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Kawka M, Lucas A, Riad AM, Hawkins D, de Madaria E, West H, Jakaityte I, Lee MJ, Kouli O, Ruanne R, Gujjuri RR, Brown S, Cambridge WA, Pandanaboyana S, Kamarajah SK, McLean KA. Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach. HPB (Oxford) 2024; 26:859-872. [PMID: 38735815 DOI: 10.1016/j.hpb.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/07/2024] [Accepted: 04/18/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Pancreatitis is a common surgical emergency, associated with pain and poor quality of life for patients. However, assessment of patient-reported outcome measures in these patients is unclear. This study aimed to identify and evaluate the methodological quality of the health-related quality of life instruments used for patients with acute or chronic pancreatitis. METHODS Prospective studies that evaluated health-related quality of life in acute or chronic pancreatitis were identified from systematic review of MEDLINE, EMBASE, and Web of Science until 28th June 2023 (PROSPERO: CRD42021274743). Instrument characteristics were extracted, and methodological quality assessed using COSMIN (COnsensus-based Standards for the selection of health status Measurement Instruments) guidelines and GRADE approach. Narrative synthesis was conducted, with recommendations for use based on COSMIN criteria, evaluated according to World Health Organisation (WHO) quality of life domains. RESULTS From 3850 records screened, 41 quality of life instruments were identified across 138 studies included. The majority (69.8%, n = 26) were designed to assess general health-related quality of life, whereas the remainder were abdominal-specific (n = 5) or pancreas-specific (n = 10). Only ten instruments (24.3%) demonstrated sufficient content validity, incorporating items in ≥5 WHO quality of life domains. However, only nine instruments (21.9%) incorporated public and patient involvement. Only the Gastrointestinal Quality of Life Index and PAN-PROMISE met the criteria to be recommended for use based on COSMIN methodological assessment. CONCLUSION There is significant heterogeneity in instruments used to assess quality of life after pancreatitis, with almost all instruments considered insufficient. Robust, validated, and relevant instruments are needed to better understand and determine appropriate interventions to improve quality of life for these patients.
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Li SZ, Zhen TT, Wu Y, Wang M, Qin TT, Zhang H, Qin RY. Quality of life after pancreatic surgery. World J Gastroenterol 2024; 30:943-955. [PMID: 38516249 PMCID: PMC10950648 DOI: 10.3748/wjg.v30.i8.943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/29/2023] [Accepted: 01/31/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Pancreatic surgery is challenging owing to the anatomical characteristics of the pancreas. Increasing attention has been paid to changes in quality of life (QOL) after pancreatic surgery. AIM To summarize and analyze current research results on QOL after pancreatic surgery. METHODS A systematic search of the literature available on PubMed and EMBASE was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies were identified by screening the references of retrieved articles. Studies on patients' QOL after pancreatic surgery published after January 1, 2012, were included. These included prospective and retrospective studies on patients' QOL after several types of pancreatic surgeries. The results of these primary studies were summarized inductively. RESULTS A total of 45 articles were included in the study, of which 13 were related to pancreaticoduodenectomy (PD), seven to duodenum-preserving pancreatic head resection (DPPHR), nine to distal pancreatectomy (DP), two to central pancreatectomy (CP), and 14 to total pancreatectomy (TP). Some studies showed that 3-6 months were needed for QOL recovery after PD, whereas others showed that 6-12 months was more accurate. Although TP and PD had similar influences on QOL, patients needed longer to recover to preoperative or baseline levels after TP. The QOL was better after DPPHR than PD. However, the superiority of the QOL between patients who underwent CP and PD remains controversial. The decrease in exocrine and endocrine functions postoperatively was the main factor affecting the QOL. Minimally invasive surgery could improve patients' QOL in the early stages after PD and DP; however, the long-term effect remains unclear. CONCLUSION The procedure among PD, DP, CP, and TP with a superior postoperative QOL is controversial. The long-term benefits of minimally invasive versus open surgeries remain unclear. Further prospective trials are warranted.
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Affiliation(s)
- Shi-Zhen Li
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Ting-Ting Zhen
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Yi Wu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Ting-Ting Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Hang Zhang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Ren-Yi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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Hasse JM, Meng S, Silpe S, Naziruddin B. Nutrition challenges following total pancreatectomy with islet autotransplantation. Nutr Clin Pract 2024; 39:86-99. [PMID: 38213274 DOI: 10.1002/ncp.11106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 01/13/2024] Open
Abstract
Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical treatment option for patients with chronic pancreatitis who have not responded to other therapies. TP offers pain relief whereas IAT preserves beta cell mass to reduce endocrine insufficiency. During the surgical procedure, the entire pancreas is removed. Islet cells from the pancreas are then isolated, purified, and infused into the liver via the portal vein. Successful TPIAT relieves pain for a majority of patients but is not without obstacles, specifically gastrointestinal, exocrine, and endocrine challenges. The postoperative phase can be complicated by gastrointestinal symptoms causing patients to have difficulty regaining adequate oral intake. Enteral nutrition is frequently provided as a bridge to oral diet. Patients undergoing TPIAT must be monitored for macronutrient and micronutrient deficiencies following the procedure. Exocrine insufficiency must be treated lifelong with pancreatic enzyme replacement therapy. Endocrine function must be monitored and exogenous insulin provided in the postoperative phase; however, a majority of patients undergoing TPIAT require little or no long-term insulin. Although TPIAT can be a successful option for patients with chronic pancreatitis, nutrition-related concerns must be addressed for optimal recovery.
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Affiliation(s)
- Jeanette M Hasse
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Shumei Meng
- Division of Endocrinology, Internal Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Stephanie Silpe
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Bashoo Naziruddin
- Islet Cell Laboratory, Baylor Research Institute, Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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Nanno Y, Hodges JS, Freeman ML, Trikudanathan G, Schwarzenberg SJ, Downs EM, Ramanathan K, Pruett TL, Beilman GJ, Chinnakotla S, Hering BJ, Bellin MD. Early Metabolic Measures Predict Long-term Insulin Independence in Recipients of Total Pancreatectomy and Islet Autotransplantation. Transplant Direct 2024; 10:e1561. [PMID: 38094130 PMCID: PMC10715795 DOI: 10.1097/txd.0000000000001561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 01/05/2024] Open
Abstract
Background Although diabetes after total pancreatectomy and islet autotransplantation (TP-IAT) is one of the biggest concerns for TP-IAT recipients and physicians, reliable prediction of post-TP-IAT glycemic control remains unestablished. This study was conducted to identify early predictors of insulin independence and goal glycemic control by hemoglobin A1c (HbA1c) ≤ 6.5% after TP-IAT. Methods In this single-center, retrospective study, patients who underwent TP-IAT (n = 227) were reviewed for simple metabolic markers or surrogate indices of β-cell function obtained 3 mo after TP-IAT as part of standard clinical testing. Long-term metabolic success was defined as (1) insulin independence and (2) HbA1c ≤ 6.5% 1, 3, and 5 y after TP-IAT. Single- and multivariate modeling used 3-mo markers to predict successful outcomes. Results Of the 227 recipients, median age 31 y, 30% male, 1 y after TP-IAT insulin independence, and HbA1c ≤ 6.5% were present in 39.6% and 72.5%, respectively. In single-predictor analyses, most of the metabolic markers successfully discriminated between those attaining and not attaining metabolic goals. Using the best model selected by random forests analysis, we accurately predicted 1-y insulin independence and goal HbA1c control in 77.3% and 86.4% of the patients, respectively. A simpler "clinically feasible" model using only transplanted islet dose and BETA-2 score allowed easier prediction at a small accuracy loss (74.1% and 82.9%, respectively). Conclusions Metabolic testing measures performed 3 mo after TP-IAT were highly associated with later diabetes outcomes and provided a reliable prediction model, giving valuable prognostic insight early after TP-IAT and help to identify recipients who require early intervention.
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Affiliation(s)
- Yoshihide Nanno
- Department of Surgery, University of Minnesota, Minneapolis, MN
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - James S. Hodges
- Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | | | | | | | - Elissa M. Downs
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | | | | | | | - Srinath Chinnakotla
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Bernhard J. Hering
- Department of Surgery, University of Minnesota, Minneapolis, MN
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
| | - Melena D. Bellin
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
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5
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Downs EM, Eaton A, Witkowski P, Wijkstrom M, Walsh M, Trikudanathan G, Singh VK, Schwarzenberg SJ, Pruett TL, Posselt A, Naziruddin B, Nathan JD, Mokshagundam SP, Morgan K, Lara LF, Gardner TB, Freeman ML, Ellery K, Chinnakotla S, Beilman GJ, Adams D, Ahmad S, Abu-El-Haija M, Bellin MD. Nutritional Risks in Patients Undergoing Total Pancreatectomy Islet AutoTransplantation in the POST Consortium. J Gastrointest Surg 2023; 27:1893-1902. [PMID: 37442881 PMCID: PMC11335039 DOI: 10.1007/s11605-023-05770-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/17/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND AND AIMS Total pancreatectomy with islet autotransplantation (TPIAT) can relieve pain for individuals with acute recurrent or chronic pancreatitis. However, TPIAT may increase the risk of poor nutritional status with complete exocrine pancreatic insufficiency, partial duodenectomy, and intestinal reconstruction. Our study's objective was to evaluate nutritional status, anthropometrics, and vitamin levels before and after TPIAT. METHODS The multicenter Prospective Observational Study of TPIAT (POST) collects measures including vitamins A, D, and E levels, pancreatic enzyme dose, and multivitamin (MVI) administration before and 1-year after TPIAT. Using these data, we studied nutritional and vitamin status before and after TPIAT. RESULTS 348 TPIAT recipients were included (68% adult, 37% male, 93% Caucasian). In paired analyses at 1-year follow-up, vitamin A was low in 23% (vs 9% pre-TPIAT, p < 0.001); vitamin E was low in 11% (vs 5% pre-TPIAT, p = 0.066), and 19% had vitamin D deficiency (vs 12% pre-TPIAT, p = 0.035). Taking a fat-soluble multivitamin (pancreatic MVI) was associated with lower risk for vitamin D deficiency (p = 0.002). Adults were less likely to be on a pancreatic MVI at follow-up (34% vs 66% respectively, p < 0.001). Enzyme dosing was adequate. More adults versus children were overweight or underweight pre- and post-TPIAT. Underweight status was associated with vitamin A (p = 0.014) and E (p = 0.02) deficiency at follow-up. CONCLUSIONS Prevalence of fat-soluble vitamin deficiencies increased after TPIAT, especially if underweight. We strongly advocate that all TPIAT recipients have close post-operative nutritional monitoring, including vitamin levels. Pancreatic MVIs should be given to minimize risk of developing deficiencies.
