91 JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 19 No. 2 – Mar 2018. [ISSN 1590-8577] ORIGINAL ARTICLE JOP. J Pancreas (Online) 2018 Mar 30; 19(2):91-95. ABSTRACT Introduction Exocrine Pancreatic Insufficiency is a common finding in patients requiring pancreatic surgery, and for those without evidence of preoperative exocrine pancreatic insufficiency, it frequently manifests during the postoperative period. Surgeons’ practices of assessing and treating exocrine pancreatic insufficiency are variable. We aim to define surgeons’ perception of exocrine pancreatic insufficiency and evaluate their use of pancreas enzyme replacement therapy prior to and following resection. Methods An cross sectional survey was designed and conducted to determine the surgeons role in the diagnosis and management of exocrine pancreatic insufficiency using the online tool SurveyMonkey.com. It was disseminated anonymously to members of The Pancreas Club by its website administrator. The answers were analyzed and described. Results Approximately half of the respondents (52.5%) reported assessing their patients for exocrine pancreatic insufficiency preoperatively. While 48.5% did that routinely, the rest relied on the presence of symptoms to initiate evaluation. The preferred method of assessing for exocrine pancreatic insufficiency was fecal elastase test (48%). A third of surgeons did not objectively test for exocrine pancreatic insufficiency. Half of the respondees reported prescribing pancreas enzyme replacement therapy preoperatively but only one third did so routinely. Among the other half who had never prescribed pancreas enzyme replacement therapy preoperatively, 92.6% considered prescribing it postoperatively yet only 40% did so routinely. Creon was more frequently prescribed (85.2%) over the other available formulae. We did not find a consensus on the quantity of lipase replacement units for main meals (24,000 to 108,000 units) nor for snacks (10,000 to 40,000 units). Conclusion Exocrine pancreatic insufficiency is a manageable condition that is overlooked by healthcare providers who care for pancreatic disease. A high index of suspicion should guide surgeons to start pancreas enzyme replacement therapy empirically preoperatively as part of patient optimization for surgery, and treatment should be resumed postoperatively when patients resale a solid diet. Received February 06th, 2018 - Accepted March 14th, 2018 Keywords Exocrine Pancreatic Insufficiency; surgery Abrreviations EPI exocrine pancreatic insufficiency; PERT pancreas enzyme replacement therapy Correspondence Gareth Morris-Stiff Section of Hepato-Pancreato-Biliary Surgery, Digestive Diseases and Surgery Institute Cleveland Clinic, 9500 Euclid Ave, A100 Cleveland, OH 44195 Tel +1-216.445.6033 Fax +1-216.444.2153 E-mail morrisg4@ccf.org Perioperative Exocrine Pancreatic Insufficiency and Pancreatic Enzyme Replacement Therapy Essa M Aleassa 1,2 , Gareth Morris-Stiff 1 1 Section of Hepato-Pancreato-Biliary Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA 2 Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates INTRODUCTION In patients in which pancreatic acinar cells mass is depleted there may be inadequate enzyme secretion to the duodenum leading to malabsorption of ingested carbohydrates, proteins, and lipids. This state of pancreatic dysfunction is known as exocrine pancreatic insufficiency (EPI). In patients undergoing surgical management of their pancreatic disease, EPI can arise either pre- or post- operatively. In the pre-operative setting, EPI may be due to parenchymal damage secondary to underlying pancreatic disease as in the case of chronic pancreatitis, or as a result of occlusion of the pancreatic duct as is seen in the case of periampullary cancer [1, 2]. The principle aetiopathological factor for post-operative EPI is resection of functional pancreas parenchyma [3]. The effects of resection are exacerbated when the remaining parenchyma is abnormal such as in chronic or post-obstructive pancreatitis. In addition, pancreatic and gastrointestinal reconstruction resulting in dysregulation and asynchrony of enzyme secretion is another hypothesis for EPI pathophysiology that will also play an important role in the development of EPI [4]. Retrospective observational studies report that EPI is a common finding in the pre-operative setting, and that the incidence of EPI increases post-operatively [5]. Patients with EPI are classically said to present with weight-loss, diarrhea or steatorrhea, however, these symptoms may take weeks or months to manifest [6]. The importance of identification of EPI and its treatment with PERT has been highlighted in the recommendations of the National Comprehensive Cancer Network (NCCN) that advocate the immediate initiation of PERT in all patients presenting with pancreatic cancer [7]. The relatively limited literature