Indications For Total Pancreatectomy Research Articles

Total Pancreatectomy: No Peri-Operative Mortality and Good Long Term Qol Can Be Achieve

Introduction: Indications for total pancreatectomy (TP) can be divided in: size or localisation of tumor, troubles in the perioperative period of partial pancreatectomy, technical difficulties and therapy-refractory pain in chronic pancreatitis. Morbidity and mortality rates are reported around 38-69% and >20%, respectively. Method: Retrospective collection of data for patients that underwent TP between 2014 and 2021 at our institution. Also an original survey to investigate the quality of life (QoL) of all surviving patients was performed. Results: A total of 14 patients underwent TP. Indications for TP were size or localisation of tumor (12 cases) and technical difficulties (2 cases). Complications Clavien-Dindo ≥ III were reported in only two cases. There was no 30-days mortality. Analysis of survival demonstrated that cancer patients had a significantly worse overall survival (p=0.021). The median overall adjusted (cancer related) survival was 13 months (3-20, SD 7.2 Mo). All non-cancer patients are alive. QoL analysis revealed good glycemic control, without diarrhoea, loss of weight or malabsorption syndrome. All patients surveyed reported a good QoL. Conclusions: Our series shows that TP can be performed in selected indications with acceptable morbidity and low mortality. The overall survival was defined by the underlying diagnosis and not the TP or apancreatic state. With multidisciplinary long term care good endocrine and exocrine control can be achieved providing a good QoL.

Perioperative management of endocrine insufficiency after total pancreatectomy for neoplasia.

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. 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. 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. 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.

Are there still indications for total pancreatectomy?

Total pancreatectomy is associated with short- and long-term high complication rate and without evidence of oncologic advantages. Several metabolic consequences are co-related with the apancreatic state. The unstable diabetes related to the total resection of the pancreas expose the patients to short- and long-term life-threatening complications. Severe hypoglycemia is a short-term dangerous complication that can also cause patients’ death. Chronic complications of severe diabetes (cardiac and vascular diseases, neuropathy, nephropathy, and retinopathy) are also cause of morbidity, mortality and worsening of quality of life. For this reasons the number of total pancreatectomies performed has certainly decreased over time. However, today there are still some indications for this kind of procedures. Chronic pancreatitis untreatable with conventional treatments, surgical treatment of precancerous pancreatic lesions, surgical treatment of locally advanced pancreatic cancer and the management of patients with extraordinary high-risk pancreatic texture after pancreaticoduodenectomy represent possible indications for total pancreatectomy and are analyzed in the present paper.