Pancreatic resection: effects on glucose metabolism

Long-term follow-up of patients with multiple endocrine neoplasia type 1

Whether early surgical treatment of non-functioning pancreas islet cell tumor (NFPT) provides a favorable quality of life and life expectancy in patients with multiple endocrine neoplasia type 1 (MEN1) remains controversial. We analyzed the long-term clinical courses and surgical outcomes of 14 Japanese patients with MEN1-associated NFPTs. NFPTs smaller than 20 mm in diameter did not show any apparent growth over a long monitoring period. Furthermore, these small NFPTs did not metastasize to regional lymph nodes or the liver. On the other hand, the development of additional NFPTs or metastasis was found in five of six patients with large (35 mm or larger) NFPTs. Among the seven patients who underwent a partial pancreatectomy, six patients developed impaired glucose tolerance or diabetes. The accumulation of more prospective data is needed to clarify the optimal surgical indications for patients with NFPTs, especially among the Japanese population, which has a relatively low insulin secretion potency compared with non-Hispanic white and African-American populations.

Central pancreatectomy with pancreaticogastrostomy in children

Children requiring surgical intervention for pancreatic disease may be at risk long term for exocrine insufficiency and glucose intolerance. Pediatric surgeons must balance the need to perform adequate surgical resection while preserving as much normal pancreatic parenchyma as possible. Neoplasms of the middle pancreatic segment with low malignant potential and isolated trauma to the pancreatic body or neck represent 2 conditions where extensive pancreatic resection is unnecessary. Central pancreatectomy for such lesions is well described in adults. Reconstruction of the distal pancreatic remnant is traditionally performed via Roux-en-Y pancreaticojejunostomy. Pancreaticogastrostomy is an alternative approach that has been used to reconstruct the distal pancreas in the adults. Pancreaticogastrostomy offers several technical advantages over pancreaticojejunostomy. Because children may be uniquely susceptible to the long-term consequences of excessive pancreatic resection, 2 cases using this technique of central pancreatectomy with pancreaticogastrostomy are described.

Postoperative glycemic control after central pancreatectomy for mid-gland lesions

INTRODUCTION

Patients undergoing partial pancreatectomy are at risk for developing surgically induced diabetes. Patients with lesions in the neck and body of the pancreas are at increased risk because traditional resectional approaches (pancreaticoduodenectomy or distal pancreatectomy) must be extended to remove the tumor with adequate margins. Increasingly, we have been performing pancreatic parenchyma-sparing resections (central pancreatectomy with pancreaticogastrostomy) in an effort to reduce the risk of postpancreatectomy endocrine insufficiency.

METHODS

The operative records of patients who underwent pancreatectomy at our institution from 1999 to 2005 were reviewed. We identified 26 patients who underwent central pancreatectomy with pancreaticogastrostomy reconstruction for cystic lesions (n = 23), neuroendocrine tumors (n = 2), and Frantz's tumor (n = 1). Charts were reviewed for patient demographics, volume of resection, complications, and evaluation of postoperative glycemic control.

RESULTS

The mean follow-up was 33 months (range 3-72 months). The average volume of pancreas resected was 49.6 +/- 38.6 cm(3), and the mean diameter of the lesions was 2.6 +/- 1.5 cm. Nine complications occurred in eight patients (overall morbidity 31%), and the average length of stay was 6.9 +/- 2.7 days. Pancreatic leaks (n = 2; 7.7%) were successfully managed nonoperatively. There was no operative mortality, and there has been no tumor recurrence. None of the patients were diabetic preoperatively. Postoperatively, two (7.7%) developed endocrine insufficiency with a mean postoperative hemoglobin A1c (HbA1c) value of 7.65%. Neither patient has required exogenous insulin. HbA1c in the remaining patients was 5.9% +/- 0.5%.

CONCLUSIONS

Pancreatic parenchyma-sparing surgery for lesions in the midportion of the gland can be performed with acceptable morbidity. Postoperative glycemic control after pancreatic parenchyma-sparing surgery compares favorably with that reported for patients with traditional resections.

Total pancreatectomy: indications, operative technique, and postoperative sequelae

Total pancreatectomy has been used to treat both benign and malignant disease of the pancreas, but its use has been limited by concerns about management of the a-pancreatic state with its attendant total endocrine and exocrine insufficiency. Here, we review the indications for total pancreatectomy, operative technique, and improvements in the postoperative management of patients. Total pancreatectomy remains a viable option in the treatment of intractable pain associated with chronic pancreatitis, multicentric or extensive neuroendocrine tumors, patients with familial pancreatic cancer with premalignant lesions, and in patients with intraductal papillary mucinous neoplasia with diffuse ductal involvement or invasive disease. Improvements in postoperative management include auto-islet cell transplantation, advances in insulin formulations, and the use of glucagon rescue therapy which allow much tighter control of blood glucose than previously possible. This markedly lessens the risk of life-threatening hypoglycemia and decreases the risk of long-term complications, resulting in improved quality of life for these patients.

Central pancreatectomy for benign pancreatic pathology/trauma: is it a reasonable pancreas-preserving conservative surgical strategy alternative to standard major pancreatic resection?

