Changes in pancreatic function after pancreatoduodenectomy

Mapping global new-onset, worsening, and resolution of diabetes following partial pancreatectomy: a systematic review and meta-analysis

BACKGROUND AND AIMS

Partial pancreatectomy, commonly used for chronic pancreatitis, or pancreatic lesions, has diverse impacts on endocrine and metabolism system. The study aims to determine the global prevalence of new-onset, worsening, and resolution of diabetes following partial pancreatectomy.

METHODS

The authors searched PubMed, Embase, Web of Science, and Cochrane Library from inception to October, 2023. DerSimonian-Laird random-effects model with Logit transformation was used. Sensitivity analysis, meta-regression, and subgroup analysis were employed to investigate determinants of the prevalence of new-onset diabetes.

RESULTS

A total of 82 studies involving 13 257 patients were included. The overall prevalence of new-onset diabetes after partial pancreatectomy was 17.1%. Univariate meta-regression indicated that study size was the cause of heterogeneity. Multivariable analysis suggested that income of country or area had the highest predictor importance (49.7%). For subgroup analysis, the prevalence of new-onset diabetes varied from 7.6% (France, 95% CI: 4.3-13.0) to 38.0% (UK, 95% CI: 28.2-48.8, P <0.01) across different countries. Patients with surgical indications for chronic pancreatitis exhibited a higher prevalence (30.7%, 95% CI: 21.8-41.3) than those with pancreatic lesions (16.4%, 95% CI: 14.3-18.7, P <0.01). The type of surgical procedure also influenced the prevalence, with distal pancreatectomy having the highest prevalence (23.7%, 95% CI: 22.2-25.3, P <0.01). Moreover, the prevalence of worsening and resolution of preoperative diabetes was 41.1 and 25.8%, respectively.

CONCLUSIONS

Postoperative diabetes has a relatively high prevalence in patients undergoing partial pancreatectomy, which calls for attention and dedicated action from primary care physicians, specialists, and health policy makers alike.

Long-term Metabolic Morbidity and Steatohepatosis Following Standard Pancreatic Resections and Parenchyma-sparing, Local Extirpations for Benign Tumor: A Systematic Review and Meta-analysis

OBJECTIVE

To assess metabolic dysfunctions and steatohepatosis after standard and local pancreatic resections for benign and premalignant neoplasms.

SUMMARY OF BACKGROUND DATA

Duodenopancreatectomy, hemipancreatectomy, and parenchyma-sparing, limited pancreatic resections are currently in use for nonmalignant tumors.

METHODS

Medline, Embase, and Cochrane libraries were searched for studies reporting measured data of metabolic functions following PD, pancreatic left resection (PLR), duodenum-sparing pancreatic head resection (DPPHR), pancreatic middle segment resection (PMSR), and tumor enucleation (TEN). Forty cohort studies comprising data of 2729 patients were eligible.

RESULTS

PD for benign tumor was associated in 46 of 327 patients (14.1%) with postoperative new onset of diabetes mellitus (pNODM) and in 109 of 243 patients (44.9%) with postoperative new onset of pancreatic exocrine insufficiency measured after a mean follow-up of 32 months. The meta-analysis displayed pNODM following PD in 32 of 204 patients (15.7%) and in 10 of 200 patients (5%) after DPPHR [P < 0.01; OR: 0.33; (95%-CI: 0.15-0.22)]. PEI was found in 77 of 174 patients following PD (44.3%) and in 7 of 104 patients (6.7%) following DPPHR (P < 0.01;OR: 0.15; 95%-CI: 0.07-0.32). pNODM following PLR was reported in 107 of 459 patients (23.3%) and following PMSR 23 of 412 patients (5.6%) (P < 0.01; OR: 0.20; 95%-CI: 0.12-0.32). Postoperative new onset of pancreatic exocrine insufficiency was found in 17% following PLR and in 8% following PMSR (P < 0.01). pNODM following PPPD and tumor enucleation was observed in 19.7% and 5.7% (P < 0.03) of patients, respectively. Following PD/PPPD, 145 of 608 patients (23.8%) developed a nonalcoholic fatty liver disease after a mean follow-up of 30.4 months. Steatohepatosis following DPPHR developed in 2 of 66 (3%) significantly lower than following PPPD (P < 0.01).

