Postoperative Blood Glucose Management After Total Pancreatectomy Combined With Total Gastrectomy And Autologous Small Intestine Transplantation

Summary

This article reports a case of glycemic management following total pancreatectomy combined with autologous small intestine transplantation. The approach utilized a continuous glucose monitoring system (CGMS) in conjunction with dietary management, achieving effective control of the patient's blood glucose levels.

Abstract

Total pancreatectomy and total gastrectomy combined with autologous small intestine transplantation is a rarely reported surgical approach in the treatment of pancreatic cancer. This article summarizes the nursing experience of blood glucose management in a patient who underwent total pancreatectomy, total gastrectomy, and autologous small intestine transplantation. Because of marked postoperative glycemic instability and impaired intestinal absorption, personalized blood glucose management targets and proactive insulin pump therapy were implemented to address the unique characteristics of postoperative blood glucose metabolism and the effect of associated complications on blood glucose levels. Additionally, family involvement in diarrhea and dietary management, as well as comprehensive follow-up care after discharge, were integrated. Postoperatively, the patient did not experience ketoacidosis or severe hypoglycemia, with a coefficient of variation (CV) ranging from 24.5% to 31.2%. The patient recovered and was discharged on postoperative day (POD) 68. One year of follow-up revealed stable blood glucose levels without severe hypoglycemia or hyperglycemia.

Introduction

Fluctuation in blood glucose levels is characterized by unstable blood glucose levels between glycemic peaks and nadirs. Its evaluation should encompass two primary aspects: amplitude (reflecting the degree of blood glucose deviation) and time (reflecting the frequency of blood glucose changes). Key indicators include standard deviation (SD), diurnal fluctuation, coefficient of variation (CV), and mean amplitude of glycemic excursions (MAGE)¹. A CV target value of ≤33% is calculated as SD / mean blood glucose (MBG) × 100%. Given its independence from average blood glucose levels, straightforward calculation method, and ease of clinical application, CV is recommended as the preferred indicator². Studies have indicated that for each 10% increase in postoperative CV, patients’ mortality increases by 26%. Furthermore, the risk of infection increases 3.5-fold when CV ≥ 30%³. Pancreatic cancer, which is highly malignant and often diagnosed late, has a low radical resection rate, with only 15%–20% of patients being eligible for surgery under conventional treatment strategies⁴. Tumor involvement of the superior mesenteric artery (SMA) is a primary factor hindering radical resection⁵. Radical resection combined with autologous small intestine transplantation has been used to address unreconstructable or poorly reconstructable SMA involvement in selected patients with pancreatic cancer^6,7. In such cases, intestinal resection and reconstruction may be required because of tumor involvement of the mesenteric root and the resulting difficulty in preserving adequate intestinal perfusion. Consequently, postoperative management is more complex than that after conventional pancreatic resection, as intestinal dysfunction, diarrhea, and unstable nutrient absorption may further aggravate glycemic fluctuation^8,9.

Total pancreatectomy may be required when the tumor extensively involves the pancreas and major peripancreatic vessels. Pancreatogenic diabetes occurs after total pancreatectomy because complete pancreatic resection results in loss of endogenous insulin secretion¹⁰. This endocrine insufficiency may increase sensitivity to exogenous insulin and contribute to severe glucose metabolism dysregulation, marked glycemic variability, and impaired quality of life^10,11. Currently, combined autologous small intestine transplantation is rarely used for pancreatic cancer^12,13, and its implications for postoperative nursing and metabolic management have been insufficiently described. In particular, the coexistence of absolute insulin deficiency, unstable intestinal absorption, and diarrhea creates unique challenges for postoperative glycemic management. Here, the postoperative glycemic management of a patient with pancreatic cancer who underwent total pancreatectomy combined with autologous small intestine transplantation is reported, with particular attention to glycemic variability control, diarrhea, nutritional management, and multidisciplinary nursing care.

