Improving nutritional status assessment in patients with chronic pancreatitis.

INTRODUCTION: Chronic pancreatitis (CP) is a progressive inflammatory disorder causing irreversible destruction of pancreatic tissue, leading to malnutrition. A previous study has found that currently used screening methods (periodic recording of body weight and faecal and serological markers) fall short in identifying and curbing malnutrition. Moreover, data is lacking regarding change in nutritional status over time. The aim of our study is to investigate changes in nutritional status in CP patients over time and to determine whether a more extensive set of measurements would be beneficial for nutritional screening of these patients. METHODS: CP patients who had undergone a nutritional assessment in 2012 were recruited to undergo a second assessment. The assessment consisted of anthropometric measurements, bioelectrical impedance analysis (BIA), handgrip strength (HGS), the Mini Nutritional Assessment (MNA), determination of faecal and serological markers and the Short Form Health (SF-36) questionnaire. These two assessments were compared and correlations between the various measures were calculated. RESULTS: Twenty-eight patients underwent a second assessment. An increase in fat mass and a decrease in both fat free mass (FFM) and HGS were observed. The number of patients scoring under the 10th percentile for FFM (43%-54%) and HGS in their dominant side (38%-46%) increased. FFM and HGS were positively correlated (R = 0.57). CONCLUSION: Even though current guidelines for CP follow-up were adhered to, there was a general deterioration in nutritional status. HGS correlated with FFM. HGS might be useful as a screening instrument for malnutrition in CP patients.

Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer.

INTRODUCTION: In pancreatic cancer, preoperative biliary drainage (PBD) increases complications compared with surgery without PBD, demonstrated by a recent randomised controlled trial (RCT). This outcome might be related to the plastic endoprosthesis used. Metal stents may reduce the PBD-related complications risk. METHODS: A prospective multicentre cohort study was performed including patients with obstructive jaundice due to pancreatic cancer, scheduled to undergo PBD before surgery. This cohort was added to the earlier RCT (ISRCTN31939699). The RCT protocol was adhered to, except PBD was performed with a fully covered self-expandable metal stent (FCSEMS). This FCSEMS cohort was compared with the RCT's plastic stent cohort. PBD-related complications were the primary outcome. Three-group comparison of overall complications including early surgery patients was performed. RESULTS: 53 patients underwent PBD with FCSEMS compared with 102 patients treated with plastic stents. Patients' characteristics did not differ. PBD-related complication rates were 24% in the FCSEMS group vs 46% in the plastic stent group (relative risk of plastic stent use 1.9, 95% CI 1.1 to 3.2, p=0.011). Stent-related complications (occlusion and exchange) were 6% vs 31%. Surgical complications did not differ, 40% vs 47%. Overall complication rates for the FCSEMS, plastic stent and early surgery groups were 51% vs 74% vs 39%. CONCLUSIONS: For PBD in pancreatic cancer, FCSEMS yield a better outcome compared with plastic stents. Although early surgery without PBD remains the treatment of choice, FCSEMS should be preferred over plastic stents whenever PBD is indicated. TRIAL REGISTRATION NUMBER: Dutch Trial Registry (NTR3142).

[Patients with upper abdominal pain and echographically-proven gallstones: start with expectative management]. / Patiënten met bovenbuikklachten en echografisch aangetoonde galstenen: beginnen met een expectatief beleid.

Three patients, two women aged 33 and 75 years and a 62-year-old man, presented with gallstones and upper abdominal pain due to functional dyspepsia, chronic constipation, and oesophageal spasm, respectively. After a period of watchful waiting, the first patient insisted on having a cholecystectomy, but her complaints persisted. In the second patient, the complaints disappeared after treatment with a bulking agent and magnesium oxide. The third patient received medication as well: a proton-pump inhibitor, prokinetic agents, a calcium antagonist and Helicobacter eradication, and recovered. The presence of gallstones is relatively easy to assess by ultrasound imaging, but the decision whether abdominal symptoms are related to gallbladder stones remains a diagnostic challenge for the clinician. The key question for the family practitioner, gastroenterologist and surgeon is which patients with upper abdominal pain and proven gallbladder stones might benefit from a cholecystectomy. The patients described illustrate that upper abdominal pain is not invariably related to symptomatic gallbladder disease. The published evidence supports initial watchful waiting with additional diagnostic investigation, and cholecystectomy only later if judged to be necessary.

New strategies for the treatment of gallstone disease.

BACKGROUND: Symptomatic gallstones are generally accepted as being the indication for cholecystectomy. Generally, severe abdominal pain in epigastrium and in the right upper abdominal quadrant, and lasting for more than 15 min, is thought to be caused by gallstones. However, many patients with other abdominal complaints undergo cholecystectomy and are satisfied with the outcome of surgery. Possible ways to improve the results of cholecystectomy are discussed. METHODS: Review of previous work by the authors. RESULTS: The introduction of laparoscopic cholecystectomy has even led to an increase in cholecystectomies; in a higher complication rate; and in increased costs of the treatment of gallstone disease. Because of faster recovery, 70% of symptomatic gallstone patients are able and willing to undergo laparoscopic cholecystectomy in day care. Cholecystectomy after sphincterotomy and stone extraction in patients who have stones in the gallbladder was demonstrated to prevent gallstone-related symptoms in at least 40% of patients. If the gallbladder had to be removed later for symptomatic disease, however, this did not result in a higher rate of conversions and complications. Because of shortage in operation capacity in The Netherlands, there is a considerable delay between the diagnosis of symptomatic stones and cholecystectomy. Better selection of patients for cholecystectomy will not only improve the results of cholecystectomy, it will also reduce the number of cholecystectomies and patients on waiting lists. Delay of cholecystectomy is associated with more complications, longer operative times, higher conversion rates to open cholecystectomy and prolonged hospitalization. The efficacy of the bile salt ursodeoxycholic acid in preventing gallstone-related pain attacks and complications in patients with contraindications for operation or waiting to undergo cholecystectomy should be investigated further, since two retrospective studies have demonstrated favourable outcomes for this strategy. CONCLUSION: The results of cholecystectomy are likely to be improved by better selection of patients, prevention of delay of the procedure and possibly treatment with ursodeoxycholic acid.

Nutritional status in patients with chronic pancreatitis.

OBJECTIVE: Chronic pancreatitis (CP) patients have an increased risk of malnutrition. Information about nutritional status of CP outpatients is scarce, and simple, sensitive methods to identify patients at risk are lacking. This explorative cross-sectional study was performed to survey the nutritional status of CP outpatients. SUBJECTS: Fifty patients with chronic or recurrent acute pancreatitis (RAP) had a nutritional assessment performed. Scores on nutritional screening tools and a quality of life questionnaire were assessed. General observations and relations between parameters were described. RESULTS: Thirty-nine patients had CP and eleven patients had RAP. According to the nutritional screening tools, 28-50% of the patients had a moderate or high risk of malnutrition. All domains of the Short Form Health Survey were significantly lowered in CP patients (all P0.001) compared with the Dutch norm values. A considerable number of patients scored below the 5th percentile on anthropometric measures. Mini Nutritional Assessment could not identify all patients with very low anthropometric scores. Substantial weight loss was not a sensitive indicator for functional impairment. CONCLUSION: CP outpatients are at risk of malnutrition. Currently used screening methods (for example, weight loss) are likely to be not sensitive enough to identify all patients with impaired body composition and restricted function. Therefore, some patients with objective decline in nutritional status will remain unidentified. An extended nutritional assessment is recommendable in CP patients.