Nutrition and Cancer
ISSN: 0163-5581 (Print) 1532-7914 (Online) Journal homepage: http://www.tandfonline.com/loi/hnuc20
Importance of Pancreatic Enzyme Replacement Therapy after Surgery of Cancer of the Esophagus or the Esophagogastric Junction Thomas Kiefer, Dorothea Krahl, Kathrin Osthoff, Peter Thuss-Patience, Jörg Bunse, Ulrich Adam, Marc H. Jansen, Rudolf Ott, Robert Pfitzmann, Matthias Pross, Thomas Kohlmann, Georg Daeschlein, Hermann Buhlert, Heinz Völler & Carsten Hirt To cite this article: Thomas Kiefer, Dorothea Krahl, Kathrin Osthoff, Peter Thuss-Patience, Jörg Bunse, Ulrich Adam, Marc H. Jansen, Rudolf Ott, Robert Pfitzmann, Matthias Pross, Thomas Kohlmann, Georg Daeschlein, Hermann Buhlert, Heinz Völler & Carsten Hirt (2017): Importance of Pancreatic Enzyme Replacement Therapy after Surgery of Cancer of the Esophagus or the Esophagogastric Junction, Nutrition and Cancer, DOI: 10.1080/01635581.2017.1374419 To link to this article: http://dx.doi.org/10.1080/01635581.2017.1374419
Published online: 25 Sep 2017.
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Date: 27 September 2017, At: 11:54
NUTRITION AND CANCER https://doi.org/10.1080/01635581.2017.1374419
Importance of Pancreatic Enzyme Replacement Therapy after Surgery of Cancer of the Esophagus or the Esophagogastric Junction
Downloaded by [Australian Catholic University] at 11:54 27 September 2017
€rg Bunsec, Ulrich Adamd, Thomas Kiefera, Dorothea Krahla, Kathrin Osthoffa, Peter Thuss-Patienceb, Jo e f g h Marc H. Jansen , Rudolf Ott , Robert Pfitzmann , Matthias Pross , Thomas Kohlmanni, Georg Daeschleinj, €llera,k, and Carsten Hirtl Hermann Buhlerta, Heinz Vo a Department of Rehabilitation/Internal Medicine, Klinik am See, R€ udersdorf, Germany; bDepartment of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin-Franklin/Charite, Berlin, Germany; cDepartment of General and Visceral Surgery, Sana Hospital Lichtenberg, Sana Hospitals Berlin-Brandenburg, Affiliated Teaching, Hospital to the Charite, Berlin, Germany; dDepartment of Surgery, Humboldt-Klinikum, Berlin, Germany; eDepartment of Surgery, HELIOS Klinikum Emil von Behring, Berlin, Germany; fDepartment of Surgery, Waldkrankenhaus Berlin-Spandau, Berlin, Germany; gDepartment of Surgery, DRK Kliniken, Berlin-Mitte, Berlin, Germany; hDepartment of Surgery, DRK Kliniken Berlin, K€openick, Berlin, Germany; iInstitute for Community Medicine, Methods of Community Medicine, University Medicine Greifswald, Greifswald, Germany; jDepartment of Dermatology, University Medicine Greifswald, Greifswald, Germany; kCenter of Rehabilitation Research, University of Potsdam, Potsdam, Germany; l Department of Internal Medicine C, Hematology/Oncology, University of Greifswald, Greifswald, Germany
ABSTRACT
ARTICLE HISTORY
After surgical treatment of cancer of the esophagus or the esophagogastric junction we observed steatorrhea, which is so far seldom reported. We analyzed all patients treated in our rehabilitation clinic between 2011 and 2014 and focused on the impact of surgery on digestion of fat. Reported steatorrhea was anamnestic, no pancreatic function test was made. Here we show the results from 51 patients. Twenty-three (45%) of the patients reported steatorrhea. Assuming decreased pancreatic function pancreatic enzyme replacement therapy (PERT) was started or modified during the rehabilitation stay (in the following called STEAC). These patients were compared with the patients without steatorrhea and without PERT (STEA¡). Maximum weight loss between surgery and rehabilitation start was 18 kg in STEAC patient and 15.3 kg in STEA¡ patients. STEAC patients gained more weight under PERT during the rehabilitation phase (3 wk) than STEA¡ patients without PERT (C1.0 kg vs. ¡0.3 kg, P D 0.032). We report for the first time, that patients after cancer related esophageal surgery show anamnestic signs of exocrine pancreas insufficiency and need PERT to gain body weight.