Case presentation:

A 68-year-old female patient, measuring 163 cm in height and weighing 56 kg at admission, presented with a 2-month history of pancreatic cancer. She was admitted to the hospital for further surgical management after completing six cycles of neoadjuvant modified FOLFIRINOX (fluorouracil, irinotecan, leucovorin, oxaliplatin) chemotherapy. At admission, the patient was generally stable. No relevant family history of pancreatic or other hereditary malignant disease was documented, and no remarkable social history directly related to the present illness was reported. Notably, she had no prior history of diabetes, with an admission random blood glucose level of 6.2 mmol/L and a glycated hemoglobin level of 6.0%. Preoperative assessment suggested a pancreatic head malignancy with vascular involvement. Imaging findings indicated tumor invasion of the superior mesenteric artery (SMA) and adjacent major peripancreatic vessels, which were consistent with the subsequent intraoperative findings. The patient completed six cycles of neoadjuvant chemotherapy before surgical evaluation, with radiographic disease control achieved and no treatment-limiting toxicity or interruption of the treatment course.

Diagnosis, assessment, and plan:

Following a comprehensive preoperative evaluation, surgery was performed under general anesthesia on June 30. Intraoperatively, the tumor was located in the pancreatic head and infiltrated the SMA, celiac trunk, common hepatic artery, superior mesenteric vein, and left renal vein. Several varicose veins were also observed in the hepatic hilum and around the pancreatic head and gastric wall. These findings indicated extensive involvement of the mesenteric root and major peripancreatic vessels, making conventional resection insufficient to achieve radical tumor removal while preserving adequate intestinal perfusion. Therefore, the patient underwent total pancreatectomy, total gastrectomy, and autologous small intestine transplantation.

Following surgery, the patient exhibited a minimum blood glucose level of 2.7 mmol/L, a maximum blood glucose excursion of 15.6 mmol/L, and a CV of 60% on the first postoperative day (POD). Subsequently, the endocrinology and surgical teams collaboratively established a blood glucose target of 8-12 mmol/L. A 40 U insulin + 40 mL normal saline micropump infusion was initiated for maintenance. Blood glucose was prospectively controlled using an insulin pump, with monitoring conducted every 1–2 h.

Intervention Time	Nutritional Approach	Intervention Measures
POD 1-5	Total parenteral nutrition	Regular insulin 50 U + 50 mL of normal saline via micro-pump intravenous infusion; prospective insulin pump management
POD 6	Parenteral nutrition combined with enteral nutrition	Regular insulin 50 U + 50 mL of normal saline via micro-pump intravenous infusion; prospective insulin pump management; family involvement in the management of diarrhea
POD 8	Oral intake	Regular insulin 50 U + 50 mL of normal saline via micro-pump intravenous infusion; prospective insulin pump management; CGM combined with family involvement in the management of diarrhea and diet
POD 16	Oral intake	CGM combined with subcutaneous insulin injection

Table 1: Intervention schedule. The table summarizes the nutritional approach and corresponding intervention measures at different postoperative time points. The columns present the intervention time, nutritional approach, and intervention measures, including insulin infusion, prospective insulin pump adjustment, CGM-guided monitoring, and family-assisted diarrhea and dietary management. Abbreviations: POD, postoperative day; CGM, continuous glucose monitoring; U, unit.

Protocol

This study was approved by the Ethics Committee of The First Affiliated Hospital, Zhejiang University School of Medicine (Approval No.: 2025B-0085). The study adhered to the ethical standards established by the hospital as well as the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The reagents and the equipment used are listed in the Table of Materials.

1. Surgical procedure

1. Preoperative preparation and tumor assessment
   1. The tumor location in the pancreatic head and its invasion into adjacent vascular structures were evaluated.
   2. The involvement of the superior mesenteric artery, celiac trunk, common hepatic artery, and superior mesenteric vein was assessed.
   3. Varices around the pancreatic head and gastric wall were identified prior to surgical intervention.
2. Surgical execution
   1. Total pancreatectomy and total gastrectomy were performed under general anesthesia.
   2. Autologous small intestine transplantation was conducted during the same operative session.
   3. All vascular invasions, including left renal vein and hepatic hilum involvement, were documented.
3. Immediate postoperative monitoring
   1. Metabolic monitoring was initiated immediately following surgical closure.
   2. Baseline glucose parameters were established for subsequent glycemic management.
   3. Hemodynamic stability and initial recovery parameters were documented.