CONCLUSION

Standard pancreatic resections for benign tumor carry a considerable high risk for a new onset of diabetes, pancreatic exocrine insufficiency and following PD for steatohepatosis. Parenchyma-sparing, local resections are associated with low grade metabolic dysfunctions.

Resection of the duodenum causes long-term endocrine and exocrine dysfunction after Whipple procedure for benign tumors - Results of a systematic review and meta-analysis

BACKGROUND

Metabolic dysfunctions after pancreatoduodenectomy (PD) need to be considered when pancreatic head resection is likely to lead to long-term survival.

METHODS

Medline, Embase and Cochrane Library were searched for studies reporting measured data of metabolic function after PD and duodenum-sparing total pancreatic head resection (DPPHR). Data from 23 cohort studies comprising 1019 patients were eligible; 594 and 910 patients were involved in systematic review and meta-analysis, respectively.

RESULTS

The cumulative incidence of postoperative new onset of diabetes mellitus (pNODM) after PD for benign tumors was 46 of 321 patients (14%) measured after follow-up of in mean 36 months postoperatively. New onset of postoperative exocrine insufficiency (PEI) was exhibited by 91 of 209 patients (44%) after PD for benign tumors measured in mean 23 months postoperatively. The meta-analysis indicated pNODM after PD for benign tumor in 32 of 208 patients (15%) and in 10 of 178 patients (6%) after DPPHR (p = 0.007; OR 3.01; (95%CI:1.39-6.49)). PEI was exhibited by 80 of 178 patients (45%) after PD and by 6 of 88 patients (7%) after DPPHR (p < 0.001). GI hormones measured in 194 patients revealed postoperatively a significant impairment of integrated responses of gastrin, motilin, insulin, secretin, PP and GIP (p < 0.050-0.001) after PD. Fasting and stimulated levels of GLP-1 and glucagon levels displayed a significant increase (p < 0.020/p < 0.030). Following DPPHR, responses of gastrin, motilin, secretin and CCK displayed no change compared to preoperative levels.

CONCLUSIONS

After PD, duodenectomy, rather than pancreatic head resection is the main cause for long-term persisting, postoperative new onset of DM and PEI.

Risk factors for development of diabetes mellitus (Type 3c) after partial pancreatectomy: A systematic review

OBJECTIVES

Type 3c diabetes mellitus (T3cDM) occurring post pancreatectomy can be challenging to treat due to the frequent combination of decreased circulating levels of insulin and glucagon and concurrent exocrine insufficiency. Relatively, little is known regarding the risk factors for development of T3cDM post pancreatectomy. Our aim was to review the literature and assess what is known of the risk factors for the development of new-onset DM following partial pancreatic resection and where possible determines the incidence, time of onset and the management approach to hyperglycaemia in this context.

DESIGN

Medline and Embase databases were reviewed using specific keyword criteria. Original manuscripts published in 1990 or later included. Articles with study population <20, lacking information on new-onset DM, follow-up duration or specifically targeting rare procedures/pathology were excluded. The Newcastle Ottawa Quality Assessment form was applied. Results reported according to PRISMA guidelines. Pooled effect size calculated using random effects model.

PATIENTS

Thirty six articles were identified that described a total of 5636 patients undergoing pancreaticoduodenectomy, 3922 patients having distal pancreatectomy and 315 with central pancreatectomy.

RESULTS

The incidence of new-onset DM was significantly different between different types of resection from 9% to 24% after pancreaticoduodenectomy (pooled estimate 16%; 95% CI: 14%-17%), 3%-40% after distal pancreatectomy (pooled estimate 21%; 95% CI: 16%-25%) and 0%-14% after central pancreatectomy (pooled estimate 6%; 95% CI: 3%-9%). Surgical site, higher preoperative HbA1c, fasting plasma glucose and lower remnant pancreatic volume had strongest associations with new-onset DM.

CONCLUSIONS

This systematic review supports that risk of development of T3cDM is associated with type of pancreatic resection, lower remnant pancreatic volume and higher preoperative HbA1c.

