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PubMed1989

[Digestive physiopathology of the pancreatectomized patient. Comparison of the results of total pancreatectomy and pancreaticoduodenectomy with preservation of the pylorus].

The authors analyze their experience with pancreatectomy, pointing out the digestive pathophysiologic sequelae of the operated patients. A follow-up protocol based on upper digestive endoscopy, laboratory tests, scintigraphic and pH-metric tests compares the results achieved after total pancreatectomy with the results of pancreaticoduodenectomy. Total pancreatectomy is complicated by peptic ulcer, stump gastritis and gastroenteric dyskinesia. The preservation of the pylorus and the separation of the gastric anastomosis from the biliary one avoid the pathologic biliary reflux and minimize the functional and organic sequelae of the operation.

Adenocarcinoma↗

PubMed1989

Contribution of partial pancreatectomy, systemic hormone delivery, and duct obliteration to glucose regulation in canine pancreas. Importance in pancreas transplantation.

Our aim was to isolate and determine the contribution of partial pancreatectomy, systemic delivery of pancreatic hormones, and duct obliteration to glucose regulation after segmental pancreas transplantation in dogs. Fasting, postprandial, and intravenous glucose-stimulated glucose, insulin, glucagon, pancreatic polypeptide (PP), and cholecystokinin (CCK) and intravenous bombesin-stimulated PP levels were studied in beagles at three successive intervals in a crossover design. The first was 6 wk after partial (approximately 70%) pancreatectomy with intact regular enteric exocrine drainage from the duodenal pancreatic remnant, the next was 2 wk after venous transposition with systemic delivery of pancreatic hormones, and the third was 6 wk after in situ duct obliteration of the remnant. With partial pancreatectomy, K values were modestly diminished (30%), and a concomitant reduction of second-phase intravenous glucose-stimulated insulin release was observed. Other parameters were not significantly affected. Venous transposition doubled peripheral plasma levels of insulin under all conditions. Fasting glucose, PP, and CCK levels decreased slightly. Other parameters were not affected. Duct obliteration of the systemic draining pancreatic remnants seriously impaired glucose sensitivity, resulting in a 50% reduction of K values and fasting and sustained postprandial hyperglycemia (approximately 8 mM) and a 70-50% reduction (acute and overall responses, respectively) of intravenous glucose-stimulated insulin. Fasting hormone and postprandial insulin, glucagon, and CCK levels were not affected. The postprandial PP response was severely reduced, and bombesin-stimulated PP release was abolished by duct obliteration. We conclude that histological changes associated with duct obliteration are the major determinants of glucose regulation in segmental pancreas transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1989

Distal pancreatectomy with and without splenectomy. A comparative study.

Twenty-one patients undergoing distal pancreatectomy from January 1980 through April 1987 were studied retrospectively. Group I (n = 10) had distal pancreatectomy with splenectomy, and Group II (n = 11) had distal pancreatectomy with splenic preservation. The groups were comparable in mean age and extent of pancreatic resection. Operative time in Group I patients who did not require additional major procedures was 3.74 +/- 1.01 hours, compared with 2.86 +/- 1.68 hours for similar Group II patients. The overall complication rate in Group I was 40 per cent, including two pancreatic fistulas, one subphrenic abscess, and one gastric fistula. In Group II the overall complication rate was 36.4 per cent, with one pancreatic fistula, one subphrenic abscess, and one colonic fistula. Splenic infarction occurred in only one patient (Group II), in whom both splenic vessels were ligated. No patient developed insulin-dependent diabetes. There were no deaths. The mean hospitalization time was 18.8 days in Group I, and 17.5 days in Group II. Splenectomy should not be considered a routine part of distal pancreatic resection. Splenic preservation can be achieved in selected cases with no increase in complication rate, operative time, or length of postoperative hospitalization.

Adult↗

PubMed1988

[Experimental study on glucose turnover and amino acid metabolism after total pancreatectomy].

