Chapter 20: Pancreatic Disease in Adults

Mary Phillips (Guildford), Irantzu Arregui-Fresneda (Southampton),

Sinead Duggan (Dublin), Kathryn Freeman (Sheffield), Laura McGeeney (Cambridge)

The Royal Surrey County Hospital NHS Foundation Trust

Regional Hepato-Pancreatico-Biliary Unit (Surrey and Sussex)

Pancreatic Disease

• Developing Guidelines • Content • Future work

Developing the Guidelines

• ‘ New’ Dietetic speciality • Regionalisation of services in 2003-5 • 22 x specialist centres:

– Severe cases acute and chronic pancreatitis – Pancreatic resection

• Annual meetings of NIGPS at the Pancreatic Society of Great Britain and Ireland est. 2008

• Dozens of requests for help with patient management

• Issues with pancreatic enzyme use within dietetics

Literature....

71% response rate from 31 specialist centres (prior to completion of centralisation of services.)

Post operative feeding

Type of feed and pre-op assessment

Is there a concern about nutrition?

• 37.5% of readmissions due to malnutrition / dehydration (Grewal et al, 2011)

• 65-68% patients malnourished prior to surgery (Wigmore et al, 1997, Schnelldorfer & Adams, 2005, Jo et al, 2006)

• Concern over undiagnosed DM and PEI prior to surgery.

Implications of malnutrition

• Poor wound healing (Gupt & Ihmaidat, 2003) • Readmissions (37.5% Grewal et al, 2011) • Increased risk of pancreatic fistula (Kanda et al, 2011) • Chest infection (Gupt & Ihmaidat, 2003) • Reduced performance status (Barber et al, 1999) • Increased morbidity in PD (25.7% - 37%, Crucitti et al, 1998) • Increased mortality in PD (8.1% to 18.5%, Crucitti et al, 1998) • Prolonged length of stay (Garth et al, 2010)

Pancreatic Enzyme Replacement Therapy (PERT)

Funding!

Duggan S.N., Smyth N.D., O’Sullivan M., Feehan S., Ridgway P.F. & Conlon K.C. (2012) A transatlantic survey of nutrition practice in acute pancreatitis. J Hum Nutr Diet. doi:10.1111/j.1365-277X.2012.01256.x

253 Dietitians responded from UK, Ireland and Canada

Timing of nutritional support

Is feeding being delayed in obese patients? Early enteral feeding is recommended, but only

48.7% (DGH) / 64.8% (University Hospital) aimed to do so.

Benefit of feeding in the first 48 hours

Petrov M.S, Pylypchuk R.D, Uchugina A.F, A systematic review on the timing of artificial nutrition in acute pancreatitis. British Journal of Nutrition 2009;101:787-793

Route of feeding

Barriers to feeding

Awareness of national / international literature

PENG guide

• Acute Pancreatitis – Requirements; feeding routes,

• Chronic Pancreatitis – Requirements; micronutrients

• Pancreatic Cancer – operable and palliative – Duodenal stents

• Pancreatic Enzyme Replacement Therapy (PERT)

Requirements in AP Nutrient Requirements 1,2

Energy 15-25kcal/kg in early stage of complicated disease

25-35kcal/kg in stable disease / recovery phase

Protein 1-1.5 g/kg/day

Fat 30% of total energy

Carbohydrates 50% of total energy

Feed Type Peptide feeds are likely to be required in patients with extensive

disease 1,2,8

Some patients may tolerate standard polymeric feeds15

Monitoring As per Chapter 6: Monitoring, plus:

Triglycerides 1,16

Blood Glucose 1

Pain, especially if associated with EN

Management of Complications Post Op Complications Dietetic Management

Delayed gastric emptying:

(nausea, vomiting, early

satiety)

Pro-kinetics, good blood glucose control, small frequent meals and snacks. In practice

patients often have NJ feeding or TPN followed by gradual reintroduction of liquids / soft

moist diet.

Pancreatic leak/ fistula No specific dietary changes required. Some units use NJ feeding and NBM to reduce

stimulation of pancreatic enzymes.

Chyle leak Replace fluid and electrolytes losses. Nutrition can be provided by TPN, EN with an MCT

feed, a minimal fat oral diet or an oral MCT diet.

Dumping syndrome (in the

presence of partial

gastrectomy)

Smaller, more frequent meals, limiting fluid consumption during meals, eating fewer simple

carbohydrates, eat more complex carbohydrates and foods high in soluble fibre, laying down

after eating

Weight loss See below

Micronutrient deficiency (due to

poor intake or malabsorption)

Individual micronutrient or multivitamin/mineral supplementation. PERT if required

Diabetes (especially if blood

sugars are deranged before

resection) 34

Insulin, tablets or diet treated as appropriate. Anecdotally, diabetes is more common after a

distal pancreatectomy than after pancreatico-duodenectomy

Where now.....

• NICE guidelines – Acute Pancreatitis – Chronic Pancreatitis – Pancreatic Cancer

• Multi-centre trials to strengthen evidence • Education sessions in surgical / gastroenterology

conferences • Work with pharmacy regarding PERT PGD’s and

prescribing

We would like to thank • PENG for supporting the development of

this chapter • Abbott Healthcare for financially

supporting our annual meeting

Thank you Any Questions?

Chapter 20: Pancreatic Disease in AdultsPancreatic DiseaseDeveloping the GuidelinesLiterature....Post operative feedingType of feed and pre-op assessmentIs there a concern about nutrition?Implications of malnutritionPancreatic Enzyme Replacement Therapy (PERT)Funding!Slide Number 11Slide Number 12Slide Number 13Timing of nutritional supportBenefit of feeding in the first 48 hoursRoute of feedingBarriers to feedingAwareness of national /� international literaturePENG guideRequirements in APManagement of ComplicationsWhere now.....Slide Number 23Slide Number 24