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Wei J, Ou Y, Chen J, Yu Z, Wang Z, Wang K, Yang D, Gao Y, Liu Y, Liu J, Zheng X. Mapping global new-onset, worsening, and resolution of diabetes following partial pancreatectomy: a systematic review and meta-analysis. Int J Surg 2024; 110:1770-1780. [PMID: 38126341 PMCID: PMC10942179 DOI: 10.1097/js9.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
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.
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Affiliation(s)
- Junlun Wei
- Department of Endocrinology and Metabolism, Center for Diabetes and Metabolism Research
| | - Yiran Ou
- Department of Endocrinology and Metabolism, Center for Diabetes and Metabolism Research
| | - Jiaoting Chen
- Department of Endocrinology and Metabolism, Center for Diabetes and Metabolism Research
| | - Zhicheng Yu
- Department of Economics, Keio University, Minato city, Tokyo, Japan
| | - Zhenghao Wang
- Department of Endocrinology and Metabolism, Center for Diabetes and Metabolism Research
| | - Ke Wang
- Department of Vascular Surgery, University Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, People’s Republic of China
| | - Dujiang Yang
- Department of General Surgery, Division of Pancreatic Surgery, West China Hospital, Sichuan University
| | - Yun Gao
- Department of Endocrinology and Metabolism, Center for Diabetes and Metabolism Research
| | - Yong Liu
- Department of General Surgery, Division of Pancreatic Surgery, West China Hospital, Sichuan University
| | - Jiaye Liu
- Department of Respiratory and Critical Care Medicine, Frontiers Science Center for Disease-Related Molecular Network, Center of Precision Medicine, Precision Medicine Key Laboratory of Sichuan Province
- Laboratory of Thyroid and Parathyroid diseases, Frontiers Science Center for Disease-Related Molecular Network
- Department of General Surgery, Division of Thyroid Surgery, West China Hospital, Sichuan University
| | - Xiaofeng Zheng
- Department of Endocrinology and Metabolism, Center for Diabetes and Metabolism Research
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Imamura S, Niwano F, Babaya N, Hiromine Y, Matsumoto I, Kamei K, Yoshida Y, Taketomo Y, Yoshida S, Takeyama Y, Noso S, Maeda N, Ikegami H. High Incidence of Diabetes Mellitus After Distal Pancreatectomy and Its Predictors: A Long-term Follow-up Study. J Clin Endocrinol Metab 2024; 109:619-630. [PMID: 37889837 PMCID: PMC10876401 DOI: 10.1210/clinem/dgad634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 10/29/2023]
Abstract
CONTEXT Glucose tolerance worsens after distal pancreatectomy (DP); however, the long-term incidence and factors affecting interindividual variation in this worsening are unclear. OBJECTIVE To investigate the changes in diabetes-related traits before and after DP and to clarify the incidence of diabetes and its predictors. METHODS Among 493 registered patients, 117 underwent DP. Among these, 56 patients without diabetes before surgery were included in the study. Glucose and endocrine function were prospectively assessed using a 75-g oral glucose tolerance test preoperatively, 1 month after DP, and every 6 months thereafter for up to 36 months. Pancreatic volumetry was performed using multidetector row computed tomography before and after surgery. RESULTS Insulin secretion decreased and blood glucose levels worsened after DP. Residual pancreatic volume was significantly associated with the reserve capacity of insulin secretion but not with blood glucose levels or the development of diabetes. Among 56 patients, 33 developed diabetes mellitus. The cumulative incidence of diabetes at 36 months after DP was 74.1%. Multivariate Cox regression analysis showed that impaired glucose tolerance as a preoperative factor as well as a decreased insulinogenic index and impaired glucose tolerance at 1 month postoperatively were identified as risk factors for diabetes following DP. CONCLUSION Impaired glucose tolerance and reduced early-phase insulin response to glucose are involved in the development of new-onset diabetes after DP; the latter is an additional factor in the development of diabetes and becomes apparent when pancreatic beta cell mass is reduced after DP.
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Affiliation(s)
- Shuzo Imamura
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Fumimaru Niwano
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Naru Babaya
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yoshihisa Hiromine
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Keiko Kamei
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yasunori Taketomo
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Sawa Yoshida
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Norikazu Maeda
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
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Yoo D, Kang M, Jung J. Risk of Ischemic Heart Disease in Patients With Postpancreatectomy Diabetes and Pancreatic Cancer: A Population-Based Study. J Am Heart Assoc 2023; 12:e031321. [PMID: 38084734 PMCID: PMC10863790 DOI: 10.1161/jaha.123.031321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/09/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Postpancreatectomy diabetes can be caused by resection of functioning pancreatic tissue and is associated with postoperative pancreatic islet cell mass loss and subsequent endocrine dysfunction. Diabetes is a well-known risk factor for ischemic heart disease. However, no previous studies have investigated ischemic heart disease in patients with postpancreatectomy diabetes and pancreatic cancer. METHODS AND RESULTS Rates of patients with diabetes diagnosed with pancreatic cancer who underwent pancreatectomy between 2002 and 2019 in South Korea were obtained from the Korean National Health Insurance Service database. Patient-level propensity score matching was conducted to reduce the possibility of selection bias, and multivariate Cox proportional hazards models were used to determine the association between postpancreatectomy diabetes and ischemic heart disease. In total, 30 242 patients were initially enrolled in the study. After applying exclusion criteria and propensity score matching, 2952 patients were included in the comparative analysis between the postpancreatectomy group with diabetes and the group without diabetes. Patients in the postpancreatectomy group with diabetes had significantly higher rates of ischemic heart disease than those in the group without diabetes. In total, 3432 patients were included in the comparison between the postpancreatectomy and prepancreatectomy groups with diabetes. There was no significant difference in the risk of ischemic heart disease between the postpancreatectomy and prepancreatectomy groups with diabetes. CONCLUSIONS Patients who developed diabetes after pancreatectomy had a higher risk of ischemic heart disease than patients who did not develop diabetes after pancreatectomy, and the rate of ischemic heart disease in these patients was similar to that in patients preoperatively diagnosed with diabetes.
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Affiliation(s)
- Daegwang Yoo
- Division of Hepatobiliary and Pancreatic Surgery, Department of SurgerySoonchunhyang University College of Medicine, Soonchunhyang University Seoul HospitalSeoulSouth Korea
| | - Minsun Kang
- Artificial Intelligence and Big‐Data Convergence Center, Gil Medical CenterGachon University College of MedicineIncheonSouth Korea
| | - Jaehun Jung
- Artificial Intelligence and Big‐Data Convergence Center, Gil Medical CenterGachon University College of MedicineIncheonSouth Korea
- Department of Preventive MedicineGachon University College of MedicineIncheonSouth Korea
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Infante M, Ricordi C. The unique pathophysiological features of diabetes mellitus secondary to total pancreatectomy: proposal for a new classification distinct from diabetes of the exocrine pancreas. Expert Rev Endocrinol Metab 2023; 18:19-32. [PMID: 36692892 DOI: 10.1080/17446651.2023.2168645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Diabetes of the exocrine pancreas (DEP; a.k.a. pancreatic diabetes or pancreatogenic diabetes or type 3c diabetes mellitus or T3cDM) refers to different diabetes types resulting from disorders of the exocrine pancreas. DEP is characterized by the structural and functional loss of glucose-normalizing insulin secretion in the context of exocrine pancreatic dysfunction. Among these forms, new-onset diabetes mellitus secondary to total pancreatectomy (TP) has unique pathophysiological and clinical features, for which we propose a new nomenclature such as post-total pancreatectomy diabetes mellitus (PTPDM). AREAS COVERED TP results in the complete loss of pancreatic parenchyma, with subsequent absolute insulinopenia and lifelong need for exogenous insulin therapy. Patients with PTPDM also exhibit deficiency of glucagon, amylin and pancreatic polypeptide. These endocrine abnormalities, coupled with increased peripheral insulin sensitivity, deficiency of pancreatic enzymes and TP-related modifications of gastrointestinal anatomy, can lead to marked glucose variability and increased risk of iatrogenic (insulin-induced) severe hypoglycemic episodes ('brittle diabetes'). EXPERT OPINION We believe that diabetes mellitus secondary to TP should not be included in the DEP spectrum in light of its peculiar pathophysiological and clinical features. Therefore, we propose a new classification for this entity, that would likely provide more accurate prognosis and treatment strategies.
