Pancreatic exocrine insufficiency following pancreatoduodenectomy: A prospective bi-center study

V J Kroon; L A Daamen; D S J Tseng; A Roele- de Vreugd; L J H Brada; O R Busch; T C Derksen; A Gerritsen; S J E Rombouts; F J Smits; M S Walma; R A W Wennink; M G Besselink; H C van Santvoort; I Q Molenaar

doi:10.1016/j.pan.2022.08.002

Pancreatic exocrine insufficiency following pancreatoduodenectomy: A prospective bi-center study

V J Kroon, L A Daamen, D S J Tseng, A Roele- de Vreugd, L J H Brada, O R Busch, T C Derksen, A Gerritsen, S J E Rombouts, F J Smits, M S Walma, R A W Wennink, M G Besselink, H C van Santvoort, I Q Molenaar

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Abstract

BACKGROUND/OBJECTIVES: Pancreatic exocrine insufficiency (PEI) is a common complication following pancreatoduodenectomy (PD) leading to malnutrition. The course of PEI and related symptoms and vitamin deficiencies is unknown. This study aimed to assess the (long-term) incidence of PEI and vitamin deficiencies after PD.

METHODS: A bi-centre prospective observational cohort study was performed, including patients who underwent PD for mainly pancreatic and periampullary (pre)malignancies (2014-2018). Two cohorts were formed to evaluate short and long-term results. Patients were followed for 18 months and clinical symptoms were evaluated by questionnaire. PEI was based on faecal elastase-1 (FE-1) levels and/or clinical symptoms.

RESULTS: In total, 95 patients were included. After three months, all but three patients had developed PEI and 27/29 (93%) patients of whom stool samples were available showed abnormal FE-1 levels, which did not improve during follow-up. After six months, all patients had developed PEI. During follow-up, symptoms resolved in 35%-70% of patients. Vitamin D and K deficiencies were observed in 48%-79% of patients, depending on the moment of follow-up; 0%-50% of the patients with deficiencies received vitamin supplementation.

DISCUSSION: This prospective study found a high incidence of PEI after PD with persisting symptoms in one-to two thirds of all patients. Limited attention was paid to vitamin deficiencies. Improved screening and treatment strategies for PEI and vitamins need to be designed.

Original language	English
Pages (from-to)	1020-1027
Number of pages	8
Journal	Pancreatology
Volume	22
Issue number	7
DOIs	https://doi.org/10.1016/j.pan.2022.08.002
Publication status	Published - Nov 2022

Keywords

Exocrine Pancreatic Insufficiency/epidemiology
Humans
Pancreas
Pancreaticoduodenectomy/adverse effects
Prospective Studies
Vitamin A
pancreatic cancer
pancreatic surgery
pancreatic enzyme replacement therapy
Pancreatic exocrine insufficiency

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1-s2.0-S1424390322004732-mainFinal published version, 869 KBLicence: CC BY

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Kroon, V. J., Daamen, L. A., Tseng, D. S. J., de Vreugd, A. R., Brada, L. J. H., Busch, O. R., Derksen, T. C., Gerritsen, A., Rombouts, S. J. E., Smits, F. J., Walma, M. S., Wennink, R. A. W., Besselink, M. G., van Santvoort, H. C., & Molenaar, I. Q. (2022). Pancreatic exocrine insufficiency following pancreatoduodenectomy: A prospective bi-center study. Pancreatology, 22(7), 1020-1027. https://doi.org/10.1016/j.pan.2022.08.002

@article{78ea0ecc02fd4cdfad24282455fe7bf0,

title = "Pancreatic exocrine insufficiency following pancreatoduodenectomy: A prospective bi-center study",

abstract = "BACKGROUND/OBJECTIVES: Pancreatic exocrine insufficiency (PEI) is a common complication following pancreatoduodenectomy (PD) leading to malnutrition. The course of PEI and related symptoms and vitamin deficiencies is unknown. This study aimed to assess the (long-term) incidence of PEI and vitamin deficiencies after PD.METHODS: A bi-centre prospective observational cohort study was performed, including patients who underwent PD for mainly pancreatic and periampullary (pre)malignancies (2014-2018). Two cohorts were formed to evaluate short and long-term results. Patients were followed for 18 months and clinical symptoms were evaluated by questionnaire. PEI was based on faecal elastase-1 (FE-1) levels and/or clinical symptoms.RESULTS: In total, 95 patients were included. After three months, all but three patients had developed PEI and 27/29 (93%) patients of whom stool samples were available showed abnormal FE-1 levels, which did not improve during follow-up. After six months, all patients had developed PEI. During follow-up, symptoms resolved in 35%-70% of patients. Vitamin D and K deficiencies were observed in 48%-79% of patients, depending on the moment of follow-up; 0%-50% of the patients with deficiencies received vitamin supplementation.DISCUSSION: This prospective study found a high incidence of PEI after PD with persisting symptoms in one-to two thirds of all patients. Limited attention was paid to vitamin deficiencies. Improved screening and treatment strategies for PEI and vitamins need to be designed.",

