Mary Phillips
About
My research project
Long term effects of pancreatico-duodenectomyThis observational study explores the impact of pre and post operative sarcopenia on surgical outcomes and tolerance of adjuvant chemotherapy. The study also explores long term implications such as micronutrient deficiency, onset of type 3c diabetes, other gastrointestinal complications and osteoporosis.
Supervisors
This observational study explores the impact of pre and post operative sarcopenia on surgical outcomes and tolerance of adjuvant chemotherapy. The study also explores long term implications such as micronutrient deficiency, onset of type 3c diabetes, other gastrointestinal complications and osteoporosis.
My qualifications
Affiliations and memberships
NICE Expert advisor: Pancreatitis
Chair: Nutrition Interest Group of the Pancreatic Society of Great Britain and Ireland
Clinical Lead: Pancreas, Gastroenterology Specialist Group, British Dietetic Association
Teaching
BSc Nutrition and Dietetics
MSc Advanced Practice: Prescribing
MSc Nutritional Medicine
Publications
Background and aims Patients with pancreatic cancer often experience significant deterioration in nutritional status over time. Malnutrition is complex and multifactorial, with malabsorption, pain, toxic dependencies, co-morbidities and malignant processes all playing a role. The aims of this systematic review were to assess nutritional changes over time and identify tolerance of nutritional intervention, thus identifying potential areas for further research to improve patient outcomes. Materials and methods A systematic review of MEDLINE, EMBASE and PubMed was carried out in February 2020, identifying 2620 articles. After screening to exclude those reporting short-term measures, with only one data point, or in the wrong population, thirteen papers were selected for analysis (four trials in neo-adjuvant treatment, five in populations undergoing palliative treatment for pancreatic cancer, and four in mixed populations undergoing pancreatic resection). Results Overall, studies were limited by predominantly retrospective designs, and poor control of potentially confounding variables. Meta-analysis could not be performed due to heterogenicity in study design and reporting methods. Surgery in mixed cohorts did not appear to result in weight loss. Only one small intervention study was identified. Patients with pancreatic cancer experienced a decline in nutritional status, with 44-63% of patients undergoing neoadjuvant chemotherapy having low muscle mass prior to starting treatment. Conclusion There is a paucity of data regarding nutritional intervention in pancreatic cancer. Future work should include the use of validated functional and clinical assessment tools to further explore the impact of nutritional intervention, and the relationship between nutritional status and outcome.
Background Patients with chronic pancreatitis experience malnutrition, osteoporosis, pancreatic exocrine insufficiency and have a 80% lifetime risk of diabetes (1). These are progressive consequences and require proactive surveillance for detection and optimisation of treatment. The NICE pancreatitis guidelines recommend long-term follow up for patients with chronic pancreatitis (1). European guidelines recommend regular assessment of bone density, biochemical assessment of micronutrient status and a comprehensive nutritional assessment (2). The aim of this survey was to assess compliance with the NICE guidelines by analysing current practice in patients with chronic pancreatitis after pancreaticoduodenectomy. Methods A UK wide electronic survey was developed using Qualtrics® software (SAP America Inc. USA) to capture all the nutritional aspects of follow-up thought to be relevant in the long term. Markers of endocrine failure and malnutrition (weight, nutritional assessment and biochemical, vitamin and mineral screens), smoking and alcohol cessation advice and the use of dual energy x-ray absorptiometry (DEXA) scans were included. The survey was piloted on 5 staff locally prior to being circulated through a professional network – the Pancreatic Society of Great Britain and Ireland (PSGBI). Data were analysed using Chi-Square tests in SPSS (Version 26). Results One hundred and one (23% response rate) clinicians completed the survey, with 83 useable data sets. Eighty eight percent worked in tertiary centres. Lifelong follow up was only offered in tertiary centres (n = 12) and was only provided by surgeons or dietitians (p = 0.03). The duration of follow up did not vary by region (p = 0.463). Patients in the South of England were more likely to undergo a micronutrient screen (p = 0.027). Only 26% of all patients were offered a DEXA scan. Clinicians with more than 10-years’ experience were more likely to assess weight (p = 0.039), glucose and HbA1c (p = 0.035) and assess symptoms (p = 0.031). Conclusions This survey demonstrated a need to improve the provision of long-term follow up for patients with chronic pancreatitis. Lack of clarity on the format and who within the clinical team should take responsibility may explain the lack of structured follow-up in this patient group. The importance of long-term assessment needs to be included in training programmes for junior clinicians, to standardise management, improve nutritional screening and improve access to bone mineral density scanning and diabetes screening. Responsibility for follow up should be agreed between primary, secondary and tertiary care.
