S3-Leitlinie Klinische Ernährung bei Pankreaserkrankungen

Sowohl die akute als auch die chronische Pankreatitis sind häufige Erkrankungen, die ein erhebliches Risiko für eine Mangelernährung mit sich bringen und eine Ernährungstherapie erfordern können. In ca. 20% der akuten Pankreatitiden tritt eine nekrotisierende Pankreatitis auf, die mit einer erhöhten Morbidität und Mortalität verbunden ist. Hier ist oftmals eine Ernährungstherapie mittels einer enteralen oder parenteralen Ernährung notwendig, die neben medikamentösen, endoskopischen, radiologischen oder chirurgischen Maßnahmen eine etablierte Säule der multimodalen Therapie darstellt.

Bei der chronischen Pankreatitis handelt es sich um eine chronische Entzündung der Bauchspeicheldrüse mit Entwicklung einer Fibrose und langfristig Atrophie des Organs. Bauchschmerzen, die zu einer verminderten oralen Aufnahme von Nährstoffen führen, sowie exokrines und endokrines Versagen sind häufige Komplikationen der Krankheit. All diese Faktoren stellen Risikofaktoren für eine Unter- bzw. Mangelernährung dar. Daher sollten Patienten mit chronischer Pankreatitis als ernährungsmedizinische Risikopatienten betrachtet, untersucht und entsprechend behandelt werden. Darüber hinaus sollte bei Patienten mit chronischer Pankreatitis auf Osteoporose und ein erhöhtes Frakturrisiko geachtet werden, und entsprechende Präventivmaßnahmen erwogen werden.

Evaluation of five nutritional scores as predictors of postoperative outcome following pancreatic resection: A prospective, single-center study

BACKGROUND AND AIMS

Patients undergoing pancreatic resection are commonly malnourished. It is still unclear whether nutritional scores reliably predict postoperative outcomes after pancreatic resection. This study evaluated whether five commonly used preoperative nutritional screening scores predicted severe complications and length of stay.

METHODS

Patients scheduled for pancreatic resection (pancreatoduodenectomy, distal and total pancreatectomy) at a national referral center for pancreatic surgery from September 2022 to June 2023 were prospectively screened for malnutrition with MNA, MUST, SGA, SNAQ, and NRS2002 scores. Postoperative complications were classified using the Clavien-Dindo classification. #NCT05608538.

RESULTS

Three hundred patients were enrolled, including 168 pancreatoduodenectomies (56%), 102 distal pancreatectomies (34%), and 30 total pancreatectomies (10%). Final pathology revealed malignancy in 203 cases (67.7%). When applying the scores, the proportion of patients malnourished or at risk of malnutrition ranged from 21.7% for SGA to 79.3% for NRS2002. After adjusting for selected confounders, only an MNA <17 was associated with severe postoperative complications (OR 8.39, 95%CI [1.95-32.31], p = 0.01). MNA, SGA, and SNAQ predicted the length of stay (all p < 0.01), while MNA and SGA also correlated with a higher probability of having a greater heterogeneity in the length of stay (p = 0.04 and 0.002, respectively).

DISCUSSION

We promote using MNA to detect malnourished patients at risk of severe postoperative complications and longer hospitalization after pancreatic surgery. SGA and SNAQ may also have value in predicting patients who will be hospitalized longer. More prospective studies will be needed to corroborate these findings.

Diagnostic test accuracy of preoperative nutritional screening tools in adults for malnutrition: a systematic review and network meta-analysis

BACKGROUND

Good nutritional screening tests can triage malnourished patients for further assessment and management by dietitians before surgery to reduce the risk of postoperative complications. The authors assessed the diagnostic test accuracy of common nutritional screening tools for preoperative malnutrition in adults undergoing surgery and determined which test had the highest accuracy.

METHODS

MEDLINE, EMBASE, CINAHL, and Web of Science were searched for relevant titles with no language restriction from inception till 1 January 2023. Studies reporting on the diagnostic test accuracy of preoperative malnutrition in adults using one or more of the following index nutritional screening tools were included: Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment (MNA), short-form Mini Nutritional Assessment (MNA-SF), Nutritional Risk Index (NRI), Nutrition Risk Screening Tool 2002 (NRS-2002), and Preoperative Nutrition Screening (PONS). The reference standard was the Subjective Global Assessment (SGA) before surgery. Random-effects bivariate binomial model meta-analyses, meta-regressions, and a network meta-analysis were used to estimate the pooled and relative sensitivities and specificities.

RESULTS

Of the 16 included studies (5695 participants with an 11 957 index and 11 957 SGA tests), all were conducted after hospital admission before surgery. Eleven studies ( n =3896) were at high risk of bias using the Quality Assessment of Diagnostic Accuracy Studies tool due to a lack of blinded assessments. MUST had the highest overall test accuracy performance (sensitivity 86%, 95% CI: 75-93%; specificity 89%, 95% CI: 83-93%). Network meta-analysis showed NRI had similar relative sensitivity (0.93, 95% CI: 0.77-1.13) but lower relative specificity (0.75, 95% CI: 0.61-0.92) than MUST.

CONCLUSIONS

Of all easy-to-use tests applicable at the bedside, MUST had the highest test accuracy performance for screening preoperative malnutrition. However, its predictive accuracy is likely insufficient to justify the application of nutritional optimization interventions without additional assessments.

Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist

While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.

ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis

Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.

Malnutrition by GLIM criteria in chronic pancreatitis: Prevalence, predictors, and its impact on quality of life

INTRODUCTION

Malnutrition in chronic pancreatitis (CP) has prognostic value and there is limited data on the prevalence, predictors of malnutrition in CP and its effect on Quality of life (QoL).

METHODS

A retrospective study was conducted in patients with CP to assess the prevalence of malnutrition as per the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multivariable-adjusted regression was used to identify independent predictors of both malnutrition and global QoL.

RESULTS

A total of 297 patients were included and the most common etiology of CP was idiopathic (75%) and alcohol (25%). The prevalence of malnutrition was 46.4% as per GLIM criteria. On univariate analysis, the risk of malnutrition was significantly higher in alcoholic etiology (p = 0.001), current alcohol consumption (p = 0.001), smokers (p < 0.001), those having higher cumulative days of pain in last 6 months (p < 0.001) and lower daily calorie intake (p = 0.019). On multivariate analysis, malnutrition was independently associated with current alcohol consumption (Odds ratio: 3.22, p = 0.017), current smokers (OR: 2.23, p = 0.042) and those having higher cumulative days of abdominal pain (OR: 1.01, p < 0.001), while higher daily calorie intake (per 100 kcal) (OR:0.94, p = 0.023) has reduced risk of malnutrition. Malnutrition (p = 0.015) and higher cumulative days of abdominal pain (p < 0.001) were independently associated with lower global QoL in patients with CP.