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Affiliation(s)
- Elissa M Downs
- Department of Pediatrics, University of Minnesota & Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN, AOB20155454, USA.
| | - Anne Eaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Piotr Witkowski
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Matthew Walsh
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Guru Trikudanathan
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Vikesh K Singh
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Sarah J Schwarzenberg
- Department of Pediatrics, University of Minnesota & Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN, AOB20155454, USA
| | - Timothy L Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Andrew Posselt
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Jaimie D Nathan
- Department of Pediatric Abdominal Transplant and Hepatopancreatobiliary Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Katherine Morgan
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA
| | - Luis F Lara
- Department of Medicine, The Ohio State Wexner University Medical Center, Columbus, OH, USA
| | - Timothy B Gardner
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Martin L Freeman
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kate Ellery
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Srinath Chinnakotla
- Department of Pediatrics, University of Minnesota & Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN, AOB20155454, USA
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David Adams
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA
| | - Syed Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Melena D Bellin
- Department of Pediatrics, University of Minnesota & Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN, AOB20155454, USA
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Chen ME, Desai CS. Current practices in islet cell autotransplantation. Expert Rev Endocrinol Metab 2023; 18:419-425. [PMID: 37680038 DOI: 10.1080/17446651.2023.2256407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Chronic pancreatitis and recurrent acute pancreatitis comprise a spectrum of disease that results in complications related to exocrine and endocrine insufficiency and chronic pain with narcotic dependence and poor quality of life. The mainstay of therapy has been medical and endoscopic therapy; surgery, especially total pancreatectomy, was historically reserved for few select patients as the obligate exocrine insufficiency and pancreatogenic diabetes (type 3C) are challenging to manage. The addition of islet cell autotransplantation after total pancreatectomy helps to mitigate brittle type 3c diabetes and prevents mortality related to severe hypoglycemic episodes and hypoglycemic unawareness. There have been more recent data demonstrating the safety of surgery and the beneficial long-term outcomes. AREAS COVERED The purpose of this review is to describe the current practices in the field of islet cell autotransplantation including the selection and evaluation of patients for surgery, their preoperative work up and management, surgical approach, post-operative management and outcomes. EXPERT OPINION Total pancreatectomy and islet cell autotransplantation has the ability to drastically improve quality of life and prevent brittle diabetes for patients suffering with chronic pancreatitis.
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Affiliation(s)
- Melissa E Chen
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Chirag S Desai
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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Bellin MD, Ramanathan K, Chinnakotla S. Total Pancreatectomy with Islet Auto-Transplantation: Surgical Procedure, Outcomes, and Quality of Life. Adv Surg 2023; 57:15-30. [PMID: 37536850 DOI: 10.1016/j.yasu.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Chronic pancreatitis is a progressive and irreversible process of pancreatic inflammation and fibrosis that can lead to intractable abdominal pain and severely impaired quality of life (QoL). Often patients are refractory to standard medical or endoscopic treatments. Total pancreatectomy (TP) and islet auto-transplantation (TP-IAT) can offer pain relief to patients by removing the entire pancreas and the auto-transplant component ameliorates the resulting diabetes. QoL is significantly improved after TP-IAT when insulin independence is present. Recent data support offering TP-IAT rather than TP alone and treating with exogenous insulin for patients with debilitating chronic pancreatitis.
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Turner KM, Wahab SA, Delman AM, Brunner J, Smith MT, Choe KA, Patel SH, Ahmad SA, Wilson GC. Predicting endocrine function after total pancreatectomy and islet cell autotransplantation: A novel approach utilizing computed tomography texture analysis. Surgery 2023; 173:567-573. [PMID: 36241471 DOI: 10.1016/j.surg.2022.06.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/13/2022] [Accepted: 06/27/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Islet cell autotransplantation is an effective method to prevent morbidity associated with type IIIc diabetes after total pancreatectomy. However, there is no valid method to predict long-term endocrine function. Our aim was to assess computed tomography texture analysis as a strategy to predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation. METHODS All patients undergoing total pancreatectomy and islet cell autotransplantation from 2007 to 2020 who had high-quality preoperative computed tomography imaging available for texture analysis were included. The primary outcome was optimal long-term endocrine function, defined as stable glycemic control with <10 units of insulin/day. RESULTS Sixty-three patients met inclusion criteria. Median yield was 6,111 islet equivalent/kg body weight. At a median follow-up of 64.2 months, 12.7% (n = 8) of patients were insulin independent and 39.7% (n = 25) demonstrated optimal endocrine function. Neither total islet equivalent nor islet equivalent/kg body weight alone were associated with optimal endocrine function. To improve endocrine function prediction, computed tomography texture analysis parameters were analyzed, identifying an association between kurtosis (odds ratio, 2.32; 95% confidence interval, 1.08-4.80; P = .02) and optimal endocrine function. Sensitivity analysis discovered a cutoff for kurtosis = 0.60, with optimal endocrine function seen in 66.7% with kurtosis ≥0.60, compared with only 26.2% with kurtosis <0.60 (P < .01). On multivariate logistic regression including islet equivalent yield, only kurtosis ≥0.60 (odds ratio, 5.61; 95% confidence interval, 1.56-20.19; P = .01) and fewer small islet equivalent (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .02) were associated with optimal endocrine function, with the whole model demonstrating excellent prediction of long-term endocrine function (area under the curve, 0.775). CONCLUSION Computed tomography texture analysis can provide qualitative data, that when used in combination with quantitative islet equivalent yield, can accurately predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH. https://twitter.com/KevinTurnerMD
| | - Shaun A Wahab
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH. https://twitter.com/ShaunWahabMD
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - John Brunner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Milton T Smith
- Department of Internal Medicine, Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH. https://twitter.com/SyedAAhmad5
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH.
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Khazaaleh S, Babar S, Alomari M, Imam Z, Chadalavada P, Gonzalez AJ, Kurdi BE. Outcomes of total pancreatectomy with islet autotransplantation: A systematic review and meta-analysis. World J Transplant 2023; 13:10-24. [PMID: 36687559 PMCID: PMC9850868 DOI: 10.5500/wjt.v13.i1.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/24/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite the increased use of total pancreatectomy with islet autotransplantation (TPIAT), systematic evidence of its outcomes remains limited.
AIM To evaluate the outcomes of TPIAT.
METHODS We searched PubMed, EMBASE, and Cochrane databases from inception through March 2019 for studies on TPIAT outcomes. Data were extracted and analyzed using comprehensive meta-analysis software. The random-effects model was used for all variables. Heterogeneity was assessed using the I2 measure and Cochrane Q-statistic. Publication bias was assessed using Egger’s test.
RESULTS Twenty-one studies published between 1980 and 2017 examining 1011 patients were included. Eighteen studies were of adults, while three studied pediatric populations. Narcotic independence was achieved in 53.5% [95% Confidence Interval (CI): 45-62, P < 0.05, I2 = 81%] of adults compared to 51.9% (95%CI: 17-85, P < 0.05, I2 = 84%) of children. Insulin-independence post-procedure was achieved in 31.8% (95%CI: 26-38, P < 0.05, I2 = 64%) of adults with considerable heterogeneity compared to 47.7% (95%CI: 20-77, P < 0.05, I2 = 82%) in children. Glycated hemoglobin (HbA1C) 12 mo post-surgery was reported in four studies with a pooled value of 6.76% (P = 0.27). Neither stratification by age of the studied population nor meta-regression analysis considering both the study publication date and the islet-cell-equivalent/kg weight explained the marked heterogeneity between studies.
CONCLUSION These results indicate acceptable success for TPIAT. Future studies should evaluate the discussed measures before and after surgery for comparison.
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Affiliation(s)
- Shrouq Khazaaleh
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Cleveland, OH 44126, United States
| | - Sumbal Babar
- Department of Internal Medicine-Infectious Diseases Division, University of Texas Health Science Center at San Antonio, San Antonio, TX 78249, United States
| | - Mohammad Alomari
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FI 33324, United States
| | - Zaid Imam
- Department of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Pravallika Chadalavada
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FI 33331, United States
| | - Adalberto Jose Gonzalez
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FI 33331, United States
| | - Bara El Kurdi
- Department of Gastroenterology and Hepatology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78249, United States
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Total pancreatectomy and islet cell autotransplantation: a 10-year update on outcomes and assessment of long-term durability. HPB (Oxford) 2022; 24:2013-2021. [PMID: 35927127 DOI: 10.1016/j.hpb.2022.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/13/2022] [Accepted: 07/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Total pancreatectomy and islet cell autotransplantation (TPIAT) offers an effective, lasting solution for the management of chronic pancreatitis up to 5-years post-operatively. Our aim was to assess durability of TPIAT at 10-years. METHODS Patients undergoing TPIAT for chronic pancreatitis eligible for 10-year follow-up were included. Primary outcomes, including endocrine function and narcotic requirements, were reported at 5-, 7.5-, and 10-years post-operatively. RESULTS Of the 231 patients who underwent TPIAT, 142 met inclusion criteria. All patients underwent successful TPIAT with an average of 5680.3 islet equivalents per body weight. While insulin independence tended to decrease over time (25.7% vs. 16.0% vs. 10.9%, p = 0.11) with an increase in HbA1C (7.6% vs. 8.2% vs. 8.4%, p = 0.09), partial islet function persisted (64.9% vs. 68.0% vs. 67.4%, p = 0.93). Opioid independence was achieved and remained durable in the majority (73.3% vs. 72.2% vs. 75.5%, p = 0.93). Quality of life improvements persisted, with 85% reporting improvement from baseline at 10-years. Estimated median overall survival was 202.7 months. CONCLUSION This study represents one of the largest series reporting on long-term outcomes after TPIAT, demonstrating excellent long-term pain control and durable improvements in quality of life. Islet cell function declines over time however stable glycemic control is maintained.
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Chinnakotla S, Beilman GJ, Vock D, Freeman ML, Kirchner V, Dunn TB, Pruett TL, Amateau SK, Trikudanathan G, Schwarzenberg SJ, Downs E, Armfield M, Ramanathan K, Sutherland DE, Bellin MD. Intraportal Islet Autotransplantation Independently Improves Quality of Life After Total Pancreatectomy in Patients With Chronic Refractory Pancreatitis. Ann Surg 2022; 276:441-449. [PMID: 35762611 PMCID: PMC9388605 DOI: 10.1097/sla.0000000000005553] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine if islet autotransplantation (IAT) independently improves the quality of life (QoL) in patients after total pancreatectomy and islet autotransplantation (TP-IAT). BACKGROUND TP-IAT is increasingly being used for intractable chronic pancreatitis. However, the impact of IAT on long-term islet function and QoL is unclear. METHODS TP-IAT patients at our center >1 year after TP-IAT with ≥1 Short Form-36 QoL measure were included. Patients were classified as insulin-independent or insulin-dependent, and as having islet graft function or failure by C-peptide. The associations of insulin use and islet graft function with QoL measures were analyzed by using a linear mixed model, accounting for time since transplant and within-person correlation. RESULTS Among 817 islet autograft recipients, 564 patients [median (interquartile range) age: 34 (20, 45) years, 71% female] and 2161 total QoL surveys were included. QoL data were available for >5 years after TP-IAT for 42.7% and for >10 years for 17.3%. Insulin-independent patients exhibited higher QoL in 7 of 8 subscale domains and for Physical Component Summary and Mental Component Summary scores ( P <0.05 for all). Physical Component Summary was 2.91 (SE=0.57) higher in insulin-independent patients ( P <0.001). No differences in QoL were observed between those with and without graft function, but islet graft failure was rare (15% of patients). However, glycosylated hemoglobin was much higher with islet graft failure. CONCLUSIONS QoL is significantly improved when insulin independence is present, and glycosylated hemoglobin is lower with a functioning islet graft. These data support offering IAT, rather than just performing total pancreatectomy and treating with exogenous insulin.