New-onset diabetes after pancreatoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Pancreatoduodenectomy may lead to new-onset diabetes mellitus, also known as type 3c diabetes, but the exact risk of this complication is unknown. The aim of this review was to assess the risk of new-onset diabetes mellitus after pancreatoduodenectomy.

METHODS

A literature search was performed in PubMed, Embase (Ovid), and the Cochrane Library for English articles published from March 1993 until March 2017 (PROSPERO registry number: CRD42016039784). Studies reporting on the risk of new-onset diabetes mellitus after pancreatoduodenectomy were included. For meta-analysis, studies were pooled using the random-effects model. All studies were appraised according to the Newcastle-Ottawa Scale.

RESULTS

After screening 1,523 studies, 22 studies involving 1,121 patients were eligible. The mean weighted overall proportion of new-onset diabetes mellitus after pancreatoduodenectomy was 16% (95% confidence interval, 12%-20%). We found no significant difference in risk of new-onset diabetes mellitus when pancreatoduodenectomy was performed for nonmalignant disease after excluding patients with chronic pancreatitis (19% risk; 95% confidence interval, 7%-43%; 6 studies) or for malignant disease (22% risk; 95% confidence interval, 14%-32%; 11 studies), P = .71. Among all patients, 6% (95% confidence interval, 4%-10%) developed insulin-dependent new-onset diabetes mellitus.

CONCLUSION

This systematic review identified a clinically relevant risk of new-onset diabetes mellitus after pancreatoduodenectomy of which patients should be informed preoperatively.

Favorable glycemic response after pancreatoduodenectomy in both patients with pancreatic cancer and patients with non-pancreatic cancer

Diabetes mellitus (DM) is prevalent in patients with pancreatic cancer and tends to improve after tumor resection. However, the glycemic response of non-pancreatic cancer patients after surgery has not been examined in detail. We aimed to investigate the changes in glucose metabolism in patients with pancreatic cancer or non-pancreatic cancer after pancreatoduodenectomy (PD).We prospectively enrolled 48 patients with pancreatic cancer and 56 patients with non-pancreatic cancer, who underwent PD. Glucose metabolism was assessed with fasting glucose, glycated hemoglobin (HbA1c), plasma C-peptide and insulin, quantitative insulin check index (QUICKI), and a homeostatic model assessment of insulin resistance (HOMA-IR) and β cell (HOMA-β) before surgery and 6 months after surgery. Patients were divided into 2 groups: "improved" and "worsened" postoperative glycemic response, according to the changes in HbA1c and anti-diabetic medication. New-onset DM was defined as diagnosis of DM ≤ 2 years before PD, and cases with DM diagnosis >2 years preceding PD were described as long-standing DM.After PD, insulin resistance (IR), as measured by insulin, HOMA-IR and QUICKI, improved significantly, although C-peptide and HOMA-β decreased. At 6 months after PD, new-onset DM patients showed improved glycemic control in both pancreatic cancer patients (75%) and non-pancreatic cancer patients (63%). Multivariate analysis showed that long-standing DM was a significant predictor for worsening glucose control (odds ratio = 4.01, P = .017).Favorable glycemic control was frequently observed in both pancreatic cancer and non-pancreatic cancer after PD. PD seems to contribute improved glucose control through the decreased IR. New-onset DM showed better glycemic control than long-standing DM.

Risk factors of exocrine and endocrine pancreatic insufficiency after pancreatic resection: A multi-center prospective study

Management of functional consequences after pancreatic resection has become a new therapeutic challenge. The goal of our study is to evaluate the risk factors for exocrine (ExoPI) and endocrine (EndoPI) pancreatic insufficiency after pancreatic surgery and to establish a predictive model for their onset.

PATIENTS AND METHODS

Between January 1, 2014 and June 19, 2015, 91 consecutive patients undergoing pancreatoduodenectomy (PD) or left pancreatectomy (LP) (72% and 28%, respectively) were followed prospectively. ExoPI was defined as fecal elastase content<200μg per gram of feces while EndoPI was defined as fasting glucose>126mg/dL or aggravation of preexisting diabetes. The volume of residual pancreas was measured according to the same principles as liver volumetry.