BACKGROUND

The aim of this study was to assess the technical feasibility, safety and outcome of central pancreatectomy (CP) with pancreaticogastrostomy or pancreaticojejunostomy in appropriately selected patients with benign central pancreatic pathology/trauma. Benign lesions/trauma of the pancreatic neck and proximal body pose an interesting surgical challenge. CP is an operation that allows resection of benign tumours located in the pancreatic isthmus that are not suitable for enucleation.

METHODS

Between January 2000 and December 2005, eight central pancreatectomies were carried out. There were six women and two men with a mean age of 35.7 years. The cephalic pancreatic stump is oversewn and the distal stump is anastomosed end-to-end with a Roux-en-Y jejunal loop in two and with the stomach in six patients. The indications for CP were: non-functional islet cell tumours in two patients, traumatic pancreatic neck transection in two and one each for insulinoma, solid pseudopapillary tumour, splenic artery pseudoaneurysm and pseudocyst. Pancreatic exocrine function was evaluated by a questionnaire method. Endocrine function was evaluated by blood glucose level.

RESULTS

Morbidity rate was 37.5% with no operative mortality. Mean postoperative hospital stay was 10.5 days. Neither of the patients developed pancreatic fistula nor required reoperations or interventional radiological procedures. At a mean follow up of 26.4 months, no patient had evidence of endocrine or exocrine pancreatic insufficiency, all the patients were alive and well without clinical and imaging evidence of disease recurrence.

CONCLUSION

When technically feasible, CP is a safe, pancreas-preserving pancreatectomy for non-enucleable benign pancreatic pathology/trauma confined to pancreatic isthmus that allows for cure of the disease without loss of substantial amount of normal pancreatic parenchyma with preservation of exocrine/endocrine function and without interruption of enteric continuity.

Interventional strategies to prevent beta-cell apoptosis in islet transplantation

A substantial proportion of the transplanted islet mass fails to engraft due to death by apoptosis, and a number of strategies have been explored to inhibit beta-cell loss. Inhibition of extrinsic signals of apoptosis (i.e., cFLIP or A20) have been explored in experimental islet transplantation but have only shown limited impact. Similarly, strategies targeted at intrinsic signal inhibition (i.e., BCL-2) have not yet provided substantial improvement in islet engraftment. Recently, investigation of downstream apoptosis inhibitors that block the final common pathway (i.e., X-linked inhibitor of apoptosis protein [XIAP]) have demonstrated promise in both human and rodent models of engraftment. In addition, XIAP has enhanced long-term murine islet allograft survival. The complexities of both intrinsic and extrinsic apoptotic pathway inhibition are discussed in depth.

Diabetic control after total pancreatectomy

BACKGROUND

Diabetes after total pancreatectomy is commonly described as 'brittle' with most series reporting outcomes after resection for pancreatitis alone. The aim of this study was to determine glycaemic control in patients resected for benign and malignant disease.

METHODS

A retrospective analysis of all patients undergoing total pancreatectomy (1989-2003) from a single institution was done. Data of diabetic control were obtained from case notes, general practitioners and telephonic consultation. Comparison was made against a matched type 1 diabetic population.

RESULTS

Forty-seven patients with a median age of 59 years (range 17-85 years) and median follow-up of 50 months (range 5-136 months) were identified. Thirty-five underwent primary resection with 11 receiving completion procedures. Thirty were for malignancy (19 deceased) and 17 for benign/indeterminate histology (2 deceased). Thirty-three patients were available for detailed follow-up. There was no significant difference between median HbA(1c) of the study group and the control (8.2% versus 8.1%). The majority of patients reported diabetic control and daily performance as excellent or good. Resection for pancreatitis gave poorer subjective control (p < 0.05) than those resected for malignancy. Two patients required in-patient treatment for diabetic complications, with no deaths related to diabetes observed.

CONCLUSION

Diabetes after total pancreatectomy is not necessarily associated with poor glycaemic control and in the majority results in equivalent biochemical control compared to a normal type 1 diabetic population.

Epidemiology data on 108 MEN 1 patients from the GTE with isolated nonfunctioning tumors of the pancreas

OBJECTIVE

To analyze the penetrance and clinical course of isolated nonfunctioning tumors of the pancreas (NFTP) in MEN 1 patients, and to propose a strategy for managing them.

SUMMARY BACKGROUND DATA

Pancreaticoduodenal tumors develop in a majority of MEN 1 patients and are a major cause of death. The natural history of NFTP is poorly defined, and no clear-cut guidelines have been widely accepted regarding treatment.

METHODS

Data on 108 patients with isolated NFTP among 579 MEN 1 patients from the French Endocrine Tumor Study Group (GTE) were analyzed. Survival rates were calculated using the Kaplan-Meier method.

RESULTS

The penetrance of NFTP was 34% at age 50, making it the most frequent pancreaticoduodenal tumor in MEN 1 patients. Forty-three patients (40%) underwent surgery, 32 of them curatively. No patient died because of surgery. Average life expectancy for patients with NFTP was shorter than that for MEN 1 patients who did not have pancreaticoduodenal tumors. Thirteen patients died during follow-up, 10 due to NFTP. Tumor size was correlated with the risks of metastasis and death. These risks were low for patients with tumors<or=20 mm.

