Salena Ward, Richard Cade, Sean Mackay, Sayed Hassen, Simon Banting, Peter Gibson Eastern Health Clinical School, Monash University and Box Hill Hospital, Eastern Health Melbourne, Australia Conjoint Australia and New Zealand Upper GI and HPB Meeting Queenstown, 28 th September, 2010
Acknowledgements Grant: RACS AstraZeneca Upper GI Research Grant 2009 Acknowledgement of project support: Eastern Health Clinical School Monash University Gastroenterology Unit, Eastern Health Laboratory staff: Rosemary Rose, Paul Rose, Lily Lim
Ethics Project approved by the Eastern Health Research and Ethics Committee
Background Clinical problem: Difficulty with nutrition after upper major gastrointestinal operations (Oesophagectomy, Gastrectomy, Pancreatico duodenectomy) Malabsorption (diarrhoea, steatorrhoea) Loss of weight / failure to regain weight Sometimes responds to a trial of empirical oral pancreatic enzyme supplementation
Background One postulated cause for this is pancreatic exocrine insufficiency (PEI) primary (pancreatic failure) secondary due to altered anatomy and physiology poor mixing of pancreatic fluid with chyme rapid gut transit inability to liquefy food (to produce chyme) food bypassing duodenum (hence not producing secretin and stimulating pancreas)
Background Some published literature of PEI post operatively Pancreatico duodenectomy Author Year PEI Test Result Matsumoto 2006 Stool Elastase 50% (2 yrs) Falconi 2008 72hr faecal chymotrypsin 33% Yasuda 2000 Faecal chymotrypsin Lower post vs pre op Ong 2000 Faecal chymotrypsin 36% low Gastrectomy Author Year PEI Test Result Armbrecht 1988 Faecal fat 3 day test 100% abnormal Hillman 1968 Faecal fat 3 day test (wt 6kg < preop) 100% abnormal Malfertheiner 1984 FDL test (urine) 75% abnormal Friess 1996 Secretin cerulein test 3months post op Reduction: trypsin 89% chymotrypsin 91% amylase 72%
Background Pancreatic exocrine function tests: Direct Invasive: Gastroduodenal tube Non invasive: serum or faecal markers Indirect Faecal fat excretion (3 day) test Urinary excretion tests Triglyceride breath tests
Background Carbon 13 labelled mixed triglyceride breath 6 hour breath test (C13 MTG BT) Literature on accuracy of test to diagnose steatorrhoea: 1. Iglesias Garcia, Dominguez Munoz 43 patients, 13C MTG BT vs faecal fat test Correlation coefficient (r) = 0.7 Sensitivity 90.5%, Specificity 91% 2. Vantrappen et al. 1989. 29 patients, 25 control. 13C MTG BT (6hr) vs duodenal sampling (lipase) r = 0.89, sensitivity 89%, specificity 81%
Aim To measure the incidence of PEI post UGI resections (pancreaticoduodenectomy, gastrectomy, oesophagectomy) using the 6 hour C13 MTG BT compare with controls
Method Participants: Controls without major UGI resection 3 Test groups 3 months post UGI resection Recruitment conducted from August 2009 to August 2010 from public outpatient clinics, private consulting rooms and medical record searches.
Method Test: C13 MTG BT using the 13C IRIS (infra red isotope spectrometer) (Wagner Analysen Technik) Subtrate ingested at start of test: 200mg C13 MTG, 20g butter, 2 pieces white bread, 200ml water Breath samples collected every half hour for 6 hours
Method Outcome measures: Primary endpoint: cumulative percentage C13 excreted in 6 hours (cum.%c13 6hr) Secondary endpoint: time at peak rate of C13 excretion (time at peak %C13/hr). Statistical analysis: Mann Whitney U test was used to compare postoperative groups with the control group.
Sample Results Healthy control peak rate of C13 excretion 6 hour cumulative %C13 excreted
Results Primary endpoint: cumulative percentage of C13 excretion over 6 hours Operation No. cum.%c13-6hr Mean Range p Control 11 29.6 19.9 44.7 Oesophagectomy 13 24.7 10.2 43.8 NS Gastrectomy 10 29.5 12.6 41.7 NS Pancreaticoduodenectomy 10 29.8 0.9 40.9 NS NS = non significant
Results Secondary endpoint: time at peak rate of C13 excretion Operation No. time at peak-%c13/hr (mins) Median Range p Control 11 210 120 330 Oesophagectomy 13 120 60 300 NS Gastrectomy 10 120 60 180 <0.01 Pancreaticoduodenectomy 10 165 90 330 NS NS = non significant
Results Percentage of post operative patients lower than control cumulative excretion of C13 over 6 hours (ie <19.9%) Operation No. cum.%c13-6hr < control No. Percentage Oesophagectomy 13 5 38.5% Gastrectomy 10 2 20.0% Pancreaticoduodenectomy 10 2 20.0% All post-op 33 9 27.3%
Conclusions The normal cumulative 6 hour excretion of C13 using this test protocol for the C13 MTG breath test is >19.9% There is no significant difference in pancreatic exocrine function post UGI resections using the C13 MTG breath test in this study. There appears to be an earlier digestion implying faster gut transit post gastrectomy Fat digestion/absorption may be impaired in 27% of patients after major UGI resection.
Discussion In clinical practice, if a patient post upper GI resection is not thriving: Try empirical oral pancreatic enzyme supplements Persist with higher doses Perform 3 day faecal fat test (gold standard) Perform C13 mixed triglyceride breath test Further study with this test is required.