Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS).

BACKGROUND: The optimal nutritional therapy in the field of pancreatic surgery is still debated. METHODS: An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. RESULTS: The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. CONCLUSION: The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.

Hyperplastic polyps of the gastric antrum in patients with gastrointestinal blood loss.

The significance of hyperplastic polyps of the gastric antrum in anemic patients with suspected gastrointestinal bleeding has not been determined. The aim of this study is to evaluate the prevalence and prognosis of such polyps in this patient group. Clinical records of patients referred to our endoscopy lab from November 1999 to February 2003 for the evaluation of iron deficiency anemia or suspected gastrointestinal bleeding were reviewed. There were 987 patients. Fourteen patients (1.4%) had hyperplastic polyps in the gastric antrum. Five of the patients reported melena, but the rest were asymptomatic. Multiple antral polyps were present in seven cases. The largest polyp measured 5.0 cm. Helicobacter pylori infection was present in one patient. All patients were anemic and nine had documented iron deficiency. No follow-up information was available in four patients. Hyperplastic polyps of the gastric antrum are a rare but significant cause of gastrointestinal blood loss in older patients. Removal of the polyps using endoscopic or surgical methods may be required for resolution of the blood loss along with iron supplementation. Gastroenterologists should be aware that hyperplastic polyps of the gastric antrum might result in gastrointestinal blood loss and iron deficiency anemia.

Selenium concentrations in pancreatic juice of patients with chronic pancreatitis.

BACKGROUND: Free radicals have been implicated as an important mediator in the pathogenesis of tissue injury. Experimental animal models would suggest selenium deficiency contributes to the pathogenesis of chronic pancreatitis (CP). In clinical studies, low plasma selenium levels have been reported in patients with CP. To the best of our knowledge, selenium levels have not been measured in pancreatic juice. METHODS: Twenty-seven patients with chronic intermittent upper quadrant abdominal pain were studied. The diagnosis of CP was made by endoscopic retrograde cholangiopancreatography. Patients were allowed to eat an ad libitum western diet. None of the patients was taking selenium supplements. Patients underwent upper endoscopy with routine conscious sedation. Secretin (0.2 microg/kg) was given i.v. immediately before intubation. Pancreatic juice collected from the duodenum was immediately frozen in liquid nitrogen and stored at -80 degrees C until the assay was performed. Selenium levels of the pancreatic juice were determined using the inductively coupled plasma-mass spectrometry method. RESULTS: Twelve patients had an abnormal pancreatogram. The gender and median age in controls and CP were 11 females and 4 males (54 years, range 32-78) and 7 females and 5 males (56 years, range 37-79), respectively. The etiology of CP was alcohol and idiopathic. The median selenium concentration in controls was 4 microg/mL (range, 2-11.5) and in CP 4.5 microg/mL (range, 2-16). There was not a statistically significant difference between the 2 groups (p = not significant). CONCLUSIONS: The pancreatic juice concentration of selenium is similar in patients with CP compared with age matched controls. Our results would therefore suggest that the effects of selenium on pancreatic injury might be systemic rather than local tissue effect.