CONCLUSIONS

NFTP are currently the most common tumors of the pancreaticoduodenal region in patients with MEN 1. Prevention of tumor spread by surgery should be balanced with potential operative mortality and morbidity. We do not recommend routine surgery for NFTP<or=20 mm.

Insulin secretory defect plays a major role in the development of diabetes in patients with distal pancreatectomy

To investigate the pathogenesis of distal pancreatectomy (d-Px)-induced diabetes in Korean patients, we investigated insulin secretory and sensitivity indexes obtained by oral glucose tolerance testing in 20 patients that had received d-Px (10 with d-Px-induced diabetes and 10 with normal glucose tolerance with d-Px [NGT d-Px]) and in 164 control subjects (77 with type 2 diabetes mellitus and 87 with NGT) that did not receive d-Px. The pancreatectomized subjects had lower fasting serum insulin, homeostasis model assessment of pancreatic beta-cell function (HOMA-beta) levels, and insulinogenic indices than the NGT controls. The HOMA-beta values of nonobese NGT d-Px- and d-Px-induced diabetic subjects were 73.7% and 38.7% of those for nonobese NGT controls, respectively, and HOMA-beta was significantly lower only for d-Px-induced diabetic subjects (P < .01). In obese subjects, the HOMA-beta values of obese d-Px-induced diabetic subjects were significantly lower than those of obese NGT controls (P < .05). The insulin sensitivity was significantly lower in nonobese type 2 diabetes mellitus controls than in nonobese NGT d-Px or in nonobese d-Px-induced diabetic subjects (P < .001 and .05, respectively). These results show that a reduced insulin secretory function is a typical feature of glucose homeostasis in distal pancreatectomized patients and that insulin secretory defect plays a major role in the development of diabetes in these patients. In addition, the study suggests that pancreatic resections of 60% or less and body mass index are not the main causes of diabetes onset after d-Px in this study.

Predictors of intensive care unit admission and related outcome for patients after pancreaticoduodenectomy

High-volume centers have low morbidity and mortality after pancreaticoduodenectomy (PD). Less is known about treatment pathways and their influence on intensive care unit (ICU) utilization. Patients who underwent PD at a tertiary cancer center during the five-year period between January 1998 and December 2003 were identified from a prospective database. Preoperative and intraoperative factors relating to ICU admission and outcome were analyzed. Five hundred ninety-one pancreaticoduodenectomies were performed during the study period. Of these, 536 patients had complete records for analysis. Of the 536 patients, 51 (10%) were admitted to the ICU after surgery. Admission to the ICU was associated with decreased overall survival (P < .0001). Of the preoperative predictors of ICU admission, serum creatinine, albumin, and increased body mass index (BMI) were associated with ICU admission (P = .02, .05, and .002, respectively). Age, blood glucose, diagnosis of diabetes mellitus, and chronic obstructive pulmonary disease were not predictive of ICU admission on univariate analysis. Of the intraoperative factors, longer operative time and estimated blood loss (EBL) correlated with ICU admission (P = .003 and .0001, respectively). On multivariate analysis, only preoperative BMI and intraoperative EBL were independent predictors of ICU admission (P = .03 and .003, respectively). Patients with a preoperative BMI greater than 30 had a substantially higher risk of ICU admission (relative risk 2.4). The majority of patients who undergo PD do not require admission to the ICU. Factors most associated with ICU admission after PD are increased preoperative BMI and intraoperative blood loss.

Factors associated with insulin and narcotic independence after islet autotransplantation in patients with severe chronic pancreatitis

BACKGROUND

For patients who suffer from severe chronic pancreatitis, total pancreatectomy can alleviate pain, and islet autotransplantation (IAT) might preserve endocrine function and circumvent the complications of diabetes. Factors that determine success after this operation have not been clearly defined.

STUDY DESIGN

From 2000 to 2004, 45 total or subtotal pancreatectomies with IAT were performed. Patient characteristics, narcotic usage and insulin requirements were recorded at routine followup. Narcotic usage was standardized by conversion to morphine equivalents (MEs). Univariate and multivariate statistical analyses were performed to determine factors associated with insulin and narcotic independence.

RESULTS

Forty-five patients (30 women, 15 men), with a mean age of 39 years (range 16 to 62 years) underwent total or completion (n=41) or subtotal (n=4) pancreatectomies with IAT. Forty percent of patients were insulin free after a mean followup of 18months (range 1 to 46months). Factors associated in univariate analyses with insulin independence included female gender (p=0.004), lower body weight (kg) (p=0.04), more islet equivalents per kg body weight (IEQ/kg) transfused (<0.05), lower mean insulin requirement for the first 24hours postoperation (p=0.002), and lower mean insulin requirement at discharge (p=0.0005). A multiple logistic regression using gender, body mass index, and IEQ/kg identified female gender as the only notable variable associated with insulin independence. There was a notable reduction (p < 0.0001) of postoperative MEs (mean 90 mg) compared with preoperative MEs (mean 206 mg) for the entire cohort; 58% of patients are narcotic independent. In the subset of patients with>5months followup (n=32), 23 (72%) are narcotic free, with a substantial decrease in ME usage (p=0.01).