Glucose turnover and plasma amino acid profile were measured in total pancreatectomized dogs to clarify the mechanism of hyperaminoacidemia after total pancreatectomy. Twenty-one male mongrel dogs underwent total gastrectomy and pancreatectomy and were divided into two groups. I(-) group (n = 11) was treated without insulin and I(+) group (n = 10) received insulin postoperatively. Another 15 dogs of S group received only splenectomy. Glucose appearance rate (Ra), plasma amino acid profile and blood sugar level (BS) were measured before operation, and on the 1st and 3rd postoperative days. Significantly higher Ra and BS were observed in I(-) group than in S group postoperatively and either decreased or unaltered by the glucagon infusion. On the other hand, Ra and BS in I(+) group were maintained at the same levels as S group and increased significantly by the glucagon infusion. Hyperaminoacidemia was observed after total pancreatectomy regardless of insulin treatment. Branched chain amino acids (BCAA) were significantly elevated in I(-) group but not in I(+) group. Glucagon infusion decreased almost all amino acids levels except BCAA in both groups. These results suggest that mechanism of hyperaminoacidemia observed in totally pancreatectomized dogs is the reduced amino acids uptake by the liver related to glucagon deficiency.

Amino Acids↗

PubMed1988

[Influence of total pancreatectomy on the secretion of human growth hormone and the endocrine pancreas].

To evaluate the effect of total pancreatectomy on the secretion of human growth hormone, twenty-six patients undergoing total pancreatectomy and twelve healthy subjects (controls) were investigated. Blood glucose (BG), plasma insulin (IRI), C-peptide (CPR), immunoreactive glucagon (IRG) and human growth hormone (HGH) levels were determined. In the glucose tolerance test, the mean basal blood glucose level in the patients before operation was significantly higher than the level in the controls. The basal blood glucose level in the patients after operation was still higher than the level before operation. The responses of IRI, CPR, and IRG secretion after arginine infusion in the patients before operation were less than those in the controls. After operation, arginine infusion did not alter the levels of IRI, CPR and IRG. The mean basal HGH levels were not significantly different between the controls and the patients before and after operation. However, a statistically significant correlation was shown between the basal values of plasma HGH and those of plasma IRI in the patients after operation. Thus, it suggested that the basal secretion of HGH is closely related to the exogenous plasma insulin levels in the pancreatectomized patients. After arginine infusion, the HGH levels in the patients before operation were lower than the those in the controls, but insignificant. After operation, mean HGH levels were significantly lower than those before operation. These findings suggested the absence of pancreatic endocrine function caused by total pancreatectomy resulted in decreased responses of HGH secretion after arginine infusion.

Adult↗

PubMed1986

[Postoperative management of total pancreatectomy].

Sixteen patients given total pancreatectomy were experienced, and the essential points of postoperative management were reported. The morbid states after total pancreatectomy consist of: a deficiency of pancreatic endocrine function, a deficiency of pancreatic exocrine function, loss of the duodenum and upper jejunum, the influence of partial or total gastrectomy, and the influence of dissection around the superior mesenteric artery. These states influence each other and become more complicated. The management period is divided into five parts as follows; a period of intravenous nutrition, the early half; water replacement period, the late half; hyperalimentation period, a period of intravenous and enteral nutrition, a period of enteral, intravenous and oral nutrition, a period of oral and enteral nutrition, and a period of oral nutrition. In each period, a special form of management is needed. The essential points of long-term management are as follows: The use of suitable doses of pancreatic enzyme and antidiarrheal agents for the cure of severe maldigestion and malabsorption. Also, intermittent IVH or elemental diet are effective for recovery from deteriorative malnutrition. For the prevention of hypoglycemic attack, training of the patients and the maintainance of good nutrition are important. These patients have a high incidence of infection, and so speedy treatment must be given if this occurs. Fatty liver must be treated by intermittent IVH or elemental diet. As total pancreatectomy imposes a severe burden on the patient, including self-injection of insulin, the indications of this operation must be decided carefully giving due consideration to its radicality.

