New treatment strategies cut diabetes, fatty liver risk after pancreatic surgery

Researchers have identified treatment strategies that can reduce the incidence of diabetes and fatty liver disease — two common complications following pancreatic resection surgery.

The strategies are tailored to the site of resection: for patients who undergo removal of the pancreatic tail, surgeons aim to preserve as much pancreatic tissue as possible to protect blood sugar regulation; for those who have the pancreatic head removed, post-operative supplementation with digestive enzymes helps counter the fatty liver risk that arises from impaired nutrient absorption.

The findings are significant in that they identify core strategies for managing metabolic function and quality of life after pancreatic and biliary cancer surgery, moving the field beyond a focus on survival alone.

A research team led by professor Yoon Yoo-seok of the surgery department at Seoul National University Bundang Hospital validated separate prevention strategies for diabetes and fatty liver disease following pancreatic resection in patients with pancreatic cancer or pancreatobiliary disease, through two independent multicenter studies.

The pancreas serves a dual role: an endocrine function — secreting insulin to regulate blood sugar — and an exocrine function — producing enzymes that aid in the digestion and absorption of food. When part of the pancreas is removed to treat pancreatic cancer or surrounding tumors, both functions decline, raising the risk of metabolic conditions such as diabetes and fatty liver disease. Preventing this post-operative metabolic deterioration has emerged as a new priority in pancreatic surgery, alongside improving survival rates.

The research team first turned its attention to the deterioration of blood sugar control after surgery for cancer of the pancreatic tail. Because the tail of the pancreas contains a high concentration of insulin-producing beta cells, a wider resection leads to greater loss of glycemic control and a higher risk of diabetes. The team proposed and validated a surgical strategy that precisely limits the extent of resection to preserve as much pancreatic parenchyma as possible.

In an analysis of 320 patients who underwent distal pancreatectomy at three institutions, there was no significant difference in survival or recurrence rates between patients who received a standard wide resection and those in the tissue-preserving group. One year after surgery, however, glycated hemoglobin (HbA1c) rose by 0.57 percentage points from pre-operative levels in the standard resection group, compared with just 0.16 percentage points in the preservation group. The results indicate that minimized, tailored resection achieves equivalent oncological outcomes while substantially slowing the worsening of blood sugar control.

For fatty liver disease, which commonly develops when the head of the pancreas is removed in cases of pancreatic or bile duct cancer, the team pursued a strategy of replenishing the digestive enzymes lost after surgery through high-dose pancreatic enzyme supplements.

When the head of the pancreas is resected during a pancreaticoduodenectomy, the pancreatic enzymes normally secreted from that region become deficient, impairing nutrient absorption and raising the risk of fatty liver disease. Prophylactic administration of pancreatic enzymes after surgery supports nutrient absorption and, in turn, reduces that risk.

An analysis of 94 patients who underwent pancreaticoduodenectomy in a randomized controlled trial across seven institutions found that the incidence of fatty liver disease one year after surgery was 9.5 percent in the group that received pancreatic enzyme supplements — less than half the 23.1 percent rate in the placebo group. Patients who lost more than 5 percent of their body weight in the three months following surgery showed a particularly elevated risk of fatty liver disease, underscoring the need for aggressive enzyme replacement therapy in that group.

Together, the two studies establish a precision treatment framework that addresses metabolic surgical complications — including diabetes and fatty liver disease — by matching the intervention to the site of resection: minimizing the surgical extent to protect endocrine function, and using pharmacological supplementation to compensate for exocrine deficiency.

"The pancreas plays a central role in blood sugar regulation and digestion, and surgery must be guided by strategies that preserve not only endocrine and exocrine function but also long-term quality of life — going beyond simple survival rates," professor Yoon said. "Carefully designing individualized pre- and post-operative treatment plans that account for tumor location, the feasible extent of resection, post-operative weight changes and digestive function will contribute greatly to improving patient outcomes."