2. Glycemic management

1. Intravenous insulin preparation
   1. 40 units of regular insulin were diluted in 40 mL of 0.9% normal saline to achieve a concentration of 1 U/mL.
   2. The insulin solution was prepared for continuous intravenous infusion using a micropump.
   3. The concentration was verified, and the syringe was appropriately labeled before administration.
2. Initial insulin dosing procedure
   1. For blood glucose 12.1–16.7 mmol/L, the first dose was set at 0 U, and the initial flow rate was set at 2.0 mL/h.
   2. For blood glucose 16.8–19.9 mmol/L, the first dose was set at 3 U, and the initial flow rate was set at 3.0 mL/h.
   3. For blood glucose ≥20.0 mmol/L, the first dose was set at 6.0 U, and the initial flow rate was set at 6.0 mL/h.
3. Prospective insulin adjustment with parenteral nutrition
   1. The total glucose content in the 2550 mL parenteral nutrition solution (250 g glucose) was calculated.
   2. The infusion rate was maintained at 80 mL/h using an infusion pump, delivering approximately 7.8 g of glucose per hour.
   3. Insulin was administered at a glucose-to-insulin ratio of 5:1, and the flow rate was increased by 1.6–2.0 mL/h from the original insulin pump setting.
4. Individualized nutritional and insulin coordination
   1. Parenteral nutrition was individualized according to the patient's postoperative nutritional requirements.
   2. The insulin infusion regimen was adjusted in parallel with changes in glucose delivery during nutritional support.
   3. Glucose variability was monitored, and the insulin-to-glucose ratio was adjusted as clinically indicated.

3. Glucose monitoring and hypoglycemia management

1. Glucose monitoring procedure
   1. Blood glucose was monitored every 1–2 h during insulin pump therapy.
   2. Continuous glucose monitoring data were obtained from the Continuous glucose monitoring (CGM) system.
   3. Blood glucose ranges and coefficient of variation (CV) values were extracted from monitoring records.
2. Hypoglycemia classification and intervention
   1. Hypoglycemia was managed promptly upon detection according to ADA classification criteria (Grade 1: glucose <3.9 mmol/L and ≥3.0 mmol/L; Grade 2: glucose <3.0 mmol/L; Grade 3: severe event characterized by altered mental and/or physical status requiring assistance for treatment, irrespective of glucose level; Grade 4: unconsciousness or seizures).
   2. Oral glucose supplementation was administered for conscious patients with mild hypoglycemia.
   3. Intravenous glucose supplementation was provided for severe hypoglycemia or when oral intake was contraindicated.
3. Data documentation and analysis
   1. The coefficient of variation (CV) for each 24-h period during hospitalization was calculated as SD/mean × 100%.
   2. Data were compiled from bedside glucose monitoring records, CGM records, and the electronic medical record.
   3. Descriptive analysis of glucose ranges, CV values, and hypoglycemic episodes was performed.

4. Glycemic data assessment

1. Continuous monitoring data extraction
   1. The complete continuous glucose monitoring dataset was obtained from the Continuous glucose monitoring (CGM) system.
   2. Data integrity and completeness were verified for the entire hospitalization period.
   3. Any technical issues or data gaps that could affect analysis were documented.
2. Glycemic variability calculation
   1. The coefficient of variation (CV) for each 24-h period was calculated as SD/mean × 100%.
   2. Patterns of glucose variability across different postoperative days were identified.
   3. CV values were correlated with clinical interventions and nutritional changes.
3. Data source integration
   1. Blood glucose ranges were extracted from bedside glucose monitoring records.
   2. CGM records were compiled for trend analysis and pattern recognition.
   3. Electronic medical records were reviewed for contextual clinical information.
4. Descriptive statistical analysis
   1. Hypoglycemic episodes were summarized by frequency, severity, and temporal distribution.
   2. The relationship between glucose variability and clinical outcomes was analyzed.
   3. All glycemic data were documented in a standardized format for reporting.