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Affiliation(s)
- Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David Vock
- Division of Biostatistics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Martin L. Freeman
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Varvara Kirchner
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ty B. Dunn
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Timothy L. Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Stuart K. Amateau
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Guru Trikudanathan
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Elissa Downs
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Matthew Armfield
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Karthik Ramanathan
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Melena D. Bellin
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
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12
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Szempruch KR, Walter K, Ebert N, Bridgens K, Desai CS. Pharmacological management of patients undergoing total pancreatectomy with auto-islet transplantation. Pancreatology 2022; 22:656-664. [PMID: 35490122 DOI: 10.1016/j.pan.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/17/2022] [Accepted: 04/15/2022] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis results in permanent parenchymal destruction of the pancreas gland leading to anatomical and physiological consequences for patients. Surgical management varies, and some patients require total pancreatectomy with autologous islet cell transplantation (TPIAT). Patients undergoing TPIAT require complex and diligent management after surgery. This encompasses the management of glucose control (endocrine function of the pancreas) and supplementing loss of exocrine function of the pancreas with digestive enzymes. Other areas of management include optimizing pain relief while reducing narcotic usage, providing antimicrobial prophylaxis, and reducing loss of islet cells by improving its integrity through anticoagulation and use of anti-inflammatory agents. Each aspect of care is unique to this population. However, comprehensive reviews on its pharmacological management are scarce. This review will discuss the available literature to date surrounding all aspects of pharmacological management of patients undergoing TPIAT.
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Affiliation(s)
- Kristen R Szempruch
- Pharmacy Department, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Krysta Walter
- Pharmacy Department, Michigan Medicine, Ann Arbor, MI, USA
| | - Natassha Ebert
- Pharmacy Department, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Kathryn Bridgens
- Department of Nutrition and Food Services, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Chirag S Desai
- Department of Surgery, Transplant, University of North Carolina Medical Center, Chapel Hill, NC, USA.
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13
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Perito ER, Pohl JF, Bakker C, Armfield MA, Barth B, Cuneo A, Mascarenhas M, Mehta M, Schwarzenberg SJ. Outpatient Pain Management in Children With Chronic Pancreatitis: A Scoping Systematic Review. Pancreas 2022; 51:135-147. [PMID: 35404888 PMCID: PMC9009154 DOI: 10.1097/mpa.0000000000001973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Although pain management is central to pediatric chronic pancreatitis (CP) care, no evidence-based guidelines exist. In this scoping systematic review, we sought promising strategies for CP pain treatment in children. METHODS We systematically reviewed literature on pain management in children and adults with CP, and 2 conditions with similar pain courses: juvenile idiopathic arthritis and sickle cell disease. RESULTS Of 8997 studies identified, 287 met inclusion criteria. There are no published studies of analgesic medications, antioxidants, dietary modification, integrative medicine, or regional nerve blocks in children with CP. In adults with CP, studies of nonopioid analgesics, pancreatic enzymes, and dietary interventions have mixed results. Retrospective studies suggest that endoscopic retrograde cholangiopancreatography and surgical procedures, most durably total pancreatectomy with islet autotransplant, improve pain for children with CP. Follow-up was short relative to a child's life. Large studies in adults also suggest benefit from endoscopic therapy and surgery, but lack conclusive evidence about optimal procedure or timing. Studies on other painful pediatric chronic illnesses revealed little generalizable to children with CP. CONCLUSIONS No therapy had sufficient high-quality studies to warrant untempered, evidence-based support for use in children with CP. Multicenter studies are needed to identify pain management "best practices."
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Affiliation(s)
- Emily R Perito
- From the Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - John F Pohl
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Matthew A Armfield
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Bradley Barth
- Department of Pediatrics, University of Texas Southwestern and Children's Medical Center Dallas, Dallas, TX
| | - Addison Cuneo
- From the Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Maria Mascarenhas
- Department of Pediatrics, Children's Hospital of Philadelphia/University of Pennsylvania, Philadelphia, PA
| | - Megha Mehta
- Department of Pediatrics, University of Texas Southwestern and Children's Medical Center Dallas, Dallas, TX
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14
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Hung J, Awasthi R, Klibanov AL, Kelly KA. Identification of Novel Ligands for Targeted Antifibrotic Therapy of Chronic Pancreatitis. Int J Nanomedicine 2021; 16:5495-5512. [PMID: 34429596 PMCID: PMC8374843 DOI: 10.2147/ijn.s318331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/15/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Chronic pancreatitis (CP) is an inflammatory disorder of the pancreas that leads to impaired pancreatic function. The limited therapeutic options and the lack of molecular targeting ligands or non-serum-based biomarkers hinder the development of target-specific drugs. Thus, there is a need for an unbiased, comprehensive discovery and evaluation of pancreatitis-specific ligands. METHODS This study utilized a computational-guided in vivo phage display approach to select peptide ligands selective for cellular components in the caerulein-induced mouse model of CP. The identified peptides were conjugated to pegylated DOPC liposomes via the reverse-phase evaporation method, and the in vivo specificity and pharmacokinetics were determined. As proof of concept, CP-targeted liposomes were used to deliver an antifibrotic small molecular drug, apigenin. Antifibrotic effects determined by pancreatic histology, fibronectin expression, and collagen deposition were evaluated. RESULTS We have identified five peptides specific for chronic pancreatitis and demonstrated selectivity to activated pancreatic stellate cells, acinar cells, macrophages, and extracellular matrix, respectively. MDLSLKP-conjugated liposomes demonstrated an increased particle accumulation by 1.3-fold in the inflamed pancreas compared to the control liposomes. We also observed that targeted delivery of apigenin resulted in improved acini preservation, a 37.2% and 33.1% respective reduction in collagen and fibronectin expression compared to mice receiving the free drug, and reduced oxidative stress in the liver. CONCLUSION In summary, we have developed a systematic approach to profile peptide ligands selective for cellular components of complex disease models and demonstrated the biomedical applications of the identified peptides to improve tissue remodeling in the inflamed pancreas.
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Affiliation(s)
- Jessica Hung
- Department of Biomedical Engineering, School of Engineering, University of Virginia, Charlottesville, Virginia, 22908, USA
| | - Rohni Awasthi
- Department of Biomedical Engineering, School of Engineering, University of Virginia, Charlottesville, Virginia, 22908, USA
| | - Alexander L Klibanov
- Department of Biomedical Engineering, School of Medicine, University of Virginia, Charlottesville, Virginia, 22908, USA
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, 22908, USA
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, Virginia, 22908, USA
- Department of Radiology, University of Virginia, Charlottesville, Virginia, 22908, USA
| | - Kimberly A Kelly
- Department of Biomedical Engineering, School of Medicine, University of Virginia, Charlottesville, Virginia, 22908, USA
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15
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Naples R, Perlmutter BC, Thomas JD, McMichael J, Bottino R, Solomina J, Trucco M, Augustin T, Simon R, Walsh RM. Clinical Significance of Postoperative Antibiotic Treatment for Positive Islet Cultures After Total Pancreatectomy With Islet Autotransplantation. Pancreas 2021; 50:1000-1006. [PMID: 34629454 DOI: 10.1097/mpa.0000000000001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Islet cultures are routinely performed in total pancreatectomy with islet autotransplantation (TPIAT), and the need for empiric antibiotic treatment based on culture results is unknown. We evaluated the effect of postoperative antibiotic treatment for positive islet cultures on clinical infection. METHODS Seventy-nine patients undergoing TPIAT were reviewed. Prophylactic perioperative ceftriaxone and metronidazole were administered, and transplanted islet preparations included ciprofloxacin. Postoperative antibiotics were not routinely given for positive cultures unless a clinical infection was suspected. The primary end point was 30-day infectious complications. RESULTS Fifty-one patients (65%) had a positive culture. Overall, 39 patients (87%) had organisms susceptible to our perioperative antibiotic regimen. There was no difference in the infectious complication rate between those with positive compared with negative cultures (16% vs 29%, P = 0.17). Patients with a positive culture had similar 30-day postoperative infectious complication rates whether receiving postoperative antibiotics (n = 7) or not (14% vs 16%, P = 0.91). Only 1 patient had a correlation of clinical and islet cultures. CONCLUSIONS Beyond prophylactic antibiotics, empiric antibiotic treatment for a positive culture is not warranted and provides a rationale for the abandonment of routine cultures in TPIAT.
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Affiliation(s)
- Robert Naples
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Breanna C Perlmutter
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Jonah D Thomas
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - John McMichael
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Rita Bottino
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Julia Solomina
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Massimo Trucco
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Toms Augustin
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Robert Simon
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - R Matthew Walsh
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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16
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Lara LF, Wastvedt S, Hodges JS, Witkowski P, Wijkstrom M, Walsh RM, Singh VK, Schwarzenberg SJ, Pruett TL, Posselt A, Naziruddin B, Nathan JD, Morgan KA, Mitchell R, Kirchner VA, Mokshagundam SL, Hatipoglu B, Gardner TB, Freeman ML, Chinnakotla S, Beilman GJ, Abu-El-Haija M, Conwell DL, Bellin MD. The Association of Smoking and Alcohol Abuse on Anxiety and Depression in Patients With Recurrent Acute or Chronic Pancreatitis Undergoing Total Pancreatectomy and Islet Autotransplantation: A Report From the Prospective Observational Study of TPIAT Cohort. Pancreas 2021; 50:852-858. [PMID: 34347725 PMCID: PMC8373657 DOI: 10.1097/mpa.0000000000001850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Smoking and alcohol use are risk factors for acute and chronic pancreatitis, and their role on anxiety, depression, and opioid use in patients who undergo total pancreatectomy and islet autotransplantation (TPIAT) is unknown. METHODS We included adults enrolled in the Prospective Observational Study of TPIAT (POST). Measured variables included smoking (never, former, current) and alcohol abuse or dependency history (yes vs no). Using univariable and multivariable analyses, we investigated the association of smoking and alcohol dependency history with anxiety and depression, opioid use, and postsurgical outcomes. RESULTS Of 195 adults studied, 25 were current smokers and 77 former smokers, whereas 18 had a history of alcohol dependency (of whom 10 were current smokers). A diagnosis of anxiety was associated with current smoking (P = 0.005), and depression was associated with history of alcohol abuse/dependency (P = 0.0001). However, active symptoms of anxiety and depression at the time of TPIAT were not associated with smoking or alcohol status. Opioid use in the past 14 days was associated with being a former smoker (P = 0.005). CONCLUSIONS Active smoking and alcohol abuse history were associated with a diagnosis of anxiety and depression, respectively; however, at the time of TPIAT, symptom scores suggested that they were being addressed.