Pancreatico-duodenectomy (PD) includes resection of the duodenum and use of the proximal jejunum in a blind loop, thus reducing the absorptive capacity for vitamins and minerals. Several studies have analysed the frequency of micronutrient deficiencies, but there is a paucity of data on those taking routine supplements. A retrospective review of medical notes was undertaken on 548 patients under long-term follow-up following PD in a tertiary hepato-pancreatico-biliary centre. Data were available on 205 patients from 1-14 years following PD, and deficiencies were identified as follows: vitamin A (3%), vitamin D (46%), vitamin E (2%), iron (42%), iron-deficiency anaemia (21%), selenium (3%), magnesium (6%), copper (1%), and zinc (44%). Elevated parathyroid hormone was present in 11% of cases. There was no significant difference over time (p > 0.05). Routine supplementation with a vitamin and mineral supplement did appear to reduce the incidence of biochemical deficiency in vitamin A, vitamin E, and selenium compared to published data. However, iron, vitamin D, and zinc deficiencies were prevalent despite supplementation and require surveillance.
Background Pancreatico-duodenectomy (PD) results in major anatomical changes that have an impact on nutritional status and quality of life. Issues such as pancreatic exocrine insufficiency (PEI), diabetes mellitus (DM), malnutrition, micronutrient deficiency, osteoporosis and other gastrointestinal diseases are common in the post-operative setting (1, 2). Appropriate treatment of these surgical consequences is associated with improved survival (3, 4), and should improve quality of life. The aim of this survey was to assess current practice and identify which disciplines were reviewing patients following PD, what format that review takes and the duration of follow up. Methods A UK wide electronic survey was developed using Qualtrics® software (SAP America Inc. USA) to capture all the nutritional aspects of follow up thought to be relevant in the long term. Markers of endocrine failure and malnutrition (weight, nutritional assessment and biochemical vitamin and mineral screens), smoking and alcohol cessation advice and the use of dual energy x-ray absorptiometry (DEXA) scans were included. The survey was piloted on 5 staff locally prior to being circulated through a professional network – the Pancreatic Society of Great Britain and Ireland (PSGBI). Data were analysed using Chi-Square tests in SPSS (Version 26). Results One hundred and one (23% response rate) clinicians completed the survey, with 83 useable data sets. Surgeons and dietitians were most likely to reply to the questionnaire, 88% of respondents worked in tertiary centres, half (55%) had more than 10 years’ experience. There were highly significant variations in practice according to clinician experience, underlying pathology, and institution (p
Malnutrition in chronic pancreatitis is complex and multifactorial, with malabsorption, pain, toxic dependencies and co-morbidities, such as diabetes, each playing a role. The aims of this systematic review were to assess the impact of nutritional intervention on markers of nutritional status in this complex patient group, A systematic review of EMBASE and PubMed was carried out in February 2020, identifying 2620 articles. After screening to exclude those reporting short term changes (less than 3 months), with only one data point, or in the wrong population, eight papers were selected for analysis. Seven studies documented the impact of a nutritional intervention, one was an observational study only. Overall, studies were limited by predominantly retrospective designs, heterogenous populations and poor control of potentially confounding variables. Data could not be combined due to variability in reporting methods. All studies exploring nutritional intervention, whether that consisted of advice by a specialist dietitian, dose escalation of pancreatic enzymes, oral nutritional supplements or enteral feeding, demonstrated improved body weight and pain control, whereas patients who did not receive an intervention deteriorated nutritionally. Patients with chronic pancreatitis benefit from nutritional intervention. Further work is required to explore the impact of nutritional intervention on body composition and functional outcomes.
