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Darden CM, Mohammed ARH, Kirkland J, Kuncha J, Lawrence MC, Danobeitia JS, Beecherl E, Lee SHS, Gupta A, Naziruddin B. Total pancreatectomy with islet autotransplantation outcomes in patients with pancreatitis of genetic etiology: A single-center experience with a large cohort of patients. J Gastrointest Surg 2024:S1091-255X(24)00481-5. [PMID: 38834105 DOI: 10.1016/j.gassur.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/15/2024] [Accepted: 05/27/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE Total pancreatectomy with islet autotransplantation (TPIAT) is an effective treatment for patients with chronic pancreatitis (CP) when other interventions are unsuccessful. CP has many etiologies including heredity. Metabolic and pain relief outcomes after TPIAT are presented among patients with a genetic CP etiology compared with those with a nongenetic etiology in a large cohort of patients who underwent this procedure at our center. METHODS A retrospective analysis was performed of 237 patients undergoing TPIAT between 2006 and 2023. We analyzed the differences in patients with genetic (n = 56) vs nongenetic CP etiologies (n = 181) in terms of pre-TPIAT factors including patient characteristics and disease state, results from the isolation process, and outcomes such as long-term glycemic and pain control. RESULTS Patients with genetic CP underwent TPIAT at a significantly younger age (32.3 vs 41.3 years nongenetic; P < .0001) and endured symptoms for a significantly longer period (10 vs 6 years; P < .01). A significantly lower mass of islets was isolated from patients with genetic CP (P < .01), which increased with body mass index in both groups. Despite lower yields, patients with genetic CP maintained metabolic function similar to patients with nongenetic CP, as indicated by insulin independence and C-peptide, blood glucose, and hemoglobin A1C levels after TPIAT. Post-transplant narcotic usage and pain scores significantly decreased compared with those before TPIAT, and more patients with genetic CP were pain free and narcotic free after TPIAT. CONCLUSION Our data validate TPIAT as a beneficial procedure for patients enduring CP of genetic etiology. Pain that is inevitably recurrent after minor interventions owing to the nature of the disease and favorable TPIAT outcomes should be considered in the decision to perform early TPIAT in cases of genetic CP.
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Affiliation(s)
- Carly M Darden
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | | | - Jeffrey Kirkland
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Jayachandra Kuncha
- Islet Cell Laboratory, Baylor Scott & White Research Institute, Dallas, TX, United States
| | - Michael C Lawrence
- Islet Cell Laboratory, Baylor Scott & White Research Institute, Dallas, TX, United States
| | - J Sebastian Danobeitia
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Ernest Beecherl
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Seung Hee S Lee
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Amar Gupta
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Bashoo Naziruddin
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States.
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Vonderau JS, Desai CS. Type 3c: Understanding pancreatogenic diabetes. JAAPA 2022; 35:20-24. [PMID: 36219100 DOI: 10.1097/01.jaa.0000885140.47709.6f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACT Type 3c diabetes, also known as pancreatogenic diabetes, occurs when primary pancreatic disorders damage the pancreatic islets of Langerhans. Although often misdiagnosed as type 2 diabetes, type 3c diabetes is different in cause, clinical presentation, treatment, and prognosis. Patients with type 3c diabetes are more likely to experience complications and death related to hypoglycemic events. This article reviews the causes and management of type 3c diabetes, which is estimated to affect 5% to 10% of all patients with diabetes.
