Abstract:Previous clinical study has demonstrated that 30-40% of patients undergoing pancreaticoduodenectomy (PD) developed hepatic steatosis. However, nonalcoholic steatohepatitis (NASH) is a little-known complication after PD. Recently we encountered two patients with PD who later developed NASH diagnosed by liver biopsy. Case 1 was a 79-year-old woman who underwent PD for intraductal papillary mucinous neoplasm (IPMN). She had postoperative severe diarrhea due to pseudomembranous enterocolitis. Severe liver dysfunct… Show more
“…It has been suggested that malnutrition due to pancreatic exocrine insufficiency is a main cause of NAFLD after PD, because supplementation of high-dose pancreatic enzyme improves it. Previously, we hypothesized its mechanism as follows: pancreatic exocrine insufficiency after PD is associated with fat malabsorption, resulting in fatty acid deficiency, which leads to increased conversion of carbohydrates into fat (i.e., increased fat deposition) in the liver [6,7]. In the three patients who developed NAFLD after PD at our institution, daily stool fat excretion was examined 7 RPV remnant pancreatic volume days after cessation of pancreatic enzyme supplementation, revealing that it exceeded markedly the definition of steatorrhea as a daily excretion higher than 5-8 g: 45 g, 52 g and 68 g, respectively [16].…”
Section: Discussionmentioning
confidence: 99%
“…In 2010, we reported the incidence of NAFLD after PD as 37.0% and revealed that NAFLD after PD was significantly associated with the following three factors: pancreatic adenocarcinoma, resection line, and postoperative diarrhea, suggesting the contribution of malnutrition due to pancreatic exocrine deficiency . We also encountered two patients with PD who later developed NASH confirmed by liver biopsy, in whom treatment of infectious complications and high‐dose pancreatic enzyme supplementation improved liver dysfunction and liver steatosis . The pathogenesis of NAFLD after PD may therefore differ from that of conventional NAFLD.…”
“…It has been suggested that malnutrition due to pancreatic exocrine insufficiency is a main cause of NAFLD after PD, because supplementation of high-dose pancreatic enzyme improves it. Previously, we hypothesized its mechanism as follows: pancreatic exocrine insufficiency after PD is associated with fat malabsorption, resulting in fatty acid deficiency, which leads to increased conversion of carbohydrates into fat (i.e., increased fat deposition) in the liver [6,7]. In the three patients who developed NAFLD after PD at our institution, daily stool fat excretion was examined 7 RPV remnant pancreatic volume days after cessation of pancreatic enzyme supplementation, revealing that it exceeded markedly the definition of steatorrhea as a daily excretion higher than 5-8 g: 45 g, 52 g and 68 g, respectively [16].…”
Section: Discussionmentioning
confidence: 99%
“…In 2010, we reported the incidence of NAFLD after PD as 37.0% and revealed that NAFLD after PD was significantly associated with the following three factors: pancreatic adenocarcinoma, resection line, and postoperative diarrhea, suggesting the contribution of malnutrition due to pancreatic exocrine deficiency . We also encountered two patients with PD who later developed NASH confirmed by liver biopsy, in whom treatment of infectious complications and high‐dose pancreatic enzyme supplementation improved liver dysfunction and liver steatosis . The pathogenesis of NAFLD after PD may therefore differ from that of conventional NAFLD.…”
“…Jaundice due to steatohepatitis following pancreatoduodenectomy is a rare occurrence [7, 8, 9, 10, 11]. Our patient progressed rapidly to liver failure and jaundice subsequent to NASH.…”
Section: Introductionmentioning
confidence: 80%
“…According to previous reports, non-alcoholic fatty liver disease and NASH following pancreatoduodenectomy can be improved by the administration of pancreatic enzymes [10]. After switching the patient's treatment from oral to intravenous zinc, serum zinc levels rose rapidly and ammonia levels declined.…”
Section: Discussionmentioning
confidence: 99%
“…The presence of secondary kwashiorkor can be indicative of blind loop formation and exocrine pancreatic failure, and is associated with inadequate protein ingestion [4]. It has recently been reported that steatohepatitis occurs in 20–40% of patients who undergo pancreatoduodenectomy [7, 8, 9, 10, 11]. Pancreatoduodenectomy can result in deficiencies of vitamins and trace elements such as zinc, which can lead to fatty liver disease [7, 8, 9, 10, 11].…”
This report describes a case of liver failure secondary to pancreatoduodenectomy and rapid recovery following treatment. A 68-year-old woman with cancer on the ampulla of Vater underwent surgery for pancreatoduodenectomy. The patient developed liver failure 3 months postsurgically. She was hospitalized after presenting with jaundice, hypoalbuminemia and decreased serum zinc. Computed tomography (CT) of the abdomen showed a reduction in CT attenuation values postoperatively. We suspected fatty liver due to impaired absorption caused by pancreatoduodenectomy. We initiated treatment with branched-chain amino acids and a zinc formulation orally. Trace elements were administered intravenously. Two months after treatment, there was a noticeable improvement in CT findings. The patient’s jaundice and hypoalbuminemia prompted a liver biopsy, which led to a diagnosis of non-alcoholic steatohepatitis.
Aim
The aim of this study was to evaluate risk factors for nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD), with a special focus on remnant pancreatic volume (RPV) as assessed using computed tomography (CT).
Methods
From February 2004 to June 2017, 101 patients who underwent PD in our institution were enrolled. We defined a CT attenuation value of less than 40 HU as hepatic steatosis and measured RPV at 7 days, 3 months, and 1 year after PD using the SYNAPSE VINCENT system. The incidence of NAFLD and RPV were compared between the two groups according to reconstruction with pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ).
Results
The incidence of NAFLD at 3 months after PD was 39.6% (40/101). The RPV ratio (RPV at 3 months or 1 year divided by RPV at 7 days after PD) at both 3 months and 1 year was significantly smaller in the PG group than in the PJ group (59% vs 73%, P < .001 and 53% vs 67% P < .01, respectively). A positive correlation between the RPV ratio and liver CT value at 3 months was found. The multivariate analysis identified three independent risk factors for NAFLD: female sex (odds ratio [OR] 8.16, 95% confidence interval [95% CI] 2.27‐35.9, P < .001), PG reconstruction (OR 3.87, 95% CI 1.04‐15.6, P = .04), and RPV ratio ≤60% (OR 3.44, 95% CI 1.06‐11.8, P = .001).
Conclusion
Atrophic change in the remnant pancreas is significantly associated with the development of NAFLD, and PJ reconstruction may be superior to PG from the viewpoint of NAFLD development.
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