total pancreatectomy for chronic pancreatitisstandard total pancreatectomy and the duodenum...

Gut, 1988, 29, 358-365

Total pancreatectomy for chronic pancreatitisI P LINEHAN, M A LAMBERT, D C BROWN, A B KURTZ, P B COTTON, ANDR C G RUSSELL

From the Departments of Surgery, Gastroenterology and Medicine, The Middlesex Hospital and MedicalSchool, London

SUMMARY The operation oftotal pancreatectomy is performed rarely. Its role in the management ofpatients with chronic pancreatitis remains to be elucidated. We have reviewed our series of 29 totalpancreatectomies for benign disease [14 women median age 39 years; 15 men median age 34 years].Twelve underwent standard total pancreatectomy, in 17 duodenum preserving total pancreatectomy(DPTP) was performed. There was one death (mortality 3.4%). In no patient was the totalpancreatectomy the first operative procedure. The patients were compared with age and sexmatched diabetic control subjects selected on a best fit basis from the diabetic clinic database. Theaetliology of the pancreatitis was idiopathic nine, pancreas divisum nine, alcohol eight and othercauses three. The indication for surgery was pain 27, acute pancreatitis one and cholangitis withpancreatitis one. The complications ofthe procedures were mainly caused by infection [wound three,chest six and central line sepsis four] and in two there was a leak from the duodenum; no patientrequired re-operation. The postoperative stay [standard total, median 21 days (range 13-98) DPTPmedian 31 days (range 17-49)] has lengthened over the period due to greater attention to analgesic,diabetic and enzyme deficiency control before discharge. In standard total pancreatectomy therewere five major hypoglycaemic episodes with only two in 17 DPTP patients. The per cent ideal bodyweight, the insulin requirement and the HbAl compared less well in standard total pancreatectomygroup compared with controls than did DPTP. With both groups large doses ofenzyme replacementwere required, and this proved of importance in diabetic control. Our experience with totalpancreatectomy suggests that pain will be improved in over 80% of patients and that the results ofsurgery will improve with prolonged follow up provided attention is given to analgesic abuse, enzymedeficiency and diabetes.

The role of surgery in the management of chronicpancreatitis is a subject of debate.' Most would agreethat the place for surgery is clear when there is acomplication of chronic pancreatitis amenable tosurgical intervention. Unfortunately the problemoften facing the clinician is that of a patient withchronic pain, on an increasing dosage and strength ofanalgesia, whose quality of life is destroyed by theeffects of both pain and analgesia. There is a group ofpatients who fail to respond to, or who relapse after,non-surgical procedures such as nerve blocks andendoscopic sphincterotomies: of these, there aresome whose symptoms are not relieved by pancreaticAddress for correspondence: Mr R C G Russell, FRCS, Consultant Surgeon,The Middlesex Hospital, London WIN SAA.

Received for publication 31 August 1987.

drainage procedures or partial pancreatectomies. Inthe patient with intractable pancreatic pain the lesseroperative procedures have usually been tried buthave failed. This type of patient is usually on highdoses of narcotic analgesics but still incapacitated byunremitting pain; there is little to offer than totalpancreatectomy.

In the management of a benign disease it isappropriate, when considering major ablative resec-tion, to try to minimise the sequelae that may follownon-essential parts of the standard procedure. Partialgastrectomy has been done with total pancreatec-tomy since the earliest days2`; however, there isincreasing evidence that total pancreatectomy ispossible and safe if the stomach, pylorus`7 and(where possible) the duodenum"' are preserved. If

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Totalpancreatectomy for chronic pancreatitis

the patient has not undergone a previous Whipple-type pancreatoduodenectomy the procedure ofchoice performed in this department is the duo-denum preserving total pancreatectomy.`A major criticism of total pancreatectomy is that

the resultant diabetes is labile, difficult to manageand dangerous.` This paper reviews our experiencewith total pancreatectomy and examines the manage-ment of these patients in the long term.

