1
|
Tan SYC, Tsoukalas T, Javier K, Fazon T, Singh S, Vardy J. Recommendations on the surveillance and supplementation of vitamins and minerals for upper gastrointestinal cancer survivors: a scoping review. J Cancer Surviv 2024:10.1007/s11764-024-01666-4. [PMID: 39207682 DOI: 10.1007/s11764-024-01666-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 08/17/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Early-stage upper gastrointestinal (UGI) cancer patients, after surgery, have altered gastrointestinal functions, compromising their nutritional status and health outcomes. Nutritional care provision to UGI survivors rarely focuses on long-term survivorship. Here, we explore recommendations for surveillance of micronutrient deficiency and supplementation for UGI cancer survivors after surgery. METHODS A scoping review, based on the Joanna Briggs Institute methodology for scoping reviews. Six databases (Medline, Embase, CINAHL, Cochrane, Scopus, and PsycINFO) and 21 cancer-related organisation websites were searched. Publications between 2010 and March 2024 with recommendations aimed at adult UGI cancer (oesophageal, gastric, pancreatic, small bowel, and biliary tract) survivors were included. RESULTS Twenty-six publications met the selection criteria: 11 reviews (8 narrative reviews, 2 systematic, 1 meta-analysis), 7 expert opinions, 6 guidelines, and 2 consensus papers. Twenty-two publications recommended monitoring of micronutrient deficiencies, and 23 suggested supplementation, with 8 lacking details. Most were targeted at patients with gastric cancer (n = 19), followed by pancreatic cancer (n = 7) and oesophageal cancer (n = 3) with none for biliary tract and small bowel cancers. Vitamin B12 and iron were the most consistently recommended micronutrients across the three tumour groups. CONCLUSION Limited publications recommend surveillance of micronutrient status in UGI cancer survivors during the survivorship phase, especially for oesophageal and pancreatic cancer survivors; most were narrative reviews. These recommendations lacked details, and information was inconsistent. IMPLICATIONS FOR CANCER SURVIVORS Long-term UGI cancer survivors are at risk of micronutrient deficiency after surgery. A standardised approach to prevent, monitor, and treat micronutrient deficiencies is needed.
Collapse
Affiliation(s)
- Sim Yee Cindy Tan
- Sydney Medical School, University of Sydney, Concord, NSW, Australia.
- Concord Cancer Centre, Concord Hospital, Concord, NSW, Australia.
- Nutrition and Dietetics Department, Concord Hospital, Concord, NSW, Australia.
| | - Tiffany Tsoukalas
- Discipline of Nutrition and Dietetics, Sydney Nursing School, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Kirsten Javier
- Cowra Community Health, Cowra Health Service, Cowra, NSW, Australia
| | - Tiffany Fazon
- Psycho-Oncology Cooperative Research Group (PoCOG), School of Psychology, Faculty of Science, University of Sydney, Camperdown, NSW, Australia
| | - Sheena Singh
- Nutrition and Dietetics Department, Concord Hospital, Concord, NSW, Australia
| | - Janette Vardy
- Sydney Medical School, University of Sydney, Concord, NSW, Australia
- Concord Cancer Centre, Concord Hospital, Concord, NSW, Australia
| |
Collapse
|
2
|
Hall LA, Powell-Brett S, Halle-Smith J, Ward L, Wiggins T, Markar SR, Roberts KJ. Pancreatic exocrine insufficiency after non-pancreatic upper gastrointestinal surgery: meta-analysis. Br J Surg 2024; 111:znad369. [PMID: 38064682 DOI: 10.1093/bjs/znad369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/12/2023] [Accepted: 10/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Untreated pancreatic exocrine insufficiency (PEI) results in substantial patient harm. Upper gastrointestinal surgery (bariatric metabolic surgery and oesophagogastric resection) affects the delicate physiology of pancreatic exocrine function and may result in PEI. The aim of this study was to assimilate the literature on incidence, diagnosis, and management of PEI after bariatric metabolic surgery and oesophagogastric resection. METHODS A systematic review of PubMed, MEDLINE, and Embase databases identified studies investigating PEI after non-pancreatic upper gastrointestinal surgery. Meta-analyses were undertaken for incidence of PEI and benefit of pancreatic enzyme replacement therapy. RESULTS Among 1620 patients from 24 studies included in quantitative synthesis, 36.0% developed PEI. The incidence of PEI was 23.0 and 50.4% after bariatric metabolic surgery and oesophagogastric resection respectively. Notably, the incidence of PEI was 44% after biliopancreatic diversion with duodenal switch and 66.2% after total gastrectomy. The most common diagnostic test used was faecal elastase 1 (15 of 31 studies), with less than 200 µg/g being diagnostic of PEI. A total of 11 studies considered the management of pancreatic exocrine insufficiency, with 78.6% of patients responding positively to pancreatic enzyme replacement when it was prescribed. CONCLUSION PEI is common after non-pancreatic upper gastrointestinal surgery and patients may benefit from enzyme replacement therapy.
Collapse
Affiliation(s)
- Lewis A Hall
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Scientists, University of Birmingham, Birmingham, UK
| | - Sarah Powell-Brett
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - James Halle-Smith
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - Liz Ward
- Department Therapies and Dietetics, Churchill Hospital, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - Tom Wiggins
- Department of Bariatric Surgery and Upper Gastrointestinal Surgery, Birmingham Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sheraz R Markar
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Keith J Roberts
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
- College of Medical and Dental Scientists, University of Birmingham, Birmingham, UK
| |
Collapse
|
3
|
Zheng Y, Mostamand S. Nutrition in children with exocrine pancreatic insufficiency. Front Pediatr 2023; 11:943649. [PMID: 37215591 PMCID: PMC10196508 DOI: 10.3389/fped.2023.943649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is a condition defined as pancreatic loss of exocrine function, including decreased digestive enzymes and bicarbonate secretion, which leads to maldigestion and malabsorption of nutrients. It is a common complication in many pancreatic disorders. If left undiagnosed, EPI can cause poor digestion of food, chronic diarrhea, severe malnutrition and related complications. Nutritional status and fat-soluble vitamins should be carefully assessed and monitored in patients with EPI. Early diagnosis of EPI is clinically important for appropriate nutritional support and initiating pancreatic enzyme replacement therapy (PERT) which could significantly improve patient outcomes. The evaluation of nutritional status and related unique management in children with EPI will be discussed in this review.
Collapse
Affiliation(s)
- Yuhua Zheng
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Shikib Mostamand
- Gastroenterology, Hepatology, and Nutrition, Stanford Children’s Health & Stanford University School of Medicine, Palo Alto, CA, United States
| |
Collapse
|
4
|
Hall LA, Powell-Brett S, Thompson O, Smith D, Bradley E, Smith S, Vickrage S, Kemp-Blake J, Roberts KJ, Shah T. Casting a Wider NET: Pancreatic Exocrine Insufficiency Induced by Somatostatin Analogues among Patients with Neuroendocrine Tumours? Cancers (Basel) 2023; 15:cancers15071933. [PMID: 37046594 PMCID: PMC10093494 DOI: 10.3390/cancers15071933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
Somatostatin-analogues (SSAs) are a first-line treatment of unresectable neuroendocrine tumours (NETs). However, SSAs inhibit pancreatic secretions, which could lead to pancreatic exocrine insufficiency (PEI). PEI is known to be detrimental to patient quality of life and nutritional status. This study aimed to evaluate the effect of SSAs on pancreatic exocrine function in patients with NETs, using the 13C-mixed triglyceride breath test (13C-MTGT). Exocrine function was assessed using the 13C-MTGT at baseline and after a third SSA injection (two months). A quotient of 13CO2/12CO2 was measured by mass spectrometry, and the cumulative percent dose recovered at 6 h (cPDR) is reported. The secondary endpoints investigated were change in weight, HbA1C, and vitamin D levels. Ten patients completed the study. Exocrine function reduced in all patients (n = 10) following SSA therapy (median reduction from baseline: -23.4% (range: -42.1-0.5%, p = 0.005)). vitamin D levels decreased in all but one patient (median decrease from baseline: -26.5%, (-44.7-10%; p = 0.038)), and median HbA1C levels increased by 8.0% (0-59.3%; p = 0.008). Change in weight was not significant (median decrease from baseline: -0.21% (-4.5-3.5%, p = 1.000)). SSA therapy has a consistent impact on exocrine function from early in the treatment course, but the long-term clinical effects of this remain to be defined. Further studies are required to determine the clinical relevance of this observation and optimise the management of PEI in this cohort.