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Affiliation(s)
- Jennifer Shurney Vonderau
- Jennifer Shurney Vonderau is a clinical assistant professor in the PA program at the University of North Carolina at Chapel Hill, N.C. Chirag S. Desai is a professor of surgery, surgical director of liver transplant, and director of chronic pancreatitis and autologous islet cell transplant in the Department of Surgery, Division of Abdominal Transplant at the University of North Carolina Medical Center in Chapel Hill. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Ludwig S, Distler M, Schubert U, Schmid J, Thies H, Welsch T, Hempel S, Tonn T, Weitz J, Bornstein SR, Ludwig B. Quality of life and metabolic outcomes after total pancreatectomy and simultaneous islet autotransplantation. COMMUNICATIONS MEDICINE 2022; 2:24. [PMID: 35603294 PMCID: PMC9053265 DOI: 10.1038/s43856-022-00087-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 02/07/2022] [Indexed: 12/16/2022] Open
Abstract
Background Pancreas surgery remains technically challenging and is associated with considerable morbidity and mortality. Identification of predictive risk factors for complications have led to a stratified surgical approach and postoperative management. The option of simultaneous islet autotransplantation (sIAT) allows for significant attenuation of long-term metabolic and overall complications and improvement of quality of life (QoL). The potential of sIAT to stratify a priori the indication for total pancreatectomy is yet not adequately evaluated. Methods The aim of this analysis was to evaluate the potential of sIAT in patients undergoing total pancreatectomy to improve QoL, functional and overall outcome and therefore modify the surgical strategy towards earlier and extended indications. A center cohort of 24 patients undergoing pancreatectomy were simultaneously treated with IAT. Patients were retrospectively analyzed regarding in-hospital and overall mortality, postoperative complications, ICU stay, hospital stay, metabolic outcome, and QoL. Results Here we present that all patients undergoing primary total pancreatectomy or surviving complicated two-stage pancreas resection and receiving sIAT show excellent metabolic outcome (33% insulin independence, 66% partial graft function; HbA1c 6,1 ± 1,0%) and significant benefit regarding QoL. Primary total pancreatectomy leads to significantly improved overall outcome and a significant reduction in ICU- and hospital stay compared to a two-stage completion pancreatectomy approach. Conclusions The findings emphasize the importance of risk-stratified pancreas surgery. Feasibility of sIAT should govern the indication for primary total pancreatectomy particularly in high-risk patients. In rescue completion pancreatectomy sIAT should be performed whenever possible due to tremendous metabolic benefit and associated QoL. Pancreas surgery is complicated and associated with substantial risks and even danger of death. The surgical removal of the whole pancreas can be necessary for some indications but results in a severe form of diabetes. The method of islet autotransplantation (IAT) involves taking the pancreas, isolating the insulin-producing cells and returning these to the patient. This helps to preserve insulin production and minimises the impact of diabetes. We retrospectively analyzed a cohort of patients undergoing pancreatectomy that were simultaneously treated with IAT. The analysis included short-term and long-term surgical and diabetes-related outcomes as well as quality of life. All parameters indicated the benefit of IAT in patients that require extensive pancreas surgery. Offering IAT to patients may reduce surgical complications after pancreatectomy, enhance recovery, and therefore facilitate faster initiation of other therapies where needed. Ludwig and Distler et al. evaluate quality of life and metabolic outcomes in patients undergoing total pancreatectomy and simultaneous islet autotransplantation. The authors report benefits in terms of glycemic control, as well as improvements in quality of life, following the procedure.
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Swauger SE, Hornung LN, Elder DA, Balamurugan AN, Vitale DS, Lin TK, Nathan JD, Abu-El-Haija M. Predictors of Glycemic Outcomes at 1 Year Following Pediatric Total Pancreatectomy With Islet Autotransplantation. Diabetes Care 2022; 45:295-302. [PMID: 35007330 PMCID: PMC8914422 DOI: 10.2337/dc21-1222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/23/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Total pancreatectomy with islet autotransplantation (TPIAT) is indicated to alleviate debilitating pancreas-related pain and mitigate diabetes in patients with acute recurrent and chronic pancreatitis when medical/endoscopic therapies fail. Our aim was to evaluate predictors of insulin requirement at 1 year following TPIAT in a cohort of children. RESEARCH DESIGN AND METHODS This was a review of 43 pediatric patients followed after TPIAT for 1 year or longer. Primary outcome was insulin use at 1 year, categorized as follows: insulin independent, low insulin requirement (<0.5 units/kg/day), or high insulin requirement (≥0.5 units/kg/day). RESULTS At 1 year after TPIAT, 12 of 41 (29%) patients were insulin independent and 21 of 41 (51%) had low and 8 of 41 (20%) had high insulin requirement. Insulin-independent patients were younger than those with low and high insulin requirement (median age 8.2 vs. 14.6 vs. 13.1 years, respectively; P = 0.03). Patients with insulin independence had a higher number of transplanted islet equivalents (IEQ) per kilogram body weight (P = 0.03) and smaller body surface area (P = 0.02), compared with those with insulin dependence. Preoperative exocrine insufficiency was associated with high insulin requirement (P = 0.03). Higher peak C-peptide measured by stimulated mixed-meal tolerance testing (MMTT) at 3 and 6 months post-TPIAT was predictive of lower insulin requirement at 1 year (P = 0.006 and 0.03, respectively). CONCLUSIONS We conclude that insulin independence following pediatric TPIAT is multifactorial and associated with younger age, higher IEQ per kilogram body weight transplanted, and smaller body surface area at time of operation. Higher peak C-peptide measured by MMTT following TPIAT confers a higher likelihood of low insulin requirement.
