Pancreatic Cancer. Landelijke richtlijn, Versie: 3.0

Transcription

1 Pancreatic Cancer Landelijke richtlijn, Versie: 3.0 Laatst gewijzigd : Methodiek: Consensus based Verantwoording: Dutch Dieticians Oncology Group

2 Inhoudsopgave General...1 The Untreated Patient...2 Nutritional Status...2 Steatorrhea...2 Obstruction...3 Diabetes Mellitus...4 Surgery...6 Nutrition Intervention...6 Delayed Gastric Emptying...7 Steatorrhea...8 Dumping Syndrome...8 Diabetes Mellitus...9 Suture Leakage...10 Chyle Leak...10 Chemotherapy...12 Recovery and Rehabilitation...13 Palliative Care i

3 General The Dutch Dietitians Oncology Group (DDGO) guidelines for pancratic cancer outline tumor specific nutritional therapy. For general nutrition treatment guidelines and common nutrition related problems see the General Nutrition and Dietary Intervention Guidelines. 10/08/18 Pancreatic Cancer (3.0) 1

4 The Untreated Patient This chapter is divided into subchapters and/or paragraphs. In the left column, click on the subchapter and/or paragraph title to view the contents. Nutritional Status 80% of patients have a reduced diet at time of diagnosis. Unintended weight and muscle loss with pancreas cancer is due to cachexia as a result of metabolic dysregulation in combination with a reduced intake and increased losses. Prior to diagnosis, many patients present with malaise complaints including fatigue, anorexia, quick satiety, taste and smell changes, and a reduced appetite. Pain, nausea or vomiting can also lead to a reduced intake. Digestive and absorption complications including steatorrhea can occur with pancreatic insufficiency as insufficient pancreatic enzymes are supplied to the intestines for digestion. If the tumor blocks the ductus choledochus or the ductus pancreaticus, insufficient digestive enzymes (bile and/or pancreatic juice) are secreted into the intestine which causes disruption in the digestion of fat. Indications suggest that these symptoms are progressive with irresectable tumors. Prevalence varies from 50 to 100% in the literature, depending on how exocrine pancreatic insufficiency is measured. Postoperatively, digestion and resorption can improve as a result of better bile and pancreatic secretion through the new anastomoses. Nutritional status can rapidly deteriorate with exocrine pancreatic insufficiency. Assess the nutritional status. Assess whether there are food-related symptoms present that increase the risk of malnutrition an unfavorable body composition. Assess if the patient would benefit from nutritional care. Determine the nutrition intervention goals. Discuss intake in relation to requirements, weight changes and determine body composition if necessary. Discuss bowel habits. Explain the role of pancreatic enzymes in digestion and the nutritional status. If needed initiate pancreatic enzyme supplementation. Match pancreatic enzyme supplementation to intake (fat). Keep in mind remaining pancreatic function. Discuss with the patient the relationship between nutritional status, disease, and treatment. Evaluate intake and symptoms, and determine target weight and if possible body composition If possible, encourage physical activity preferable under supervision of a (oncology) physiotherapist. In complex situations consult a rehabilitation or sports physician Evaluate if nutrition intervention goals are being achieved. Protein enrichment. Energy: Resting energy expenditure plus additional factors. Other nutrients according to general recommendations. See applicable Symptoms. Steatorrhea Steatorrhea (fatty diarrhea) can be caused through a decreased production of digestive enzymes due to pancreatic tissue function loss. Digestive enzymes produced in the pancreas include amylase, protease and lipase. These enzymes are needed for carbohydrate, protein and fat digestion, respectively. The tumor can also cause impediment to the secretion of these enzymes. In both situations, there is a reduced availability of digestive enzymes in the small intestine. These causes can also lead to an insufficient amount of bicarbonate (produced in the pancreas). Bicarbonate plays a role in the neutralization of gastric acid, as enzymes function best in a basic environment. Steatorrhoea can also be caused when a blockage 10/08/18 Pancreatic Cancer (3.0) 2