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Affiliation(s)
- Marco Infante
- Cell Transplant Center, Diabetes Research Institute (DRI), University of Miami Miller School of Medicine, Miami, FL, USA
- Section of Diabetes and Metabolic Disorders, UniCamillus, Saint Camillus International University of Health Sciences, Rome, Italy
- Diabetes Research Institute Federation (DRIF), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Rome, Italy
| | - Camillo Ricordi
- Cell Transplant Center, Diabetes Research Institute (DRI), University of Miami Miller School of Medicine, Miami, FL, USA
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Niwano F, Babaya N, Hiromine Y, Matsumoto I, Kamei K, Taketomo Y, Yoshida S, Takeyama Y, Noso S, Ikegami H. Three-Year Observation of Glucose Metabolism After Pancreaticoduodenectomy: A Single-Center Prospective Study in Japan. J Clin Endocrinol Metab 2022; 107:3362-3369. [PMID: 36074913 PMCID: PMC9693916 DOI: 10.1210/clinem/dgac529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT The glucose tolerance of patients changes considerably from before to after pancreaticoduodenectomy wherein approximately half of the pancreas is resected. OBJECTIVE The aim of this prospective study was to investigate the incidence of and risk factors for diabetes after pancreaticoduodenectomy. METHODS This study is a part of an ongoing prospective study, the Kindai Prospective Study on Metabolism and Endocrinology after Pancreatectomy (KIP-MEP) study. Of the 457 patients enrolled to date, 96 patients without diabetes who underwent pancreaticoduodenectomy were investigated in this study. Preoperatively, 1 month post-pancreaticoduodenectomy, and every 6 months thereafter, the glucose metabolism and endocrine function were evaluated using the 75 g oral glucose tolerance test. Various other metabolic, endocrine, and exocrine indices were also examined over a period of up to 36 months. RESULTS Of the 96 patients analyzed in this study, 33 were newly diagnosed with diabetes. The cumulative diabetes incidence at 36 months following pancreaticoduodenectomy was 53.8%. The preoperative insulinogenic index and ΔC-peptide in the glucagon stimulation test were significantly lower in the progressors to diabetes than in the nonprogressors. Multivariate Cox regression analysis demonstrated that the insulinogenic index was the only significant risk factor for new-onset diabetes. CONCLUSION The majority of patients developed new-onset diabetes after pancreaticoduodenectomy, and a low value of the insulinogenic index was suggested to be a risk factor for diabetes. Preoperative assessment for the prediction of the onset of diabetes serves as useful information for patients and is important for postoperative glycemic control and diabetes management in patients who require pancreaticoduodenectomy.
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Affiliation(s)
- Fumimaru Niwano
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Naru Babaya
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yoshihisa Hiromine
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Keiko Kamei
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yasunori Taketomo
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Sawa Yoshida
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Hiroshi Ikegami
- Correspondence: Hiroshi Ikegami, MD, PhD, Department of Endocrinology, Metabolism, and Diabetes, Kindai University Faculty of Medicine 377-2 Ohno-higashi, Osaka-sayama, Osaka 589-8511, Japan.
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Hempel S, Oehme F, Ehehalt F, Solimena M, Kolbinger FR, Bogner A, Welsch T, Weitz J, Distler M. The Impact of Pancreatic Head Resection on Blood Glucose Homeostasis in Patients with Chronic Pancreatitis. J Clin Med 2022; 11:jcm11030663. [PMID: 35160113 PMCID: PMC8837045 DOI: 10.3390/jcm11030663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Chronic pancreatitis (CP) often leads to recurrent pain as well as exocrine and/or endocrine pancreatic insufficiency. This study aimed to investigate the effect of pancreatic head resections on glucose metabolism in patients with CP. METHODS Patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD), Whipple procedure (cPD), or duodenum-preserving pancreatic head resection (DPPHR) for CP between January 2011 and December 2020 were retrospectively analyzed with regard to markers of pancreatic endocrine function including steady-state beta cell function (%B), insulin resistance (IR), and insulin sensitivity (%S) according to the updated Homeostasis Model Assessment (HOMA2). RESULTS Out of 141 pancreatic resections for CP, 43 cases including 31 PPPD, 2 cPD and 10 DPPHR, met the inclusion criteria. Preoperatively, six patients (14%) were normoglycemic (NG), 10 patients (23.2%) had impaired glucose tolerance (IGT) and 27 patients (62.8%) had diabetes mellitus (DM). In each subgroup, no significant changes were observed for HOMA2-%B (NG: p = 0.57; IGT: p = 0.38; DM: p = 0.1), HOMA2-IR (NG: p = 0.41; IGT: p = 0.61; DM: p = 0.18) or HOMA2-%S (NG: p = 0.44; IGT: p = 0.52; DM: p = 0.51) 3 and 12 months after surgery, respectively. CONCLUSION Pancreatic head resections for CP, including DPPHR and pancreatoduodenectomies, do not significantly affect glucose metabolism within a follow-up period of 12 months.
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Affiliation(s)
- Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Florian Ehehalt
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Paul Langerhans Institute Dresden, Helmholtz Center Munich, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Michele Solimena
- Paul Langerhans Institute Dresden, Helmholtz Center Munich, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Fiona R. Kolbinger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Paul Langerhans Institute Dresden, Helmholtz Center Munich, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Correspondence: ; Tel.: +49-351-458-18264
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Yamada D, Takahashi H, Asukai K, Hasegawa S, Wada H, Matsuda C, Yasui M, Omori T, Miyata H, Sakon M. Investigation of the influence of pancreatic surgery on new-onset and persistent diabetes mellitus. Ann Gastroenterol Surg 2021; 5:575-584. [PMID: 34337306 PMCID: PMC8316753 DOI: 10.1002/ags3.12435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022] Open
Abstract
AIM The management of diabetes mellitus (DM) after pancreatic surgery is a long-standing issue. We aimed to investigate DM concerning pancreatic surgery, including new onset diabetes mellitus (NODM), DM resolution, and the change in insulin excretion before/after pancreatic surgery. METHODS We retrospectively investigated three different cohorts (total 403 patients) undergoing pancreatectomy. Of those, 275 patients without preoperative DM were investigated for the risk factors of NODM. Fifty-four patients without preoperative DM of the other cohort were assessed for pre/postoperative 24-hour urinary C-peptide excretion (24-hr CPR). To evaluate the influence of pancreatic surgery on DM treatment in patients with preoperative DM, 74 patients were investigated. In all those patients, the pancreatic volume in pre/postoperative images was assessed to estimate the resected pancreatic volume. RESULTS NODM was observed in 60 patients (21%), and a lower ratio of remnant pancreatic volume (RRPV) was the only significant risk factor for NODM. Postoperative 24-hr CPR was significantly associated with two factors, RRPV and preoperative 24-hr CPR. Nine of 74 patients with preoperative DM achieved DM resolution after pancreatic surgery, and the presence of gastrointestinal anastomosis was a significant preferable factor for DM resolution. CONCLUSIONS Considering the management of DM after surgery, both predicting the postoperative pancreatic volume and the presence of gastrointestinal reconstruction are significant. We concluded that the combined assessment of the predicted remnant pancreatic volume and the preoperative 24-hr CPR value is useful to predict the postoperative pancreatic function.