Methods

PATIENTSSince 1979, any patient who had undergone one oftwo types of total pancreatectomy carried out in thishospital (Fig. 1) was under the joint care of aconsultant physician (PBC) and a consultant surgeon(RCGR). During this time a specific follow up clinicwas established in conjunction with a consultantphysician responsible for diabetic care (ABK). Apartfrom regular review the patients had open access tothis clinic if they had problems.Two main types of operation were done; the

standard total pancreatectomy and the duodenumpreserving total pancreatectomy. In the former astandard Whipple type procedure was carried outremoving the antrum, pylorus, duodenum and all theremaining pancreas. In the latter the stomach,pylorus and duodenum were preserved but all thepancreas was removed.9

In these 29 patients 26 previous pancreatic resec-

tions had been performed.Twenty seven of the 29 patients described attend

regularly and have been seen in the two monthsbefore the preparation date of this manuscript(October, 1986).Two patients are not included in the follow up

data: one patient died two days after surgery; onepatient has been lost to follow up, but a report in

November 1985 stated that he was alive four yearsafter total pancreatectomy.

Figure Diagrammatic representation of the two types ofpancreatic operation carried out.

Three patients, whose management has been ham-pered by major psychological problems have beenexcluded: one patient has proven hypoglycaemiaartefacta; one patient refuses to eat; one patient eatsbut is thought to induce vomiting.These patients represent failure of patient selec-

tion rather than of operative technique. They areexcluded from analysis in this series as their insulinrequirement, body weight and enzyme replacementare not representative of a 'normal' postoperativesubject.The assessment of the diabetic control was based

on the clinical and biochemical review on each clinicvisit. Three parameters were derived for the purposeof group comparisons: (a) percentage ideal bodyweight (%IBW) - the ideal body weight was takenfrom each patient's height and sex, assuming amedium frame size '2; the weight recorded at the mostrecent clinic visit was expressed as a percentage ofthis ideal body weight. This was considered to be acrude index of nutritional status. (b) Insulin require-ment/kg/24 hours (IR) - the daily dose of insulinrecorded at the most recent visit, was expressed inunits per kg body weight. (c) The mean glycaemiccontrol (HbAl) - all the values of the HbAlc werenoted, where possible for the preceding 12 months.Each total pancreatectomy patient was matched

for age and sex with a non-surgical insulin dependentpatient from the diabetic clinic. The three parameterswere calculated for the controls; these were com-pared using a Mann-Whitney test in the groups: (1)all pancreatectomies versus controls; (2) standardpancreatectomies versus controls; (3) duodenumpreserving pancreatectomies versus controls.The incidence of severe and moderate hypogly-

caemic episodes was noted for patients and controls:a severe episode being one in which the patient isadmitted to hospital unconscious, a moderateepisode being one in which someone else has tointervene in order to abort the attack but the patientdoes not require admission.

Results

Between 1979 and the 31 May 1986, 259 operativepancreatic procedures were carried out for benigndisease at the Middlesex Hospital. Twenty eight totalpancreatectomies were done for chronic pancreatitisand one for acute pancreatitis. Total pancreatectomytherefore comprised only 112% of all pancreaticprocedures for benign disease.There was one death (mortality=3.4%): this was

in the case where surgery was performed for fulmi-nant acute pancreatitis. A 23 year old woman, who asa child had had surgical correction of Fallot's tetra-logy, developed acute pancreatitis in the remnant

Standard total pancreatectomy Duodenum preserving total\%//$1 pancreatectomy

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Linehan, Lambert, Brown, Kurtz, Cotton, and Russell

Table 1 Age at operation and follow up experience

Patients Median age at operation (range)

14 Women 390(years (1 9-50)15 Men 34 0 years (21-45)1 death (operative mortality=3.4%)1 lost to follow up

Totalpancreatecbotnies (n)

Year Stanidard Duodenum-preserving1979 11981 31983 31984 5 51985 91986 3 (1 January, 2 March)

Median follow up=22-0 months (6-89); cumulative experience=60.8 patient years.

Table 2 Age and duration ofdisease by aetiological groups

Age at operation Duration in yearsAetiology ti Mediani (range) Median (range)

Idiopathic 9 38 (21-46) 8 (2-15)P divisum 9 40 (23-50) 11 (3-35)Alcohol 8 36 (23-45) 3 (2-13)Congenital 1 19 17Trauma 1 33 14latrogenic 1 38 7

after a pancreatoduodenectomy for chronic pan-creatitis. Supportive treatment failed and she under-went an emergency completion pancreatectomy. Shedied two days postoperatively of adult respiratorydistress syndrome.Table 1 summarises the age at operation of the 29

patients and follow up experience of 27. One patientlost to follow up is known to be alive. No patient hasbeen followed up less than six months.