5 of bile is present. Bile is necessary for the emulsification of fat in the intestine. Unlike the digestion of carbohydrates and proteins, the digestion of fats is almost entirely dependent on the lipase produced in the pancreas. Lipase is the most acid-sensitive digestive enzymes. Due to the reduced availability of bicarbonate, intestinal content becomes rapidly acidic which decreases lipase activity. Digestive disorders usually manifest first as abdominal pain, gas formation and steatorrhea. The patient may have a more frequent and a higher volume of fecal output. Stool is often greasy and sticky. With decreased bile in the small intestine, stool can change in colour. Steatorrhea can be stressful to the patient and can adversely affect the quality of life. When clinical symptoms of steatorrhea are present, measurement of the quantitative fat in faeces can confirm the diagnosis of exocrine pancreatic insufficiency. Fecal elastase-1 can also be measured to demonstrate exocrine pancreatic insufficiency. Elastasis is less sensitive to, among other things, accelerated intestinal passage. Both measurements together give a good insight into the absorption capacity. Due to poor absorption of fats, there is a risk of deficiency of fat-soluble vitamins A, D, E and K. Consult with the physician regarding pancreatic enzyme supplementation. Consult with the physician if additional medication is required for gastric acid inhibition. Inform the patient about the amount and use of enzyme supplementation in relation to the amount of fat consumed. With persistent steatorrhea: monitor fat-soluble vitamins blood levels in consultation with the physician. Richtlijn: Pancreatic Cancer (3.0) Protein and energy in according to calculated nutrition requirements; Avoid limited fat foods. Distribute pancreatic enzyme intake in between meals, depending on the fat intake per meal. Also advise to consume with midday meals if they contain fat. Adjust the dosage based on evaluation of bowel movement pattern. Supplement fat-soluble vitamins when deficiency is present. Obstruction Gastrointestinal obstruction: The duodenum can be obstructed due to tumour growth, increasing the difficulty of bolus passage. If the patient is no longer treated curatively, a nutritional stent can be placed, which (temporarily) eliminates the obstruction. With time, the stent can eventually be closed off due to tumour growth. Depending on the prognosis, a bypass operation can be considered. See Stent. Bile duct obstruction: The liver produces ml bile per day. Upon occlusion of the bile ducts, bile builds up in the gallbladder or liver resulting in insufficient bile release for the emulsification of fat. Due to the accumulation of bile in the liver, liver function complications and cholangitis can occur. Symptoms and signs of bile duct obstruction include nausea, itching, jaundice, dark urine, decolorized stools and steatorrhea. Routinely inserting internal or external stents or draining is not frequently preformed due to possible postoperative complications. Indications for drainage include cholangitis, severe jaundice (serum bilirubin> 250 µmol/l) and severe malnutrition. Preferred solutions include internal drainage with endoprosthesis or Endoscopic Retrograde Cholangio-Pancreatography (ERCP). Pancreatitis (5-10%) is the most important complication. When internal drainage is not possible, an external percutaneous biliary drainage: percutaneous transhepatic cholangiography and biliary drain (PTC), can be used. Bile losses via the PTC drain can be large, disturbing the fluid and electrolyte balance. This is considered when the entire amount of bile is drained. In addition, duodenal secretions are also drained via a PTC drain. Bile can be returned to the body via a nasal gastric or duodenum tube. Return of bile via the stomach is not preferred because this can result in an increased risk of developing gastritis. Uncoloured stool is a sign of insufficient bile flow to the intestine and can indicate the need for bile return as well as restoration of the fluid and electrolyte balance. The purpose of returning bile is to rebalance fluid and electrolytes, as well as to restore the enterohepatic cycle. There is discussion about the usefulness of returning bile. There is 10/08/18 Pancreatic Cancer (3.0) 3

