Transient Exocrine Pancreatic Insufficiency: First Report of an Unrecognized Complication of Cytoreductive Surgery and HIPEC.
BACKGROUND
As cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are being increasingly adopted as the standard treatment for peritoneal surface malignancies, familiarity with this procedure's adverse events is also growing. Herein, we describe an unreported adverse event of exocrine pancreatic insufficiency (EPI) following CRS and HIPEC.


PATIENTS AND METHODS
Patients who underwent CRS and HIPEC between 9/2016 and 9/2017 were prospectively recruited. Fecal elastase-1 (FE1) and Clostridium difficile toxins were tested in all patients in the immediate postoperative period. Patients with diarrhea who had low FE1 were started on oral pancreatic enzyme replacement therapy (PERT) and their symptomatic progression was followed.


RESULTS
A total of 26 patients were included. Eleven patients (42.31%) developed postoperative refractory diarrhea, nine of whom had a low FE1 level. These patients were treated with PERT either directly or after completion of antibiotics course if C. difficile toxin was positive. Eight patients demonstrated symptomatic resolution of their diarrhea, and thus the diagnosis of EPI was established (30.77%). Patients with diarrhea had lower FE1 levels, and were more likely to have had a terminal ileum resection and had a longer hospital stay. Regression analysis identified the rapid rise of a patient's core temperature by >1°C within 15 minutes as the sole predictor of EPI occurrence.


CONCLUSION
EPI is a potential adverse event following CRS and HIPEC and might be largely responsible for refractory diarrhea. In our patients with refractory diarrhea and low FE1, PERT provided immediate symptomatic relief. The biological basis of this phenomenon remains unclear and warrants further investigation.
['Naffouje|Samer A|SA|', 'Salti|George I|GI|']
D000368:Aged D010478:Chemotherapy, Cancer, Regional Perfusion D003131:Combined Modality Therapy D065426:Cytoreduction Surgical Procedures D003967:Diarrhea D056947:Enzyme Replacement Therapy D010188:Exocrine Pancreatic Insufficiency D005243:Feces D005260:Female D006801:Humans D006979:Hyperthermia, Induced D008297:Male D008875:Middle Aged D010196:Pancreatic Elastase D010534:Peritoneal Neoplasms D011183:Postoperative Complications D011184:Postoperative Period D012189:Retrospective Studies D016896:Treatment Outcome
exocrine pancreatic insufficiency CRS and HIPEC diarrhea fecal elastase