OOSO MEETING: Dietetic Update Liz Ward Specialist Dietitian, UGI Churchill Hospital, Oxford 14.04.18

Aims: Dietetic Audit of Weight Loss Results of Dietetic Questionnaire Pancreatic Enzymes Eating following UGI Surgery Covered in Dec 2016: Malabsorption Vitamin Deficiencies Improving the Dietetic Service for UGI patients

Dietetic Audit In 2016 we visit Seattle as an MDT team and made several changes on our return Instigated the “pureed diet” post surgery This has worked well but I was concerned regarding post surgery weight loss May to October 2017: Audit of post surgery weight loss

Dietetic Audit: What did we look at? 40 patients Average weight loss at week 1-2, 3-4 and 5-6 post discharge Use of Jejunostomy tubes Symptoms: constipation, diarrhoea, weight loss, N&V, weak/tiredness, dumping, poor appetite, dehydration, swallowing difficulties, acid reflux, malabsorption Reasons for E&D difficulties: portions, palatability, frequency, limited choice, anxiety

Dietetic Audit: What did we find? Only 10% of patients left the hospital using there jej tubes for feed 23% of patients needed to start feed once at home due to significant weight loss Difficult to arrange at home Post code dependent Can take several weeks to organise retrospectively Greater average weight loss in the non jej fed group At 1-2 weeks: average 5.6kg loss (max 14.2kg) At 3-4 weeks: average 5.9kg loss (max 12.5kg) At 5-6 weeks: average 7.9kg loss (max 15.5kg)

Dietetic Audit: interpreting the results Factors responsible for the weight loss: Portion sizes, palatability of pureed diet, poor appetite, weakness and tiredness, altered bowel habits, symptoms of dumping Limit the desire to eat Limit the ability to eat Negative impact on eating behaviour hence weight loss

Dietetic Audit: change to practice Many of the factors that impact on post surgery weight loss cannot be modified: Small portion sizes Radical changes to eating patterns Change of focus from F&V to protein Early satiety (feeling full quickly) Poor appetite due to hormonal changes The pureed diet is necessary to prevent gastric tube distention, obstruction and blockages during the early weeks Decision made to routinely use the jejunostomy tubes for feeding on discharge for a minimum of 2 weeks (commenced 3rd December 2017) Results so far are promising…

Aims: Dietetic Audit of Weight Loss Results of Dietetic Questionnaire Pancreatic Enzymes Eating following UGI Surgery

Results of Dietetic Questionnaire: Patient questionnaire to capture your views and suggestions

Results of Dietetic Questionnaire: Looking for your views of the Dietetic service you received and how to improve the service. 40 questionnaires were returned Summary of results: 64% would like a pre surgery group education session “a group session is always good, we learn from one another” “it would have been nice to have met before the operation to discuss the effects of the operation on diet” 72% felt that they had enough dietary information on going home “despite the information given, it was still a surprise”

Results of Dietetic Questionnaire: 53% of you felt confident about how much and what to eat but 20% suggested that you would have liked more information “We did not realise how difficult it would be after surgery and CRT… we were not really prepared for the problems that occurred” “the difficulty was not stressed to us, i.e. the problems with eating and drinking were considerable”

Results of Dietetic Questionnaire: What changes have we made in response to the questionnaire: Updated all of our patient information Group Education Sessions - we are very keen to run these but need to secure funding to do Aim to routinely telephone patients at 1-2, 3-4 and 5-6 weeks post discharge to review progress We always encourage you to contact for advice

Aims: Dietetic Audit of Weight Loss Results of Dietetic Questionnaire Pancreatic Enzymes Eating following UGI Surgery

Pancreatic enzymes What are pancreatic enzymes What is the effect of surgery on pancreatic enzymes Symptoms of a lack of enzymes Impact on nutritional status What can you do to help? Are medications required?

Pancreatic enzymes What are pancreatic enzymes and what is their function? Pancreatic enzymes are digestive juices produced by the pancreas to digest protein, fat and carbohydrate Protease, lipase, amylase If not fully digested, the absorption of protein, fat and carbohydrate is affected This affects the absorption of fat soluble vitamins, e.g. vitamin A, D, E and also zinc, calcium, selenium and magnesium

Surgery and pancreatic enzymes Why does surgery to the stomach and oesophagus reduce pancreatic enzymes? Timing of gastric emptying versus pancreatic secretion Reduced pancreatic stimulation due to a reduction of stomach acid (surgery or antacid) Often a combination of reduced pancreatic enzyme release and the enzymes not reaching the food can lead to poor digestion and poor absorption

What are the symptoms? Symptoms of pancreatic insufficiency: Flatulence Diarrhoea Pale stools Foul smelling Floating stools that are difficult to flush away Vitamin deficiencies, weight loss leading to malnutrition

