Mary Phillips

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.

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 

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.

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.

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.