Collapse
Affiliation(s)
- Lewis A Hall
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sarah Powell-Brett
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- The Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Oscar Thompson
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Daniel Smith
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Elizabeth Bradley
- Department of Nutrition and Dietetics, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Stacey Smith
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Suzanne Vickrage
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Joanne Kemp-Blake
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Keith J Roberts
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- The Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Tahir Shah
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| |
Collapse
|
5
|
Lan X, Robin G, Kasnik J, Wong G, Abdel-Rahman O. Challenges in Diagnosis and Treatment of Pancreatic Exocrine Insufficiency among Patients with Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2023; 15:1331. [PMID: 36831673 PMCID: PMC9953920 DOI: 10.3390/cancers15041331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most common malignancy of the pancreas and is associated with an extremely poor prognosis. Many PDAC patients suffer from profound nutritional complications such as nutrient deficiencies, weight loss, malnutrition, and cancer cachexia. These complications cause barriers to effective anticancer treatments, gravely influence their quality of life, and decrease their overall survival. Pancreatic exocrine insufficiency (PEI) is defined as impaired digestion due to inadequate secretion of pancreatic enzymes and is a common cause of malnutrition in PDAC. This review first summarizes the existing literature around malnutrition in PDAC, with a particular focus on PEI and its management with pancreatic enzyme replacement therapy (PERT). Second, we summarize existing guidelines and recommendations for the management of PEI among patients with PDAC. Lastly, we highlight potential gaps of knowledge of PEI among healthcare providers resulting in underdiagnosis and treatment, which may have implications for the quality of life and overall survival of PDAC patients.
Collapse
Affiliation(s)
- Xiaoyang Lan
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Gabrielle Robin
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Jessica Kasnik
- Nutrition Services, Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada
| | - Grace Wong
- Pharmacy Department, Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada
| | - Omar Abdel-Rahman
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB T6G 1Z2, Canada
| |
Collapse
|
6
|
Zeng XP, Zeng JH, Wang R, Wang W. Pathogenesis, diagnosis, and treatment of malnutrition in patients with chronic pancreatitis. Shijie Huaren Xiaohua Zazhi 2023; 31:92-97. [DOI: 10.11569/wcjd.v31.i3.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Chronic pancreatitis (CP) is a persistent and progressive pancreatic inflammatory disease. Malnutrition is a common clinical manifestation in CP patients, which is mainly caused by pancreatic exocrine insufficiency but may also be related to pancreatic endocrine insufficiency and changes of living habit. At present, there is still a lack of gold standard for the diagnosis of malnutrition in patients with CP. Clinicians should comprehensively evaluate such patients through anthropometric parameters, test parameters, imaging diagnosis, pancreatic exocrine function detection, etc., detect malnutrition early, and take timely intervention measures, including improving diet and living habits, enteral/parenteral nutrition, pancreatic enzyme replacement therapy, acid suppressant adjuvant therapy, regulating intestinal flora, and administration of Chinese medicine. And endoscopic and surgical treatment should be used when necessary.
Collapse
Affiliation(s)
- Xiang-Peng Zeng
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou 350001, Fujian Province, China
| | - Jing-Hui Zeng
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou 350001, Fujian Province, China
| | - Rong Wang
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou 350001, Fujian Province, China
| | - Wen Wang
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou 350001, Fujian Province, China
| |
Collapse
|
7
|
Liu C, Liu L, Chen M. Experience of living with symptom clusters in postoperative pancreatic cancer patients. Eur J Oncol Nurs 2023; 62:102266. [PMID: 36709717 DOI: 10.1016/j.ejon.2022.102266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/17/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The purpose of this study was to describe symptom clusters (SCs), and symptom experiences in early postoperative patients with pancreatic cancer who are recovering at home. METHODS From October 2021 and April 2022,15 patients following pancreatic cancer surgery were recruited from a tertiary hospital in Jiangsu Province by maximum variation sampling. Semi-structured interviews were performed to collect data and thematic analysis was conducted to analyze the data. RESULTS Three themes were extracted from the data. The first theme "difference in symptom perception and cognition" illustrated factors such as patient knowledge, expected recovery status, and risk perception could influence patient symptom experience. Most patients actually reported fewer and less severe symptoms than previous studies. The second theme "the results of symptom cluster" demonstrated anorexia-distress SC, bowel-digestive related SC and sleep disturbance related SC, and anorexia-distress SC should be considered as the priority SC given its multidimensional significance for patients. The last theme described the patient's positive attitudes, behaviours and barriers to coping with symptoms, namely "symptom self-management experience". CONCLUSION There are differences in the perception and interpretation of SCs in postoperative pancreatic cancer patients. Understanding the meaning of individual differences in the experience of symptoms can assist patients in the management of SCs. Medical staff should combine patient self-management strategies and evidence-based data to provide appropriate support at different stages to improve patient symptom management and quality of life.
Collapse
Affiliation(s)
- Changying Liu
- School of Nursing, Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Linglong Liu
- School of Nursing, Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Mingxia Chen
- School of Nursing, Nanjing Medical University, Nanjing, Jiangsu, China.
| |
Collapse
|
8
|
Digestive enzyme supplementation in prescription drugs, over-the-counter drugs, and enzyme foods. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2022. [DOI: 10.1007/s40005-022-00605-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
9
|
Murruste M, Kirsimägi Ü, Kase K, Veršinina T, Talving P, Lepner U. Complications of chronic pancreatitis prior to and following surgical treatment: A proposal for classification. World J Clin Cases 2022; 10:7808-7824. [PMID: 36158501 PMCID: PMC9372835 DOI: 10.12998/wjcc.v10.i22.7808] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/22/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic pancreatitis (CP) is a long-lasting disease frequently associated with complications for which there is no comprehensive pathophysiological classification.
AIM The aims of this study were to: Propose a pathophysiological classification of the complications of CP; evaluate their prevalence in a surgical cohort prior to, and following surgical management; and assess the impact of the surgical treatment on the occurrence of new complications of CP during follow-up. We hypothesized that optimal surgical treatment can resolve existing complications and reduce the risk of new complications, with the exclusion of pancreatic insufficiency. The primary outcomes were prevalence of complications of CP at baseline (prior to surgical treatment) and occurrence of new complications during follow-up.
METHODS After institutional review board approval, a prospective observational cohort study with long-term follow-up (up to 20.4 years) was conducted. All consecutive single-center adult patients (≥ 18 years of age) with CP according to the criteria of the American Pancreas Association subjected to surgical management between 1997 and 2021, were included. The prevalence of CP complications evaluated, according to the proposed classification, in a surgical cohort of 166 patients. Development of the pathophysiological classification was based on a literature review on the clinical presentation, course, and complications of CP, as well a review of previous classification systems of CP.
RESULTS We distinguished four groups of complications: Pancreatic duct complications, peripancreatic complications, pancreatic hemorrhages, and pancreatic insufficiency (exocrine and endocrine). Their baseline prevalence was 20.5%, 23.5%, 10.2%, 31.3%, and 27.1%, respectively. Surgical treatment was highly effective in avoiding new complications in the first and third groups. In the group of peripancreatic complications, the 15-year Kaplan-Meier prevalence of new complications was 12.1%. The prevalence of pancreatic exocrine and endocrine insufficiency increased during follow-up, being 66.4% and 47.1%, respectively, at 15 years following surgery. Pancreatoduodenal resection resulted optimal results in avoiding new peripancreatic complications, but was associated with the highest rate of pancreatic exocrine insufficiency.
CONCLUSION The proposed complication classification improves the understanding of CP. It could be beneficial for clinical decision making, as it provides an opportunity for more comprehensive judgement on patient’s needs on the one hand, and on the pros and cons of the treatment under consideration, on the other. The presence of complications of CP and the risk of development of new ones should be among the main determinants of surgical choice.
Collapse
Affiliation(s)
- Marko Murruste
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Karri Kase
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Tatjana Veršinina
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Peep Talving
- Department of Surgery, Board, North Estonia Medical Centre, Tallinn 13419, Estonia
| | - Urmas Lepner
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| |
Collapse
|
10
|
Liu Y, Yin XY, Wang D, Dong ZQ, Hao L, Chen C, Wang T, Zhang D, Ma JY, Yang HY, Li J, Zhang LL, Bi YW, Zhang Y, Xin L, Chen H, Zhang QS, Xie T, Lu GT, Li ZS, Liao Z, Hu LH. Risk factor analysis and nomogram development for steatorrhea in idiopathic chronic pancreatitis. J Dig Dis 2022; 23:331-340. [PMID: 35703114 DOI: 10.1111/1751-2980.13102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Steatorrhea, a sign of severe pancreatic exocrine insufficiency (PEI), is related to consequences caused by pancreatitis. This study aimed to identify predictors and to construct a nomogram for steatorrhea in idiopathic chronic pancreatitis (ICP). METHODS ICP patients admitted to our hospital from January 2000 to December 2013 were enrolled in this retrospective-prospective cohort study and randomly assigned to the training and validation cohorts. The cumulative rate of steatorrhea was calculated. A Cox proportional hazard regression model was used to identify predictors for steatorrhea and construct the nomogram. Internal and external validation of the nomogram was then performed. RESULTS There were 1633 ICP patients enrolled, with a median follow-up duration of 9.8 years and 20.8% (339/1633) of patients developed steatorrhea following onset of ICP. Steatorrhea was observed in 93, 115, and 133 patients at 1, 3, and 5 years following diagnosis of CP, with a cumulative rate of 6.5% (95% confidence interval [CI] 5.1%-7.9%), 8.0% (95% CI 6.2%-9.8%), and 9.3% (95% CI 6.6%-12.0%), respectively. Male sex (hazard ratio [HR] 2.479, P < 0.001), diabetes mellitus at/before diagnosis of ICP (HR 2.274, P = 0.003), and aged less than 18 years at onset of ICP (HR 0.095, P < 0.001) were identified risk factors for steatorrhea. Initial manifestations were associated with development of steatorrhea. The nomogram was proven to have good concordance indexes. CONCLUSIONS We identified predictors and developed a nomogram for predicting steatorrhea in ICP. It was recommended that high-risk populations be followed up closely, which might contribute to the early diagnosis and treatment of PEI.