CONCLUSION

Malnutrition is frequent in patients with CP; and current alcohol consumption, smoking and higher cumulative days of abdominal pain independently predicts risk of developing malnutrition. Patients with malnutrition and higher cumulative days of pain has poorer quality of life.

Prospective trial to evaluate the prognostic value of different nutritional assessment scores for survival in pancreatic ductal adenocarcinoma (NURIMAS Pancreas SURVIVAL)

BACKGROUND

Malnutrition is associated with poor survival in pancreatic cancer patients. Nutritional scores show great heterogeneity diagnosing malnutrition. The aim of this study was to find the score best suitable to identify patients with malnutrition related to worse survival after surgery for pancreatic ductal adenocarcinoma (PDAC). This study represents a follow-up study to the prospective NURIMAS Pancreas trial that evaluated short term impact of nutritional score results after surgery.

METHODS

Risk of malnutrition was evaluated preoperatively using 12 nutritional assessment scores. Patients were followed-up prospectively for at least 3 years. Patients at risk for malnutrition were compared with those not at risk according to each score using Kaplan-Meier survival statistics.

RESULTS

A total of 116 patients receiving a PDAC resection in curative intent were included. Malnutrition according to the Subjective Global Assessment score (SGA), the Short Nutritional Assessment Questionnaire (SNAQ), and the INSYST2 score was associated with worse overall survival (SGA: at-risk: 392 days; not at-risk: 942 days; P = 0.001; SNAQ: at-risk: 508 days; not at-risk: 971 days; P = 0.027; INSYST2: at-risk: 538 days; not at risk: 1068; P = 0.049). In the multivariate analysis, SGA (hazard ratio of death 2.16, 95% confidence interval 1.34-3.47, P = 0.002) was associated with worse overall survival.

CONCLUSIONS

Malnutrition as defined by the Subjective Global Assessment is independently associated with worse survival in resected PDAC patients. The SGA should be used to stratify PDAC patients in clinical studies. Severely malnourished patients according to the SGA profit from intensified nutritional therapy should be evaluated in a randomized controlled trial.

Fully Covered Self-Expanding Metal Stent vs Multiple Plastic Stents to Treat Benign Biliary Strictures Secondary to Chronic Pancreatitis: A Multicenter Randomized Trial

BACKGROUND & AIMS

Benign biliary strictures (BBS) are complications of chronic pancreatitis (CP). Endotherapy using multiple plastic stents (MPS) or a fully covered self-expanding metal stent (FCSEMS) are acceptable treatment options for biliary obstructive symptoms in these patients.

METHODS

Patients with symptomatic CP-associated BBS enrolled in a multicenter randomized noninferiority trial comparing 12-month treatment with MPS vs FCSEMS. Primary outcome was stricture resolution status at 24 months, defined as absence of restenting and 24-month serum alkaline phosphatase not exceeding twice the level at stenting completion. Secondary outcomes included crossover rate, numbers of endoscopic retrograde cholangiopancreatography (ERCPs) and stents, and stent- or procedure-related serious adverse events.

RESULTS

Eighty-four patients were randomized to MPS and 80 to FCSEMS. Baseline technical success was 97.6% for MPS and 98.6% for FCSEMS. Eleven patients crossed over from MPS to FCSEMS, and 10 from FCSEMS to MPS. For MPS vs FCSEMS, respectively, stricture resolution status at 24 months was 77.1% (54/70) vs 75.8% (47/62) (P = .008 for noninferiority intention-to-treat analysis), mean number of ERCPs was 3.9 ± 1.3 vs 2.6 ± 1.3 (P < .001, intention-to-treat), and mean number of stents placed was 7.0 ± 4.4 vs 1.3 ± .6 (P < .001, as-treated). Serious adverse events occurred in 16 (19.0%) MPS and 19 (23.8%) FCSEMS patients (P = .568), including cholangitis/fever/jaundice (9 vs 7 patients respectively), abdominal pain (5 vs 5), cholecystitis (1 vs 3) and post-ERCP pancreatitis (0 vs 2). No stent- or procedure-related deaths occurred.

CONCLUSIONS

Endotherapy of CP-associated BBS has similar efficacy and safety for 12-month treatment using MPS compared with a single FCSEMS, with FCSEMS requiring fewer ERCPs over 2 years. (ClinicalTrials.gov, Number: NCT01543256.).

Consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines

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.

Perioperative Nutritional Aspects in Total Pancreatectomy: A Comprehensive Review of the Literature

Total pancreatectomy (TP) is a highly invasive procedure often performed in patients affected by anorexia, malabsorption, cachexia, and malnutrition, which are risk factors for bad surgical outcome and even may cause enhanced toxicity to chemo-radiotherapy. The role of nutritional therapies and the association between nutritional aspects and the outcome of patients who have undergone TP is described in some studies. The aim of this comprehensive review is to summarize the available recent evidence about the influence of nutritional factors in TP. Preoperative nutritional and metabolic assessment, but also intra-operative and post-operative nutritional therapies and their consequences, are analyzed in order to identify the aspects that can influence the outcome of patients undergoing TP. The results of this review show that preoperative nutritional status, sarcopenia, BMI and serum albumin are prognostic factors both in TP for pancreatic cancer to support chemotherapy, prevent recurrence and prolong survival, and in TP with islet auto-transplantation for chronic pancreatitis to improve postoperative glycemic control and obtain better outcomes. When it is possible, enteral nutrition is always preferable to parenteral nutrition, with the aim to prevent or reduce cachexia. Nowadays, the nutritional consequences of TP, including diabetes control, are improved and become more manageable.

Exocrine pancreas insufficiency: clinical significance and approaches to correction from evidence medicine

Exocrine pancreatic insufficiency (EPI) is a common complication of both benign and malignant diseases of the pancreas, as well as a consequence of radical surgical operations on the pancreas and a whole range of other variable extra-pancreatic causes. In clinical practice in the adult population, most cases of EPI are associated with chronic pancreatitis, while in the pediatric population with cystic fibrosis. The regression of the production of digestive enzymes in EPI mediates the development of the syndrome of maldigestion and malabsorption, leading to the progressive development of malnutrition, the importance of which is often underestimated by practitioners. At the same time, the development of nutritional deficiency is not just a complication of EPI, but also has an important effect on the course of the underlying causative disease, worsening the prognosis and quality of life of the patient, and is also a proven risk factor for osteoporosis and sarcopenia. To date, compensation for the absolute deficiency of pancreatic enzymes using enzyme replacement therapy is the only possible way to correct the EPI and prevent nutritional deficiency.