AETIO LOGYPostulated aetiologies are listed in Table 2 with themedian age at operation and median duration ofdisease before total pancreatectomy.The congenital case presented with jaundice at the

age of 2 years and was found to have a choledochalcyst which was drained. At the age of 8 she developedpancreatitis and by the age of 19 had undergoneanother three major pancreatobiliary surgical pro-cedures by which time she had end stage chronicpancreatitis requiring 2400 mg pethidine/day. Thetraumatic case arose from blunt abdominal injuryduring a football match in which the pancreas was

transected by compression against the spine; he wasalso noted to have pancreas divisum. The iatrogenic

case had a biliary operation carried out abroad for abenign tumour of the gall bladder, this was followedby the onset of her pancreatitis and therefore we mustconsider the operation to have been the likely cause.We do not know the exact nature of the biliarysurgery in this case.

PREVIOUS PROCEDURESTables 3 and 4 list the numbers of non-operative andoperative procedures, respectively, carried out onthese patients before the total pancreatectomy. InTable 3, nerve block includes one epidural for shortterm relief and seven coeliac plexus blocks. The threeendoscopic accessory sphincteroplasties were donebefore we abandoned this procedure because of itslack of benefit and high technical failure rate. InTable 4 the bypasses include biliary and gastrointes-tinal bypasses. Six of the 11 drainage proceduresundertaken in the pancreas divisum group wereoperative accessory sphincteroplasties. In none ofthe patients was total pancreatectomy the first opera-tive procedure.Not all of these 66 previous operative procedures

had been performed in this department.

PREOPERATIVE DIABETIC STATUSAt the time of total pancreatectomy 19 patients were

Table 3 Non operative procedures before totalpancreatectomy

Nphinicterototnies EndoscopicNerve

Aetiology ni blocks Accessory Major Duct ablation

Idiopathic 9 5 1 1P divisum 9 3Alcohol 8 3CongenitalTrauma 1latrogenic 1

Total number of non-operative procedures= 14.

Table 4 Operative procedures before total pancreatectomy

PanicreaticLaparo-

Aetiology 0i tovny C/ole Bypass Resection Drainiage

Idiopathic 9 1 4 1 8 2P divisum 9 1 6 1 1Alcohol 8 4 4 1 7 lCongenital 2 2 2Trauma 1 1 1 2 1latrogenic I I lAll patients 29 5 11 7 26 17

Total number of operative procedures=66.

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not diabetic; seven were insulin dependent, two on

oral hypoglycaemics and one on diet control alone.

INDICATION FOR SURGERYNo patient underwent total pancreatectomy untilprolonged and repeated periods of inpatient andoutpatient therapy had failed. The diagnosis of allpatients was reviewed by a physician before referralfor total pancreatectomy and frequently independentopinions were sort. All patients were counselledabout the diabetes and patients in the latter half ofthe series spoke to patients who had had such an

operation. The authors were aware, as a result ofultrasound imaging, that the pancreas was not grosslyabnormal in some patients; in these subjects thegreatest care was taken to exclude alternative path-ology, and only to undertake surgery as the lastresort.Twenty seven of the total pancreatectomies were

carried out for relief of pain. The one case done forfulminant pancreatitis has already been described.One patient who had previously undergone a distalpancreatectomy for chronic pancreatitis, developedfurther pancreatitis in the head causing biliary ob-struction and cholangitis; he had a completion pan-createctomy undertaken as he was already insulindependent and required enzyme replacements.

PROCEDURES CARRIED OUT

The 29 cases comprised 12 standard pancreatec-tomies (pancreatoduodenectomy and antrectomy)and 17 duodenum preserving total pancreatectomies.(Fig. 1)

