Ann Surg Treat Res.  2021 Apr;100(4):200-208. 10.4174/astr.2021.100.4.200.

Changes in postoperative long-term nutritional status and quality of life after total pancreatectomy

Affiliations
  • 1Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

Abstract

Purpose
Quality of life (QoL) is widely known to be poor after total pancreatectomy (TP) due to the loss of pancreatic function and poor nutritional status, but prospective studies on changes in QoL over time are lacking. The aim of this study was to prospectively evaluate the short- and long-term consequences of pancreatic exocrine insufficiency, changes in nutritional status, and their associated effects on QoL after TP.
Methods
Prospective data were collected from patients who underwent TP between 2008 and 2018. Validated questionnaires (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ] Core 30, EORTC QLQ-pancreatic cancer module, and the Mini Nutritional Assessment), measured frequency of bowel movement, relative body weight (RBW), triceps skinfold thickness (TSFT), and serum levels of protein, albumin, transferrin, and hemoglobin A1c were collected serially for 1 year.
Results
Thirty patients who underwent TP were eligible for the study. Bowel movement frequency increased over time, and the RBW and TSFT were lowest by 1 year. The global health status score showed no significant difference over time. At 3 months, physical and role function scores as well as symptoms of fatigue, constipation, and digestive difficulties worsened significantly. Most indices recovered after 1 year, but poorer physical function scores, digestive difficulties, and altered bowel habits persisted.
Conclusion
Because some symptoms do not recover over time, careful follow-up and supportive postoperative management are needed for TP patients, including nutritional support with pancreatic enzyme replacement and education about medication adherence and diet.

Keyword

Exocrine pancreatic insufficiency; Nutritional status; Pancreatic diseases; Pancreatectomy; Quality of life

Figure

  • Fig. 1 Changes in exocrine function. (A) Relative body weight was highest preoperatively and continued to decrease over time. (B) Bowel movement frequency increased over time. (C) Mini Nutritional Assessment (MNA) score was lowest preoperatively, peaked at 3 months of follow-up, and then decreased almost to the preoperative state by 1 year of follow-up. (D) Triceps skinfold thickness (TSFT) decreased significantly after surgery. Preop, preoperative; Postop, postoperative. *P < 0.050.

  • Fig. 2 Changes in nutritional parameters. (A) Protein was highest at 3 months of follow-up but decreased to preoperative levels by 1 year of follow-up. (B) Albumin was highest at 3 months of follow-up but decreased to preoperative levels by 1 year of follow-up. (C) Transferrin was lowest at 3 months of follow-up but increased past the preoperative levels at 1 year of follow-up. Preop, preoperative; Postop, postoperative.

  • Fig. 3 Changes in endocrine function. Hemoglobin A1c (HbA1c) increased slightly at 3 months and was maintained at this level until 1 year of follow-up. Preop, preoperative; Postop, postoperative.

  • Fig. 4 Changes in quality of life. (A) EORTC QLQ-C30 functional scores showed that the physical function and role function scores decreased at 3 months of follow-up, whereas the role function score recovered after 1 year of follow-up while the physical function score worsened. (B) EORTC QLQ-C30 symptom scores showed that fatigue and constipation worsened at 3 months of follow-up but recovered at 1 year of follow-up. (C) EORTC QLQ-PAN26 functional scores showed no significant differences, but the trend of the sexuality scores seemed to decrease over time. (D) EORTC QLQ-PAN26 symptom scores showed that digestive and altered bowel habit symptoms continued to worsen over time. EORTC QLQ-C30, European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30; EORTC QLQ-PAN26, EORTC QLQ pancreatic cancer module; Preop, preoperative; Postop, postoperative.


