Glycemia control after total pancreatoduodenectomy

Abstract

   Aim. To study the features of correction of carbohydrate metabolism disorders and nutritional deficiency in patients after total pancreatoduodenectomy; to develop a unified protocol for managing patients after total pancreatoduodenectomy.   Materials and methods. From 2007 to 2022, 62 patients underwent total pancreatoduodenectomy in the Hepatopancreatic Surgery Unit of the Botkin Hospital. The patients were divided into two groups, comparable in terms of basic parameters. The first group included patients (n = 32) who underwent “classical” total pancreatoduodenectomy with gastric resection and splenectomy. The second group consisted of patients (n = 30) who underwent total pancreatoduodenectomy in the modification of Botkin Hospital. In the perioperative period, patients of both groups were examined for carbohydrate metabolism with the selection and assessment of the average daily dose of short-acting and long-acting insulin, assessment of enzyme and protein deficiency with the selection of enzyme replacement therapy and nutritional support. For a more accurate assessment of carbohydrate metabolism disorders, all patients underwent continuous monitoring of the level of glycemia intraoperatively and in the early postoperative period (FreeStyle Libre flash monitoring system, Abbott). The glycated hemoglobin level was assessed on day 90 and body mass index – on days 30, 60 and 90 after surgery.   Results. The mean level of glycemia in patients after total pancreatoduodenectomy in the modification of the Botkin Hospital accounted for 8.0 mmol/l and the variability (daily fluctuations in glycemia) comprised 39 %, which was significantly lower compared to the group of “classical” total pancreatoduodenectomy with 7.6 mmol/l and 48 %, respectively. Seven patients (21.9 %) after total pancreatoduodenectomy in the modification of the Botkin Hospital experienced a severe hypoglycemic episode, while a similar severe hypoglycemic episode was noted in 25 patients (80.6 %) after pancreatectomy in its “classical” variant, of which 18 patients (60 %) required hospitalization in the endocrinology unit in order to correct the sugar-lowering therapy. In turn, only three patients (9.4 %) after total pancreatoduodenectomy modified by the Botkin Hospital required hospitalization due to severe hypoglycemia. The mean level of glycated hemoglobin in patients of the first and second groups on day 90 accounted for 7.2 % and 7.7 %, respectively (p = 0.789). The average body mass index on day 90 after surgery was higher in the group of organ-preserving total pancreatoduodenectomy: 24 kg/m2, compared to the “classical” pancreatectomy with 21.2 kg/m2 (p = 0.001). The daily dose of both short-acting and long-acting insulin was higher in the organ-preserving total pancreatoduodenectomy group of 17.4 ± 5.6 U/day and 12 ± 4.6 U/day, respectively, compared to the group of “classical” total pancreatoduodenectomy of 13.8 ± 4.6 U/day and 10.8 ± 2.7 U/day, respectively. This can be attributed to the faster normalization of the patient's body weight and the preserved function of physiological digestion due to the pylorus-preserving variant of total pancreatoduodenectomy.   Conclusion. Management of patients after total pancreatoduodenectomy is claimed to be an extremely complex task that requires a multidisciplinary approach involving surgeons, intensivists, endocrinologists and gastroenterologists at all stages of patient management. Organ-preserving modification of total pancreatoduodenectomy with preservation of the stomach, spleen and splenic vessels in the modification of the Botkin Hospital improves treatment results and simplifies the selection of insulin therapy for this group of patients.