AN EXPERIMENTAL EVALUATION OF THE EFFECTIVENESS OF

PANCREATIN IN REDUCING FECAL NITROGEN AND

FAT LOSS FOLLOWING TOTAL GASTRECTOMY*
TILDEN C. EVERSON, M.D., PH.D.
CHICAGO, ILLINOIS
FROM THE DEPARTMENT OF SURGERY, COLLEGE OF MEDICINE, UNIVERSITY OF ILLINOIS

KELLING6 in 1923 apparently was the first creatica, i.e., where there is an absence of
to report the use of pancreatin in an at- external pancreatic secretion from the small
tempt to improve assimilation of protein intestine, has been conclusively demon-
and fat following total gastrectomy. How- strated by Beazell, Schmidt and Ivy,' and
ever, Kelling made no mention of dosage, there are sound physiologic reasons why
nor was evidence presented to indicate the oral administration of pancreatin might
clearly whether or not the substance was of be expected to improve fat and nitrogen
real value in the two patients to whom it assimilation following total gastrectomy.
was given. Emery3 found in a metabolic 1. There is probably decreased stimula-
study of one dog with a total gastrectomy tion of- pancreatic secretion following total
that the administration of large amounts of gastrectomy. The secretogogic effect of
fresh pancreas (450 Gm. per day) reduced hydrochloric acid upon the pancreas is lost
fecal nitrogen excretion to a normal level when the stomach is removed. Moreover,
and improved the absorption of fat. Like- vagotomy which is performed incidental to
wise, the effectiveness of the addition of total gastrectomy results in decreased se-
raw pancreas or pancreatin to the diet in cretion of pancreatic juice in response to
improving the general nutritional status of various types of stimuli.8
dogs with a total gastrectomy has been re- 2. Improper or inadequate mixing of
ported by Ivy.5 On the other hand, Bussa- food with pancreatic secretions may occur
barger and Jung2 found that the adminis- following total gastrectomy. In the normal
tration of 0.25 Gm. of pancreatin per day individual there is a physiologic increase in
to rats which had been subjected to total secretion of pancreatic juice following in-
gastrectomy did not measurably improve gestion of food. Following total gastrec-
the nutritional status of the animals. Rekers, tomy it is possible that the ingested food
Pack, and Rhoads7 treated one patient with might be well down the intestinal tract
a total gastrectomy with 25 Gm. of oral increased amounts of pancreatic
pancreatic enzymes daily and obtained a before the are delivered into the upper in-
marked decrease in the fecal fat and nitro- secretions
gen excretion under this regimen. testine. Furthermore, when an esophagoje-
The efficacy of pancreatin in reducing junostomy type of anastomosis is per-
fecal fat and nitrogen loss following liga- formed after total gastrectomy, the pancre-
tion of the pancreatic ducts or achylia pan- atic secretions would have to traverse the
* The technical assistance of Everett Hoppe is
entire duodenum and afferent jejunal limb
here acknowledged. Submitted for publication before making contact with the food; and
August, 1951. thus significant quantities of these juices
406
Volume 133
Number 3 EFFECTIVENESS OF PANCREATIN FOLLOWING TOTAL
might be reabsorbed before reaching the
food.
METHOD OF STUDY
The effectiveness of pancreatin* in re-
ducing fecal fat and nitrogen loss following
total gastrectomy was evaluated in 12 dogs.
The dogs were given constant daily diets
calculated and chemically analyzed to fur-
nish 80 calories per kilogram of body
weight and containing 5 Gm. of protein
