Can racecadotril (acetorphan) be given post Whipple (pancreaticoduodenectomy) surgery?

Racecadotril Use Post-Whipple Surgery

Racecadotril should not be used post-Whipple surgery as there is no evidence supporting its efficacy in this specific clinical context, and other management approaches are preferred for post-pancreaticoduodenectomy complications.

Post-Whipple Complications and Management

Delayed Gastric Emptying (DGE)

• DGE is a common complication after pancreaticoduodenectomy (Whipple procedure), occurring in approximately 10-25% of patients 1
• DGE may necessitate insertion of a nasojejunal feeding tube in some patients, but there are no acknowledged pharmacological strategies specifically recommended to prevent or treat this condition 1
• DGE can be classified as primary (without identifiable cause) or secondary (due to complications like intra-abdominal abscess, collections, or anastomotic leaks) 2
• For secondary DGE, treatment should focus on addressing the underlying cause rather than symptomatic management 2

Bowel Function Management Post-Whipple

• Enhanced Recovery After Surgery (ERAS) guidelines recommend a multimodal approach to stimulating bowel movement post-pancreaticoduodenectomy, focusing on:
  • Appropriate use of epidural anesthesia 1
  • Maintaining near-zero fluid balance 1
  • Oral laxatives (such as magnesium sulfate or bisacodyl) 1
  • Chewing gum to accelerate gastrointestinal transit 1
• There is no high-level evidence supporting any specific motility-enhancing drug for post-Whipple patients 1

Racecadotril Evidence

• Racecadotril is an enkephalinase inhibitor with antisecretory properties in the gastrointestinal tract 3, 4
• It has been primarily studied for infectious and secretory diarrhea, not for post-surgical gastrointestinal dysfunction 3, 5
• A randomized trial of racecadotril for chemotherapy-induced diarrhea failed to demonstrate any effect on diarrhea incidence compared to placebo 1
• There is no evidence in current guidelines supporting racecadotril use specifically after pancreaticoduodenectomy 1

Nutrition Management Post-Whipple

• Most patients can tolerate normal oral intake soon after elective pancreaticoduodenectomy 1
• Early oral intake has been shown to be feasible and safe in patients undergoing Whipple procedures 1
• Enteral tube feeding has not shown benefit over early oral diet in patients undergoing major upper gastrointestinal and hepatopancreaticobiliary surgery 1
• Artificial nutrition (enteral or parenteral) should be considered selectively only in patients with prolonged DGE 1

Practical Recommendations

• For primary DGE unresponsive to medical treatments, endoscopic intervention may be beneficial, allowing patients to start oral intake sooner 2
• For patients with persistent diarrhea post-Whipple, consider:
  • Loperamide as first-line therapy based on established guidelines for diarrhea management 1
  • Octreotide for refractory cases, as it has shown efficacy in treating various forms of diarrhea 1
• Specialized centers with experienced surgeons should manage Whipple procedures to ensure optimal outcomes and appropriate management of complications 6

Pitfalls and Caveats

• Avoid empiric use of medications without evidence in the post-Whipple setting, as they may interfere with recovery or mask signs of complications
• DGE is often over-diagnosed; care should be taken to ensure this doesn't encourage unnecessary nasogastric tube insertion 1
• Patient-controlled oral intake progression is as safe as surgeon-controlled stepwise increases, provided patients are informed about potential impaired gut function in the early postoperative period 1
• Pylorus-preserving pancreaticoduodenectomy with an ante-colic (rather than retro-colic) duodenojejunostomy may result in less DGE 1