6 therefore no national consensus on timing and amount. A low-threshold return via a feeding tube can be used if there is already a tube in place. Inquire about drainage method (internal or external) and determine potential losses. Assess if the patient would benefit from nutritional care: If a stent is placed, no additional intervention is required. Use protein-enriched food to optimize nutritional status prior to any surgery. Discuss weather bile return is necessary. Richtlijn: Pancreatic Cancer (3.0) Small frequent meals. A fat restriction is usually not necessary. Consider fat in emulsified form, such as butter and margarine, instead of oil. If more energy is required, preferably consume extra protein and carbohydrates instead of more fats. Vitamin A, D, E and K supplementation if deficiencies arise. Strive for an adequate fluid and electrolyte balance. Additional fluid and electrolytes such as sodium, should be if possible consumed with food, if not possible infusion should be considered. Start polymer feeding and upon indication (eg. steatorrhea) oligomeric (semi-elementary) tube feeding. Diabetes Mellitus A tumor in the tail of the pancreas can lead to diabetes mellitus. The endocrine secretion of both insulin and glucagon decreases, reducing the body's ability to compensate for high and low blood sugar levels. Some patients have pre-existing diabetes prior to the pancreatic cancer diagnosis. Diabetes treatment in pancreatic cancer is aimed at preventing high and low blood glucose levels. Oral blood glucose lowering agents and insulin are often required. Control of glucose levels is often seen as less important, however, there are indications that having a better blood glucose level control (between 4-8 mmol/l) may reduce complications after surgery. In addition, complications are discovered earlier, as glucose levels deteriorate with symptoms including fever and infection. Both hyperglycaemia and hypoglycaemia can reduce a patient s well-being. If the patient does not have proper control over blood glucose levels, energy (carbohydrates) is excreted through the urine. Nutritional intervention is typically cardiovascular disease prevention, which is usually an important target of diabetes, however, with a short-term life expectancy, this is not relevant. Monitor and evaluate blood glucose control. Collect information regarding diabetes mellitus related symptoms including hypoglycaemia and hyperglycaemia. Collect a diet history focusing on carbohydrate distribution throughout the day. When insulin depended, discuss the possible effects of insulin and nutrition on blood glucose regulation. Inform the patient on how to deal with hyper and hypoglycaemia. Discuss additional check-ups with the physician, GP or nurse regarding measurement of blood glucose levels, or assess whether self-monitoring is possible. If necessary, consult regarding insulin adjustment. Assess if the proposed dietary advice is obtainable and when necessary make adjustments. When oral blood glucose lowering agents are used (potentially in combination with long acting insulin): spread meals (with carbohydrates) over the day and avoid skipping meals. When rapid or short acting insulin is used: 10/08/18 Pancreatic Cancer (3.0) 4

7 Richtlijn: Pancreatic Cancer (3.0) Adjust insulin to carbohydrate intake; Consultation to a dietitian specializing in diabetes can be considered. 10/08/18 Pancreatic Cancer (3.0) 5

8 Surgery After surgery, the patient may develop symptoms including pain, anorexia, decreased intake, nausea, vomiting and steatorrhea. Complications such as delayed stomach emptying, suture leakage and dumping syndrome occur in 30-60% of patients. About 10% of patients suffer from chyle leakage. A pancreatic duodenectomy is a high risk operation that is therefore only performed in specialized centers. Nutrition Intervention Preoperatively, a malnourished patient is feed seven to ten days with clinical nutrition to optimize nutritional status, according to the Malnutrition Guidelines for Patients with Cancer. Initiating or adjusting enzyme supplementation can help improve nutritional status. It has been shown that patients have fewer postoperative complications when early tube feeding is provided after pancreatic surgery. There are indications that enhanced recovery after surgery (ERAS) is possible with pancreatic tumors. The patient may then use early postoperative oral feeding as simply eating stimulates the entire digestive system. However, many patients have postoperative gastrointestinal dysregulation increasing the risk of inadequate nutrition, especially in case of complications, therefore tube feeding is appropriate. Parenteral nutrition postoperatively after a pancreatic duodenectomy is associated with an increase in postoperative infections, bleeding and fistula formation. There is no consensus on the optimal route of administration for tube feeding in this patient group. Many centers choose a nasal-jejunum tube or a jejunostomy placed during surgery. A jejunostomy lead to a higher risk of complications (4%), but a nasal-jejunum tube can dislocate easily. In the early postoperative days, a dislocated nasal-jejunum tube can not be replaced endoscopically due to the risk of suture leakage. During a gastroscopy, a lot of pressure is put on the on the newly created links. Placing a feeding tube in the stomach does not make sense with gastrointestinal dysfunction. Postoperatively, exocrine pancreatic insufficiency can also occur. When polymeric tube feeding is insufficiently digested, an oligomeric (semi-elementary) feed should be considered. Difficulties often arise when a patient is able to progress to oral intake: pain, anorexia, and complaints with a full feeling. Stomach function return is regularly delayed, which poses a risk dumping syndrome and there is often a lack of pancreatic enzymes. An enzyme shortage also occurs if (temporarily) somatostatin is to be used when at risk for suture leakage. Somatostatin inhibits the formation of the digestive enzymes insulin and glucagon, inhibits the secretion of stomach acid and hormones produced in the gastrointestinal tract, and reduces blood supply to the intestines. The production of gastrin, cholecystokinin and secretin is also reduced, resulting in less pancreatic bicarbonate and enzyme secretion leading to insufficient neutralization of gastric acid secretion. Pancreatic enzyme supplementation is an essential part of post-operative nutrition treatment. Determine the patient s energy, protein, fluid, and other nutrient requirements. Determine the nutrition intervention goals. Discuss with the patient the nutrition-related symptoms that can occur after surgery and provide information over adjusted nutrition measures if these symptoms arise. Assess oral intake and monitor tube feeding progression. Adjust nutritional intervention only after evaluation. Initiate tube feeding (naso-gastric tube) immediately with insufficient intake. If a nasal-jejunum tube is necessary (with gastric retention), this can only be inserted 7 days after surgery due to the risk of suture leakage with an early postoperative endoscope. Short term parenteral nutrition can be considered, however its appropriateness is a national topic of discussion. Inquire about colour, frequency and consistency of stool. Consult with the physician about initiation of enzyme supplementation when steatorrhoea is present and explain the relationship between enzymes and nutrition to the patient. Adjust the dosage and/or the distribution of enzymes based on nutritional intervention. Monitor weight and body composition regularly. Note: Patients often receive pre-and postoperative infusions. Fluid retention of 5 to 10kg is common. Weight is therefore postoperatively a less reliable measure of nutritional status. If possible, encourage physical activity preferable under supervision of a (oncology) physiotherapist. 10/08/18 Pancreatic Cancer (3.0) 6

