Fat malabsorption and reduced exocrine pancreatic function after gastroesophageal cancer surgery

Patients post-gastroesophageal cancer surgery frequently present with clinical features of malabsorption and are often treated empirically with pancreatic enzyme replacement therapy (PERT). Primary aim was to objectify the presence of fat malabsorption in patients after gastroesophageal surgery and, secondary, to measure exocrine pancreatic function.

Eligible patients were those who underwent gastroesophageal cancer surgery (2017-2021), were at least six months post-surgery, maintained an oral diet, and showed no evidence of recurrent disease. Treatment with PERT was ceased prior to this study. Fecal fat balance test (coefficient of fat absorption, CFA (%)) was used to measure absorption of fat. The CFA was determined by collecting feces over three days to measure daily fecal fat excretion (g/d), along with a four-day (weighted) nutritional diary, to establish the average daily fat intake (g/d). Fat malabsorption was defined as a CFA <85%. Exocrine pancreatic function was measured using fecal elastase-1 (FE-1).

We included 90 patients (50 after esophagectomy with gastric tube reconstruction and 40 after (sub)total gastrectomy with Roux-en-Y reconstruction). Fecal analysis were conducted at a median of 17 months (IQR 11-28) post-surgery. A CFA <85% was found in 24% of patients after gastric tube reconstruction, accompanied by low levels of FE-1 in 33%. After Roux-en-Y reconstruction a CFA <85% was present in 43%, of which 71% had low levels of FE-1.

Fat malabsorption is common after gastrectomy with Roux-en-Y reconstruction and after esophagectomy with gastric tube reconstruction, partly accompanied by reduced FE-1 levels. Clinicians should remain alert to malabsorption during follow-up and an empirical trial with PERT can be considered, although further studies are needed to evaluate its effects on absorption, symptoms, and quality of life.