Enzyme replacement following total pancreatectomy; population analysis

Introduction: Total pancreatectomy (TPE) inevitably leads to absolute exocrine pancreatic insufficiency (EPI). No specific recommendations are available for enzyme replacement in such cases. The aim of our analysis was to explore the actual EPI replacement rates among patients following TPE after a certain period of time from the surgery. Methods: This retrospective analysis of living patients who had undergone TPE more than 2 years ago was done using a simple questionnaire to investigate the following: BMI prior to TPE, 3 months after TPE and at the time of data collection (in 2022), together with the actual number of daily bowel movements; and the replacement characteristics – the daily dose, its scheme and subjective satisfaction evaluation. Results: In total, we obtained data from 26 living patients with the history of TPE with their median follow up of 56 months (30–157). Malignant disease was confirmed in 69% patients based on histology; a benign tumor was present in the rest, although malignancy had been suspected preoperatively. Median BMI decreased from preoperative 27.4 (19.1–41.1) to 24.1 (19.8–33.7) 3 months following TPE, and median BMI value of 25.5 (21.2–34.5) was established at 30–157 months from TPE. The mean number of daily bowel movements was 2.2 (median 2, range 1–8) and the mean daily replacement dose was 182,000 units of lipase (median 175,000 u., range 0–250,000 u.) at the time of our investigation. Subjective satisfaction was reported by 85% responders and a lack of satisfaction despite maximum EPI replacement was expressed by 15% responders. Conclusion: BMI decreased shortly after TPE. In the long term, up to 80% of the patients achieved preoperative BMI values ±10% after TPE. Due to persistent steatorrhea and more frequent bowel movements despite enzyme replacement, 15% of the patients remained subjectively dissatisfied after TPE, but 85% of the patients did not perceive even more frequent bowel movements as unpleasant and were satisfied with their condition. The need of individualized enzyme replacement therapy of EPI following TPE is evident.