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Perioperative management of endocrine insufficiency after total pancreatectomy for neoplasia

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Abstract

Purpose

Indications for total pancreatectomy (TP) have increased, including for diffuse main duct intrapapillary mucinous neoplasms of the pancreas and malignancy; therefore, the need persists for surgeons to develop appropriate endocrine post-operative management strategies. The brittle diabetes after TP differs from type 1/2 diabetes in that patients have absolute deficiency of insulin and functional glucagon. This makes glucose management challenging, complicates recovery, and predisposes to hospital readmissions. This article aims to define the disease, describe the cause for its occurrence, review the anatomy of the endocrine pancreas, and explain how this condition differs from diabetes mellitus in the setting of post-operative management. The morbidity and mortality of post-TP endocrine insufficiency and practical treatment strategies are systematically reviewed from the literature. Finally, an evidence-based treatment algorithm is created for the practicing pancreatic surgeon and their care team of endocrinologists to aid in managing these complex patients.

Methods

A PubMed, Science Citation Index/Social sciences Citation Index, and Cochrane Evidence-Based Medicine database search was undertaken along with extensive backward search of the references of published articles to identify studies evaluating endocrine morbidity and treatment after TP and to establish an evidence-based treatment strategy.

Results

Indications for TP and the etiology of pancreatogenic diabetes are reviewed. After TP, ~80% patients develop hypoglycemic episodes and 40% experience severe hypoglycemia, resulting in 0–8% mortality and 25–45% morbidity. Referral to a nutritionist and endocrinologist for patient education before surgery followed by surgical reevaluation to determine if the patient has the appropriate understanding, support, and resources preoperatively has significantly reduced morbidity and mortality. The use of modern recombinant long-acting insulin analogues, continuous subcutaneous insulin infusion, and glucagon rescue therapy has greatly improved management in the modern era and constitute the current standard of care. A simple immediate post-operative algorithm was constructed.

Conclusion

Successful perioperative surgical management of total pancreatectomy and resulting pancreatogenic diabetes is critical to achieve acceptable post-operative outcomes, and we review the pertinent literature and provide a simple, evidence-based algorithm for immediate post-resection glycemic control.

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Acknowledgements

The authors would like to acknowledge Daphne O’Reilly MD and Maria Ferrera MD for their contributions to this project. Dr. Maker is supported by the NIH/NCI K08CA190855.

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Authors and Affiliations

  1. Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, 835 S. Wolcott Ave. MC790, Chicago, IL, 60612, USA

    Ajay V. Maker

  2. Creticos Cancer Center, Advocate Illinois Masonic Medical Center, University of Illinois Metropolitan Group Hospitals Residency Program in General Surgery, Chicago, IL, USA

    Ajay V. Maker & Raashid Sheikh

  3. Department of Medicine, Division of Endocrinology, University of Illinois at Chicago and Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA

    Vinita Bhagia

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  1. Ajay V. Maker
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  2. Raashid Sheikh
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  3. Vinita Bhagia
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Diabetes Control and Complications Trial (DCCT) Research Group

Contributions

Study conception and design—AVM; acquisition of data—RS, AVM, and VB; analysis and interpretation of data—RS, AVM, and VB; drafting of manuscript—RS and AVM; critical revision of manuscript—RS, AVM, and VB.

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Correspondence to Ajay V. Maker.

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Maker, A.V., Sheikh, R., Bhagia, V. et al. Perioperative management of endocrine insufficiency after total pancreatectomy for neoplasia. Langenbecks Arch Surg 402, 873–883 (2017). https://doi.org/10.1007/s00423-017-1603-8

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  • DOI: https://doi.org/10.1007/s00423-017-1603-8

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