Glycemic Change After Pancreaticoduodenectomy

The purpose of this population-based study was to determine the change of glucose metabolism in patients undergoing pancreaticoduodenectomy (PD). We conducted a nationwide cohort study using data from Taiwan’s National Health Insurance Research Database collected between 2000 and 2010. Our sample included 861 subjects with type 2 diabetes mellitus (DM) and 3914 subjects without DM. Of 861 subjects with type 2 diabetes, 174 patients (20.2%) experienced resolution of their diabetes after PD, including patients with pancreatic ductal adenocarcinoma (PDAC) (20.5%), and non-PDAC (20.1%). Using a multiple logistic regression model, we found that subjects with comorbid chronic pancreatitis (odds ratio, 0.356; 95% CI, 0.167–0.759; P1⁄4 0.007) and use of insulin (odds ratio, 0.265; 95% CI, 0.171–0.412; P< 0.001) had significantly lower rates of resolution of diabetes. In the 3914 subjects without diabetes, the only statistically significant comorbidity contributing to pancreatogenic diabetes was chronic pancreatitis (odds ratio, 1.446; 95% CI, 1.146–1.823; P1⁄4 0.002). Subjects with comorbid chronic pancreatitis and use of insulin had lower rates of resolution of DM after PD. In subjects without diabetes, chronic pancreatitis contributed significantly to the development of pancreatogenic DM. (Medicine 94(27):e1109) Abbreviations: CCI = Charlson comorbidity index, DM = diabetes mellitus, ICD-9 = International Classification of Disease, Ninth Revision, NHIRD = National Health Insurance Research Database, PC = pancreatic cancer, PD = pancreaticoduodenectomy, PDAC = pancreatic ductal adenocarcinoma. INTRODUCTION ancreaticoduodenectomy (PD) is performed for the treatment Kuo, MD, Ching-Y PhD, Hsieh, MS, Feipei Lai, and Yu-Wen Tien, MD, PhD both surgical skills and perioperative care, PD has become safer and it is now more widely used in the treatment of cancer as well as noncancerous diseases. The favorable survival rates after PD in the treatment of noncancerous diseases make metabolic outcomes after this procedure increasingly important. Pancreatectomy often results in the deterioration of glucose homeostasis because the pancreas is the main organ responsible for hormonal regulation of glucose metabolism. Pancreatectomy-associated diabetes is defined as pancreatogenic diabetes mellitus (DM; the onset of DM after pancreatectomy), and occurrence rates vary (20–50%) depending on the type of the pancreatic resection procedure as well as the underlying disease. PD includes removal of the pancreatic head; therefore, theoretically, the procedure reduces the number of islet cells and worsens the glycemic status. However, PD can result in the resolution of diabetes. Several studies have addressed the resolution of diabetes after PD in pancreatic ductal adenocarcinoma (PDAC) patients, particularly in patients diagnosed with new onset diabetes, or pancreatic cancer (PC) development within 2 years of diabetes diagnosis. Pannala et al attributed DM resolution after PD to resection of tumor along with tumor-secreted diabetogenic products. However, we found DM resolved after PD in some patients both with and without PDCA and postulated that PD-associated anatomic change may play a role in resolution of DM after PD. PD-associated anatomical changes include resection of pancreatic head, duodenum, and most proximal part of jejunum (10– 15 cm). After PD, another 30 to 40-cm-long jejunum will be brought up for pancreatic and biliary anastomosis, which will make the last enteral anastomosis (gastrojejunostomy in standard PD or duodenojejunostomy in pylorus-preserving PD) created on jejunum about 50 to 60 cm distal to Treitz ligament. The change in the food passage route after PD is quite similar to that after Rouxen-Y gastric bypass for morbid obesity. This reconstruction allows food to pass directly into the distal jejunum without passing through the duodenum (foregut and hindgut theories of bariatric surgery). These patients had increased postprandial secretion of gut hormone contributing to improved insulin resistance and glucose metabolism. According to these findings, PD may have positive and negative effects on glucose metabolism. The aim of this study was to use the reimbursement databases of Taiwan’s National Health Insurance (NHI) to investigate the factors contributing to changes in glucose metabolism after PD, and therefore, the resolution of diabetes and pancreatogenic diabetes.