[Indications for Surgical Therapy in Chronic Pancreatitis]

Chronic pancreatitis is a recurrent disease with repeating exacerbations of inflammation of the pancreatic gland - associated with belt-like back pain. Without treatment, recurrent chronic pancreatitis leads to development of opioid-dependent pain. The chronic pancreatitis leads to recurrent hospital stays for the affected patient and socioeconomic challenges. In progress it can lead to local complications of chronic pancreatitis, such as formation of pseudocysts, biliary duct obstruction, duodenal obstruction or portal hypertension. The aim of this article is a detailed description of the indication for surgical therapy in chronic pancreatitis. The underlying analysis was a systematic literature research and evaluation, the formulation of key questions according to the PICO system and the evaluation of indications and key statements and questions, as implemented in a three level Delphi process among the members of the pancreas research group and the indications for the surgery group of the German Society of General and Visceral Surgery (DGAV). Surgical resection of the inflammatory pancreatic head pseudotumour, after initial conservative therapy, is a highly efficient therapy for the control of pain and the avoidance of complications in chronic pancreatitis. For this purpose, well evaluated surgical strategies are available. Delay in surgical therapy can lead to chronic pain, kachexia and malnutrition and increase complications of surgical therapy.

Preclinical insights into the gut-skeletal muscle axis in chronic gastrointestinal diseases

Muscle wasting represents a constant pathological feature of common chronic gastrointestinal diseases, including liver cirrhosis (LC), inflammatory bowel diseases (IBD), chronic pancreatitis (CP) and pancreatic cancer (PC), and is associated with increased morbidity and mortality. Recent clinical and experimental studies point to the existence of a gut‐skeletal muscle axis that is constituted by specific gut‐derived mediators which activate pro‐ and anti‐sarcopenic signalling pathways in skeletal muscle cells. A pathophysiological link between both organs is also provided by low‐grade systemic inflammation. Animal models of LC, IBD, CP and PC represent an important resource for mechanistic and preclinical studies on disease‐associated muscle wasting. They are also required to test and validate specific anti‐sarcopenic therapies prior to clinical application. In this article, we review frequently used rodent models of muscle wasting in the context of chronic gastrointestinal diseases, survey their specific advantages and limitations and discuss possibilities for further research activities in the field. We conclude that animal models of LC‐, IBD‐ and PC‐associated sarcopenia are an essential supplement to clinical studies because they may provide additional mechanistic insights and help to identify molecular targets for therapeutic interventions in humans.

Deviations from a clinical pathway post pancreatoduodenectomy predict 90-day unplanned re-admission

Deviations from a post-PD clinical care pathway are common. Poor nutrition and cardiac co-morbidities are associated with an increased likelihood of deviation. As the number of deviations increase, so does the risk of significant complications and interventions, delayed discharge and 90-day re-admission rate.

ESPEN guideline on clinical nutrition in acute and chronic pancreatitis

Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20% of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.

[The effectiveness of pancreatic enzyme replacement therapy using microencapsulated pancreatin preparations in the correction of nutritional status in patients with chronic pancreatitis: a prospective observational study]

AIM

The goal is to evaluate the effectiveness of pancreatic enzyme replacement therapy (PERT) using microencapsulated pancreatin preparations for the correction of nutritional status in patients with chronic pancreatitis (CP) and associated exocrine pancreatic insufficiency (EPI).

MATERIALS AND METHODS

The study included 58 patients with CP who were divided into two groups depending on the results of a laboratory assessment of indicators of nutritional status: group I (n=30) consisted of patients with CP and signs of EPI (according to low elastase test values) without deviations in nutritional status; Group II (n=28) consisted of patients with CP with a EPI and an abnormal nutritional status. In both groups, patients during the entire observation period (8-12 months) received PERT using microencapsulated pancreatin preparations at a dose adjusted for the severity of permanent residence permit. Before and after the PERT course, the dynamics of anthropometric [body weight, body mass index (BMI)] and laboratory indicators of nutritional status (total protein, albumin, vitamins D and B12, transferrin, iron and magnesium) were evaluated.

RESULTS

After the completion of PERT, a significant tendency towards an increase in BMI in patients was noted in both groups. In group I, this indicator increased from 21.45 [95% confidence interval (CI) 19.80-23.92] kg/m2 to 22.15 (95% CI 20.31-23.86) kg/m2, and in II group - from 19.22 (95% CI 18.33-21.99) kg/m2 to 22.0 (95% CI 19.97-24.08) kg/m2. At the same time, the duration of PERT (months) significantly correlated with the dynamics of the patient's body weight (r=0.4679; 95% CI 0.2384-0.6479, p=0.0002). When assessing laboratory markers of nutritional status after PERT, a general tendency was found to increase the levels of total protein, albumin, vitamin D, magnesium, transferrin, and iron in both groups, however, statistically significant differences in the dynamics were observed mainly in group II patients. So, the level of total protein in group II increased from 69.05 (95% CI 65.6717-70.9000) g/l to 72.8 (95% CI 71.1358-74.9000) g/l, vitamin D - from 10.6 (95% CI 32.8397-38.9603) ng/ml to 17.1 (95% CI 12.0166-23.6232) ng/ml, magnesium - from 0.72 ( 95% CI 0.6892-0.7825) mmol/L to 0.795 (95% CI 0.7692-0.8800) mmol/L, and transferrin from 2.91 (95% CI 2.1800-3.3656 ) g/l to 2.92 (95% CI 2.4000-3.5200) g/l.

CONCLUSION

A prospective observational study demonstrated the effectiveness of PERT using microencapsulated pancreatin preparations in the correction of nutritional status in patients with CP.

The Impact of Preoperative Immune Modulating Nutrition on Outcomes in Patients Undergoing Surgery for Gastrointestinal Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

To define the influence of preoperative immune modulating nutrition (IMN) on postoperative outcomes in patients undergoing surgery for gastrointestinal cancer.

BACKGROUND

Although studies have shown that perioperative IMN may reduce postoperative infectious complications, many of these have included patients with benign and malignant disease, and the optimal timing of such an intervention is not clear.

METHODS

The Embase, Medline, and Cochrane databases were searched from 2000 to 2018, for prospective randomized controlled trials evaluating preoperative oral or enteral IMN in patients undergoing surgery for gastrointestinal cancer. The primary endpoint was the development of postoperative infectious complications. Secondary endpoints included postoperative noninfectious complications, length of stay, and up to 30-day mortality. The analysis was performed using RevMan v5.3 software.