and 4 Gm. of fat per kilogram of body
weight. Consecutive seven day metabolic
periods were performed on each animal.
Control periods during which no added
medication was given were conducted be-
fore and after each test period during which
pancreatin was given. The effect of 10 Gm.
of pancreatin added to the daily diet on
fecal fat and nitrogen loss was studied in 12
animals. In addition, the effect of a daily
dosage of 30 Gm. of pancreatin was studied
in five of the animals. Likewise, the effect
of 10 Gm. of pancreatin daily on the fecal
fat and nitrogen loss in normal animals was
studied in six dogs. Carmine markers were
used to demarcate the fecal collection
periods. The feces for each period was
mixed in a Waring blender and fat and total
nitrogen were determined on aliquot sam-
ples. Nitrogen was determined with Hoff-
man's modification of the Koch and
McMeekin direct Nesslerization micro
Kjeldahl method.4 Fat was determined
using the Soxhlet method.
RESULTS AND DISCUSSION
The effect of 10 Gm. of pancreatin added
to the daily diet on the percentage fecal ex-
cretion of ingested nitrogen in the 12 dogs
with total gastrectomy is graphically pre-
sented in Figure 1. In ten of the 12 ani-
* Pancreatin used was either Viokase supplied
by the Vio Bin Corporation, Monticello, Ill., or
Pancreatin, supplied by Wilson Laboratories, Chi-
cago, Ill.
407
GASTRECTOMY
mals, the percentage fecal nitrogen excre-
tion was less during the pancreatin period
than during the control periods before and
after the administration of pancreatin. The
average percentage fecal nitrogen excretion
during the pancreatin period in these 12
animals was 26.3 per cent as compared with
an average fecal nitrogen loss of 39.7 per
cent and 49.2 per cent during the control
periods before and after the administration
of pancreatin. The average percentage ex-
cretions during the two control periods
were statistically not significantly different.9
However, the average percentage fecal
nitrogen excretion during the pancreatin
period statistically was significantly differ-
ent from the average percentage excretion
during both of the control periods.
The influence of a larger daily dose of
30 Gm. of pancreatin on percentage fecal
nitrogen loss in five dogs with a total gas-
trectomy is illustrated in Figure 2. In one
animal (Dog No. 7) which failed to re-
spond to a daily dose of 10 Gm. there was
an appreciable reduction in the percentage
fecal nitrogen excretion with the larger
dose of pancreatin. Three of the other four
animals showed only slightly greater reduc-
tion in fecal nitrogen loss when compared
with the effect of the smaller amount of
pancreatin. Accordingly, it appears that in
most of the animals studied a daily dose of
10 Gm. of pancreatin was sufficient to ob-
tain a near maximal effect in reducing fecal
nitrogen loss.
The effect of 10 Gm. of pancreatin added
to the daily diet on the percentage fecal
excretion of ingested fat is represented in
Figure 3. In eight of the 12 animals with
total gastrectomy there was some reduc-
tion in percentage fecal fat excretion dur-
ing the pancreatin period as compared with
the control periods before and after the
administration of pancreatin. However, in
several of the animals the decrease was very
slight. The average percentage fecal fat
excretion during the pancreatin period in
 TILDEN C. EVERSON Aiinials of Surgery
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408
Volume 135 EFFECTIVENESS OF PANCREATIN FOLLOWING TOTAL GASTRECTOMY
Number 3

