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Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Sep 27, 2021; 13(9): 885-903
Published online Sep 27, 2021. doi: 10.4240/wjgs.v13.i9.885
Neoadjuvant treatment: A window of opportunity for nutritional prehabilitation in patients with pancreatic ductal adenocarcinoma
Ilaria Trestini, Marco Cintoni, Emanuele Rinninella, Futura Grassi, Salvatore Paiella, Roberto Salvia, Emilio Bria, Carmelo Pozzo, Sergio Alfieri, Antonio Gasbarrini, Giampaolo Tortora, Michele Milella, Maria Cristina Mele
Ilaria Trestini, Michele Milella, Section of Oncology, Department of Medicine, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
Marco Cintoni, Scuola di Specializzazione in Scienza dell’Alimentazione, Università di Roma Tor Vergata, Roma 00133, Italy
Emanuele Rinninella, Futura Grassi, UOC Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico A. Gemelli IRCCS, Roma 00168, Italy
Emanuele Rinninella, Sergio Alfieri, Antonio Gasbarrini, Maria Cristina Mele, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma 00168, Italy
Salvatore Paiella, Roberto Salvia, General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
Emilio Bria, Carmelo Pozzo, Giampaolo Tortora, Oncologia Medica Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
Emilio Bria, Carmelo Pozzo, Giampaolo Tortora, Oncologia Medica Unit, Università Cattolica del Sacro Cuore, Roma 00168, Italy
Sergio Alfieri, Digestive Surgery Unit and Pancreatic Surgery Gemelli Center Director, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
Antonio Gasbarrini, UOC di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
Maria Cristina Mele, UOSD Nutrizione Avanzata in Oncologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma 00167, Italy
Author contributions: Trestini I and Cintoni M were involved in the collection and synthesis of all data and manuscript writing; Rinninella E, Grassi F, Paiella S, Salvia R, Pozzo C, Alfieri S, and Gasbarrini A oversaw the project progress and were involved in the final editing of the manuscript; Bria E, Tortora G, and Milella M were involved in the writing and revision of the manuscript; Mele MC was involved in the idea, writing, and revision of the manuscript; All authors have read and approved the final manuscript.
Conflict-of-interest statement: Trestini I reported speakers’ fees from Mylan and Fresenius Kabi. Bria E received speakers’ and travels’ fee from MSD, Astra-Zeneca, Celgene, Pfizer, Helsinn, Eli-Lilly, BMS, Novartis and Roche; consultant’s fee from Roche, Pfizer; institutional research grants from Astra-Zeneca, Roche. Bria E is currently supported by the Associazione Italiana per la Ricerca sul Cancro (AIRC) under Investigator Grant (IG) No. IG20583. Bria E is currently supported by Institutional funds of Università Cattolica del Sacro Cuore (UCSC-project D1-2018/2019). Tortora G is supported by AIRC, IG18599, AIRC 5x1000 21052. Milella M reported personal fees from Pfizer, EUSA Pharma and Astra Zeneca. Other Authors declare no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Marco Cintoni, MD, Doctor, Scuola di Specializzazione in Scienza dell’Alimentazione, Università di Roma Tor Vergata, Viale Oxford 81, Roma 00133, Italy. marco.cintoni@gmail.com
Received: February 12, 2021
Peer-review started: February 12, 2021
First decision: May 13, 2021
Revised: May 28, 2021
Accepted: July 20, 2021
Article in press: July 20, 2021
Published online: September 27, 2021
Processing time: 218 Days and 2.1 Hours
Abstract

Patients affected by pancreatic ductal adenocarcinoma (PDAC) frequently present with advanced disease at the time of diagnosis, limiting an upfront surgical approach. Neoadjuvant treatment (NAT) has become the standard of care to downstage non-metastatic locally advanced PDAC. However, this treatment increases the risk of a nutritional status decline, which in turn, may impact therapeutic tolerance, postoperative outcomes, or even prevent the possibility of surgery. Literature on prehabilitation programs on surgical PDAC patients show a reduction of postoperative complications, length of hospital stay, and readmission rate, while data on prehabilitation in NAT patients are scarce and randomized controlled trials are still missing. Particularly, appropriate nutritional management represents an important therapeutic strategy to promote tissue healing and to enhance patient recovery after surgical trauma. In this regard, NAT may represent a new interesting window of opportunity to implement a nutritional prehabilitation program, aiming to increase the PDAC patient’s capacity to complete the planned therapy and potentially improve clinical and survival outcomes. Given these perspectives, this review attempts to provide an in-depth view of the nutritional derangements during NAT and nutritional prehabilitation program as well as their impact on PDAC patient outcomes.

Keywords: Pancreatic cancer; Neoadjuvant treatment; Pancreatic cancer surgery; Nutritional status; Nutritional prehabilitation; Malnutrition

Core Tip: Among pancreatic ductal adenocarcinoma patients with resectable or borderline resectable disease, and those with locally advanced disease with a feasibility of surgical resection of up to 30%, neoadjuvant treatment (NAT) has become the standard of care. NAT may impair functional reserve and lead to nutritional depletion, which may affect therapeutic tolerance, postoperative outcomes or even prevent the possibility of surgery. This review suggests that NAT timeframe may provide a valuable opportunity for nutritional prehabilitation program to minimize the NAT-related nutritional derangements, increase patient’s capacity to complete planned therapy, promote tissue healing, and enhance patient’s recovery, thus potentially improve outcomes.