CONCLUSIONS

The likelihood of glycemic control after IAT is related to both patient characteristics and islet cell mass. Based on these data, more islet cells may be required for insulin independence than previously thought.

The favorable outcome of human islet transplantation in Korea: experiences of 10 autologous transplantations

BACKGROUND

Cystic neoplasms of the pancreas are an increasingly diagnosed entity, and surgical resection of the pancreas is advocated. Islet autotransplantation is a therapeutic approach used to prevent diabetes in cases of pathologically benign neoplasm after major pancreatectomy.

METHODS

A total of 10 patients underwent pancreatectomy with islet autotransplantation. To evaluate islet transplantation efficiency, the authors compared 23 subjects who did not undergo islet transplantation after partial pancreatectomy with 87 subjects with normal glucose tolerance and with 77 diabetic subjects that did not undergo pancreatectomy.

RESULTS

Ten female patients with nine cystic neoplasms and one patient with pancreatic injury underwent transplantation. Their mean islet equivalents (IEQ) was 3,159 IEQ/kg. During follow-up, two recipients required insulin or oral agents. At the 12-month follow-up, homeostasis model assessment (HOMA)-beta was 77.36+/-17.68, the insulinogenic index (INSindex) was 0.49+/-0.11, and fasting C-peptide and hemoglobin A1c were 1.28+/-0.18 ng/mL and 5.73+/-0.26%, respectively. Islet replacement was found to increase HOMA-beta by approximately 17% compared with distal pancreatectomy in normal glucose tolerance subjects without islet autotransplantation and by 46% compared with distal pancreatectomy diabetes subjects without islet autotransplantation. Factors different in the two insulin and oral hypoglycemic agent (OHA)-requiring recipients and the eight insulin- and OHA-free recipients were pancreatectomy extent, preoperative glucose metabolism insufficiency, age, and underlying cystic neoplasm disease.

CONCLUSIONS

Even partial islet graft function can have a beneficial metabolic effect on the recipient in terms of metabolic parameters such as HOMA-beta and INSindex. This study suggests that islet replacement should be considered for experimental procedures in benign pancreatic conditions.

Pancreatic polypeptide administration reduces insulin requirements of artificial pancreas in pancreatectomized dogs

An artificial endocrine pancreas is a mechanical device that frequently measures blood glucose and adjusts the rate of insulin infusion to maintain normoglycemia. In this study, we evaluated the effect of pancreatic polypeptide (PP) on insulin requirements after total pancreatectomy. However, other endocrine hormones are needed not only to facilitate the effect of insulin, but also to regulate insulin functions in vivo. In this study, the effect of PP infusion on insulin requirements after total pancreatectomy in dogs is examined. After total pancreatectomy, five dogs were supported by artificial endocrine pancreas model STG-22 for 72 h. In a second group of five dogs, both insulin and PP were infused. Mean blood glucose levels and insulin requirements were compared between the two groups. There was no difference in mean plasma glucose levels between the two groups. In all 10 dogs, the mean blood glucose level for 72 h was 110 +/- 4 mg/dL and was tightly controlled between 65 and 190 mg/dL. However, the insulin requirement for the first and second postoperative days in the group treated with PP was significantly less than that of the control group (90.0 +/- 20.8 mU/kg vs. 445.0 +/- 151.9 mU/kg; P < 0.05, and 562.7 +/- 126.5 mU/kg vs. 1007.7 +/- 144.9 mU/kg; P < 0.05, respectively). We conclude that infusion of PP reduces the insulin requirement for the initial 48 h in pancreatectomized dogs treated with an artificial endocrine pancreas.

Glycaemic effects of incretins in Type 1 diabetes mellitus

The remission phase of Type 1 diabetes mellitus is associated with substantial recovery of beta-cell function and with marked improvement of endogenous insulin responses to meals in the early months after diagnosis, accompanied by little or no improvement in the insulin response to parenteral glucose, suggesting that the incretin function may be important in glycaemic regulation in this phase of diabetes. Preservation of the insulin response to parenteral glucagon-like peptide-1 (GLP-1), contrasting with lack of stimulation of insulin secretion by the other known incretin gastric inhibitory polypeptide (GIP), prompted studies with exogenous GLP-1 in recent-onset Type 1 diabetes. These studies showed substantial reduction of glycaemic excursions after ingestion of mixed nutrients during intravenous infusion of GLP-1 without administration of insulin, in subjects with a range of endogenous secretion of insulin in response to meals as demonstrated by blood levels of the insulin-connecting peptide (CP). These effects were independent of stimulation of blood levels of CP and were reproduced in volunteers with no endogenous release of CP in response to meals. The glycaemic effects were associated with inhibition of abnormal rises of blood levels of glucagon, and with suppression of endogenous release of human pancreatic polypeptide (HPP), by GLP-1. It was hypothesized that a major component of the glycaemic effect is attributable to the known action of GLP-1 to inhibit gastric emptying and to inhibit glucagon secretion. Studies of the effects of GLP-1 agonists (GLP-1 and exendin-4) given together with established insulin doses before a meal supported the hypothesis. The more prolonged actions of exendin-4 were accompanied by greater and more prolonged reduction of glycaemic effects of ingestion of meals in volunteers with CP-negative Type 1 diabetes mellitus, during intensive insulin therapy, in whom delay of gastric emptying was confirmed by studies of blood levels of acetaminophen ingested with the meals. Side effect-free doses of exendin-4 given together with insulin in volunteers with CP-negative Type 1 diabetes receiving continuing intensive insulin therapy demonstrated the capacity of this combination therapy to normalize blood glucose levels after ingestion of meals that were consistent with the dietary program of the volunteers, without apparent increased risk of hypoglycaemia within a normal between-meals interval. It is suggested that further and more prolonged studies of the use of long-acting GLP-1 agonists as congeners with insulin in Type 1 diabetes mellitus are indicated.