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hidenori Takahashi
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Kei Asukai
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Shinichiro Hasegawa
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Wada
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Chu Matsuda
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masayoshi Yasui
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Takeshi Omori
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Miyata
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masato Sakon
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
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Niwano F, Babaya N, Hiromine Y, Matsumoto I, Kamei K, Noso S, Taketomo Y, Takeyama Y, Kawabata Y, Ikegami H. Glucose Metabolism After Pancreatectomy: Opposite Extremes Between Pancreaticoduodenectomy and Distal Pancreatectomy. J Clin Endocrinol Metab 2021; 106:e2203-e2214. [PMID: 33484558 PMCID: PMC8063252 DOI: 10.1210/clinem/dgab036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT The rate of glucose metabolism changes drastically after partial pancreatectomy. OBJECTIVE This work aims to analyze changes in patients' glucose metabolism and endocrine and exocrine function before and after partial pancreatectomy relative to different resection types (Kindai Prospective Study on Metabolism and Endocrinology after Pancreatectomy: KIP-MEP study). METHODS A series of 278 consecutive patients with scheduled pancreatectomy were enrolled into our prospective study. Of them, 109 individuals without diabetes, who underwent partial pancreatectomy, were investigated. Data were compared between patients with pancreaticoduodenectomy (PD, n = 73) and those with distal pancreatectomy (DP, n = 36). RESULTS Blood glucose levels during the 75-g oral glucose tolerance test (75gOGTT) significantly decreased after pancreatectomy in the PD group (area under the curve [AUC] -9.3%, P < .01), and significantly increased in the DP population (AUC + 16.8%, P < .01). Insulin secretion rate during the 75gOGTT and glucagon stimulation test significantly decreased after pancreatectomy both in the PD and DP groups (P < .001). Both groups showed similar homeostasis model assessment of insulin resistance (HOMA-IR) values after pancreatectomy. Decrease in exocrine function quality after pancreatectomy was more marked in association with PD than DP (P < .01). Multiple regression analysis indicated that resection type and preoperative HOMA-IR independently influenced glucose tolerance-related postoperative outcomes. CONCLUSIONS Blood glucose levels after the OGTT differed markedly between PD and DP populations. The observed differences between PD and DP suggest the importance of individualization in the management of metabolism and nutrition after partial pancreatectomy.
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Affiliation(s)
- Fumimaru Niwano
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Naru Babaya
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Yoshihisa Hiromine
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Keiko Kamei
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Yasunori Taketomo
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Yumiko Kawabata
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
- Correspondence: Hiroshi Ikegami, MD, PhD, Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osaka-sayama, Osaka, 589-8511, Japan.
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9
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Jung W, Kim H, Kwon W, Jang JY. Atrophy of remnant pancreas after pancreatoduodenectomy: Risk factors and effects on quality of life, nutritional status, and pancreatic function. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:239-249. [PMID: 33773065 DOI: 10.1002/jhbp.949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Factors aggravating remnant pancreas atrophy following pancreatoduodenectomy and the effects of atrophy have not been extensively studied. This study aimed to evaluate the clinical factors affecting remnant pancreas atrophy and assess the effects of atrophy on quality of life, nutritional status, and pancreatic exocrine and endocrine functions. METHODS Data collected prospectively from 122 patients who completed 12 months of follow-up, including computed tomography and the quality-of-life questionnaire, were analyzed. Pancreas volume was measured using a computed tomography volumetry program. Endocrine and exocrine functions were evaluated. RESULTS Malignancy and adjuvant chemoradiotherapy were associated with severity of atrophy. At 12 postoperative months, quality-of-life scores and nutritional indexes were mostly not associated with atrophy, but stool elastase level decreased significantly and incidence of new-onset diabetes mellitus was higher in the severe atrophy group. Postprandial 2-hour blood glucose and glycosylated hemoglobin levels were also higher in this group. CONCLUSIONS Remnant pancreas atrophy was more severe in patients with malignant disease who received adjuvant chemoradiotherapy and was associated with pancreatic exocrine and endocrine functions. More careful monitoring and active management of exocrine and endocrine deficiencies are necessary for patients who underwent pancreatoduodenectomy for malignant disease and received chemoradiotherapy.
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Affiliation(s)
- Woohyun Jung
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.,Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
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10
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Current situation, consensus and controversy of perioperative nutrition management in pancreatic surgery: A narrative review. JOURNAL OF PANCREATOLOGY 2021. [DOI: 10.1097/jp9.0000000000000066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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11
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Yamazaki T, Aoki T, Tashiro Y, Koizumi T, Kusano T, Matsuda K, Fujimori A, Yamada K, Nogaki K, Hakozaki T, Wada Y, Shibata H, Tomioka K, Enami Y, Murakami M. Relationship Between Remnant Pancreatic Volume and Endocrine Function After Pancreaticoduodenectomy. Am Surg 2021; 88:233-237. [PMID: 33522272 DOI: 10.1177/0003134821989049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Decreased pancreatic volume (PV) is a predictive factor for diabetes mellitus (DM) after surgery. There are few reports on PV and endocrine function pre- and post-surgery. We investigated the correlation between PV and insulin secretion. METHODS Seventeen patients underwent pancreaticoduodenectomy (PD) Pre- and post-surgery PV and C-peptide index (CPI) measurements were performed. Additionally, the correlation between PV and CPI was analyzed. RESULTS The mean preoperative PV (PPV) was 55.1 ± 31.6 mL, postoperative remnant PV (RPV) was 25.3±17.3 mL, and PV reduction was 53%. The mean preoperative C-peptide immunoreactivity (CPR) was 1.39 ± .51 and postoperative CPR was .85±.51. The mean preoperative CPI was 1.29±.72 and postoperative CPI was .73 ± .48. Significant correlations were observed between RPV and post CPR (ρ = .507, P = .03) and post CPI (ρ = .619, P = .008). DISCUSSION There was a significant correlation between RPV and CPI after PD. A smaller RPV resulted in lower insulin secretion ability, increasing the potential risk of new-onset DM after PD.