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Affiliation(s)
- Sarah E Swauger
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lindsey N Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Deborah A Elder
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Appakalai N Balamurugan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine Cincinnati, OH
| | - David S Vitale
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tom K Lin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine Cincinnati, OH
| | - Maisam Abu-El-Haija
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Vonderau JS, Williams BM, DeCherney S, Jones MS, McKnight L, Hanson M, Hanson H, Desai CS. Use of Continuous Glucose Monitoring for evaluation of hypoglycemia pre- and post-operatively for patients undergoing Total Pancreatectomy with Autologous Islet Cell Transplant. Clin Transplant 2021; 35:e14450. [PMID: 34358370 DOI: 10.1111/ctr.14450] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Total pancreatectomy with autologous islet transplant (TPAIT) is indicated for patients with chronic pancreatitis to improve quality of life while reducing complications from hypoglycemia. Continuous glucose monitoring (CGM) was used to assess overall islet function and the incidence of hypoglycemia pre- and post-operatively. METHODS Nineteen patients who underwent TPAIT at a single center from 2018 to 2020 were included. Pre-operatively, patients were defined by diabetic status. HbA1c, stimulated C-peptide, and CGM were used to characterize glycemic function. RESULTS Pre-operatively, three patients had diabetes, and 16 patients did not have diabetes. Eight out of 16 non-diabetic patients were insulin independent (50%). Of six non-diabetic patients with > 10% hypoglycemia on pre-operative CGM, 33% were insulin-independent post-operatively (P = .3). Of non-diabetic patients with ≥ 80% time in the euglycemic range, 62% were insulin-independent post-operatively (P = .2). For patients without diabetes, the median percent time in hypoglycemic range was reduced from 8% to 1% (P = .001). Delta C-peptide had a positive correlation with islet yield (P = .03). DISCUSSION Conventional evaluation of TPAIT patients assesses primarily beta cell function. As pancreatogenic diabetes is concerning principally for the risk of hypoglycemia, assessment of alpha cell function can improve the quality of care. CGM better captures islet function and increases the identification of hypoglycemia.
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Affiliation(s)
- Jennifer S Vonderau
- Division of Abdominal Transplant, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brittney M Williams
- Division of Abdominal Transplant, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stephen DeCherney
- Division of Endocrinology & Metabolism, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Morgan S Jones
- Division of Endocrinology & Metabolism, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lauren McKnight
- Division of Endocrinology & Metabolism, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Marilyn Hanson
- Division of Abdominal Transplant, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Harlan Hanson
- Division of Abdominal Transplant, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Chirag S Desai
- Division of Abdominal Transplant, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
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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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Tellez SE, Hornung LN, Courter JD, Abu-El-Haija M, Nathan JD, Lawson SA, Elder DA. Inaccurate Glucose Sensor Values After Hydroxyurea Administration. Diabetes Technol Ther 2021; 23:443-451. [PMID: 33314990 PMCID: PMC8881951 DOI: 10.1089/dia.2020.0490] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objective: To assess the degree, duration, mean absolute relative difference (MARD), and error analysis of discrepant values per continuous glucose monitoring (CGM) systems after hydroxyurea (HU) administration. Research Design and Methods: Inpatient glucometer and CGM data from 16 total pancreatectomy/islet autotransplantation patients using Dexcom Professional G4 and 12 patients using Dexcom G6 were analyzed after daily dosing with HU. Timing of HU dosing and median of 9.5 days of sensor and glucometer values were assessed per patient. Results: A large positive elevation of sensor readings was identified after HU dosing. The greatest discrepancy between glucometer and sensor readings occurred 0.5-2 h after HU administration [G4 (mean 3.0 mmol/L, median 2.4 mmol/L, MARD 55%), G6 (mean 4.2 mmol/L, median 4.6 mmol/L, MARD 91%)]. The discrepancy was <1.1 mmol/L, mean (-0.5 mmol/L) and median (-0.5 mmol/L), MARD 14% (G4) and <1.1 mmol/L, mean (0.3 mmol/L) and median (0.3 mmol/L), MARD 17% (G6), by 6 h after administration. Error analysis with the G6 system found 94% of pairs in clinically acceptable range by 6-9 h after HU administration. Aspirin, also given once daily, did not result in glucose value discrepancy with the G6 system but variability was observed with the G4 system. Conclusions: There was marked elevation of sensor glucose readings compared with glucometer values [up to 13.9 mmol/L (G4), 13 mmol/L (G6)] from 0.5 to 6 h after HU administration. It is important to counsel a patient using a Dexcom CGM system and HU therapy on this finding and to advise reliance on glucometer testing for accurate glucose assessment up to 6-9 h after HU administration.
