Diabetic control and nutritional status up to 1 year after total pancreatectomy: a nationwide multicentre prospective study

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Dear Editor Total pancreatectomy is increasingly performed worldwide with aftercare using newly developed insulin products and high-titre pancrelipase1–4. Furthermore, recent advances in diagnostic modalities have led to an increase in the number of patients diagnosed with existing lesions in the remnant pancreas during follow-up after initial pancreatectomy5. However, current data on diabetes management and nutritional status following total pancreatectomy from large nationwide series remain lacking, and the differences between one-stage total pancreatectomy and completion pancreatectomy are not known. The aim of this study was to assess glycaemic control and nutritional status after total pancreatectomy. In a prospective nationwide multicentre study, data were assessed for 216 consecutive patients who underwent total pancreatectomy, including one-stage total pancreatectomy and completion pancreatectomy, between August 2015 and December 2017 in 68 Japanese centres (Trial registration UMIN-CTR #UMIN000018763). Of the 216 patients, 180 patients with a follow-up period of 1 year were included in the study. Changes in glycaemic control and nutritional status within a year after surgery were investigated, in addition to the differences between one-stage total pancreatectomy (106 patients) and completion pancreatectomy (74 patients). Data were collected at 1, 3, 6 and 12 months after surgery (postoperative month (POM) 1, 3, 6, and 12) during the follow-up period. Clinicopathological characteristics of the 180 patients undergoing total pancreatectomy are presented in Table S1. Glycated haemoglobin (HbA1c) levels were used to assess glycaemic control during follow-up. HbA1c levels increased by POM 3 and were maintained at a higher level for up to 12 months (Fig. 1a). Of the 180 patients, 54 (30.0 per cent) 60 (34.7 per cent), and 70 (41.7 per cent) patients experienced one or more hypoglycaemic events on a monthly basis at POM 1, POM 6 and POM 12, respectively (Fig. 1b). Body weight after total pancreatectomy decreased by POM 3. Subsequently, weight stabilized and was maintained at lower level up to POM 12 (Fig. 1c). Prognostic nutritional index (PNI; albumin (g/l) + 5 × total lymphocyte count (×109/l)) level decreased to the lowest level at POM 1, and steadily recovered to the preoperative level by POM 3 (Fig. 1d). Longitudinal outcomes after total pancreatectomy a Changes of glycated haemoglobin (HbA1c) level before and after total pancreatectomy. b Frequency of hypoglycaemia per month after total pancreatectomy. c Changes of weight loss after total pancreatectomy. d Changes in the prognostic nutritional index level before and after total pancreatectomy. Plots display the mean and error bars display the standard deviation of the mean. POM, postoperative month Bonferroni multiple comparisons tests. Longitudinal outcomes after total pancreatectomy a Changes of glycated haemoglobin (HbA1c) level before and after total pancreatectomy. b Frequency of hypoglycaemia per month after total pancreatectomy. c Changes of weight loss after total pancreatectomy. d Changes in the prognostic nutritional index level before and after total pancreatectomy. Plots display the mean and error bars display the standard deviation of the mean. POM, postoperative month Bonferroni multiple comparisons tests. Comparisons of the HbA1c levels, hypoglycaemic events, weight loss and PNI levels between one-stage total pancreatectomy and completion pancreatectomy groups are shown in Fig. S2. HbA1c levels of completion pancreatectomy at POM 1 were significantly, although temporarily, higher than those of one-stage total pancreatectomy, but were mostly similar in the two groups. The one-stage total pancreatectomy and completion pancreatectomy groups lost an average of 4.5 kg and 3.3 kg, respectively, during the 12 months after surgery. Body weight stabilized at POM 1 after completion pancreatectomy, while it did not stabilize until POM 3 after one-stage total pancreatectomy. There were no significant differences in hypoglycaemic events or postoperative PNI level between the two groups. This prospective study on diabetes management and nutritional status following total pancreatectomy demonstrated that glycaemic control was insufficient within a year after total pancreatectomy. Strict glycaemic control was probably difficult because of frequent hypoglycaemic events. Conversely, a recovery trend or nutritional status stabilization was confirmed by POM 3 following total pancreatectomy. The postoperative course with respect to glycaemic control and nutritional status between one-stage total pancreatectomy and completion pancreatectomy were largely similar. Supplementary material is available at BJS online. The authors are especially grateful to the 68 principal institutes of the Japanese Society of Hepato-Biliary-Pancreatic Surgery that kindly took part in this study. The authors would like to thank Editage (https://www.editage.jp) for the English language review. Disclosure: The authors declare no conflict of interest.