Enteral Nutrition↗

PubMed1987

Experimental diabetes in cats induced by partial pancreatectomy alone or combined with local injection of alloxan.

Experimental diabetes was produced in cats by partial pancreatectomy using a short and technically simple surgical procedure. Electrocautery was used to cauterize pancreatic blood vessels and seal free edges of remaining pancreatic tissue to prevent secretion of pancreatic enzymes into the peritoneal cavity. In a second group of animals, partial pancreatectomy was followed by local injection of alloxan into an arterial branch of the cranio-mesenteric artery. The combined procedure resulted in diabetes mellitus in 100% (8 of 8) animals as compared to only 70% (14 of 20) in those subjected to partial pancreatectomy alone. In addition, the alloxan-pancreatectomized cats had a reduced latency period prior to onset of chronic hyperglycemia (4.8 days compared to 19.3 days postoperatively in pancreatectomized cats). The diabetic cats were maintained in poor metabolic control (blood glucose approximately 300 mg/dl) by daily injections of low doses of long-acting insulin. Pancreatic enzyme supplementation was given by mouth. Weight changes and blood glucose levels were monitored carefully to maintain the health of the animals while keeping them in poor metabolic control.

Alloxan↗

PubMed1985

[Value of total parenteral nutrition after total pancreatectomy].

The authors report 5 cases of Total Pancreatectomy (T.P.) treated with Total Parenteral Nutrition (T.P.N.) in which the non-protein calorie supply consisted of lipids and carbohydrates ("dual energy system"). This form of nutrition, which provided a high energy supply with a reduced glucose intake, prevented the problems associated with hypertonic glucose solutions in the unstable diabetes which follows total pancreatectomy. The authors compared these cases with an earlier series of 11 cases of Total pancreatectomy who were not treated with Total Parenteral Nutrition and observed that the patients treated with TPN had a better recovery, a better glucose homeostasis, a reduction in the complications and mortality and a decreased length of stay in hospital.

Blood Glucose↗

PubMed1984

[The pathogenesis of diabetes produced by subtotal pancreatectomy, with special reference to the cell kinetics of the islet cells].

The pathogenesis of the diabetes produced by the subtotal pancreatectomy was investigated from the pancreatic endocrine function and the cell kinetics of the islet cells. The authors prepared the following two groups in the rats. The first group was 90% pancreatectomized rats and the second group was the 60% pancreatectomized rats. Most of the 90% pancreatectomized rats developed diabetes twelve weeks after operation. In these diabetic rats the insulin secretion was undetectable during glucose infusion. To the contrary, the relative increase of the glucagon secretion was found during arginine infusion in spite of the hyperglycemia. However, non of the 60% pancreatectomized rats developed diabetes during post-operative course up to 6 months. To investigate the cell kinetics of the islet cells, the 3H-thymidine autoradiography was prepared at several intervals after operation. The results of the thymidine labelling index showed two phase of regeneration. The first phase was observed on three to seven days after pancreatectomy and the second phase was on fourteen to twenty-eight days. After the second phase of regeneration, the degeneration of the B-cells was observed in the 90% pancreatectomized rats. On the ninetieth days after operation the atrophy of the islets and the disturbance of the arrangement of A, B and D cells were observed by the immuno-histochemical studies. Meanwhile, the 60% pancreatectomized rats did not show degeneration of the islets. These results show that the onset of diabetes after subtotal pancreatectomy was produced by degeneration of the B cells surpassing their regenerative capacity.

Animals↗

PubMedDate not supplied

The effect of pancreatectomy in lipoprotein lipase activity: an experimental study in pancreatectomized rats.

