Although the main goal of PD is complete removal of the underlying malignancy, the surgery has obvious pathophysiological consequences. Post-PD patients often struggle, for example, with delayed gastric emptying based on the removal of gastric pacemaker cells, which can affect how much oral intake the patient can tolerate.4

Patients also lose part of the exocrine and endocrine function of the pancreas based on its removal, which can lead to diarrhea and  diabetes/hepatic steatosis.

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Clinical studies show that 10% to 40% of post-PD patients will develop hepatic steatosis.5 These patients are significantly different than the “traditional” patient with hepatic steatosis, as they are often not obese and have no evidence of insulin resistance. The relative exocrine insufficiency — a sequelae of the PD surgery — leads to a choline deficiency and overall malabsorption, leading to reduced transport of triglycerides from the liver and the resulting excessive deposition.

These patients can develop significant liver dysfunction over time and even rarely present with acute liver failure and hepatic encephalopathy.

There is no consensus on how to prevent such outcomes, but some post-PD nutritional protocols will place patients on high dose pancreatic enzymes and add specific supplements to their diet, including L-carnitine, selenium, zinc sulfate, branch chain amino acids, and medium chain triglycerides.5

RELATED: Pancreatic Cancer: Adding Vandetanib to Gemcitabine Fails To Improve Overall Survival

Nutrition is a critical factor to consider both in the pre- and postoperative period for patients undergoing a Whipple procedure. Identifying malnutrition early in the postoperative state is necessary for improving a patient’s outcomes and quality of life.


  1. Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg. 2006;244(1):10-5.
  2. Fong Y, Gonen M, Rubin D, Radzyner M, Brennan MF. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg. 2005;242(4):540-4; discussion 544-7.
  3. Gerritsen A, Besselink MG, Gouma DJ, Steenhagen E, Borel Rinkes IH, Molenaar IQ. Systematic review of five feeding routes after pancreatoduodenectomy. Br J Surg. 2013;100(5):589-98; discussion 599.
  4. Karagianni VT, Papalois AE, Triantafillidis JK. Nutritional status and nutritional support before and after pancreatectomy for pancreatic cancer and chronic pancreatitis. Indian J Surg Oncol. 2012;3(4):348-59.
  5. Kang CM, Lee JH. Pathophysiology after pancreaticoduodenectomy. World J Gastroenterol. 2015;21(19):5794-804.