Diagnosis and management of pancreatic insufficiency in patients with gastrectomy due to cancer or gastric ulcers: a virtual roundtable expert discussion

ABSTRACT

Introduction

Pancreatic exocrine insufficiency (PEI) is common after gastric resection for cancer or ulcers but is under-recognized and undertreated. Although pancreatic enzyme replacement therapy (PERT) is the mainstay of PEI management, robust evidence supporting its use after gastric surgery is limited.

Areas covered

In the absence of guideline recommendations specific for patients with pancreatic insufficiency after gastrectomy, a panel of experts from different geographical regions convened in a virtual meeting to discuss their approach to patient management.

Expert opinion

Pancreatic insufficiency after gastrointestinal surgery is not a simple post-surgical complication as several factors contribute to its development. Although the pancreas is unimpaired after gastrectomy, it cannot function normally in the altered environment. Pancreatic insufficiency can be challenging to diagnose in gastrectomy patients due to nonspecific symptoms and the absence of a simple diagnostic test. Fecal elastase appears to be the default test, although it is not sufficiently sensitive nor reliable for diagnosing or monitoring PEI. Patients with maldigestion symptoms after gastrectomy are treated pragmatically: those with clinical suspicion of pancreatic insufficiency receive a trial of PERT and are monitored for symptom improvement. There is a clear need for high-quality evidence from clinical trials to guide the management of this patient population.

KEYWORDS:

• Pancreatic exocrine insufficiency
• gastrectomy
• pancreatic enzyme replacement therapy
• maldigestion syndrome
• expert opinion

Article highlights

• Most patients who undergo partial or total gastrectomy for cancer or gastric ulcers develop a postoperative maldigestion syndrome that can cause morbidity and reduce quality of life.

• Evidence-based recommendations specific to the management of maldigestion syndrome in gastrectomy patients are lacking.

• A panel of surgeons from five countries (Australia, Germany, Italy, the Netherlands, United Kingdom) convened virtually to share their personal experience and institutional approach to the diagnosis and management of gastrectomy patients.

• A major cause of maldigestion syndrome after gastrectomy is asynchrony between the intestinal transit of food and delivery of pancreatic enzymes. Other contributors include nerve lesions, radiotherapy, hormonal factors, and anatomical reconstructions.

• Diagnosing pancreatic insufficiency in gastrectomy patients is complicated by the nonspecific nature of the symptoms and the absence of a simple diagnostic test.

• Early detection and appropriate treatment of postoperative maldigestion syndrome are best provided by a multidisciplinary team comprising physicians (surgeon, oncologist, gastroenterologist), specialist nurses, and dieticians.

• The current management approach is pragmatic: patients with a clinical suspicion of pancreatic insufficiency are prescribed pancreatic enzyme replacement therapy and monitored for symptom improvement.

• High-quality evidence from well-conducted clinical trials is required to guide the management of gastrectomy patients in future.

Declaration of Interest

D Croagh was supported by Viatris who provided a research grant to his department at Monash University. He received an honorarium for participation in this advisory board. MI van Berge Henegouwen is a consultant for Viatris, Johnson & Johnson, Alesi Surgical, Braun, Stryker and Medtronic. All fees were paid to institution. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

Writing assistance for this article was provided by Content Ed Net (Madrid, Spain).

Additional information

Funding

The advisory board meeting was sponsored by Viatris.