EFFECTS OF A STANDARDIZED PANCREATIC EXOCRINE INSUFFICIENCY CARE PROTOCOL ON WEIGHT RECOVERY, CHEMOTHERAPY FEASIBILITY, AND ONCOLOGIC OUTCOMES AFTER PANCREATECTOMY
Poowanon Saksiri1, Thakerng Pitakteerabundit1, Tortrakoon Thongkan1, Siriyupa kaewbunsri1, Ponlagrit Kumwichar11. Prince of Songkla University Faculty of Medicine, Hat Yai, Songkhla, Thailand.
Background: Pancreatic exocrine insufficiency (PEI) is a frequent consequence of pancreatectomy, contributing to malnutrition, delayed postoperative recovery, and reduced ability to initiate adjuvant chemotherapy. Although pancreatic enzyme replacement therapy (PERT) is widely recommended, its real-world clinical impact remains uncertain. This study assessed postoperative weight trajectory, chemotherapy feasibility, and oncologic outcomes before and after implementation of a standardized postoperative PEI care protocol.
Methods: A retrospective cohort of adult patients who underwent pancreatectomy from April 2017 to March 2025 was analyzed. A standardized PERT protocol, introduced in October 2021, included routine enzyme supplementation and blood-based assessment of micronutrient status (iron, magnesium, zinc, copper, folate, vitamin B12). Patients were grouped into pre-protocol and post-protocol cohorts. Longitudinal analyses incorporated inverse probability of treatment weighting (IPTW) to balance pre- and post-protocol characteristics.
Results: Of 324 eligible patients, 318 were analyzed (156 pre-protocol; 162 post-protocol). Rates of clinically relevant postoperative pancreatic fistula were comparable (5.1% vs 4.5%). After IPTW adjustment, 161 patients remained in the pre-protocol group and 154 in the post-protocol group. All patients experienced postoperative weight loss, but patterns differed substantially. The post-protocol cohort reached maximal weight loss at 6 months, whereas the pre-protocol cohort continued to decline until 9 months. By 12 months, the post-protocol group demonstrated significantly less weight reduction (mean difference 1.64 kg; 95% CI 0.97-2.31; p < 0.001), with the difference persisting through month 21. Among 157 patients requiring adjuvant chemotherapy, the post-protocol cohort showed a trend toward higher initiation (OR 1.15; 95% CI 0.99-1.34), earlier treatment (OR 1.12; 95% CI 0.95-1.32), and chemotherapy completion (OR 1.13; 95% CI 0.93-1.36), though none reached statistical significance. A nonsignificant trend toward improved disease-free survival was observed in the post-protocol group (HR 0.67; 95% CI 0.41-1.14). No significant relationship was found between individual micronutrient levels and weight recovery or chemotherapy feasibility.
Conclusions: Implementation of a standardized postoperative PEI care protocol incorporating routine PERT and micronutrient assessment significantly improved long-term postoperative weight recovery. Although trends toward higher chemotherapy initiation and improved disease-free survival were observed, these did not reach statistical significance. The protocol primarily enhanced nutritional recovery, while potential oncologic benefits warrant further prospective investigation.
Weight change after surgeryIMAGE CAPTION: Weight change after surgery
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