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Affiliation(s)
- Siobhan E. Tellez
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Address correspondence to: Siobhan E. Tellez, MSN, CNP, Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 9024, Cincinnati, OH 45229, USA
| | - Lindsey N. Hornung
- Divisions of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joshua D. Courter
- Divisions of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Maisam Abu-El-Haija
- Divisions of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jaimie D. Nathan
- Divisions of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sarah A. Lawson
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Deborah A. Elder
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Tellez SE, Hornung LN, Courter JD, Abu-El-Haija M, Nathan JD, Lawson SA, Elder DA. Improved Glycemic Outcomes with Early Initiation of Insulin Pump Therapy in Pediatric Postoperative Total Pancreatectomy with Islet Autotransplantation. J Clin Med 2021; 10:jcm10112242. [PMID: 34064129 PMCID: PMC8196743 DOI: 10.3390/jcm10112242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/13/2021] [Accepted: 05/15/2021] [Indexed: 01/06/2023] Open
Abstract
Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure for patients with chronic pancreatitis and poor quality of life. Euglycemia is critical for islet cell survival and engraftment. We reviewed clinical care practice and hypothesized that early in-hospital transition from intravenous insulin to insulin pump therapy, managed by an endocrine unit trained on post-surgical care, would improve glucose control and impact the length of hospital stay. We completed a retrospective analysis of 40 pediatric patients who underwent TPIAT. Comparative hospitalized postoperative groups included those who received insulin intravenously, followed by multiple daily injections, subsequently managed by pump therapy (n = 14), versus those who received insulin intravenously followed by early pump therapy provided on the endocrine unit trained to manage post-surgical patients (n = 26). The outcomes analyzed included percentage of blood glucoses in target (4.44–6.66 mmol/L (80–120 mg/dL)), hypoglycemia (<3.33 mmol/L (<60 mg/dL)) and hyperglycemia (>7.77 mmol/L (>140 mg/dL)), blood glucose variability, and length of hospital unit stay post-ICU. Hospitalized patients with early transition to pump therapy on a specialized endocrine unit had a higher proportion of glucose values in the target range (61% vs. 51%, p = 0.0003), a lower proportion of hyperglycemia (15% vs. 19%, p = 0.04), and a lower proportion of hypoglycemia, though not statistically significant (3.4% vs. 4.4%, p = 0.33). Early pump users also had lower variability in glucose values over 10 days post-intravenous insulin (p = 0.001), and the post-transition median length of stay was shorter by 5 days (median: 11.5 vs. 16.5 days, p = 0.005). Early in-hospital pump therapy managed by the specialized endocrine unit improved glucose outcomes and reduced the duration of in-unit stay.
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Affiliation(s)
- Siobhan E. Tellez
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH 45229, USA; (S.A.L.); (D.A.E.)
- Correspondence:
| | - Lindsey N. Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital, Cincinnati, OH 45229, USA;
| | - Joshua D. Courter
- Division of Pharmacy, Cincinnati Children’s Hospital, Cincinnati, OH 45229, USA;
| | - Maisam Abu-El-Haija
- Division of Gastroenterology, Cincinnati Children’s Hospital, Cincinnati, OH 45229, USA;
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Jaimie D. Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital, Cincinnati, OH 45229, USA;
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Sarah A. Lawson
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH 45229, USA; (S.A.L.); (D.A.E.)
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Deborah A. Elder
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH 45229, USA; (S.A.L.); (D.A.E.)
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
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DiGiusto M, Wolf RM, Arcara KM, Vanderhoek SM. Use of Continuous Glucose Monitoring to Facilitate Perioperative Glycemic Management: A Case Report. A A Pract 2021; 15:e01438. [PMID: 33760759 DOI: 10.1213/xaa.0000000000001438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Perioperative glycemic management remains an important variable in a host of postoperative outcomes, including wound infection, reoperation, and death. Patients with diabetes mellitus are increasingly utilizing continuous glucose monitors to assist with glycemic management; the ability to harness the intensive monitoring capabilities of continuous glucose monitoring (CGM) technology perioperatively presents a promising opportunity to improve patient outcomes. Here, we assessed the accuracy of CGM compared to capillary point-of-care and arterial blood analysis in 2 cases where CGM was utilized as an adjunct method of perioperative glucose monitoring.