9 Evaluate if nutrition intervention goals are being achieved. Richtlijn: Pancreatic Cancer (3.0) Protein enrichment. Energy: Resting energy expenditure plus additional factors. Other nutrients according to general recommendations. Follow a protein and energy enriched diet a least 3 months post surgery or until target weight has been reached. Small frequent meals spread out over the day. Eat mindfully and chew foods thoroughly. Distribute pancreatic enzymes over meals, depending on fat intake per meal. Advise to also consume enzymes with snacks if they contain fat. Adjust dosage based on the bowel habits. If inadequate intake: Full or supplementary polymer tube feed or, in the event of signs of digestive disorders: oligomeric feeds. Polymer feed with enzyme supplementation is possible, but there is no consensus about the dosage and distribution of enzymes with continuous tube feeding. Supplement fat-soluble vitamins when deficiencies arise. Strive for an adequate fluid and electrolyte balance. Supplement electrolytes if necessary. See Symptoms. Delayed Gastric Emptying Delayed gastric emptying (gastroparesis) is the most common complication affecting dietary intake after a pancreatic duodenectomy. Gastroparesis is suggested when a stomach siphon needs to be placed 4 to 7 days after surgery because oral nutrition is insufficiently tolerated. Food entering the stomach builds up and is often vomited out as the stomach is not able to move food further into the gastrointestinal tract. Even without consumption, a build up of gastric acid and saliva can occur eventually leading to vomiting. Symptoms of gastroparesis include, a constant feeling of fullness, nausea and repeated vomiting which are annoying for the patient, have an impact on nutritional status, and increase morbidity (aspiration pneumonia and a longer hospital length of stay). The physiology of gastric emptying and motility is a very complex system and is influenced by the combination of the consistency, osmolarity and volume of food. Delayed gastric emptying can be stimulated by orally consuming food in portions and not continuously taking small sips and bits throughout the day. Surgical removal of the duodenum and cutting of the vagus nerve also affect the physiology of gastric emptying after a pancreatic duodenectomy due to the influence of gastrointestinal hormones. Delayed gastric emptying is associated with the occurrence of other postoperative abdominal complications including a pancreatic fistula. Preoperatively existing diabetes is also associated with delayed gastric emptying. The more serious the complications, the more often gastroparesis occurs. When no complications are present after surgery, only 1% of patients experience delayed gastric emptying. This increases to 28% with mild complications such as wound infection, and up to 43% when severe complications are present including anastomosis leakage, bleeding or sepsis. With severe vomiting, a stomach siphon is introduced which removes stomach contents while an IV is placed or tube feeding is started or restarted but further then the stomach. If tube feeding is needed in combination with stomach siphoning, a double tube can be used which suctions out of the stomach and fees into the jejunum. A disadvantage of a double tube is that the feeding tube portion can easily become dislodged, leading to inadequate feeding. Symptoms recover quickly, within two to six weeks, however depending on the complications, symptoms can last for much longer. Find out if the patient can and may use oral nutrition or is if tube feeding is advised. Consult the physician regarding the use of medication such as anti-emetics, laxatives and prokinetics. Discuss with the patient portion size and distribution of food throughout the day if oral nutrition is possible with gastric retention. Monitor fluid and electrolyte balance. Hypokalemia often occurs with gastroparesis, however, other electrolytes should also be monitored to prevent deficiency. Evaluate if nutrition intervention goals are being achieved. 10/08/18 Pancreatic Cancer (3.0) 7