Reference

1. Hartwig W, Gluth A, Hinz U, Bergmann F, Spronk PE, Hackert T, et al. Total pancreatectomy for primary pancreatic neoplasms: renaissance of an unpopular operation. Ann Surg. 2015; 261:537–546. PMID: 24979606.
2. Müller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, et al. Is there still a role for total pancreatectomy? Ann Surg. 2007; 246:966–974. PMID: 18043098.
Article
3. Epelboym I, Winner M, DiNorcia J, Lee MK, Lee JA, Schrope B, et al. Quality of life in patients after total pancreatectomy is comparable with quality of life in patients who undergo a partial pancreatic resection. J Surg Res. 2014; 187:189–196. PMID: 24411300.
Article
4. Suzuki S, Kajiyama H, Takemura A, Shimazaki J, Nishida K, Shimoda M. The clinical outcomes after total pancreatectomy. Dig Surg. 2017; 34:142–150. PMID: 27701159.
Article
5. Datta J, Lewis RS Jr, Strasberg SM, Hall BL, Allendorf JD, Beane JD, et al. Quantifying the burden of complications following total pancreatectomy using the postoperative morbidity index: a multiinstitutional perspective. J Gastrointest Surg. 2015; 19:506–515. PMID: 25451733.
Article
6. Zakaria HM, Stauffer JA, Raimondo M, Woodward TA, Wallace MB, Asbun HJ. Total pancreatectomy: short- and long-term outcomes at a high-volume pancreas center. World J Gastrointest Surg. 2016; 8:634–642. PMID: 27721927.
Article
7. Ryska M, Rudis J. Pancreatic fistula and postoperative pancreatitis after pancreatoduodenectomy for pancreatic cancer. Hepatobiliary Surg Nutr. 2014; 3:268–275. PMID: 25392838.
8. Kusakabe J, Anderson B, Liu J, Williams GA, Chapman WC, Doyle MMB, et al. Long-term endocrine and exocrine insufficiency after pancreatectomy. J Gastrointest Surg. 2019; 23:1604–1613. PMID: 30671791.
Article
9. Watanabe Y, Ohtsuka T, Matsunaga T, Kimura H, Tamura K, Ideno N, et al. Longterm outcomes after total pancreatectomy: special reference to survivors' living conditions and quality of life. World J Surg. 2015; 39:1231–1239. PMID: 25582768.
Article
10. Billings BJ, Christein JD, Harmsen WS, Harrington JR, Chari ST, Que FG, et al. Quality-of-life after total pancreatectomy: is it really that bad on long-term follow-up? J Gastrointest Surg. 2005; 9:1059–1066. PMID: 16269376.
Article
11. Pulvirenti A, Pea A, Rezaee N, Gasparini C, Malleo G, Weiss MJ, et al. Perioperative outcomes and long-term quality of life after total pancreatectomy. Br J Surg. 2019; 106:1819–1828. PMID: 31282569.
Article
12. Scholten L, Latenstein AE, van Eijck C, Erdmann J, van der Harst E, Mieog JS, et al. Outcome and long-term quality of life after total pancreatectomy (PANORAMA): a nationwide cohort study. Surgery. 2019; 166:1017–1026. PMID: 31500907.
13. Scholten L, Stoop TF, Del Chiaro M, Busch OR, van Eijck C, Molenaar IQ, et al. Systematic review of functional outcome and quality of life after total pancreatectomy. Br J Surg. 2019; 106:1735–1746. PMID: 31502658.
Article
14. Struyvenberg MR, Fong ZV, Martin CR, Tseng JF, Clancy TE, Fernández-Del Castillo C, et al. Impact of treatments on diabetic control and gastrointestinal symptoms after total pancreatectomy. Pancreas. 2017; 46:1188–1195. PMID: 28902790.
Article
15. Yang DJ, Xiong JJ, Liu XT, Li J, Dhanushka Layanthi Siriwardena KM, Hu WM. Total pancreatectomy compared with pancreaticoduodenectomy: a systematic review and meta-analysis. Cancer Manag Res. 2019; 11:3899–3908. PMID: 31123419.