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Affiliation(s)
- Tatsuya Yamazaki
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Takeshi Aoki
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Yoshihiko Tashiro
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Tomotake Koizumi
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Tomokazu Kusano
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Kazuhiro Matsuda
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Akira Fujimori
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Kosuke Yamada
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Koji Nogaki
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Tomoki Hakozaki
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Yusuke Wada
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Hideki Shibata
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Kodai Tomioka
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Yuta Enami
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
| | - Masahiko Murakami
- Department of General and Gastroenterological Surgery, School of Medicine, 13059Showa University, Tokyo, Japan
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12
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Diabetes mellitus in intraductal papillary mucinous neoplasms: A systematic review and meta-analysis. Surgery 2020; 169:411-418. [PMID: 32838986 DOI: 10.1016/j.surg.2020.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/07/2020] [Accepted: 07/03/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Our current knowledge of diabetes mellitus in intraductal papillary mucinous neoplasm is very limited and its prevalence and predictive value for malignant transformation are not clear. This study sought to systematically review the literature to define the prevalence of diabetes mellitus in intraductal papillary mucinous neoplasm and to evaluate the association of diabetes mellitus with the progression to high-grade dysplasia or invasive cancer. METHODS A PubMed/Medline systematic search was performed to identify studies reporting data on preoperative diabetes mellitus in intraductal papillary mucinous neoplasm. Articles meeting the predefined inclusion criteria were analyzed and a meta-analysis was performed. The study was preregistered (PROSPERO ID: CRD42020153581). RESULTS From the initially detected 827 studies, 27 studies including resected patients with histologically confirmed intraductal papillary mucinous neoplasm were included. The global prevalence of preoperative diabetes mellitus was 25% (1,112 of 4,412); whereas new-onset/worsening diabetes mellitus was reported in 6% of patients (68 of 1,202). The meta-analysis revealed that patients with pre-existing diabetes mellitus had an increased risk of harboring a main pancreatic duct involvement (risk ratio 1.43, 95% confidence interval: 1.21-1.69, P < .001), high-grade dysplasia (risk ratio 1.27, 95% confidence interval: 1.01-1.59, P = .04), and invasive cancer (risk ratio 1.61, 95% confidence interval: 1.33-1.95, P < .001). CONCLUSION The prevalence of diabetes mellitus in intraductal papillary mucinous neoplasm is high, and diabetic patients demonstrate an increased risk of a more aggressive disease. Therefore, diabetes mellitus should be increasingly considered in the stratification of patients with intraductal papillary mucinous neoplasm. Further investigations to determine the mechanisms behind the association with progression should be carried out.
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13
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Hartman V, Op de Beeck B, Chapelle T, Bracke B, Ysebaert D, De Block C, Roeyen G. Prediction of exocrine and endocrine insufficiency after pancreaticoduodenectomy using volumetry. Acta Chir Belg 2020; 120:257-264. [PMID: 31008690 DOI: 10.1080/00015458.2019.1607140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: The aim of this study is to evaluate the use of pancreatic volumetric assessment to predict exocrine and endocrine insufficiency after pancreaticoduodenectomy.Methods: Thirty-seven patients who underwent pancreaticoduodenectomy were included in the study. Endocrine function was assessed in all patients without a history of diabetes using an oral glucose tolerance test. A 13C-labeled mixed triglyceride (MTG) breath test evaluated exocrine function before and after resection. Volumetric measurements were performed on CT or MRI.Results: The volumetric measurements could not predict pre- or postoperative diabetes. Moreover, the resected volume was significantly lower in patients who developed diabetes after resection. Comparing patients with a normal and disturbed postoperative MTG, postoperative volumes and parenchymal thickness were significantly different. The parenchymal thickness on postoperative imaging is withheld as a predictive factor (OR = .85 [95% CI .71-1.01], p = .049). The best cutoff value to predict exocrine insufficiency is a parenchymal thickness of less than 11.4 mm (AUC = .76, p = .025, sensitivity = 88.9%, specificity = 70.0%).Conclusions: Pancreatic remnant volumetry and parenchymal thickness measurement after pancreaticoduodenectomy are correlated with exocrine insufficiency, but with limited predictive value. None of the preoperative measurements are withheld to predict postoperative exocrine function. Pre- and postoperative volumetry appear to have no use in predicting postoperative diabetes.
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Affiliation(s)
- V. Hartman
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - B. Op de Beeck
- Department of Radiology, Antwerp University Hospital, Edegem, Belgium
| | - T. Chapelle
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - B. Bracke
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - D. Ysebaert
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - C. De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Edegem, Belgium
| | - G. Roeyen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
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14
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Tariq M, Jajja MR, Maxwell DW, Galindo RJ, Sweeney JF, Sarmiento JM. Diabetes development after distal pancreatectomy: results of a 10 year series. HPB (Oxford) 2020; 22:1034-1041. [PMID: 31718897 DOI: 10.1016/j.hpb.2019.10.2440] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 10/05/2019] [Accepted: 10/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Limited literature is available on the postoperative development of impaired glucose tolerance (IGT) and new-onset diabetes mellitus (NODM) following Distal Pancreatectomy (DP). We aimed to study the post-surgical clinical evolution of IGT/DM and its association with preoperative glycemic profiles of patients undergoing DP. METHODS Pre- and postoperative glycemic laboratories were measured in patients undergoing DP by the senior author from 2007-2017. Multivariate risk factor analysis was performed to determine risk factors for new-onset IGT/DM after DP. Kaplan-Meier curves were constructed for development of NODM postoperatively. RESULTS Of 216 included patients, n = 63, n = 68 and n = 85 were preoperatively diagnosed with no-diabetes (No-DM), pre-diabetes (Pre-DM), and diabetes (DM), respectively. At 2-year follow-up, n = 37, n = 80 and n = 99 were classified as No-DM, Pre-DM or DM, respectively. Pre-diabetics had a higher risk of developing postoperative dysglycemia (RR 2.230, 95% CI 1.732-2.870, p = 0.001). Preoperative OGTT>130, HbA1c >6.0, and chronic pancreatitis were risk factors for postoperative DM. CONCLUSION 40% of patients undergoing DP were unaware of their dysglycemic status (pre-DM or DM) pre-operatively. At 2-year follow-up, 36% non-diabetic and 57% pre-diabetic patients had developed NODM. Appropriate pre-operative diabetic assessment is warranted for all patients undergoing pancreatic resections.
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Affiliation(s)
- Marvi Tariq
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA; Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohammad R Jajja
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA; Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel W Maxwell
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA; Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA.
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15
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Wu L, Nahm CB, Jamieson NB, Samra J, Clifton-Bligh R, Mittal A, Tsang V. Risk factors for development of diabetes mellitus (Type 3c) after partial pancreatectomy: A systematic review. Clin Endocrinol (Oxf) 2020; 92:396-406. [PMID: 32017157 DOI: 10.1111/cen.14168] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/02/2020] [Accepted: 02/02/2020] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Linda Wu
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nigel B Jamieson
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Jaswinder Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
- Faculty of Medical and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Venessa Tsang
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Andreasi V, Partelli S, Capurso G, Muffatti F, Balzano G, Crippa S, Falconi M. Long-Term Pancreatic Functional Impairment after Surgery for Neuroendocrine Neoplasms. J Clin Med 2019; 8:jcm8101611. [PMID: 31623399 PMCID: PMC6832294 DOI: 10.3390/jcm8101611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/23/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022] Open
Abstract
Radical surgery represents the only curative treatment for pancreatic neuroendocrine neoplasms (PanNEN). The aim of this study was to evaluate the postoperative onset of diabetes mellitus (DM) and/or pancreatic exocrine insufficiency (PEI) in surgically treated PanNEN. Consecutive PanNEN patients, without preoperative DM, who underwent partial pancreatic resection, were included. After a median follow-up of 72 months, overall 68/276 patients (24%) developed DM. Patients who developed DM were significantly older (p = 0.002) and they had a higher body mass index (BMI) (p < 0.0001) than those who did not; they were more frequently male (p = 0.017) and with nonfunctioning neoplasms (p = 0.019). BMI > 25 Kg/m2 was the only independent predictor of DM (p = 0.001). Overall, 118/276 patients (43%) developed a PEI, which was significantly more frequent after pancreaticoduodenectomy (p < 0.0001) and in patients with T3-T4 tumors (p = 0.001). Pancreaticoduodenectomy was the only independent predictor of PEI (p < 0.0001). Overall, 54 patients (20%) developed disease progression. Patients with and without DM had similar progression free survival (PFS), whereas patients without PEI had better five-year-PFS (p = 0.002), although this association was not confirmed in multivariate analysis. The risk of DM and PEI after surgery for PanNEN is relatively high but it does not affect PFS. BMI and pancreatic head resection are independent predictors of DM and PEI, respectively.