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Affiliation(s)
- Luis F. Lara
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, OH
| | - Solvejg Wastvedt
- School of Public Health, University of Minnesota Minneapolis, MN
| | - James S. Hodges
- School of Public Health, University of Minnesota Minneapolis, MN
| | | | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Vikesh K. Singh
- Department of Medicine, Division of Gastroenterology, John Hopkins Medical Institutions, Baltimore, MD
| | | | - Timothy L. Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Andrew Posselt
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Bashoo Naziruddin
- Department of Surgery, Islet Cell Processing Laboratory, Baylor Health, Dallas, TX
| | - Jaimie D. Nathan
- Division of Surgery, Cincinnati Children’s Hospital Medical Center
- Department of Surgery, University of Cincinnati, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Katherine A. Morgan
- Department of Surgery, Division of GI and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC
| | - Rebecca Mitchell
- School of Public Health, University of Minnesota Minneapolis, MN
| | - Varvara A. Kirchner
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | | | - Betul Hatipoglu
- Department of Medicine, Division of Clinical and Molecular Endocrinology, University Hospitals, Cleveland, OH
| | - Timothy B. Gardner
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Martin L. Freeman
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical School, Minneapolis, MN
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Maisam Abu-El-Haija
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital
| | - Darwin L. Conwell
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, OH
| | - Melena D. Bellin
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN
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17
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Maatman TK, Zyromski NJ. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2020.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Saleh M, Sharma K, Kalsi R, Fusco J, Sehrawat A, Saloman JL, Guo P, Zhang T, Mohamed N, Wang Y, Prasadan K, Gittes GK. Chemical pancreatectomy treats chronic pancreatitis while preserving endocrine function in preclinical models. J Clin Invest 2021; 131:143301. [PMID: 33351784 PMCID: PMC7843231 DOI: 10.1172/jci143301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/01/2020] [Indexed: 12/20/2022] Open
Abstract
Chronic pancreatitis affects over 250,000 people in the US and millions worldwide. It is associated with chronic debilitating pain, pancreatic exocrine failure, and high risk of pancreatic cancer and usually progresses to diabetes. Treatment options are limited and ineffective. We developed a new potential therapy, wherein a pancreatic ductal infusion of 1%-2% acetic acid in mice and nonhuman primates resulted in a nonregenerative, near-complete ablation of the exocrine pancreas, with complete preservation of the islets. Pancreatic ductal infusion of acetic acid in a mouse model of chronic pancreatitis led to resolution of chronic inflammation and pancreatitis-associated pain. Furthermore, acetic acid-treated animals showed improved glucose tolerance and insulin secretion. The loss of exocrine tissue in this procedure would not typically require further management in patients with chronic pancreatitis because they usually have pancreatic exocrine failure requiring dietary enzyme supplements. Thus, this procedure, which should be readily translatable to humans through an endoscopic retrograde cholangiopancreatography (ERCP), may offer a potential innovative nonsurgical therapy for chronic pancreatitis that relieves pain and prevents the progression of pancreatic diabetes.
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Affiliation(s)
- Mohamed Saleh
- Division of Pediatric Surgery
- Division of Pediatric Endocrinology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Jami L. Saloman
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Department of Neurobiology, Pittsburgh Center for Pain Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ping Guo
- Department of Clinical Science, Colorado State University, Fort Collins, Colorado, USA
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19
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Narayanan S, Bhutiani N, Adamson DT, Jones CM. Pancreatectomy, Islet Cell Transplantation, and Nutrition Considerations. Nutr Clin Pract 2020; 36:385-397. [PMID: 33002260 DOI: 10.1002/ncp.10578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pancreatic islet transplantation is a reliable approach for treating insulin-deficient diabetes. This established β-cell replacement approach has shown considerable improvements in the last 2 decades. It has helped achieve metabolic homeostasis and safe outcomes for a subset of patients with type 1 diabetes and severe pancreatitis. Nutrition support, until recently, was considered as a secondary factor, merely identified as a means of providing all the necessary nutrients for such patients. However, new literature suggests that several factors, such as the route, timing, quantity, and composition of all the nutrients administered, have key disease-altering properties and are vital during the perioperative management of such patients. This review will highlight the benefits of performing the clinical islet transplantation on a subgroup of patients with type 1 diabetes and pancreatitis and summarize new data that identify the pivotal role of nutrition support as a critical intervention in their management.
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Affiliation(s)
- Siddharth Narayanan
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Neal Bhutiani
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Dylan T Adamson
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Christopher M Jones
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
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20
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Maatman TK, Zyromski NJ. Chronic Pancreatitis. Curr Probl Surg 2020; 58:100858. [PMID: 33663691 DOI: 10.1016/j.cpsurg.2020.100858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas K Maatman
- Resident in General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas J Zyromski
- Professor of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA..
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21
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Abu-El-Haija M, Anazawa T, Beilman GJ, Besselink MG, Del Chiaro M, Demir IE, Dennison AR, Dudeja V, Freeman ML, Friess H, Hackert T, Kleeff J, Laukkarinen J, Levy MF, Nathan JD, Werner J, Windsor JA, Neoptolemos JP, Sheel ARG, Shimosegawa T, Whitcomb DC, Bellin MD. The role of total pancreatectomy with islet autotransplantation in the treatment of chronic pancreatitis: A report from the International Consensus Guidelines in chronic pancreatitis. Pancreatology 2020; 20:762-771. [PMID: 32327370 DOI: 10.1016/j.pan.2020.04.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 03/18/2020] [Accepted: 04/06/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advances in our understanding of total pancreatectomy with islet autotransplantation (TPIAT) have been made. We aimed to define indications and outcomes of TPIAT. METHODS Expert physician-scientists from North America, Asia, and Europe reviewed the literature to address six questions selected by the writing group as high priority topics. A consensus was reached by voting on statements generated from the review. RESULTS Consensus statements were voted upon with strong agreement reached that (Q1) TPIAT may improve quality of life, reduce pain and opioid use, and potentially reduce medical utilization; that (Q3) TPIAT offers glycemic benefit over TP alone; that (Q4) the main indication for TPIAT is disabling pain, in the absence of certain medical and psychological contraindications; and that (Q6) islet mass transplanted and other disease features may impact diabetes mellitus outcomes. Conditional agreement was reached that (Q2) the role of TPIAT for all forms of CP is not yet identified and that head-to-head comparative studies are lacking, and that (Q5) early surgery is likely to improve outcomes as compared to late surgery. CONCLUSIONS Agreement on TPIAT indications and outcomes has been reached through this working group. Further studies are needed to answer the long-term outcomes and maximize efforts to optimize patient selection.
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Affiliation(s)
- Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Takayuki Anazawa
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Ashley R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, University of Leicester, UK
| | - Vikas Dudeja
- Department of Surgery, University of Miami, Miami, FL, USA
| | - Martin L Freeman
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Helmut Friess
- Department of Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Jorg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Marlon F Levy
- Division of Transplant Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, University of Munich, LMU, Germany
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - John P Neoptolemos
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Andrea R G Sheel
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - David C Whitcomb
- Department of Medicine, Cell Biology & Physiology, and Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melena D Bellin
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA; Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.
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22
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Shanbhogue KP, Pourvaziri A, Jeyaraj SK, Kambadakone A. Endoscopic and surgical treatment options for chronic pancreatitis: an imaging perspective. Abdom Radiol (NY) 2020; 45:1397-1409. [PMID: 31707437 DOI: 10.1007/s00261-019-02249-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic pancreatitis is a chronic fibro-inflammatory syndrome characterized by chronic pancreatic inflammation leading to fibrosis and scarring. Patients with this multifactorial debilitating illness often require endoscopic or surgical intervention for treatment. Radiologists play a crucial role in pre-therapeutic workup as well as post-treatment imaging of chronic pancreatitis. This review summarizes the most common surgical and endoscopic treatment options that are currently available for chronic pancreatitis, including the implications on imaging.
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Kent ML, Hurley RW, Oderda GM, Gordon DB, Sun E, Mythen M, Miller TE, Shaw AD, Gan TJ, Thacker JKM, McEvoy MD. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives. Anesth Analg 2020; 129:543-552. [PMID: 30897590 DOI: 10.1213/ane.0000000000003941] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naïve patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.
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Affiliation(s)
- Michael L Kent
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Robert W Hurley
- Departments of Anesthesiology and Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Gary M Oderda
- College of Pharmacy, University of Utah, Salt Lake City, Utah
| | - Debra B Gordon
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Eric Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Monty Mythen
- University College London National Institute of Health Research (NIHR) Biomedical Research Centre, London, United Kingdom
| | - Timothy E Miller
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Julie K M Thacker
- Division of Advanced Oncologic and Gastrointestinal Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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J. C. C, Parks RW. Chronic Pancreatitis—Update on Pathophysiology and Therapeutic Approaches. Indian J Surg 2020. [DOI: 10.1007/s12262-019-02059-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AbstractChronic pancreatitis is an inflammatory condition characterized by structural change within the pancreas, that leads to progressive and irreversible loss of functioning pancreatic parenchyma, exocrine/endocrine dysfunction and an increased risk of pancreatic ductal adenocarcinoma. Whilst hallmarks of advanced disease are readily identifiable on routine clinical imaging, concordance between structural changes within the pancreas and symptoms is poor, such that early diagnosis can be challenging. Traditionally, chronic pancreatitis has been managed with a ‘step-up’ approach of measures including analgesia, therapeutic endoscopy and surgery (in a select minority of patients). Accumulating evidence is emerging to challenge this approach: early surgical intervention may offer the opportunity to interrupt the disease process before irreversible sequelae become established. This article provides an overview of the pathophysiology underlying chronic pancreatitis together with a review of the current evidence to support established and novel therapeutic approaches to the disease.
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Lara LF, Bellin MD, Ugbarugba E, Nathan JD, Witkowski P, Wijkstrom M, Steel JL, Smith KD, Singh VK, Schwarzenberg SJ, Pruett TL, Naziruddin B, Long-Simpson L, Kirchner VA, Gardner TB, Freeman ML, Dunn TB, Chinnakotla S, Beilman GJ, Adams DB, Morgan KA, Abu-El-Haija MA, Ahmad S, Posselt AM, Hughes MG, Conwell DL. A Study on the Effect of Patient Characteristics, Geographical Utilization, and Patient Outcomes for Total Pancreatectomy Alone and Total Pancreatectomy With Islet Autotransplantation in Patients With Pancreatitis in the United States. Pancreas 2019; 48:1204-1211. [PMID: 31593020 PMCID: PMC7952005 DOI: 10.1097/mpa.0000000000001405] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES A selective therapy for pancreatitis is total pancreatectomy and islet autotransplantation. Outcomes and geographical variability of patients who had total pancreatectomy (TP) alone or total pancreatectomy with islet autotransplantation (TPIAT) were assessed. METHODS Data were obtained from the Healthcare Cost and Utilization Project National Inpatient Sample database. Weighed univariate and multivariate analyses were performed to determine the effect of measured variables on outcomes. RESULTS Between 2002 and 2013, there were 1006 TP and 825 TPIAT in patients with a diagnosis of chronic pancreatitis, and 1705 TP and 830 TPIAT for any diagnosis of pancreatitis. The majority of the TP and TPIAT were performed in larger urban hospitals. Costs were similar for TP and TPIAT for chronic pancreatitis but were lower for TPIAT compared with TP for any type of pancreatitis. The trend for TP and TPIAT was significant in all geographical areas during the study period. CONCLUSIONS There is an increasing trend of both TP and TPIAT. Certain groups are more likely to be offered TPIAT compared with TP alone. More data are needed to understand disparities and barriers to TPIAT, and long-term outcomes of TPIAT such as pain control and glucose intolerance need further study.
