Indication for Pancreatic Enzyme Substitution following Gastric Resection

The present review addresses the problems resulting from disturbances in exocrine pancreatic function and adaptation following partial or total gastrectomy, the ability to diagnose them and some options for their treatment. Patients who have had gastric or pancreatic surgery frequently develop a maldigestion syndrome which significantly affects their quality of life and their professional and social rehabilitation. One major cause of maldigestion in these patients is exocrine pancreatic insufficiency, with asynchrony of gastrointestinal hormone release. The principal associated symptoms are steathorrea, meteorism and weight loss. If maldigestion occurs, the exocrine pancreatic function should be measured by indirect or direct pancreatic function tests, and, if necessary, pancreatic enzyme treatment can be initiated. Pancreatic enzyme substitution, used in combination with a high-energy diet and distributed over 6–8 meals per day, may improve the postoperative nutritional status and the often non-specific symptoms in these patients, although randomized cross-over studies with larger patient populations proving a benefit of enzyme substitution are still missing and there is evidence that many patients with maldigestion and exocrine pancreatic insufficiency after gastrectomy do not respond adequately to pancreatic enzyme substitution. The required dose of the pancreatic enzyme must be individually adjusted in order to prevent underestimation or overestimation, and it must be kept in mind that there exists no linear relationship between the dose of the pancreatic enzyme and the symptoms of maldigestion. Restriction of the daily amount of fat ingested, or addition of intestinal motility inhibitors and gastric acid blockers in patients with partial gastrectomy might improve the efficiency of pancreatic enzyme substitution in these patients.