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Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Gabriele Capurso
- Biliopancreatic Endoscopy Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
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17
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Cho YJ, Namgoong JM, Kim DY, Kim SC, Kwon HH. Suggested Indications for Enucleation of Solid Pseudopapillary Neoplasms in Pediatric Patients. Front Pediatr 2019; 7:125. [PMID: 31001506 PMCID: PMC6456698 DOI: 10.3389/fped.2019.00125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/15/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Solid pseudopapillary neoplasms (SPNs) are rare, low-grade, malignant neoplasms that can occur in pediatric patients. Although complete resection of the tumor is the principle treatment, SPN enucleation (EN) has been reported to be effective in children. This study aimed to examine the feasibility and safety of EN by comparing it with conventional pancreatectomy (CP), and to present the indications for its use in pediatric patients. Methods: We retrospectively reviewed the medical records of 66 patients who underwent surgery for SPN at our institution from October 1992 to April 2018. Surgical methods, postoperative complications, hospital stay, and recurrence were compared. Results: Of the 66 patients, 15 (22.7%) were treated with EN and 51 (77.3%) were treated with CP. The mean duration of EN operation was 262 min (±145 min) and of CP was 345 min (±195 min). There was no statistically significant difference between the two methods (P = 0.13). To objectively compare the mass size between patients, we introduced a tumor size/intraperitoneal width ratio, which also revealed no significant difference between the 2 surgery groups (P = 0.21). The EN group had one case of recurrence at the resection site. The complications observed were fluid collection, splenic infarctions, hematomas, pancreatic fistulas, portal vein thromboses, and chylous drainage, among which pancreatic fistulas were the most frequent followed by moderate-severe fistulas in the EN group (P < 0.001). The mean postoperative fasting time (EN 17.0 ± 8.7 days vs. CP 5.1 ± 3.3 days, P < 0.001) and mean hospital stay (EN 23.4 ± 10.0 days vs. CP 13.2 ± 6.5 days, P = 0.002) showed statistically significant differences. Conclusion: Compared with CP treatment, EN of SPNs in children has the disadvantages of prolonged fasting times and hospital stays to recover from moderate pancreatic fistulas. However, if appropriate indications are applied, EN can be considered a safe and effective surgical procedure for children.
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Affiliation(s)
- Yu Jeong Cho
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong Chul Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyun Hee Kwon
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
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18
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Scholten L, Mungroop TH, Haijtink SAL, Issa Y, van Rijssen LB, Koerkamp BG, van Eijck CH, Busch OR, DeVries JH, Besselink MG. New-onset diabetes after pancreatoduodenectomy: A systematic review and meta-analysis. Surgery 2018; 164:S0039-6060(18)30081-3. [PMID: 29779868 DOI: 10.1016/j.surg.2018.01.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/07/2018] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Lianne Scholten
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Timothy H Mungroop
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Simone A L Haijtink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Yama Issa
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - L Bengt van Rijssen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands.
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Maignan A, Ouaïssi M, Turrini O, Regenet N, Loundou A, Louis G, Moutardier V, Dahan L, Pirrò N, Sastre B, Delpero JR, Sielezneff I. Risk factors of exocrine and endocrine pancreatic insufficiency after pancreatic resection: A multi-center prospective study. J Visc Surg 2018; 155:173-181. [PMID: 29396112 DOI: 10.1016/j.jviscsurg.2017.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- A Maignan
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France
| | - M Ouaïssi
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France; CHRU, hôpital de Trousseau, service de chirurgie digestive, oncologique, endocrinienne et de transplantation hépatique, 37170 Chambray-les-Tours, France.
| | - O Turrini
- Institut Paoli-Calmette, service de chirurgie oncologique, 13009 Marseille, France
| | - N Regenet
- Hôpital Hôtel-Dieu, service de chirurgie digestive et endocrinienne, 44000 Nantes, France
| | - A Loundou
- AP-HM, Aix Marseille université, faculté de médecine de Marseille, service de santé publique et biostatistique, 13005 Marseille, France
| | - G Louis
- AP-HM, hôpital de la Timone, service de radiologie, 13005 Marseille, France
| | - V Moutardier
- AP-HM, hôpital Nord, service de chirurgie digestive générale, endocrinienne, 13005 Marseille, France
| | - L Dahan
- AP-HM, hôpital de la Timone, service d'oncologie digestive, 13005 Marseille, France
| | - N Pirrò
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France
| | - B Sastre
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France
| | - J-R Delpero
- Institut Paoli-Calmette, service de chirurgie oncologique, 13009 Marseille, France
| | - I Sielezneff
- AP-HM, hôpital de la Timone, service de chirurgie digestive et viscérale, 13005 Marseille, France
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Park SY, Park KM, Shin WY, Choe YM, Hur YS, Lee KY, Ahn SI. Functional and morphological evolution of remnant pancreas after resection for pancreatic adenocarcinoma. Medicine (Baltimore) 2017; 96:e7495. [PMID: 28700497 PMCID: PMC5515769 DOI: 10.1097/md.0000000000007495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 05/31/2017] [Accepted: 06/21/2017] [Indexed: 01/05/2023] Open
Abstract
Functional and morphological evolution of remnant pancreas after resection for pancreatic adenocarcinoma is investigated.The medical records of 45 patients who had undergone radical resection for pancreatic adenocarcinoma from March 2010 to September 2013 were reviewed retrospectively. There were 34 patients in the pancreaticoduodenectomy (PD) group and 10 patients in the distal pancreatectomy (DP) group. One patient received total pancreatectomy. The endocrine function was measured using the glucose tolerance index (GTI), which was derived by dividing daily maximum serum glucose fluctuation by daily minimum glucose. Remnant pancreas volume (RPV) was estimated by considering pancreas body and tail as a column, and head as an ellipsoid, respectively. The pancreatic atrophic index (PAI) was defined as the ratio of pancreatic duct width to total pancreas width. Representative indices of each patient were compared before and after resection up to 2 years postoperatively.The area under receiver operating characteristic curve of GTI for diagnosing DM was 0.823 (95% confidence interval, 0.699-0.948, P < .001). Overall, GTI increased on postoperative day 1 (POD#1, mean ± standard deviation, 1.79 ± 1.40 vs preoperative, 1.02 ± 1.41; P = .001), and then decreased by day 7 (0.89 ± 1.16 vs POD#1, P < .001). In the PD group, the GTI on POD#14 became lower than preoperative (0.51 ± 0.38 vs 0.96 ± 1.37; P = .03). PAI in the PD group was significantly lower at 1 month postoperatively (0.22 ± 0.12 vs preoperative, 0.38 ± 0.18; P < .001). In the PD group, RPV was significantly lower at 1 month postoperatively (25.3 ± 18.3 cm vs preoperative, 32.4 ± 20.1 cm; P = .02), due to the resolution of pancreatic duct dilatation. RPV of the DP group showed no significant change. GTI was negatively related to RPV preoperatively (r = -0.317, P = .04), but this correlation disappeared postoperatively (r = -0.044, P = .62).Pancreatic endocrine functional deterioration in pancreatic adenocarcinoma patients may in part be due to pancreatic duct obstruction and dilatation caused by the tumor. After resection, this proportion of endocrine insufficiency is corrected.
