cpd accredited - mpc · 2018-12-10 · 5 vol 1 no 1 - november/december 2018 of the tumour on...

Continuing Medical Education on all aspects of the pancreas

Volume 1 No 2 - November/December 2018

CPD Accredited

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References: 1. Struyvenberg MR, Martin CR, Freedman SD. Practical guide to exocrine pancreatic insufficiency – Breaking the myths. BMC Medicine. 2017;15:29. 2. Australasian guidelines for the management of pancreatic exocrine insufficiency. 2015. Available from: http://pancreas.org.au/wp-content/uploads/2016/01/APC-GUIDE-LINES-2015.pdf. Last accessed 13 Sep 2017. 3. Creon® 10000 Approved Package Insert, September 2005. 4. Creon® 25000 Approved Package Insert, February 2016. 5. Solvay Pharmaceuticals. NDA 20-725 for Creon® (Pancrelipase Delayed-release Capsules) Briefing Document for December 2, 2008 Antiviral Drugs Advisory Committee.S1 Creon® 10000. Each capsule contains enteric coated granules of Pancreatin 150 mg. S1 Creon® 25000. Each capsule contains enteric coated granules of Pancreatin 300 mg. Registration Numbers: Namibia South AfricaCreon® 10000 04/11.1/1015 33/11.1/0340Creon® 25000 04/11.1/1016 28/11.1/0645For full prescribing information refer to the package insert approved by the Medicines Regulatory Authority. Abbott Laboratories S.A. (Pty) Ltd. 1940/014043/07. Abbott Place, 219 Golf Club Terrace, Constantia Kloof, 1709. Tel: (011) 858 2000. Publication Date: October 2018. Promotional review number: ZAECRE180099

12596 Creon Consumer advert.indd 1 2018/10/24 17:45

3 Vol 1 No 1 - November/December 2018

Editorial

Editor: Professor José RamosHead HPB SurgeryUniversity of the WitwatersrandDonald Gordon Medical CentreJohannesburg

Editor: Prof. José Ramos

Production Editors: Ann Lake Publications

Ann Lake

Helen Gonçalves

Design: Jane Gouveia

Enquiries: Ann Lake Publications

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Disclaimer

The content contained in this publication contains medical or health sciences information and is intended for professional use within the medical field. No suggested test or procedure should be carried out unless, in the reader’s judgement, its risk is justified. Because of rapid advances in the medical sciences, we recommend that the independent verification of diagnoses and drug dosages should be made. Discussions views, and recommendations as to medical procedures, products, choice of drugs, and drug dosages are the views of the authors. The views expressed by the editor or authors in this newsletter do not necessarily reflect those of the sponsors or publishers. The sponsors, publishers and editor will not be liable for any damages or injuries of any kind arising from the use or misuse of information provided in this publication and do not support the use of products for off label indications. The views and opinions expressed in these articles were in no way influenced by Abbott Laboratories.

EditorialProfessor José Ramos

Pancreas CancerProfessor José Ramos

Depression related to patients suffering from Pancreatic CancerMr Gerhard Grundling

Medical schemes and their duty of confidentialityMs Peta Durrant

Nutrition and pancreatic surgery. Short and long term goalsMs Abby Courtenay

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Contents

ear colleague

We welcome you to the second issue of Volume 1 of Pancreas

Matters. We have been encouraged by the favourable response to the first issue and trust that you will find this second issue educational and beneficial.

We have chosen to focus on pancreatic cancer which remains a deadly disease with a high mortality rate and an increasing incidence. Although advances have been made in the surgical, locoregional and systemic treatment of this disease, most patients will die within a relatively short time after initial diagnosis.

Patients with pancreatic cancer should be treated by a multidisciplinary team in a high-volume centre. There is clear evidence that treatment in an expert centre is associated with lower morbidity and mortality rates, increased resection rates, and better survival figures.

The first paper provides a broad overview of what is a highly complex disease. Although advances have been made in understanding risk factors and genetic mutations that occur in pancreatic cancer, the exact cause of the disease remains unknown in the majority of patients. Early detection is important to diagnose early stage disease which may be amenable to potentially curative treatment. Surgical resection remains the only potentially curative modality. However,

few patients are candidates for surgery, the disease being advanced in most patients at the time of diagnosis. Newer neoadjuvant strategies have emerged which may improve resectability and possibly overall survival. Despite successful surgery, most patients will still die of cancer recurrence. Better systemic therapy including chemotherapy as well as immunotherapy holds the key to improving survival in pancreatic cancer.

As doctors, we tend to focus mainly on diagnosing and managing this disease. We are possibly guilty of not taking full cognisance of the devastating psychological implications of the diagnosis of pancreatic cancer and the profound physiological consequences of the disease and our treatment interventions. Mr Grundling has written an excellent article on the depression that patients suffer when confronted by this life changing illness. He provides an insightful and profound overview of the psychological stress that patients and family members experience when confronted with the diagnosis of pancreatic cancer. It is vital that a psychologist be part of the multidisciplinary team tasked with managing these patients.

Ms Courtenay’s paper on nutritional aspects of pancreatic cancer and surgery is compre-hensive yet readable and practical. She pro-vides important theoretical background in-formation enabling us to better understand the nutritional and metabolic consequences of this disease, and how best to ensure nu-tritional health thereby maintaining quality of life. The dietician is a vital member of the multidisciplinary team involved in the care of his patients.

Your feedback and suggestions are welcome. Please let us know about topics involving the pancreas that you would like us to cover in future issues.


Pancreas Cancer

Professor José RamosHead HPB SurgeryUniversity of the WitwatersrandDonald Gordon Medical CentreJohannesburg

alignancies of the pancreas can arise from different cells. Ade-nocarcinomas arise from ductal (or rarely acinar) cells in the

exocrine pancreas and are the commonest of the pancreatic malignancies accounting for over 90% of pancreatic cancers. Neuro-endocrine tumours arise from neuroendo-crine cells and are the second commonest malignancies making up about 5% of pan-creatic malignancies. Lymphomas and rarer tumours such as solid pseudo-papillary neo-plasms may also be encountered.

This review of pancreatic cancer (PC) will concentrate on adenocarcinomas, these being the commonest and most difficult to treat.

EpidemiologyPC is the 10th or 11th commonest malig-nancy in Westernised populations with over 50,000 new cases being diagnosed in the USA, 10,000 in the UK and over 80,000 in Europe in 2015. Worldwide 460,000 new cases were reported in 2017 with over 400,000 patients predicted to die of PC. De-spite being less common than other cancers, it is now the fourth commonest cause of cancer deaths, this being an indication of its high mortality rate. By 2030 it is estimated that PC will be the second leading cause of cancer-related mortality.

While the overall trend of most cancers has been to progressively decline with time, the incidence (and therefore the mortality) of PC continues to rise. It has the highest mortality rates of any cancer with mortality rates be-ing similar to incidence rates in most popula-tions. According to GLOBOCAN, deaths from pancreatic cancer are expected to rise by up to 40% in the next 12 to 15 years.