Additional publications
Peer reviewed publications
- Standard Nutritional Assessment Tools Are Unable to Predict Loss of Muscle Mass in Patients Due to Undergo Pancreatico-Duodenectomy: Highlighting the Need for Detailed Nutritional Assessment. Phillips, M.E.; Robertson, M.D.; Bennett-Eastley, K.; Rowe, L.; Frampton, A.E.; Hart, K.H. Nutrients 2024, 16, 1269. https://doi.org/10.3390/nu16091269
- ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis. Arvanitakis M, Ockenga J, Bezmarevic M, Gianotti L, Krznarić Ž, Lobo DN, Löser C, Madl C, Meier R, Phillips M, Rasmussen HH, Van Hooft JE, Bischoff SC. Clin Nutr. 2024 Feb;43(2):395-412. doi: 10.1016/j.clnu.2023.12.019. Epub 2023 Dec 27. PMID: 38169174.
- Comprehensive, long-term evaluation of pancreatic exocrine insufficiency after pancreatoduodenectomy. Sarah Powell-Brett, James Halle-Smith, Lewis A Hall, James Hodson, Mary E Phillips, Keith Roberts. Pancreatology. 2024 Mar;24(2):298-305. doi: 10.1016/j.pan.2023.11.016. Epub 2023 Dec 12. PMID: 38216353.
- Do Patients Benefit from Micronutrient Supplementation following Pancreatico-Duodenectomy? Phillips ME, Hart KH, Frampton AE, Robertson MD. Nutrients. 2023 Jun 19;15(12):2804. doi: 10.3390/nu15122804. PMID: 37375707; PMCID: PMC10301063.
- Recent Advances in Pancreatic Ductal Adenocarcinoma: Strategies to Optimise the Perioperative Nutritional Status in Pancreatoduodenectomy Patients. Halle-Smith, J.M.; Powell-Brett, S.F.; Hall, L.A.; Duggan, S.N.; Griffin, O.; Phillips, M.E.; Roberts, K.J. Cancers 2023, 15, 2466. https://doi.org/10.3390/cancers15092466Bedside naso-jejunal placement is more difficult, but successful in patients with COVID-19 in critical care: A retrospective service evaluation of a dietitian-led service. Mary E Phillips; Jessica Zekavica; Rajesh Kumar; Rajiv Lahiri; Justin Kirk-Bayley; Amish Patel; Adam E Frampton. Journal of the Intensive Care Society 2023, 0 10.1177/17511437231153045
- Bedside naso-jejunal placement is more difficult, but successful in patients with COVID-19 in critical care: A retrospective service evaluation of a dietitian-led service. Phillips, Mary, Zekavica, Jessica, Kumar, Rajesh, Lahiri, Rajiv, Kirk-Bayley, Justin, Patel, Amish, Frampton, Adam. 10.1177/17511437231153045. Journal of the Intensive Care Society. February 2023
- Assessing impact, needs and quality of life among informal carers of people with pancreatic cancer: The Pan-carer study protocol. Linda Sharp, Keno N Mentor, Sanjay Pandanaboyana, Ella Watson, Keith Roberts, Michael Silva, Mary Phillips, Ajith Siriwardena, John Hammond, Alex Bradshaw, Catherine Exley, Jennifer Deane. BMJ Open BMJ Open. 2023 May 15;13(5):e068178. doi: 10.1136/bmjopen-2022-068178. PMID: 37188466; PMCID: PMC10186426
- Critically ill patients with and without SARS-CoV-2 better achieve energy and protein targets with a high-energy, high-protein peptide-based enteral tube feed; insights from a multicentre clinical audit performed during the COVID-19 pandemic. Green, Ben, Phillips, Mary, Morgan, L. Hughes, K. Terblanche, E. King, S. Fiddes, A. &twal, Kiranjit Hubbard, Gary Stratton, Rebecca. (2022). Clinical Nutrition ESPEN. 2022, 48. 506-507. 10.1016/j.clnesp.2022.02.073.