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Long-term outcomes after pancreaticoduodenectomy using pair-watch suturing technique: Different roles of pancreatic duct dilatation and remnant pancreatic volume for the development of pancreatic endocrine and exocrine dysfunction. Pancreatology 2017; 17:814-821. [PMID: 28705553 DOI: 10.1016/j.pan.2017.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/19/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND We evaluated long-term outcomes including endo- and exocrine functions after pancreaticoduodenectomy (PD) with standardized pancreaticojejunostomy, paying attention to postoperative pancreatic duct dilatation (PDD) and remnant pancreatic volume (RPV), and examined whether postoperative pancreatic fistula (POPF) influenced the configuration of remnant pancreas. METHODS We analyzed the records of 187 patients with PD who could have RPV measured by CT volumetry at 1 month after operation and had been followed for more than 6 months. We assessed the risk factors of diabetes mellitus (DM) and PDD, and evaluated association between RPV and pancreatic endo- and exocrine functions assessed by several markers such as albumin, cholesterol, amylase and HbA1c. RESULTS Regarding RPV, pancreatic exocrine functions were significantly impaired in the small-volume group (SVG: less than 10 ml) than in the large-volume group (LVG: 10 ml or more). The incidence of new-onset or exacerbation of DM did not differ between SVG and LVG. PDD and the primary disease (pancreatic ductal adenocarcinoma compared to bile duct cancer) were selected as the independent risk factors of new-onset or exacerbation of DM by multivariate analysis. Unexpectedly, there was no significant association between POPF and PDD. CONCLUSIONS Early occurrence of POPF after PD did not influence the development of PDD in late period, and long-term follow-up should be made by paying attention to PDD and RPV, because PDD was recognized as the most important risk factor of new-onset or exacerbation of DM and the patients with small RPV suffered from prolonged exocrine dysfunction rather than endocrine dysfunction.
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Gilliland TM, Villafane-Ferriol N, Shah KP, Shah RM, Tran Cao HS, Massarweh NN, Silberfein EJ, Choi EA, Hsu C, McElhany AL, Barakat O, Fisher W, Van Buren G. Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection. Nutrients 2017; 9:nu9030243. [PMID: 28272344 PMCID: PMC5372906 DOI: 10.3390/nu9030243] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/20/2017] [Accepted: 02/28/2017] [Indexed: 12/15/2022] Open
Abstract
Pancreatic cancer is an aggressive malignancy with a poor prognosis. The disease and its treatment can cause significant nutritional impairments that often adversely impact patient quality of life (QOL). The pancreas has both exocrine and endocrine functions and, in the setting of cancer, both systems may be affected. Pancreatic exocrine insufficiency (PEI) manifests as weight loss and steatorrhea, while endocrine insufficiency may result in diabetes mellitus. Surgical resection, a central component of pancreatic cancer treatment, may induce or exacerbate these dysfunctions. Nutritional and metabolic dysfunctions in patients with pancreatic cancer lack characterization, and few guidelines exist for nutritional support in patients after surgical resection. We reviewed publications from the past two decades (1995–2016) addressing the nutritional and metabolic status of patients with pancreatic cancer, grouping them into status at the time of diagnosis, status at the time of resection, and status of nutritional support throughout the diagnosis and treatment of pancreatic cancer. Here, we summarize the results of these investigations and evaluate the effectiveness of various types of nutritional support in patients after pancreatectomy for pancreatic adenocarcinoma (PDAC). We outline the following conservative perioperative strategies to optimize patient outcomes and guide the care of these patients: (1) patients with albumin < 2.5 mg/dL or weight loss > 10% should postpone surgery and begin aggressive nutrition supplementation; (2) patients with albumin < 3 mg/dL or weight loss between 5% and 10% should have nutrition supplementation prior to surgery; (3) enteral nutrition (EN) should be preferred as a nutritional intervention over total parenteral nutrition (TPN) postoperatively; and, (4) a multidisciplinary approach should be used to allow for early detection of symptoms of endocrine and exocrine pancreatic insufficiency alongside implementation of appropriate treatment to improve the patient’s quality of life.
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Affiliation(s)
- Taylor M Gilliland
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Nicole Villafane-Ferriol
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Kevin P Shah
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Rohan M Shah
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Hop S Tran Cao
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Nader N Massarweh
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Eric J Silberfein
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Eugene A Choi
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Cary Hsu
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Amy L McElhany
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Omar Barakat
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - William Fisher
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - George Van Buren
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
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Yun SP, Seo HI, Kim S, Kim DU, Baek DH. Does the pancreatic volume reduction rate using serial computed tomographic volumetry predict new onset diabetes after pancreaticoduodenectomy? Medicine (Baltimore) 2017; 96:e6491. [PMID: 28353594 PMCID: PMC5380278 DOI: 10.1097/md.0000000000006491] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Volume reduction of the pancreatic tissues following a pancreatectomy can lead to the deterioration of glucose homeostasis. This is defined as pancreatogenic diabetes mellitus (DM). The objective of this study was to investigate the occurrence of new-onset DM (NODM) and evaluate the risk factors, including the pancreas volume reduction rate in patients undergoing pancreaticoduodenectomy (PD).Sixty-six patients without preoperative DM underwent PD for periampullary tumors between August 2007 and December 2012 and were included in this analysis. These patients underwent follow-up tests and abdominal computed tomography (CT) scan 7 days, 6 months, 12 months, 24 months, and 36 months after the operation. The pancreas volume reduction rate was calculated by CT volumetry. The patients were divided into 2 groups according to the postoperative development of DM.After PD, newly diagnosed DM occurred in 16 patients (24.2%). The incidence of DM was highest among patients with carcinomas with an advanced T stage. The pancreatic volume reduction rate after 6 and 12 months in the NODM group was significantly higher than the normal glucose group in the univariate analysis. In the multivariate analysis, the pancreatic volume reduction rate 6 months after PD was the only significant predictive factor for the development of NODM (P = 0.002).This study suggests that the pancreatic volume reduction rate 6 months after PD was the only significant predictive factor for the development of NODM. CT volumetry of the pancreas may be useful as a predictor of NODM after PD.