EARLY COMPLICATIONS

Ten of the 28 surviving patients had no early com-plications after surgery. One patient had a pneumo-thorax secondary to an attempt at subclavian vein

cannulation for parenteral nutrition. One patientdeveloped a psychosis, presumably from alcoholwithdrawal. One patient had a wound haematomawhich discharged spontaneously. One patient wasfound to be anaemic and was transfused five dayspostoperatively; this was thought to be because ofinadequate peroperative replacement.The major problem was with sepsis. One patient

had a urinary tract infection, two had wound infec-tions and six had chest infections. Four patients hadcentral (feeding) line sepsis which in three causedsepticaemia.Four patients had complications specific to duo-

denum preserving pancreatectomy. One patient wasnoted to be draining bile postoperatively presumablyas a result of unrecognised bile duct damage, thissettled spontaneously; he became the first patientwith a late biliary stricture. One patient had a bout of

haematemesis and melaena for which on endoscopyno cause could be found; this settled on conservativemanagement and was thought to be caused bybleeding from the duodenum. The last two patients inthis series to undergo pancreatectomy (in Februaryand March 1986) developed leaks from the pan-creatic duct stump, one was accompanied by signific-ant intra-abdominal bleeding and required ultra-sound guided drainage; the other stump leak drainedthrough the drains left at operation, requiring nointervention. Both the leaks stopped spontaneouslywithin 21 days and the tracks have remained healedsince. Four subsequent patients not included in thisseries because of short follow up have had noduodenal complication.Four patients initially had difficulty with stabilisa-

tion of diabetes in the immediate postoperativeperiod: of these, one has since been lost to follow up,one is now known to have hypoglycaemia artifactaalthough this was not the case in the immediatepostoperative period and two now have no problemswith diabetic control despite full time employmentinvolving shiftwork.Two patients developed a recurrence of their usual

pain before discharge; this settled spontaneously.

POSTOPERATIVE STAY IN HOSPITALThe median postoperative stay for the standard totalpancreatectomies was 21 days (range=13-98) andfor duodenum preserving total pancreatectomies was31 days (range= 17-49). The longer hospital stay ismore related to the recent extra care with diabeticeducation, and attempt to wean off all analgesicsbefore leaving hospital.

Table 5 Readmissions

Total days in hospital

AdnissionsIpatient Median (Range)

All patients 13 (2-115)0 (n= 1())1 (n=8) 8 (2-30)2 (n=4) 12-5 (7-38)3 (n=5) 36 (13-115)

Indications for admissioon t

Pain and weight loss+ diarrhoea 7Pain and vomiting (no cause found) 6Pain alone 5Diabetic instability 3Vomiting and diarrhoea 2Severe hypoglycaemia 2Biliary reconstruction 2Hypoglycaemia artefacta 1Drug dependency 1Tubogram (elective admission) 1Laparotomy for obstruction (adhesions) 1

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HISTOLOGYIn two cases the pancreas showed acute pancreatitis,one with abscess formation; these were the only twocases in which the indication for total pancreatec-tomy was other than pain. In 25 cases the removedpancreas showed chronic pancreatitis, but in three itwas only mild. In one case the pancreas showed smalladenomatous nodules whose significance was inde-terminate but no other abnormality. In one case thepancreas was within normal limits, but no otherabnormality has been found on subsequent followup, and at one year the progress of the patient was

good without pain.

SUBSEQUENT READMISSIONS

Seventeen patients have required readmission, thetotal number of readmissions for the group was 31.One of these admissions was planned for a post-operative tubogram, the remaining 30 were for themanagement of problems. The indications and num-

bers of admissions are given in Table 5 with medianand cumulative duration of stay.

LATE NON-DIABETIC COMPLICATIONSOf the 27 patients followed up there were only twopatients with a late complication directly attributableto the procedure other than hypoglycaemia: both hadrecurrent cholangitis after a duodenum preservingtotal pancreatectomy, secondary to a biliary stric-ture. This required biliary reconstruction six monthsafter the pancreatectomy in one case, done 10months ago; he remains well and free from cholangi-tis. The other case was managed by the endoscopicinsertion of stents less than three months ago.

POSTOPERATIVE DIABETIC STATUS

The patients are all managed by 'normal' - that is,twice daily injection of a combination of rapidlyabsorbed and intermediate insulins, with the excep-tion of two patients who are controlled using an

insulin pump. One of these patients was in the'anorexic' group and one was a young fit man.