- Training 1,200 dietitians: An evaluation of a training course for non-specialist dietitians on the management of pancreatic exocrine insufficiency. Mary E. Phillips, Laura M. McGeeney, Oonagh Griffin, Kathryn Freeman, Sarah Dann, Sinead N. Duggan, Committee Members of the Nutrition Interest Group of the Pancreatic Society of Great Britain and Ireland. Clinical Nutrition Open Science, 2022; 44:155-162
- Nutritional assessment and management in acute pancreatitis – ongoing lessons of the NCEPOD report. Phillips M.E; Smith N, McPherson S, O’Reilly D.A. J Hum Nutr Diet 2022 Jun;35(3):504-511
- Long-term effects of clinical interventions on nutritional status in patients with chronic pancreatitis - A systematic review. Phillips M.E, Robertson M, Hart K, Kumar R, Pencavel T.D. Clinical Nutrition ESPEN 2022; 48:178-185
- A Consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines. Phillips M.E, Hopper A, Leeds J.S, Roberts K.R, McGeeney L.M, Duggan S.N, Kumar R. BMJ Open Gastroenterol, 2021 Jun;8(1):e000643. doi: 10.1136/bmjgast-2021-000643
- Long term changes in nutritional status and body composition in patients with malignant pancreatic disease. Phillips M.E, Robertson M, Hart K, Kumar R, Pencavel T.D. Clinical Nutrition ESPEN 2021;44:85-95
- Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer?, Sarah Blacker, Rajiv P. Lahiri, Mary Phillips, Graham Pinn, Tim D. Pencavel, Rajesh Kumar, Angela T. Riga, Tim R. Worthington, Nariman D. Karanjia & Adam E. Frampton. Expert Review of Gastroenterology & Hepatology, 2021 DOI: 10.1080/17474124.2021.1915127
- COVID PAN collaborative group, SARS-CoV-2 infection in acute pancreatitis increases disease severity and 30-day mortality: COVID PAN collaborative study. Pandanaboyana S, Moir J, Leeds JS Kofi Oppong, Aditya Kanwar, Ahmed Marzouk, Ajay Belgaumkar, Ajay Gupta, Ajith K Siriwardena, Ali Raza Haque, Altaf Awan, Anita Balakrishnan, Arab Rawashdeh, Bogdan Ivanov, Chetan Parmar, Christopher M Halloran, Clifford Caruana, Cynthia-Michelle Borg, Dhanny Gomez, Dimitrios Damaskos, Dimitrios Karavias, Guy Finch, Husam Ebied, James K Pine, James R A Skipworth, James Milburn, Javed Latif, Jeyakumar Ratnam Apollos, Jihène El Kafsi, John A Windsor, Keith Roberts, Kelvin Wang, Krish Ravi, Maria V Coats, Marianne Hollyman, Mary Phillips, et al. Gut 2021;70:1061-1069
- Complex Enterally Tube-Fed Community Patients Display Stable Tolerance, Improved Compliance and Better Achieve Energy and Protein Targets with a High-Energy, High-Protein Peptide-Based Enteral Tube Feed: Results from a Multi-Centre Pilot Study. Green, B., Sorensen, K., Phillips, M., et al,. Nutrients, 2020; 12. 3538; doi:10.3390/nu12113538
- ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Arvanitakis. M, Ockenga J, Bezmarevic M, Gianotti L, Krznaric Z, Lobo DN, Loser C, Madl C, Meier R, Phillips M.E, et al, Clin Nutr. 2020;39(3);612-631
- Pancreatic exocrine insufficiency and enteral feeding: a practical guide with case studies, Phillips M. E, Berry A, Gettle L.S, Practical Gastroenterology, Series #181 November 2018
- United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU) J Matthias Löhr, et al, HaPanEU/UEG Working Group. UEG Journal, First Published March 1, 2017.
- Nutritional Therapy in Chronic Pancreatitis. Domínguez-Muñoz J.E, Phillips M.E. Gastroenterology Clinics. 2017;946: 47(1)
- Pancreatic resection: nutritional implications and long term follow up, Phillips M. E, Practical Gastroenterology, March 2016
- Clinical, anthropometric and laboratory nutritional markers of pancreatic exocrine insufficiency: relavelence and diagnostic use. Björn Lindkvist, Mary E. Phillips, Enrique Domínguez-Muñoz, Pancreatology 2015; 15(6): 589-597
- Invited Review: Pancreatic exocrine insufficiency following pancreatic resection. Phillips M.E, Pancreatology 2015;15(5): 449-455
- An Unusual Complication of PEG Feeding After Pancreatico-Gastrostomy. Phillips M.E, Hosie K, Griffiths E.J, Low N, Gallagher M.C, Tibbs C.J, Karanjia N.D. JOP. 2014 May 27;15(3):258-60.
