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Early Dumping and Reactive Hypoglycemia After Pancreaticoduodenectomy: the Relationship Between Gastric Emptying, Pylorus Preservation and Glycemic Control
Lukas Kazianka*, Emanuel Steiner, Robert Breuer, Franz X. Felberbauer, Klaus Sahora, Josef Friedl, Johannes Miholic
Medical University of Vienna, Vienna, Austria
Background. Dumping and reactive hypoglycemia may accompany rapid gastric emptying after upper gastrointestinal surgery. Prancreaticoduodenectomy(PD) is carried out with pylorus preservation(PPPD) or distal gastrectomy(Whipple procedure). The latter procedure was demonstrated to be followed by accelerated gastric emptying and improved glycemic control when compared to PPPD. Postprandial dumping and hypoglycemia might however ensue. It was the purpose of this study to assess whether signs and symptoms of dumping occur after PD.
Patients and methods. Patients having undergone Whipple's procedure(n=7), PPPD(n=8), and 10 healthy controls were studied. The patients' median age was 65(range: 36-70) years, the male/female ratio was 1.8. There were no significant differences between the operation groups with respect to age, gender and interval since operation. After measuring baseline HbA1c, plasma glucose, insulin, hematocrit(Hct) and Sigstad's dumping score were measured before and 10, 20, 30, 60, 90, 120, 150 and 180 minutes after a 250ml liquid test meal(21g protein, 31g fat, 26g carbohydrates). Variables are presented as median and range, and were tested for significance using Wilcoxon's test.
Results. Three out of seven Whipple patients(43%) and one out of eight PPPD subjects(13%) suffered from postprandial dumping symptoms(Sigstad Score ≥7)[N.S.]. The difference between postprandial and baseline hematocrit(a marker of dumping induced hemoconcentration) was significantly higher in Whipples. Whipple subjects had significantly lower integrated glucose concentrations during the second postprandial hour, when reactive hypoglycemia usually occurs. The HbA1c-concentrations were lower after Whipple PD, as was fasting glucose[N.S.]. Although glycemic control in Whipples was found to be better than in PPPD, glucose tolerance was best in healthy controls.
Comment. As shown in earlier reports, glycemic control after Whipple's procedure is improved when compared to PPPD, probably because of a stimulation of the enteroinsular axis induced by accelerated gastric emptying. The lower decrease of hematocrit in Whipples and the lower glucose concentration during the second postprandial hour may therefore be interpreted as signs of early and late dumping. The favourable fasting glucose and HbA1c levels in Whipple patients suggest a beneficial effect of rapid gastric emptying on long-term glycemic control, which is well known after a variety of gastric operations. The present study demonstrates that despite laboratory signs of early(hematocrit changes) and late dumping(reactive hypoglycemia) can be identified, the patients' symptoms are rather scarce and mild. This study's favourable results are preliminary due to the limited number of cases. Further research on the relationship between mode of operation, gastric emptying and glycemic control after PD is warranted.
Dumping Symptoms and Glycemic Control after PD
| PPPD (n=8) | Whipple (n=7) | Controls (n=10) | p-Value (Whipple vs. PPPD) | | Interval since operation (months) | 48 (8-118) | 12 (2-70) | - | 0.32 | | GIQLI | 102 (63-119) | 124 (73-132) | 140 (129-144) | 0.082 | | Hct30min - Fasting Hemactocrit (%) | -2.4 (-3.9 - -1.7) | -1.1 (-1.9 - 2.3) | -1.9 (-3.6 - 0.7) | 0.002 | | Dumping during test (Sigstad Score ≥7) | 1/8 (13%) | 3/7 (43%) | 0/10 | 0.23 | | Postmeal glucose nadir (mg/dl) | 114 (58-208) | 89 (66-145) | 67 (55-89) | 0.2 | | Fasting glucose (mg/dl) | 105 (80-153) | 89 (82-141) | 82 (69-90) | 0.057 | | HbA1c (%) | 6.2 (4.5-6.8) | 5.3 (4.8-5.8) | 4.9 (4.4-5.6) | 0.049 | | Integrated glucose 60-120min | 8378 (3960-15840) | 6135 (4965-10080) | 4388 (4020-6120) | 0.023 |
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