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Affiliation(s)
| | | | | | - Dong Uk Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dong Hoon Baek
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Efficacy and Safety of Pancrelipase/Pancreatin in Patients With Exocrine Pancreatic Insufficiency and a Medical History of Diabetes Mellitus. Pancreas 2016; 45:679-86. [PMID: 26495784 DOI: 10.1097/mpa.0000000000000514] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aim of this study was to perform exploratory analyses of the efficacy and safety of pancrelipase delayed-release capsules (Creon) in patients with exocrine pancreatic insufficiency (EPI) with (n = 36) and without (n = 18) concurrent diabetes mellitus (DM). METHODS This was a retrospective, post hoc, subgroup (±DM) analysis of a double-blind, randomized, placebo-controlled trial of pancrelipase in patients with EPI due to chronic pancreatitis or pancreatectomy (total or partial). After a 5-day placebo run-in period (baseline), patients were randomized to pancrelipase (72,000 lipase units/meal, 36,000/snack) or placebo for 7 days. Outcomes included changes in coefficients of fat absorption (CFA) and nitrogen absorption (CNA) from baseline to the end of the double-blind period. RESULTS Mean changes in nutrient absorption were greater with pancrelipase versus placebo in patients with DM (CFA, 36.0% vs 7.5%, P < 0.0001; CNA, 33.4% vs 3.7%, P = 0.0002) and without DM (CFA, 25.2% vs 12.3%, P = 0.0326; CNA, 39.1% vs 17.6%, P = 0.1187). Diabetes mellitus was not significantly associated with outcomes for CFA (P = 0.0802) and CNA (P = 0.2934). Incidences of adverse events, including hypoglycemia and hyperglycemia, were similar in the pancrelipase and placebo arms. CONCLUSIONS Pancrelipase improved fat and protein absorption in patients with EPI due to chronic pancreatitis or pancreatectomy, with or without DM, and matched the safety profile previously reported.
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Abstract
OBJECTIVES Glucose homeostasis changes after pancreatic resection are not well understood. We aimed to identify the incidence of, and risk factors for, a change in glucose homeostasis in patients who underwent pancreatectomy for benign pancreatic tumors. METHODS Clinical and pathological data from 229 patients were collected prospectively and analyzed retrospectively. The pancreas resection volume was calculated by computed tomography volumetry. RESULTS After pancreatectomy, newly diagnosed diabetes mellitus (DM) occurred in 52 patients (22.7%) and impaired fasting glucose and impaired glucose tolerance occurred in 74 patients (32.3%). The incidence of DM was highest for patients who underwent distal pancreatectomy (DP) (30.5%). Patients in the DP group had a significantly increased rate of DM as the pancreatic resection volume (in milliliters) and resected volume ratio (in percent) increased. A high body mass index and older age were significant risk factors for the development of DM by multivariate analysis. CONCLUSIONS The resection volume of the pancreas is associated with a change in glucose homeostasis after pancreatectomy. Therefore, preservation of the pancreatic parenchyma is important to minimize the onset of DM in patients with a high pancreatic resected volume ratio (>35.6%) in DP, a high body mass index, or in old age.
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Leal JN, Kingham TP, D’Angelica MI, DeMatteo RP, Jarnagin WR, Kalin MF, Allen PJ. Intraductal Papillary Mucinous Neoplasms and the Risk of Diabetes Mellitus in Patients Undergoing Resection Versus Observation. J Gastrointest Surg 2015; 19:1974-81. [PMID: 26160323 PMCID: PMC4809678 DOI: 10.1007/s11605-015-2885-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 06/23/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study is to determine the prevalence of diabetes mellitus (DM) in patients with intraductal papillary mucinous neoplasm of the pancreas (IPMN) and compare rates of new/progressive DM between IPMN patients undergoing pancreatectomy versus observation. METHODS Patients diagnosed with IPMN were identified from institutional databases, divided into two groups based on treatment type, pancreatectomy versus clinical observation, and subsequently evaluated. Standard demographic and clinicopathologic variables, fasting glucose, diabetic status, and pancreatic volume data, were obtained and compared between groups. RESULTS One hundred thirty-four IPMN patients were identified; 103 (77 %) underwent pancreatectomy and 31 (23 %) were observed. Baseline DM rate was 18 % (24/134). This was not different between groups [17 % (17/103) resected vs. 23 % (7/31) observed, p = 0.51]. Median follow-up was 53 months and new/progressive DM occurred in 37 (28 %) patients with no difference between groups [29 (28 %) resected vs. 8 (26 %) observed, p = 0.74]. Among resected patients, degree of dysplasia was associated with increase risk of new/progressive DM [moderate dysplasia OR 5.76 (1.24-26.79) and severe dysplasia OR 9.43 (1.54-57.74), p = 0.04], while procedure type and remnant volume were not. CONCLUSIONS The incidence and prevalence of DM among patients with IPMN was high and did not differ between resected and observed groups. Degree of dysplasia, not the amount of resected pancreas, was associated with increased risk of DM, suggesting that the presence or development of DM may be a marker of malignant progression. Confirmatory studies are required.
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Affiliation(s)
- Julie N. Leal
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Michael I. D’Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Ronald P. DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - William R. Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Marcia F. Kalin
- Department of Endocrinology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Peter J. Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Phillip V, Zahel T, Danninger A, Erkan M, Dobritz M, Steiner JM, Kleeff J, Schmid RM, Algül H. Volumetric gain of the human pancreas after left partial pancreatic resection: A CT-scan based retrospective study. Pancreatology 2015; 15:542-547. [PMID: 26145835 DOI: 10.1016/j.pan.2015.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 02/09/2015] [Accepted: 06/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Regeneration of the pancreas has been well characterized in animal models. However, there are conflicting data on the regenerative capacity of the human pancreas. The aim of the present study was to assess the regenerative capacity of the human pancreas. METHODS In a retrospective study, data from patients undergoing left partial pancreatic resection at a single center were eligible for inclusion (n = 185). Volumetry was performed based on 5 mm CT-scans acquired through a 256-slice CT-scanner using a semi-automated software. RESULTS Data from 24 patients (15 males/9 females) were included. Mean ± SD age was 68 ± 11 years (range, 40-85 years). Median time between surgery and the 1st postoperative CT was 9 days (range, 0-27 days; IQR, 7-13), 55 days (range, 21-141 days; IQR, 34-105) until the 2nd CT, and 191 days (range, 62-1902; IQR, 156-347) until the 3rd CT. The pancreatic volumes differed significantly between the first and the second postoperative CT scans (median volume 25.6 mL and 30.6 mL, respectively; p = 0.008) and had significantly increased further by the 3rd CT scan (median volume 37.9 mL; p = 0.001 for comparison with 1st CT scan and p = 0.003 for comparison with 2nd CT scan). CONCLUSIONS The human pancreas shows a measurable and considerable potential of volumetric gain after partial resection. Multidetector-CT based semi-automated volume analysis is a feasible method for follow-up of the volume of the remaining pancreatic parenchyma after partial pancreatectomy. Effects on exocrine and endocrine pancreatic function have to be evaluated in a prospective manner.
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Affiliation(s)
- Veit Phillip
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Tina Zahel
- Institut für diagnostische und interventionelle Radiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Assiye Danninger
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Mert Erkan
- Department of Surgery, Koc University School of Medicine, Istanbul, Turkey; Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Martin Dobritz
- Institut für diagnostische und interventionelle Radiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Jörg M Steiner
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany; Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843-4474, USA
| | - Jörg Kleeff
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Roland M Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Hana Algül
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany.
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Kang CM, Lee JH. Pathophysiology after pancreaticoduodenectomy. World J Gastroenterol 2015; 21:5794-5804. [PMID: 26019443 PMCID: PMC4438013 DOI: 10.3748/wjg.v21.i19.5794] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 02/25/2015] [Accepted: 04/17/2015] [Indexed: 02/06/2023] Open
Abstract
Pancreaticoduodenectomy (PD) will result in removal of important multiorgans in upper intestinal tract and subsequently secondary physiologic change. In the past, surgeons just focused on the safety of surgical procedure; however, PD is regarded as safe and widely applied to treatment of periampullary lesions. Practical issues after PD, such as, effect of duodenectomy, metabolic surgery-like effect, alignment effect of gastrointestinal continuity, and non-alcoholic fatty liver disease were summarized and discussed.