RESULTS

Sixteen studies reporting on 1387 patients (715 IMN group, 672 control group) were included. Six of the included studies reported on a mixed population of patients undergoing all gastrointestinal cancer surgery. Of the remaining, 4 investigated IMN in colorectal cancer surgery, 2 in pancreatic surgery, and another 2 in patients undergoing surgery for gastric cancer. There was 1 study each on liver and esophageal cancer. The formulation of nutrition used in all studies in the treated patients was Impact (Novartis/Nestlé), which contains ω-3 fatty acids, arginine, and nucleotides. Preoperative IMN in patients undergoing surgery for gastrointestinal cancer reduced infectious complications [odds ratio (OR) 0.52, 95% confidence interval (CI) 0.38-0.71, P < 0.0001, I = 16%, n = 1387] and length of hospital stay (weighted mean difference -1.57 days, 95% CI -2.48 to -0.66, P = 0.0007, I = 34%, n = 995) when compared with control (isocaloric isonitrogeneous feed or normal diet). It, however, did not affect noninfectious complications (OR 0.98, 95% CI 0.73-1.33, P = 0.91, I = 0%, n = 1303) or mortality (OR 0.55, 95% CI 0.18-1.68, P = 0.29, I = 0%, n = 955).

CONCLUSION

Given the significant impact on infectious complications and a tendency to shorten length of stay, preoperative IMN should be encouraged in routine practice in patients undergoing surgery for gastrointestinal cancer.

Efficacy of enteral glutamine supplementation in patients with severe and predicted severe acute pancreatitis- A randomized controlled trial

BACKGROUND

In severe acute pancreatitis (AP), intravenous glutamine has been shown to reduce the rate of complications, hospital stay, and mortality. In the present randomized trial, we aimed to evaluate the effect of enteral glutamine supplementation on clinical outcomes, gut permeability, systemic inflammation, oxidative stress, and plasma glutamine levels in patients with severe and predicted severe AP.

METHODS

Patients with AP admitted within 72 h of onset of symptoms were included. The primary outcome measure was development of infected pancreatic and peri-pancreatic necrosis and in-hospital mortality. High-sensitivity C-reactive protein (HS-CRP) and interleukin-6 (IL-6) were evaluated as markers of inflammation; plasma thiobarbituric acid reactive substances (TBARS) and activities of serum superoxide dismutase and glutathione peroxidase were determined to evaluate oxidative stress; serum polyethylene glycol (PEG) was tested for intestinal permeability; subjective global assessment (SGA) was used for nutritional assessment, and an improvement in organ function was measured by the Modified Marshall score. Intention-to-treat analysis was used. A p-value of < 0.05 was considered statistically significant.

RESULTS

After power calculation, we enrolled 18 patients in the glutamine and 22 in the control arm. There was no significant improvement in the development of infected necrosis and in-hospital mortality between the groups. Improvement in Modified Marshall score was observed in a higher proportion of patients receiving glutamine (15 [83.3%] vs. 12 [54.5%]; p = 0.05). Plasma glutamine levels improved more in glutamine-treated group (432.72 ± 307.83 vs. 618.06 ± 543.29 μM/L; p = 0.004), while it was lower in controls (576.90 ± 477.97 vs. 528.20 ± 410.45 μM/L; p = 0.003). PEG level was lower after glutamine supplementation (39.91 ± 11.97 vs. 32.30 ± 7.39 ng/mL; p = 0.02). Statistically significant reduction in IL-6 concentration was observed in the glutamine group at the end of treatment (87.44 ± 7.1 vs. 63.42 ± 33.7 μM/L; p = 0.02).

CONCLUSIONS

Despite absence of improvement in infected necrosis and in-hospital mortality, enteral glutamine supplementation showed improvement in gut permeability, oxidative stress, and a trend towards improvement in organ function as depicted by improvement in the Modified Marshall score.

TRIAL REGISTRATION

NCT01503320.

Nutritional Therapy in Chronic Pancreatitis

Malnutrition is a frequent complication in patients with chronic pancreatitis. Maldigestion as a consequence of pancreatic exocrine insufficiency is the major cause of malnutrition in these patients. Together with that, toxic habits and alterations of the gastroduodenal transit may play a relevant role. Malnutrition in chronic pancreatitis is associated with osteoporosis, sarcopenia, poor quality of life, and increased mortality. An adequate nutritional evaluation including anthropometric, biochemical, and morphologic parameters is recommended in these patients. Nutritional advice and support together with an adequate pancreatic enzyme replacement therapy are indicated.

Evaluation of Blood Biomarkers Associated with Risk of Malnutrition in Older Adults: A Systematic Review and Meta-Analysis

Malnutrition is a common yet under-recognized problem in hospitalized patients. The aim of this paper was to systematically review and evaluate malnutrition biomarkers among order adults. Eligible studies were identified through Cochrane, PubMed and the ProQuest Dialog. A meta-regression was performed on concentrations of biomarkers according to malnutrition risks classified by validated nutrition assessment tools. A total of 111 studies were included, representing 52,911 participants (55% female, 72 ± 17 years old) from various clinical settings (hospital, community, care homes). The estimated BMI (p < 0.001) and concentrations of albumin (p < 0.001), hemoglobin (p < 0.001), total cholesterol (p < 0.001), prealbumin (p < 0.001) and total protein (p < 0.05) among subjects at high malnutrition risk by MNA were significantly lower than those without a risk. Similar results were observed for malnutrition identified by SGA and NRS-2002. A sensitivity analysis by including patients with acute illness showed that albumin and prealbumin concentrations were dramatically reduced, indicating that they must be carefully interpreted in acute care settings. This review showed that BMI, hemoglobin, and total cholesterol are useful biomarkers of malnutrition in older adults. The reference ranges and cut-offs may need to be updated to avoid underdiagnosis of malnutrition.

Prospective trial to evaluate the prognostic value of different nutritional assessment scores in pancreatic surgery (NURIMAS Pancreas)

BACKGROUND

Preoperative nutritional status has an impact on patients' clinical outcome. For pancreatic surgery, however, it is unclear which nutritional assessment scores adequately assess malnutrition associated with postoperative outcome.

METHODS

Patients scheduled for elective pancreatic surgery at the University of Heidelberg were screened for eligibility. Twelve nutritional assessment scores were calculated before operation, and patients were categorized as either at risk or not at risk for malnutrition by each score. The postoperative course was monitored prospectively by assessors blinded to the nutritional status. The primary endpoint was major complications evaluated for each score in a multivariable analysis corrected for known risk factors in pancreatic surgery.

