Pancreatic enzyme replacement therapy: exocrine pancreatic insufficiency after gastrointestinal surgery

Abstract

Exocrine pancreatic insufficiency (EPI) and resultant maldigestion occurs in up to 80% of patients following gastric, duodenal or pancreatic surgery. Accurate diagnosis is required to determine the appropriate intervention, but the conventional method of faecal fat quantification is time-consuming and not always readily available. The optimized (13)C-mixed triglyceride ((13)C-MTG) breath test is an accurate alternative post-surgery. Pancreatic enzyme replacement therapy (PERT) is indicated post-surgery in patients with clinically evident steatorrhoea, weight loss or maldigestion-related symptoms. Given its favourable safety profile, PERT is also appropriate in asymptomatic patients with high faecal fat excretion as such patients are at high risk for nutritional deficits. However, published data evaluating PERT in this setting are limited. Uncoated powder preparations may be preferred in cases of low gastric acidity and partial or total gastric resection. In clinical studies, enteric-coated microspheres were associated with greater weight gain after surgery vs. uncoated preparations. This was confirmed in a recent study using the (13)C-MTG breath test; fat absorption increased from <40% without therapy to almost 60% with enteric-coated minimicrospheres (40 000 lipase units/meal), with >60% of patients achieving normal breath test results (i.e. normal fat digestion) during PERT. A therapeutic algorithm for the treatment of EPI after surgery is also discussed.

Potential for Screening for Pancreatic Exocrine Insufficiency Using the Fecal Elastase-1 Test

“…Impairments in fat digestion affect the absorption of the fatsoluble vitamins A, D, E, and K, all of which, together with other PEI-related nutritional deficits, could be associated with complications such as cardiovascular disease, compromised immunity, cancerogenicity, psychological disorders, hypoprothrombinemia, bleeding disorders, night blindness, and muscle weakness [10][11][12]. Early detection of PEI can help prevent malabsorption-/malnutrition-associated complications by enabling expedient treatment with pancreatic enzyme replacement therapy (PERT), which numerous clinical trials have shown to be highly effective, not only in patients with CP, but also following pancreatic surgery, and in children and adults with CF [6,[13][14][15][16]. Clinically, the most common cause of PEI is CP, although symptoms of PEI may not appear until several years after disease onset [17].…”

“…PEI is caused by numerous pancreatic disorders, including chronic pancreatitis (CP), cystic fibrosis (CF), diabetes, obstruction of the pancreatic duct system by a tumor or stricture, or loss of pancreatic parenchyma following pancreatic resection [3]. PEI may also be caused by extra-pancreatic conditions, including gastric surgery, celiac disease, Zollinger-Ellison syndrome, and HIV infection [4][5][6]. Mild PEI is difficult to detect in patients as it may be asymptomatic [7]; however, as PEI progresses, they may present with frequent diarrhea, gas and bloating, which can cause abdominal pain, and weight loss due to impaired nutrient absorption [8].…”

Randomised clinical trial: a 1‐week, double‐blind, placebo‐controlled study of pancreatin 25 000 Ph. Eur. minimicrospheres (Creon 25000 MMS) for pancreatic exocrine insufficiency after pancreatic surgery, with a 1‐year open‐label extension

“…However, pancreatic resection results in pancreatic exocrine insufficiency (PEI) in many patients, and those undergoing total pancreatectomy are devoid of any pancreatic function 5–8. PEI leads to the maldigestion of food and the malabsorption of nutrients, and the symptoms include steatorrhoea, abdominal pain, flatulence, weight loss and malnutrition 9.…”

Systematic Review of Exocrine Pancreatic Insufficiency after Gastrectomy for Cancer

“…Whether these theories, solely or in combination, may attribute to a decreased exocrine function of the pancreas is yet to be determined [9] .…”