Received 12 September 2016 Accepted 6 July 2017
Introduction Esophageal cancer is the 6th most common cause of cancer-related mortality worldwide (1,2). Treatment of patients with cancer of the esophagus or of the esophagogastric junction consists of surgery, radiation, chemotherapy and targeted therapy. Depending on age, stage and medical fitness one or more treatment modalities are used but for patients with localized esophageal cancer surgical resection remains the mainstay of treatment (3,4), and has a major impact on patients nutritional status. In Germany, rehabilitation is an integral part of the treatment of patients with esophageal cancer in order to restore some or all of the patient’s physical, sensory, and mental capabilities that were lost due to disease or treatment. Many patients who were admitted to our rehabilitation clinic with cancer of the esophagus or the esophagogastric junction after surgery with or without CONTACT Thomas Kiefer [email protected] 15562 R€ udersdorf bei Berlin, Germany. © 2017 Taylor & Francis Group, LLC
chemotherapy/irradiation report flatulence, diarrhea, weight loss and signs of steatorrhea (pale color, foul smell, stool is lose, bulky, and floats in the toilet bowl). Symptoms of exocrine pancreatic insufficiency like steatorrhea, are a well-known problem in patients following surgical treatment of gastric cancer, and significantly affect quality of life as well as professional and social rehabilitation (5). In contrast, there are only very few reports on pancreatic exocrine insufficiency in patients after esophagectomy (6). Here we report retrospective data of patients after surgery of cancer of the esophagus or the esophagogastric junction, who were treated during 4 years in our rehabilitation clinic.
Methods This is a retrospective analysis of all patients who were treated at our rehabilitation clinic between January 2011 Department of Rehabilitation/Internal Medicine, Klinik am See, Seebad 84,
Downloaded by [Australian Catholic University] at 11:54 27 September 2017
2
T. KIEFER ET AL.
and December 2014. We were interested in the impact of the resection of the distal esophagus with esophagogastric anastomosis on the ability to gain weight during the three weeks stay at our rehabilitation clinic. We collected data on weight loss due to disease and therapy before the start of the rehabilitation, signs of steatorrhea, initiation or dose modification of PERT during rehabilitation and appetite (patients were asked at the beginning of the rehabilitation stay, whether appetite is normal or reduced). Reported steatorrhea was anamnestic, no pancreatic function test was made. Apart from PERT initiation or modification all patients were treated in the same way and got the same dietary counselling during the rehabilitation stay (i.e. instruction in chewing well, in eating six to eight small portions and in eating highenergy-content portions). In addition, body weight at the beginning and at the end of the rehabilitation was noted and if the change of the body weight was not documented for the complete duration of the rehabilitation stay (regularly 21 days) it was projected to 21 days. In total we identified 72 patients with cancer of the esophagus or of the esophagogastric junction. Twenty-one patients were not included in the analysis for a variety of reasons. Since our aim was to study the impact of surgery on digestion of fat eight patients were excluded since no surgery was performed, but palliative radiotherapy or radio-chemotherapy. Insufficient documentation of change in body weight during the rehabilitation stay led to exclusion of additional seven patients. Three patients had to be treated by diuretics or infusion due to edema or hypovolemia. Because diuretics and infusion falsify real body weight gain during the rehabilitation stay, these patients could not be included in our analysis. Another three patients interrupted the rehabilitation stay prematurely. Here we report on the remaining 51 patients.
Carcinoma were located in the upper, middle, lower esophagus and in the esophagogastric junction type I and II in 1, 7, 22, 13, and 8 patients, respectively. Thirtyone patients suffered from adenocarcinoma, nineteen from squamous cell carcinoma. Forty-five (88%) received abdomino-thoracic esophagectomy with reconstruction of gastrointestinal continuity using a gastric tube with high intrathoracic anastomosis (on height of the azygos vein). In the remaining six patients, a Roux-en-Y esophagojejunostomy, colon or jejunal interposition were performed. Twenty-nine patients received a more aggressive therapy (i.e., surgery plus neoadjuvant chemotherapy plus adjuvant chemotherapy or surgery plus neoadjuvant chemotherapy plus adjuvant radiotherapy or surgery plus neoadjuvant radiochemotherapy C/– adjuvant chemotherapy or surgery plus adjuvant radiochemotherapy). Twenty-two patients were treated more moderately with exclusive surgery or surgery plus neoadjuvant chemotherapy or surgery plus adjuvant chemotherapy. The majority of the patients received a curative therapy. Only two patients were treated in a palliative setting, since metastases had been detected. We compared patients, who reported steatorrhea (stool of pale color, foul smell, stool is lose, bulky, and floats in the toilet bowl) and in which PERT (containing lipase 25.000–50.000 U per meal) was initiated (n D 20) or doses were modified (n D 3) during the rehabilitation stay (STEAC) with patients who showed no steatorrhea with or without PERT (STEA¡) at the beginning of the rehabilitation stay. Patient characteristics and results of the comparison STEAC vs. STEA¡ are shown in Table 1. Statistical analyses were performed using WinSTAT (WinSTAT for Microsoft Excel, Version 2012.1, R. Fitch Software, 79189 Bad Krozingen, Germany). Differences between groups of patients were analyzed using t-test for
Table 1. Patients characteristics and results.