Males have a higher risk of developing PC than females with a lifetime risk in males of 1 in 869 and 1 in 1125 in females in South Africa, according to the 2014 National Can-cer Registry. The age standardised incidence rate for PC in South Africa is reported at 0.95 in males and 0 .73 in females. This is signifi-cantly lower than international figures of be-

tween 8 and 10.8 cases per 100 000, this dis-crepancy most likely being due to poor and incomplete data collection in South Africa.The majority of cases occur in older popu-lations with a peak incidence after the age of 60. Up to 10% of cases however arise in patients under the age of 50.

Aetiology and risk factors for pancreatic cancerThe cause of PC remains unknown in most patients. Over 80% are due to sporadically occurring mutations with less than 10% due to identified inherited germline muta-tions. Mutations in BRCA2, p16, ATM, STK11, PRSS1/PRSS2, SPINK1, PALB2, and DNA mis-match repair genes are associated with vary-ing degrees of increased risk for pancreatic carcinoma. Familial PC, defined as at least two first-degree relatives with pancreatic cancer, account for only 5%–10% of all pan-creatic cancer cases. Risk increases as the number of first-degree relatives increases. Multiple combinations of genetic mutations are commonly found in PC.

The main epidemiological risk factors identi-fied are smoking and obesity. A BMI of over 30 is associated with a 20% - 40% higher risk of dying from pancreatic cancer. Both type I and type II diabetes mellitus are as-sociated with an increased risk of pancreat-ic cancer with an odds ratio of 2.0. Chronic pancreatitis is associated with a significantly higher risk of PC with the lifetime risk being estimated at about 5%. Various dietary fac-tors have been linked to an increased risk of PC however the relative risk is low.

The most frequent precursors of PC are mi-croscopic pancreatic intraepithelial neopla-sia (PanIN), intraductal papillary mucinous neoplasm (IPMN), and mucinous cystic neo-plasm.

PresentationInitial symptoms are largely determined by the anatomical location of the malignancy within the pancreas and the effect of the mass on adjacent structures such as ducts. Those tumours arising close to the bile duct will typically present earlier with obstructive jaundice whereas those arising in the body and tail tend to present later with more ad-vanced disease as early symptoms may be absent. Tumours causing obstruction of the pancreatic duct may present with symptoms of exocrine insufficiency such as steator-rhoea and increased flatulence. New onset of diabetes may be the presenting symptom of pancreas cancer in up to 25% of patients. Pancreatitis may be the first manifestation of PC.

Pain associated with pancreatic cancer is typically reported in the epigastrium or left upper quadrant and often radiates to the back. Unexpected weight loss may be the first symptom of advanced disease. Non-metastatic manifestations of underly-ing malignancy include spontaneous deep vein thrombosis. Patients with advanced disease may present with metastatic symp-toms such as malignant ascites, pleural ef-fusions or palpable masses in the umbilical region or distant lymph nodes.

Alarm symptoms for PC• Jaundice• New-onset diabetes• Loose, oily stools, bloating, flatulence• Persistent abdominal and back pain• Unexpected weight loss• Acute pancreatitis of unknown aetiology

Diagnosis PC may be diagnosed during the investiga-tion of symptoms such as those mentioned above, or else incidentally on abdominal im-aging. Typically, these patients would have had an abdominal ultrasound or cross-sec-tional imaging with CAT scan or MRI. Either the mass itself would be noted or the effect

Fig 1. Cystic neoplasm of the pancreas


of the tumour on adjacent structures such as ducts causing dilatation of the bile or pan-creatic duct. The presence of a double-duct sign where both the pancreatic and bile duct are dilated implies the presence of malig-nancy in over 95% of patients. This may be detected on ultrasound, CT or MRI.

Endoscopic ultrasound (EUS) is a highly sen-sitive and specific modality to document and diagnose pancreatic tumours. Any masses seen can be accurately biopsied by fine nee-dle or core needle to confirm malignancy and the type thereof.

The radiological characteristics of the mass can often suggest the likelihood of malig-nancy although cytological or histological confirmation may be required in order to treat appropriately. It is not always neces-sary to obtain cytological or histological con-firmation in order to determine the need for surgical exploration. Should initial chemo-

therapy or radiation therapy however be re-quired, then confirmation of the malignancy is necessary in order to institute treatment.Tumour markers may be elevated in PC. CA-19-9 is the commonest marker seen in this disease. However, false positives and nega-tives are often seen and a normal level does not exclude malignancy. CEA is occasionally raised. Tumour markers should not be used as a screening test for PC. It is only appro-priate to perform these markers once the tumour has been diagnosed. In cases where the marker is positive, it can then be used to monitor response to treatment.

StagingOnce the diagnosis of PC has been made, or the findings are suggestive thereof, staging is necessary in order to determine appropri-ate management. Good quality cross-sec-tional imaging is vital in order to accurately stage patients. Tumour characteristics that

need to be evaluated include size, position, extension beyond the pancreas, involvement of surrounding vasculature, and the pres-ence of liver, peritoneal or lung metastases At presentation, PC can be staged in three broad groups:• Localised (resectable) 10-15% • Locally advanced (borderline resectable)

30-40%• Advanced/metastatic (unresectable)

50-60%

Management principlesEarly or localised tumours are typically treat-ed by surgical resection, this affording the patient the best chance of potential cure or long-term survival. It is essential that the surgical resection is complete with negative margins (R-0 resection). The presence of positive microscopic (R-1) or macroscopic (R-2) margins adversely affects survival signifi-cantly. Unfortunately a minority of patients present initially with resectable disease.

The type of resection performed depends on the position of the tumour. Those arising in the head or neck region will require a pan-creaticoduodenectomy (Whipple operation) which involves resection of the duodenum, head and neck of pancreas, adjacent lymph nodes, bile duct and gallbladder, and part of the stomach in the classical operation. A py-lorus preserving Whipple is a variant of the operation where the stomach is preserved. This may have some nutritional benefit in the longer term although this is debatable. Very radical surgery and extended lymph-adenectomy has not been shown to improve survival.

Fig 2. Anatomy of the pancreas and adjacent structures

Fig 3. Ductal dilatation in PC (double-duct sign)

Fig 4. Pancreaticoduodenenctomy (Whipple operation) with different reconstructions

Portal vein

Common bile duct

Accessory pancreatic duct

Duodenal minor papilla

Duodenal major papilla

Pancreatic duct

Inferior vena cava

HeadNeck

Body

Tail

Aorta

Celiac trunkSplenic artery

Uncinate process

Superior mesenteric artery

Superior mesenteric vein

Duodenum

Before surgeryStomach

Small intestine

Body and tail of pancreas

Pancreas tumour

DuodenumStomach attached to small intestine

Remaining pancreas attached to small intestine

Bile duct attached to small intestineBile duct

Gallbladder

After surgeryStomach

Spleen

Pancreas

Small intestineColon

Liver


Tumours arising in the body and tail of the pancreas are typically managed by an ex-tended distal pancreatectomy with the spleen usually included in the en-bloc resec-tion. Localised lymph nodes are resected. In cases where splenectomy is planned or per-formed, patients should receive vaccination for prophylaxis against pneumococcus and haemophilus influenza. Total pancreatec-tomy is occasionally indicated for curative intent, particularly in patients with diffuse involvement of the pancreas by IPMN.