RESULTS

Overall, 279 patients were analysed. A major complication occurred in 61 patients (21·9 per cent). The proportion of malnourished patients differed greatly among the scores, from 1·1 per cent (Nutritional Risk Index) to 79·6 per cent (Nutritional Risk Classification). In the multivariable analysis, only raised amylase level in drainage fluid on postoperative day 1 (odds ratio (OR) 4·91, 95 per cent c.i. 1·10 to 21·84; P = 0·037) and age (OR 1·05, 1·02 to 1·09; P = 0·005) were significantly associated with major complications; none of the scores was associated with, or predicted, postoperative complications.

CONCLUSION

None of the nutritional assessment scores defined malnutrition relevant to complications after pancreatic surgery and these scores may thus be abandoned.

[Nutritional status in patients with chronic pancreatitis]

Chronic pancreatitis (CP) is an inflammatory disease of the pancreas, accompanied by damage to the functioning parenchyma and ducts to develop irreversible structural changes (fibrosis, calcification) and irreparable loss of the endocrine and exocrine functions of this organ. Maldigestion is a typical outcome of CP of any etiology with a long-term history. Fat malabsorption is considered as a basis for malnutrition in patients with CP. The severity of malnutrition in patients with CP correlates with three major pathogenetic factors: primary nutrient deficiency, pancreatic maldigestion and secondary malabsorption syndrome (nutrient loss), hypermetabolism that is caused by an inflammatory process in the pancreas and that determines the severity of the disease. Malnutrition in patients with CP is not just a complication of this disease, but has an important impact on its course. Patients with severe malnutrition are noted to have the significantly lower activity of pancreatic enzymes in the duodenal contents, feces, and blood, which is correlated with the smaller blood amount of total protein and albumin.

Clinical, anthropometric and laboratory nutritional markers of pancreatic exocrine insufficiency: Prevalence and diagnostic use

Pancreatic exocrine insufficiency (PEI) frequently occurs secondary to exocrine pancreatic disease (e.g. chronic pancreatitis, cystic fibrosis, cancer) or pancreatic/gastrointestinal surgery, resulting in the maldigestion of nutrients and consequently malnutrition. Pancreatic enzyme replacement therapy (PERT) is the cornerstone of PEI management. Despite its clinical relevance, the diagnosis of PEI in clinical practice is challenging, as the current gold standard test is cumbersome, and alternatives have limited availability or accuracy. There is a need for accurate and easily applicable diagnostic modalities. We review the prevalence of clinical symptoms and changes in anthropometric measurements and laboratory nutritional markers indicative of malnutrition in patients with PEI, and the relevance of these findings in diagnosing PEI and monitoring PERT efficacy. Based on limited available evidence, assessment of clinical symptoms, body weight, body mass index and other anthropometric parameters are not sensitive methods for PEI diagnosis, owing to high variability and multiple confounding factors, but appear useful in monitoring PERT efficacy. Limited evidence precludes strong recommendations but suggests that serum levels of vitamin E, magnesium, and plasma proteins, notably retinol binding protein, albumin, and prealbumin, may have diagnostic utility in PEI. Studies show that assessment of changes in these and other nutritional parameters is helpful in monitoring PERT efficacy. Further research is needed to confirm the diagnostic accuracy of these parameters for PEI. Until such data are available, a nutritional evaluation including circulating vitamin E, magnesium, retinol binding protein, albumin, and prealbumin may be used to evaluate the probability of PEI in clinical practice when reliable pancreatic function tests are not available.

Enteral nutrition in pancreaticoduodenectomy: a literature review

Pancreaticoduodenectomy (PD) is considered the gold standard treatment for periampullory carcinomas. This procedure presents 30%–40% of morbidity. Patients who have undergone pancreaticoduodenectomy often present perioperative malnutrition that is worse in the early postoperative days, affects the process of healing, the intestinal barrier function and the number of postoperative complications. Few studies focus on the relation between enteral nutrition (EN) and postoperative complications. Our aim was to perform a review, including only randomized controlled trial meta-analyses or well-designed studies, of evidence regarding the correlation between EN and main complications and outcomes after pancreaticoduodenectomy, as delayed gastric emptying (DGE), postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), length of stay and infectious complications. Several studies, especially randomized controlled trial have shown that EN does not increase the rate of DGE. EN appeared safe and tolerated for patients after PD, even if it did not reveal any advantages in terms of POPF, PPH, length of stay and infectious complications.

Early discharge after pancreatoduodenectomy: what helps and what prevents?

OBJECTIVES

Shorter hospital stay after pancreatoduodenectomy (PD) is a desired goal. Implementation of enhanced recovery after surgery (ERAS) protocols can possibly help in achieving this target. We aimed to determine the factors influencing the successful implementation of ERAS protocols by analyzing their relation to the surrogate marker of enhanced recovery, namely, duration of hospital stay.

METHODS

A retrospective analysis of a prospectively maintained ERAS database of 208 consecutive patients who underwent PD at a tertiary referral care center was done.

RESULTS

Two hundred eight patients underwent a classical PD with a median duration of hospital stay of 8 days (range, 4-52 days) with an overall morbidity rate of 34.5% and a mortality rate of 3.8%. The 30-day readmission rate was 4% (8 patients). An elevated body mass index (relative risk, 1.098; 95% confidence interval, 1.015-1.188; P = 0.02) and respiratory comorbidities (relative risk, 8.024; 95% confidence interval, 2.018-31.904; P = 0.003) were independent factors resulting in a longer (>8 days) hospital stay.

CONCLUSIONS

Being overweight or obese and respiratory comorbidities are independent predictors of prolonged hospital stay despite the implementation of ERAS protocol. Hypoalbuminemia does not have a direct effect on hospital stay but may predispose the patient to the development of complications.

Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial

BACKGROUND/OBJECTIVES

Invasive procedures such as surgery cause immunosuppression, leading to increased risk of complications, infections and extended hospital stay. Emerging research around immune-enhancing nutrition supplements and their ability to reduce postoperative complications and reduce treatment costs is promising. This randomised controlled trial aims to examine the effect of preoperative immunonutrition supplementation on length of hospital stay (LOS), complications and treatment costs in both well-nourished and malnourished gastrointestinal surgery patients.

SUBJECTS/METHODS

Ninety-five patients undergoing elective upper and lower gastrointestinal surgery were recruited. The treatment group (n=46) received a commercial immuno-enhancing supplement 5 days preoperatively. The control group (n=49) received no supplements. The primary outcome measure was LOS, and secondary outcome measures included complications and cost.

RESULTS

A nonsignificant trend towards a shorter LOS within the treatment group was observed (7.1 ± 4.1 compared with 8.8 ± 6.5 days; P=0.11). For malnourished patients, this trend was greater with hospital stay reduced by 4 days (8.3 ± 3.5 vs 12.3 ± 9.5 days; P=0.21). Complications and unplanned intensive care admission rates were very low in both the groups. The average admission cost was reduced by AUD1576 in the treatment group compared with the control group (P=0.37).