10 Richtlijn: Pancreatic Cancer (3.0) With oral intake: Small frequent meals; do not consistently eat and avoid taking small sips and bites throughout the day. Strive for portion eating; Mindful eating, chew food thoroughly; Avoid high fat and protein foods; Avoid high fibre foods. When oral intake is inadequate: Start or restart tube feeding to the jejunum; Start polymer tube feeding; In the event of a digestive disorder, oligomeric or polymeric tube feeding with enzyme supplementation can be suggested. Steatorrhea The main cause of postoperative steatorrhea is the loss of active pancreatic tissue due to surgery thereby reducing the production of digestive enzymes and bicarbonate. After removal of the gall bladder and the altered junction of the bile ducts on the jejunum, patients often experience green bile rich feces as the bile is not mixed with the food. Steatorrhea can also occur postoperatively due the use of somatostatin. Additionally, pancreatic enzymes are not synchronized with the food in the intestine and therefore no not function adequately. This missing synchronization can occur with both a non-pyloric preserving and pyloric preserving pancreatic duodenectomy. Postoperatively, a third of patients need immediate pancreatic enzyme supplementation, and eventually approximately two thirds of patients develop the need for supplementation. After a pancreatic duodenectomy, acidity levels in the stomach may become too high due to gastric acid inhibition and/or too low in the intestine due to decreased bicarbonate to buffer the stomach acid. The pancreatic enzyme capsule will not dissolve adequately in this case and must be broken open to allow optimal release of the enzymes. With a total pancreas removal, digestive complications always develop and enzyme supplementation is always necessary. A severe fat restriction is also not indicated in this situation. Consult with the physician regarding pancreatic enzyme supplementation. Consult with the physician if additional medication is required for gastric acid inhibition. Inform the patient about the amount and use of enzyme supplementation. With persistent steatorrhea: monitor fat-soluble vitamins blood levels in consultation with the physician. Do not limit fat intake. Distribute pancreatic enzyme intake between meals, depending on the fat intake per meal. Also advise to consume with midday meals if they contain fat. Break up enzyme capsules if necessary and mix the content with something, such as apple juice, orange juice or yogurt. Opening of the capsules is needed when there is a presence of swallowing complications, inadequate enzymes action at the recommended dosage, and altered gastric acidity. Do not chew on capsule contents, as this may cause irritation of the mucous membranes. With tube feeding: oligomer feeds with out enzymes or polymer feeding with enzymes. Supplement fat-soluble vitamins when deficiency is present. Dumping Syndrome In both a non-pyloric preserving pancreatic duodenectomy (whipple procedure) and a pyloric preserving pancreatic duodenectomy, dumping syndrome may develop due to accelerated gastric emptying. Treatment for early and late dumping syndrome is different. Most patients experience early dumping 10/08/18 Pancreatic Cancer (3.0) 8