5. Diarrhea and nutrition management

1. Enteral nutrition initiation
   1. Postoperative intestinal function was assessed to determine readiness for enteral nutrition.
   2. Enteral nutrition was initiated according to established intestinal tolerance criteria.
   3. The initial enteral feeding volume, rate, and formula composition were documented.
2. Gastrointestinal monitoring
   1. Stool frequency and characteristics were recorded daily.
   2. Intake and output balance were monitored meticulously.
   3. Abdominal distension, tolerance, and gastrointestinal symptoms were assessed.
3. Antidiarrheal treatment adjustment
   1. The antidiarrheal treatment was adjusted according to the patient's diarrhea status.
   2. Medications were titrated based on stool frequency and consistency.
   3. Adverse effects of antidiarrheal medications were monitored.
4. Nutritional strategy optimization
   1. Nutritional support was optimized according to the patient's absorption status.
   2. The parenteral nutrition strategy was re-assessed according to intestinal tolerance and diarrhea status.
   3. The insulin regimen was modified to reflect changes in glucose input and absorption.

6. Pancreatic enzyme replacement

1. Enzyme therapy initiation
   1. Pancreatic enzyme replacement was administered concurrently with enteral nutrition.
   2. The initial dose was determined based on anticipated nutritional intake and enzyme requirements.
   3. The patient was educated on the proper timing of enzyme administration with meals.
2. Dose titration procedure
   1. The enzyme dose was adjusted according to bowel movement frequency.
   2. The dose was titrated based on dietary intake volume and macronutrient composition.
   3. Gastrointestinal tolerance and symptoms were monitored during dose adjustment.
3. Efficacy monitoring
   1. Stool consistency and frequency were assessed as indicators of enzyme adequacy.
   2. Nutritional markers and weight trends were monitored.
   3. Any steatorrhea or malabsorption symptoms were documented.
4. Long-term management planning
   1. Maintenance dosing guidelines were established for discharge planning.
   2. The patient was provided with education on dose adjustment for varying meal sizes.
   3. Follow-up assessments were scheduled for ongoing enzyme optimization.

7. Family-assisted dietary management

1. Continuous glucose monitoring utilization
   1. Continuous glucose monitoring was used to track real-time blood glucose levels.
   2. CGM data access was shared with designated family members.
   3. Alarm settings were established for hypo- and hyperglycemic thresholds.
2. Dietary and activity documentation
   1. Family members were asked to record the patient's nutritional intake accurately.
   2. Meal timing and composition were documented in a standardized log.
   3. Physical activity duration and intensity were recorded concurrently with glucose data.
3. Data analysis and correlation
   1. The effects of food quantity on blood glucose were analyzed based on CGM curves.
   2. The impact of food type on glycemic responses was evaluated.
   3. Dietary records were correlated with glucose patterns to identify individualized trends.
4. Collaborative care planning
   1. Individualized dietary plans were developed jointly with the patient and family.
   2. Insulin regimens were designed to accommodate the patient's lifestyle and preferences.
   3. Education was provided on carbohydrate counting and meal planning principles.

8. Transition to subcutaneous insulin

1. Transition criteria assessment
   1. Glycemic variability trends were evaluated to confirm stability.
   2. Nutritional intake consistency and adequacy were assessed.
   3. Readiness for transition was determined based on predefined metabolic criteria.
2. Subcutaneous insulin initiation
   1. Transition from continuous intravenous insulin infusion to subcutaneous administration was performed.
   2. Subcutaneous insulin was administered before meals and at bedtime.
   3. Initial subcutaneous doses were calculated based on intravenous insulin requirements.
3. Ongoing regimen adjustment
   1. The subcutaneous regimen was continuously adjusted according to glucose monitoring results.
   2. Basal and bolus insulin doses were titrated based on fasting and postprandial glucose.
   3. Hypoglycemia was monitored during the transition period.
4. Discharge insulin planning
   1. An individualized subcutaneous insulin regimen was continued before meals and at bedtime.
   2. Detailed written instructions were provided for home insulin administration.
   3. Protocols for dose adjustment were established, guided by blood glucose records and dietary intake.