To investigate the etiology of hyperlipemia induced by total pancreatectomy in rats, the authors determined lipoprotein lipase (LPL) activity and performed the intravenous fat loading test (IVFLT). LPL activity was remarkably reduced after total pancreatectomy, but recovered almost completely with administration of 4 i.u./Kg of insulin. The results of IVFLT showed positive correlation with LPL activity changes. The elimination rate K of IVFLT also recovered with the administration of insulin. On the other hand, in our previous reports no evidence of increase in lipid synthesis in the liver of depancreatectomized rats was found. From these results, the authors tentatively concluded that the main cause of pancreatectomy-induced hyperlipemia was a delay in the removal of lipids from the blood, due to decreased LPL activity caused by a lack of insulin.

Animals↗

PubMed1993

Capacity to secrete islet hormones after subtotal pancreatectomy for pancreatic cancer.

OBJECTIVE: To find out if the capacity to secrete insulin and glucagon was affected by pancreatectomy. Insulin and glucagon secretion was measured before and three months after subtotal pancreatectomy. DESIGN: Open study. SETTING: University hospital. SUBJECTS: Five patients who each underwent removal of roughly 85% of the pancreas for cancer. INTERVENTIONS: Arginine 5 g given intravenously during glucose infusions that were varied in strength to give blood glucose concentrations of about 5, 15, and 28 mmol/l. MAIN OUTCOME MEASURES: Fasting concentrations of glucose, insulin, and glucagon; and effect of arginine on insulin and glucagon secretion at the different blood glucose concentrations. RESULTS: Fasting concentrations of glucose in blood and insulin and glucagon in plasma were not significantly affected by the operation, but arginine-induced secretion of insulin and glucagon were severely impaired. The mean (SEM) insulin response to arginine was reduced from 316 (101) to 129 (29) pmol/l (p < 0.05) and when the patients were at the most hyperglycaemic from 1292 (316) to 474 (115) pmol/l (p < 0.05). The ratio of the change in response of insulin to blood glucose concentrations was also reduced (from 76.8 (25.9) to 27.9 (8.6) pmol/l/mmol/l) (p < 0.01). The plasma glucagon response to arginine was also reduced, by 40% at 5 and 15 mmol/l of glucose, and by 80% at 28 mmol/l glucose (p < 0.05). CONCLUSION: Though diabetes does not usually develop after subtotal pancreatectomy, the capacity to secrete insulin and glucagon was considerably reduced.

Aged↗

PubMed1993

What constitutes curative pancreatectomy for adenocarcinoma of the pancreas?

This is a review of the recent advances in radical pancreatectomy for adenocarcinoma of the pancreas. Over the last three decades, the operative mortality rate has decreased sharply to below 5%. On the basis of the clinicopathological evidence of the extent of the cancer, extended pancreatectomy with lymphatic and connective tissue clearance, in place of the traditional Whipple's procedure or total pancreatectomy is increasingly justified. In fact, use of this procedure has markedly reduced locoregional recurrence, and has improved the 5-year survival rate of pancreatic adenocarcinoma patients to more than 25%. However, such a beneficial effect is limited to those with less advanced cancer, for example, that in which the main tumor is 4 cm or less in diameter, nodal involvement is limited to the peripancreatic groups, and portal vein invasion is slight or absent. Future efforts should be aimed at developing adjuvant therapy that is equally as effective in reducing both locoregional recurrence and liver metastasis.

Adenocarcinoma↗

PubMed1996

[Adjuvant therapies in combination with pancreatectomy for carcinoma of the pancreas].

In the treatment of adenocarcinoma of the pancreas, surgical resection is the only curative strategy. However, the long-term survival rate after pancreatectomy remains poor, and most patients died of loco-regional and/or hepatic recurrence. Thus, we should perform effective adjuvant therapies in combination with surgery, in order to completely prevent these two types of cancer relapse. The present article is designed to introduce the recent reports on the adjuvant chemo-and/or radio-therapies for this cancer. As for loco-regional control, extended pancreatectomy plus chemoradiation seems to be most promising, and preoperative chemoradiation will be more popular in the near future. In order to decrease hepatic metastasis, our "2-channel chemotherapy", a continuous infusion of 5-FU via both hepatic artery and portal vein, is very promising. If postoperative survival is improved by combining these two types of regional therapy, the role of pancreatectomy will be enlarged and more widely understood in the near future.

