Enzyme replacement following total pancreatectomy; population analysis
Authors:
M. Gregořík 1; P. Skalický 1; J. Tesaříková 1; B. Mohelníková-Duchoňová 2; D. Klos 1; M. Loveček 1
Authors‘ workplace:
I. chirurgická klinika Fakultní nemocnice Olomouc
1; Onkologická klinika Lékařské fakulty Univerzity Palackého Olomouc
2
Published in:
Rozhl. Chir., 2022, roč. 101, č. 11, s. 530-534.
Category:
Original articles
doi:
https://doi.org/10.33699/PIS.2022.101.11.530–534
Overview
Introduction: Total pancreatectomy (TPE) inevitably leads to absolute exocrine pancreatic insufficiency (EPI). No specific recommendations are available for enzyme replacement in such cases. The aim of our analysis was to explore the actual EPI replacement rates among patients following TPE after a certain period of time from the surgery.
Methods: This retrospective analysis of living patients who had undergone TPE more than 2 years ago was done using a simple questionnaire to investigate the following: BMI prior to TPE, 3 months after TPE and at the time of data collection (in 2022), together with the actual number of daily bowel movements; and the replacement characteristics – the daily dose, its scheme and subjective satisfaction evaluation.
Results: In total, we obtained data from 26 living patients with the history of TPE with their median follow up of 56 months (30–157). Malignant disease was confirmed in 69% patients based on histology; a benign tumor was present in the rest, although malignancy had been suspected preoperatively. Median BMI decreased from preoperative 27.4 (19.1–41.1) to 24.1 (19.8–33.7) 3 months following TPE, and median BMI value of 25.5 (21.2–34.5) was established at 30–157 months from TPE. The mean number of daily bowel movements was 2.2 (median 2, range 1–8) and the mean daily replacement dose was 182,000 units of lipase (median 175,000 u., range 0–250,000 u.) at the time of our investigation. Subjective satisfaction was reported by 85% responders and a lack of satisfaction despite maximum EPI replacement was expressed by 15% responders.
Conclusion: BMI decreased shortly after TPE. In the long term, up to 80% of the patients achieved preoperative BMI values ±10% after TPE. Due to persistent steatorrhea and more frequent bowel movements despite enzyme replacement, 15% of the patients remained subjectively dissatisfied after TPE, but 85% of the patients did not perceive even more frequent bowel movements as unpleasant and were satisfied with their condition. The need of individualized enzyme replacement therapy of EPI following TPE is evident.
Keywords:
BMI – total pancreatectomy – enzyme replacement
Sources
1. Kunovský L, Dítě P, Bojková M, et al. Diagnostika a terapie chronické pankreatitidy dle UEG guidelines. Vnitř Lék. 2021;67(2):85–91. doi:10.36290/ vnl.2021.019.
2. Kunovský L, Dítě P, Jabandžiev P, et al. Causes of exocrine pancreatic insufficiency other than chronic pancreatitis. J Clin Med. 2021;10(24):5779. doi:10.3390/ jcm10245779.
3. Stoop TF, Ateeb Z, Ghorbani P, et al. Impact of endocrine and exocrine insufficiency on quality of life after total pancreatectomy. Ann Surg Oncol. 2020;27(2):587–596. doi:10.1245/s10434- 019-07853-3.
4. Chaudhary A, Domínguez-Muñoz JE, Layer P, et al. Pancreatic exocrine insufficiency as a complication of gastrointestinal surgery and the impact of pancreatic enzyme replacement therapy. Dig Dis. 2020;38(1):53–68. doi:10.1159/000501675.
5. Yuasa Y, Murakami Y, Nakamura H, et al. Histological loss of pancreatic exocrine cells correlates with pancreatic exocrine function after pancreatic surgery. Pancreas 2012;41(6):928–933. doi:10.1097/ MPA.0b013e31823d837d.
6. Lohr JM, Dominguez-Munoz E, Rosendahl J, et al. United European gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroentrology Journal 2017;5(2):153– 199. doi:10.1177/2050640616684695.