Number of patients Gender (m/f) Tumor Stage at initial diagnosis I II III IV Age at rehabilitation (median) Time between surgery and start of rehabilitation (median, days) Therapeutic approach: curative / palliative Max. weight loss before start of rehabilitation (median) Appetite normal / reduced Bodyweight at beginning of rehabilitation (median) Weight gain during rehabilitation (median) Six-minute-walk-test (meter, median)
All patients
STEAC patients
STEA¡ patients
51 40/11 7 8 22 4 61.8 130 49/2 16.6 29/22 68.9 C0.3 kg 379
23 17/6 4 4 9 2 59.9 112 2 18.0 12/11 67.3 C1.0 kg 353
28 23/5 3 4 13 2 63.3 146 0 15.3 17/11 70.2 ¡0.3 kg 401
P n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. (0,18) n.s. n.s. 0.032 n.s. (0,11)
STEAC; patients with steatorrhea, pancreatic enzyme replacement started during the stay in the rehabilitations clinic or increased of the already prescribed pancreatic enzyme dosage. STEA¡, patients without steatorrhea, pancreatic enzyme replacement not necessary or initiated before start of rehabilitation, palliative means here metastasized disease, but general condition of the patients is well enough for the rehabilitation stay, appetite: patients were asked at the beginning of the rehabilitation stay, whether appetite is normal or reduced, projected to 21 days, 6-min-walk-test at the beginning of rehabilitation, P-values from t-tests (continuous variables) or chi-squared tests (categorical variables).
NUTRITION AND CANCER
continuous variables and chi-squared-tests for categorical variables. P values
ISSN: 0163-5581 (Print) 1532-7914 (Online) Journal homepage: http://www.tandfonline.com/loi/hnuc20
Importance of Pancreatic Enzyme Replacement Therapy after Surgery of Cancer of the Esophagus or the Esophagogastric Junction Thomas Kiefer, Dorothea Krahl, Kathrin Osthoff, Peter Thuss-Patience, Jörg Bunse, Ulrich Adam, Marc H. Jansen, Rudolf Ott, Robert Pfitzmann, Matthias Pross, Thomas Kohlmann, Georg Daeschlein, Hermann Buhlert, Heinz Völler & Carsten Hirt To cite this article: Thomas Kiefer, Dorothea Krahl, Kathrin Osthoff, Peter Thuss-Patience, Jörg Bunse, Ulrich Adam, Marc H. Jansen, Rudolf Ott, Robert Pfitzmann, Matthias Pross, Thomas Kohlmann, Georg Daeschlein, Hermann Buhlert, Heinz Völler & Carsten Hirt (2017): Importance of Pancreatic Enzyme Replacement Therapy after Surgery of Cancer of the Esophagus or the Esophagogastric Junction, Nutrition and Cancer, DOI: 10.1080/01635581.2017.1374419 To link to this article: http://dx.doi.org/10.1080/01635581.2017.1374419
Published online: 25 Sep 2017.