Collapse
Affiliation(s)
- Yu Liu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China.,Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Xiao Yi Yin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhi Qi Dong
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lu Hao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Department of Gastroenterology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Cui Chen
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Teng Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Di Zhang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jia Yi Ma
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Huai Yu Yang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Juan Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Ling Ling Zhang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Ya Wei Bi
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Yuan Zhang
- Department of Ophthalmology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Lei Xin
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Hui Chen
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Qi Sheng Zhang
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ting Xie
- Department of Gastroenterology, Zhongda Hospital, Southeast University, Nanjing, Jiangsu Province, China
| | - Guo Tao Lu
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Liang Hao Hu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| |
Collapse
|
11
|
de Rijk FEM, van Veldhuisen CL, Besselink MG, van Hooft JE, van Santvoort HC, van Geenen EJM, Hegyi P, Löhr JM, Dominguez-Munoz JE, de Jonge PJF, Bruno MJ, Verdonk RC, Zou WB, Engjom T, Ooi CY, Sutton R, Frulloni L, Neoptolemos J, Wilcox C, Miroslav V, Trikudanathan G, Liao Z, Hauge T, Mössner J, Hoge C, Fockens P, Mieog S, Capurso G, Cui Y, de Madaria E, Distler M, Aghdassi A, Whitcomb DC, Russell K, Beyer G, Kunovsky L, Kwanten W, Nava AK, Conlon K, Siriwardena A, Paiella S, Alconchel F, Marino MV, de Meijer VE, Domingo C, Kleeff J, Lakshmanan A, Lie Chu MJ, Bouwense S, Nashidengo PR, Konstantinos P, Muttillo EM, Umar GI, Castro Santiago MJ, Lopez-Lopez V, Torri F, Schmelzle M, Ignatavicius P, Wicherts D, Gomes A, Machairas NA, Dorovinis PI, Serrablo A, Soreide K, Rahbari M, Jie Chu MJ, Ptasnuka M, Petrulionis M, Noel CB, Castro E, Di Martino M, Recordare A, Stättner S, Ausania F, Hartman V, Roeyen G, Egorov V, Vanagas T, Ebrahim M, Arabadzhieva E, Malleo G, Li L, Adams D, Oracz G, Nageshwar RD, Waldthaler A, Masamune A, Drewes AM, Amodio A, Tirkes T, Srivastava A, Beilman GJ, Berger Z, Lindkvist B, Cavestro GM, Gariepy C, Czakó L, Di Leo M, Sharma V, Lakhtakia S, Rana SS, Duggan SN, Kwon CI, Phillips AE, Forsmark CE, Gleeson FC, Lehman GA, Greenhalf W, Costamagna G, Halloran CM, Friess H, Rasmussen HH, Ikeura T, Haldorsen IS, Itoi T, Izbicki JR, Windsor J, Poulsen JL, Frokjaer JB, Larino-Noia J, Wang D, Garcia JI, Kalaitzakis E, Wertheim-Tysarowska K, Kubota K, Larusch J, Lerch MM, Hu LH, Frulloni L, Erkan M, Machicado JD, Arvanitakis M, Buchler MW, Levy MF, Heyman MB, Nojgaard C, Khashab MA, Delhaye M, Ogura T, Okazaki K, Ghaneh P, Banks PA, Gupta P, Papachristou GI, Michl P, Levy P, Pukitis A, Pezzilli R, Baron RD, Amann ST, Schwarzenberg SJ, Isaji S, Olesen SS, Novovic S, Hughes SJ, Werlin SL, Gonska T, Gardner TB, Topazian MD, Trikudanathan G, Weiss FU, Akshintala VS, Morinville VD, Rebours V, Vincze A, Singh VK, Cui N, Zhang H, Li ZS, Liao Z. Diagnosis and treatment of exocrine pancreatic insufficiency in chronic pancreatitis: An international expert survey and case vignette study. Pancreatology 2022; 22:457-465. [PMID: 35346599 DOI: 10.1016/j.pan.2022.03.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Despite evidence-based guidelines, exocrine pancreatic insufficiency is frequently underdiagnosed and undertreated in patients with chronic pancreatitis. Therefore, the aim of this study is to provide insight into the current opinion and clinical decision-making of international pancreatologists regarding the management of exocrine pancreatic insufficiency. METHODS An online survey and case vignette study was sent to experts in chronic pancreatitis and members of various pancreatic associations: EPC, E-AHPBA and DPSG. Experts were selected based on publication record from the past 5 years. RESULTS Overall, 252 pancreatologists participated of whom 44% had ≥ 15 years of experience and 35% treated ≥ 50 patients with chronic pancreatitis per year. Screening for exocrine pancreatic insufficiency as part of the diagnostic work-up for chronic pancreatitis is performed by 69% and repeated annually by 21%. About 74% considers nutritional assessment to be part of the standard work-up. Patients are most frequently screened for deficiencies of calcium (47%), iron (42%), vitamin D (61%) and albumin (59%). In case of clinically steatorrhea, 71% prescribes enzyme supplementation. Of all pancreatologists, 40% refers more than half of their patients to a dietician. Despite existing guidelines, 97% supports the need for more specific and tailored instructions regarding the management of exocrine pancreatic insufficiency. CONCLUSION This survey identified a lack of consensus and substantial practice variation among international pancreatologists regarding guidelines pertaining the management of exocrine pancreatic insufficiency. These results highlight the need for further adaptation of these guidelines according to current expert opinion and the level of available scientific evidence.
Collapse
Affiliation(s)
- Florence E M de Rijk
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands.
| | - Charlotte L van Veldhuisen
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter Hegyi
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - J-Matthias Löhr
- Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Juan E Dominguez-Munoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Intestinal Absorption of Lipids Using a Pancreatic Enzyme-Free Nutritional Supplement in Patients with Cystic Fibrosis: A Randomized, Double-Blind, Crossover Pilot Trial. Nutrients 2022; 14:nu14030680. [PMID: 35277038 PMCID: PMC8838800 DOI: 10.3390/nu14030680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/23/2022] Open
Abstract
Nutritional supplements for patients with exocrine pancreatic insufficiency (EPI) typically utilize pancreatic enzyme replacement therapy (PERT) which is associated with gastrointestinal side effects. We evaluated serum triglyceride levels in patients with cystic fibrosis following consumption of an enzyme-modified oil oral nutritional supplement (EMO-ONS) versus a standard triacylglycerol-based ONS product (TAG-ONS) used concomitantly with PERT and patient tolerability between the two approaches. Ten subjects with CF and EPI taking PERT were enrolled in a single-center, double-blind, cross-over proof of concept trial. Five subjects randomized to Arm 1 were administered a PERT placebo and EMO-ONS and 5 subjects in Arm 2 were administered TAG-ONS+PERT. After 4 to 14 days, subjects received the opposite ONS. Serum triglyceride levels were measured at baseline and hourly for 6 h. Following the above, subjects were randomly assigned to receive 2 daily servings of EMO-ONS+PERT placebo or TAG-ONS+PERT at home for 7-days, self-reporting gastrointestinal symptoms daily. Mean change in peak serum triglyceride levels were similar for both groups (EMO-ONS = 41.9 ± 46.7 mg/dL vs. TAG-ONS+PERT = 46.4 ± 44.1 mg/L; p = 0.85). There was no difference in mean ratio of the serum triglyceride AUC between the two groups (p = 0.58) or self-reported gastrointestinal tolerance. EMO-based products may provide a PERT-free alternative to traditional ONS products in patients with cystic fibrosis.
