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

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.