Effects of total pancreatectomy in a patient with diabetes

Abstract

Pancreatectomy, the completeness of which was established at autopsy, was performed for carcinoma in a patient who was already diabetic and had chronic diarrhea. The stomach, duodenum, spleen, and left adrenal were also removed. For approximately three months the patient remained in sufficiently good condition to permit metabolic studies. Loss of the pancreas led to a marked increase in diarrhea, the daily fecal weight on one occasion being 5,580 Gm., even though the patient was receiving powdered pancreas in large amounts. Atropine was more effective than pancreatin in controlling fecal volume and its effect was augmented by a sharp reduction in dietary fat. Intestinal absorption of both fat and protein, already less than normal before operation, was strikingly diminished thereafter. The large loss of nitrogen in the feces (12.3 Gm. daily) was accompanied by the relatively low urinary loss of 4.68 Gm. per day. Analyses of food and excreta showed a slightly positive calcium and phosphorus balance, despite the severe diarrhea. Extirpation of the pancreas was not followed by any increase in the requirement for insulin which, with a diet containing 400 Gm. carbohydrate, averaged about 40 units per day. Sensitivity to insulin was marked, the patient experiencing frequent hypoglycemic reactions. With the patient receiving constant feedings every two hours and a constant supply of insulin derived from the daily injection of protamine zinc insulin, the blood sugar exhibited a definite diurnal pattern, the lowest values occurring during the night. The phenomenon is presumably related to rhythmic variations in the activity of the liver. When the patient was maintained on three injections of crystalline insulin per day, the last dose being given before supper, the fasting blood sugars were essentially normal. This is contrary to the usual finding in severe, spontaneous diabetes. Also at variance with the behavior of such patients was the response in the present case to intravenously administered glucose, the resultant blood sugar curves being less “diabetic” than might be expected. The postabsorptive respiratory quotients varied from .77 to .80, values which are considerably higher than those for totally depancreatized dogs or severely diabetic human beings. Of the total calories derived from the metabolic mixture, 27.7 per cent came from carbohydrate, 9.4 per cent from protein and 62.9 per cent from fat. When insulin and food were withheld, the D N ratio of the urine was 2.42 and 3.59 on two occasions, respectively. Permanent withdrawal of insulin resulted within six days in the death of the patient in diabetic coma. Values for serum amylase fell to low levels shortly after operation, but later returned to normal. One month after removal of the pancreas, serum lipids had declined from 20 to 30 per cent below the immediate postoperative value, but they never reached subnormal levels. Pancreatectomy produced no striking changes in serum carbon dioxide, pH, Cl, Na, K, Ca, P, or in plasma proteins. The considerable loss of nutriment through diarrhea may explain certain apparent differences between the diabetes in this case and the spontaneous disease of ordinary diabetic patients.