Collapse
|
13
|
Malykh MV, Dubtsova EA, Vinokurova LV, Kiryukova MA, Bordin DS. Nutritional status of patients undergoing pancreatic resection. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2022:60-65. [DOI: 10.31146/1682-8658-ecg-195-11-60-65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Changes in the exocrine function of the pancreas often develops after proximal and distal resections. Exocrine pancreatic insufficiency (EPI) is characterized by a reduced secretion of pancreatic enzymes, because of which the digestion and absorption of nutrients is impaired. Clinical manifestations of EPI and, as a consequence, changes in nutritional status significantly affect the quality of life of patients.
Collapse
Affiliation(s)
- M. V. Malykh
- Moscow Clinical Research Center named after A. S. Loginov
| | - E. A. Dubtsova
- Moscow Clinical Research Center named after A. S. Loginov
| | | | | | - D. S. Bordin
- Moscow Clinical Research Center named after A. S. Loginov; Moscow State University of Medicine and Dentistry named after A. I. Yevdokimov; Tver State Medical University
| |
Collapse
|
14
|
Blonk L, Wierdsma NJ, Jansma EP, Kazemier G, van der Peet DL, Straatman J. Exocrine pancreatic insufficiency after esophagectomy: a systematic review of literature. Dis Esophagus 2021; 34:6131382. [PMID: 33558869 DOI: 10.1093/dote/doab003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/18/2020] [Accepted: 12/14/2020] [Indexed: 12/26/2022]
Abstract
Complaints of maldigestion, malabsorption, and unintended weight loss after esophagectomy are often attributed to an impaired exocrine pancreatic function. This review systematically summarizes all literature reporting on the presence of exocrine pancreatic insufficiency (EPI) after esophagectomy and the effect of treatment with pancreatic enzymes on gastrointestinal complaints, body weight, and quality of life. Databases of PubMed, Embase, and Wiley/Cochrane Library were searched systematically until July 2020. Studies reporting on EPI and pancreatic enzyme replacement therapy after esophagectomy were included. The Newcastle-Ottawa scale was used to assess study quality. Four studies, including 158 patients, were selected. The maximum score for study quality was six (range 4-6). Exocrine pancreatic function was investigated in three studies, measured by fecal elastase-1 and 72-hour fecal fat excretion. Fecal elastase-1 levels <200 μg/g were reported in 16% of patients at 4 months, 18% at 6 months, and 31% at 18-24 months postoperatively. A decreased fecal fat absorption was noticed in 57% 1 month postoperatively. Treatment with pancreatic enzymes was reported in two studies. In patients with fecal elastase-1 levels <200 μg/g, 90% of patients reported improvement in symptoms and 70% reported improvement in weight. In patients with complaints of steatorrhea, 87% noticed settlement of symptoms. Based on current literature, complaints of maldigestion, malabsorption, and unintended weight loss after esophagectomy are common and can be related to an impaired exocrine pancreatic function. High-quality studies evaluating the presence of EPI and the effect of treatment with pancreatic enzymes after esophagectomy are needed to verify this conclusion.
Collapse
Affiliation(s)
- L Blonk
- Amsterdam UMC, Cancer Center Amsterdam, Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Amsterdam UMC, Department of Nutrition and Dietetics, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - N J Wierdsma
- Amsterdam UMC, Department of Nutrition and Dietetics, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - E P Jansma
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - G Kazemier
- Amsterdam UMC, Cancer Center Amsterdam, Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - D L van der Peet
- Amsterdam UMC, Cancer Center Amsterdam, Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J Straatman
- Amsterdam UMC, Cancer Center Amsterdam, Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Trestini I, Cintoni M, Rinninella E, Grassi F, Paiella S, Salvia R, Bria E, Pozzo C, Alfieri S, Gasbarrini A, Tortora G, Milella M, Mele MC. Neoadjuvant treatment: A window of opportunity for nutritional prehabilitation in patients with pancreatic ductal adenocarcinoma. World J Gastrointest Surg 2021; 13:885-903. [PMID: 34621468 PMCID: PMC8462076 DOI: 10.4240/wjgs.v13.i9.885] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/28/2021] [Accepted: 07/20/2021] [Indexed: 02/06/2023] Open
Abstract
Patients affected by pancreatic ductal adenocarcinoma (PDAC) frequently present with advanced disease at the time of diagnosis, limiting an upfront surgical approach. Neoadjuvant treatment (NAT) has become the standard of care to downstage non-metastatic locally advanced PDAC. However, this treatment increases the risk of a nutritional status decline, which in turn, may impact therapeutic tolerance, postoperative outcomes, or even prevent the possibility of surgery. Literature on prehabilitation programs on surgical PDAC patients show a reduction of postoperative complications, length of hospital stay, and readmission rate, while data on prehabilitation in NAT patients are scarce and randomized controlled trials are still missing. Particularly, appropriate nutritional management represents an important therapeutic strategy to promote tissue healing and to enhance patient recovery after surgical trauma. In this regard, NAT may represent a new interesting window of opportunity to implement a nutritional prehabilitation program, aiming to increase the PDAC patient's capacity to complete the planned therapy and potentially improve clinical and survival outcomes. Given these perspectives, this review attempts to provide an in-depth view of the nutritional derangements during NAT and nutritional prehabilitation program as well as their impact on PDAC patient outcomes.
Collapse
Affiliation(s)
- Ilaria Trestini
- Section of Oncology, Department of Medicine, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Marco Cintoni
- Scuola di Specializzazione in Scienza dell’Alimentazione, Università di Roma Tor Vergata, Roma 00133, Italy
| | - Emanuele Rinninella
- UOC Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico A. Gemelli IRCCS, Roma 00168, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma 00168, Italy
| | - Futura Grassi
- UOC Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico A. Gemelli IRCCS, Roma 00168, Italy
| | - Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Emilio Bria
- Oncologia Medica Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
- Oncologia Medica Unit, Università Cattolica del Sacro Cuore, Roma 00168, Italy
| | - Carmelo Pozzo
- Oncologia Medica Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
- Oncologia Medica Unit, Università Cattolica del Sacro Cuore, Roma 00168, Italy
| | - Sergio Alfieri
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma 00168, Italy
- Digestive Surgery Unit and Pancreatic Surgery Gemelli Center Director, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
| | - Antonio Gasbarrini
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma 00168, Italy
- UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
| | - Giampaolo Tortora
- Oncologia Medica Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
- Oncologia Medica Unit, Università Cattolica del Sacro Cuore, Roma 00168, Italy
| | - Michele Milella
- Section of Oncology, Department of Medicine, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Maria Cristina Mele
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma 00168, Italy
- UOSD Nutrizione Avanzata in Oncologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
| |
Collapse
|
16
|
Kozlova IV, Bykova AP. Osteosarcopenia in chronic pancreatitis. TERAPEVT ARKH 2021; 93:869-875. [DOI: 10.26442/00403660.2021.08.200971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 11/22/2022]
Abstract
Aim. To determine clinical features and some mechanisms of osteosarcopenia development in patients with chronic pancreatitis (CP).
Materials and methods. A casecontrol study was conducted on the basis of the Saratov State Clinical Hospital 5 in 20152018 of patients with CP. In a study of 161 patients with CP included, the control group 30 healthy individuals. Patients were divided into groups according to the etiology of CP: 79 with toxic-metabolic CP, 82 with biliary CP. To determine the risks of low-energy fractures, 154 patients were tested with the Fracture risk assessment tool (FRAX). Along with the standard examination, 30 patients with CP dual-energy X-ray absorptiometry was performed. To assess the state of skeletal muscles, body mass index was determined, hand-held dynamometry was performed, and a set of Short Physical Performance Battery (SPPB) tests was used. Along with the assessment of traditional risk factors for osteosarcopenia gender, age, state of reproductive function in women, body mass index, functional state of the pancreas (pancreas) the quantitative content of interleukins (IL)-2, 6, 8 in in colonic biopsies was analyzed by enzyme-linked immunosorbent assay (ELISA).
Results. Bone disorders, according to densitometry, was detected in 70.0% of patients with CP, in 13.3% of the control group. Presarcopenia was detected in 62 (38.5%) patients with CP, sarcopenia in 34 (21.1%), in the control group presarcopenia and sarcopenia were not detected. Sarcopenia was statistically significantly more common in toxic-metabolic CP than in biliary CP (2=11.6; p0.001). Correlations of the lumbar spine T-score and IL-6 (r=-0.29; p=0.03), IL-8 (r=-0.29; p=0.04) were revealed. Correlations between sarcopenia and the concentration of cytokines in the in the colon mucosa in CP were determined (IL-2: r=0.44; p0.001; IL-6: r=0.48; p0.001; IL-8: r=0.42; p0.001).
Conclusion. The development of osteopenia and sarcopenia syndromes in CP is interrelated and associated with both traditional risk factors and an increased concentration of cytokines in the in the colon mucosa.