CONCLUSIONS

Preoperative immunonutrition therapy in gastrointestinal surgery has the potential to reduce the LOS and cost, with greater treatment benefit seen in malnourished patients; however, there is a need for additional research with greater patient numbers.

Nutritional risk is still a clinical predictor of postoperative outcomes in laparoscopic abdominal surgery

BACKGROUND

The relationship between nutritional risk and postoperative recovery of patients with major laparoscopic abdominal surgery is still unclear. The present study was designed to assess the value of the nutritional risk screening in predicting the postoperative outcomes in this cohort of patients.

METHODS

Data from a consecutive series of 75 patients undergoing various elective major laparoscopic abdominal operations was prospectively collected. Nutritional risk was defined by the Nutritional Risk Screening 2002 (NRS 2002) score and correlated to the incidence of postoperative complications and hospital stay. Multivariate regression identified factors associated with 30-day complications [odds ratio (95 % confidence interval)].

RESULTS

The overall incidence of nutritional risk was 34.7 %. There was a significantly higher infectious complication rate of 38.5 % in patients at nutritional risk, compared to 12.2 % in patients at no risk (p = 0.008). No significant difference of postoperative hospital stay and overall complications was found in patients at nutritional risk or not. Nutritional risk was identified as an independent predictor of postoperative infectious complications (odds ratio 4.87 [1.33-17.84]; p = 0.017).

CONCLUSIONS

The present study reinforces the value of the NRS 2002 to identify patients at higher risk of infectious complications after major laparoscopic abdominal surgery. In the era of minimally invasive surgery, the problem of nutritional risk still deserves our attention and concern.

Evolution of pancreatoduodenectomy in a tertiary cancer center in India: improved results from service reconfiguration

BACKGROUND

Pancreatic cancer incidence in India is low. Over the years, refinements in technique of pancreatoduodenectomy (PD) may have improved outcomes. No data is available from India, South-Central, or South West Asia to assess the impact of these refinements.

PURPOSE

To assess the impact of service reconfiguration and standardized protocols on outcomes of PD in a tertiary cancer center in India.

METHODS

Three specific time periods marking major shifts in practice and performance of PD were identified, viz. periods A (1992-2001; pancreaticogastrostomy predominantly performed), B (2003-July 2009; standardization of pancreaticojejunal anastomosis), and C (August 2009-December 2011; introduction of neoadjuvant chemo-radiotherapy and increased surgical volume).

RESULTS

500 PDs were performed with a morbidity and mortality rate of 33% and 5.4%, respectively. Over the three periods, volume of cases/year significantly increased from 16 to 60 (p < 0.0001). Overall incidence of post-operative pancreatic anastomotic leak/fistula (POPF), hemorrhage, delayed gastric emptying (DGE), and bile leak was 11%, 6%, 3.4%, and 3.2%, respectively. The overall morbidity rates, as well as, the above individual complications significantly reduced from period A to B (p < 0.01) with no statistical difference between periods B and C.

CONCLUSION

Evolution of practice and perioperative management of PD for pancreatic cancer at our center improved perioperative outcomes and helped sustain the improvements despite increasing surgical volume. By adopting standardized practices and gradually improving experience, countries with low incidence of pancreatic cancer and resource constraints can achieve outcomes comparable to high-incidence, developed nations.

SYNOPSIS

The manuscript represents the largest series on perioperative outcomes for pancreatoduodenectomy from South West and South-Central Asia - a region with a low incidence of pancreatic cancer and a disproportionate distribution of resources highlighting the impact of high volumes, standardization and service reconfiguration.

Nutritional status and nutritional support before and after pancreatectomy for pancreatic cancer and chronic pancreatitis

Cachexia, malnutrition, significant weight loss, and reduction in food intake due to anorexia represent the most important pathophysiological consequences of pancreatic cancer. Pathophysiological consequences result also from pancreatectomy, the type and severity of which differ significantly and depend on the type of the operation performed. Nutritional intervention, either parenteral or enteral, needs to be seen as a method of support in pancreatic cancer patients aiming at the maintenance of the nutritional and functional status and the prevention or attenuation of cachexia. Oral nutrition could reduce complications while restoring quality of life. Enteral nutrition in the post-operative period could also reduce infective complications. The evidence for immune-enhanced feed in patients undergoing pancreaticoduodenectomy for pancreatic cancer is supported by the available clinical data. Nutritional support during the post-operative period on a cyclical basis is preferred because it is associated with low incidence of gastric stasis. Postoperative total parenteral nutrition is indicated only to those patients who are unable to be fed orally or enterally. Thus nutritional deficiency is a relatively widesoread and constant finding suggesting that we must optimise the nutritional status both before and after surgery.

Amino acid malnutrition in patients with chronic pancreatitis and pancreatic carcinoma

OBJECTIVES

Chronic pancreatitis (CP) and pancreatic cancer (CA) have been associated with intestinal malabsorption and inflammation. However, little is known about the changes in amino acid metabolism in such patients.

METHODS

The circulating amino acid levels were determined in 12 patients with CP, 12 CA patients, and 12 controls.

RESULTS

Total amino acid concentrations were 2850 +/- 71 micromol/L in controls, 2640 +/- 96 micromol/L in CP patients, and 2210 +/- 123 micromol/L in CA patients (P < 0.001). In CP patients, significant reductions in the concentrations of citrulline, gamma-aminobutyric acid, taurine, and aspartic acid were found (P < 0.05), whereas in CA patients, the levels of phosphoethanolamine, gamma-aminobutyric acid, aspartic acid, taurine, arginine, threonine, alanine, citrulline, and tryptophan were reduced. There was a significant inverse relationship between the total amino acid levels and the white blood cell counts (r = -0.44, P = 0.008).

CONCLUSIONS

Both patients with CP and with CA exhibit alterations in amino acid levels. The mechanisms underlying these defects may involve intestinal malabsorption as well as systemic inflammation. Providing selective amino acid supplementation to such patients may minimize the excess morbidity and mortality associated with protein malnutrition.