- A safe, effective, and cheap method of achieving pancreatic rest in patients with chronic pancreatitis with refractory symptoms and malnutrition. Pancreas. 2009 Aug;38(6):689-92. Lordan JT, Phillips ME, Chun JY, Worthington TR, Menezes NM, Lightwood R, Hussain F, Tibbs C, Karanjia ND.
- Feeding patients following pancreaticoduodenectomy: a UK national survey. Ann R Coll Surg Engl 2009 Jul;91(5):385-8. Phillips ME, Lordan JT, Menezes NM, Karanjia ND
- An Evaluation of Gastrostomy Care in a District General Hospital. Khoshnaw H, Phillips ME, Baseby A, Chapman G, Hendry S. Journal of Nutrition, Health and Aging. 2004; 8(4):309
- An elemental diet for bowel obstruction in pregnancy: a case study. J Hum Nutr Diet. 2004 Dec; 17(6):543-5. Phillips ME, Curtis P, Karanjia ND
- Failure to gain weight on long-term parenteral nutrition attributed to tri-iodothyronine thyrotoxicosis. Nutrition 2004 Nov-Dec;20(11-12):1018-21. Livingstone C, Phillips ME, Davis J, Marvin V, Stebbing J
Books
- Nutritional management of the surgical patient. Phillips M.E, Published by Wiley, 2023. https://www.wiley.com/en-gb/Nutritional+Management+of+the+Surgical+Patient-p-9781119809098
- Exocrine Pancreatic Insufficiency, 3rd Edition Editors; Morris-Stiff G, Phillips M E and Leeds, J.S, 2024 (in press)
Book Chapters
- Enteral Nutrition in patients with pancreatic exocrine insufficiency. Phillips M E, Exocrine Pancreatic Insufficiency, 3rd Edition Editors: Morris-Stiff G, Phillips M.E, Leeds J.S, 2024 (in press)
- Nutritional Support. Phillips M.E, Exocrine Pancreatic Insufficiency, 3rd Edition Editors: Morris-Stiff G, Phillips M.E, Leeds J.S, 2024 (in press)
- Acute Pancreatitis, Phillips M.E, Advanced Nutrition and Dietetics in Gastroenterology, 2nd Edition, Ed: Lomar M, 2020
- Pancreatic Disease, Phillips M.E Oxford Handbook of Nutrition and Dietetics, 3rd Edition, Ed. Gandy J, Madden A, 2020
- Nutrition in Pancreatic Cancer, Phillips, M.E, Griffin O. Clinical Pancreatology 2020 3rd Edition, Ed. Dominguez-Munoz E.
- Pancreatic Disease, Phillips M.E Manual of Dietetic Practice, 6th Edition, Ed. Gandy J, 2019 (e-print)
- Pancreatic Cancer, Phillips M.E, Manual of Dietetic Practice, 6th Edition, Ed. Gandy J, 2019 (e-print)
- Pancreatic Disease, Phillips M, Manual of Dietetic Practice, 5th Edition, Ed: Gandy J, 2014
- Pancreatitis, Phillips M, Advanced Nutrition and Dietetics in Gastroenterology, Ed: Lomar M, 2014
National Guidelines
- UEG/EPC Pancreatic Exocrine Insufficiency guidelines, 2022-2023
- UK National Guidelines for the management of PEI: Project lead, 2019-2020
- NCEPOD: Highs and Lows, Peri-operative diabetes, advisory panel member, 2017 – 2018
- NICE Guidelines: Pancreatitis, guideline committee member, 2016- 2018
- HaPanEU Management of chronic pancreatitis – member of nutrition working group, 2017
- NCEPOD: Treat the Cause, advisory panel member, 2015-2016