Collapse
|
17
|
Gastrointestinal Tolerance and Protein Absorption Markers with a New Peptide Enteral Formula Compared to a Standard Intact Protein Enteral Formula in Critically Ill Patients. Nutrients 2021; 13:nu13072362. [PMID: 34371872 PMCID: PMC8308653 DOI: 10.3390/nu13072362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/04/2021] [Accepted: 07/08/2021] [Indexed: 11/18/2022] Open
Abstract
The aim of this exploratory study was to investigate gastrointestinal tolerance and protein absorption markers with a new enteral peptide formula (PF) compared to an isocaloric enteral intact protein standard formula (SF) containing the same amount of protein in ICU patients. Patients admitted to a cardio-thoracic intensive care unit expected to receive tube feeding for ≥5 days were randomized to receive either PF (1.5 kcal/mL) or SF in a double-blind manner for ≤14 days. Twenty-six patients were randomized (13 SF and 13 PF) and 23 (12 SF and 11 PF) completed at least 5 days of product administration. There were no statistically significant differences between the feeds during the first 5 days of intervention for diarrhea (SF:3 (23%); PF:5 (39%), p = 0.388), vomiting (SF:1 (8%); PF:2 (15%), p = 0.549), constipation (SF:7 (54%), PF:3 (23%), p = 0.115), and high gastric residual volume (>500 mL: SF:1 (8%); PF: 2 (15%), p = 0.535). There were no differences in plasma amino acids or urinary markers of protein absorption and metabolism. In conclusion, no major differences were found in tolerability and protein absorption markers between the standard intact protein formula and the peptide formula.
Collapse
|
18
|
Khan M, Rutkowski W, Vujasinovic M, Löhr JM. Adherence to European Guidelines for Treatment and Management of Pancreatic Exocrine Insufficiency in Chronic Pancreatitis Patients. J Clin Med 2021; 10:jcm10122737. [PMID: 34205772 PMCID: PMC8233716 DOI: 10.3390/jcm10122737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 12/16/2022] Open
Abstract
European evidence-based guidelines for the treatment and management of chronic pancreatitis (CP) have been made available following the harmonizing diagnosis and treatment of CP across Europe (HaPanEU) initiative by the United European Gastroenterology (UEG). The aim of this study was to evaluate adherence to the guideline recommendations in the management of patients with pancreatic exocrine insufficiency (PEI) at Karolinska University Hospital in Stockholm. UEG guideline recommendations were evaluated and categorized into 55 different quality indicators (QIs). Data from a retrospective cohort of CP patients being treated at Karolinska University Hospital were evaluated with regard to overall adherence as well as adherence to specific QIs. A total number of 118 patients out of 956 patients diagnosed with CP were eligible for inclusion with mean overall adherence of 61.9% to the defined QIs. A significant difference in mean overall adherence was shown between patients diagnosed with CP prior to 1 January 2016 and following 1 January 2016 (59.3% and 67.7% respectively, p = 0.004), with linear regression analysis also demonstrating improvement correlating to date of diagnosis (p = 0.002). In conclusion, diagnosis and treatment of PEI improved after the HaPanEU guidelines became available and is continuously improving; however, there is room for further improvement.
Collapse
Affiliation(s)
- Mashroor Khan
- Department of Medicine Huddinge, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden; (M.K.); (M.V.)
| | - Wiktor Rutkowski
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Huddinge, SE-141 86 Stockholm, Sweden;
- Department of Clinical Science, Innovation and Technology, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department of Medicine Huddinge, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden; (M.K.); (M.V.)
- Department of Clinical Science, Innovation and Technology, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden
| | - Johannes Matthias Löhr
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Huddinge, SE-141 86 Stockholm, Sweden;
- Department of Clinical Science, Innovation and Technology, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden
- Correspondence: ; Tel.: +46-8-5858-9591
| |
Collapse
|
19
|
Diarrhea due to SARS-CoV-2-Related Exocrine Pancreatic Insufficiency. Case Rep Gastrointest Med 2021; 2021:9920981. [PMID: 34094606 PMCID: PMC8163531 DOI: 10.1155/2021/9920981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/04/2021] [Accepted: 05/17/2021] [Indexed: 01/08/2023] Open
Abstract
Gastrointestinal symptoms, especially diarrhea, are common with novel coronavirus SARS-CoV-2 infection. Angiotensin-converting enzyme-2 (ACE-2) receptors are heavily expressed in enterocytes and serve as entry receptors for SARS-CoV-2. ACE-2 receptors may also be responsible for pancreatic injury in patients infected with SARS-CoV-2. Diarrhea associated with SARS-CoV-2 is usually believed to be due to viral invasion of enterocytes. However, exocrine pancreatic insufficiency resulting from SARS-CoV-2 is another plausible mechanism leading to diarrhea in such patients. We present a case series of three SARS-CoV-2-infected patients with predominant respiratory symptoms at presentation who developed diarrhea, and further fecal analysis revealed exocrine pancreatic insufficiency as the underlying mechanism.
Collapse
|
20
|
Choi CCM, Choi J, Houli N, Smith M, Usatoff V, Lipton L, Chan S. Evaluation of palliative treatments in unresectable pancreatic cancer. ANZ J Surg 2021; 91:915-920. [PMID: 33870626 DOI: 10.1111/ans.16669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/19/2021] [Accepted: 02/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) presents as unresectable disease in 80% of patients. Limited Australian data exists regarding management and outcome of palliative management for PDAC. This study aims to: (i) identify patients with PDAC being managed with palliative intent; (ii) assess the type of palliative management being used. METHODS A prospectively maintained pancreatic database at Western Health (2015-2017) was used to identify patient demographics; stage and multidisciplinary decision regarding resectability and operative interventions; palliative care; use of chemotherapy, radiotherapy and; management of exocrine and endocrine insufficiency. Data on chemotherapy use, number of hospital admissions, emergency department attendances and intensive care unit admissions 30 days prior to death were recorded. RESULTS One-hundred and eleven patients had diagnosis of PDAC, 15% with locally advanced and 45% with metastatic PDAC. Among the locally advanced and metastatic PDAC, 48% received biliary stent insertions, 93% had palliative care referral, 45% received palliative chemotherapy and 10% received radiotherapy. Dietitian referral occurred in 79% and 36% were prescribed with a pancreatic enzyme replacement therapy. Diabetes mellitus was present in 52% of which 31% was new onset. Within 30 days prior to death, 11% patients received palliative chemotherapy, 32% were hospitalized and 11% visited an emergency department more than once. Sixty-five percent died in hospital. CONCLUSION A high proportion of patients diagnosed with locally advanced and metastatic PDAC received palliative care referrals and appropriate level of end-of-life care. Further prospective studies are necessary, examining the management and impacts of pancreatic insufficiency in this group.
Collapse
Affiliation(s)
- Colin Chan-Min Choi
- Department of Upper Gastrointestinal/Hepatobiliary (HPB) Surgery, Western Health, Melbourne, Victoria, Australia
| | - Julian Choi
- Department of Upper Gastrointestinal/Hepatobiliary (HPB) Surgery, Western Health, Melbourne, Victoria, Australia.,Department of Surgery, Western Clinical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nezor Houli
- Department of Upper Gastrointestinal/Hepatobiliary (HPB) Surgery, Western Health, Melbourne, Victoria, Australia
| | - Marty Smith
- Department of Upper Gastrointestinal/Hepatobiliary (HPB) Surgery, Western Health, Melbourne, Victoria, Australia
| | - Val Usatoff
- Department of Upper Gastrointestinal/Hepatobiliary (HPB) Surgery, Western Health, Melbourne, Victoria, Australia.,Department of Surgery, Western Clinical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lara Lipton
- Department of Oncology, Western Health, Melbourne, Victoria, Australia
| | - Steven Chan
- Department of Upper Gastrointestinal/Hepatobiliary (HPB) Surgery, Western Health, Melbourne, Victoria, Australia.,Department of Surgery, Western Clinical School, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
21
|
Maev IV, Kucheryavyy YA, Andreev DN. Exocrine pancreas insufficiency: clinical significance and approaches to correction from evidence medicine. TERAPEVT ARKH 2021; 93:509-515. [PMID: 36286789 DOI: 10.26442/00403660.2021.04.200800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
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.
Collapse
|
22
|
Quast DR, Breuer TGK, Nauck MA, Janot-Matuschek M, Uhl W, Meier JJ. Insulinbedarf und Glukosehomöostase bei Menschen nach partieller und totaler Pankreatektomie im Vergleich zu Menschen mit anderen Diabetesformen. DIABETOL STOFFWECHS 2021. [DOI: 10.1055/a-1344-0323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Zusammenfassung
Einleitung Pankreasresektionen werden bei schwerwiegenden Pankreaserkrankungen durchgeführt. Bei Komplikationen einer chronischen Pankreatitis, teilweise jedoch auch bei Raumforderungen, kann eine Pankreasteilresektion sinnvoll sein. Eine totale Pankreatektomie führt zum absoluten Insulinmangel und der Notwendigkeit einer Insulintherapie. Bei Teilresektionen (partielle Pankreatektomie) werden weniger gravierende Konsequenzen für den Glukosemetabolismus erwartet. Es ist das Ziel der vorliegenden Arbeit, die Insulinregime nach Pankreatektomie mit denen anderer Diabetesformen zu vergleichen.
