Timothy B. Gardner and Kerrington D. Smith (eds.)Pancreatology10.1007/978-3-319-53091-8_12

12. Optimizing Nutrition for the Patient after Pancreaticoduodenectomy: Pancreatic Insufficiency

Jeannine B. Mills¹

(1)

Gastrointestinal Cancer Group, One Medical Center Drive, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA

Jeannine B. Mills

Email: Jeannine.B.Mills@Hitchcock.org

Keywords

Exocrine pancreatic insufficiencyPancreatic enzyme replacement therapyMalnutrition/undernutritionCachexia

Case Study

A 52-year-old with history of pancreatic cancer who was well nourished preoperatively underwent Whipple resection and gastrojejunostomy. The patient reports to surgery clinic 4 weeks postoperatively and has a weight of 129 lbs, decreased appetite, dysgeusia, early satiety, and intolerance to higher fat foods; he has an obvious loss in lean body mass based on nutrition focused physical assessment. He describes his bowel movements as yellow, oily, and malodorous.

My Management

A.

Start on pancreatic enzyme replacement therapy after diagnosis of exocrine pancreatic insufficiency (EPI).

May not be necessary to dose via J-tube with semi-elemental or elemental enteral formulas vs. isotonic enteral formulas.
B.

There is a risk of clogging jejunostomy tube and/or decreasing efficacy of enzymes, but pancreatic enzyme capsules can be opened and emptied into either thickened acidic liquid suspension or thin food (apple sauce) or mixed with sodium bicarbonate to then infuse via J-tube.
C.

Dosing recommendations are 1000–2000 IU/kg lipase per meal or 25,000–50,000 IU lipase for main meal and 10,000–25,000 IU lipase for snacks, without exceeding 10,000 IU/kg lipase per day. Lipase per meal titrates up as the volume of food increases and/or signs/symptoms of EPI are apparent.
D.

Dose enzymes with first bite of food and throughout meal. This may make a difference for some patients though may also be dependent on transit time of food through the gut postoperatively.

Diagnosis and Assessment

Malnutrition is prevalent in pancreatic cancer and may have significant and adverse impact on quality of life and overall survival. It is estimated that more than 80% of patients with pancreatic adenocarcinoma will have weight loss at the time of presentation. Malnutrition “should be considered a significant independent risk factor in patients with pancreatic cancer and one of the primary goals of treatment should be to improve nutritional status.” Studies demonstrate that improvement in nutrition status is correlated with better survival and quality of life despite stage of disease [1–6].

Patients with pancreatic cancer also experience the highest incidence of cachexia estimated at 70–80% and is associated with poorer disease and surgical outcomes. The impact of cachexia on prognosis and outcome is significant including reduced treatment tolerance, worsened postoperative outcome, higher rates of metastatic disease, more progressive disease, reduced survival, and of course decreased quality of life. Malabsorption through EPI is an exacerbating factor of cachexia in pancreatic cancer [2].

Weight loss in pancreatic cancer is associated with reduced survival. It was found that a weight loss of >5% and ≤10% of total body weight provided a 3.9-fold higher relative risk of death than those without weight loss, while a weight loss >10% of total body weight provided a sevenfold higher relative risk of death than those without weight loss [7].

In surgical patients, malnutrition and cachexia have been associated with infection, poor wound healing, increased postoperative complications, increased length of stay, and increased morbidity [8, 9]. Postoperative weight loss is an independent prognostic factor. Hashimoto et al. showed that severe weight loss is associated with poor prognosis and a trend toward shorter survival [10].

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