Of (Regional) Total Pancreatectomy

Metabolic Consequences of (Regional) Total Pancreatectomy CAROLYN M. DRESLER, M.D.,* JOSEPH G. FORTNER, M.D.,* KATHERINE McDERMOTT, R.N.,* and DAIVA R. BAJORUNAS, M.D.t Little information has been reported on the metabolic charac- From the Departments of Surgery* and Medicine,t Memorial teristics of the totally pancreatectomized patient or the efficacy Sloan-Kettering Cancer Center and Cornell University of medical management after radical pancreatic surgery. The Medical College, New York, New York prospective evaluation of 49 such patients, with 31% followed for 48 or more months, forms the basis of this report. The major immediate postoperative challenge is control of diarrhea and weight stabilization. Chronically patients have an increased daily caloric requirement (mean ± SE, 56 ± 1 kcal/kg), not wholly 'brittle.' It is assumed that the diabetes is otherwise similar explained by moderate steatorrhea (fecal fat excretion, 16% ± 2% to the spontaneously occurring disorder in adults, re- ofunrestricted fat intake). Despite persistent malabsorption, de- quiring similar management. Pancreatic exocrine defi- ficiencies in fat-soluble vitamin, magnesium, and trace element ciency has been studied as it relates to steatorrhea but serum levels can be prevented in most patients. Pancreatogenic diabetes is characterized by (1) absence of the major glucoregu- with limited information on other nutritional deficiencies. latory hormones insulin and glucagon, (2) instability, and (3) Particularly striking is the absence of information on the frequent hypoglycemia, with the latter parameters improving with long-term consequences of the operation. rigorous home glucose monitoring. No patient has developed This report concerns the prospective evaluation of 49 clinically overt diabetic micro- or macrovascular disease. Per- who had a total as of a re- formance status in long-term survivors has been reasonable. patients pancreatectomy part However adverse chronic sequelae of the operation occur and section that included a regional lymph node dissection, include an unusual frequency of liver disease, characterized by sympathectomy, and segmental portal vein resection with accelerated fatty infiltration, and osteopenia, with an 18% re- reconstruction (regional total pancreatectomy). Acute and duction in radial bone mineral content noted in pancreatectomized chronic indices of malabsorption are reported. The dia- patients studied more than 5 years after surgery. betic state is characterized and its management discussed. Adverse chronic sequelae ofthe operation include an un- T n HE FIRST TOTAL PANCREATECTOMY in humans usual frequency of liver disease and osteopenia; note- was performed in 1942.' The value of this pro- worthy are the absence ofclinically overt diabetic micro- cedure in treating a variety oftumors ofthe pan- and macrovascular disease and the reasonable perfor- creas has been evaluated in many reports in the interven- mance status in long-term survivors. ing 47 years.'2 Little information, however, has been reported on the metabolic characteristics of the totally Materials and Methods pancreatectomized patient or the efficacy of medical management. The diabetic state is often characterized as Patient Characteristics The study population consists of all patients who un- Supported in part by the General Motors Surgical Research Laboratory derwent a complete pancreatic resection at Memorial and General Clinical Research Center grant RR-00 102 from the National Sloan-Kettering Cancer Center by one surgeon (JG Fort- Institutes of Health to the Rockefeller University. ner) during the period January 1978 to June 1988 (n Address reprint requests to Daiva R. Bajorunas, M.D., Division of = 45). Four additional patients who had the procedure Endocrinology, Memorial Sloan-Kettering Cancer Center, 1275 York earlier (1972, 1975, 1975, 1976) are included as well. The Ave., New York, NY 10021. Dr. Dresler's current address is Department of Surgery, Washington 28 men and 21 women were 54 ± 2 years in age (mean University School of Medicine, St. Louis, MO 63110. ± SE; range, 29 to 72 years) at time of surgery. Accepted for publication August 3, 1990. Two patients had a standard total pancreatic resection. 