Post-pancreatectomy diarrhea: incidence, risk factors, management, and impact on quality of life. A prospective, single-center longitudinal analysis

Background Post-pancreatectomy diarrhea (PPD) significantly impairs outcomes and patient’s quality of life (QoL). Its origin is multifactorial, extending beyond exocrine pancreatic insufficiency. Even with Pancreatic Enzyme Replacement Therapy (PERT), persistent PPD can lead to malnutrition and inhibit adjuvant treatments. This study aimed to evaluate the incidence, risk factors, management, and impact on QoL of PPD. Methods This prospective longitudinal study enrolled patients undergoing pancreatectomy at a single tertiary center from 2023 to 2025. Postoperatively (at 7, 30, and 90 days), an adapted STIDAT questionnaire assessed PPD presence, patient-reported severity, frequency, medication use, associated symptoms, and QoL. Results A total of 237 patients were included (pancreatoduodenectomy [PD]: 54%, distal pancreatectomy [DP]: 35%, total pancreatectomy [TP]: 11%). Overall PPD incidence was 32%, 41%, and 33% at 7, 30, and 90 days respectively. PPD was most frequent and severe after TP and PD (62% and 50% at 30 days) and least after DP (22.0% at 30 days) (p<0.001). PPD severity correlated with worse QoL and higher STIDAT scores at all time points. Most PPD patients required PERT, with median dose of 85.000 LU/day by 90 days, and up to 37% also needed anti-diarrheals. Common 30-day symptoms included urgency (52%), abdominal discomfort (69.4%), and incontinence (18.4%). At multivariable analysis, pancreatic ductal adenocarcinoma, vascular resection, and arterial divestment were independent predictors of moderate-to-severe PPD, while DP was protective. Conclusion PPD is an impactful complication after pancreatectomy, affecting more than one-third of patients even after correct PERT. Patients undergoing vascular resection and arterial divestment are at higher risk for severe PPD and require tailored postoperative management to reduce its downside effects, which include impaired QoL.