keywords = "Exocrine Pancreatic Insufficiency/epidemiology, Humans, Pancreas, Pancreaticoduodenectomy/adverse effects, Prospective Studies, Vitamin A, pancreatic cancer, pancreatic surgery, pancreatic enzyme replacement therapy, Pancreatic exocrine insufficiency",

author = "Kroon, {V J} and Daamen, {L A} and Tseng, {D S J} and {de Vreugd}, {A Roele-} and Brada, {L J H} and Busch, {O R} and Derksen, {T C} and A Gerritsen and Rombouts, {S J E} and Smits, {F J} and Walma, {M S} and Wennink, {R A W} and Besselink, {M G} and {van Santvoort}, {H C} and Molenaar, {I Q}",

note = "Funding Information: This work was supported by an unrestricted research grant from Mylan Healthcare B.V., a Viatris company and from the University Medical Center Utrecht , Utrecht, the Netherlands. Funding Information: The diagnosis of PEI is generally based upon clinical symptoms and can be supported by laboratory faecal testing. Typical manifestations of PEI include steatorrhea, weight loss, muscle wasting, foul smelling stools, malabsorption, and flatulence [2,7,8]. Malabsorption caused by PEI, resulting in malnutrition, can be reflected by the presence of serum vitamin A, D, E and K deficiencies [9]. Laboratory tests are direct tests such as 72-h faecal fat excretion, and indirect tests such as faecal elastase-1 (FE-1) [10]. Of these, FE-1 testing is most commonly used, as it is easy, quick and non-invasive. Elastase-1 is an enzyme produced by the pancreas and excreted in the faeces, which gives an approximation of the pancreatic exocrine function [11]. Nevertheless, the diagnostic accuracy of FE-1 is only moderate, given that its correlation with severity of clinical symptoms following resection for (pre)malignancies was found to be mediocre [ 11–13].This work was supported by an unrestricted research grant from Mylan Healthcare B.V., a Viatris company and from the University Medical Center Utrecht, Utrecht, the Netherlands. Publisher Copyright: {\textcopyright} 2022 The Authors",

year = "2022",

month = nov,

doi = "10.1016/j.pan.2022.08.002",

language = "English",

volume = "22",

pages = "1020--1027",

journal = "Pancreatology",

issn = "1424-3903",

publisher = "S. Karger AG",

number = "7",

}

Kroon, VJ, Daamen, LA, Tseng, DSJ, de Vreugd, AR, Brada, LJH, Busch, OR, Derksen, TC, Gerritsen, A, Rombouts, SJE, Smits, FJ, Walma, MS, Wennink, RAW, Besselink, MG, van Santvoort, HC & Molenaar, IQ 2022, 'Pancreatic exocrine insufficiency following pancreatoduodenectomy: A prospective bi-center study', Pancreatology, vol. 22, no. 7, pp. 1020-1027. https://doi.org/10.1016/j.pan.2022.08.002

