Treatment of pancreatic exocrine insufficiency in patients undergoing pancreaticoduodenectomy: a systematic review and cross-sectional study

Abstract

Background: Pancreatic exocrine insufficiency (PEI) is frequently seen in patients with pancreatic cancer (PC), particularly post-pancreaticoduodenectomy (PD). Manifestations of PEI contribute to nutritional complications, reduced quality of life and decreased survival. Pancreatic enzyme replacement therapy (PERT) is well established as the mainstay of pharmacological treatment for PEI, however, PEI remains undertreated and underdiagnosed. Research is limited that investigates this in the context of PC in Australasia. Methods: This thesis included two studies: a systematic review and a cross-sectional survey. Firstly, a systematic review was conducted to investigate the postoperative prevalence of PERT prescription in patients post-PD globally. Secondly, an online survey was conducted to investigate the practices and experiences of clinicians in Australasia in prescribing and monitoring PERT to patients with pancreatic cancer. Results: The systematic review revealed a postoperative prevalence of PERT prescription ranging from 13-97%, alongside a median prevalence of 51%, with significant variation by country and continent. In the cross-sectional survey, 41.8% (46/110) of Australasian clinicians routinely prescribe PERT to patients post-PD in their practice, suggesting that approximately 60% of Australasian clinicians are not routinely commencing PERT in this patient population. 37.3% (41/110) of clinicians reported prescribing PERT in alignment with the Australasian guidelines. Conclusion: Collectively, these results suggest that PEI is being undertreated with PERT globally, and the clinical consequences of this are substantial. Investigations diagnosing PEI and ensuring PERT adequacy are underutilised by clinicians in Australasia. An education programme is warranted to provide clear guidelines for optimal use of PERT and its effects on postoperative outcomes in PC.