RESULTS

The ExoPI and EndoPI rates at 6 months were 75.9% and 30.8%, respectively. The rate of ExoPI after PD was statistically significantly higher than after LP (98% vs. 21%; P<0.001), while the rate of EndoPI was lower after PD vs. LP, but this difference did not reach statistical significance (28% vs. 38.5%; P=0.412). There was no statistically significant difference in ExoPI found between pancreatico-gastrostomy (PG) and pancreatico-jejunostomy (PJ) (100% vs. 98%; P=1.000). Remnant pancreatic volume less than 39.5% was predictive of ExoPI.

CONCLUSION

ExoPI occurs quasi-systematically after PD irrespective of the reconstruction scheme. The rate of EndoPI did not differ between PD and LP.

Distal Enteral Feeding Helps Blood Sugar Control in Pancreatectomized Patients

BACKGROUND

The change in the route of food passage after pancreaticoduodenectomy (PD) is quite similar to the change after gastric bypass surgery; both procedures bypass the duodenum and directly connect to the distal jejunum. Moreover, both procedures result in resolution of type 2 diabetes mellitus. Therefore, more distal enteral anastomosis after PD may further improve glycemic status.

METHODS

To test the effect of distal enteral feeding on glucose metabolism in patients after PD, we performed a meal test on 20 patients via a nasogastric tube [proximal feeding group (PFG)] on post-operative day 5 and then via an intra-operatively placed jejunostomy feeding tube [distal feeding group (DFG)] on post-operative day. Blood samples were assessed for hormones and glucose.

RESULTS

The AUC0-120 min levels of GLP-1, C-peptide, and insulin after distal feeding were significantly higher than after proximal feeding. The AUC0-120 min levels of glucose in the DFG were significantly lower than in the PFG.

CONCLUSIONS

More distal enteral feeding contributed to better glucose metabolism after PD.

Elevated pancreatic polypeptide levels in pancreatic neuroendocrine tumors and diabetes mellitus: causation or association?

Pancreatic neuroendocrine tumors (PNETs) that secrete primarily pancreatic polypeptide (PP) are rare and usually nonfunctional. There are approximately 2 dozen reports of PP-secreting PNETs, 3 of which have been associated with diabetes mellitus (DM). None suggest a mechanism for the association between PP-secreting PNETs and DM. We describe 5 patients with PP-producing tumors who were diagnosed with DM at the same time as their PNETs, review the literature on PP, and consider its role in the pathophysiology of DM. The cases discussed were extracted from our surgical neuroendocrine tumor database. We examined all patients with PP-predominant PNETs--both with DM (n = 5) and without (n = 8). The 5 patients with DM at the time of PNET diagnosis demonstrated improvement or resolution of their DM postoperatively. In the patients with PP-secreting PNETs but no diagnosis of DM preoperatively, 1 became hypoglycemic postoperatively, and 2 others developed postoperative DM. The 5 cases discussed in detail raise the question of whether the hypersecretion of PP in PNETs might be an important event leading to the development of DM. Although the literature does not provide a mechanism for this association, it may be related to the role of PP in hepatic glucose regulation.

[Blood glucose control and risk of progressing to a diabetic state during clinical follow up after cephalic duodenopancreatectomy]

INTRODUCTION

Pancreatic resection carries a theoretical risk of developing diabetes; however few studies have demonstrated the effect of a cephalic duodenopancreatectomy on post-operative blood glucose control.

MATERIAL AND METHODS

An analysis was made of the post-operative clinical follow up of 70 patients subjected to a cephalic duodenopancreatectomy in our Hospital between March 1993 and November 2009. The surgical indication was due to primary pancreatic disease in 30 patients (21 adenocarcinoma of the pancreas, 6 chronic pancreatitis, 1 endocrine carcinoma, 1 cystadenoma and 1 complicated pseudocyst). The pancreas was not affected in the other 40 patients (24 ampullary carcinomas, 11 cholangiocarcinomas, 3 duodenal carcinomas, 1 papillary adenoma and 1 adenomatous hyperplasia of the bile duct). Data on the pre- and post-operative diabetic state were collected.

