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 clinic....

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....

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.