TY - JOUR

T1 - Pancreatic exocrine insufficiency following pancreatoduodenectomy

T2 - A prospective bi-center study

AU - Kroon, V J

AU - Daamen, L A

AU - Tseng, D S J

AU - de Vreugd, A Roele-

AU - Brada, L J H

AU - Busch, O R

AU - Derksen, T C

AU - Gerritsen, A

AU - Rombouts, S J E

AU - Smits, F J

AU - Walma, M S

AU - Wennink, R A W

AU - Besselink, M G

AU - van Santvoort, H C

AU - Molenaar, I Q

N1 - Funding Information: This work was supported by an unrestricted research grant from Mylan Healthcare B.V., a Viatris company and from the University Medical Center Utrecht , Utrecht, the Netherlands. Funding Information: The diagnosis of PEI is generally based upon clinical symptoms and can be supported by laboratory faecal testing. Typical manifestations of PEI include steatorrhea, weight loss, muscle wasting, foul smelling stools, malabsorption, and flatulence [2,7,8]. Malabsorption caused by PEI, resulting in malnutrition, can be reflected by the presence of serum vitamin A, D, E and K deficiencies [9]. Laboratory tests are direct tests such as 72-h faecal fat excretion, and indirect tests such as faecal elastase-1 (FE-1) [10]. Of these, FE-1 testing is most commonly used, as it is easy, quick and non-invasive. Elastase-1 is an enzyme produced by the pancreas and excreted in the faeces, which gives an approximation of the pancreatic exocrine function [11]. Nevertheless, the diagnostic accuracy of FE-1 is only moderate, given that its correlation with severity of clinical symptoms following resection for (pre)malignancies was found to be mediocre [ 11–13].This work was supported by an unrestricted research grant from Mylan Healthcare B.V., a Viatris company and from the University Medical Center Utrecht, Utrecht, the Netherlands. Publisher Copyright: © 2022 The Authors

PY - 2022/11

Y1 - 2022/11

N2 - BACKGROUND/OBJECTIVES: Pancreatic exocrine insufficiency (PEI) is a common complication following pancreatoduodenectomy (PD) leading to malnutrition. The course of PEI and related symptoms and vitamin deficiencies is unknown. This study aimed to assess the (long-term) incidence of PEI and vitamin deficiencies after PD.METHODS: A bi-centre prospective observational cohort study was performed, including patients who underwent PD for mainly pancreatic and periampullary (pre)malignancies (2014-2018). Two cohorts were formed to evaluate short and long-term results. Patients were followed for 18 months and clinical symptoms were evaluated by questionnaire. PEI was based on faecal elastase-1 (FE-1) levels and/or clinical symptoms.RESULTS: In total, 95 patients were included. After three months, all but three patients had developed PEI and 27/29 (93%) patients of whom stool samples were available showed abnormal FE-1 levels, which did not improve during follow-up. After six months, all patients had developed PEI. During follow-up, symptoms resolved in 35%-70% of patients. Vitamin D and K deficiencies were observed in 48%-79% of patients, depending on the moment of follow-up; 0%-50% of the patients with deficiencies received vitamin supplementation.DISCUSSION: This prospective study found a high incidence of PEI after PD with persisting symptoms in one-to two thirds of all patients. Limited attention was paid to vitamin deficiencies. Improved screening and treatment strategies for PEI and vitamins need to be designed.

AB - BACKGROUND/OBJECTIVES: Pancreatic exocrine insufficiency (PEI) is a common complication following pancreatoduodenectomy (PD) leading to malnutrition. The course of PEI and related symptoms and vitamin deficiencies is unknown. This study aimed to assess the (long-term) incidence of PEI and vitamin deficiencies after PD.METHODS: A bi-centre prospective observational cohort study was performed, including patients who underwent PD for mainly pancreatic and periampullary (pre)malignancies (2014-2018). Two cohorts were formed to evaluate short and long-term results. Patients were followed for 18 months and clinical symptoms were evaluated by questionnaire. PEI was based on faecal elastase-1 (FE-1) levels and/or clinical symptoms.RESULTS: In total, 95 patients were included. After three months, all but three patients had developed PEI and 27/29 (93%) patients of whom stool samples were available showed abnormal FE-1 levels, which did not improve during follow-up. After six months, all patients had developed PEI. During follow-up, symptoms resolved in 35%-70% of patients. Vitamin D and K deficiencies were observed in 48%-79% of patients, depending on the moment of follow-up; 0%-50% of the patients with deficiencies received vitamin supplementation.DISCUSSION: This prospective study found a high incidence of PEI after PD with persisting symptoms in one-to two thirds of all patients. Limited attention was paid to vitamin deficiencies. Improved screening and treatment strategies for PEI and vitamins need to be designed.

KW - Exocrine Pancreatic Insufficiency/epidemiology

KW - Humans

KW - Pancreas

KW - Pancreaticoduodenectomy/adverse effects

KW - Prospective Studies

KW - Vitamin A

KW - pancreatic cancer

KW - pancreatic surgery

KW - pancreatic enzyme replacement therapy

KW - Pancreatic exocrine insufficiency

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U2 - 10.1016/j.pan.2022.08.002

DO - 10.1016/j.pan.2022.08.002

M3 - Article

C2 - 35961936

SN - 1424-3903

VL - 22

SP - 1020

EP - 1027

JO - Pancreatology

JF - Pancreatology

IS - 7

ER -

Pancreatic exocrine insufficiency following pancreatoduodenectomy: A prospective bi-center study

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