Nutritional Risks in Patients Undergoing Total Pancreatectomy Islet AutoTransplantation in the POST Consortium.

BACKGROUND AND AIMS: Total pancreatectomy with islet autotransplantation (TPIAT) can relieve pain for individuals with acute recurrent or chronic pancreatitis. However, TPIAT may increase the risk of poor nutritional status with complete exocrine pancreatic insufficiency, partial duodenectomy, and intestinal reconstruction. Our study's objective was to evaluate nutritional status, anthropometrics, and vitamin levels before and after TPIAT. METHODS: The multicenter Prospective Observational Study of TPIAT (POST) collects measures including vitamins A, D, and E levels, pancreatic enzyme dose, and multivitamin (MVI) administration before and 1-year after TPIAT. Using these data, we studied nutritional and vitamin status before and after TPIAT. RESULTS: 348 TPIAT recipients were included (68% adult, 37% male, 93% Caucasian). In paired analyses at 1-year follow-up, vitamin A was low in 23% (vs 9% pre-TPIAT, p < 0.001); vitamin E was low in 11% (vs 5% pre-TPIAT, p = 0.066), and 19% had vitamin D deficiency (vs 12% pre-TPIAT, p = 0.035). Taking a fat-soluble multivitamin (pancreatic MVI) was associated with lower risk for vitamin D deficiency (p = 0.002). Adults were less likely to be on a pancreatic MVI at follow-up (34% vs 66% respectively, p < 0.001). Enzyme dosing was adequate. More adults versus children were overweight or underweight pre- and post-TPIAT. Underweight status was associated with vitamin A (p = 0.014) and E (p = 0.02) deficiency at follow-up. CONCLUSIONS: Prevalence of fat-soluble vitamin deficiencies increased after TPIAT, especially if underweight. We strongly advocate that all TPIAT recipients have close post-operative nutritional monitoring, including vitamin levels. Pancreatic MVIs should be given to minimize risk of developing deficiencies.

Evolving pharmacotherapeutic strategies for small bowel adenocarcinoma.

IMPORTANCE OF THE FIELD: Owing to nonspecific signs and symptoms, the majority of patients with small bowel adenocarcinoma (SBA) present with advanced-stage disease. Few studies in the literature adequately address the role of chemotherapy in SBA. The regimens used in colon and gastric cancers have been tried in SBA with varying degrees of success. AREAS COVERED IN THIS REVIEW: The authors explore the natural history and diagnostic evaluation of SBA, followed by a focused review of existing studies on individual agents and combinations used in the therapy of this malignancy. WHAT THE READER WILL GAIN: 5-fluorouracil-based chemotherapy seems to offer a clinical benefit in advanced SBA. The reader will acquire considerable insights about the most effective chemotherapy drugs and combination regimens used in advanced SBA. TAKE HOME MESSAGE: Given the rarity of this malignancy, multicenter, randomized clinical trials are essential in the design of optimal therapeutic strategies for SBA. The role of adjuvant therapy in SBA remains to be clarified. Prospective evaluation of new agents and their incorporation into various therapeutic schemes for advanced/metastatic disease is also necessary. Until then, therapeutic decisions should be individualized and based on the benefits and toxicities of the most effective drugs or combinations.