Improved outcomes for benign disease with limited pancreatic head resection

We sought to determine whether duodenum-preserving pancreatic head resections (DPPHRs) offer improved outcomes for benign disease of the proximal pancreas. A single-cohort study was performed of 86 consecutive patients who underwent DPPHR, extended lateral pancreaticojejunostomy with excavation of the pancreatic head (ELPJ), standard or pylorus-sparing Whipple procedure (WHIP), or distal pancreatectomy (DPR). Aspects of cost, complications (mortality and morbidity), and outcomes were assessed during a follow-up period of 6-63 months (mean, 3 years). Twelve DPPHR and 12 ELPJ procedures were performed for benign lesions or chronic pancreatitis (CP), as were 7 of 30 WHIP procedures and 12 of 16 DPRs. Operative time was significantly less than that for WHIP in ELPJ and DPR procedures. Major complications occurred in 40% of WHIPs and 25% of DPPHRs but only 16% of ELPJs (P < 0.05). Thirty-day mortality was 2 of 30 for WHIP but 0 for all other procedures. Pancreatic or biliary leak occurred in 3 of 30 WHIPs, 3 of 12 DPPHRs, 1 of 16 DPRs, and 0 of 12 ELPJs. New diabetes occurred in 25% of patients who underwent WHIP but only 8% of both DPPHR and ELPJ patients. Full functional recovery was similar for CP patients in both DPPHR and ELPJ. DPPHR and ELPJ are effective surgical approaches to the treatment of benign tumors and CP and are safer than WHIP with lower morbidity and mortality risks. The incidence of new diabetes is less with both ELPJ and DPPHR.

The feasibility and morbidity of distal pancreatectomy in extensive cytoreductive surgery for advanced epithelial ovarian cancer

INTRODUCTION

Pancreatic metastasis of ovarian cancer is extremely rare and its therapeutic approach is not well documented. The objective of this study is to evaluate the feasibility and morbidity of pancreatic resection as a component of extensive cytoreductive surgery in epithelial ovarian cancer (EOC) patients with pancreas metastasis.

METHODS

Between December 2000 and February 2003, 98 EOC patients were treated with primary cytoreduction. Six (6.12%) of these patients had pancreatic tail metastasis and were operated on using the distal pancreatectomy.

RESULTS

Preoperatively, only 1 (16.7%) of the 6 patients had signs of metastasis to the pancreas on computed tomography (CT). Optimal cytoreduction (absent or < or =1 cm macroscopic residual tumor size) was achieved in all patients. In the early postoperative period, there were 4 patients (66.7%) with complications and no perioperative mortality. In 1 patient (16.7%), glucose intolerance as a late complication of pancreatic resection was detected. All patients received six cycles of platinum-based adjuvant chemotherapy following a cytoreductive operation. Mean follow-up was 27 months (range 9-36), and 3 (50%) patients are still alive at the end of the study period. The two-year survival rate was 66.7%.

CONCLUSION

In conclusion, if optimal cytoreduction is foreseen in advanced epithelial ovarian cancer with pancreatic tail metastasis, distal pancreatectomy should be kept in mind. This procedure has acceptable morbidity and seems to be an attribute for survival.

Diabetes Mellitus As The Presenting Feature Of Extrahepatic Cholangiocarcinoma In Situ: Case Report And Review Of Literature

OBJECTIVE

To report a case of newly recognized diabetes, manifested by hyperglycemic crisis, as the presenting feature of an extrahepatic cholangiocarcinoma in situ.

METHODS

We summarize the initial clinical manifestations and pertinent laboratory, radiologic, and pathologic findings in a patient with hyperglycemic emergency and a biliary carcinoma in situ. A review of the literature involving cholangiocarcinoma, pancreatic tumors, and diabetes mellitus is also presented.

RESULTS

An 85-year-old woman with no prior history of hyperglycemia presented to the hospital in hyperglycemic crisis, without identifiable precipitants. Further work-up disclosed a tumor in the common bile duct. Pathologic analysis, after pancreatoduodenectomy, demonstrated a carcinoma in situ without extension to nearby structures. Adjacent pancreatic islet cells appeared normal. Screening for all relevant islet cell autoantibodies was negative. After tumor removal, mild hyperglycemia persisted, although without insulin requirements.

