Brazilian consensus- and evidence-BASED RECOMMENDATIONS in the diagnosis and treatment of PANCREATIC EXOCRINE insufficiency in patients AFTER digestive surgeries.

Andre Luis  Montagnini; Ulysses Ribeiro Junior; Jose  Jukemura; Estela Regina  Figueira; Maira Andrade Nacimbem  Marzinotto; Anna Carolina Batista  Dantas; Antonio Carlos  Valezi; Marcus Fernando Kodama  Pertille; Nora Manoukian  Forones; Guilherme de Andrade Gagheggi Ravanini; Pedro  Portari Filho; Alexandre Ferreira  Oliveira; Rodrigo Nascimento  Pinheiro; Alessandro Landskron  Diniz; Cassio Virgílio Cavalcante de  Oliveira; Claudemiro  Quireze Junior; Paulo  Kassab; Wanderley Marques  Bernardo; Paulo  Herman

doi:10.1590/0102-67202025000042e1911

article.authors690e8a0707fec

Andre Luis Montagnini Universidade de São Paulo https://orcid.org/0000-0002-9575-9196
- Conceptualization
- Investigation
- Data Curation
- Writing – Original Draft Preparation
- Visualization
Ulysses Ribeiro Junior Universidade de São Paulo https://orcid.org/0000-0003-1711-7347
- Conceptualization
Jose Jukemura Universidade de São Paulo https://orcid.org/0000-0002-3943-7088
- Data Curation
Estela Regina Figueira Universidade de São Paulo https://orcid.org/0000-0002-7856-8670
- Data Curation
- Writing – Original Draft Preparation
Maira Andrade Nacimbem Marzinotto Universidade de São Paulo https://orcid.org/0000-0001-8432-8617
- Data Curation
- Writing – Original Draft Preparation
Anna Carolina Batista Dantas Universidade de São Paulo https://orcid.org/0000-0001-9505-6784
- Data Curation
Antonio Carlos Valezi Universidade Estadual de Londrina https://orcid.org/0000-0003-3940-1525
- Data Curation
Marcus Fernando Kodama Pertille Universidade de São Paulo https://orcid.org/0000-0003-0200-7858
- Data Curation
- Writing – Original Draft Preparation
Nora Manoukian Forones Universidade Federal de São Paulo https://orcid.org/0000-0001-9414-0343
- Data Curation
Guilherme de Andrade Gagheggi Ravanini Universidade Federal do Estado do Rio de Janeiro https://orcid.org/0000-0002-4969-5742
- Data Curation
Pedro Portari Filho Universidade Federal do Estado do Rio de Janeiro https://orcid.org/0000-0001-9676-6358
- Data Curation
Alexandre Ferreira Oliveira Universidade Federal de Juiz de Fora https://orcid.org/0000-0002-7500-6752
- Data Curation
Rodrigo Nascimento Pinheiro Hospital de Base https://orcid.org/0000-0002-2715-7628
- Data Curation
Alessandro Landskron Diniz AC Camargo Hospital https://orcid.org/0000-0001-9671-2026
- Data Curation
Cassio Virgílio Cavalcante de Oliveira Universidade Federal de Goiás https://orcid.org/0000-0001-8385-7656
- Data Curation
Claudemiro Quireze Junior Universidade de São Paulo https://orcid.org/0000-0002-5569-5052
- Data Curation
Paulo Kassab Universidade de São Paulo https://orcid.org/0000-0002-5115-6297
- Data Curation
Wanderley Marques Bernardo Universidade de São Paulo https://orcid.org/0000-0002-8597-5207
- Investigation
- Methodology
- Writing – Original Draft Preparation
- Data Curation
Paulo Herman Universidade de São Paulo https://orcid.org/0000-0003-2859-5846
- Conceptualization

DOI:

https://doi.org/10.1590/0102-67202025000042e1911

Palavras-chave:

Pancreatic exocrine insufficiency, surgery, pancreatectomy, esophagectomy, gastrectomy, bariatric surgery

Resumo

Background: Pancreatic exocrine insufficiency (PEI) is a condition characterized by reduced exocrine secretion, leading to decreased food digestion, and digestive tract surgeries can be a cause. Postoperative de novo PEI 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 PEI 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 PEI 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 PEI 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 PEI 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 PEI 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.