Material und Methodik Es wurden Patientencharakteristika und Details der postoperativen Insulintherapie von pankreasoperierten Patienten einer spezialisierten Universitätsklinik für Viszeralchirurgie ausgewertet. Diese Daten wurden mit Kohorten nicht operierter Patienten mit Typ-1-Diabetes (T1DM; absoluter Insulinmangel) bzw. Typ-2-Diabetes (T2DM; Insulinresistenz und relativer Insulinmangel), jeweils unter Insulintherapie, verglichen. Ergänzt wurde diese Datenanalyse durch eine Literaturrecherche zu den Stichworten „pancreatogenic diabetes“, „type 3c diabetes“ und „pancreatectomy diabetes“.
Ergebnisse Daten von 32 (68,8 % Frauenanteil) bzw. 41 (43,9 % Frauenanteil) Patienten nach totaler bzw. partieller Pankreatektomie wurden analysiert. Vor der totalen Pankreatektomie hatten 56,3 % der Patienten einen Diabetes mellitus, postoperativ bestand bei allen Patienten eine Insulinpflichtigkeit. Dabei waren die Insulindosierungen im Vergleich mit Patienten mit T1DM (unter intensivierter Insulintherapie) signifikant niedriger (p < 0,0001). Die Dosierungen von Basal- (48,6 % weniger) und Mahlzeiteninsulin (38,1 % weniger) waren gleichermaßen betroffen. Eine partielle Pankreatektomie führte deutlich seltener zu einem Diabetes mellitus, und eine Insulintherapie war nur bei 26,8 % der Patienten erforderlich.
Diskussion Der basale und prandiale Insulinbedarf nach Pankreatektomie ist niedriger als bei einem T1DM und einem T2DM. Dies sollte bei der Blutzuckereinstellung nach Pankreatektomie berücksichtigt werden.
Collapse
Affiliation(s)
- Daniel Robert Quast
- Diabeteszentrum Bochum/Hattingen, St. Josef-Hospital Bochum, Klinikum der Ruhr-Universität Bochum, Bochum
| | - Thomas Georg Karl Breuer
- Diabeteszentrum Bochum/Hattingen, St. Josef-Hospital Bochum, Klinikum der Ruhr-Universität Bochum, Bochum
| | - Michael Albrecht Nauck
- Diabeteszentrum Bochum/Hattingen, St. Josef-Hospital Bochum, Klinikum der Ruhr-Universität Bochum, Bochum
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz
| | - Monika Janot-Matuschek
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital Bochum, Klinikum der Ruhr-Universität Bochum, Bochum
| | - Waldemar Uhl
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital Bochum, Klinikum der Ruhr-Universität Bochum, Bochum
| | - Juris Jendrik Meier
- Diabeteszentrum Bochum/Hattingen, St. Josef-Hospital Bochum, Klinikum der Ruhr-Universität Bochum, Bochum
| |
Collapse
|
23
|
Maev IV, Kucheryavyy YA, Gubergrits NB, Bonnacker I, Shelest EA, Janssen-van Solingen GP, Domínguez-Muñoz JE. Differences in In Vitro Properties of Pancreatin Preparations for Pancreatic Exocrine Insufficiency as Marketed in Russia and CIS. Drugs R D 2020; 20:369-376. [PMID: 33211277 PMCID: PMC7691409 DOI: 10.1007/s40268-020-00326-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 12/18/2022] Open
Abstract
Background Pancreatic enzyme-replacement therapy (PERT), provided as pancreatin to patients with pancreatic exocrine insufficiency (PEI), is considered an essential substitute for the pivotal physiological function the pancreas fulfills in digestion. PEI involves a reduction in the synthesis and secretion of pancreatic enzymes (lipase, protease, amylase), which leads to an inadequate enzymatic response to a meal and consequently to maldigestion and malabsorption of nutrients. The efficacy of PERT is strongly dependent on enzyme activity, dissolution, and pancreatin particle size. Objective The physiological properties of eight pancreatin preparations (nine batches; five different brands) available in Russia and CIS (Commonwealth of Independent States: Armenia, Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Uzbekistan) were investigated. Methods The lipase activity, dissolution, and particle size distribution of samples from multiple batches of pancreatin of different strengths were measured. Results Regarding lipase activities, all pancreatin preparations except Micrazim® matched the labeled content. Considerable differences were observed in particle size and dissolution. Conclusion Pancreatin preparations available in Russia and CIS demonstrate product-to-product and batch-to-batch variability regarding the measured properties of lipase activity, dissolution, and particle size. This may impact the efficacy of PERT and therefore clinical outcomes.
Collapse
Affiliation(s)
- Igor V Maev
- A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia
| | - Yury A Kucheryavyy
- A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia
| | - Natalya B Gubergrits
- Donetsk National Medical University, Ministry of Health of Ukraine, Lyman, Ukraine
| | | | | | | | - J Enrique Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| |
Collapse
|
24
|
Shandro BM, Ritehnia J, Chen J, Nagarajah R, Poullis A. The investigation and management of pancreatic exocrine insufficiency: A retrospective cohort study. Clin Med (Lond) 2020; 20:535-540. [PMID: 33199316 PMCID: PMC7687321 DOI: 10.7861/clinmed.2020-0506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreatic exocrine insufficiency (PEI) is associated with significant gastrointestinal symptoms, but is readily treated by pancreatic enzyme replacement therapy (PERT). We reviewed our current practice and examined the factors that predict repeating a positive faecal elastase-1 (FE1; <200 μg/g), the repeat FE1 being normal, initiation of PERT and clinical response to treatment. A single-centre retrospective cohort study was conducted. Outpatients with FE1 <200 μg/g between 2012 and 2018 were included. Logistic regression was used to explore the associations with each outcome, with statistical adjustment for confounders. Two-hundred and ten patients were included; 28.1% of patients had their FE1 repeated, 47.5% of whom had a normal repeat result. Patients with initial FE1 <15 μg/g were unlikely to be reclassified on repeat testing. Patients with a confirmatory low FE1, abnormal pancreatic imaging or abnormal nutrition blood tests were more likely to be started on PERT (all p<0.05). Patients with abnormal pancreatic imaging were 10 times more likely to respond to PERT (odds ratio 10.70; 95% confidence interval 1.62-70.70; p=0.01). Augmenting clinical judgement with pancreatic imaging and repeat FE1 testing could improve the rate of PERT prescription and inform the approach to non-response, particularly in cases where there is diagnostic doubt.
Collapse
Affiliation(s)
| | | | - Joshua Chen
- St George's, University of London, London, UK
| | - Rani Nagarajah
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Andrew Poullis
- St George's University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
25
|
State of the Art in Exocrine Pancreatic Insufficiency. Medicina (B Aires) 2020; 56:medicina56100523. [PMID: 33036352 PMCID: PMC7599987 DOI: 10.3390/medicina56100523] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/26/2022] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is defined as the maldigestion of foods due to inadequate pancreatic secretion, which can be caused by alterations in its stimulation, production, transport, or interaction with nutrients at duodenal level. The most frequent causes are chronic pancreatitis in adults and cystic fibrosis in children. The prevalence of EPI is high, varying according to its etiology, but it is considered to be underdiagnosed and undertreated. Its importance lies in the quality of life impairment that results from the malabsorption and malnutrition and in the increased morbidity and mortality, being associated with osteoporosis and cardiovascular events. The diagnosis is based on a set of symptoms, indicators of malnutrition, and an indirect non-invasive test in at-risk patients. The treatment of choice combines non-restrictive dietary measures with pancreatic enzyme replacement therapy to correct the associated symptoms and improve the nutritional status of patients. Non-responders require the adjustment of pancreatic enzyme therapy, the association of proton pump inhibitors, and/or the evaluation of alternative diagnoses such as bacterial overgrowth. This review offers an in-depth overview of EPI in order to support the proper management of this entity based on updated and integrated knowledge of its etiopathogenesis, prevalence, diagnosis, and treatment.