CONCLUSION

Extrahepatic cholangiocarcinoma and diabetes are not usually associated, and to our knowledge, this is the first reported case of a hyperglycemic emergency with this specific type of tumor. The cause-and-effect relationship between the patient's biliary carcinoma in situ and diabetes obviously cannot be confirmed; however, in the absence of other identifiable conditions, it is reasonable to speculate that some factor (or factors) produced by the tumor had a role in the metabolic decompensation. Such a relationship has been considered by others concerning the well-described association between diabetes and carcinoma of the pancreas, in which the underlying pathophysiologic process seems to be insulin resistance. This unusual case of secondary diabetes emphasizes the importance of considering the precise "cause" of the hyperglycemia when the presentation is atypical, as it was in this older, lean patient without risk factors for diabetes.

Pancreaticogastrostomy: a novel application after central pancreatectomy

BACKGROUND

Limited middle segment pancreatectomy, or central pancreatectomy, has been described for sparing normal pancreatic tissue during resection of benign neoplasms of the pancreatic neck. Anatomic reconstruction after central pancreatectomy has been reported in other series with creation of a Roux-en-Y loop of jejunum for a mucosa-to-mucosa pancreaticojejunostomy.

STUDY DESIGN

Hospital charts and outpatient records were reviewed for 12 consecutive patients undergoing central pancreatectomy from August 1999 to November 2002.

RESULTS

We performed central pancreatectomy with pancreaticogastrostomy in 12 patients: 5 with serous cystadenomas, 6 with mucinous cystadenomas, and 1 with neuroendocrine tumor. All tumors were located in the body or neck of the pancreas, measuring a mean +/- standard deviation (SD) of 2.5 +/- 1.2 cm. Median postoperative hospital stay was 6.5 days (range 5 to 15 days). There were no intraoperative complications. Perioperative complications included two urinary tract infections and one readmission for acute pancreatitis. There were no pancreatic leaks or fistulas in this series. Two of the 12 patients experienced endocrine insufficiency with elevated glycosylated hemoglobin levels during outpatient followup. None of the 12 patients experienced exocrine insufficiency.

CONCLUSIONS

Central pancreatectomy with pancreaticogastrostomy reconstruction is safe and technically advantageous over Roux-en-Y pancreaticojejunostomy, and should be considered a safe reconstruction technique after central pancreatectomy for benign disease.

Surgical management of chronic pancreatitis and the role of islet cell autotransplantation

Chronic pancreatitis is a disease characterized by disabling pain, inability to eat, steatorrhea, and eventual malnutrition. This often results in repeated hospitalizations and attempts to control symptoms with various analgesic regimens. As a result, the medical treatment of chronic pancreatitis is one of symptomatic management. Eventually, in some, nutritional supplementation becomes a necessity. For a fortunate few, the disease apparently burns itself out in time, lessening pain and improving appetite. In many patients, frustration over pain management and repeated hospitalizations leads to surgical treatment. Various procedures have been devised but, generally, fall into 2 categories: operations to decompress dilated ducts and operations to resect diseased pancreas. Results with either approach are unpredictable and often unsuccessful. For those without dilated ducts or with recurrent pain after surgery, total pancreatectomy has been suggested to remove all inflammatory tissue. This can be coupled with islet cell autotransplantation to avoid the dangers of pancreatogenic diabetes. Appropriate care of the removed pancreas and islet cell separation and purification are critical to this procedure to produce viable cells. Dispersed islets have been shown to successfully engraft and function for indefinite periods of time. Although insulin independence may not be achieved, easier maintenance of blood glucose can usually be realized.

Islet autotransplantation for the prevention of surgical diabetes after extended pancreatectomy for the resection of benign tumors of the pancreas

OBJECTIVE

The objective of this article is to report a single-center experience with islet autotransplantation after extensive pancreatic resection for benign tumors of the pancreas.

MATERIALS AND METHODS

Seven patients underwent extensive left pancreatectomy for benign lesions located at the neck of the pancreas. Once an unequivocal diagnosis of a benign nature was ascertained, the rest of the specimen was processed and the unpurified pancreatic digest was infused into the portal vein. The results were compared with those of 8 autotransplantations performed for chronic pancreatitis over the same period.

RESULTS

Tumors were 4 cystadenomas, 2 insulinomas and 1 neuroendocrine tumor. Mean islet yields were 275,000 islet equivalents (IEQ) versus 129,000 in chronic pancreatitis (P =.04) or 6700 IEQ/g of tissue versus 1900 (P =.002), resulting in transplantation of 4200 IEQ/kg body weight vs 2150 in chronic pancreatitis (P =.03), respectively at 4-month to 7.5-year follow-up, all patients are alive and 6 of 7 are off insulin. All patients off insulin after at least 1 year currently have a normal IVGTT, with K values ranging between -1.19 and -2.36 (normal < -1.00). All patients, including 1 on insulin, display positive basal and glucagon-stimulated C-peptide levels.

CONCLUSIONS

Compared with chronic pancreatitis tissue resected for benign tumors is more likely to achieve good islet yields, and thus insulin independence after autotransplantation. Islet autotransplantation should be considered when extensive pancreatectomy is required for resection of a benign tumor, and only if the benign nature of the lesion is demonstrated unequivocally.

Effect of surgery for chronic pancreatitis on pancreatic function: pancreatico-jejunostomy and duodenum-preserving resection of the head of the pancreas

BACKGROUND

Resection and drainage procedures are performed for chronic pancreatitis. After resection, pancreatic function deteriorates; however, little is known about the effect of drainage procedures.