What you can do? If you have symptoms, record and let us know Unlike other affects of surgery, a lack of pancreatic enzymes can be treated and symptoms improved or resolved Treatment: Creon 25,000* Taken with all meals/snacks that contain carbohydrate, protein and fat Upto 12 capsules per day Start with a low dose and self titrate to size and content of meals/snacks *other preparations are available

www.creon.com

Other considerations The enzyme source is from pig pancreas It is temperature and pH sensitive Take with a small amount of cold liquid Do not sprinkle, crush or chew If need to open, mix it with acid fruit puree Split the dose throughout the meal Possible side effects: Flatulence, abdominal bloating, nausea, mouth ulcers, anal irritation Ensure you are taking an A-Z multivitamin and mineral supplement daily

Benefits of pancreatic enzymes Pancreatic insufficiency is well documented post gastrectomy and more recently post oesophagectomy: A UK study (2013) looked at post oesophagectomy patients with severe symptoms 90% of those who commenced on enzymes had improvements in symptoms 70% increased their weight Also consider the improvement to vitamin and mineral absorption

Aims: Dietetic Audit of Weight Loss Results of Dietetic Questionnaire Pancreatic Enzymes Eating following UGI Surgery

Nutrition challenges Many nutritional challenges following an oesophagectomy or gastrectomy Dumping Taste changes Lack of appetite Restriction of portion size Frequency of eating Low mood impacting on energy and appetite Diarrhoea Food sticking in the oesophagus Delayed stomach emptying

Why little and often? Smaller capacity due to no stomach or a greatly reduced size You will no longer have a reservoir function: Store, churn, breakdown, start digestive process You may not feel unwell, bloated or uncomfortable but still at risk of: Stretching your stomach tube, distorting it and affecting it’s long-term function Driving food and fluids through your system quickly and reducing absorption of nutrients Increasing the likelihood of dumping syndrome

Why little and often? To achieve adequate nutrition - energy, protein, vitamins and minerals. Requires more than 3 small meals to get enough. Ensure the often is of good quality protein rich not carbohydrate heavy added vitamins and minerals as you progress Low fruit and veg intake in the early months is expected – not aiming for a “balanced diet” Eating more frequently will help to recover a poor appetite

What is a good quality small meal? Provide a good protein source Meat, fish, seafood Eggs, cheese, milk Nuts – ground or as a snack Lentils, pulses Protein should provide the bulk of the meal rather than carbohydrates and vegetables Ensure calcium rich foods are included in your diet Provide protein Good source of energy Required for bone health Split calcium intake throughout the day to maximise absorption Use varied sources, not just milk Cheese, yoghurt, bony fish Ensure milk alternatives are fortified

What is a good quality small meal? Provide energy from carbohydrate: Avoid sweet breads, pastries, biscuits or cakes that may cause dumping and add little to the diet You may want to focus on low GI carbohydrate foods if you experience dumping regularly Avoid over filling with carbs; only a small portion Carbs should add a small quantity to the meal (do not bulk up on potatoes or pasta to fuel yourself). This will have the opposite affect Consider alternatives if you experience dumping regularly: spelt flour, pumpernickel bread.

What about Fruit and Veg? Introduce fruit, vegetables and salad when: weight has stabilised no dumping eating pattern is established In small quantities Avoid over-filling Avoid fruit juices

Further information

Nutrition challenges Dumping Taste changes Lack of appetite Restriction of portion size Frequency of eating Low mood impacting on energy and appetite Diarrhoea Lactose intolerance Food sticking in the oesophagus Delayed stomach emptying

Dumping Syndrome Dumping is not just diarrhoea Dumping is the rapid delivery of food and nutrients to the intestine Due to the lack of stomach reservoir Rapid transit time Two types of dumping “Early” and “Late” Dumping is often avoidable Can limit daily activities, cause food aversions so always best to identify the cause

Early and Late Dumping Food moves rapidly from the stomach or stomach tube A large nutrient load hits the intestine In response water is drawn from surrounding tissues Drop in blood pressure Bowels open urgently Bloating Nausea Fullness Palpitations Flushing Sweating Faintness Followed by loose/urgent stools

Early and Late Dumping Tiredness Tremors Palpitations Sweating Giddiness Nausea Rapid glucose absorption High insulin release in response Hypoglycaemia (low blood sugar) Can occur 1-3 hours after eating Try to reduce and avoid late dumping rather than treating with sweets or sugar or glucose tablets

How to avoid dumping? Firstly, identify the cause: Volume Fat Sugar Combination Reduce portions further Split meals into 2 sittings Avoid fluids pre and post meals Check labels for fat and sugar Separate main course and desserts (1hr) Limit to safe, tolerated foods then slowly reintroduce variety

Nutrition challenges Dumping Taste changes Lack of appetite Restriction of portion size Frequency of eating Low mood impacting on energy and appetite Diarrhoea Lactose intolerance Food sticking in the oesophagus Delayed stomach emptying

When to contact? Severe reflux, nausea or more pronounced early satiety can be a sign of delayed gastric emptying Your ability to eat may worsen as the day progresses An endoscopy +/- pyloric stretch may be required Food sticking can be a sign of a narrowing or stricture at the join or anastomosis You may experience regurgitation or vomiting Change to a soft or pureed diet An endoscopy +/- stretch may be required

The aim of nutrition advice Support recovery from treatment Help to reduce side-effects of surgery and treatment Help to prevent long-term complications Improve and maintain QOL Not just about weight gain…

Thank you for listening Any questions?