Collapse
|
26
|
Abstract
Nutrition and gastrointestinal cancer are inextricably linked. The metabolic effects of cancer along with changes in dietary intake, the development of cancer cachexia and the presence of sarcopenia can influence changes in body composition. These have a negative impact on quality of life and tolerance to cancer treatment. Treatment for cancer presents some significant nutritional challenges as nutrition impact symptoms may develop, be exacerbated by treatment and may contribute to a worsening in nutritional status. Nutrition screening and assessment should be an integral part of holistic patient care. The provision of appropriate, evidence-based dietary advice should occur before, during and after cancer treatment. Appropriate and timely methods of nutritional support across the spectrum of gastrointestinal cancer are needed to ensure that people are adequately supported during courses of treatment that can span weeks and months. These can range from standard approaches of supplementing oral intake to complex interventions such as managing high output intestinal stomas. The gastrointestinal tract is particularly susceptible to impact from systemic anti-cancer treatments and radiotherapy. Gastrointestinal late effects of cancer treatment are now recognised to present particular challenges in terms of both medical and nutritional management. These late effects have a significant impact on the individual and their quality of life in addition to implications for the health service. Dietary intake following cancer treatment has an impact on quality of life and future research may demonstrate its influence on the risk of recurrence of gastrointestinal cancer.
Collapse
|
27
|
Martin-Perez E, Domínguez-Muñoz JE, Botella-Romero F, Cerezo L, Matute Teresa F, Serrano T, Vera R. Multidisciplinary consensus statement on the clinical management of patients with pancreatic cancer. Clin Transl Oncol 2020; 22:1963-1975. [PMID: 32318964 PMCID: PMC7505812 DOI: 10.1007/s12094-020-02350-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/01/2020] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer (PC) remains one of the most aggressive tumors with an increasing incidence rate and reduced survival. Although surgical resection is the only potentially curative treatment for PC, only 15–20% of patients are resectable at diagnosis. To select the most appropriate treatment and thus improve outcomes, the diagnostic and therapeutic strategy for each patient with PC should be discussed within a multidisciplinary expert team. Clinical decision-making should be evidence-based, considering the staging of the tumor, the performance status and preferences of the patient. The aim of this guideline is to provide practical and evidence-based recommendations for the management of PC.
Collapse
Affiliation(s)
- E Martin-Perez
- Department of Surgery, Hospital Universitario de La Princesa, Diego de Leon 62, 28006, Madrid, Spain.
| | - J E Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - F Botella-Romero
- Department of Endocrinology, Hospital General Universitario, Albacete, Spain
| | - L Cerezo
- Department of Radiation Oncology, Hospital Universitario de La Princesa, Madrid, Spain
| | - F Matute Teresa
- Department of Radiology, Hospital Clínico San Carlos, Madrid, Spain
| | - T Serrano
- Department of Pathology, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.,Oncology Program, CIBEREHD National Biomedical Research Institute on Liver and Gastrointestinal Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - R Vera
- Department of Medical Oncology, Complejo Hospitalario de Navarra, Pamplona, Spain
| |
Collapse
|
28
|
Kim H, Yoon YS, Han Y, Kwon W, Kim SW, Han HS, Yoon DS, Park JS, Park SJ, Han SS, Lee SE, Choi SH, Han IW, Kim E, Jang JY. Effects of Pancreatic Enzyme Replacement Therapy on Body Weight and Nutritional Assessments After Pancreatoduodenectomy in a Randomized Trial. Clin Gastroenterol Hepatol 2020; 18:926-934.e4. [PMID: 31520730 DOI: 10.1016/j.cgh.2019.08.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/18/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We studied the effects of pancreatic enzyme replacement therapy (PERT) on body weight, nutritional status, and quality of life (QoL) in patients with pancreatic exocrine insufficiency after pancreatoduodenectomy. METHODS We performed a randomized, double-blind trial of 304 patients who underwent pancreatoduodenectomy at 7 tertiary referral hospitals in South Korea. Patients with fecal levels of elastase of 200 μg/g or less, before and after surgery, were assigned randomly to groups that received PERT (a single capsule of 40,000 IU pancreatin, Norzyme (40,000 IU, Pankreatan; Nordmark Arzneimittel GmbH & Co, Uetersen, Germany), 3 times each day during meals for 3 months; n = 151) or placebo (n = 153). Protocol completion was defined as taking more than two thirds of the total dose without taking other digestive enzymes; the protocol was completed by 71 patients in the PERT group and 93 patients in the placebo group. Patients underwent a physical examination, oral glucose tolerance tests, and blood tests at baseline and at month 3 of the study period. The primary end point was change in body weight. Secondary end points were changes in bowel habits, nutritional parameters, and QoL. RESULTS In the per-protocol analysis, 3 months after the study began, patients in the PERT group gained a mean of 1.09 kg in weight and patients in the placebo group lost a mean of 2.28 kg (difference between groups, 3.37 kg; P < .001). However, no difference in body weight was observed between groups in the intent-to-treat analysis. Three months after the study began, the mean serum levels of prealbumin increased by 10.9 mg/dL in the PERT group and increased by 7.8 mg/dL in the placebo group (P = .002). Poor compliance to PERT was a significant risk factor for weight loss (P < .001). There was no significant difference in QoL scores between groups. CONCLUSIONS In the intent-to-treat analysis of data from a randomized trial, we found no significant effect of PERT on mean body weights of patients with pancreatic exocrine insufficiency after pancreatoduodenectomy. However, with active education and monitoring, PERT could increase body weight and nutritional parameters. ClinicalTrials.gov no: NCT02127021.
Collapse
Affiliation(s)
- Hongbeom Kim
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea; Department of Surgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Youngmin Han
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea; Center for Liver and Pancreatobilary Cancer, National Cancer Center, Goyang, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Dong-Sup Yoon
- Department of Surgery, Gangnam Severance Hospital, Seoul, Korea
| | - Joon Seong Park
- Department of Surgery, Gangnam Severance Hospital, Seoul, Korea
| | - Sang-Jae Park
- Center for Liver and Pancreatobilary Cancer, National Cancer Center, Goyang, Korea
| | - Sung-Sik Han
- Center for Liver and Pancreatobilary Cancer, National Cancer Center, Goyang, Korea
| | - Seung Eun Lee
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea
| | - Seong Ho Choi
- Department of Surgery, Samsung Medical Center, Seoul, Korea
| | - In Woong Han
- Department of Surgery, Dongguk University Ilsan Hospital, Goyang, Korea; Department of Surgery, Samsung Medical Center, Seoul, Korea
| | - Eunjung Kim
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea; Department of Nursing, Graduate School, Kyung Hee University, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
| |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW The aim was to review evidence about diabetes secondary to hereditary pancreatitis, seeking novel diagnostic and treatment features. RECENT FINDINGS Hereditary pancreatitis (HP) is an autosomal dominant condition, characterized by recurrent episodes of acute pancreatitis, progression to fibrosis, and chronic pancreatitis. Clinical presentation includes diabetes of the exocrine pancreas (DEP). HP prevalence ranges from 0.3 to 0.57 per 100,000 people, with up to 80% of these develop DEP. This condition often requires specific interventions: with regard to metabolic control, metformin is the first choice for those with mild DEP, and for those in advanced disease, insulin is considered the first-line therapy. Insulin analogues and insulin pump therapy are preferred due to the brittle glycemic pattern and risk of hypoglycemia. In case of exocrine insufficiency, pancreatic enzyme replacement therapy is recommended. Pancreatic polypeptide administration is a promising novel treatment feature. DEP due to HP appears to be a misdiagnosed condition. The requirement of specific management demonstrates the importance of this matter; therefore, appropriate recognition and classification are important.
Collapse
Affiliation(s)
- Gabriel Xavier Ramalho
- School of Medicine, Faculty of Education and Health Sciences, University Center of Brasilia (UniCEUB), Brasilia, Brazil
| | - Marcio Garrison Dytz
- School of Medicine, Faculty of Education and Health Sciences, University Center of Brasilia (UniCEUB), Brasilia, Brazil.
- Endocrinology Division, Department of Intern Medicine, Sobradinho Regional Hospital, Brasilia, Brazil.
- Endocrinology and Metabolism Medical Residency, Superior School of Health Sciences (ESCS), Brasilia, Brazil.