Patients with locally advanced/borderline re-sectable tumours are increasingly managed with neoadjuvant strategies to increase the likelihood of successful resection. This typ-ically involves systemic chemotherapy and possibly radiation therapy. Previously, the only chemotherapy agents available were gemcitabine and 5-fluoruracil. These how-ever were of limited benefit in converting borderline resectable patients to resection. More recently good data has emerged on the increased efficacy of a combination of oxaliplatin and irinotecan (FOLFIRINOX) in achieving tumour response, with shrinkage often being seen. External beam radiation therapy or stereotactic body radiation ther-apy (SBRT) may be added to neoadjuvant chemotherapy to achieve the desired re-sponse and permit successful R-0 resection. There is now good evidence. That neoadju-vant strategies have improved disease-free and overall survival after successful surgical resection.

Tumour extension to the adjacent veins, usu-ally the super mesenteric or portal vein does not necessarily preclude successful resection and venous resection with reconstruction may be required in order to completely re-move the tumour with clear margins. Arterial resection can be performed in expert centres. However, there is debate as to whether any survival benefit is seen in these patients. In general, tumour extension to the regional arteries is considered a contraindication to resection.

Following resection, final pathological stag-ing is available which will then guide the need for further adjuvant chemotherapy. In most cases lymph node involvement will be

noted thus adjuvant therapy tends to be pre-scribed after most resections. The standard of care for adjuvant chemotherapy in pan-creatic cancer is currently a combination of gemcitabine and capecitabine. Gemcitabine together with paclitaxel (Abraxane) is also an effective adjuvant combination.

Patients who do not respond to neoadju-vant treatment and remain unresectable, or whose disease progresses, should then be considered for palliative therapy.

Surgical resection is not indicated in patients with metastatic disease with rare exceptions. Palliation will be the main treatment goal in these patients.

Complications and consequences of pancreatic resectionPatients should be carefully selected for sur-gery. Apart from correctly assessing resect-ability, patients should be fit enough to un-dergo these major procedures. This involves a careful preoperative medical assessment and correction of underlying medical prob-lems. These patients should also be managed in high-volume centres by a multidisciplinary team experienced in the management of PC. If these criteria are fulfilled, the majority of patients should survive the surgery with mor-tality rates of 0-3% to be expected. There is now good evidence that better postoperative outcomes and improved disease-free and overall survival for patients with PC will be found in high-volume expert centres.

Morbidity following major resections is high, 30 to 45% of patients having some form of complication. These however can usually be successfully resolved in centres experienced

with the management of these patients. Interventional radiology can typically deal with most post-operative complications such as intra-abdominal collections and bleeding from false aneurysms, these being the more serious adverse events. General complica-tions such as pneumonia and DVT can be minimised by aggressive physiotherapy and anticoagulation. Surgical re-exploration is seldom required.

Following recovery from surgery, patients can anticipate a fairly normal quality of life. Dietary modifications may include eating smaller meals on a regular basis and limiting the intake of high carbohydrate -containing fluids. Dieticians play an important role in the post-operative nutritional management of these patients. Pancreatic exocrine or en-docrine dysfunction may occur or, existing dysfunction may worsen. This can be man-aged by the administration of insulin and pancreatic enzyme replacement therapy (PERT). Most patients who have had a major pancreatic resection will have some form of exocrine insufficiency and should be consid-ered for PERT. Dietary fat restriction is not necessary and should be discouraged.

Survival in PCThe prognosis for patients with PC is gener-ally poor as most of these cancers will have metastasised at the time of diagnosis, ei-ther overtly or microscopically. Survival will be influenced by the stage at presentation, whether the tumours are resected or not, margin and lymph node status after resec-tion, and whether neoadjuvant or adjuvant treatment modalities are utilised. The re-sponse to treatment is also an important indicator of ultimate prognosis.

Palliation in PCThe majority of patients with PC will not have resectable disease and thus will be candidates only for palliation. The inability to potentially cure these patients should however not detract from the need to actively treat these patients in order to resolve common problems associated with PC and to maintain a good quality of life. Symptoms resulting from the tumour and complications thereof should be identified Fig 5. Locally advanced PC with vascular involvement

Table 1. Survival in PC

Stage Median survival 5-year survival

Resectable 24 months 10-35%

Locally advanced/unresectable

6-18 months 2-5%

Metastatic 3-12 months <1%


and managed, ideally with minimal morbidity and high efficacy. Palliative chemotherapy and/or radiotherapy play an important role in the management of these patients with good evidence to show that quality of life is improved or maintained, and overall survival possibly extended. Apart from the active medical management of the patient, they and their family need psychological support and counselling. Organisations such as Hospice play a vital role particularly in the terminal phase of the disease.

The following problems will need to be ad-dressed by either medical, endoscopic, inter-ventional radiological, or occasionally surgi-cal modalities.• Pain• Jaundice• Depression • Gastric outlet obstruction• Malnutrition and cancer cachexia• Malignant ascites• Diabetes• Pancreatic exocrine insufficiency• Intestinal obstruction

Surveillance after resectionDespite successful surgical resection. the majority of patients will unfortunately recur with either localised or metastatic disease. It is essential that these patients be regularly followed up by the management team which includes the surgeon, oncologist, endocrinolo-gist, psychologist and dietician. Primary care physicians need to be actively involved in the follow-up of these patients and have an important role to play in the ongoing man-agement of these patients. Patients are nat-urally devastated if recurrence is document-ed despite having undergone major surgical intervention as well as arduous chemo- and/or radiotherapy. It is vital to counsel patients about this possibility prior to embarking on major surgery. It is an unfortunate reality that recurrence cannot be cured with current treatment options although patients may benefit from further palliative chemotherapy or radiation therapy.

Increasingly aggressive and radical surgery has had a limited impact on overall out-come and more effective systemic therapy with chemotherapy and immunotherapy is required in future to improve survival in this deadly disease.

Take-home message

• Pancreatic cancer incidence is rising• Prognosis is poor with most patients

dying of the disease within 6-18 months

• Complete surgical resection remains the only potentially curative treatment for PC although most patients will still recur after successful surgery

• Early diagnosis is important to maximise the potential for surgical resection

• Neoadjuvant strategies may improve resectability, and recurrence-free and overall survival

• PC should be managed by a multidisciplinary team in centres with experience and appropriate expertise

• Palliative therapy should be actively implemented by a dedicated team in order to maintain quality of life and possibly improve survival

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References: 1. Domínguez-Muñoz JE. Pancreatic exocrine insufficiency: diagnosis and treatment. J Gastroenterol Hepatol 2011;26 Suppl 2:12–16. 2. Creon® 25000 Approved package insert February 2016. 3. Creon® 10000 Approved package insert September 2005. 4. Sikkens ECM, et al. Pancreatic enzyme replacement therapy in chronic pancreatitis. Best Pract Res Clin Gastroenterol 2010;24:337–347. 5. Data on File. Abbott Laboratories. Creon® Scientific Brochure 2013. 6. Borowitz D, et al. Cystic Fibrosis Foundation evidence-based guidelines for management of infants with cystic fibrosis. J Pediatr 2009;155:S73–S93. 7. Halm U, et al. A double-blind, randomized, multicentre, crossover study to prove equivalence of pancreatin minimicrospheres versus microspheres in exocrine pancreatic insufficiency. Aliment Pharmacol Ther 1999;13:951–957.