Adenocarcinoma↗

PubMed1998

Effect of partial pancreatectomy on beta-cell mass in the remnant pancreas of Wistar fatty rats.

Wistar fatty rat, which has been established by transferring the fa gene of Zucker fatty rat to the Wistar Kyoto rat, has many features in common with human NIDDM. It exhibits hyperglycemic obesity with hyperinsulinemia and insulin resistance. It is unclear, however, whether a defect in the beta-cell proliferation is related to the onset of diabetes mellitus together with insulin resistance in this model rat. To determine this, we compared non-fasting plasma glucose levels, insulin content and beta-cell mass in the remnant pancreas of Wistar fatty rats with those in their diabetic-resistant lean counterparts after a 70% partial pancreatectomy. We also examined whether such a defect, if present, could be improved by either phlorizin or nicotinamide. We further investigated if there were any differences in these parameters between the phenotypically identical but genotypically different Wistar lean rats with a gene type of homogeneous Fa/Fa and that of heterogeneous Fa/fa. Male rats, 6 weeks of age, were allocated at random into two groups: 70% pancreatectomy (Px) and sham-pancreatectomy (sham). A sustained hyperglycemia was evident in the Px Wistar fatty rats after surgery, which was accompanied by a reduction of insulin content and beta-cell mass in the remnant pancreas. The changes in insulin content and beta-cell mass were unaffected by restoration of normoglycemia, induced by phlorizin injection. The administration of nicotinamide partially ameliorated the sustained hyperglycemia by a slight but not significant increase in beta-cell mass. No discernible difference in the above parameters was observed between the Wistar lean rats with Fa/Fa and those with Fa/fa. These findings suggest that Wistar fatty rats have a poor capacity for proliferation of pancreatic beta-cells, which causes the onset of overt diabetes along with insulin resistance due to extreme obesity.

Animals↗

PubMed1995

Role of total pancreatectomy in the treatment of patients with end-stage chronic pancreatitis.

Forty patients underwent total pancreatoduodenectomy for end-stage chronic pancreatitis. There were 34 men and six women of median age 39 (range 21-66) years. Alcoholism was the major aetiological agent (30 patients), and five patients had had previous acute idiopathic pancreatitis. The overwhelming indication for operation was severe abdominal pain, complicated by failing exocrine and endocrine function. Resection was performed in one (17 patients) or two (23) stages, following previous proximal (seven) or distal (16) pancreatectomy; progression from partial to total pancreatectomy occurred over an interval of 8-96 (median 15) months. A further six patients had undergone previous pseudocyst or duct drainage procedures. The pylorus was preserved in 28 patients and the spleen in ten. Median operating time was 6 (range 2.5-8.5) h and median blood loss 2000 (range 500-16,000) ml. There were two hospital deaths and three patients required reoperation. Of 38 survivors, 30 obtained complete or substantial relief of pain. There were 15 late deaths at 2.5-120.0 months after operation, 13 in the alcohol group and 11 disease-related. Total pancreatectomy can relieve the intractable pain of chronic pancreatitis at the cost of possible premature death from continuing alcohol abuse.

Abdominal Pain↗

PubMed1991

Pancreaticoduodenal transplantation with enteric drainage following native total pancreatectomy for chronic pancreatitis: a case report.