9. Discharge education and follow-up

1. Pre-discharge education program
   1. Comprehensive education on blood glucose monitoring techniques was provided.
   2. The patient and family were trained on insulin injection techniques and site rotation.
   3. Education was provided on hypoglycemia recognition, treatment, and prevention strategies.
   4. Instruction was provided on dietary management principles and meal planning.
2. Home care preparation
   1. Education was provided on home care requirements and emergency contacts.
   2. An adequate supply of glucose monitoring equipment and insulin was ensured.
   3. Coordination with home health services was performed if indicated.
3. Post-discharge follow-up procedure
   1. Multidisciplinary follow-up was continued after discharge to support glycemic management.
   2. Initial follow-up appointments were scheduled within 1–2 weeks of discharge.
   3. Recovery progress was monitored, and management strategies were adjusted accordingly.
4. Long-term data collection and outpatient adjustment
   1. The patient and family were instructed to continue glucose recording after discharge.
   2. Diet documentation was maintained to support pattern analysis.
   3. Outpatient insulin adjustment was enabled under follow-up guidance based on recorded data.

Results

Early glycemic outcomes during personalized target setting and prospective insulin pump management

During the early postoperative period, individualized glycemic targets and prospective insulin pump management were implemented to address post-pancreatectomy insulin deficiency, increased sensitivity to exogenous insulin, impaired intestinal function, and unstable glucose absorption^14,15,16

Discussion

Glycemic management after total pancreatectomy combined with autologous small intestine transplantation is particularly challenging because absolute insulin deficiency occurs simultaneously with marked instability in nutrient absorption. Compared with conventional total pancreatectomy, the addition of intestinal resection, reconstruction, and autologous intestinal transplantation may further complicate postoperative care by increasing the risk of diarrhea, impaired absorption, and nutritional instability. In this setting...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
0.9% normal saline (sodium chloride injection)	Baxter	N/A	Used as diluent for insulin infusion. IV insulin with Actrapid may be prepared in 0.9% sodium chloride.
Blood glucometer	Roche	Accu-Chek Guide	Used for bedside capillary blood glucose monitoring.
Continuous glucose monitoring system (Guardian 4 sensor and transmitter)	Medtronic	MMT-7841 (transmitter)	Used for continuous glucose monitoring and CV assessment.
Enteral nutrition formula	Hospital-prepared homogenized diet	N/A	Used for postoperative nutritional support.
Enteral nutrition tube	Kangaroo	N/A	Used for enteral nutrition and pancreatic enzyme administration.
Insulin injection supplies (pen needles / syringes)	BD	N/A	Used for subcutaneous insulin from POD 16 onward.
Insulin micropump / infusion pump	Baxter	Spectrum IQ Infusion System	Used for continuous intravenous insulin infusion and rate adjustment.
Linezolid intravenous infusion	Pfizer	ZYVOX I.V. 2 mg/mL	Glucose-containing IV medication referenced in the manuscript and requiring temporary insulin pump adjustment.
Montmorillonite powder / diosmectite	Ipsen	Smecta 3 g sachet	Used as antidiarrheal medication. Diosmectite/Smecta is commonly supplied as 3 g powder for oral suspension in sachets.
Pancreatic enzyme preparation (20,000 IU)	Viatris	Creon 20000	Used for pancreatic enzyme replacement during enteral nutrition and oral intake. Creon is a pancrelipase product indicated for pancreatic exocrine insufficiency.
Parenteral nutrition solution	Hospital pharmacy compounded PN	N/A	Used from POD 1–5; glucose-containing PN requiring insulin adjustment.
Probiotics	BioGaia	BioGaia Protectis	Used as adjunctive antidiarrheal/gut microbiota support. BioGaia Protectis products contain Lactobacillus reuteri strains.
Regular insulin (human insulin)	Novo Nordisk	Actrapid 100 IU/mL vial	Used for continuous intravenous insulin infusion.
Sodium bicarbonate	Baxter	N/A	Used as diluent for pancreatic enzyme preparation before tube administration.