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Affiliation(s)
- Luis F. Lara
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Melena D. Bellin
- Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN
| | - Emmanuel Ugbarugba
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jaimie D. Nathan
- Department of Surgery, Cincinnati Children’s Hospital, Cincinnati, OH
| | | | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jennifer L. Steel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kerrington D. Smith
- Division of Surgical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Center, Baltimore, MD
| | | | - Timothy L. Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Bashoo Naziruddin
- Islet Cell Laboratory, Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | | | - Varvara A. Kirchner
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Timothy B. Gardner
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Martin L. Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical School, Minneapolis, MN
| | - Ty B. Dunn
- Division of Transplant Surgery, The University of Pennsylvania, Philadelphia, PA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - David B. Adams
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | | | | | - Syed Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Andrew M. Posselt
- Department of Surgery, University of California-San Francisco, San Francisco, CA
| | | | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
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Tian X, Ma Y, Gao H, Zhuang Y, Yang Y. Surgical options for control of abdominal pain in chronic pancreatitis patients. J Pain Res 2019; 12:2331-2336. [PMID: 31440077 PMCID: PMC6666366 DOI: 10.2147/jpr.s208212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 07/02/2019] [Indexed: 01/10/2023] Open
Abstract
Background Long lasting and unbearable abdominal pain is the most common symptom of chronic pancreatitis (CP). This study aimed to evaluate surgical options for the control of chronic pancreatic pain based on anatomical morphological changes. Methods A retrospective review of patients who underwent surgery for treatment of chronic pancreatic pain in Peking University First Hospital between January 2000 and December 2017 was performed. The surgical options included modified Puestow procedure, Frey procedure, Beger procedure, pancreaticoduodenectomy (PD) or pylorus preserving pancreaticoduodenectomy (PPPD), distal pancreatectomy and total pancreatectomy. Results Among 116 patients, pain relief rate after surgery was 82.6% (95/115) while 22 (23.2%) cases suffered recurrent chronic pancreatic pain during follow-up. Pain relief rate was 83.1% (54/65) after modified Puestow procedure, 63.6% (7/11) after distal pancreatectomy, 83.3% (10/12) after PD/PPPD, 86.7% (13/15) after Frey procedure, and 90% (9/10) after Beger procedure. Pain recurrence rate was 27.8% (15/54) after modified Puestow procedure, 42.9% (3/7) after distal pancreatectomy, 10% (1/10) after PD/PPPD, 15.4% (2/13) after Frey procedure, and 11.1% (1/9) after Beger procedure. Conclusion The surgical options for the control of chronic pancreatic pain according to the anatomical morphological changes of CP is reasonable and effective. The procedure of distal pancreatectomy alone should be cautiously used for pain relief.
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Affiliation(s)
- Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
| | - Yongsu Ma
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
| | - Hongqiao Gao
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
| | - Yan Zhuang
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
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Wang J, Zhang Y, Cloud C, Duke T, Owczarski S, Mehrotra S, Adams DB, Morgan K, Gilkeson G, Wang H. Mesenchymal Stem Cells from Chronic Pancreatitis Patients Show Comparable Potency Compared to Cells from Healthy Donors. Stem Cells Transl Med 2019; 8:418-429. [PMID: 30680957 PMCID: PMC6477001 DOI: 10.1002/sctm.18-0093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 11/07/2018] [Indexed: 12/27/2022] Open
Abstract
Mesenchymal stem cells (MSCs) are proven to be beneficial in islet transplantation, suggesting a potential therapeutic role of them in total pancreatectomy with islet autotransplantation (TP-IAT) for chronic pancreatitis (CP) patients. We investigated whether MSCs derived from CP patients are suitable for use in autologous cell therapy. MSCs from healthy donors (H-MSCs) and CP patients (CP-MSCs) were studied for phenotype, colony formation potential, multilineage differentiation ability, proliferation, senescence, secretory characters, and immunosuppressive functions. The potential protective effect of CP-MSCs was evaluated on hypoxia-induced islet cell death. Cell surface markers were similar between H-MSCs and CP-MSCs, as well as the ability of colony formation, multilineage differentiation, secretion of vascular endothelial growth factor and transforming growth factor (TGF-β), senescence, and inhibition of T cells proliferation in vitro. We found that growth differentiation factor 6 and hepatocyte growth factor (HGF) were significantly downregulated, whereas TGFβ and matrix metalloproteinase-2 were significantly upregulated in CP-MSCs compared with H-MSCs, among 84 MSC-related genes investigated in this study. MSCs from CP patients secreted less HGF, compared with the H-MSCs. A higher interferon-γ-induced indoleamine 2,3-dioxygenase expression was observed in CP-MSCs compared to H-MSCs. Moreover, CP-MSCs prevented hypoxia-induced β cell deaths to a similar extent as H-MSCs. Regardless of moderate difference in gene expression, CP-MSCs possess similar immunomodulatory and prosurvival functions to H-MSCs, and may be suitable for autologous cell therapy in CP patients undergoing TP-IAT. Stem Cells Translational Medicine 2019;8:418-429.
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Affiliation(s)
- Jingjing Wang
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Yong Zhang
- College of Life ScienceQingdao Agricultural UniversityQingdaoPeople's Republic of China
| | - Colleen Cloud
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Tara Duke
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Stefanie Owczarski
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Shikhar Mehrotra
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - David B. Adams
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Katherine Morgan
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Gary Gilkeson
- Department of MedicineMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Hongjun Wang
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
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Abstract
The selection of optimum surgical procedure from the range of reported operations for chronic pancreatitis (CP) can be difficult. The aim of this study is to explore geographical variation in reporting of elective surgery for CP. A systematic search of the literature was performed using the Scopus database for reports of five selected procedures for CP: duodenum-preserving pancreatic head resection, total pancreatectomy with islet autotransplantation (TPIAT), Frey pancreaticojejunostomy, thoracoscopic splanchnotomy and the Izbicki V-shaped resection. The keyword and MESH heading 'chronic pancreatitis' was used. Overall, 144 papers met inclusion criteria and were utilized for data extraction. There were 33 reports of duodenum-preserving pancreatic head resection. Twenty-one (64%) were from Germany. There were 60 reports of TPIAT, 53 (88%) from the USA. There are only two reports of TPIAT from outwith the USA and UK. The 34 reports of the Frey pancreaticojejunostomy originate from 12 countries. There were 20 reports of thoracoscopic splanchnotomy originating from nine countries. All three reports of the Izbicki 'V' procedure are from Germany. There is geographical variation in reporting of surgery for CP. There is a need for greater standardization in the selection and reporting of surgery for patients with painful CP.
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29
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Retrospective Evaluation of the Perioperative Management of Patients Undergoing Total Pancreatectomy With Islet Autotransplantation: Single Institution Review. Pancreas 2019; 48:228-232. [PMID: 30629028 PMCID: PMC7179733 DOI: 10.1097/mpa.0000000000001236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The aim of this retrospective descriptive study was to examine associations with the perioperative management of patients undergoing total pancreatectomy with islet autotransplantation, which may impact complication rate and hospital length of stay. METHODS We retrospectively collected data on 165 patients, and 161 patients were included in the final analysis. Data collected included preoperative, intraoperative, and postoperative patient and procedural characteristics. RESULTS Approximately 46.6% of patients experienced 1 or more complications. The occurrence of complications was associated with postoperative day 1 hemoglobin levels, use of intraoperative goal-directed therapy, estimated intraoperative blood loss, and total amount of intraoperative insulin given. Hospital length of stay was significantly associated with number of complications, use of goal-directed therapy, procedure duration, and postoperative day 1 hemoglobin levels. CONCLUSIONS Overall, our retrospective descriptive study adds to the emerging body of literature determining optimal perioperative management of patients undergoing total pancreatectomy with islet autotransplantation.
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30
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Jawahar AP, Narayanan S, Loganathan G, Pradeep J, Vitale GC, Jones CM, Hughes MG, Williams SK, Balamurugan AN. Ductal Cell Reprogramming to Insulin-Producing Beta-Like Cells as a Potential Beta Cell Replacement Source for Chronic Pancreatitis. Curr Stem Cell Res Ther 2019; 14:65-74. [DOI: 10.2174/1574888x13666180918092729] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 01/19/2023]
Abstract
Islet cell auto-transplantation is a novel strategy for maintaining blood glucose levels and
improving the quality of life in patients with chronic pancreatitis (CP). Despite the many recent advances
associated with this therapy, obtaining a good yield of islet infusate still remains a pressing
challenge. Reprogramming technology, by making use of the pancreatic exocrine compartment, can
open the possibility of generating novel insulin-producing cells. Several lineage-tracing studies present
evidence that exocrine cells undergo dedifferentiation into a progenitor-like state from which they can
be manipulated to form insulin-producing cells. This review will present an overview of recent reports
that demonstrate the potential of utilizing pancreatic ductal cells (PDCs) for reprogramming into insulin-
producing cells, focusing on the recent advances and the conflicting views. A large pool of ductal
cells is released along with islets during the human islet isolation process, but these cells are separated
from the pure islets during the purification process. By identifying and improving existing ductal cell
culture methods and developing a better understanding of mechanisms by which these cells can be manipulated
to form hormone-producing islet-like cells, PDCs could prove to be a strong clinical tool in
providing an alternative beta cell source, thus helping CP patients maintain their long-term glucose levels.
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Affiliation(s)
- Aravinth P. Jawahar
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Siddharth Narayanan
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Gopalakrishnan Loganathan
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Jithu Pradeep
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Gary C. Vitale
- Division of General Surgery, University of Louisville, Louisville, KY, 40202, United States
| | - Christopher M. Jones
- Division of Transplant Surgery, University of Louisville, Louisville, KY, 40202, United States
| | - Michael G. Hughes
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Stuart K. Williams
- Department of Physiology, University of Louisville, Louisville, KY, 40202, United States
| | - Appakalai N. Balamurugan
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
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Abstract
PURPOSE OF REVIEW We reviewed the current state of total pancreatectomy with islet autotransplantation (TPIAT) for chronic pancreatitis and recurrent acute pancreatitis (RAP). RECENT FINDINGS An increasing number of centers in the United States and internationally are performing TPIAT. In selected cases, TPIAT may be performed partially or entirely laparoscopically. Islet isolation is usually performed at the same center as the total pancreatectomy surgery, but new data suggest that diabetes outcomes may be nearly as good when a remote center is used for islet isolation. Ongoing clinical research is focused on patient and disease factors that predict success or failure to respond to TPIAT. Causes of persistent abdominal pain after TPIAT may include gastrointestinal dysmotility and central sensitization to pain. Several clinical trials are underway with anti-inflammatory or other islet protective strategies to better protect islets at the time of infusion and thereby improve the diabetes results of the procedure. SUMMARY In summary, there is an increasing body of literature emerging from multiple centers highlighting the benefits and persistent challenges of TPIAT for chronic pancreatitis and RAP. Ongoing study will be critical to optimizing the success of this procedure.