16. Suzuki S, Miura J, Shimizu K, Tokushige K, Uchigata Y, Yamamoto M. Clinicophysiological outcomes after total pancreatectomy. Scand J Gastroenterol. 2016; 51:1526–1531. PMID: 27461044.
Article
17. Kim H, Yoon YS, Han Y, Kwon W, Kim SW, Han HS, et al. Effects of pancreatic enzyme replacement therapy on body weight and nutritional assessments after pancreatoduodenectomy in a randomized trial. Clin Gastroenterol Hepatol. 2020; 18:926–934. PMID: 31520730.
Article
18. Maker AV, Sheikh R, Bhagia V. Diabetes Cont rol and Compl icat ions Tr ial (DCCT) Research Group. Perioperative management of endocrine insufficiency after total pancreatectomy for neoplasia. Langenbecks Arch Surg. 2017; 402:873–883. PMID: 28733926.
Article
19. Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature: what does it tell us? J Nutr Health Aging. 2006; 10:466–485. PMID: 17183419.
20. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993; 85:365–376. PMID: 8433390.
Article
21. Fitzsimmons D, Johnson CD, George S, Payne S, Sandberg AA, Bassi C, et al. Development of a disease specific quality of life (QoL) questionnaire module to supplement the EORTC core cancer QoL questionnaire, the QLQ-C30 in patients with pancreatic cancer. EORTC Study Group on Quality of Life. Eur J Cancer. 1999; 35:939–941. PMID: 10533475.
22. Anwar S, Tan W, Yu J, Hutson A, Javle M, Iyer R. Quality-of-life (QoL) as a predictive biomarker in patients with advanced pancreatic cancer (APC) receiving chemotherapy: results from a prospective multicenter phase 2 trial. J Gastrointest Oncol. 2014; 5:433–439. PMID: 25436122.
23. Lis CG, Gupta D, Grutsch JF. Patient satisfaction with quality of life as a predictor of survival in pancreatic cancer. Int J Gastrointest Cancer. 2006; 37:35–44. PMID: 17290079.
Article
24. Stoop TF, Ateeb Z, Ghorbani P, Scholten L, Arnelo U, Besselink MG, et al. Impact of endocrine and exocrine insufficiency on quality of life after total pancreatectomy. Ann Surg Oncol. 2020; 27:587–596. PMID: 31562603.
Article
25. Rijssen LB, Gerritsen A, Henselmans I, Sprangers MA, Jacobs M, Bassi C, et al. Core set of outcomes in pancreatic cancer (COPRAC): an international Delphi study among patients and health care providers. Ann Surg. 2019; 270:158–164. PMID: 29261524.
26. Struyvenberg MR, Martin CR, Freedman SD. Practical guide to exocrine pancreatic insufficiency: breaking the myths. BMC Med. 2017; 15:29. PMID: 28183317.
Article
27. Dresler CM, Fortner JG, McDermott K, Bajorunas DR. Metabolic consequences of (regional) total pancreatectomy. Ann Surg. 1991; 214:131–140. PMID: 1867520.
Article
28. Gilliland TM, Villafane-Ferriol N, Shah KP, Shah RM, Tran Cao HS, Massarweh NN, et al. Nutritional and metabolic derangements in pancreatic cancer and pancreatic resection. Nutrients. 2017; 9:243.
Article
29. Nanashima A, Hiyoshi M, Imamura N, Yano K, Hamada T, Hamada R, et al. Clinical significance of preoperative nutritional parameter and patient outcomes after pancreatectomy: a retrospective study at two academic institute. Ann Hepatobiliary Pancreat Surg. 2019; 23:168–173. PMID: 31225419.
Article
30. Roberts KJ, Blanco G, Webber J, Marudanayagam R, Sutcliffe RP, Muiesan P, et al. How severe is diabetes after total pancreatectomy? A case-matched analysis. HPB (Oxford). 2014; 16:814–821. PMID: 24344937.
Article
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