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

2. 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

3. 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

4. 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

5. 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)

6. 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

7. 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…

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

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

10. 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”

11. 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”

12. 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

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

14. 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?

15. 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

16. 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

17. 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

18. 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

20. 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

21. 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

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

23. 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

24. 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

25. 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

26. 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

27. 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.

28. 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

29. Further information

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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…

38. Thank you for listening Any questions?