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Bellin MD, Abu-El-Haija M, Morgan K, Adams D, Beilman GJ, Chinnakotla S, Conwell DL, Dunn TB, Freeman ML, Gardner T, Kirchner VA, Lara LF, Long-Simpson L, Nathan JD, Naziruddin B, Nyman JA, Pruett TL, Schwarzenberg SJ, Singh VK, Smith K, Steel JL, Wijkstrom M, Witkowski P, Hodges JS. A multicenter study of total pancreatectomy with islet autotransplantation (TPIAT): POST (Prospective Observational Study of TPIAT). Pancreatology 2018; 18:286-290. [PMID: 29456124 PMCID: PMC5879010 DOI: 10.1016/j.pan.2018.02.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Total pancreatectomy with islet autotransplantation (TPIAT) is considered for managing chronic pancreatitis in selected patients when medical and endoscopic interventions have not provided adequate relief from debilitating pain. Although more centers are performing TPIAT, we lack large, multi-center studies to guide decisions about selecting candidates for and timing of TPIAT. METHODS Multiple centers across the United States (9 to date) performing TPIAT are prospectively enrolling patients undergoing TPIAT for chronic pancreatitis into the Prospective Observational Study of TPIAT (POST), a NIDDK funded study with a goal of accruing 450 TPIAT recipients. Baseline data include participant phenotype, pancreatitis history, and medical/psychological comorbidities from medical records, participant interview, and participant self-report (Medical Outcomes Survey Short Form-12, EQ-5D, andPROMIS inventories for pain interference, depression, and anxiety). Outcome measures are collected to at least 1 year after TPIAT, including the same participant questionnaires, visual analog pain scale, pain interference scores, opioid requirements, insulin requirements, islet graft function, and hemoglobin A1c. Health resource utilization data are collected for a cost-effectiveness analysis. Biorepository specimens including urine, serum/plasma, genetic material (saliva and blood), and pancreas tissue are collected for future study. CONCLUSIONS This ongoing multicenter research study will enroll and follow TPIAT recipients, aiming to evaluate patient selection and timing for TPIAT to optimize pain relief, quality of life, and diabetes outcomes, and to measure the procedure's cost-effectiveness. A biorepository is also established for future ancillary studies.
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Affiliation(s)
- Melena D Bellin
- University of Minnesota Medical School, Minneapolis, MN, United States.
| | | | - Katherine Morgan
- The Medical University of South Carolina, Charleston, SC, United States
| | - David Adams
- The Medical University of South Carolina, Charleston, SC, United States
| | - Gregory J Beilman
- University of Minnesota Medical School, Minneapolis, MN, United States
| | | | - Darwin L Conwell
- The Ohio State Wexner University Medical Center, Columbus, OH, United States
| | - Ty B Dunn
- University of Minnesota Medical School, Minneapolis, MN, United States
| | - Martin L Freeman
- University of Minnesota Medical School, Minneapolis, MN, United States
| | - Timothy Gardner
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | | | - Luis F Lara
- The Ohio State Wexner University Medical Center, Columbus, OH, United States
| | | | - Jaimie D Nathan
- Cincinnati Children's Hospital, Cincinnati, OH, United States
| | | | - John A Nyman
- University of Minnesota Medical School, Minneapolis, MN, United States
| | - Timothy L Pruett
- University of Minnesota Medical School, Minneapolis, MN, United States
| | | | - Vikesh K Singh
- John Hopkins Medical Institutions, Baltimore, MD, United States
| | | | - Jennifer L Steel
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Martin Wijkstrom
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | | | - James S Hodges
- University of Minnesota School of Public Health, Minneapolis, MN, United States
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Bogachus LD, Bellin MD, Vella A, Robertson RP. Deficient Glucagon Response to Hypoglycemia During a Mixed Meal in Total Pancreatectomy/Islet Autotransplantation Recipients. J Clin Endocrinol Metab 2018; 103:1522-1529. [PMID: 29351616 PMCID: PMC6276676 DOI: 10.1210/jc.2017-02182] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/12/2018] [Indexed: 12/26/2022]
Abstract
CONTEXT Total pancreatectomy and intrahepatic islet autotransplantation (TP/IAT) is performed to alleviate severe abdominal pain, avoid narcotic use, maintain islet function, and avoid diabetes in patients with chronic pancreatitis. However, many TP/IAT recipients complain of postprandial hypoglycemia. OBJECTIVE This study was designed to discover the mechanisms of this problem. DESIGN Participants consumed a triple-isotope mixed meal. SETTING This study was performed in a hospital research unit. PARTICIPANTS We studied 10 TP/IAT recipients and 10 age- and body mass index-matched control subjects. Seven of 10 recipients had a history of postprandial hypoglycemia. INTERVENTIONS Participants were given a [1-13C]-labeled mixed meal and two tracer infusions ([6,6-2H2]- and [6-3H]-glucose). MAIN OUTCOME MEASURES Glucose kinetics and concentrations of regulatory hormones were determined. RESULTS Immediately after the meal, peak glucose was elevated in recipients compared with control subjects [266 ± 20 mg/dL (14.8 ± 1.1 mmol/L) vs 185 ± 13 mg/dL (10.3 ± 0.7 mmol/L); P = 0.01]. However, mean Δ glucose for TP/IAT recipients between minutes 240 and 360 postprandially was significantly lower than for control subjects (P < 0.05); six of the seven recipients with a history of hypoglycemia experienced abnormally low postprandial Δ glucose. Δ Glucagon remained unchanged (minutes 240 to 360; P = 0.58) in TP/IAT recipients despite abnormal decreases in postprandial glucose. Radioisotopic studies revealed that meal appearance, glucose disappearance, and endogenous glucose production in TP/IAT recipients were not different from control subjects. CONCLUSION Initially high glucose levels followed by hypoglycemia with an absent glucagon response is a mechanistic sequence that contributes to postprandial hypoglycemia after TP/IAT.
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Affiliation(s)
- Lindsey D Bogachus
- Pacific Northwest Diabetes Research Institute, Seattle, Washington
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition,
University of Washington, Seattle, Washington
| | - Melena D Bellin
- Department of Medicine and Pediatrics, Division of Diabetes, Endocrinology, and
Metabolism, University of Minnesota, Minneapolis, Minnesota
| | - Adrian Vella
- Mayo Clinic College of Medicine, Division of Endocrinology, Diabetes, and
Metabolism, Rochester, Minnesota
| | - R Paul Robertson
- Pacific Northwest Diabetes Research Institute, Seattle, Washington
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition,
University of Washington, Seattle, Washington
- Department of Medicine and Pediatrics, Division of Diabetes, Endocrinology, and
Metabolism, University of Minnesota, Minneapolis, Minnesota
- Correspondence and Reprint Requests: R. Paul Robertson, MD, Pacific Northwest Diabetes Research Institute, 720
Broadway, Seattle, Washington 98122. E-mail:
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34
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Morgan KA, Lancaster WP, Owczarski SM, Wang H, Borckardt J, Adams DB. Patient Selection for Total Pancreatectomy with Islet Autotransplantation in the Surgical Management of Chronic Pancreatitis. J Am Coll Surg 2017; 226:446-451. [PMID: 29289751 DOI: 10.1016/j.jamcollsurg.2017.12.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Best practice to select patients with chronic pancreatitis for surgical management with total pancreatectomy with islet autotransplantation (TPIAT) is in evolution as new discoveries are made in the pathogenesis of chronic pancreatitis. STUDY DESIGN A prospectively maintained database of patients undergoing TPIAT was reviewed. Islet function was inferred from daily insulin requirement. Pain relief was evaluated by healthcare use and narcotic use. Quality of life (QOL) was measured with the RAND 12-Item Short Form Survey. RESULTS One hundred and ninety-five patients (141 women, aged 40.3 years, BMI 26.5 kg/m2) underwent TPIAT. Mean duration of disease before operation was 8.1 years. Fifty-six (29%) patients had pancreatic operations before TPIAT, 37 (19%) patients were diabetic preoperatively, and 52 (27%) patients were smokers. A mean of 3,253 islet equivalents transplanted/kg were harvested. Insulin independence was achieved in 29%, 28%, and 23% of patients at 1, 2, and 5 years postoperative. Nonsmokers with a shorter duration of chronic pancreatitis and no earlier pancreas operation were more likely to be insulin free. Median number of preoperative emergency department visits and hospitalizations were 6.6 and 4.3 annually, respectively, compared with 0 at 1, 2, and 5 years postoperative. Median oral morphine equivalents were 214 mg/kg preoperation and 60, 64, 69, at 1, 2, 5 years postoperative. Preoperative, 1, 2, 5 years postoperative QOL scores were 29, 36, 34, and 33 (physical; p < 0.01) and 39, 44, 42, and 42 (mental health; p < 0.02). Genetic pancreatitis patients were more often narcotic free and had better QOL than patients with pancreatitis of other causes. At 5 years, overall survival was 92.3%. CONCLUSIONS Total pancreatectomy with islet autotransplantation is a durable operation, with islet function, pain relief, and QOL improvements persisting to 5 years postoperative. Patients with genetic pancreatitis, short duration of disease, and nonsmokers have superior outcomes.
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Affiliation(s)
- Katherine A Morgan
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC.
| | - William P Lancaster
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC
| | - Stefanie M Owczarski
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC
| | - Hongjun Wang
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC
| | - Jeffrey Borckardt
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC
| | - David B Adams
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC
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Pain Control, Glucose Control, and Quality of Life in Patients With Chronic Pancreatitis After Total Pancreatectomy With Islet Autotransplantation: A Preliminary Report. Transplant Proc 2017; 49:2333-2339. [DOI: 10.1016/j.transproceed.2017.10.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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The Characteristics of Aborted Procedures in Total Pancreatectomy With Islet Autotransplantation for Chronic Pancreatitis. Pancreas 2017; 46:e76-e78. [PMID: 28902801 DOI: 10.1097/mpa.0000000000000908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Total Pancreatectomy With Islet Autotransplantation for Acute Recurrent and Chronic Pancreatitis. ACTA ACUST UNITED AC 2017; 15:548-561. [PMID: 28895017 DOI: 10.1007/s11938-017-0148-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The first total pancreatectomy and islet autotransplantation (TP-IAT) was performed for chronic pancreatitis in 1977 with the goal to ameliorate the pain and simultaneously preserve islet function. We reviewed the recent medical literature regarding indications, patient suitability, current outcomes, and challenges in TP-IAT. RECENT FINDINGS Current indications for TP-IAT include intractable pain secondary to chronic pancreatitis (CP) or acute recurrent pancreatitis (ARP) with failed medical and endoscopic/surgical management. Independent studies have shown that TP-IAT is associated with elimination or significant improvement in pain control and partial or full islet graft function in the majority of patients. In single-center cost analyses, TP-IAT has been suggested to be more cost-effective than medical management of chronic pancreatitis. While initially introduced as a surgical option for adults with long-standing chronic pancreatitis, TP-IAT is now often utilized in children with chronic pancreatitis and in children and adults with intractable acute recurrent pancreatitis. The surgical procedure has evolved over time with some centers offering minimally invasive operative options, although the open approach remains the standard. Despite many advances in TP-IAT, there is a need for further research and development in disease diagnosis, patient selection, optimization of surgical technique, islet isolation and quality assessment, postoperative patient management, and establishment of uniform metrics for data collection and multicenter studies. TP-IAT is an option for patients with otherwise intractable acute recurrent or chronic pancreatitis which presents potential for pain relief and improved quality of life, often with partial or complete diabetes remission.