S1 Creon® 10000. Each capsule contains enteric coated granules of Pancreatin 150 mg. S1 Creon® 25000. Each capsule contains enteric coated granules of Pancreatin 300 mg. Registration Numbers: Namibia South AfricaCreon® 10000 04/11.1/1015 33/11.1/0340Creon® 25000 04/11.1/1016 28/11.1/0645For full prescribing information refer to the package insert approved by the Medicines Regulatory Authority. Abbott Laboratories S.A. (Pty) Ltd. 1940/014043/07. Abbott Place, 219 Golf Club Terrace, Constantia Kloof, 1709.Tel: (011) 858 2000. Publication Date: June 2018. Promotional review number: ZAECRE180084


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hen being confronted with a life threatening diagnosis most people will be distraught and would need to adjust to

all the implications of such a diagnosis. Liter-ature indicates that if the diagnosis is that of pancreatic cancer the impact would have a negative influence on quality of life as well as on the progression of the illness. There-fore psychological distress should be regard-ed as a vital sign that has to be identified and treated when it occurs. If neglected, pa-tients would utilise health services and visit emergency health services more, leading to an increased economic burden of pancreatic cancer.1

In this regard the World Cancer Declaration of 2013 by the Union for International Can-cer Control (UICC) states in target 8: “...and distress management services will be univer-sally available.”5

This declaration clarifies the important sup-portive role that mental health practitioners have to play in the management of pancre-atic cancer patients.

IncidenceWhen considering the incidence of depres-sion and anxiety in cancer patients com-pared to the general population, studies indicate that it is twice as high.2 When com-pared with all other tumours of the digestive system, pancreatic cancer patients present with the highest co-morbidity rate of major depression.3 This co-morbid presentation between pancreatic cancer and major de-pression has been known since the 1930’s. In an early study published in 1931 in JAMA, Yaskin indicated that a triad of anxiety, de-pression and impending doom tend to be present with pancreatic cancer. Since then researchers have been interested in the inci-dence and association between depression and pancreatic cancer.4

The prevalence of depression in people with pancreatic cancer has been shown to range from 33% to 50%.4 A study by Fras et al, fre-quently referenced in the literature regarding

pancreatic cancer and depression found that more than half of patients diagnosed with pancreatic cancer reported psychological symptoms up to 43 months before the occur-rence of somatic complaints.6 A study by Hol-land et al, found that patients with advanced stage pancreatic cancer had more severe depression, severe anxiety and total mood disturbance when compared to patients with other advanced abdominal cancers.7

Diagnosis, presentation and screening methodsAccording to the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) the criteria for the diagnosis of major depression consists of:The individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either: 1. depressed mood or 2. loss of interest or pleasure.• Depressed mood most of the day,

nearly every day.• Markedly diminished interest or

pleasure in all, or almost all, activities most of the day, nearly every day.

• Significant weight loss when not di-eting or weight gain, or decrease or increase in appetite nearly every day.

• Insomnia or hypersomnia nearly ev-ery day.

• A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).

• Fatigue or loss of energy nearly every day.

• Feelings of worthlessness or exces-sive or inappropriate guilt nearly ev-ery day.

• Diminished ability to think or con-centrate, or indecisiveness, nearly every day.

• Recurrent thoughts of death, recur-rent suicidal ideation without a spe-cific plan, or a suicide attempt or a specific plan for committing suicide.8

As indicated above symptoms include de-creased appetite, weight loss and fatigue. These symptoms may be due to the cancer and can then incorrectly be attributed to depression.10 When diagnosing depression in patients with cancer, attention should be given to psychological and cognitive symp-toms such as thoughts of death and suicidal ideation, guilt, worthlessness, impaired con-centration, indecisiveness, diminished inter-

est and diminished pleasure. These symp-toms should be used as the basis to diagnose depression in cancer patients.11

When pancreatic cancer is diagnosed in patients there is typically a process that pa-tients experience consisting of initial shock and denial of the diagnosis, diminished cog-nitive ability, a mix of depressive and anxiety symptoms, sleep problems and loss of appe-tite. It is important to note that in a relatively short period of approximately 10 days these symptoms will subside in more or less 50% of patients.4,11

For physicians dealing with patients diag-nosed with pancreatic cancer, it is impera-tive that they should screen for the presence of depression without having to resort to prolonged psychiatric interviews. Screening should enable physicians to identify patients with depression at acceptable levels of cer-tainty. In this regard the literature suggests two methods of screening that could be done separately or combined.

The first would be to use the two questions that relate to the core symptoms of depres-sion namely: • sad mood and • loss of interest and pleasure.

These questions have a positive predictive val-ue of 57% and a negative predictive value of 98%. If patients indicate that they do feel sad and experience a loss of interest and pleasure it would be necessary to further investigate for depression and/or refer the patient for diagnosis and management of depression.15

The second screening method is the “Distress Thermometer” (Figure 1). Here the patient is asked to circle the number that best de-scribe his or her distress during the last week. Studies indicate that 4 and above indicate patients that should further be investigated for depression.17

To further investigate for depression, there are 4 symptoms to enquire about that dis-tinguish between depression and cancer, namely: • Loss of sexual interest• Anxiety• Mood variation• Terminal insomnia16

Anxiety has been shown to occur in 48% of patients with pancreatic cancer and depression.18

Depression related to patients suffering from pancreatic cancer

Mr Gerhard GrundlingClinical Psychologist, BenoniDirector: Clinical Psychology Forum of SAMD: Glynnview Multi Professional Practice: Glynnview Psychiatric Hospital


Figure 1.

Pain is a presenting problem in 80% of pa-tients with pancreatic cancer. It is also known that a bilateral relationship exists between pain and depression, if the one increases so does the other. Levels of anxiety can also im-pact on mood and pain. In this regard it has been observed that patients awaiting che-motherapy had more severe depression than those awaiting surgery.9 Due to the high inci-dence of pain and depression, psychological management should give attention to both.

The risk of non adherence to treatment is 3 times higher amongst patients with depres-sion and cancer than those patients without depression. Non-adherence to treatment could lead to treatment failures. The risk of suicide is twice as high for patients with depression compared to the general popula-tion. Suicide risk factors are males and older patients and certain cancers, including pan-creatic cancer.14

Resilience and factors influencing psychological distressThe level of psychological distress that patients experience would be mediated strongly by patients’ resilience to adversity. Resilience will be supported by executive functions. Executive functions are processes that all have to do with managing oneself and one’s resources. These are skills involv-ing mental control and self-regulation. Exec-utive functions develop and change over the course of an individual’s lifespan. Executive functions are constantly in a state of flux and can therefore deteriorate or improve depending on various factors such as envi-ronmental influences and illness. Executive functions that are important in this regard are self-control/inhibition (internal locus of control) and flexibility or the ability to access and/or generate different perspectives.12,13

Concerning pancreatic cancer patients vari-ous factors will impact on the level of psycho-logical distress (leading to depression) that patients experience namely:4,10

• Medical factors: Advanced disease, poor prognosis, treatment, pain, physical dis-ability and family history of depression

• Psychological factors: History of depression or psychosis, perception of cancer and its impact, fear of losing control over body functions, changes in appearance, fear of painful death, disability, ability to cope and the ability to adjust and modify plans

• Social factors: Availability of social support from family, friends and colleagues, financial concerns and fear of being ostracised

The relationship between depression and pancreatic cancerPsychosocial distress is a common occurrence when pancreatic cancer is diagnosed and as indicated earlier a substantial number of patients would develop depression. Cancer patients are vulnerable to the medical, psychological and social factors indicated above and it is well recognised that depression impacts on quality of life of these patients.