Patients routinely monitor their blood glucose withreagent strips and also tested their urine - thusassessing possible calorie loss.One patient who has been insulin dependent since

1977 and had a total pancreatectomy done in 1983 hasperipheral neuropathy; this was only represented byloss of the ankle jerks. One patient who had onlybeen diabetic since total pancreatectomy in 1984 hadpossible peripheral neuropathy, the diagnosis com-

plicated by carpal tunnel syndrome. Neither of thesepatients had any history of alcohol abuse.There were no other longterm complications of

diabetes but the follow up period was too short, evenfor our earliest case, to draw any conclusions. The

Table 6 Hypoglycaemic episodes in the pancreatectomygroups and controls

Hvpogtycaemnic episodes

Moderate Severe

Standard totalpancreatectomy (n = 10) 5 (3*)

Duodenal preservingpancreatectomy (n = 17) 2 2 (1*)

Diabetic controls (n =27) 1

* During periods of severe malabsorption.

frequency of hypoglycaemic episodes is tabulated inTable 6. The standard total pancreatectomy groupappeared to have a high number of severe hypo-glycaemic episodes compared with the controls,however, three of these episodes occurred very earlyon when the patients had marked diarrhoea as aresult of pancreatic insufficiency. Although mildhypoglycaemic episodes are not routinely recordedby the patients our impression is that these are morefrequent if episodes of diarrhoea and malabsorptionoccur.Comparisons of the different groups and diabetic

controls are summarised in Table 7. There is asignificant difference between the whole total pan-createctomy group and the diabetic controls, how-ever, when the two different operative proceduregroups are compared independently with theirrespective controls a significant difference is shownbetween the standard pancreatectomy group and thediabetic controls for all three parameters. There wasno significant difference between the duodenumpreserving pancreatectomy group and the controlsfor any of the three parameters compared.

PANCREATIC ENZYME REPIACEMENT THERAPYThe status of the patients with respect to pancreaticenzyme replacement therapy is summarised in Table8. Of the 24 patients included in this part of the study,we do not have adequate records on two, 18 areon stable doses of enzyme replacement with nodiarrhoea (up to four bowel actions per day), six areunstable and are currently altering their enzymereplacement therapy. Of the six who are unstable onepatient is thought to have the dumping syndromeafter a standard total pancreatectomy but has refusedto have a dumping provocation test, and three seemto be resistant to all the currently available prepara-tions despite high doses and H2 blockers.

Pancreatic insufficiency has a relationship withdiabetic management. Of the eight patients who hadhad severe hypoglycaemic episodes four of theseoccurred at times when the patients had diarrhoea.

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Table 7 Comparisons ofpancreatectomy group.s and controls

11lBW Unaitskg124 hr HbAl1i Mediani (ranige) Mediani (range) Mediani (rtatnge)

All 24 100(7 (748 -138X2) 0.55 (0.33-081) 10.3 (6.7-14.8)Controls 24 1110 (95.1)0-1352) (061 (0.41-1-01) 98 (68-14.2)p 0(01 (028 0(68

Standard 10 8X97(748-X110.4) 0(49 (0.32- 071) 11.2(8.6-14-8)Controls 10 1156 (99.3-125 7) 0.64 (0.46- 088) 10.0 (6.7-14.0)p 0(004 0(024 (0((3

DPTI1 14 1019 (80.9-138-2) 0.66 (0.35-081) 10()(68-X11-7)Controls 14 1097 (95.0-135 2) 0(61 (0(41-1.01) 92 (68-X14-2)p (0.44 0.67 (019

DPTP=duodenum-preserving total pancreatectomy group.

Four patients who had diarrhoea and have since hadthe pancreatic enzyme replacement altered to controlthis, have volunteered the fact that their diabetes hadbecome simpler to control and that their insulinrequirement had increased.

Pancreatic insufficiency was associated with pain oftwo types in some of these patients. One type of painwas a colicky right sided pain similar to that seen inthe irritable bowel syndrome. The other type of painwas similar to that of chronic pancreatitis before totalpancreatectomy but of lesser severity. In somepatients, both types of pain responded to correctionof pancreatic insufficiency but often took two to fourweeks to do so.