RESULTS

Before resection, 49 patients (70.0%) had a normal glucose without the need for treatment. Seventeen patients required oral diabetic treatment, 3 subcutaneous insulin, and only one was treated by diet. The duodenopancreatectomy worsened glucose control in 47.1% of the patients (23 of the previously non-diabetics and 10 of those treated with oral diabetics). Glucose control was worse when the surgical indication was due to primary involvement of the gland (progression of 63.3%) compared with patients with disease (progression of 35.0%) (P<.05).

CONCLUSIONS

Our results show that resection of the head of the pancreas favours the appearance of post-operative diabetes, particularly when the surgical indication is due to primary pancreatic involvement.

Improvement of glucose metabolism after a pancreatoduodenectomy

OBJECTIVES

The aim of this study was to investigate the mechanisms of the change in glucose metabolism after a pancreatoduodenectomy (PD).

METHODS

Oral glucose tolerance tests were performed in 17 patients before and 1 month after a PD. The changes in plasma glucose and insulin concentrations, homeostasis model of insulin resistance, and insulinogenic index (beta-cell function) were analyzed. Two additional factors, gastric emptying function and plasma glucagon-like peptide-1 (GLP-1) concentration, that possibly affect perioperative glucose metabolism were also assessed.

RESULTS

The plasma glucose and insulin concentrations were significantly lower after the operation, especially in preoperative diabetic patients. beta-Cell function did not change after the operation. On the other hand, insulin resistance became normal 1 month after the operation. The value of gastric emptying function after the operation was not statistically different in comparison with that before the operation. Postoperative plasma GLP-1 concentration was significantly higher than the preoperative value.

CONCLUSIONS

beta-Cell function is maintained after a PD, whereas the improvement of insulin resistance may cause a short-term transient improvement of the glucose metabolism after the operation. The significance of increased postoperative GLP-1 concentration remains an unsolved issue.

Interactions between the endocrine and exocrine pancreas and their clinical relevance

In consequence of the close anatomical and functional links between the exocrine and endocrine pancreas, any disease affecting one of these parts will inevitably affect the other. Pancreatic conditions which might cause diabetes mellitus include acute and chronic pancreatitis, pancreatic surgery, cystic fibrosis and pancreatic cancer. The development of diabetes greatly influences the prognosis and quality of life of patients with exocrine pancreatic diseases. It may cause life-threatening complications, such as hypoglycemia, due to the lack of glucagon and the impaired absorption of nutrients, or the micro- and macrovascular complications may impair the organ functions. Diabetes mellitus is an independent risk factor of mortality in those with exocrine pancreatic diseases. The treatment of pancreatic diabetes, a distinct metabolic and clinical form of diabetes, requires special knowledge. Diet and pancreatic enzyme replacement therapy may be sufficient in the early stages. Oral antidiabetic drugs are not recommended. If the diet proves inadequate to reach the glycemic goals, insulin treatment with multiple injections is required. Impairments of the exocrine pancreatic function and morphology in diabetic patients are frequent and well known. Atrophy of the exocrine tissue may be caused by the lack of trophic insulin, whereas pancreatic fibrosis can result from activation of stellate cells by hyperglycemia, or from microangiopathy and neuropathy. The regulation of the exocrine pancreatic function is also damaged because of the impaired effect of islet hormones. In the event of a proven impairment of the pancreatic exocrine function in diabetes mellitus, pancreatic enzyme replacement therapy is indicated. This may improve the nutritional condition of the patient and decrease the metabolic instability.

Long-term pancreatic endocrine function following pancreatoduodenectomy with pancreaticogastrostomy

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate long-term pancreatic endocrine function following pancreatoduodenectomy with pancreaticogastrostomy.

METHODS

Records of 52 patients who had survived for three or more years following pancreatoduodenectomy with pancreaticogastrostomy were studied retrospectively. Serum HbA(1c) levels had been measured prior to and at 3- to 6-month intervals after surgery.