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Bogachus LD, Oseid E, Bellin M, Vella A, Robertson RP. Deficient Endogenous Glucose Production During Exercise After Total Pancreatectomy/Islet Autotransplantation. J Clin Endocrinol Metab 2017; 102:3288-3295. [PMID: 28911142 PMCID: PMC5587075 DOI: 10.1210/jc.2017-00923] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/06/2017] [Indexed: 01/08/2023]
Abstract
CONTEXT Total pancreatectomy followed by intrahepatic islet autotransplantation (TP/IAT) is performed to alleviate severe, unrelenting abdominal pain caused by chronic pancreatitis, to improve quality of life, and to prevent diabetes. OBJECTIVE To determine the cause of exercise-induced hypoglycemia that is a common complaint in TP/IAT recipients. DESIGN Participants completed 1 hour of steady-state exercise. SETTING Hospital research unit. PATIENTS AND OTHER PARTICIPANTS We studied 14 TP/IAT recipients and 10 age- and body mass index-matched control subjects. INTERVENTIONS Peak oxygen uptake (VO2) was determined via a symptom-limited maximal cycle ergometer test. Fasted subjects then returned for a primed [6,6-2H2]-glucose infusion to measure endogenous glucose production while completing 1 hour of bicycle exercise at either 40% or 70% peak VO2. MAIN OUTCOME MEASURES Blood samples were obtained to measure glucose metabolism and counterregulatory hormones before, during, and after exercise. RESULTS Although the Borg Rating of Perceived Exertion did not differ between recipients and control subjects, aerobic capacity was significantly higher in controls than in recipients (40.4 ± 2.0 vs 27.2 ± 1.4 mL/kg per minute; P < 0.001). This difference resulted in workload differences between control subjects and recipients to reach steady-state exercise at 40% peak VO2 (P = 0.003). Control subjects significantly increased their endogenous glucose production from 12.0 ± 1.0 to 15.2 ± 1.0 µmol/kg per minute during moderate exercise (P = 0.01). Recipients did not increase endogenous glucose production during moderate exercise (40% peak VO2) but succeeded during heavy exercise, from 10.1 ± 0.4 to 14.8 ± 2.0 µmol/kg per minute (70% peak VO2; P = 0.001). CONCLUSIONS Failure to increase endogenous glucose production during moderate exercise may be a key contributor to the hypoglycemia TP/IAT recipients experience.
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Affiliation(s)
- Lindsey D. Bogachus
- Pacific Northwest Diabetes Research Institute, Seattle, Washington 98122
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, Washington 98195
| | - Elizabeth Oseid
- Pacific Northwest Diabetes Research Institute, Seattle, Washington 98122
| | - Melena Bellin
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicines and Pediatrics, University of Minnesota, Minneapolis, Minnesota 55455
| | - Adrian Vella
- Division of Endocrinology, Diabetes, and Metabolism, Mayo Clinic College of Medicine, Rochester, Minnesota 55905
| | - R. Paul Robertson
- Pacific Northwest Diabetes Research Institute, Seattle, Washington 98122
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, Washington 98195
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicines and Pediatrics, University of Minnesota, Minneapolis, Minnesota 55455
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Moran RA, Klapheke R, John GK, Devlin S, Warren D, Desai N, Sun Z, Walsh C, Kalyani RR, Hall E, Stein EM, Kalloo AN, Zaheer A, Hirose K, Makary MA, Singh VK. Prevalence and predictors of pain and opioid analgesic use following total pancreatectomy with islet autotransplantation for pancreatitis. Pancreatology 2017; 17:732-737. [PMID: 28733148 DOI: 10.1016/j.pan.2017.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 06/12/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & OBJECTIVES Total pancreatectomy with islet autotransplantation (TPIAT) is employed for the management of refractory pain in chronic pancreatitis (CP) with the prospect of partial beta cell preservation. The primary aim of this study is to evaluate the prevalence and predictors of abdominal pain and opioid use following TPIAT. METHODS A single center cohort study of all adult patients who underwent TPIAT from 2011 to 2015 for CP. Postoperative pain outcomes included: opioid use, ongoing abdominal pain and new characteristic abdominal pain. Multiple logistic regression analysis was used to evaluate known and potential predictors of postoperative pain outcomes. RESULTS During the study period, 46 patients underwent TPIAT. Following surgery, 89% of patients had resolution of their pre-operative abdominal pain; however, 83% of patients developed a new characteristic abdominal pain. Opioid independence was achieved in 46% of patients. Acute recurrent pancreatitis (ARP) (OR: 11.66; 95%CI: 1.47-92.39; p = 0.02) but not pain duration >3 years or ≥ 5 ERCPs was independently associated with resolution of pre-operative abdominal pain on multiple logistic regression. None of these factors were associated with cessation of opioid use. CONCLUSION While the majority of patients have resolution of their initial abdominal pain following TPIAT, many will also develop a new characteristic abdominal pain and only half of all patients achieve opioid independence. ARP is the only independent factor associated with positive postoperative pain outcomes and should be considered a standard criterion for patient selection.
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Affiliation(s)
- Robert A Moran
- Pancreatitis Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert Klapheke
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - George K John
- Pancreatitis Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Devlin
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Warren
- The Comprehensive Transplantation Unit, Johns Hopkins University School of Medical, Baltimore, MD, USA
| | - Niraj Desai
- The Comprehensive Transplantation Unit, Johns Hopkins University School of Medical, Baltimore, MD, USA
| | - Zhaoli Sun
- The Comprehensive Transplantation Unit, Johns Hopkins University School of Medical, Baltimore, MD, USA
| | - Christi Walsh
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medical, Baltimore, MD, USA
| | - Rita R Kalyani
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medical, Baltimore, MD, USA
| | - Erica Hall
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medical, Baltimore, MD, USA
| | - Ellen M Stein
- Pancreatitis Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anthony N Kalloo
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Atif Zaheer
- Pancreatitis Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Abdominal Imaging, Department of Radiology, Johns Hopkins University School of Medical, Baltimore, MD, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medical, Baltimore, MD, USA
| | - Martin A Makary
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medical, Baltimore, MD, USA
| | - Vikesh K Singh
- Pancreatitis Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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John GK, Singh VK, Moran RA, Warren D, Sun Z, Desai N, Walsh C, Kalyani RR, Hall E, Hirose K, Makary MA, Stein EM. Chronic Gastrointestinal Dysmotility and Pain Following Total Pancreatectomy with Islet Autotransplantation for Chronic Pancreatitis. J Gastrointest Surg 2017; 21:622-627. [PMID: 28083839 DOI: 10.1007/s11605-016-3348-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 12/30/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The prevalence and impact of chronic gastrointestinal dysmotility following total pancreactectomy with islet autotransplantation (TP-IAT) for chronic pancreatitis is not known. METHODS A cross-sectional study of all patients who underwent TP-IAT at our institution from August 2011 to November 2015 was undertaken. The GCSI (Gastroparesis Cardinal Symptom Index), PAGI-SYM (Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index), PAC-SYM (Patient Assessment of Constipation Symptoms), Bristol stool chart, 12-item Short Form Health Survey (SF-12), and visual analog scale for pain were administered ≥4 weeks following TP-IAT. KEY RESULTS The prevalence of any dysmotility symptoms in patients who completed the survey (33/45, 73%) post-TP-IAT was 45%. Post-TP-IAT, the mean reduction in opioid dosing was 77.6 oral morphine equivalents (OMEs) (95% CI 32.1-123.0, p = 0.002) with 42% of patients requiring no opioids. There was significant negative correlation between dysmotility scores and SF-12 physical scores (r = -0.46, p = 0.008, 95% CI -0.70 to -0.13). Self-reported abdominal pain had significant negative correlation with both physical and mental SF-12 scores (r = -0.67, p < 0.001, 95% CI -0.83 to -0.41 and r = -0.39, p = 0.03, 95% CI -0.65 to -0.04). There was no correlation between gastrointestinal dysmotility and self-reported pain. CONCLUSIONS AND INFERENCES Symptoms of chronic gastrointestinal dysmotility and chronic abdominal pain are common post-TP-IAT and will need to be better recognized and differentiated to improve the management of these patients.
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Affiliation(s)
- George K John
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA.,Pancreatitis Center, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Robert A Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA.,Pancreatitis Center, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Daniel Warren
- Division of Surgical Oncology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Zhaoli Sun
- Division of Surgical Oncology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Niraj Desai
- Division of Surgical Oncology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Christi Walsh
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Rita R Kalyani
- Division of Transplant Surgery, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Erica Hall
- Division of Transplant Surgery, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Kenzo Hirose
- Pancreatitis Center, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA.,Division of Surgical Oncology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Martin A Makary
- Pancreatitis Center, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA.,Division of Surgical Oncology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
| | - Ellen M Stein
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA. .,Pancreatitis Center, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA. .,Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA.
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Bellin MD, Beilman GJ, Dunn TB, Pruett TL, Sutherland DER, Chinnakotla S, Hodges JS, Lane A, Ptacek P, Berry KL, Hering BJ, Moran A. Sitagliptin Treatment After Total Pancreatectomy With Islet Autotransplantation: A Randomized, Placebo-Controlled Study. Am J Transplant 2017; 17:443-450. [PMID: 27459721 PMCID: PMC5266635 DOI: 10.1111/ajt.13979] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/19/2016] [Accepted: 07/12/2016] [Indexed: 01/25/2023]
Abstract
Insulin independence after total pancreatectomy and islet autotransplant (TPIAT) for chronic pancreatitis is limited by a high rate of postprocedure beta cell apoptosis. Endogenous glucagon-like peptide-1 and glucose-dependent insulinotropic peptide, which are increased by dipeptidyl peptidase 4 inhibitor therapy (sitagliptin) may protect against beta cell apoptosis. To determine the effect of sitagliptin after TPIAT, 83 adult TPIAT recipients were randomized to receive sitagliptin (n = 54) or placebo (n = 29) for 12 months after TPIAT. At 12 and 18 months after TPIAT, participants were assessed for insulin independence; metabolic testing was performed with mixed meal tolerance testing and frequent sample intravenous glucose tolerance testing. Insulin independence did not differ between the sitagliptin and placebo groups at 12 months (42% vs. 45%, p = 0.82) or 18 months (36% vs. 44%, p = 0.48). At 12 months, insulin dose was 9.0 (standard error 1.7) units/day and 7.9 (2.2) units/day in the sitagliptin and placebo groups, respectively (p = 0.67) and at 18 months 10.3 (1.9) and 7.1 (2.6) units/day, respectively (p = 0.32). Hemoglobin A1c levels and insulin secretory measures were similar in the two groups, as were adverse events. In conclusion, sitagliptin could be safely administered but did not improve metabolic outcomes after TPIAT.
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Affiliation(s)
- M D Bellin
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - G J Beilman
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - T B Dunn
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - T L Pruett
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - D E R Sutherland
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - S Chinnakotla
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - J S Hodges
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - A Lane
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - P Ptacek
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - K L Berry
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - B J Hering
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
| | - A Moran
- Departments of Pediatrics, Surgery, Biostatistics, Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN
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Muratore S, Zeng X, Korc M, McElyea S, Wilhelm J, Bellin M, Beilman G. Metastatic Pancreatic Adenocarcinoma After Total Pancreatectomy Islet Autotransplantation for Chronic Pancreatitis. Am J Transplant 2016; 16:2747-52. [PMID: 27137483 PMCID: PMC5007168 DOI: 10.1111/ajt.13851] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 04/21/2016] [Indexed: 01/25/2023]
Abstract
Total pancreatectomy with islet autotransplantation (TPIAT) is being used increasingly as a definitive treatment for chronic pancreatitis. Patients with chronic pancreatitis have an elevated risk of pancreatic cancer, which can also masquerade as acute or chronic pancreatitis, making the diagnosis challenging. We describe here the first case of pancreatic ductal adenocarcinoma developing in the liver of a patient after TPIAT for presumed benign chronic pancreatitis. Retrospective analysis of the patient's preoperative serum revealed normal carbohydrate antigen 19-9 and carcinoembryonic antigen levels but elevated levels of microRNAs -10b, -30c, and -106b compared with controls. Screening guidelines are important to reduce the risk of transplantation of malignant tissue. More sensitive screening tools, including the potential use of microRNAs, are needed to detect early preclinical disease, given the highly malignant nature of pancreatic cancer.
