Pancreatic enzyme replacement therapy: exocrine pancreatic insufficiency after gastrointestinal surgery

Exocrine pancreatic insufficiency (EPI) and resultant maldigestion occurs in up to 80% of patients following gastric, duodenal or pancreatic surgery. Accurate diagnosis is required to determine the appropriate intervention, but the conventional method of faecal fat quantification is time-consuming and not always readily available. The optimized (13)C-mixed triglyceride ((13)C-MTG) breath test is an accurate alternative post-surgery. Pancreatic enzyme replacement therapy (PERT) is indicated post-surgery in patients with clinically evident steatorrhoea, weight loss or maldigestion-related symptoms. Given its favourable safety profile, PERT is also appropriate in asymptomatic patients with high faecal fat excretion as such patients are at high risk for nutritional deficits. However, published data evaluating PERT in this setting are limited. Uncoated powder preparations may be preferred in cases of low gastric acidity and partial or total gastric resection. In clinical studies, enteric-coated microspheres were associated with greater weight gain after surgery vs. uncoated preparations. This was confirmed in a recent study using the (13)C-MTG breath test; fat absorption increased from <40% without therapy to almost 60% with enteric-coated minimicrospheres (40 000 lipase units/meal), with >60% of patients achieving normal breath test results (i.e. normal fat digestion) during PERT. A therapeutic algorithm for the treatment of EPI after surgery is also discussed.