Diabetes management in patients undergoing total pancreatectomy: A single center cohort study

Abstract

BackgroundTotal pancreatectomy (TP) has been increasingly performed in recent years. However, studies on diabetes management after TP during different postoperative periods are still limited.ObjectivesThis study aimed to evaluate the glycemic control and insulin therapy of patients undergoing TP during the perioperative and long-term follow-up period.MethodsNinety-three patients undergoing TP for diffuse pancreatic tumors from a single center in China were included. Based on preoperative glycemic status, patients were divided into three groups: nondiabetic group (NDG, n = 41), short-duration diabetic group (SDG, preoperative diabetes duration ≤12 months, n = 22), and long-duration diabetic group (LDG, preoperative diabetes duration >12 months, n = 30). Perioperative and long-term follow-up data, including the survival rate, glycemic control, and insulin regimens, were evaluated. Comparative analysis with complete insulin-deficient type 1 diabetes mellitus (T1DM) was conducted.ResultsDuring hospitalization after TP, glucose values within the target (4.4-10.0 mmol/L) accounted for 43.3% of the total data, and 45.2% of the patients experienced hypoglycemic events. Patients received continuous intravenous insulin infusion during parenteral nutrition at a daily insulin dose of 1.20 ± 0.47 units/kg/day. In the long-term follow-up period, glycosylated hemoglobin A1c levels of 7.43 ± 0.76% in patients following TP, as well as time in range and coefficient of variation assessed by continuous glucose monitoring, were similar to those in patients with T1DM. However, patients after TP had lower daily insulin dose (0.49 ± 0.19 vs 0.65 ± 0.19 units/kg/day, P < 0.001) and basal insulin percentage (39.4 ± 16.5 vs 43.9 ± 9.9%, P = 0.035) than patients with T1DM, so did those using insulin pump therapy. Whether in the perioperative or long-term follow-up period, daily insulin dose was significantly higher in LDG patients than in NDG and SDG patients.ConclusionsInsulin dose in patients undergoing TP varied according to different postoperative periods. During long-term follow-up, glycemic control and variability following TP were comparable to complete insulin-deficient T1DM but with fewer insulin needs. Preoperative glycemic status should be evaluated as it could guide insulin therapy after TP.

An Uncommon Cause of Recurrent Presyncope, Dizziness, and Tachycardia: A Case Report of Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS)

“…The management of type 3c diabetes, with all its difficulties and potential complications, as described above, is a long-term challenge for caregivers. In the pre-CGM era, the total loss of glycemic control was associated with severe complications in patients undergoing total pancreatectomy [ 35 , 66 , 69 ].…”

“…Due to the reduction in or loss of functional endocrine pancreatic tissue, i.e., mainly insulin, glucagon, somatostatin, and pancreatic polypeptide-secreting cells, it is pathophysiologically and clinically different from type 1 diabetes. Diabetes type 3c is mainly characterized by an extraordinary insulin sensitivity, which can be explained in terms of the missing counterregulatory glucagon [ 32 , 33 , 34 , 35 , 36 ]. Patients suffering from this type of diabetes have a high susceptibility to hypoglycemia since the autonomic symptoms of hypoglycemia can be missing.…”

“…In the case of total pancreatectomy, which leads to a total loss of glycemic control, 1 IU of insulin can lead to a decrease in blood glucose of 50–70 mg/dL (personal experience; insulin correction factor [see above]; this is compared to 30–40 mg/dL in type 1 diabetes) depending on the time of day, which makes the management of type 3c diabetes challenging. A current review article by Zhao and colleagues provides an in-depth discussion of this topic [ 35 ]. Currently, the HbA1c of our patient is 6.6% [59.6 mmol/mol], corresponding to an average blood glucose of 143 mg/dL with a time in range (70–180 mg/dL) of approximately 70%, as documented by the CGM device.…”

Insulin Resistance in End-Stage Renal Disease Patients: A Review

“…Since the glycolysisinhibiting protein O-linked N-acetyl glucosamine-ylation is present in pancreatic sections of nondiabetic CKD patients, levels of uremia might be a risk factor for beta cell failure after transplantation (Mallone and Eizirik, 2020). Finally, recent studies suggest that both corticosteroids and tacrolimus directly interfere with beta cell stimulussecretion coupling, possibly contributing to their failure (Zhao et al, 2023). Discerning the effect of immunosuppression on beta cells could influence therapeutic stratification in the future (Michaud et al, 2022).…”

“…Insulin In healthy nondiabetic people, the pancreatic beta cells secrete half of the daily insulin requirement (about 0.5 units/kg/day) at a steady basal rate independent of glucose levels (Zhao et al, 2023). The other half is secreted in response to prandial glucose stimulation.…”