7. Dominguez-Munoz E, Drewes AM, Lindkvist B, et al. Recommendations from the United European gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis. Pancreatology 2018;18(8):847–854. doi:10.1016/j.pan.2018.09.016.
8. Del Chiaro M, Rangelova E, Segersvard R, et al. Are there still indications for total pancreatectomy? Updates Surg. 2019;68(3):257–263. doi:10.1007/s13304- 016-0388-6.
9. Nentwich MF, El Gammal AT, Lemcke T, et al. Salvage completion pancreatectomies as damage control for post-pancreatic surgery complications: a single-center retrospective analysis. World J Surg. 2015;39(6):1550–1556. doi:10.1007/ s00268-015-2969-9.
10. Ryska M, Rudiš J. Totální pankreatektomie u maligního onemocnění slinivky břišní – od historie k dnešku. Rozhl Chir. 2016;95(10):345–349.
11. Loveček M, Skalický P, Köcher M, et al. Krvácení po pankreatektomii (PPH), prevalence, diagnostika a řešení. Rozhl Chir. 2016;95:350–357.
12. Lovecek M, Havlik R, Kocher M, et al. Pseudoaneurysm of the gastroduodenal artery following pancreatoduodenectomy. Stenting for hemorhage. Wideochir Inne Tech Maloinwazyjne 2014;9(2):297–301. doi:10.5114/wiitm.2011.38178.
13. Ghaneh P, Neoptolemos JP. Pancreatic exocrine insufficiency following pancreatic resection. Digestion 1999;60(Suppl1):104–110. doi:10.1159/000051464.
14. Eaton AA, Gonen M, Karanicolas P, et al. Health-related quality of life following pancreatectomy: results from a randomized controlled trial. Ann Surg Oncol 2016;23(7):2137–2145. doi:10.1245/ s10434-015-5077-z.
15. Shaw CM, O´Hanlon DM, McEntee GP. Long-term quality of life following pancreaticoduodenectomy. Hepato-gastroenterology 2005;52(63):927–932.
16. Sikkens ECM, Cahen DL, vanEijck C, et al. The daily practice of pancreatic enzyme replacement therapy after pancreatic surgery: a northern European survey. J Gastrointest Surg 2012;16(8):1487–1492. doi:10.1007/s11605-012-1927-1.
17. Fragoso AV, Pedroso MR, Herman P, et al. Comparing the enzyme replacement therapy cost in post pancreatectomy patients due to pancreatic tumor and chronic pancreatitis. Arq Gastroenterol. 2016;53(2):94–97. doi:10.1590/S0004- 28032016000200008.
18. Barkin JA, Westermann A, Hoos W, et al. Frequency of appropriate use of pancreatic enzyme replacement therapy and symptomatic response in pancreatic cancer patients. Pancreas 2019;48(6):780–786. doi:10.1097/ MPA.0000000000001330.
19. Pezzili R, Caccialanza R, Capurso G, et al. Pancreatic enzyme replacement therapy in pancreatic cancer. Cancers (Basel) 2020;12:275. doi:10.3390/cancers12020275.
20. Roberts KJ, Bannister CA, Schrem H. Enzyme replacement improves survival among patients with pancreatic cancer: results of population based study. Pancreatology 2019;19(1):114–121. doi:10.1016/j.pan.2018.10.010.
21. Kumar TK, Tewari M, Shukla SK, et al. Pancreatic exocrine insufficiency occurs in most patients following pancreaticoduodenectomy. Indian J Cancer 2021;58(4):511–517. doi:10.4103/ijc. IJC_764_18.
22. Arya VB, Senniappan S, Demirbilek H, et al. Pancreatic endocrine and exocrine function in children following near-total pancreatectomy for diffuse congenital hyperinsulinism. PloS One. 2014;9(5):e98054. doi:10.1371/journal. pone.0098054.
23. Braga M, Zerbi A, Dal Cin S, et al. Postoperative management of patients with total exocrine pancreatic insufficiency. British Journal of Surgery 1990;77:669–672. doi:10.1002/bjs.1800770626.
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Surgery Orthopaedics Trauma surgeryArticle was published in
Perspectives in Surgery
2022 Issue 11
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