11 syndrome. Early dumping syndrome symptoms include feeling bloated/full, abdominal pain, intestinal cramping, diarrhea, palpitations, dizziness, weakness and drowsiness. This occurs half an hour to an hour after consuming a meal as the food bolus enters the intestine at an accelerated rate leading to an hypertonic environment. This draws fluid from the blood vessels to the intestine, resulting in a reduced plasma volume. Late dumping syndrome symptoms occur one and a half hours after consuming a meal due to hypoglycaemia caused by enhanced insulin delivery and intestinal hormones entero-glucagon and gastric inhibitory polypeptide (GIP). Late dumping is characterized by perspiration, trembling, weakness, concentration complications, confusion and hunger. Collect a diet history focusing on volume, frequency and speed of eating and drinking moments in a day, use of milk products, mono- and disaccharides, and the use of solid and liquid products together. Ask about the length of the dumbing syndrome symptoms experienced. Inform the patient about the necessary dietary adjustments. Richtlijn: Pancreatic Cancer (3.0) Mindful eating, chew food thoroughly; Six to nine small meals a day. Limit fluid intake in combination with solid foods (none of maximum one beverage with a meal). Avoid, or limit to two or three glasses of milk and milk products throughout the day. Acidic milk products are often better tolerated due to the lower lactose content. Limit consumption of mono- and disaccharides: especially in liquid form as these can cause symptoms (soda, lemonade and fruit juice). Diabetes Mellitus Postoperatively, diabetes mellitus can result from loss of active pancreatic tissue due to the resection. This occurs particularly and frequently after a resection of (part of) the pancreatic tail and less often after a resection of the pancreatic head. With a total pancreatectomy, diabetes mellitus always develops and insulin treatment needed. This diabetes mellitus is difficult to adjust. Increased blood sugar directly after surgery may be due to preoperative late diabetes but can also be associated with postoperative stress or the use of octreotide (which inhibits the production of insulin and glucagon), and is therefore temporary. Varying postoperative blood sugar levels occurs when insulin is used in combination with a varying dietary intake, impaired gastric emptying, vomiting and postoperative stress. Early postoperative hyperglycemia is associated with postoperative complications following a pancreatic duodenectomy. If the patient frequently experiences hyperglycaemia, carbohydrates are excreted through the urine. Immediately after surgery, it is therefore important to monitor and regulate blood glucose. The counter regulation by reduced glucagon delivery is impaired, which can cause hypoglycaemia with excessive regulation. The endocrine secretion of both insulin and glucagon is disturbed, which lead to a decreased compensation by the body with low blood sugar. Monitor and evaluate blood glucose control. Collect information regarding diabetes mellitus related symptoms including hypoglycaemia and hyperglycaemia. Collect a diet history focusing on carbohydrate distribution throughout the day. When insulin depended, discuss the possible effects of insulin and nutrition on blood glucose regulation. Inform the patient on how to deal with hyper and hypoglycaemia. Discuss additional check-ups with the physician, GP or nurse regarding measurement of blood glucose levels, or assess whether self-monitoring is possible. If necessary, consult regarding insulin adjustment. Assess if the proposed dietary advice is obtainable and when necessary make adjustments. 10/08/18 Pancreatic Cancer (3.0) 9

12 Richtlijn: Pancreatic Cancer (3.0) When oral blood glucose lowering agents are used (potentially in combination with long acting insulin): spread meals (with carbohydrates) over the day and avoid skipping meals. When rapid or short acting insulin is used: Adjust insulin to carbohydrate intake; Consultation to a dietitian specializing in diabetes can be considered. Suture Leakage Postoperative complications after pancreatic surgery occur in 30-60% of patients and are often the result of pancreatic anastomosis leakage, which causes gastric acid, intestinal enzymes, gall, pancreatic secretions or food to freely enter the abdominal cavity. In patients at high risk of suture leakage, prophylactic perioperative somatostatin (or analogue) is given to inhibit the formation of digestive enzymes, insulin and glucagon. The protocol depends on the type and extent of leakage. With slight leakage, percutaneous drainage may suffice. Nutrition intervention can include nothing per os, polymeric or oligomeric tube feeding beyond the anastomosis or parenteral nutrition. Chyle Leak Due lymph vessels damage, 3 to 15% of patients can develop chyle leakage after surgery which manifests itself as chyle accumulation in the abdominal cavity. A drain is often placed during surgery when milky fluid is present as an indicator of chyle leakage. Diagnosis is made based on excess drainage and an increased triglyceride content (> 1.24 mmol/l) or increased chylomicron percentage in the drainage fluid. Elimination of long chain triglycerides (LCTs) reduces triglycerides in the lymphatic system, which reduces drainage and brightens the color of drained fluid. The diet can be enriched using medium chain triglycerides (MCTs) to supplement energy intake. MCTs are absorbed directly outside the lymphatic system via the portal system. With severe leaks (> 1,000 ml per 24 hours), when drain volume decreases insufficiently even with restriction of LCTs, low-fat tube feeding, NPO or total parenteral nutrition can be considered to reduce lymph flow and compensate for losses. Literature outlines a LCT-restricted diet as the first step, followed by a strict fat-limited diet supplemented with MCT fatty acids, and as a third step, a fat-free diet or parenteral nutrition. After a pancreatic duodenectomy, one is often very reluctant to undergo surgery again. However, in the case of very severe leakage (> 1,500 ml per 24 hours drainage production over 5 days and/or a decrease in albumin content), lymphocyte decline or fluid and electrolyte imbalance, surgery is required to close the leakage if drainage and dietary changes have lead to inadequate results. Digestive complications, such as steatorrhoea, which may also occur postoperatively, are sometimes temporarily masked by the crucial LCT fat restriction. With large losses, the patient can develop fat-soluble vitamins and essential fatty acids deficiencies. Nutrition Intervention Consult the physician regarding nutrition intervention changes. Inform the patient about crucial dietary adjustments. Check the progress of the oral intake; In case of insufficient intake: initiate tube feeding or parenteral nutrition. Assess the chyle losses. Monitor the fluid and electrolyte balance. Strict LCT-restricted oral diet or MCT enriched tube feeding. Substitution of "regular" LCT by MCT, to optimize energy intake. With severe leakage, NPO, total parenteral nutrition or fat-restricted tube feeding. 10/08/18 Pancreatic Cancer (3.0) 10

