The Need for Pancreatic Enzyme Replacement Therapy (PERT) after Pancreatic Surgery is Determined by Tumor Location: A Prospective Cohort Study

Abstract

Introduction: Patients undergoing oncologic pancreatic surgery are at risk for pancreatic exocrine insufficiency (PEI) and for needing PERT. There are few well-designed studies on the magnitude of this risk. Methods: In 198 patient undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) for oncologic indications, we performed an 13C-labeled mixed-triglyceride breath test, immediately preoperative and approximately 6 weeks postoperative. This test gives an idea of the pancreatic remnant lipase-activity analyzing the 13CO2 in breath after a test meal with 1.3-distearyl-(13C-Carboxyl)octanol-glycerol. Cumulative 13CO2 recovery after 6 hours is expressed as ‘MTG%’ and a level <23% confirms PEI and the need for PERT. Results: In 159 patients undergoing PD for a pancreatic head tumor, MTG% decreased significantly from 33.69% to 15.61% postoperative (p=0.002) (table 1). The percentage patients diagnosed with PEI and need for PERT increased from 23.0% to 68.3% postoperative (p<0.001). This decrease in exocrine function was significant in all pathology subgroups (figure 1), but most important in pancreatic adenocarcinoma. The postoperative percentage PEI in this subgroup increased to 78.1%. The decrease in function was less pronounced, but still significant, in pancreatic neuroendocrine tumor and ampullary tumor patients (p=0.002). In contrast, 39 patients undergoing a DP for a body-tail tumor did not experience any significant change in exocrine function. Conclusion: Patients with a pancreatic head tumor treated with PD experience a significant drop in exocrine function, are at high risk for developing PEI and consequently need for PERT. Therefore, systematic screening for PEI is mandatory after PD. Patients undergoing DP rarely need PERT.Tabled 1EP02D-185 Table 1: Evolution MTG% in pancreaticoduodenectomy and distal pancreatectomy patients measured by 13C-labeled mixed-triglyceride breath testPD n=159MTG% median preopMTG% median postopp=Median Δ MTG%MTG% range preopMTG% range postop% PEI preop% PEI postopp=pancreatic adenoca30.6111.48<0.001-16.25.44-53.340.02-34.7326.678.1<0.001ampullary tumor35.5525.73<0.001-13.016.87 -67.22.1 -34.3710.045.00.034PNET38.8927.080.022-7.0618.67 - 127.3117.4 -36.6710.030.0nsIPMN32.615.610.009-5.343.5-52.324.23 -44.1226.760.0nsdist cholangioca34.0222.50.021-7.482.96-43.916.37 - 34.889.154.50.046total group PD33.4915.61<0.0001-14.972.96-127.310.02-64.7323,068.3<0.001DP n=39MTG% median preopMTG% median postopp=Median Δ MTG%MTG% range preopMTG% range postop% PEI preop% PEI postopp=total group DP38.2838.09ns-1.9119.31-56.665.76-48.7310.257.7ns Open table in a new tab