Department of Surgery, Emory University, Atlanta, GA.
Department of Surgery, Emory University, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA.
J Am Coll Surg. 2019 Apr;228(4):400-412.e2. doi: 10.1016/j.jamcollsurg.2018.12.042. Epub 2019 Jan 26.
Limited literature is available on the development of impaired glucose tolerance and diabetes mellitus after pancreaticoduodenectomy. The primary aim was to define the diabetic phenotype and correlate preoperative glycemic laboratory results to new-onset diabetes after pancreaticoduodenectomy.
In this prospective study, perioperative fasting and postprandial (oral glucose tolerance test) plasma glucose, glycated hemoglobin, insulin, and c-peptide were measured in consecutive patients undergoing pancreaticoduodenectomy by the senior author from 2006 to 2017. American Diabetes Association definitions were used for glycemic classifications. Multivariate risk factor analysis was performed.
Of 774 identified patients, 371 diabetics were excluded and 403 patients were included: 167 and 236 were preoperatively classified as nondiabetic and prediabetic, respectively. The incidence rates of diabetes at 120 months post pancreaticoduodenectomy were 9.0% (nondiabetics), 22.0% (prediabetics), and 16.6% (overall). Patients in whom diabetes developed demonstrated a 3-fold larger difference between oral glucose tolerance test and fasting glucose (Δ), and 2-fold larger Δinsulin and Δc-peptide values. Tiered multivariate analysis identified glycated hemoglobin >5.4% with a relative risk (RR) of 2.944 (p = 0.047) as an independent predictor of impaired glucose tolerance and diabetes mellitus. Analysis of patients stratified by preoperative classification identified fasting glucose >95 mg/dL (nondiabetics, RR 1.925; p = 0.002), and glycated hemoglobin ≥5.4% (prediabetics, RR 3.125; p = 0.040) as independent risk factors for diabetes. Compared with nondiabetics, prediabetics classified by any laboratory results demonstrated an RR of 2.471 (p = 0.001) for diabetes developing postoperatively. There was no association between primary pathology, advancing age, or BMI and increased risk of diabetes development.
Diabetes will develop after pancreaticoduodenectomy in approximately 16.6% of patients. A preoperative glycated hemoglobin >5.4% independently predicts new-onset diabetes. Pre- and postoperative endocrine analysis remains paramount for proper patient risk stratification.
有关胰十二指肠切除术后糖耐量受损和糖尿病发展的文献有限。主要目的是确定糖尿病表型，并将术前血糖实验室结果与胰十二指肠切除术后新发糖尿病相关联。
在这项前瞻性研究中，作者对 2006 年至 2017 年间连续接受胰十二指肠切除术的患者进行了围手术期空腹和餐后（口服葡萄糖耐量试验）血浆葡萄糖、糖化血红蛋白、胰岛素和 C 肽检测。采用美国糖尿病协会的血糖分类标准进行了多变量危险因素分析。
在确定的 774 例患者中，排除了 371 例糖尿病患者，纳入了 403 例患者：术前分别有 167 例和 236 例被归类为非糖尿病和糖尿病前期。胰十二指肠切除术后 120 个月时糖尿病的发生率分别为 9.0%（非糖尿病患者）、22.0%（糖尿病前期患者）和 16.6%（总体）。发生糖尿病的患者口服葡萄糖耐量试验和空腹血糖的差值更大（Δ），胰岛素和 C 肽的差值也更大。分层多变量分析发现，糖化血红蛋白>5.4%（RR 2.944，p=0.047）是糖耐量受损和糖尿病的独立预测因子。根据术前分类对患者进行分层分析发现，空腹血糖>95mg/dL（非糖尿病患者，RR 1.925；p=0.002）和糖化血红蛋白≥5.4%（糖尿病前期患者，RR 3.125；p=0.040）是糖尿病的独立危险因素。与非糖尿病患者相比，根据任何实验室结果分类的糖尿病前期患者术后发生糖尿病的 RR 为 2.471（p=0.001）。主要病理、年龄增长和 BMI 与糖尿病发生风险增加无关。
胰十二指肠切除术后约有 16.6%的患者会发生糖尿病。术前糖化血红蛋白>5.4%可独立预测新发糖尿病。术前和术后内分泌分析仍然是正确的患者风险分层的关键。
