect major complications in patients underwent pancreaticoduodenectomy (PD).

METHODS

This retrospective study included 265 patients underwent PD. Body composition data was extracted from the L3 level of the preoperative CT scan. Univariable and multivariable regression analyses were performed to investigate correlations between body composition data and postoperative complications. Furthermore, a subgroup analysis was conducted to explore the relationship between postoperative nutrition strategy and the outcome.

RESULTS

Of all the 265 patients, major complications occurred in 81 patients (30.6%). Cutoff values for skeletal muscle depletion were defined by ROC curve analysis from postoperative complications in skeletal muscle index (SMI) (male 47.32 cm²/m² and female 40.65 cm²/m²). Univariable analysis and multivariable regression revealed age (OR 1.49, 95% CI 1.22-1.83, p = 0.026), SMI (OR 0.77, 95% CI 0.51-0.94, p = 0.015) and skeletal muscle density (SMD) (OR 0.85, 95% CI 0.64-1.03, p = 0.029) were independent predictors for major complications. Subgroup analysis showed the initial parenteral nutrition time (IPNT) (OR 1.89, 95% CI 1.43-2.49, p = 0.032) and average protein delivery (APD) (OR 0.76, 95% CI 0.53-0.89, p = 0.021) were significantly associated with major complications in patients with lower SMI.

CONCLUSIONS

Preoperative skeletal muscle index and density were independently associated with major complications in patients underwent PD. In patients with lower SMI, early parenteral nutrition and higher protein delivery were related to better outcome.

Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period

The metabolic risk for patients undergoing abdominal cancer resection increases in the perioperative period and malnutrition may be observed. In order to prevent further weight loss, the guidelines recommend for high-risk patients the placement of a needle catheter jejunostomy (NCJ) for supplementing enteral feeding in the early and late postoperative period. Our aim was to evaluate the safety of NCJ placement and its potential benefits regarding the nutritional status in the postoperative course. We retrospectively analyzed patients undergoing surgery for upper gastrointestinal cancer, such as esophageal, gastric, and pancreato-biliary cancer, and NCJ placement during the operation. The nutritional parameters body mass index (BMI), perioperative weight loss, phase angle measured by bioelectrical impedance analysis (BIA) and the clinical outcome were assessed perioperatively and during follow-up visits 1 to 3 months and 4 to 6 months after surgery. In 102 patients a NCJ was placed between January 2006 and December 2016. Follow-up visits 1 to 3 months and 4 to 6 months after surgery were performed in 90 patients and 88 patients, respectively. No severe complications were seen after the NCJ placement. The supplementing enteral nutrition via NCJ did not improve the nutritional status of the patients postoperatively. There was a significant postoperative decline of weight and phase angle, especially in the first to third month after surgery, which could be stabilized until 4-6 months after surgery. Placement of NCJ is safe. In patients with upper gastrointestinal and pancreato-biliary cancer, supplementing enteral nutrition during the postoperative course and continued after discharge may attenuate unavoidable weight loss and a reduction of body cell mass within the first six months.