The literature indicates that paraneoplastic limbic encephalitis could be related to the development of depression and it is also recognised that tumour cells can mediate the production of serotonin antibodies in the central nervous system resulting in depression.3

Depression generally occurs before the pre-sentation of pancreatic cancer symptoms do. Due to this it is argued that depression could be related to the disease process and in this regard the bilateral relationship between depression and inflammation has received attention and has been recognised for some time already. Cytokines, especially interleu-kin-6 (IL-6) has received attention, and due to them crossing the blood brain barrier they are functionally active. It is postulated that IL-6 (and others) mediate depression through their influence on neuroplasticity, neuro-en-docrine function and the metabolism of neu-rotransmitters. Studies indicate the presence

of higher concentration of IL-6 in plasma of cancer patients – including pancreatic cancer – with depression compared to patients with-out depression and healthy people.19

One of the theories sited in literature is that the relationship between depression and cancer in general may be ascribed to immune (cytokine) disregulation and that depression could increase the subsequent risk for the development of cancer. This risk seems to be especially important with cancers with poor prognosis, including pancreatic cancer. It is important to note that there is not agreement or full understanding of the bidirectional relationship and higher incidence of the common co-occurrence and the underlying mechanisms between depression and pancreatic cancer.3,19,20

Advances in neuroscience and the concom-itant theories have enabled us to better un-derstand illness presentation. In this regard it is of value to take cognisance of the peremp-tory role of evolution in constructing modern manifestations of development and disregu-lation, in this regard the legacy of inflamma-tory bias.21 Figure 2 is of interest and applies.

TreatmentIt is imperative that depression and often co-occurring anxiety should be treated as soon as it is identified. Treatment of depres-sion will safeguard improvement in quality of life and also ensure better compliance and adherence to treatment.

Treatment can be divided into two modes, namely psychotherapeutic and psychophar-macological. Due to the psychological dis-tress that always accompanies the diagnosis of cancer, psychotherapeutic intervention should always be considered.

PsychotherapyCognitive behaviour therapy is the most commonly utilised type with patients diagnosed with cancer. A vast volume of

Figure 2. From: Miller AH, Raison CL. The role of inflammation in depression: from evolutionary imperative to modern treatment target. Nature Reviews Immunology: 2016 Jan; 16(1) Page: 2 (Accessible from PMC)

Please circle or pick a number (0-10) from the drop down box that best describes how much distress you have been experiencing in the past week including today.

Pick a number

Extreme Distress

No Distress

Hunter-gatherer Traditional Modern

Evolutionary pressure

Inflammatory bias

• Alarm• Avoidance

•Wound healing• Fighting infection

↑Infectious mortality↓Inflammatory conditions↓Autoimmunity

‘Old friends’ minimally pathogenicimmunoregulatory organisms

↓Infectious mortality↑Inflammatory conditions↑Autoimmunity

Environmental and psychosocial stress and medical illness

Depression

Pathogens

Predators

Conspecifics

Evolutionary time

BReg

cellT

Reg cell

M2 marcrophage

TGFßIL-10


evidence is available indicating evidence for its use. Mindfulness based treatments including dialectical behaviour therapy (DBT) as well as acceptance and commitment therapy (ACT) are used with good success. Family therapy and couples therapy are often needed for support to significant others and to ensure continuation of quality of life. Psycho-education would be routinely used in conjunction with the types of psychotherapies mentioned. Supportive therapy including dignity therapy that specifically addresses patients’ concerns about dying and how to prepare and deal with that as well as important issues such as last will and testaments. Dignity therapy has been shown to be valuable in patients with a life expectancy of 6 months or less. Supportive-expressive therapy is another form that has been shown to be of value. Other types of treatment may be employed depending on the presentation of depression and distress.4,7,10,14,20

PsychopharmacologyAnti-depressants are regularly used when de-pression is diagnosed in patients with pan-

creatic cancer. Literature indicates that with more severe forms of depression the use of anti-depressants should be considered and used. The class of anti-depressant would de-pend on the presentation of the depression and possible side-effects of the anti-depres-sant. Other types of psychopharmacological medications should be considered as re-quired. In complex cases referral should be considered.4,7,10,14,20

ConclusionThe co-occurrence of depression with pan-creatic cancer is well recognised. It is a bidi-rectional relationship that is presently receiv-ing more agreement on its importance and impact concerning pancreatic cancer, due to the volume of research being done. This relationship is not yet fully understood and the mechanisms involved must still be fully agreed upon but are receiving attention. It is imperative that screening for and iden-tification of psychological distress and de-pression be done with pancreatic cancer pa-tients. Depression must be diagnosed when it occurs. It is important that appropriate treatment be prescribed and implemented.

Take-home message

• Depression often presents prior to the diagnosis of pancreatic cancer.

• Depression and pancreatic cancer show a high incidence of co-occurrence and this is presently viewed as a bidirection-al relationship.

• Underlying mechanisms, especially the immune response and the influence of IL-6 is of importance.

• The various factors that accompany pancreatic cancer diagnosis leading to psychological distress must be man-aged.

• Screening, identification and diagnosis of depression are imperative.

• Treatment of depression has a positive impact on the quality of life and com-pliance and adherence to treatment; but not yet on survival.

here are numerous legal and ethi-cal rules in South Africa that relate to the confidentiality of data and information of a person. These le-

gal rules find specific application when the healthcare and lifestyle information of a per-son gets processed by a third party, in this instance a medical scheme.

Provisions contained in the soon-to-be-im-plemented Protection of Personal Informa-tion (“POPI”) Act, should also be borne in mind, namely that health information are special information, subject to more strin-gent privacy protections.

The Medical Schemes Act 131 of 1998 and the Regulation theretoThe Medical Schemes Act governs the man-ner in which a medical scheme is required to be formed and further the rules which must be adhered to by a medical scheme in their dealings with their members.

The Regulations of the Medical Schemes Act, specifically Regulation 5, contains the information that must be contained in an account from a service provider when it is sent to a medical scheme for payment. Reg-ulation 5(f) specifically states “that the rel-evant diagnostic and such other item code numbers that relate to such relevant health service”. This has the effect that the medical scheme will always have knowledge of the diagnosis of the member. This further has the effect that a dependent members con-dition may be disclosed to the main mem-ber of the scheme. Healthcare Professionals should always alert their patients to this risk.