Submit your article to this journal
Article views: 7
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hnuc20 Download by: [Australian Catholic University]
Date: 27 September 2017, At: 11:54
NUTRITION AND CANCER https://doi.org/10.1080/01635581.2017.1374419
Importance of Pancreatic Enzyme Replacement Therapy after Surgery of Cancer of the Esophagus or the Esophagogastric Junction
Downloaded by [Australian Catholic University] at 11:54 27 September 2017
€rg Bunsec, Ulrich Adamd, Thomas Kiefera, Dorothea Krahla, Kathrin Osthoffa, Peter Thuss-Patienceb, Jo e f g h Marc H. Jansen , Rudolf Ott , Robert Pfitzmann , Matthias Pross , Thomas Kohlmanni, Georg Daeschleinj, €llera,k, and Carsten Hirtl Hermann Buhlerta, Heinz Vo a Department of Rehabilitation/Internal Medicine, Klinik am See, R€ udersdorf, Germany; bDepartment of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin-Franklin/Charite, Berlin, Germany; cDepartment of General and Visceral Surgery, Sana Hospital Lichtenberg, Sana Hospitals Berlin-Brandenburg, Affiliated Teaching, Hospital to the Charite, Berlin, Germany; dDepartment of Surgery, Humboldt-Klinikum, Berlin, Germany; eDepartment of Surgery, HELIOS Klinikum Emil von Behring, Berlin, Germany; fDepartment of Surgery, Waldkrankenhaus Berlin-Spandau, Berlin, Germany; gDepartment of Surgery, DRK Kliniken, Berlin-Mitte, Berlin, Germany; hDepartment of Surgery, DRK Kliniken Berlin, K€openick, Berlin, Germany; iInstitute for Community Medicine, Methods of Community Medicine, University Medicine Greifswald, Greifswald, Germany; jDepartment of Dermatology, University Medicine Greifswald, Greifswald, Germany; kCenter of Rehabilitation Research, University of Potsdam, Potsdam, Germany; l Department of Internal Medicine C, Hematology/Oncology, University of Greifswald, Greifswald, Germany
ABSTRACT
ARTICLE HISTORY
After surgical treatment of cancer of the esophagus or the esophagogastric junction we observed steatorrhea, which is so far seldom reported. We analyzed all patients treated in our rehabilitation clinic between 2011 and 2014 and focused on the impact of surgery on digestion of fat. Reported steatorrhea was anamnestic, no pancreatic function test was made. Here we show the results from 51 patients. Twenty-three (45%) of the patients reported steatorrhea. Assuming decreased pancreatic function pancreatic enzyme replacement therapy (PERT) was started or modified during the rehabilitation stay (in the following called STEAC). These patients were compared with the patients without steatorrhea and without PERT (STEA¡). Maximum weight loss between surgery and rehabilitation start was 18 kg in STEAC patient and 15.3 kg in STEA¡ patients. STEAC patients gained more weight under PERT during the rehabilitation phase (3 wk) than STEA¡ patients without PERT (C1.0 kg vs. ¡0.3 kg, P D 0.032). We report for the first time, that patients after cancer related esophageal surgery show anamnestic signs of exocrine pancreas insufficiency and need PERT to gain body weight.
Received 12 September 2016 Accepted 6 July 2017
Introduction Esophageal cancer is the 6th most common cause of cancer-related mortality worldwide (1,2). Treatment of patients with cancer of the esophagus or of the esophagogastric junction consists of surgery, radiation, chemotherapy and targeted therapy. Depending on age, stage and medical fitness one or more treatment modalities are used but for patients with localized esophageal cancer surgical resection remains the mainstay of treatment (3,4), and has a major impact on patients nutritional status. In Germany, rehabilitation is an integral part of the treatment of patients with esophageal cancer in order to restore some or all of the patient’s physical, sensory, and mental capabilities that were lost due to disease or treatment. Many patients who were admitted to our rehabilitation clinic with cancer of the esophagus or the esophagogastric junction after surgery with or without CONTACT Thomas Kiefer [email protected] 15562 R€ udersdorf bei Berlin, Germany. © 2017 Taylor & Francis Group, LLC
chemotherapy/irradiation report flatulence, diarrhea, weight loss and signs of steatorrhea (pale color, foul smell, stool is lose, bulky, and floats in the toilet bowl). Symptoms of exocrine pancreatic insufficiency like steatorrhea, are a well-known problem in patients following surgical treatment of gastric cancer, and significantly affect quality of life as well as professional and social rehabilitation (5). In contrast, there are only very few reports on pancreatic exocrine insufficiency in patients after esophagectomy (6). Here we report retrospective data of patients after surgery of cancer of the esophagus or the esophagogastric junction, who were treated during 4 years in our rehabilitation clinic.
Methods This is a retrospective analysis of all patients who were treated at our rehabilitation clinic between January 2011 Department of Rehabilitation/Internal Medicine, Klinik am See, Seebad 84,
