Impact of nutritional status on outcome of pancreatic resections for pancreatic cancer and periampullary tumors

Abstract

The high complication rate of pancreatic resections and the poor oncologic outcome of pancreatic and periampullary malignancies cannot be explained by just a single factor. There are, however, some underlying elements that affect both surgical outcomes and cancer prognosis. Nutritional status and nutritional support/therapy are among these factors, as they strongly impact on both surgical recovery (1) and cancer survival (2). Additionally, pancreatic cancer entails specific nutritional and metabolic derangements (3) that can lead to immunological deterioration and further enhance tumor aggressiveness (4). Approximately 66% of the patients with pancreas cancer are malnourished (5). Nutritional assessment, support, and therapy are all recommended in pancreatic surgery (1). In a recent article Seika and coworkers reported on the outcome of 1,384 open pancreatoduonectomies for pancreatic and periampullary cancer. Results were reported based on patients' body mass index (BMI). BMI was found to predict early outcome and long-term survival. In detail, obesity (BMI >30.0 kg/m 2) was associated with increased frequency of post-pancreatectomy hemorrhage, postoperative pancreatic fistula (POPF), bile leakage, wound infection, SIRS/sepsis, and need for reoperation. Underweight (BMI <18.5 kg/m 2), on the other hand, was shown to have higher 30-and 90-day mortality and inferior long-term survival, despite lower incidence of post-operative complications and similar histopathology parameters (6). Higher mortality in underweight patients, despite lower incidence of postoperative complications, means high failure to rescue. Failure to rescue is a relatively new quality metric indicating the proportion of patients who are not rescued following potentially treatable complications (7). In the context of uniform postoperative management policy, higher failure to rescue clearly demonstrates the frailty of underweight patients. BMI is recommended by the World Health Organization to assess nutritional status, mainly in the assumption that it defines the excess of fat storage. In adults, a BMI <18.5 kg/m 2 corresponds to underweight, a BMI ≥25 kg/m 2 to overweight, and a BMI ≥30 kg/m 2 to obesity (8). BMI, however, can miss important nutritional conditions, such as sarcopenia, thus providing only a rough picture of nutritional status. Underweight, in cancer patients, is associated with low performance status (5), and often means cachexia. Cachexia is a complex syndrome, including weight loss, marked by muscle wasting, increased muscle protein catabolism, insulin resistance and inflammation (5). Cachexia was associated with poor outcome after pancreatoduodenectomy (9). Obesity, at the other extreme of BMI spectrum, is also a complex syndrome characterized by type 2 diabetes, coronary artery disease, hypertension, dyslipidemia, non-alcoholic fatty liver disease, and increased risk for development of several cancers (10). Actually, some patients may be metabolically obese despite normal weight making metabolic profile potentially more relevant than BMI in defining the risks associated with obesity. Patients who are metabolically obese, despite normal weight phenotype, show Editorial Comment on: Seika P, Klein F, Pelzer U, et al. Influence of the body mass index on postoperative outcome and long-term survival after pancreatic resections in patients with underlying malignancy.