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Hirata K, Nakata B, Amano R, Yamazoe S, Kimura K, Hirakawa K. Predictive factors for change of diabetes mellitus status after pancreatectomy in preoperative diabetic and nondiabetic patients. J Gastrointest Surg 2014; 18:1597-603. [PMID: 25002020 DOI: 10.1007/s11605-014-2521-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 03/31/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION This study aimed to determine risk factors for exacerbation of diabetes mellitus (DM) after pancreatectomy. METHODS Medical records of 167 patients with benign and malignant pancreaticobiliary diseases who underwent pancreaticoduodenectomy or distal pancreatectomy were retrospectively analyzed. DM was diagnosed by diabetic history or American Diabetes Association criteria. Worsened and improved DM after pancreatectomy was defined when treatment intensity or insulin/oral antidiabetic drug dosage increased or decreased, respectively, postoperatively. Long-standing DM was defined as a duration of >2 years. RESULTS In 76 preoperative diabetic patients, worsened and improved DM was observed postoperatively in 46 (60.5 %) and 9 (11.8 %) patients, respectively. In 91 preoperative nondiabetic patients, 22 (24.2 %) developed new-onset DM after pancreatectomy. Multivariate logistic analysis of the preoperative diabetic patients demonstrated long-standing DM and malignancy as independent predictors for postoperative worsened DM. No patients with long-standing DM or insulin treatment experienced improved DM after pancreatectomy. Multivariate logistic analysis of the preoperative nondiabetic patients showed body mass index of ≥25 and hard pancreatic texture as independent risk factors for new-onset postoperative DM. CONCLUSIONS These results may enable preoperative evaluation of risk factors for worsened or new-onset DM after pancreatectomy and may help plan intensive care for patients at a high risk of postoperative worsened DM.
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Affiliation(s)
- Keiichiro Hirata
- Department of Surgical Oncology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
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Postoperative chemoradiotherapy following pancreaticoduodenectomy. Impact of dose-volumetric parameters on the development of diabetes mellitus. Strahlenther Onkol 2013; 189:753-8. [PMID: 23907137 DOI: 10.1007/s00066-013-0405-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this research was to analyze the relationship between dose-volumetric parameters and the development of diabetes mellitus (DM) in patients treated with chemoradiotherapy (CRT) following curative resection for upper gastrointestinal (GI) cancers. PATIENTS AND METHODS Medical records of patients who underwent postoperative CRT following curative resection, either pancreaticoduodenectomy (PD) or pylorus preserving pancreaticoduodenectomy (PPPD) for upper GI cancers including pancreas, biliary, ampullary, and duodenal cancers, between January 2006 and December 2008 were retrospectively reviewed. A total of 42 patients who were regularly followed for at least 2 years were included for analysis. Dose-volumetric parameters such as remnant pancreatic volume, mean dose, maximum dose (Dmax), and percentage of volume receiving specific dose or more were obtained from pre- and postoperative CT scan images and treatment plan. RESULTS Dmax and V50 (percentage of volume receiving at least 50 Gy) were statistically significant factors for the development of DM (p = 0.013, p = 0.031, respectively). The sensitivity and specificity of Dmax was 0.875 and 0.559, with cut-off value of 51.1 Gy, respectively. V50 had sensitivity of 0.875 and specificity of 0.618 for cut-off value of 16 %. No patient-related factor other than pretreatment cerebrovascular events was associated with the development of DM. On multivariate analysis, V50 was the only factor with statistical significance (p = 0.028), whereas Dmax showed borderline significance (p = 0.079). CONCLUSION V50 was the only independent factor associated with the development of diabetes and may function as guideline to predict the development of DM in patients receiving CRT following curative resection.
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Nakata B, Ishikawa T, Amano R, Kimura K, Hirakawa K. Impact of preoperative diabetes mellitus on clinical outcome after pancreatectomy. Int J Surg 2013; 11:757-61. [PMID: 23891775 DOI: 10.1016/j.ijsu.2013.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 07/17/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE The goal of this study was to review published literature regarding the impact of preoperative diabetes mellitus (DM) in patients undergoing pancreatectomy. METHODS Ovid Medline(®) of a biomedical database was used on subjective literature research. RESULTS The prevalence of preoperative DM was 30.9-54.9% in patients with pancreatic cancer and was 5.3-10.8% in patients with chronic pancreatitis. There were few reports that described the relationship between preoperative DM status and postoperative morbidity/mortality, or long-term survival after pancreatectomy. The incidence of pancreatic fistula of Grade B and C [defined by International Study Group on Pancreatic Fistula Definition (ISGPF)] was similar when comparing patients with and without preoperative DM. Furthermore, the incidence of death and various morbidities (e.g., infections, cardiovascular complications, clinically significant level of acute renal failure after pancreatectomy, and delayed gastric emptying after pancreaticoduodenectomy) were not significantly different when comparing patients with and without preoperative DM. It is unclear whether preoperative DM has an impact on long-term survival after pancreatectomy, and the difficulty in assessing this parameter may be due to different definitions of DM, different surgical methods, and different comorbidities when comparing different studies. CONCLUSIONS The occurrence rates of postoperative mortality and morbidities including pancreatic fistula and renal failure of moderate to severe degrees were almost same between patients with and without preoperative DM. The influence of preoperative DM on long term survival after pancreatectomy should be elucidated by future studies under accurate and consistent definitions of DM.
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Affiliation(s)
- Bunzo Nakata
- Department of Surgery, Kashiwara Municipal Hospital, 1-7-9 Hozenji, Kashiwara City, Osaka 582-0005, Japan.
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Oh HM, Yoon YS, Han HS, Kim JH, Cho JY, Hwang DW. Risk factors for pancreatogenic diabetes after pancreaticoduodenectomy. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2012; 16:167-71. [PMID: 26388929 PMCID: PMC4575001 DOI: 10.14701/kjhbps.2012.16.4.167] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 09/15/2012] [Accepted: 10/15/2012] [Indexed: 01/28/2023]
Abstract
Backgrounds/Aims Postoperative diabetes mellitus (DM) after pancreaticoduodenectomy (PD) may compromise the long-term quality of life in survivors after the operative procedure due to the treatment difficulty and its related complications. The aim of this study is to determine the incidence of new-onset pancreatogenic DM after PD and investigate the risk factors for this complication. Methods Among 170 patients who had undergone PD between November 2003 and September 2009, 98 patients were selected for this study. The selected patients were non-diabetic prior to the operation and had undergone follow-up tests for glucose metabolism and an abdominal computed tomography (CT) scan 1 year after the operation. The clinical data of these patients were retrospectively analyzed by reviewing the medical records, radiologic images, and pathologic reports. Results Postoperative pathology confirmed malignant tumors in 91 patients, borderline malignancy in 5, and benign tumor in 2. The tumor locations included the pancreatic head (n=30), the common bile duct (CBD) (n=30), ampulla of Vater (n=30), and the duodenum (n=8). New-onset DM occurred in 17 (17.4%) of the 98 patients during the first year after the operation. The comparative analysis between postoperative DM (+) and DM (-) groups revealed that the atrophy of the remaining pancreas was the only significant risk factor for development of postoperative DM after PD. Conclusions This study suggests that the atrophy of the remaining pancreas increases the risk of pancreatogenic DM after PD, and efforts to prevent pancreatic atrophy are needed to decrease this complication.
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Affiliation(s)
- Hyoung Min Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ji Hoon Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dae-Wook Hwang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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