Poor diabetes control prior to Whipples

garychleung

PIG Meeting: 1st April 2021

66yo male with pancreatic cancer for a Whipples resection

Background

  • Recent ex-smoker
  • T2DM
  • Ex-heavy ETOH (ceased 3/12 ago)

Issues

  • Fitness for major surgery
    • CPET showed AT 10.8ml/kg/min and peak VO2 14ml/kg/min, placing him in the moderate risk category
  • High HbA1c 11.8%
    • Poor control ++ since dexamethasone used as part of NACRT
    • Known to private diabetician
    • Therapy escalated
    • BSLs improved to 12-14mmol/L

Discussion

  • Timing of surgery?
    • Ideally diabetes should be better controlled (as per out guidelines for DM + major surgery) however this is cancer surgery so a risk/benefit analysis must be undertaken
    • After NACRT, a window of opportunity exists, therefore a delay may be appropriate -> discuss with surgeon
    • Control should naturally continue to improve as the effect of the dexamethasone continues to wane
  • Diabetes plan
    • Return to private endocrinologist for ongoing care
    • An insulin infusion will almost certainly be part of this man’s care due to insulin usage, major GIT surgery and missed meals.