What is the management of a patient post total pancreatectomy (removal of the pancreas) and total splenectomy (removal of the spleen)?

From the Guidelines

Management of a patient post total pancreatectomy and total splenectomy requires immediate attention to prevent overwhelming infections, with a focus on vaccination and patient education. The patient should receive prophylactic polyvalent pneumococcal, meningococcal C conjugate, and H influenzae b (Hib) vaccines at least 4 weeks before (preferably) or 2 weeks after splenectomy, as stated in the international consensus report on the investigation and management of primary immune thrombocytopenia 1.

Key aspects of post-splenectomy care include:

• Vaccination against encapsulated organisms to prevent infections from Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae
• Patient education on the risk of postsplenectomy infection and the need to seek immediate medical attention for fevers higher than 101°F (38°C)
• Consideration of a home supply of antibiotics, such as penicillin VK, erythromycin, or levofloxacin, for use in case of a febrile illness
• Carrying a card or wearing an alert bracelet to inform physicians of the patient's asplenic status

In terms of pancreatic insufficiency, the patient will require:

• Lifelong pancreatic enzyme replacement therapy, typically using pancrelipase (Creon) with initial dosing adjusted based on symptoms and nutritional status
• Insulin therapy to manage diabetes due to the complete loss of endocrine pancreatic function
• Nutritional support, including a low-fat diet and fat-soluble vitamin supplementation (A, D, E, K)

Regular follow-up is crucial to monitor for diabetes complications, nutritional deficiencies, and cancer surveillance if the pancreatectomy was performed for malignancy. The goal of management is to mitigate the risks associated with asplenia and pancreatic insufficiency, while improving the patient's quality of life. According to the study by 1, vaccination and patient education are critical components of post-splenectomy care, and should be prioritized to prevent overwhelming infections.

From the FDA Drug Label

In Study 4, a randomized, double-blind, placebo-controlled, parallel group study was conducted in 54 adult patients, aged 32 to 75 years, with exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatectomy. Ten patients had a history of pancreatectomy (7 were treated with CREON) Only 1 of the patients with a history of total pancreatectomy was treated with CREON in the study. That patient had a CFA of 26% during the run-in period and a CFA of 73% at the end of the double-blind period

The management of a patient post total pancreatectomy and total splenectomy may involve the use of pancreatic enzyme replacement therapy, such as CREON, to improve fat absorption and nutrient absorption.

• The dosage of CREON used in the study was 72,000 lipase units per main meal and 36,000 lipase units per snack.
• The study results showed that CREON treatment improved the coefficient of fat absorption (CFA) in patients with exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatectomy.
• However, only one patient with a history of total pancreatectomy was treated with CREON in the study, and the results may not be generalizable to all patients post total pancreatectomy and total splenectomy 2.

From the Research

Management of a Patient Post Total Pancreatectomy and Total Splenectomy

Overview of Insulin Therapy

• The management of a patient post total pancreatectomy and total splenectomy requires careful consideration of insulin therapy to control blood glucose levels 3, 4, 5, 6, 7.
• Basal-bolus insulin therapy is a common approach used to manage diabetes mellitus, which involves the use of a long-acting basal insulin and a rapid-acting insulin at mealtimes 4, 6.

Initiation of Insulin Therapy

• The initiation of insulin therapy in patients with type 2 diabetes is often recommended using a basal-bolus regimen, especially in patients with severe hyperglycemia, symptomatic diabetes, or those with comorbidities 5.
• The use of insulin analogs, such as insulin glargine and insulin lispro, is preferred due to their more physiologic action and lower risk of hypoglycemia compared to human insulin regimens 4, 6.

Glycemic Control

• The goal of insulin therapy is to achieve optimal glycemic control, which can be measured by HbA1c levels, fasting plasma glucose, and blood glucose profiles 3, 4, 7.
• Studies have shown that basal-bolus insulin therapy can improve glycemic control and reduce the risk of hypoglycemia in patients with type 1 and type 2 diabetes mellitus 3, 4, 6.

Considerations for Total Pancreatectomy and Total Splenectomy

• Patients who have undergone total pancreatectomy and total splenectomy require careful management of their insulin therapy due to the loss of pancreatic function and potential for hypoglycemia 5.
• The use of basal-bolus insulin therapy and insulin analogs can help to improve glycemic control and reduce the risk of hypoglycemia in these patients 4, 6.