Brazilian consensus- and evidence-based recommendations in the diagnosis and treatment of pancreatic exocrine insufficiency in patients after digestive surgeries. Position paper of six brazilian medical societies of surgery

Consenso brasileiro e recomendações baseadas em evidências no diagnóstico e tratamento da insuficiência exócrina do pâncreas em pacientes após cirurgias do aparelho digestive. Posicionamento de seis Sociedades Médicas Brasileiras de Cirurgia

ABSTRACT

Background:  Exocrine pancreatic insufficiency (EPI) is a condition characterized by reduced exocrine secretion, leading to decreased food digestion, and digestive tract surgeries can be a cause. Postoperative “de novo” EPI is defined as the onset of digestive symptoms following surgeries, which show significant improvement after the initiation of pancreatic enzyme replacement therapy (PERT). The diagnosis of postoperative EPI may be delayed due to mild or nonspecific symptoms, both in pancreatic surgeries and in upper abdominal surgeries.

Aims:  The aim of this study was to conduct a systematic review on the diagnosis and treatment of “de novo” EPI related to digestive surgeries, in collaboration with the development of a consensus among the main surgical societies in Brazil.

Methods:  The steering committee developed 10 questions related to two areas of interest: diagnosis and treatment. A systematic review was conducted for each of the domains. The evidence was assessed for quality using the GRADEpro tool. Recommendations were formulated for each of the questions. The final report was reviewed by representatives of the surgical societies for the consolidation and approval of the recommendations through a modified Delphi system.

Results:  “De novo” EPI should be considered in case of the onset of postoperative digestive symptoms. Diagnostic methods vary in complexity of execution, with varying sensitivity and specificity in the postoperative condition. Fecal Elastase-1 (FE-1) has limited value in diagnosing EPI in the postoperative setting. PERT can be initiated based on clinical suspicion, and there is no difference in approach regarding the type of surgery performed. PERT should be started at the appropriate dose for the intensity of symptoms and adjusted up or down according to symptom control. Proper treatment of EPI leads to symptom improvement and an increase in quality of life. PERT should be maintained as long as patients have a favorable clinical response.

Conclusions:  The recommendations encompass the diagnosis and treatment of “de novo” EPI and can serve as a basis for the establishment of educational programs led by the participating surgical societies.

Keywords:
Exocrine pancreatic insufficiency; Surgery; Pancreatectomy; Esophagectomy; Gastrectomy; Bariatric surgery; Consensus

ARTICLE HIGHLIGHTS

• Biliopancreatic and upper gastrointestinal surgeries are risk factors for the development of exocrine pancreatic insufficiency (EPI).

• The diagnosis of EPI is based on clinical suspicion, the presence of digestive symptoms, and laboratory tests. Active investigation of the diagnosis allows for early initiation of pancreatic enzyme replacement therapy (PERT) and reduces the risk of long-term complications.

• The first Brazilian consensus among surgical societies related to EPI led to the development of recommendations for its diagnosis, therapeutic planning, and long-term follow-up.

CENTRAL MESSAGE  Exocrine pancreatic insufficiency (EPI) is a condition in which the pancreas does not produce sufficient digestive enzymes for the proper digestion and absorption of nutrients. When left untreated, it can lead to steatorrhea, nutrient loss, chronic malnutrition, osteoporosis, and long-term impairment of quality of life. The most common cause is chronic pancreatitis, resulting from factors such as alcoholism, genetic alterations, cystic fibrosis, or obstructive conditions of the pancreas, including pancreatic tumors. Gastrointestinal surgeries may lead to the development of EPI in previously healthy patients, a condition known as “de novo” EPI. After partial or total pancreatectomy, EPI can occur in 15-100% of patients. Among upper gastrointestinal surgeries, “de novo” EPI occurs in 16-60% of cases after esophagectomy, 9-48% after bariatric surgery, and 30-100% after gastrectomy. In these cases, the cause is related to the loss of integrity of the esophagus-gastro-duodenal axis, with suppression of hormonal stimuli (cholecystokinin and secretin) and postprandial gastrointestinal asynchrony.

PERSPECTIVES  Pancreatic and upper gastrointestinal surgeries are significant risk factors for “de novo” EPI or aggravate it if already present. Subclinical manifestations, nonspecific symptoms, and lack of awareness may delay EPI diagnosis, leading to nutritional impairment and reduced quality of life. The role of this first Brazilian consensus, validated by national surgical societies, is to serve as a foundation for the development of educational and training programs for surgeons.