Surgical Treatment of Alcohol-Associated Chronic Pancreatitis: The Challenges and Pitfalls

Long-term excessive alcohol consumption is the most common risk factor for the development of chronic pancreatitis. Management of patients with alcohol-associated chronic pancreatitis can be complicated by problems associated with dependency, psychosocial burden, and physical changes like malnutrition and hepatic insufficiency. The records of 372 consecutive patients who underwent lateral pancreaticojejunostomy (LPJ, n = 184), pancreatoduodenectomy (PD, n = 97), or distal pancreatectomy (DP, n = 91) for chronic pancreatitis were retrospectively analyzed. Long-term outcome was assessed by patient survey with a median follow up of 5.5 ± 0.2 years. Of 372 patients, 171 underwent surgery for alcohol-associated chronic pancreatitis. According to patient questioning, the prevalence of alcohol cessation before surgery in the 171 patients was 81 per cent. Operative morbidity in the 171 patients was 20 per cent, 50 per cent, and 26 per cent after LPJ, PD, and DP, respectively, with an overall perioperative mortality rate of 2 per cent. None of the patients developed delirium tremens using an alcohol withdrawal protocol. Continued alcohol abuse before surgery did not affect perioperative morbidity ( P > 0.05). Follow up was available for a total of 229 patients, of which 39 per cent with alcohol-associated chronic pancreatitis had died compared with 16 per cent in the nonalcohol group ( P < 0.001). Of the remaining 171 patients, 45 per cent with alcohol-associated chronic pancreatitis had good pain control compared with 49 per cent of the remainder ( P > 0.05). Continuation of alcohol abuse after operation did not affect success for pain control at follow up ( P > 0.05). Surgical treatment of alcohol-associated chronic pancreatitis can be performed with similar morbidity and mortality compared with other forms of chronic pancreatitis. Alcohol cessation is preferred but not mandated to achieve good operative long-term outcome. Caution needs to be taken to prevent postoperative alcohol withdrawal. Long-term follow up with psychosocial support and management of co-existing addictions is important.

Efficacy of Feeding Tube Placement during Pancreaticoduodenectomy for Chronic Pancreatitis

Malnutrition, intestinal dysmotility, and gastroparesis are frequent problems in patients with chronic pancreatitis who undergo pancreaticoduodenectomy. This has led to the practice of operative placement of enteral feeding tubes. The purpose of this study is to examine the efficacy of feeding tubes placed during pancreaticoduodenectomy in patients with chronic pancreatitis. The records of 78 consecutive patients who underwent pancreaticoduodenectomy for chronic pancreatitis were retrospectively reviewed and analyzed. Forty-nine patients who received feeding tubes at the time of operation were compared with 29 who did not have feeding tubes placed. Both groups had similar disease progress measured by duration of symptoms and preoperative nutritional status. During the observation period, there was a trend toward not using operative feeding tubes (first 6 years 84 per cent versus last 2 years 33%). The overall complication rate after pancreaticoduodenectomy was 54 per cent. Placement of a feeding tube was associated with an increase in intra-abdominal morbidity from 34 per cent to 57 per cent ( P < 0.03). None of the patients had a complication directly related to placement of the feeding tube. Eighty-eight per cent of the placed feeding tubes were used. Despite feeding tube placement, 49 per cent of patients with feeding tubes required postoperative use of total parenteral nutrition compared with 55 per cent of patients without feeding tubes ( P > 0.05). Length of hospital stay and hospital readmission during the first postoperative year were not affected by feeding tube placement. In conclusion, simultaneous feeding tube placement along with pancreatic head resection for chronic pancreatitis can be performed safely. The majority of the feeding tubes are used in postoperative care, but they do not prevent the need for total parenteral nutrition and do not shorten length of hospital stay.

Nutritional status affects the rate of pancreatic fistula after distal pancreatectomy: a multivariate analysis of 132 patients

BACKGROUND

Although malnutrition was found to increase the risk of intraabdominal and systemic complications in surgical patients, data for distal pancreatic resections are scarce.

STUDY DESIGN

Data on 132 consecutive patients undergoing distal pancreatectomy as the primary procedure for pancreatic pathology, between 1996 and 2005, were reviewed to identify risk factors for postoperative complications and determine the impact of nutritional status. Nutritional assessment was performed with clinical and laboratory variables, including unintentional weight loss, body mass index, blood albumin level, lymphocyte count, and Nutritional Risk Index (NRI) and Instant Nutritional Assessment (INA) scores.

RESULTS

Seventy-five (56.8%) patients developed 1 or more complications, including 18 (13.6%) cases of pancreatic fistula. The median values of NRI were significantly lower in patients with pancreatic fistula (96.9; 95% CI, 89.8 to 101.0) compared with those in the remaining subjects (102.5; 95% CI, 101.5 to 105.5; p=0.014). In the univariate analysis, the incidence of malnutrition defined by NRI (61% versus 30%, p=0.019) and the Instant Nutritional Assessment (67% versus 34%, p=0.017) was significantly higher in patients who developed pancreatic fistula. In the multivariate analysis, malnutrition characterized as NRI of 100 or less was the only factor that significantly increased the risk of pancreatic fistula, with an odds ratio of 8.12 (95% CI, 1.06 to 22.30).

CONCLUSIONS

Malnutrition, as defined by composite nutritional assessment scales consisting of clinical and laboratory parameters, is a major risk factor for pancreatic fistula after distal pancreatectomy.

Nutritional status and length of stay in patients admitted to an Acute Assessment Unit

BACKGROUND

The Redesigning Care initiative at Flinders Medical Centre aimed to improve access to timely, consistent, quality care. This led to the creation of an Acute Assessment Unit (AAU) where all patients are assessed by the Allied Health team on admission. This study aimed to: (i) determine the nutritional status of patients admitted to the AAU using the scored Patient Generated-Subjective Global Assessment (PG-SGA); and (ii) determine the association between nutritional status and length of stay (LOS).

METHODS

A prospective, observational study was conducted in 64 patients (mean age 79.9 +/- 11 years, 76% female). Nutritional status was assessed within 48 h of admission and LOS data were collected prospectively.

RESULTS

According to PG-SGA global rating, 53% (n = 34) of patients were malnourished. There was a weak association between PG-SGA score and LOS (r = 0.250, P = 0.046). The malnourished patients had a longer LOS by 1 day compared to well-nourished patients, and while this did not reach statistical significance (Z = -0.988, P = 0.323), it has implications for health care costs. LOS overall was short at a median of 4.5 days (range 1-24).

CONCLUSIONS

A significant proportion of patients admitted to the AAU is malnourished. There was a trend for these patients to have a longer LOS, indicating a critical need for nutritional management; however LOS as a whole was short. While nutrition support in hospital is useful in reinforcing dietary education, the short LOS emphasized the importance of discharge education and follow-up.

Operative management of chronic pancreatitis: longterm results in 372 patients

BACKGROUND

Operative treatment of chronic pancreatitis is indicated for patients with intractable pain after failed medical and endoscopic treatment, or for the presence of complications of the disease. This study evaluates a single-center experience with operative management of chronic pancreatitis.