METHODS

Pancreatic function was evaluated prospectively before and after surgery in 27 patients with duodenum-preserving resection of the head of the pancreas (DPRHP), and in 12 patients with pancreatico-jejunostomy (P-JS); 18 patients with chronic pancreatitis served as controls. Results of the 2 groups were not compared because of differences in patient characteristics and indications for surgery. Endpoints were exocrine function (fecal fat excretion, urinary PABA recovery), endocrine function (oral glucose tolerance test, serum C-peptide concentrations), and pancreatic polypeptide secretion.

RESULTS

Groups were not different with respect to age and duration of symptoms. Median urinary PABA recovery was not altered significantly after surgery: DPRHP, from 40% to 31%; P-JS, from 52% to 44%; and controls, from 43% to 48%. Median fecal fat also did not change significantly: DPRHP, from 6 to 12 g/24 h; P-JS, from 9 to 5 g/24 h; and controls, from 6 to 7 g/24 h. Although the integrated blood glucose value did not change after DPRHP, the integrated serum C-peptide value decreased after DPRHP (P<.02). After P-JS, the integrated blood glucose value decreased (P<.02), but there was no change in integrated serum C-peptide secretion. Neither integrated blood glucose nor C peptide values were affected in controls. Insulin dependency increased (22% to 33%) after DPRHP. Pancreatic polypeptide secretion decreased only after DPRHP (P=.003).

CONCLUSIONS

Surgery for chronic pancreatitis does not influence exocrine pancreatic function after either a drainage (P-JS) or a resection procedure (DPRHP). Clinical endocrine function is not affected after DPRHP but improves after P-JS.

Total pancreatectomy and autologous islet cell transplantation as a means to treat severe chronic pancreatitis

Autologous islet cell transplantation after near-total or total pancreatic resection can alleviate pain in patients with severe chronic pancreatitis and preserve endocrine function. From February 2000 to February 2003, a total of 22 patients, whose median age was 38 years, underwent pancreatectomy and autologous islet cell transplantation. Postoperative complications, metabolic studies, insulin usage, pain scores, and quality of life were recorded for all of these patients. The average number of islet cells harvested was 245,457 (range 20,850 to 607,466). Operative data revealed a mean estimated blood loss of 635 ml, an average operative time of 9 hours, and a mean length of hospital stay of 15 days. Sixty-eight percent of the patients had either a minor or major complication. Major complications included acute respiratory distress syndrome (n=2), intra-abdominal abscess (n=1), and pulmonary embolism (n=1). There were no deaths in our series. All patients demonstrated C-peptide and insulin production indicating graft function. Forty-one percent are insulin independent, and 27% required minimal amount of insulin or a sliding scale. All patients had preoperative pain and had been taking opioid analgesics; 82% no longer required analgesics postoperatively. Pancreatectomy with autologous islet cell transplantation can alleviate pain for patients with chronic pancreatitis and preserve endocrine function.

Comparison of local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (frey procedure) and duodenum-preserving resection of the pancreatic head (beger procedure)

The etiology of pain in chronic pancreatitis may be ductal hypertension, increased parenchymal pressure, or neural damage. It is difficult to assess the severity of pain in this patient population, a problem made more challenging by the frequency of narcotic dependency. Therapeutic interventions developed to relieve the pain of chronic pancreatitis include denervation of the pancreas, decompression of the main duct of the pancreas, resection of part or all of the diseased pancreas, and reduction of pancreatic secretion. Operative intervention for patients with chronic pain is indicated when severe pain, complications of pain, or potential malignancy are present. The operations that consistently provide long-lasting pain relief all have in common resection of all or a portion of the head of the pancreas. Adverse effects on exocrine and endocrine function, nutrition, and quality of life are related to the amount of pancreas resected. The ideal procedure should be easy to perform, have a low morbidity and mortality rate, provide long-lasting pain relief, and not augment endocrine and exocrine insufficiency. No single operation fulfills this ideal. The local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (LR-LPJ) proposed by Frey and the duodenum-preserving resection of the head of the pancreas (DPHR) proposed by Beger are discussed. The conceptualization, development, and technique of LR-LPJ are discussed, and comparisons of patient outcomes are made with the outcomes of other procedures for chronic pancreatitis.

Islet autotransplantation after left pancreatectomy for non-enucleable insulinoma

Insulinoma is a rare, almost always benign endocrine tumor of the pancreas, clinically characterized by hyperinsulinemic, hypoglycemic episodes. Surgical excision is the therapy of choice, which may lead to postpancreatectomy diabetes mellitus in the case of extensive pancreatic resection. We present the cases and the metabolic follow up of two patients, 81 and 73 years old, with insulinoma localized close to the main duct in the pancreatic neck. Both patients underwent an 80% left pancreatectomy, avoiding a pancreatico-enteric anastomosis. In order to prevent postpancreatectomy diabetes, the islets from the tumor-free part of the resected pancreas were isolated and injected via a right colic vein into the portal system. After a follow up of 6 and 3 years respectively, both patients remained insulin-independent without any dietary restrictions. Fasting and glucagon-stimulated C-peptide-levels and glycosylated hemoglobin remained within normal range. There were no signs of recurrent insulinoma. Liver biopsy performed in one patient at 1 year after autotransplantation, showed intact, insulin-producing islets within the portal spaces. In conclusion, autologous islet transplantation can preserve the insulin secretory reserve after extended left pancreatectomy for the treatment of benign tumors in the pancreatic neck.