- Institute of Diabetes and Endocrinology of Brasilia, SHS Qd. 6 Cj. A Bl. E Sl 1119, Brasilia, DF, 70316-902, Brazil.
| |
Collapse
|
30
|
ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2020; 39:612-631. [DOI: 10.1016/j.clnu.2020.01.004] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
|
31
|
Ru N, Zou WB, Wu H, Hu LH, Li XB, Liu GF, Li ZS, Liao Z. Chinese guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency (2018 edition). J Dig Dis 2019; 20:567-571. [PMID: 31006979 DOI: 10.1111/1751-2980.12753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/16/2019] [Accepted: 04/16/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Nan Ru
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Wen Bin Zou
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China.,Department of Gastroenterology, Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Hao Wu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Liang Hao Hu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Xiao Bin Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Gai Fang Liu
- Department of Gastroenterology, Hebei People's Hospital, Shijiazhuang, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China.,Department of Gastroenterology, Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China.,Department of Gastroenterology, Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | | |
Collapse
|
32
|
Rodrigues-Pinto E, Caldeira A, Soares JB, Antunes T, Carvalho JR, Costa-Maia J, Oliveira P, Azevedo R, Liberal R, Bouça Machado T, Magno-Pereira V, Moutinho-Ribeiro P. Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Etiology, Natural History, and Diagnosis (Part I). GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:346-355. [PMID: 31559325 DOI: 10.1159/000497388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/31/2019] [Indexed: 11/19/2022]
Abstract
Chronic pancreatitis (CP) is a heterogeneous disease, with different causes and often a long delay between onset and full classic presentation. Clinical presentation depends on the stage of the disease. In earlier stages, recurrent episodes of acute pancreatitis are the major signs dominating clinical presentation. As the inflammatory process goes on, less acute episodes occur, and pain adopts different aspects or may even disappear. After 10-15 years from onset, functional insufficiency occurs. Then, a classic presentation with pain and pancreatic exocrine and endocrine insufficiency appears. Diagnosis remains challenging in the early stages of the disease, as its initial presentation is usually ill-defined and overlaps with other digestive disorders. Computed tomography and magnetic resonance cholangiopancreatography should be the first choice in patients with suspected CP. If the results are normal or equivocal but still there is a high suspicion of CP, the next option should be endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography is mainly a therapeutic technique, and for the diagnostic purpose should only be used when all other imaging modalities and pancreatic function tests have been exhausted. Indirect tests are used to quantify the degree of insufficiency in already-established late CP. Recommendations on CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part I.
Collapse
Affiliation(s)
| | - Ana Caldeira
- Gastroenterology Department, Hospital Amato Lusitano, Castelo Branco, Portugal
| | | | - Teresa Antunes
- Gastroenterology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Joana Rita Carvalho
- Gastroenterology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - José Costa-Maia
- Surgery Department, Centro Hospitalar de São João, Porto, Portugal
| | - Pedro Oliveira
- Radiology Department, Hospital de Braga, Braga, Portugal
| | - Richard Azevedo
- Gastroenterology Department, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar de São João, Porto, Portugal
| | | | | | | |
Collapse
|
33
|
Hort A, Hameed A, Middleton PG, Pleass HC. Distal intestinal obstruction syndrome: an important differential diagnosis for abdominal pain in patients with cystic fibrosis. ANZ J Surg 2019; 90:681-686. [PMID: 31364217 DOI: 10.1111/ans.15357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
As life expectancy for those with cystic fibrosis (CF) now exceeds 40 years of age, adult hospitals away from specialized CF services are being exposed more frequently to people with acute complications of CF. Well-known manifestations of CF include pulmonary disease and pancreatic insufficiency with malabsorption. However, a less well-known entity is distal intestinal obstruction syndrome (DIOS), which is an important cause of obstructive symptoms in people with CF that must be differentiated from other causes of bowel obstruction. However, one confounding factor is that adults with CF may have elements of both DIOS and mechanical bowel obstruction due to adhesions from previous operations. A recent tragic outcome in a young adult with CF highlights the need for all doctors, both junior and senior, especially those who are not directly involved in day-to-day CF care, to understand the features of DIOS and the appropriate management, which differs from that of a mechanical bowel obstruction. This review aims to highlight the clinical and pathophysiological features of DIOS, differentiate it from other causes of bowel obstruction and contrast management strategies. Improved knowledge of DIOS will help to facilitate appropriate recognition and permit optimal, multidisciplinary management of this CF complication.
Collapse
Affiliation(s)
- Amy Hort
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Ahmer Hameed
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
| | - Peter G Middleton
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, CF Service, Westmead Hospital, Sydney, New South Wales, Australia
| | - Henry C Pleass
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
34
|
Bicakli DH, Uslu R, Güney SC, Coker A. The Relationship Between Nutritional Status, Performance Status, and Survival Among Pancreatic Cancer Patients. Nutr Cancer 2019; 72:202-208. [PMID: 31271302 DOI: 10.1080/01635581.2019.1634217] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Aim: The purpose of this study was to identify the nutritional and performance status of Pancreatic Cancer (PanCa) patients and to determine the relationship between these parameters and their survival time.Material and Methods: Ninety-six PanCa patients [59.6% F, 61.4% M; mean age: 60.7 (min:28, max:80) years] were followed up for 6-24 months. The Patient Generated Subjective Global Assessment (PG-SGA) and Eastern Comparative Oncology Group (ECOG) scale were performed. Anthropometric measurements [height, weight, mid-upper arm circumference (MUAC), calf circumference (CC) and triceps skin fold thickness (TSF)], hand grip strength (HGS) were recorded. Survival analyses were conducted using Kaplan-Meier curves.Results: Malnutrition was observed in 85.5% (n = 82) and 54.2% of all patients had poor performance status. A positive correlation was observed between malnutrition and ECOG scale of the patients (P < .01). Antropometric measurements for women and men, respectively, were 34.4 ± 3.03-34.6 ± 3.43 cm for CC; 26.9 ± 3.47-26.05 ± 3.37 cm for MUAC; 20.5 ± 6.3-13.02 ± 7.7 mm for TSF; - 31.02 ± 7.64-20.13 ± 6.04 kg for HGS. Survival time of patients with SGA-A and B was 38.0 ± 6.6 months and of those with SGA-C was 12.0 ± 3.1 months (P = .000).Conclusion: Malnutrition negatively affected both performance status and survival time among PanCa patients.
Collapse
Affiliation(s)
| | - Ruchan Uslu
- Department of Medical Oncology, Ege University School of Medicine, Bornova, Turkey
| | - Sedat Can Güney
- Department of Internal Medicine, Ege University School of Medicine, Bornova, Turkey
| | - Ahmet Coker
- Department of General Surgery, Ege University School of Medicine, Bornova, Turkey
| |
Collapse
|
35
|
Zou WB, Ru N, Wu H, Hu LH, Ren X, Jin G, Wang Z, Du YQ, Cao YN, Zhang L, Chang XY, Zhang RC, Li XB, Shen Y, Li P, Li ZS, Liao Z. Guidelines for the diagnosis and treatment of chronic pancreatitis in China (2018 edition). Hepatobiliary Pancreat Dis Int 2019; 18:103-109. [PMID: 30922816 DOI: 10.1016/j.hbpd.2019.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/02/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Wen-Bin Zou
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China
| | - Nan Ru
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Hao Wu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Xu Ren
- Department of Gastroenterology, Heilongjiang Provincial Hospital, Harbin 150030, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Yi-Qi Du
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Ya-Nan Cao
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Lei Zhang
- Department of Radiology, Shanghai First People's Hospital, Shanghai 200080, China
| | - Xiao-Yan Chang
- Department of Pathology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Rong-Chun Zhang
- Department of Gastroenterology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiao-Bin Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Yan Shen
- Department of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Peng Li
- Department of Digestive Endoscopy, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China.
| | - Zhuan Liao
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China.
| | | |
Collapse
|
36
|
Wynne K, Devereaux B, Dornhorst A. Diabetes of the exocrine pancreas. J Gastroenterol Hepatol 2019; 34:346-354. [PMID: 30151918 DOI: 10.1111/jgh.14451] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 07/31/2018] [Accepted: 08/19/2018] [Indexed: 12/11/2022]
Abstract
Diabetes of the exocrine pancreas (DEP) is a form of diabetes that occurs due to pancreatic disease. It is far more common than has been previously considered, with a recent study showing 1.8% of adults with new-onset diabetes should have been classified as DEP. The majority is misdiagnosed as type 2 diabetes mellitus (T2DM). Patients with DEP exhibit varying degrees of exocrine and endocrine dysfunction. Damage to the islet of Langerhans effects the secretion of hormones from the β, α, and pancreatic polypeptide cells; the combination of low insulin, glucagon, and pancreatic polypeptide contributes to rapid fluctuations in glucose levels. This form of "brittle diabetes" may result in the poorer glycemic control observed in patients with DEP, when compared with those with T2DM. Diabetes of the exocrine pancreas has a different natural history to other forms of diabetes; patients are more likely to require early insulin initiation compared with those with T2DM. Therefore, individuals with DEP should be advised about the symptoms of decompensated hyperglycemia, although they are less likely to develop ketoacidosis. Clinicians should screen for DEP in patients with acute or chronic pancreatitis, following pancreatic resection, or with co-existing cystic fibrosis or hemochromatosis. Incident diabetes may herald the onset of pancreatic ductal carcinoma in a small subset of patients. Once identified, patients with DEP can benefit from specific lifestyle advice, pancreatic enzyme replacement therapy, metformin treatment, appropriate insulin dosing, and monitoring. Further research is needed to establish the ideal treatment regimens to provide optimal clinical outcomes for this unique form of diabetes.
Collapse
Affiliation(s)
- Katie Wynne
- Department of Diabetes and Endocrinology, John Hunter Hospital, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
| | - Benedict Devereaux
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Anne Dornhorst
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.,Imperial College London, London, UK
| |
Collapse
|