STUDY DESIGN

The records of 372 consecutive patients who underwent lateral pancreaticojejunostomy (n = 184), pancreaticoduodenectomy (n = 97), or distal pancreatectomy (n = 91) for chronic pancreatitis between 1995 and 2003 were retrospectively reviewed and analyzed. Longterm outcomes were assessed by patient survey, with a median followup of 5.5 +/- 0.2 years.

RESULTS

Primary indication for operative treatment included intractable pain (n = 215), pancreatic duct disruption (n = 109), inflammatory mass (n = 42), or biliary obstruction (n = 6). Perioperative morbidity was 22%, 51%, and 29% after lateral pancreaticojejunostomy, pancreaticoduodenectomy, and distal pancreatectomy, respectively, with a perioperative mortality rate of 1%. Two hundred twenty-eight patients were available for longterm followup. Fifty-eight patients (25%) died in the followup period. Twenty-four percent of the remaining 170 patients were pain free, and 25% had good pain control after the procedure. On multivariate analysis, risk factors for poor pain control were pancreaticoduodenectomy (p < 0.01), preoperative narcotic dependence (p < 0.02), earlier abdominal operations (p < 0.02), and an absent history of gallstone pancreatitis (p < 0.05). Sixty-two percent returned to work. Quality of life assessed by SF-36 version 2 questionnaire showed norm-based scores between the 35th and 46th percentile and slightly below, but not substantially different from, a general population. New onset of endocrine and exocrine insufficiency was present in 35% and 29% of patients, respectively.

CONCLUSIONS

Operative management of chronic pancreatitis can be performed with low mortality and acceptable morbidity. Surgical treatment can provide good pain control, return patients to work, and achieve a satisfactory quality of life in the majority of patients. Longterm mortality is high in a subset of patients.

EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts

BACKGROUND

EUS-guided pancreaticogastrostomy (EPG) has been reported as an alternative to surgery in cases of pancreatic stricture where ERCP is unsuccessful.

OBJECTIVE

We analyzed our 3-year experience with this innovative technique.

DESIGN

Patients with failed ERCP for pancreatic drainage were offered EPG over a 3-year period and were followed up prospectively in terms of clinical and radiologic response.

SETTING

Tertiary care center offering ERCP and interventional EUS.

PATIENTS

Thirteen patients were included in this study. Seven had surgical diversion Six patients had unaltered enteral anatomy and stricture related to chronic pancreatitis (3), gallstone pancreatitis (2), and intraductal pancreatic mucinous neoplasm (1).

INTERVENTION

EUS-guided puncture and opacification of the pancreatic duct was performed, creating a transgastric fistula with placement of a guidewire into the main pancreatic duct and subsequent ductal decompression with a plastic endoprosthesis.

MAIN OUTCOME MEASUREMENTS

Mean main pancreatic duct size, pain score, and weight before and after intervention.

RESULTS

Ten patients had successful endoprosthesis placement across the pancreaticogastric fistula. One patient underwent brush cytologic study, which diagnosed pancreatic malignancy, and underwent surgical resection. After a mean follow-up of 14 months, the mean pancreatic duct size in treated patients decreased from 4.6 to 3.0 mm (P = .01); the pain score decreased from 7.3 to 3.6 (P = .01). Complications included one case of bleeding requiring hemoclip placement and 1 case of contained perforation.

LIMITATIONS

Pilot study from a single center.

CONCLUSIONS

EPG is a safe and feasible alternative to surgical intervention in this subgroup of patients where conventional ERCP is not possible.

Should Elective Surgery for Chronic Pancreatitis be Performed in High-Risk Patients?

As morbidity and mortality rates for pancreatic surgery have improved over the past decades, patients with major medical comorbidities have been considered for operative treatment. The influence of poor health status on operative morbidity in patients with chronic pancreatitis is evaluated in this study. The records of 313 consecutive patients who underwent pancreaticoduodenectomy (n = 78), distal pancreatectomy (n = 83), or lateral pancreaticojejunostomy (n = 152) for chronic pancreatitis were retrospectively reviewed and analyzed. Patients’ risk for adverse outcome resulting from overall health status was audited using age, comorbidities, and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) physiological score. Univariate analysis showed that patient's age did not contribute to change in morbidity (odds ratio [OR] = 1.01, P = 0.59). The presence of cardiac disease but not other comorbidities increased adverse outcome affected the need for intensive care unit stay and length of hospital stay (morbidity: 29% vs. 51%, OR = 2.6, P = 0.003). POSSUM physiological score was associated with an increase in morbidity and mortality (morbidity: OR = 1.16, P = 0.001; mortality: OR = 1.49, P = 0.001), in particular intraabdominal abscesses. Multivariate analysis showed that the only variable independently correlating with perioperative complications was POSSUM physiological score. Single comorbidities do not independently influence outcome after operations for chronic pancreatitis. A combination of several comorbidities is associated with an increase in postoperative infectious morbidity and mortality. High-risk patients should not be excluded from operative treatment, but need to be closely selected on a case-by-case basis.

Indications and limitations of the use of subjective global assessment in clinical practice: an update

PURPOSE OF REVIEW

Subjective global assessment is a clinical tool for assessing nutritional status that merges alterations in body composition and physiological function. Although it was first described almost two decades ago, many studies using this method have been published during the past few years. This review describes recent findings from such studies.

RECENT FINDINGS

Subjective global assessment has proved to be a good nutritional assessment and prognostic indicator in several clinical situations. Agreement between subjective global assessment and newer screening methods is not always acceptable, and it has not been validated with respect to clinical outcome. Some modifications have been suggested that may increase the sensitivity of subjective global assessment as a screening tool. A scored version of subjective global assessment for cancer patients is now being validated for use in other patient groups. This could increase its utility in nutritional intervention studies if it can be demonstrated that subtle changes in nutritional status are reflected by numerical scores in patient-generated subjective global assessment.

SUMMARY

Subjective global assessment represents a good option for assessing nutritional status in various clinical situations. As a screening tool, it better identifies established malnutrition than nutritional risk but its sensitivity is suboptimal. The scored version of subjective global assessment may have advantages and extend the usefulness of this tool even further.

Malnutrition: etiology, consequences, and assessment of a patient at risk

Malnutrition results from the imbalance of nutrients and energy provided to the body (too low), relative to its needs (too high). These needs increase dramatically with illness. This is certainly the case for patients with gastrointestinal diseases. Sub-optimal dietary intake, metabolic stress, malabsorption and increased nutrient demands, put a patient with gastrointestinal disease, at high-risk for malnutrition. The causes, consequences and assessment and monitoring indicators of malnutrition are reviewed herein.