The human body may buffer small differences in meal size and timing during a 24-h wake period provided energy balance is maintained

Because approximately 20% of the work force in the industrialized world have irregular working hours, it is pertinent to study the consequences of eating at irregular, especially nighttime hours. We studied the postprandial responses during nocturnal fasting vs. eating throughout a 24-h wake period. Seven healthy males were studied twice in a crossover design. After a 6-d diet adjustment period [high fat diet, 45 energy percent (en%) fat, 40 en% carbohydrates)] with sleep from 2300 to 0700 h, the men were kept awake for 24 h at the metabolic ward and given either 6 isoenergetic meals, i.e., every 4 h (N-eat) or 4 isoenergetic meals from 0800 to 2000 h followed by a nocturnal fast (N-fast), with the same 24-h energy intake. Energy expenditure, substrate utilization, activity, heat release, body temperature and blood variables were measured over 24 h. Energy expenditure and blood glucose, triacylglycerol, insulin and glucagon concentrations were lower and nonesterified fatty acids concentrations were higher during the nocturnal fast than during nocturnal eating (P < 0.05); however, no 24-h differences between the protocols were apparent. Nocturnal fasting slightly altered the secretory patterns of the thyroid hormones and cortisol (P < 0.05). We found no clear indication that it would be more favorable to ingest few larger daytime meals than smaller meals throughout the 24-h period. The body seems to be able to buffer small differences in meal size and timing provided energy balance is maintained.

Pancreatectomy with islet autotransplantation for the treatment of severe chronic pancreatitis: the first 40 patients at the leicester general hospital

BACKGROUND

Surgical resection of the pancreas is considered a final resort in the treatment of chronic pancreatitis. However, the opportunity to perform an islet autotransplant at the same time provides the potential to prevent the onset of diabetes.

METHODS

Pancreatectomy together with islet autotransplantation has been offered in our center since 1994. A total of 40 patients have now undergone this procedure. The follow-up times range from 6 months to 7 years. The data presented here include the annual postoperative oral glucose tolerance test and glycosylated hemoglobin (HbA(1c)) results, together with insulin and opiate requirements.

RESULTS

Nineteen male and 21 female patients (median age 44, range 21-65) have been transplanted. Pancreatitis was related to alcohol in 45% and was idiopathic in 40%. A median of 130108 (24332-1, 165538) islet equivalent (IEQ) were transplanted, which related to 2020 (320-23311) IEQ per kilogram of body weight. At 2 years posttransplant, 18 patients had a median HbA(1c) of 6.6% (5.2-19.3%), fasting C-peptide of 0.66 ng/mL (0.26-2.65 ng/mL), and required a median of 12 (0-45) units of insulin per day. At 6 years, these figures were 8% (6.1-11.1%), 1.68 ng/mL (0.9-2.78 ng/ml) and 43 U/day (6-86 U/day), respectively. The majority of patients no longer require opiate analgesia, 68% have been able to return to work, and one patient has had a baby.

CONCLUSIONS

Islet autotransplantation offers a valuable addition to surgical resection of the pancreas, as a treatment for chronic pancreatitis; and even in cases in which insulin independence is not achieved, the potential beneficial effects of C-peptide make the procedure worthwhile.

How to control blood glucose under continuous glucose challenge

A newly improved method for controlling blood glucose was compared with the standard model predictive controller under continuous glucose infusion. Continuous intravenous glucose infusion at rates of 50 or 100 mg/kg/hour was conducted on pancreatectomized dogs. An improved blood glucose control method using a combination of the proportional controller in the initial stage and the model predictive controller in the later stage was compared with the simple model predictive controller. The parameters of the controller were determined by identifying individual responses to the infused insulin during the first 60 minutes. The parameters of the proportional controller were changed at 60, 90, and 120 minutes to reflect the response to the infused insulin. The simple model predictive controller was able to reach the target level in the usual manner under the low infusion rate of glucose. However, under glucose infusion rates of 100 mg/kg/hour and more, it was difficult to reach the target level within 8 hours. In contrast, the improved system could reach the target level within 5 to 8 hours even under continuous glucose challenge. Addition of the modified proportional controller to the model predictive controller can stabilize the blood glucose control even under continuous glucose infusion.

Auto-islet transplantation after pancreatectomy

Chronic pancreatitis (CP) is an inflammatory disease that causes progressive and irreversible structural changes to the pancreas, resulting in permanent impairment of both endocrine and exocrine functions. In advanced cases of CP, pain can be relieved only with pancreatic resection. However, even partial resection of the pancreas in this setting may cause diabetes. Furthermore, postsurgical diabetes (PSD) always occurs after total or near-total pancreatectomy, which is commonly performed for CP. Auto transplantation of pancreatic islets into the portal vein after pancreatic resection can prevent PSD. The results of this strategy, which are already encouraging, are likely to improve in the near future because of significant progress in the isolation and preservation of pancreatic islets. This review discusses the current status and future prospects for auto-islet transplantation after pancreatic resection for CP.