RESULTS

Three of 42 patients with normal preoperative serum HbA(1c) levels (<or=5.8%), and five of 10 patients with elevated preoperative serum HbA(1c) levels (>5.8%) showed deterioration of glucose tolerance. Five of these eight patients developed a pancreatic fistula postoperatively. However, the average serum HbA(1c) levels of patients with normal preoperative serum HbA(1c) levels have remained within the normal range for 3-10 years after surgery.

CONCLUSIONS

Pancreatic endocrine function was maintained for a long-term period after pancreatoduodenectomy with pancreaticogastrostomy. Impaired glucose tolerance appeared to be associated with postoperative pancreatic fistula formation.

Management of a stenotic pancreatico-digestive tract anastomosis following pancreatoduodenectomy

Early postoperative complications of pancreatico-digestive anastomosis following pancreatoduodenectomy are pancreatic fistula and pancreatitis affecting the pancreatic tail. Stenosis of the anastomosis is a later complication. Symptomatic and painful presentations are difficult to treat, and the optimal treatment is not currently defined. The aim of this work was to retrospectively report two cases of pancreaticogastrostomy stenosis. In both patients, the complication was diagnosed, with pancreatitis that developed following pancreatoduodenectomy. These patients were treated surgically, by fashioning a new anastomosis. Pancreaticogastrostomy has been viewed as a simpler and more secure reconstruction technique, with a lower occurrence rate of pancreatic fistula, than that of pancreaticojejunostomy. One complication of this surgery, however, is stenosis of the anastomosis. Following pancreatoduodenectomy, stenosis of the pancreaticogastrostomy may not occur until many years later. In a significant percentage of patients it is without clinical signs. It may be discovered after systematic explorations of patients following pancreaticogastrostomy or pancreaticojejunostomy. There is no study regarding the optimal treatment of postoperative stenosis of a pancreatico-gastric anastomosis. We believe that the optimal treatment is surgical. The intervention involves resection of the stenosis, and the formation of a new anastomosis.

Changes in glucose metabolism after Kausch-Whipple pancreatectomy in pancreatic cancer and chronic pancreatitis patients

OBJECTIVE

Although changes in exocrine pancreatic function after pancreatoduodenectomy (PD) have been thoroughly analyzed in many reports, articles concerning endocrine have been few. An investigation of glucose metabolism changes in patients undergoing PD was performed.

METHODS

In the study, 20 patients were subjected to pancreatic head resection for tumorous lesions (13 neoplasmatic and 7 chronic pancreatitis) and followed-up for changes in pancreatic endocrine function. It was assessed with fasting plasma glucose measurement and oral glucose tolerance test and also the plasma insulin level during the oral glucose tolerance test. Assessment was made directly before PD followed 2 and 6 months postoperatively.

RESULTS

The percentage of neoplasmatic patients with normal glucose metabolism increased from 15% preoperatively to 39% at 2 months and 45% at 6 months after PD, whereas the diabetes/impaired glucose metabolism was observed in 31%/54%, 15%/46%, and 18%/36%, respectively. In chronic pancreatitis patients, the percentage of diabetic patients increased from 0% preoperatively to 29% at 2 months and 43% 6 months postoperatively. The average plasma insulin level decreased significantly after PD. Before the PD, the insulin curve suggested the presence of insulin resistance in pancreatic cancer patients, which was not observed after the operation.

CONCLUSIONS

Changes in glucose metabolism after PD depend on the etiology of pancreatic tumorous lesion with improvement in neoplasmatic patients and deterioration in chronic pancreatitis patients.

Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy

The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreatoduodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.

Pancreaticojejunostomy with invagination of spatulated pancreatic stump into a jejunal pouch

BACKGROUND

Pancreaticoenteric anastomosis after pancreatic resection is of major concern as anastomotic leak continues to be common. There is no unanimity for the preferred technique and overall incidence of pancreatic leak is reported to be 2% to 14%.

METHODS

A new safe method of anastomosing pancreatic stump to a jejunal pouch is described. A 15-cm length of the jejunal end is detubularized and reconfigurated into a U-shaped patch. The pancreatic stump is mobilized for about 3 cm and the duct is spatulated posteriorly and anastomosed to a cut in convex margins of the patch. This is converted into a pouch invaginating the spatulated pancreaticojejunal anastomosis.

