Abstract
Background: Treatment with pancreatic enzymes is necessary to improve nutrient digestion and to prevent malabsorption in patients with exocrine pancreatic insufficiency (EPI) after pancreatoduodenectomy. Aim of this study was to identify the optimal dosage of pancreatic enzymes in patients with EPI after pancreatoduodenectomy based on studies available and to evaluate if patients in our cohort are treated adequately.
Methods: A systematic review of literature was performed to identify all randomized controlled trials reporting on the effect of treatment with pancreatic enzymes on nutritional parameters after pancreatoduodenectomy. Alongside a prospective observational study was performed, where the administered dosage of pancreatic enzymes was evaluated by a questionnaire in patients after pancreatoduodenectomy with EPI (defined as fat absorption < 85 %), and was compared to their dietary fat intake. Endpoints of this study were (1) the percentage of patients that received an adequate dosage based on the results of the systematic literature study, (2) the ratio between reported dose lipase (PhEur units) and fat intake (g), and reported dose of protease (PhEur units) and protein intake (g).
Results: The systematic review revealed three randomized controlled trials, their results indicate that an effective dosage of pancreatic enzymes to treat EPI following pancreatoduodenectomy should consists of at least 40000 PhEur units lipase per main meal. Twenty-nine patients with EPI after pancreatoduodenectomy were included in the prospective study. The recommended dosage (minimum 40000 PhEur units of lipase) was administered in 52% of the patients. The lowest ratio of the PhEur units of lipase per gram dietary fat intake was observed during dinner (2521 ±1770 units/gram fat) and the highest ratio was observed during breakfast (4441 ± 6936 units/gram fat).
Conclusion: According to the cut-off of minimal 40000 PhEur units of lipase per main meal, only half of the patients are using the minimum dosage of pancreatic enzymes. The variability between the ratios of the reported dose of lipase (PhEur units) and fat intake (g) fat intake per main meals is large and prescribing pancreatic enzymes adjusted to fat intake (as ratio’s) seems more appropriate.