Pancreatic exocrine insufficiency after pancreaticoduodenectomy: Current evidence and management

Table 1 Definitions of Pancreatic Exocrine Insufficiency after pancreaticoduodenectomy

Ref.	Definition of pancreatic exocrine insufficiency
Sabater et al[8]	Condition wherein the amount of pancreatic secretions is not enough to maintain normal digestion
Ghaneh et al[28]	Need for new pharmacological intervention for exocrine insufficiency i.e. PERT
Sikkens et al[11]	Faecal elastase-1 < 0.200 mg/g of faeces
Halloran et al[29]	Coefficient of fat absorption < 93%
Domínguez-Muñoz et al[30]	13C-mixed triglyceride test (Percent cumulative dose of < 5% of 13CO2 at 7 h)
Yamaguchi et al[31]	BT-PABA excretion rate of < 70%
Kato et al[32]	Abnormal secretin stimulation test
Perez et al[33]	72 h faecal fat estimation
Fang et al[34]	Faecal chymotrypsin estimation

PERT: Pancreatic enzyme replacement therapy.

Table 2 Biochemical tests in the assessment of pancreatic exocrine insufficiency

Nutritional assessment	Evaluation of pancreatic function
	Exocrine markers	Markers of malabsorption
Fat soluble vitamins	Faecal elastase-1	72 h faecal fat estimation
Bone profile	Faecal chymotrypsin	BT-PABA absorption
Iron and Ferritin studies	Secretin stimulation test	13C labelled trioctanoin breath test
Micronutrient status
Glycaemic status

PABA: Para-aminobenzoic acid.

Table 3 Incidence of pancreatic exocrine insufficiency before and after pancreaticoduodenectomy

Ref.	Pre-operative incidence of PEI	Post-operative incidence of PEI	Diagnostic test
Kato et al[32]	93%	80%	Secretin stimulation
Halloran et al[29]	-	55%	Coefficient of fat absorption
Yuasa et al[42]	-	64%	13C- mixed triglyceride test
Nakamura et al[9]	-	62.3%
Hirono et al[43]	-	51%
Benini et al[41]	-	87.5%	72 h faecal fat estimation
Lemaire et al[44]	-	94%
Sato et al[45]	46%	33%	BT-PABA excretion
Fujino et al[46]	-	75%
Matsumoto et al[47]	68%	50%	Faecal elastase-1
Van der Gaag et al[48]	-	59%
Tran et al[49]	-	91%
Pessaux et al[50]	-	95%
Jang et al[51]	-	100%
Falconi et al[52]	-	24%	Faecal chymotrypsin
Fang et al[34]	-	33%
Bock et al[53]	-	52.8%	Steatorrhoea
Rault et al[54]	-	42%
Van Berge Henegouwen et al[55]	-	64.5%

PEI: Pancreatic exocrine insufficiency; PABA: Para-aminobenzoic acid.

Table 4 Incidence of pancreatic exocrine insufficiency after pancreaticoduodenectomy–evidence on the role of the type of pancreatic reconstruction

Ref.	Diagnostic test	Incidence of PEI–Pancreaticogastrostomy	Incidence of PEI–Pancreaticojejunostomy
Nakamura et al[9]	13C Triglyceride breath test	62.3%	-
Lemaire et al[44]	Faecal Fat excretion and faecal elastase-1	100%	-
Jang et al[51]	Faecal elastase-1	100% (severe)	75% (severe); 20% (mild)
Roeyen et al[63]	Need for PERT +/- any abnormal pancreatic function test	75%	45.7% (P < 0.001)
Rault et al[54]	Steatorrhoea	70%	21.7% (P < 0.025)

PEI: Pancreatic exocrine insufficiency; PERT: Pancreatic enzyme replacement therapy.