Appropriate Pancreatic Function Tests and Indication for Pancreatic Enzyme Therapy following Surgical Procedures on the Pancreas

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Exocrine pancreatic insufficiency following pancreatic surgery may be due to a preoperative disease, such as chronic pancreatitis, and/or due to the loss of functioning parenchyma through the operation. The general assumption that once the exocrine pancreatic insufficiency is established, pancreatic function necessarily deteriorates over the years, is not true for a substantial number of patients. Their exocrine pancreatic insufficiency may remain stable or even improve. Improvement may be due to postoperative alcohol abstinence and/or a preoperative mild or moderate exocrine pancreatic insufficiency. Although all direct and indirect pancreatic function tests basically can be performed postoperatively, direct tests involving intubation of the duodenum such as the secretin-pancreozymin test or the Lundh test, are not possible after conventional right-sided resection of the pancreas with antrectomy (Whipple’s operation). Pragmatically, postoperative testing for steatorrhoea as a sign of severe exocrine pancreatic insufficiency suffices. The problem is deciding at which stage of steatorrhea pancreatic enzyme substitution should be initiated. As a rule, enzyme replacement is given only when daily fat excretion exceeds 15 g, and/or the patient is losing weight, and/or has diarrhea or dyspeptic symptoms. Recommendations for postoperative enzyme substitution are difficult since the number of available studies on this topic is limited. After Whipple’s operation, drainage operations, and distal resection, enteric-coated microspheres are recommended. Additionally, in the case of Whipple’s operation, medication reducing intestinal transit time may improve the effect of the enzymes. After right-sided resection without antrectomy (duodenum-preserving resection of the head of the pancreas or pylorus-preserving pancreaticoduodenectomy), conventional enzyme granule preparations plus H₂-receptor antagonist or proton pump inhibitor are recommended. After total pancreatectomy – the most difficult postoperative situation – conventional enzyme granule preparations are recommended, but tailored to individual needs.