131 132n DRESLER AND OTHERS Ann. Surg. * August 1991 The other 47 patients had a regional total pancreatectomy, same dietary guidelines that focused on calorie-dense which included a complete pancreatectomy, subtotal gas- foods, except that a simple sugar restriction (less than 5% trectomy, duodenectomy, splenectomy, cholecystectomy sucrose calories) was introduced to aid glycemic control with removal of the common bile duct, and regional when dietary intake had stabilized. A registered dietitian lymph node dissection with accompanying resection of evaluated the patients every 3 months for the first post- the celiac and superior mesenteric ganglia and removal operative year and yearly thereafter. of lymphatic and nerve tissues surrounding the superior Diabetic management. The patients were instructed in mesenteric artery. A vagotomy was not done. The pan- the use ofa reflectance meter-assisted home glucose mon- creatic portion of the portal vein was removed en bloc itoring program'5"6 before their discharge from the hos- and reconstructed with an end-to-end anastomosis ofthe pital. Comparable mean values to laboratory glucose de- superior mesenteric vein to the portal vein. Details ofthe terminations were achieved (r = 0.85, p = 0.001) when surgical procedure have been previously described.'3" 4 the patients were monitored as inpatients. Fingerstick Table 1 depicts the diagnoses prompting the surgical pro- glucose determinations were obtained before meals and cedures. at bedtime; in the immediate posthospital discharge period and periodically thereafter, patients were asked to check Management Protocol a 3 A.M. level. Compliance with this regimen on a long- term basis was readily achieved because both patients and A team approach to patient management was used, them surgical and en- their families thought that this technique provided with all patients followed by the same with increased security from hypoglycemia. At every sub- docrine attending physicians (JG Fortner and DR Bajo- visit these records 11-year follow-up period. sequent hospital outpatient glycemic runas) for the duration of the were reviewed with the patients and their families, and The team nurse clinician provided patient education on insulin dosage adjustments were instituted. a daily basis during the initial hospitalization and was The patients were best managed on a regimen of 2:1 present at every outpatient visit. of insulin administered all patients were or 3:1 ratio NPH/Lente:regular Dietary guidelines. After operation subcutaneously in the morning, with an additional dose managed for up to 3 days in the intensive care unit and ofregular insulin administered 30 minutes before dinner. after their transfer to the general surgical floor, total par- Because ofthe frequency ofnocturnal hypoglycemia, only until enteral nutrition (TPN) was maintained adequate the exceptional patient required a second (evening) in- oral feedings were clinically feasible. Thereafter the pa- of intermediate-acting insulin. All regular insulin to 50 jection tients were placed on a high calorie (40 kcal/kg), was administered per a sliding scale regimen, depending limited in sucrose cal- three-meal, three-snack diet/day, on the result of the fingerstick glucose determination. A if were maintaining weight. Ad- ories only the patients 'salvage' regular insulin sliding scale was prescribed to ditional caloric intake was encouraged by the use of lac- before lunch and at bed- and prevent excessive hyperglycemia tose-free, lower osmolarity oral formula supplements All were to maintain use of medium-chain (MCT) oil. time. patients strongly encouraged the liberal triglyceride level of more than 11.2 fat restriction was placed and the over- a bedtime fingerstick glucose No specific dietary and were well 35% to 40% 45% mmol/L (200 mg/dL). Patients family all caloric distribution approximated fat, and symptoms of and to 20% in- versed in the signs hypoglycemia, to 50% carbohydrate, and 15% protein calorie 1 for administration take. In whose diarrhea was protracted, an empiric glucagon (in mg/mL vials) parenteral patients members in event of a serious lactose-free diet was instituted. by family the hypoglycemic episode was routinely prescribed. Patients were discharged from the hospital only when exocrine deficiency. The pa- was demonstrated and Management ofpancreatic a trend toward weight stabilization tients were instructed to take pancreatic enzyme replace- calorie counts showed an intake ofat least 2000 kcal/day. ment, of variable amounts of lipase, amylase, all were maintained on the consisting Following discharge patients and protease units depending on the commercial prepa- ration used, as soon as oral intake was instituted. Doses TABLE 1. Indications for Surgery were slowly increased to a usual maintenance dose offour Histologic Diagnoses No. of Patients to five capsules with meals and two to three capsules with snacks. The dosages of the enzymes were clinically ad- Adenocarcinoma of the pancreas 31 justed on the basis of weight, serum magnesium levels, Periampullary carcinoma 7 Islet cell carcinoma 2 and stool characteristics. Antacids or H-2 blockers were Papillocystic adenocarcinoma I not routinely prescribed. Enteric-coated microsphere for- Pancreatitis 7 mulations appeared to offer no specific advantage

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