Pancreas transplantation is usually performed in patients with denovo type I diabetes, who have advanced secondary complications. We report a case in which whole pancreaticoduodenal transplantation, with enteric drainage, was performed to correct both endocrine and exocrine deficiencies in a patient with hyperlabile diabetes and steatorrhea, unresponsive to oral enzyme replacement therapy, following staged total pancreatectomy for idiopathic or familial chronic pancreatitis. The transplant was performed one year after completion of native pancreatectomy and immediately established an insulin-independent euglycemic state, with normal oral and intravenous glucose tolerance test results and correction of steatorrhea. Beginning one year posttransplant, the patient had intermittent episodes of steatorrhea, associated with mild elevation of blood sugar levels, which were presumed to be due to rejection and, indeed, responded to antirejection treatment with antilymphocyte globulin and temporary increases in steroids dosages. At 20 months posttransplant, steatorrhea did not respond to antirejection treatment and an acute abdomen developed. Laparotomy revealed a perforated graft duodenum, which was resected; pathology showed transmural necrosis secondary to chronic rejection. The pancreas graft itself was left in situ, disconnected from the intestinal tract. The patient remained normoglycemic after graft duodenectomy but resumed oral enzyme replacement therapy in an attempt to combat recurrence of severe steatorrhea. However, his overall situation remained improved compared to pretransplant, since the exocrine deficiency was tolerable in the absence of a diabetic state. Ten months postgraft duodenectomy (38 months posttransplant), elevations in blood sugar levels were treated with another course of antirejection treatment and levels temporarily declined. At 14 months postgraft duodenectomy (42 months posttransplant), graft endocrine function again declined and exogenous insulin was resumed. Six months later, four years after the original transplant, a new enteric-drained pancreaticoduodenal graft was placed, once again resulting in an insulin-independent, steatorrheafree state. With improvements in immunosuppression, pancreas transplantation could be offered to selected patients with hyperlabile diabetes, following total pancreatectomy for benign disease; if the enteric drainage technique is used, in the absence of rejection, exocrine deficiency could be corrected as well.

Adult↗

PubMed1998

Coil embolization of bleeding visceral pseudoaneurysms following pancreatectomy: the importance of early angiography.

OBJECTIVE: To evaluate the efficacy of early angiography in the diagnosis and treatment of delayed arterial hemorrhage as a significant complication following pancreatectomy. DESIGN: Retrospective case series. SETTING: University hospital; 6-year period between January 1992 and December 1997. PATIENTS AND INTERVENTION: Of a total of 81 patients undergoing pancreatic head resection, 10 (12%) developed massive arterial hemorrhage after surgery. All 10 patients underwent an emergency angiography and 8 of these were managed by transcatheter arterial embolization. RESULTS: Before onset of major bleeding, 9 patients (90%) had developed intra-abdominal abscess resulting from pancreatic fistula or other anastomotic leak, and all 10 patients had had preliminary minor bleeding. The angiogram demonstrated an exact site of bleeding as a pseudoaneurysm in all 10 patients. Transcatheter arterial embolization achieved temporary control of bleeding in all 8 patients for whom embolization was attempted and complete hemostasis in 5 of the 8 subsequently, yielding a success rate of 63%. Overall, 4 patients (40%) died of complications related directly to the major hemorrhage or the transcatheter arterial embolization technique. CONCLUSIONS: An emergency angiography should be considered in all patients who develop either a sentinel or massive gastrointestinal bleed following pancreatectomy irrespective of suspected intra-abdominal sepsis. Transcatheter arterial embolization allows temporary control of massive hemorrhage and hemodynamic stabilization in most cases, and prevents the need for high-risk emergency surgery.

Aged↗

PubMed1976

Total pancreatectomy for recurrent medullary fat necrosis.

A patient had subcutaneous and medullary bone fat necrosis associated with chronic, recurrent pancreatitis. In the case, recurrent symptoms of pancreatitis as well as progressive bone destruction were correlated with an increase in serum lipase levels. Total pancreatectomy was followed by relief of all symptoms and healing of destroyed bone. Medullary fat necrosis may be associated with pancreatitis, pancreatic trauma, or cancer of the pancreas. Pancreatectomy may be useful if conservative treatment does not lead to healing of severe medullary fat necrosis associated with recurrent pancreatitis.

Chronic Disease↗