WORKOf the 27 patients seen regularly in the clinic eight arein full time employment, two of whom are policeofficers on shift work. Two are well and seekingwork. Two are in full time education. Three arehousewives not seeking work but are well. Ten are

Table 8 Pancreatic enzyme replacement therapy. Eighteenpatients stable (up to 2 bowel actions per day)

IDailv do.se(I1snmtber of tialet.s or (cap.iules)

Etizvntle preparati.oni ii Mediatn (Ratnge)

Pancrex V Forte 4 62.5 (30-115()(Paines and Byrne)Creon 11 5(0 (15-80)(Duphar)Pancrease 3 6(1 (25-X8))(Johnson and Johnson)

Six patients not stabilised; two patients inadequate records.

not working and not likely ever to do so again. Two ofthe patients operated on this year are not fit, one hasrecently had endoscopic insertion of stents for abiliary stricture and the other has persistent pain aftera leak from the duodenum.

Discussion

In this series we have described 29 patients who havehad total pancreatectomy for intractable pancreaticpain. We do not suggest that this procedure should beundertaken lightly nor do we recommend that it beundertaken in a unit which is not prepared to followup these patients closely and readmit them whennecessary.The absolute indications for this procedure in

chronic pancreatitis are undefined, but in a patientwho has failed all other types of therapy or surgeryand who is on a high dose of regular opiates, there islittle else to offer. It has been our experience thatthere is a group who can be predicted, from theoutset, to do badly from any procedure short of totalpancreatectomy- those who have idiopathic pan-creatitis or pancreatitis caused by pancreas divisum,who have an inordinate amount of pain associatedwith only minor diffuse fibrotic changes in thepancreas. Possibly in this very small group there willbe a place, in the future, for earlier aggressivesurgery: this will not be our recommendation untilfurther evidence is available. Our experience withalcoholic pancreatitis is that provided the patientstops drinking after an appropriate partial resectionor drainage the outlook is good, but those who havechronic pancreatitis of non-alcoholic origin due todiffuse disease do less well with partial resection. Nopatient is accepted for total pancreatectomy if he/shecontinues to take alcohol, whatever the aetiology ofthe pancreatitis.

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The large proportion of patients whose disease wasattributed to pancreas divisum reflects the belief ofthe authors'3 that this congenital variant can causepancreatitis. Although total pancreatectomy doesrelieve the pain of end stage chronic pancreatitis wehave encountered a difficult problem of recurrentpain in 10, identical in nature to that which thepatient was suffering before the operation. This isnever as severe, as frequent or as long lasting as thepreoperative pain but is often accompanied by vomit-ing. Investigation invariably reveals normal liverfunction tests, endoscopy and a ndrmal ultrasound ofthe pancreatic bed. These patients may need admis-sion for supervision in weaning off analgesics. We canonly speculate as to what the cause of the pain may beas there has never been a proven cause. One causemay be of incorrect diagnosis leading to an in-appropriate operation, however, we do not believethis to be the case. Another cause may be a 'phantom'pain similar to that seen after limb amputation.Whatever the cause, the bouts of pain recede withtime, and our experience is that patients are pain freewithin three years of the operation.The histological examination of the pancreatic

tissue removed did not confirm the clinical diagnosisin five cases, indeed in one case the histology wasnormal despite indicative preoperative investiga-tions; this patient is currently doing well without anyanalgesia although it is only eight months after herresection and therefore a placebo effect cannot beexcluded. The three cases who had only mild pan-creatitis are difficult to assess, one has recurrent painand pethidine addiction, one is a heroin addictmanaging very well on reducing doses of methadone(remaining pain free) and one is the patient who hashypoglycaemia artefacta but is pain free.The most common indication for readmission was

pain with or without vomiting and diarrhoea; this hasbeen discussed above. In three patients admissionwas required for stabilisation of diabetes early afterpancreatectomy; in all three this was relatedto poorly controlled pancreatic insufficiency. It isapparent from Table 5 that a number of patients dorequire readmission for a variety of reasons (al-though 10 have had no readmissions), the longtermmanagement of these patients commits the clinician tothe likelihood of such admissions.

