Perioperative pancreatic enzyme replacement therapy reduces morbidity in patients undergoing pancreatoduodenectomy

Abstract

Introduction: Exocrine pancreatic insufficiency (EPI) is a common entity in patients scheduled for pancreatoduodenectomy due to obstruction of the pancreatic duct. The treatment for EPI is pancreatic enzyme replacement therapy (PERT) but this is not routinely prescribed in patients undergoing PD. The aim of this study was to examine the effects of perioperative PERT on the incidence of postoperative pancreatic fistula (POPF) and surgical site infections (SSI) in patients undergoing PD. Materials & Methods: Patients undergoing PD during the period January 2014 to December 2017 were maintained database. The electronic medical record was reviewed to determine the presence of symptoms indicative of EPI and the use of PERT during the pre- and post-operative periods. The presence of a dilated pancreatic duct was ascertained through review of pre-operative cross-sectional imaging. Patients were divided into 3 groups: patients who received preoperative PERT continued into the postoperative period (Preop PERT); patients who received only postoperative PERT (Postop PERT); and patients who did not receive PERT (No PERT). A POPF was defined according to the International Study Group of Pancreatic Fistula and classified as biochemical leaks (A) or clinically significant (B or C). SSIs were classified as superficial, deep, and organ-space. The incidence of SSI and POPF were compared between groups. Results: Of 327 patients who underwent a PD, 239 (73%) had evidence of EPI, with a dilated pancreatic duct identified in 203 (62.0%) and symptoms of EPI in 142 (43.4%). The Results are summarized in Table 1. Conclusion: Patients who received preoperative PERT had lower rates of POPF both overall and clinically relevant POPF compared to those receiving postoperative PERT or no PERT. The preop PERT group also experienced less SSIs. Routine preoperative use of PERT should be considered in patients undergoing PD.