In terms of Section 57 of the Medical Schemes Act, which relates to the General Provisions on Governance and sets out the duties of the board of trustees provisions are clearly made that the trustees of the medical scheme must ensure that the rules, operation and administration of the medical scheme comply with the provisions of this Act and all other applicable laws and the trustees must take all reasonable steps to protect the confi-dentiality of medical records concerning any member’s state of health.

Regulation 15J(2)(b) and (c) of the Medical Schemes Act goes further to discuss and

make provision for the confidentiality of a members information where it is provided to a medical scheme or required by a med-ical scheme. The sections specifically state “any information pertaining to the diagno-sis, treatment or health of any beneficiary of a medical scheme must be treated as confidential” and “subject to the provisions of any other legislation, a medical scheme is entitled to access any treatment record held by a managed health care organisation or health care provider and other information pertaining to the diagnosis, treatment and health status of the beneficiary in terms of a contract entered into pursuant to regula-tion 15A, but such information may not be disclosed to any other person without the express consent of the beneficiary”.

It is evident from the contents of the Medical Schemes Act, as discussed, that a medical scheme is entitled to access confidential information relating to a member and their health status. However, it is required to keep this information confidential. There are, however, more stringent requirements on the confidentiality of an individuals information, not only related to healthcare information, in the soon-to-be-implemented Protection of Personal Information (“POPI”) Act.

Medical schemes and their duty of confidentiality

Ms Peta DurrantDirector and Principal ConsultantElsabe Klinck and AssociatesHealthcare ConsultantsJohannesburg

References available on request.


About the POPI ActThe laws and rules mentioned so far all re-late to information being kept confidential, and when it can be shared. The POPI Act also governs the collection, re-working, hold-ing and storing of information, as well the sharing and use thereof. It therefore goes beyond what is in the existing laws on priva-cy and data, and also gives more details on aspects such as disclosure and the difference between health and other personal informa-tion. POPI would apply to both the health information and lifestyle information of the member of a medical scheme.

All entities in South Africa, including medical schemes who have access to and collect the person information of members are bound by the provisions of the POPI Act. Consent must always be obtained from a member of a medical scheme for the medical scheme to be legally entitled to process personal information of its members. It is always advisable that the treating healthcare practitioner inform patients that information relating to their healthcare may be disclosed to a medical scheme in so far as ICD10 codes are attached to invoices which are sent to medical schemes.

Data subjects are the persons whose per-sonal information it is, e.g. patients, (mem-bers of the medical scheme) doctors, family members, etc. Members of Medical Schemes have the following rights under the POPI Act

• To be notified about collection of information

• To establish whether personal informa-tion is held on him/her

• To request the destruction, correction or deletion of personal information

• To object against processing of personal information, i.e. to refuse to provide information in certain circumstances (e.g. to a third party) or where it is not clear where the information would land up

• To not be subjected to automated pro-cesses that have legal consequences on creditworthiness, reliability, health, personal preferences or conduct. For example, if information from an insur-ance health assessment is automatically incorporated into medical scheme in-formation that triggers red flags on the medical scheme member. This would relate specifically to lifestyle information of the member

There are further numerous conditions to processing of information and they are as follows: • Accountability, meaning that once you

are in possession of the information you become responsible to ensure that such information is handled in accordance with the POPI Act

• Processing limitation, refers to the right to collect, and work with information. All information that one collects and works with must be done lawfully. This means there must be a legally valid justification for the collection and processing

• Purpose specification, means that one should make clear what the purpose is for which the information is collected. This must also be agreed to be the patient. For example, if information is collected for the purpose of ensuring the patient can be billed and bad debt can be followed up, it must be made clear that the information is required for that purpose

• Further processing limitation, means that if information is disclosed for a specific purpose, it cannot then be used for another purpose

• Information quality places the responsi-bility on the responsible party (the prac-tice, or the entity that subsequently, after consent, holds the information) to take steps to ensure that all personal informa-tion in its possession is complete, accu-rate, not misleading and always updated

• Openness is important in view of the fact that the National Health Act recognises that certain laws may compel us to dis-close information to others. For example, the Medical Schemes Act’s regulation 5 makes it a legal requirement that an ICD10- code, which would reveal the patient’s diagnosis, be added on an ac-count to a member and scheme. This means that although the law compels one to do so, one should still disclose that to the patient. This is of particular impor-tance if the patient is not the main mem-ber, and the account may be processed by the scheme, and a statement sent by the scheme to the main member, and not the patient who is a dependent on that member’s scheme. Healthcare pro-fessionals must therefore disclose these instances where laws require third party data provision and disclosure. Other ex-amples include adverse events reporting to companies and the Medicines Control Council, accounts and reports submitted to the Compensation Fund for occupa-tional injuries and diseases and the Road Accident Fund system. Openness also means that it be disclosed exactly on what legal basis one is compelled to pass confidential information on to a third party, and a statement that such third party then becomes a responsible party under the POPI Act, so the patient would have to direct queries to them. If the pa-tient refuses to allow these statutory dis-closures to take place, where such refusal is possible (e.g. no ICD10 code on an account to a medical scheme), the pa-tient must understand the implications thereof. This means that the scheme

will reject the account and the patient would have to pay the provider directly. In some instances it is not possible to re-fuse, e.g. when conditions are reportable under law, such as measles and cholera

• Security safeguards means that entities holding personal information must take steps to prevent loss, damage, and un-authorised and unlawful access of the information they hold

• Data subject participation

The POPI Act elevates the information relat-ing to a person’s health, as well as informa-tion relating to children, as “special” infor-mation. Processing of this information (i.e. holding, collecting, using or sharing this infor-mation) is, in general, prohibited. Permission from the patient, or the person authorised to consent (e.g. a parent/guardian of a children under 12 years of age) is required before the information may be collected or shared, etc.

Section 32 of the POPI Act excludes from the prohibition, medical practitioners and healthcare facilities, insurance companies and medical schemes/administrators deal with authorisations relating to health, but requires that information only be processed under a contractual duty of confidentiality.

ConclusionIn closing it is important to note that personal information refers to information that identifies or relates specifically to a member of a medical scheme, for example, the members name, age and identity number. Any information about a members health and wellness interests, their lifestyle, eating habits and nutrition, your exercise regime and all related information is also regarded as personal information. Thus in so far as a medical scheme is intending to share this information, they will be required to obtain specific consent for this, failure to do so will result in a violation of the contents and requirements as set out in the POPI Act.

Consents to sharing and disclosure of infor-mation must be specific, limited to a stated purpose, and only be used for that purpose. A medical scheme cannot therefore request information on lifestyle from a member for a rewards programme and then share such information to insurers. It must make clear when and how information will be destroyed and when further processing takes place, a new consent would be required, or it should be part of the initial consent.

The nature and extent of the processing of information may also be challenged, as well as whether the processing was “reasonable”, or in some cases “necessary”.

