Risk of Recurrent Hypoglycemia and Long-term Survival after total Pancreatectomy

Objective: To evaluate risk of severe hypoglycemia after total pancreatectomy (TP). Background: Historically, TP was feared due to loss of insulin and counter-regulatory hormones, as well as the risk of severe hypoglycemic events (SHE). While TP with islet auto-transplant (TPIAT) can preserve endocrine function, past studies reported 41% SHE incidence post-operatively. Advancements in insulin therapies and continuous glucose monitors (CGMs) have likely improved outcomes but are understudied in this population. Methods: This single center study analyzed TP patients from 2009-2024. CGMs (Dexcom G7) were provided for the study if patients did not have one. Demographics, survival, emergency department visits, and glycemic control were assessed. Results: Among 147 TP cases, 76 underwent TP alone and 71 TPIAT. In the TP-alone patients, two deaths (2/76; 2.63%) occurred due to hypoglycemia. Pre-operatively, TP-alone patients had higher HbA1c (7.1±2.2%) than TPIAT patients (5.9±1.3%; P <0.001). In the first month post-operatively, TP-alone patients had higher HbA1c than TPIAT-insulin dependent patients, but no difference over 10 years. Hypo/hyperglycemia-related hospital visits, median time in target range (TP: 53.5%, IQR: 36.5-68.5 vs. TPIAT insulin-dependent: 59.0%, IQR: 43.3-67.5), and glycemic variability (coefficient of variation; 31.3%, IQR 28.3-35.0 vs 32.3%, IQR 28.7-35.5) were similar between TP-alone and TPIAT-insulin dependent groups. In 14 days of CGM capture, no severe hypoglycemia was observed in TP-alone patients (<3.0 mmol/L). Conclusions: Advancements in insulins and CGMs provide acceptable outcomes after TP without supplemental islet transplantation, and lower risk of SHE than previously reported. This encouraging data may aid surgical decision-making and patient selection for surgery.