the 12 animals was 22.4 per cent as com- most of the animals studied the daily dose
pared with an average fecal fat excretion of of 10 Gm. of pancreatin was as effective as
25.3 per cent and 31.4 per cent during the a dosage three times greater.
two control periods. Statistically there was The effect of 10 Gm. of pancreatin added
no significant difference in average per- to the daily diet on fecal fat and nitrogen
centage excretion during the two control loss in six normal dogs is represented in
periods and the pancreatin period. Figure 5. There was no appreciable effect
% PERCENTAGE OF INGESTED NITROGEN AND FAT
90-.
IN FECES IN NORMAL ANIMALS
80-
70- |EZ = Control (7 days)
| = Pancreatin (7 days) 10 grams/day
60

50-
40
30
NITROGEN
20-

10-
C L
DOG
ii [IFh IIl
I 2 3 4 5 6
r

1
F A T
Fn r
2 3
r
4 5 6
FIG. 5.-The effect of 10 Gm. of pancreatin added to the daily diet on
the percentage fecal excretion of ingested nitrogen and fat in normal dogs.
The influence of the larger daily dose of on either fecal fat or nitrogen loss in normal
30 Gm. of pancreatin on the percentage animals. Obviously, as fecal fat loss is verv
fecal fat loss in five dogs with a total gas- small in normal animals, no significant de-
trectomy is -illustrated in Figure 4. In only crease would be expected by the addition
one animal was there appreciable further of pancreatin or any other substance...
reduction in percentage fecal fat excretion Thus, pancreatin in adequate dosage was
with the larger dose of pancreatin. Thus, in effective in reducing fecal nitrogen loss fol-
lowing total gastrectomy although the fecal
Fic. 1.-The effect of 10 Gm. of pancreatin nitrogen loss did not return to normal
added to the daily diet on the percentage fecal
excretion of ingested nitrogen in dogs following levels. The average percentage fecal nitro-
total gastrectomy. gen excretion in normal dogs was 12.8 per
FIG. 2.-The comparative effect of 10 and 30
Gm. of pancreatin added to the daily diet on the cent as compared with an average per-
percentage fecal excretion of ingested nitrogen in centage fecal excretion of 26.3 per cent in
dogs following total gastrectomy.
FIG. 3.-The effect of 10 Gm. of pancreatin animals with a total gastrectomy given 10
added to the daily diet on the percentage fecal Gm. of pancreatin daily. Although the ad-
excretion of ingested fat in dogs following total ministration of this dosage of pancreatin
gastrectomy.
FIG. 4.-The comparative effect of 10 and 30 did not reduce fecal nitrogen loss in ani-
Gm. of pancreatin added to the daily diet on the mals with total gastrectomy to levels com-
percentage fecal excretion of ingested fat in dogs
following total gastrectomy. parable to that of normal animals, it did
409
 TILDEN
TILDEN EVERSON
C. C.
afford measurable improvement when com-
pared with the average percentage fecal
nitrogen loss of 39.7 per cent and 49.2 per
cent in the control periods of total gastrec-
tomy animals not given pancreatin.
On the other hand, although pancreatin
appeared to be of slight to moderate value
in reducing the fecal fat loss in eight of the
12 animals with total gastrectomy, no clear
cut effect could be detected when the aver-
age percentage fecal fat loss with and with-
out pancreatin was compared for the
entire series. Moreover, the average per-
centage fecal fat loss in normal dogs was
only 2.8 per cent as compared with an
average loss of 22.4 per cent in dogs with
total gastrectomy when given pancreatin
and 25.3 per cent and 31.4 per cent during
the two control periods. Thus, although
pancreatin may have had some effect in
reducing fat loss in certain instances, the
fecal fat excretion in all animals remained
markedly elevated (8x normal) when com-
pared with normal animals.
SUMMARY
1. The effectiveness of pancreatin in re-
ducing fecal nitrogen and fecal fat loss fol-
lowing total gastrectomy was studied in 12
dogs.
2. Pancreatin in adequate dosage was
effective in appreciably reducing fecal
nitrogen loss following total gastrectomy.
However, the addition of pancreatin to the
daily diet did not restore fecal nitrogen loss
to the level of normal dogs.
410
~~March,
Annals of Surgery
1952
3. Pancreatin, in the dosages studied,
slightly or moderately reduced fecal fat loss
following total gastrectomy in eight of 12
animals. However, for the entire series of
12 animals there was no significant differ-
ence in average percentage fecal fat loss
with or without the addition of pancreatin
to the diet.
BIBLIOGRAPHY
Beazell, J. M., R. C. Schmidt and A. C. Ivy: The
Diagnosis and Treatment of Achylia Pan-
creatica. J. A. M. A., 116: 2735, 1941.
' Bussabarger, R. A., and F. T. Jung: Dietary and
Hematologic Studies after Total Gastrectomy
in the Rat. Am. J. Physiol., 117: 59, 1936.
3 Emery, E. S.: The Cause of the Faulty Digestion
in Dogs Without Stomachs. Am. J. Digest.,
2: 599, 1935.
4 Hoffman, W. S.: Photelometric Clinical Chem-
istry. New York, 1941. William Morrow.
5 Ivy, A. C.: The Effects of Gastrectomy in Ani-
mals. Am. J. Digest. Dis., 7: 500, 1940.
6 Kelling, G.: Ziir Totalresektion des carcinoma-
tosen Magens. Arch f. klin. Chir., 125: 458,
1923.
7 Rekers, P. E., G. T. Pack and C. P. Rhoads:
Metabolic Studies in Patients with Cancer of
the Gastrointestinal Tract. VI. Disorders in
Alimentary Digestion and Absorption in Pa-
tients Who Have Undergone Total Gastrec-
tomy for CarciDoma of the Stomach. Surgery,
14: 197, 1943.
8 Shingleton, W. W., B. Fawcett and J. S. Vetter:
Pancreatic Secretion and Response to Secretion
after Vagotomy and Sympathectomy, Surgical
Forum American College of Surgeons. Phila-
delphia, 1951, W. B. Saunders Co.
9 Snedecor, G. W.: Statistical Methods. Ames,
1946. Iowa State College Press.