13 Richtlijn: Pancreatic Cancer (3.0) If necessary, supplement additional fluid and electrolytes. Compensate for drain losses (additional energy and protein above calculated requirements): Fluid (equal to ml drainage fluid); Protein (30 g/l drainage loss); Energy in the form of fat that is lost (4-40 g/l drainage fluid). With severe leaks: supplementation of fat-soluble vitamins in water-soluble form if deficiencies arise. 10/08/18 Pancreatic Cancer (3.0) 11

14 Chemotherapy Adjuvant chemotherapy can improve survival. However, due to postoperative complications, 25% of patients fail to receive additional treatment. In metastatic disease, survival rates are low: median four to six months. Symptoms can include: Diarrhea, Taste and Smell Changes, and Nausea. 10/08/18 Pancreatic Cancer (3.0) 12

15 Recovery and Rehabilitation If the patient is discharged, he/she often only moderately eats, which does not lead to nutritional status optimization. Digestive complications sometimes only arise at a later stage when the patient begins to eat more. Rehabilitation and out-patient nutritional guidance are desirable for some time after treatment. Recommendations remain the same as during clinical treatment. Physical activity and exercise, preferably under guidance of a (oncologic) physiotherapist, is necessary for optimal recovery. 10/08/18 Pancreatic Cancer (3.0) 13

16 Palliative Care Palliative symptomatic treatment is aimed primarily at preventing obstruction of the duodenum and biliary tract though tumor growth, as well as pain reduction. Opiates use is associated with constipation and may mask digestion complication, which can adversely affect quality of life. Pain blockage of the plexus coeliacus does not result in the above mentioned side effects. When using opioids, a laxative is always needed. Nutritional Status Pancreatic cancer is one of the most cachectic forms of cancer. Severe refractory cachexia cannot be avoided with progression of the disease. With a life expectancy of more than 2-3 months, nutrition care is targeted at nutrition according to calculated nutrient requirements, taking into account the patient's desire to eat in combination with if the burden of dietary intervention outweighs the expected benefits. With a shorter life expectancy, comfort feeding is used. Obstruction Continuous tumor growth can cause biliary obstruction as well as gastrointestinal obstruction. Possibilities when bile ducts are obstructed includes placing an endoprosthesis in the bile ducts, applying a surgical bypass between bile ducts and/or a gastrojunjunostomy. A non-operable gastric stenosis eventually occurs in approximately 25% of patients with pancreatic cancer. A gastroenterostomy gives the best palliative care, but if there is a short life expectancy, a duodenum stent is usually placed. Patients can quickly eat and drink again, but after gastroenterostomy, dumping syndrome can be seen. Pancreatic enzyme supplementation In palliative treatment, pancreatic enzyme supplementation may be necessary to correct malabsorption. As the disease progresses, more exocrine pancreatic insufficiency occurs. Symptoms including a full and bloated feeling and flatulence are common. Pain and discomfort due to digestive problems can be reduced though pancreatic enzyme supplementation. 10/08/18 Pancreatic Cancer (3.0) 14

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