Downloaded by [Australian Catholic University] at 11:54 27 September 2017
2
T. KIEFER ET AL.
and December 2014. We were interested in the impact of the resection of the distal esophagus with esophagogastric anastomosis on the ability to gain weight during the three weeks stay at our rehabilitation clinic. We collected data on weight loss due to disease and therapy before the start of the rehabilitation, signs of steatorrhea, initiation or dose modification of PERT during rehabilitation and appetite (patients were asked at the beginning of the rehabilitation stay, whether appetite is normal or reduced). Reported steatorrhea was anamnestic, no pancreatic function test was made. Apart from PERT initiation or modification all patients were treated in the same way and got the same dietary counselling during the rehabilitation stay (i.e. instruction in chewing well, in eating six to eight small portions and in eating highenergy-content portions). In addition, body weight at the beginning and at the end of the rehabilitation was noted and if the change of the body weight was not documented for the complete duration of the rehabilitation stay (regularly 21 days) it was projected to 21 days. In total we identified 72 patients with cancer of the esophagus or of the esophagogastric junction. Twenty-one patients were not included in the analysis for a variety of reasons. Since our aim was to study the impact of surgery on digestion of fat eight patients were excluded since no surgery was performed, but palliative radiotherapy or radio-chemotherapy. Insufficient documentation of change in body weight during the rehabilitation stay led to exclusion of additional seven patients. Three patients had to be treated by diuretics or infusion due to edema or hypovolemia. Because diuretics and infusion falsify real body weight gain during the rehabilitation stay, these patients could not be included in our analysis. Another three patients interrupted the rehabilitation stay prematurely. Here we report on the remaining 51 patients.
Carcinoma were located in the upper, middle, lower esophagus and in the esophagogastric junction type I and II in 1, 7, 22, 13, and 8 patients, respectively. Thirtyone patients suffered from adenocarcinoma, nineteen from squamous cell carcinoma. Forty-five (88%) received abdomino-thoracic esophagectomy with reconstruction of gastrointestinal continuity using a gastric tube with high intrathoracic anastomosis (on height of the azygos vein). In the remaining six patients, a Roux-en-Y esophagojejunostomy, colon or jejunal interposition were performed. Twenty-nine patients received a more aggressive therapy (i.e., surgery plus neoadjuvant chemotherapy plus adjuvant chemotherapy or surgery plus neoadjuvant chemotherapy plus adjuvant radiotherapy or surgery plus neoadjuvant radiochemotherapy C/– adjuvant chemotherapy or surgery plus adjuvant radiochemotherapy). Twenty-two patients were treated more moderately with exclusive surgery or surgery plus neoadjuvant chemotherapy or surgery plus adjuvant chemotherapy. The majority of the patients received a curative therapy. Only two patients were treated in a palliative setting, since metastases had been detected. We compared patients, who reported steatorrhea (stool of pale color, foul smell, stool is lose, bulky, and floats in the toilet bowl) and in which PERT (containing lipase 25.000–50.000 U per meal) was initiated (n D 20) or doses were modified (n D 3) during the rehabilitation stay (STEAC) with patients who showed no steatorrhea with or without PERT (STEA¡) at the beginning of the rehabilitation stay. Patient characteristics and results of the comparison STEAC vs. STEA¡ are shown in Table 1. Statistical analyses were performed using WinSTAT (WinSTAT for Microsoft Excel, Version 2012.1, R. Fitch Software, 79189 Bad Krozingen, Germany). Differences between groups of patients were analyzed using t-test for
Table 1. Patients characteristics and results.
Number of patients Gender (m/f) Tumor Stage at initial diagnosis I II III IV Age at rehabilitation (median) Time between surgery and start of rehabilitation (median, days) Therapeutic approach: curative / palliative Max. weight loss before start of rehabilitation (median) Appetite normal / reduced Bodyweight at beginning of rehabilitation (median) Weight gain during rehabilitation (median) Six-minute-walk-test (meter, median)
All patients
STEAC patients
STEA¡ patients
51 40/11 7 8 22 4 61.8 130 49/2 16.6 29/22 68.9 C0.3 kg 379
23 17/6 4 4 9 2 59.9 112 2 18.0 12/11 67.3 C1.0 kg 353
28 23/5 3 4 13 2 63.3 146 0 15.3 17/11 70.2 ¡0.3 kg 401
P n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. (0,18) n.s. n.s. 0.032 n.s. (0,11)
STEAC; patients with steatorrhea, pancreatic enzyme replacement started during the stay in the rehabilitations clinic or increased of the already prescribed pancreatic enzyme dosage. STEA¡, patients without steatorrhea, pancreatic enzyme replacement not necessary or initiated before start of rehabilitation, palliative means here metastasized disease, but general condition of the patients is well enough for the rehabilitation stay, appetite: patients were asked at the beginning of the rehabilitation stay, whether appetite is normal or reduced, projected to 21 days, 6-min-walk-test at the beginning of rehabilitation, P-values from t-tests (continuous variables) or chi-squared tests (categorical variables).
NUTRITION AND CANCER
continuous variables and chi-squared-tests for categorical variables. P values