Previous reports have condemned total pancrea-tectomy as a dangerous procedure, not only fromoperative mortality, but also from late risks of fatalhypoglycaemia." It is interesting to see that in ourgroup of 24 patients who are still seen regularly, eventhough eight are exalcoholics and one of these is adrug addict, the management of the diabetes is not aproblem. One may hypothesise that on psychologicalgrounds these people are better equipped to face up

to diabetes as they made an elective decision toexchange their pain for diabetes whereas a normaldiabetic has no such choice.Our follow up experience of these patients, and

indeed those with partial pancreatectomies, suggeststhat the problems that arise with diabetic controlstem from pancreatic exocrine insufficiency ratherthan any intrinsic instability in the diabetes or thepsychology of the patient.Comparison of the two pancreatectomy groups

with the diabetic controls shows that the standardtotal pancreatectomy group differs from the controlsin that they are lighter, require less insulin perkilogram body weight and that their mean glycaemiccontrol is worse. It is worthy of note that theduodenum preserving total pancreatectomy group donot differ significantly from the controls for any ofthese measurements.We have been increasing the dosage of enzyme

replacement in these patients to try to avoid anydiarrhoea: this is not always possible with thestrength of lipase available in the current prepara-tions despite enteric coating to avoid deactivation bygastric acid. From Table 8 it may be seen that one ofour patients takes 150 tablets per day. Since westarted on this policy many patients have commentedthat not only has their diarrhoea improved, but alsotheir diabetes has been easier to control and hasneeded a higher dose of insulin. The mechanism wepropose is simple: with the rapid intestinal transitsecondary to pancreatic insufficiency the absorptionof glucose is very unpredictable; the uptake will varyfrom meal to meal depending on the fat content.There is another factor that can complicate absorp-tion, the presence of the dumping syndrome after astandard pancreatectomy with the standard partialgastrectomy. Previous studies suggest this problem isuncommon (10-13%) and rarely alters manage-ment. 4Our current practice is to try to use only three

pancreatic enzyme replacement products, a standardenteric coated tablet preparation (Pancrex V Forte,Paines and Byrne), an enteric coated granular prep-aration (Creon, Duphar Laboratories) and an entericcoated microspheric preparation (Pancrease, John-son and Johnson). We usually start our patients onthe standard preparation (as it is cheaper) andincrease the dose until diarrhoea is controlled. If wecannot control their diarrhoea with 'reasonable'doses we substitute the enteric coated preparation atthe same dose; if the diarrhoea is controlled we thenreduce the dose in steps every three to four days or ifthe patient still has diarrhoea increase the dose untilthis is controlled. A 'reasonable' dose is determinedby the patient as they have to take all the tablets orcapsules before each meal or snack. We have also

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Totalpancreatectomy for chronic pancreatitis 365

changed some of our old patients to the entericcoated preparation if they were taking a very highdose or still had diarrhoea.

Psychological factors have an important role inpatients with end stage pancreatitis as these patientsall have suffered years of chronic pain; additionallymany of the patients have problems of dependency toanalgesics and/or alcohol. The role of psychologicalfactors in the postoperative diabetic management inthis group has not yet been investigated; however, inthree patients there has been an obvious problemdirectly affecting diabetic management in one (hypo-glycaemia artefacta) and in two, problems witheating ('anorexia') causing indirect difficulties ofdiabetic management. We have not had the oppor-tunity to submit our patients to formal preoperativepsychological assessment but this would be desirable.In three patients (at least) the poor result of totalpancreatectomy possibly could have been predictedpreoperatively if there had been an appropriatemethod of assessment.

This survey of an experience with total pancreatec-tomy has tried to present the outcome after theoperation. To limit observer bias, those who advisedoperation (PBC, RCGR) were not involved with thedata collection (ML, IPL) or the diabetic manage-ment (ABK, DCB). The success of the procedure islimited by the inevitable deficiencies which thatoperation creates, and the outcome appears largelyrelated to the ability of the individual to control theprevious drug dependency, the diabetes and theenzyme deficiency. Personality thus becomes a majorfactor in outcome, and in many patients great supportand help is required during the early years followingtotal resection. Our first patient took five years tostabilise since when she has been living normally.Our conclusion in what is a young group of patients isthat prolonged care is necessary, and the end resultcan only be assessed at the five year period.

This work forms part of a thesis submitted to theUniversity of London for the degree of MS.

We are grateful to Dr W Lees and the W H Collinsx-ray diagnosis department and to the CourtauldInstitute for their help in the investigation of thepatients. We are grateful to Dr J Rode and the Bland

Sutton Institute of Pathology for their painstakinghistological studies. We would like to thank Mr SNightingale and the department of Medical photo-graphy for the illustration and Dr P Whitfield for hisstatistical advice.

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