References available on request.


he pancreas is effectively two glands intimately mixed together to form one organ.1 The resulting outcome is that it has both an en-

docrine and exocrine function. Glucose ho-meostasis is achieved through the production of glucagon, insulin, and somatostatin (endo-crine) and digestion is aided through the se-cretion of enzymes and other substances (such as sodium bicarbonate) directly into the intestinal lumen (exocrine).2 Many factors help to regulate the endo and exocrine secre-tions from the pancreas including neural and hormonal responses as well as the presence and composition of ingested food.2

Pancreatic surgery may be carried out for a variety of reasons, including benign or malignant diseases of the pancreas, duodenum and distal common bile duct.3 It remains the only curative treatment for pancreaticobiliary tumours.4 They are considered one of the most challenging operations because of the magnitude of the dissection and resection and as a result there is an extreme stress result in the body with a relatively high morbidity rate.5 As the survival of those with pancreatic malignancies is poor the implications of the surgery on long term health/ nutritional status is not always planned for. However, for curatives surgery or resections carried out for benign diseases, it is vital that the long term implications be considered, as poor nutritional status due to decreased intake and increased catabolism5 is associated with poor quality of life and reduced survival.3

Short term nutritionFirstly, nutritional status should be as-sessed by a multi-disciplinary team4 as part of the routine pre-operative assessment, as malnutrition (including weight history/recent weight loss and body mass index)5 is a known risk for surgery-related compli-cations.5,6 Various nutrition screening tools such as the subjective global assessment (SGA), malnutrition universal screening tool (MUST) and nutritional risk index (NRI)4 as well as biochemical markers are used to screen for malnutrition pre-operatively, with no one tool being more relevant or accurate

than the other.5 A malnourished patient will exhaust their nutritional reserves quickly and will thus compromise optimal recovery and healing. In addition to this sarcopenia and sarcopenia obesity (loss of muscle with a marked increase in visceral adipose)7 should also be evaluated as they are strong predic-tors of both short and long term outcomes. Preoperative nutritional support should be seriously considered if at least one of the fol-lowing criteria is met: • Weight loss > 15% within 6 months• BMI < 18.5 kg/m2 • Subjective global assessment (SGA)

grade C or nutritional risk score > 5, or • Serum albumin < 30 g/L (with no evi-

dence of hepatic or renal dysfunction)5

These parameters indicated malnutrition as well as disease associated catabolism. Take note that hypoalbuminemia is an indication of disease severity rather than just the lack of protein/ nutritional intake.5

There are various type of pancreatic resections with each having a different impact on the digestive system. However, the available data does not show any definitive nutritional advantages of one type of resection over another.5 Historically, oral feeds were discouraged in the immediate post-operative period but current evidence shows that this is not necessary in a clinically stable patient (even those with clinically irrelevant post-operative pancreatic fistulas). Early introduction of oral feeding after an operation is encouraged by protocols such as the enhanced recovery after surgery (ERAS) protocol as it has been found to reduce catabolism and reduce morbidity.5 Multiple studies have illustrated that this is a safe and feasible option with pancreatic surgery.5,8 The physiological passage of food/liquid through the gastrointestinal tract may also induce the secretion of incretin which will help regulate glucose metabolism.5 In the case of pre-operative malnutrition, those at a high risk of developing post-operative malnutrition, those with severe post-operative complications or clinically relevant pancreatic fistulas as well as well-nourished patients who do not tolerate at least 50% of their calorie and protein requirements by day 7 (post-op), may require specialised/ artificial nutrition and nutritional counselling. Bearing in mind that enteral nutrition is always the preferred route of feeding over parenteral nutrition because of the lesser incidence of infection and overall complications as well as faster recovery of digestive function and nutritional status and lesser cost.5

Long term nutritionPancreatic exocrine insufficiency (PEI) is a common long term complication amongst resection patients as well as pancreatic can-cer and chronic pancreatitis patient3 and is often undertreated.3 PEI is defined as “a con-dition in which the amount of secreted pan-creatic enzymes is not enough to maintain normal digestion”.5 PEI can lead to the mal-absorption of all macronutrients (fat, carbo-hydrates and proteins).3 This is contrary to the traditional focus, which was always on fat malabsorption only. This, together with the fact that diagnostic tests for PEI have a low sensitivity3,5 has led to unnecessary di-etary fat restrictions and delayed or absent enzyme supplementation and/ or profession-al dietary advise. PEI can be caused by a va-riety of factors including but not limited to:3

• Asynchrony of delivery of enzymes and bile

• Abnormal cholecystokinin (CCK) secretion

• Obstruction of the pancreatic anastamosis

• Changes in gut pH due to resection of the duodenum and distal stomach

• Lack of pancreatic stimulation due to secondary PEI caused by gastric and duodenal resection

• Use of inhibitory/ constipating medications

Clinical symptoms of PEI should be noted, these include:3,5,9

• Abdominal symptoms (please note that severe malabsorption can occur in the absence of abdominal symptoms)

– Bloating, distention and flatulence – Steatorrhoea (accepted as a late

symptom of malabsorption) – Diarrhoea – Faecal urgency – Reflux – Cramping abdominal pain and ab-

dominal gurgling – Delayed gastric emptying

• Endocrine function – Hypoglycaemia and hyperglycemia – Reduced insulin requirements (for

those already on insulin therapy)• Biochemical symptoms

– Vitamin A, D, E and K deficiencies – Low serum selenium, zinc, magne-

sium, calcium, phosphate, potassium – Elevated parathyroid hormone due

to vitamin D deficiency• Osteopenia/ osteoporosis• Nutritional symptoms

– Unexplained weight loss (adequate intake and in the absence of non-in-

Nutrition and pancreatic surgery. Short and long term goals

Ms Abby Courtenay RD (SA)Oxford Healthcare CentreSaxonworld orRegus Business Centre, Parkmore Johannesburgwww.abbythedietitian.co.za


fective diarrhoea) – Poor appetite/early satiety – Sarcopenia/cachexia – Weakness/fatigue – Food avoidance possibly linked to

bowel symptoms• Other

– Non-alcoholic fatty liver disease (NA-FLD) due to malabsorption of essential amino acids (such as choline) which impact apoprotein-B levels and subse-quently very-low density lipoproteins as well as insufficient insulin secretion leading to enhanced lipolysis and in-creased hepatic free fatty acid uptake and a subsequent fatty liver.

If left untreated, PEI will have a devastating effect on the patients nutritional status and on their quality of life and the resulting ca-chexia may also lead to poor survival rates.5

Pancreatic enzyme replacement therapy (PERT)PERT contains the enzymes needed for optimal digestion including a mix of lipase, amylase and protease.5 Current consensus indicates that PERT should be routinely initiated after a pancreatoduodenectomy or in patients with locally advanced pancreatic disease and should be continued/ trialled for at least 6 months.5 If a patient does not respond to PERT, bile acid malabsorption (BAM) or small intestinal bacterial overgrowth (SIBO) should be considered as their symptoms are usually difficult to distinguish from PEI.3 Once a PEI diagnosis has been confirmed, PERT should be prescribed with all meals, snacks and supplemental sip feeds with the dose depending on the portion size and energy density of the meal. The patient should be educated on how to adjust their PERT dose independently and this dosage should be reviewed regularly. It is unlikely that a patient will overdose of PERT and more likely that they will be taking an inadequate dose.5 Remember that the absence of overt steatorrhoea does not indicate optimal PERT and adequate absorption.5 Patients who require full enteral feeds should be prescribed semi-elemental peptide and triglyceride based feeds together with PERT (being careful not to clog the feeding tube) or an elemental feed (in this case PERT is not necessary). Practically, PERT should be consumed during or directly after a meal,5 with cold fluid and it should not be stored in hot conditions or direct sunlight (15-25ºC). To prevent excessive and irreversible denaturing the enzymes by the stomach acid, gastric acid suppression may be necessary.3 This being said, PERT does require a pH of >5.5 in order to be activated and so careful monitoring may be needed to get best results (prevention of rapid or delayed activation).

