Micronutrient deficiencies after pancreatico-duodenectomy: A narrative review of the literature and recommendations for clinical practice.

Micronutrient uptake is impaired after pancreatico-duodenectomy (PD) because of malabsorption, reduced absorptive capacity, and poor oral intake. Biochemical depletion is reported in cohort studies, but deficiency states are predominantly reported in case reports, making it difficult to assess occurrence rates. Although national guidelines recommend monitoring of micronutrients, there are no guidelines on what this should consist of. We undertook a narrative review to explore the incidence of deficiency and make recommendations for clinical management using data from randomized controlled trials, cohort studies, and case reports. We established that iron, zinc, and vitamin D deficiencies are common. Fat-soluble vitamin deficiencies are rare and occurred in patients who discontinued pancreatic enzymes but are otherwise nutritionally well, whereas trace element and B vitamin deficiencies occurred as part of a more generalized malnutrition state. We make recommendations for identification and treatment of micronutrient deficiencies and recommend routine assessment of iron, zinc, and vitamin D status and bone density in all patients who have undergone curative treatment and take pancreatic enzyme replacement therapy (PERT) or have benign disease. In those with malnutrition or not taking PERT, additional screening for vitamins A, E, and K; selenium; copper; and magnesium should be undertaken. A pragmatic approach should be taken for those with limited long-term survival, with a focus on iron status, as this will impact quality of life.