Neurogenic Diarrhoea Common After SMA Divestment in PDAC : BJS Open | Jun 2026

Introduction:

The increasing use of preoperative chemotherapy has expanded the surgical eligibility of patients with locally advanced pancreatic ductal adenocarcinoma (PDAC). Superior mesenteric artery (SMA) divestment and, in selected cases, SMA resection have become important techniques for achieving margin-negative resections in tumors involving the perivascular neural plexus. However, disruption of the autonomic nerve fibers surrounding the SMA can lead to postoperative neurogenic diarrhoea, a complication that is often difficult to manage and can significantly affect postoperative recovery and quality of life.

Problem Statement:

Despite growing adoption of SMA divestment procedures, data regarding the incidence, risk factors, treatment strategies, and long-term consequences of postoperative neurogenic diarrhoea remain limited. Better understanding of this complication is essential for patient counselling, perioperative planning, and postoperative management.

Summary:

This international multicentre study provides the largest evaluation to date of neurogenic diarrhoea following pancreatic resection with SMA divestment or resection after preoperative therapy for PDAC. The investigators found that neurogenic diarrhoea is a frequent postoperative complication, affecting approximately two-thirds of patients. The risk increased substantially with the extent of SMA dissection, with the highest rates observed after more extensive circumferential divestment and SMA resection. Management strategies varied considerably across centers and included antidiarrhoeal agents, opioid-based therapies, opium tincture, and octreotide, reflecting the absence of standardized treatment protocols. Although symptom resolution was achieved in approximately half of affected patients, neurogenic diarrhoea remained a challenging postoperative issue. Reassuringly, despite its high incidence and impact on postoperative care, neurogenic diarrhoea was not associated with worse overall survival. These findings suggest that while the complication can be burdensome, it should not discourage aggressive surgical approaches when oncologically indicated. The study highlights the importance of preoperative patient counselling, early recognition of symptoms, and structured postoperative management. It also underscores the urgent need for evidence-based treatment algorithms and prospective studies aimed at optimizing the prevention and management of neurogenic diarrhoea in patients undergoing advanced pancreatic cancer surgery.