Pancreaticogenic diabetes (or type 3c diabe-tes) often occurs in patients with pancreatic disease, thus all patients with pancreatic dis-ease should be routinely screened for diabe-tes (HbA1C as well as glucose levels should be checked before and after the initiation of PERT).3,10 Once PERT is initiated, blood sug-ar levels are expected to rise and thus oral medications and/ or insulin therapy should be adjusted accordingly.3

Nutritional therapyLow fat diets have traditionally been the ‘go-to’ for malabsorption symptoms. The problem with this is that whilst it may reduce steatorrhoea symptoms, it will not correct the malabsorption of nutrients, merely mask it. Low fat diets are no longer recommended for the management of PEI due to the negative effect on nutritional status.3 A dietitian with a special interest in pancreatic resections should be consulted to create an individualised plan for your patient. If the patient is nutritionally compromised, this will include recommendations on how to follow a high energy diet as well as practical hints and tips on how to fortify foods appropriately as well as advice on supplemental sip feeds (where necessary).3 As the duodenum is essential for the absorption of certain vitamins and minerals, deficiencies after a resection including the duodenum have been reported. The most common deficiencies being zinc, selenium, iron and fat soluble vitamins A, D, E and K.3 Thus, routine supplementation of trace mineral and fat soluble vitamins should be recommended and all patients with pancreatic disease should have a bone mineral density scan yearly (due to high prevalence of vitamin D deficiency and its known correlation with bone health).3

References1. Pancreas Function [Internet]. Pathology.

jhu.edu. 2018 [cited 29 August 2018]. Available from: http://pathology.jhu.edu/pancreas/basicoverview3.php?area=ba

2. Mahan L, Raymond J. Krause’s food & the nutrition care process. 14th ed. St. Louis, Missouri: Elsevier; 2017.

3. Phillips M. Pancreatic Resection: Nutrition-al Implications and Long Term Follow Up. PRACTICAL GASTROENTEROLOGY [In-ternet]. 2016 [cited 29 August 2018];150. Available from: https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-March-2016.pdf

4. Pancreatic cancer surgery and nutrition management: a review of the current lit-erature. Hepato Biliary Surgery and Nutri-tion. 2015;1(4):59-71.

5. L. Gianotti et al., Nutritional support and therapy in pancreatic surgery: A posi-tion paper of the International Study

Group on Pancreatic Surgery (ISGPS), Surgery (2018), https://doi.org/10.1016/j.surg.2018.05.040

6. Berry A. Pancreatic Surgery. Nutrition in Clinical Practice. 2013;28(3):330-357.

7. Buscemi S, Damiano G, Palumbo V, Spinelli G, Ficarella S, Monte G et al. En-teral Nutrition in Pancreaticoduodenec-tomy: A Literature Review. Nutrients. 2015;7(5):3154-3165.

8. Sandini M, Bernasconi D, Fior D, Molinelli M, Ippolito D, Nespoli L et al. A high vis-ceral adipose tissue-to-skeletal muscle ratio as a determinant of major complica-tions after pancreatoduodenectomy for cancer. Nutrition. 2016;32(11-12):1231-1237.

9. Scholten L, Mungroop T, Bengt van Ri-jssen L, Issa Y, Busch O, Besselink M. New-onset pancreatogenic diabetes (type 3c) after pancreatoduodenecto-my: A systematic review. Pancreatology. 2016;16(3):S21-S22.

10. Kim E, et al., Influence of preopera-tive nutritional status on clinical out-comes after pancreatoduodenectomy, HPB (2018), https://doi.org/10.1016/j.hpb.2018.05.004

Take-home message

• A patients pre-operative nutritional status should be assessed by a multi-disciplinary team. Consider creating a referral system with a dietitian who has a special interest in pancreatic health.

• Early post-operative oral feeding is indicated for clinically stable patients to reduce catabolism, morbidity and may also improve blood glucose control.

• PEI is a common long term complication and is often undertreated. If left untreated will have devastating effects on the patients nutritional status, quality of life and survival rate.

• PERT should be routinely initiated after PD or in patients with locally advanced pancreatic disease and trialled for 6 months. If PERT is unsuccessful, extra pancreatic factors should be considered as the cause of symptoms.

• PERT should be prescribed for all meals and snacks and the dose should be individualised and reviewed regularly (monitoring for underuse rather than overuse).

• Screen all PD patients for diabetes, osteoporosis and nutritional deficiencies (especially trace elements and fat soluble vitamins).

• Avoid unnecessary dietary restrictions as this will impact the patients nutritional status.

Disclaimer: The views and opinions expressed in these articles were in no way influenced by Abbott Laboratories

References: 1. Domínguez-Muñoz JE. Pancreatic exocrine insufficiency: diagnosis and treatment. J Gastroenterol Hepatol 2011;26 Suppl 2:12–16. 2. Creon® 25000. Approved package insert February 2016. 3. Creon® 10000. Approved package insert September 2005. 4. Solvay Pharmaceuticals. NDA 20-725 for Creon® (Pancrelipase Delayed-release Capsules) Briefing Document for December 2, 2008 Antiviral Drugs Advisory Committee.S1 Creon® 10000. Each capsule contains enteric coated granules of Pancreatin 150 mg. Registration Number: South Africa 33/11.1/0340. Namibia 04/11.1/1015. S1 Creon® 25000. Each capsule contains enteric coated granules of Pancreatin 300 mg. Registration Number: South Africa 28/11.1/0645. Namibia 04/11.1/1016.

For full prescribing information refer to the package insert approved by the Medicines Regulatory Authority. Abbott Laboratories S.A. (Pty) Ltd. 1940/014043/07. Abbott Place, 219 Golf Club Terrace, Constantia Kloof, 1709.Tel: (011) 858 2000. Publication Date: October 2018. Promotional review number: ZAECRE180101

CREON® MAKES MEALTIMES SMILE TIMES

Little people need lots of energy to grow, play and learn – which is why healthy eating is so important.

In paediatric patients with cystic fibrosis, suffering from pancreatic enzymeinsufficiency (PEI), choose Creon® to help ensure the digestion of:1,2,3


fats proteins carbohydrates

Creon® is the only pancreatic enzyme replacementtherapy (PERT) with more than 5 million patienttreatment years of experience.4

1259

7

12597 Creon Con Ad CF.indd 1 2018/10/24 17:52

Abbott Laboratories S.A. (Pty) Ltd, Reg. No. 1940/014043/07, Abbott Place, 219 Golf Club Terrace, Constantia Kloof, 1709. Tel No.: 011 858 2000. Date of Publication: November/December 2018. Promotional Review number ZAECRE180262.

cpd accredited - mpc · 2018-12-10 · 5 vol 1 no 1 - november/december 2018 of the tumour on...

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