RESULTS

Eleven cases of periampullary malignancy after pancreaticoduodenectomy have been operated on with no pancreatic leak.

CONCLUSIONS

Even a bulky pancreas can be invaginated into the pouch. The resulting anastomosis is completely intraluminal. Spatulated mucosa to mucosa anastomosis should reduce the chances of late stenosis.

Risk factors for diabetes mellitus in chronic pancreatitis

BACKGROUND & AIMS

The influence of disease progression and pancreatic surgery on the appearance of diabetes mellitus in patients with chronic pancreatitis is unknown.

METHODS

A prospective cohort study of 500 consecutive patients with chronic pancreatitis (alcoholics, 85%) followed up over a mean period of 7.0 +/- 6.8 years in a medical-surgical institution between 1973 and 1996 was performed. Multivariate analysis of risk factors for diabetes mellitus was performed after exclusion of 47 patients. Patients who underwent elective pancreatic surgery (n = 231, 51%) were compared with patients who never underwent surgery (n = 222, 49%).

RESULTS

The cumulative rate of diabetes mellitus was 83% +/- 4% 25 years after the clinical onset of chronic pancreatitis (insulin requirement, 54% +/- 6%). The prevalence of diabetes mellitus did not increase in the surgical group overall but was higher 5 years after distal pancreatectomy (57% +/- 8%) than after pancreaticoduodenectomy (36% +/- 18%), pancreatic drainage (36% +/- 13%), or cystic, biliary, or digestive drainage (24% +/- 7%) (P = 0. 005), without difference in the latter ones. Pancreatic drainage did not prevent the onset of diabetes mellitus. Distal pancreatectomy (risk ratio, 2.4; 95% confidence interval [CI], 1.6-3.8; P < 0.0001) and early onset of pancreatic calcifications (risk ratio, 3.2; CI, 2. 2-4.7; P < 0.0001) were the only independent risk factors for diabetes mellitus.

CONCLUSIONS

The risk of diabetes mellitus is not influenced by elective pancreatic surgical procedures other than distal pancreatectomy in patients with chronic pancreatitis. This risk seems to be largely caused by progression of the disease because it increased by more than 3-fold after the onset of pancreatic calcifications.

Median pancreatectomy for tumors of the neck and body of the pancreas

BACKGROUND

When enucleation is too risky because of possible damage of the main pancreatic duct, benign tumors located in the neck or body of the pancreas are usually removed by a left (spleno)-pancreatectomy or by a pancreatoduodenectomy. But standard pancreatic resection results in an important loss of normal pancreatic parenchyma and may cause impairment of exocrine and endocrine function. The aim of this study was to evaluate early and longterm results of median pancreatectomy, a limited resection of the midportion of the pancreas, in selected patients with benign or borderline tumors of the pancreas.

STUDY DESIGN

Records of patients at Ospedale Busonera between November 1985 and September 1998 were reviewed. Ten patients with tumors of the neck or body of the pancreas underwent median pancreatectomy; the cephalic stump was sutured and the distal stump was anastomosed with a Roux-en-Y jejunal loop. Followup included clinical evaluation and routine laboratory tests: abdominal ultrasonography, exocrine and endocrine pancreatic function with fecal chymotrypsin, and an oral glucose tolerance test.

RESULTS

Pathologic examination showed: insulinoma (n = 3), mucinous cystadenoma (n = 3), nonfunctioning endocrine tumor (n = 1), papillary-cystic neoplasm (n= 1), serous cystadenoma (n = 1), and intraductal mucinous tumor (n = 1). Operative mortality and morbidity were 0% and 40%, respectively; pancreatic fistula occurred in three patients. At mean followup of 62.7 months, no recurrence was found and no patient had exocrine insufficiency or glucose metabolism impairment.

CONCLUSIONS

Median pancreatectomy is a safe and effective alternative to major pancreatic resection in selected patients with benign or low-malignant lesions of the pancreas. This procedure carries a surgical risk similar to that of the standard operation, but avoids extensive pancreatic resection and pancreatic function impairment.