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Affiliation(s)
- S. Muratore
- Department of Surgery, University of Minnesota, Minneapolis, MN,Corresponding author: Sydne Muratore,
| | - X. Zeng
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - M. Korc
- Department of Medicine and the Pancreatic Cancer Signature Center, Indiana University School of Medicine, Indianapolis, IN
| | - S. McElyea
- Department of Medicine and the Pancreatic Cancer Signature Center, Indiana University School of Medicine, Indianapolis, IN
| | - J. Wilhelm
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - M. Bellin
- Department of Endocrinology, University of Minnesota, Minneapolis, MN
| | - G. Beilman
- Department of Surgery, University of Minnesota, Minneapolis, MN
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Bellin MD, Kerdsirichairat T, Beilman GJ, Dunn TB, Chinnakotla S, Pruett TL, Radosevich DR, Schwarzenberg SJ, Sutherland DER, Arain MA, Freeman ML. Total Pancreatectomy With Islet Autotransplantation Improves Quality of Life in Patients With Refractory Recurrent Acute Pancreatitis. Clin Gastroenterol Hepatol 2016; 14:1317-23. [PMID: 26965843 PMCID: PMC5538725 DOI: 10.1016/j.cgh.2016.02.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Therapeutic options are limited for patients with recurrent acute pancreatitis who have intractable symptoms despite maximal endoscopic and medical treatment, but equivocal or no morphologic or functional evidence of chronic pancreatitis. We performed a prospective observational cohort study to determine the efficacy of total pancreatectomy with islet autotransplantation (TPIAT) for these patients. METHODS We collected data from all patients undergoing TPIAT at the University of Minnesota from 2007 through 2013; 49 patients (42 female; mean age, 32.8 ± 7.8 years) had a diagnosis of recurrent acute pancreatitis not provoked by intervention, with negative or equivocal findings from nondiagnostic imaging or pancreatic function tests for chronic pancreatitis, and intractable pain between episodes. Data on insulin use, narcotic requirements, pain scores, and health-related quality of life were collected before TPIAT; 3 months, 6 months, and 1 year afterward; and then yearly. RESULTS All 49 patients studied required narcotics before TPIAT (45 daily users and 4 intermittent users); 2 had insulin-treated diabetes. At 1 year after TPIAT, 22 out of 48 patients (46%) reported no use of narcotic pain medications (P < .001 vs baseline). Health-related quality of life score, measured by the physical and mental component summary score, increased by approximately 1 standard deviation from the population mean (P < .001 for the physical component summary; P = .019 for the mental component summary). At 1 year after TPIAT, 21 out of 48 patients (45%) were insulin independent; their mean percent glycosylated hemoglobin A1c at 1 year after TPIAT was 6.0% ± 0.9% (5.2% ± 0.6% pre-TPIAT). CONCLUSIONS Patients with recurrent acute pancreatitis but lacking clear chronic pancreatitis benefit from TPIAT, with outcomes similar to those previously described for patients with chronic pancreatitis (improved quality of life and reduced narcotic use). For these patients who have otherwise limited surgical treatment options, TPIAT can be considered when medical and endoscopic therapies have failed.
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Factors Predicting Outcomes After a Total Pancreatectomy and Islet Autotransplantation Lessons Learned From Over 500 Cases. Ann Surg 2015; 262:610-22. [PMID: 26366540 DOI: 10.1097/sla.0000000000001453] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Our objective was to analyze factors predicting outcomes after a total pancreatectomy and islet autotransplantation (TP-IAT). BACKGROUND Chronic pancreatitis (CP) is increasingly treated by a TP-IAT. Postoperative outcomes are generally favorable, but a minority of patients fare poorly. METHODS In our single-centered study, we analyzed the records of 581 patients with CP who underwent a TP-IAT. Endpoints included persistent postoperative "pancreatic pain" similar to preoperative levels, narcotic use for any reason, and islet graft failure at 1 year. RESULTS In our patients, the duration (mean ± SD) of CP before their TP-IAT was 7.1 ± 0.3 years and narcotic usage of 3.3 ± 0.2 years. Pediatric patients had better postoperative outcomes. Among adult patients, the odds of narcotic use at 1 year were increased by previous endoscopic retrograde cholangiopancreatography (ERCP) and stent placement, and a high number of previous stents (>3). Independent risk factors for pancreatic pain at 1 year were pancreas divisum, previous body mass index >30, and a high number of previous stents (>3). The strongest independent risk factor for islet graft failure was a low islet yield-in islet equivalents (IEQ)-per kilogram of body weight. We noted a strong dose-response relationship between the lowest-yield category (<2000 IEQ) and the highest (≥5000 IEQ or more). Islet graft failure was 25-fold more likely in the lowest-yield category. CONCLUSIONS This article represents the largest study of factors predicting outcomes after a TP-IAT. Preoperatively, the patient subgroups we identified warrant further attention.
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Tanhehco YC, Weisberg S, Schwartz J. Pancreatic islet autotransplantation for nonmalignant and malignant indications. Transfusion 2015; 56:761-70. [DOI: 10.1111/trf.13417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 10/02/2015] [Accepted: 10/08/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Yvette C. Tanhehco
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
| | - Stuart Weisberg
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
| | - Joseph Schwartz
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
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Wilson GC, Sutton JM, Smith MT, Schmulewitz N, Salehi M, Choe KA, Levinsky NC, Brunner JE, Abbott DE, Sussman JJ, Edwards MJ, Ahmad SA. Completion pancreatectomy and islet cell autotransplantation as salvage therapy for patients failing previous operative interventions for chronic pancreatitis. Surgery 2015; 158:872-8; discussion 879-80. [PMID: 26173686 DOI: 10.1016/j.surg.2015.04.045] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 04/15/2015] [Accepted: 04/20/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE Traditional decompressive and/or pancreatic resection procedures have been the cornerstone of operative therapy for refractory abdominal pain secondary to chronic pancreatitis. Management of patients that fail these traditional interventions represents a clinical dilemma. Salvage therapy with completion pancreatectomy and islet cell autotransplantation (CPIAT) is an emerging treatment option for this patient population; however, outcomes after this procedure have not been well-studied. METHODS All patients undergoing CPIAT after previous decompressive and/or pancreatic resection for the treatment of chronic pancreatitis at our institution were identified for inclusion in this single-center observational study. Study end points included islet yield, narcotic requirements, glycemic control, and quality of life (QOL). QOL was assessed using the Short Form (SF)-36 health questionnaire. RESULTS Sixty-four patients underwent CPIAT as salvage therapy. The median age at time of CPIAT was 38 years (interquartile range [IQR], 14.7-65.4). The most common etiology of chronic pancreatitis was idiopathic pancreatitis (66%; n = 42) followed by genetically linked pancreatitis (9%; n = 6) and alcoholic pancreatitis (8%; n = 5). All of these patients had previously undergone prior limited pancreatic resection or decompressive procedure. The majority of patients (50%; n = 32) underwent prior pancreaticoduodenectomy, whereas the remainder had undergone distal pancreatectomy (17%; n = 11), Frey (13%; n = 8), Puestow (13%; n = 8), or Berne (8%; n = 5) procedures. Median time from initial surgical intervention to CPIAT was 28.1 months (IQR, 13.6-43.0). All of these patients underwent a successful CPIAT. Mean operative time was 502.2 minutes with average hospital duration of stay of 13 days. Islet cell isolation was feasible despite previous procedures with a mean islet yield of 331,304 islet cell equivalents, which totaled an islet cell autotransplantation of 4,737 ± 492 IEQ/kg body weight. Median patient follow-up was 21.2 months (IQR, 7.9-36.8). Before CPIAT, all patients required a mean of 120.8 morphine equivalent milligrams per day (MEQ/d), which improved to 48.5 MEQ (P < .001 compared with preoperative requirements) at most recent follow-up. Of these patients, 44% (n = 28) achieved narcotic independence. All patients were able to achieve stable glycemic control with a mean insulin requirement of 16 units per day. Of these patients, 20% (n = 13) were insulin independent after CPIAT. Mean postoperative glycosylated hemoglobin was 7.8% (range, 4.6-12.5). Islet cell viability was confirmed with endocrine testing and mean C-peptide levels 6 months after CPIAT were 0.91 ng/mL (range, 0.1-3.0). The SF-36 QOL survey administered postoperatively demonstrated improvement in all tested modules. CONCLUSION This study is the first to examine the results of salvage therapy with CPIAT for patients with refractory chronic pancreatitis. Patients undergoing CPIAT achieved improved postoperative narcotic requirements, stable glycemic control, and improved QOL.
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Affiliation(s)
- Gregory C Wilson
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jeffrey M Sutton
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Milton T Smith
- Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nathan Schmulewitz
- Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Marzieh Salehi
- Department of Endocrinology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nick C Levinsky
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - John E Brunner
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Michael J Edwards
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
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John GK, Singh VK, Pasricha PJ, Sinha A, Afghani E, Warren D, Sun Z, Desai N, Walsh C, Kalyani RR, Hall E, Hirose K, Makary MA, Stein EM. Delayed Gastric Emptying (DGE) Following Total Pancreatectomy with Islet Auto Transplantation in Patients with Chronic Pancreatitis. J Gastrointest Surg 2015; 19:1256-61. [PMID: 25986058 DOI: 10.1007/s11605-015-2848-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence and factors associated with delayed gastric emptying (DGE) in patients undergoing total pancreatectomy with islet auto transplantation (TP-IAT) for chronic pancreatitis are unknown. METHODS A retrospective study of all patients who underwent TP-IAT at Johns Hopkins Hospital (JHH) from August 2011 to November 2014 was performed. The International Study Group of Pancreatic Surgery (ISGPS) clinical grading of DGE was used in this study. KEY RESULTS A total of 39 patients with chronic pancreatitis underwent TP-IAT during the study period. The prevalence of DGE following TP-IAT was 35.9%. Twenty-five patients (64.1%) had no DGE, 10 (25.6%) had grade A, 2 (5.1%) had grade B, and 2 patients (5.1%) had grade C DGE. Patients with DGE had 5.7-fold higher odds of having a hospital length of stay (LOS) greater than 14 days (OR 5.70, 95% CI 1.37-23.76, p = 0.02). Patients undergoing laparoscopic TP-IAT had significantly shorter LOS (10.5 vs. 14 days, p = 0.02) and lower need for prokinetics (0.01) during the postoperative course. CONCLUSIONS AND INFERENCES DGE is common after TP-IAT and can prolong LOS. Laparoscopic TP-IAT lowers LOS and need for prokinetics postoperatively. Further studies are needed to determine if laparoscopic approaches will improve long-term dysmotility.
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Affiliation(s)
- George K John
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
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Haider M, Makary MA, Singh VK, Hirose K, Fishman EK, Zaheer A. Total pancreatectomy and islet autotransplantation for chronic pancreatitis: spectrum of postoperative CT findings. ACTA ACUST UNITED AC 2015; 40:2411-23. [DOI: 10.1007/s00261-015-0479-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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