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Affiliation(s)
- Matthew DiGiusto
- From the Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine
| | - Risa M Wolf
- Division of Endocrinology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin M Arcara
- Division of Endocrinology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samuel M Vanderhoek
- From the Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine
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Short- and long-term surgical outcomes of total pancreatectomy with islet autotransplantation: A comparative analysis of surgical technique and intraoperative heparin dosing to optimize outcomes. Pancreatology 2021; 21:291-298. [PMID: 33268025 DOI: 10.1016/j.pan.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/16/2020] [Accepted: 11/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total pancreatectomy with islet autotransplantation (TP-IAT) is an uncommon surgical procedure with unique perioperative management. We evaluated the short- and long-term morbidity and mortality of TP-IAT to optimize surgical technique and heparin dosing during islet autotransplantation. METHODS Eighty patients with chronic pancreatitis undergoing TP-IAT were reviewed. Primary outcome was to evaluate morbidity and mortality based on operative technique: classic (resection of antrum) vs pylorus-preserving. Secondary outcome was to evaluate the effect of heparin dosing (<60 vs ≥ 60 units/kg) during islet autotransplantation on postoperative hemorrhage and portal vein thrombosis (PVT) rates. RESULTS There was no 90-day mortality, and median length of stay was 9 days. All patients underwent an open operation with 53 (66%) pylorus-preserving resections. The 30-day morbidity rate was 39%, with no difference between operative technique (p = 0.82). The median dose was different for each heparin group (<60: 52 units/kg vs ≥ 60: 66 units/kg, p < 0.0001). No difference was observed in postoperative hemorrhage rates between heparin groups (<60: 9% vs ≥ 60: 9%, p = 0.97), with no known incidence of PVT. Median follow-up was 36 months (IQR, 14-71). Morbidity >30 days after TP-IAT was 43% with a higher rate in the pylorus-preserving group (55% vs 15%, p < 0.0001), mainly attributed to marginal ulcer formation (15% vs 0%, p = 0.03). CONCLUSIONS A classic TP-IAT technique should be universally adopted to achieve optimal outcomes, particularly to prevent the formation of marginal ulcers. When considering PVT versus postoperative hemorrhage risk, a lower heparin dose nearing 50 units/kg is optimal. These findings highlight potential areas for future improvement.
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Elnashar M, Vaccarezza M, Al-Salami H. Cutting-edge biotechnological advancement in islet delivery using pancreatic and cellular approaches. Future Sci OA 2020; 7:FSO660. [PMID: 33552541 PMCID: PMC7849926 DOI: 10.2144/fsoa-2020-0105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
There are approximately 1 billion prediabetic people worldwide, and the global cost for diabetes mellitus (DM) is estimated to be $825 billion. In regard to Type 1 DM, transplanting a whole pancreas or its islets has gained the attention of researchers in the last few decades. Recent studies showed that islet transplantation (ILT) containing insulin-producing β cells is the most notable advancement cure for Type 1 DM. However, this procedure has been hindered by shortage and lack of sufficient islet donors and the need for long-term immunosuppression of any potential graft rejection. The strategy of encapsulation may avoid the rejection of stem-cell-derived allogeneic islets or xenogeneic islets. This review article describes various biotechnology features in encapsulation-of-islet-cell therapy for humans, including the use of bile acids.
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Affiliation(s)
- Magdy Elnashar
- Biotechnology & Drug Development Research Laboratory, School of Pharmacy & Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia.,Centre of Excellence, Department of Polymers, National Research Centre, Cairo, Egypt
| | - Mauro Vaccarezza
- School of Pharmacy & Biomedical Science, Faculty of Health Sciences, Curtin University, Bentley, Perth, WA 6102, Australia
| | - Hani Al-Salami
- Biotechnology & Drug Development Research Laboratory, School of Pharmacy & Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia
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Abstract
This paper aims to provide an overview of islet cell transplantation in children, with specific attention to pediatric total pancreatectomy with islet autotransplantation (TPIAT). We will summarize the definition and causes of chronic pancreatitis in children, the TPIAT procedure and potential complications, the process of islet cell isolation and autotransplantation, and long-term results after TPIAT. Lastly, we will briefly discuss islet cell allotransplantation in the adult population and its potential role in treating children.
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Affiliation(s)
- Appakalai N Balamurugan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Deborah A Elder
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Maisam Abu-El-Haija
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.
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Cerise A, Nagaraju S, Powelson JA, Lutz A, Fridell JA. Pancreas transplantation following total pancreatectomy for chronic pancreatitis. Clin Transplant 2019; 33:e13731. [PMID: 31627258 DOI: 10.1111/ctr.13731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Total pancreatectomy for chronic pancreatitis leads to brittle diabetes and challenging glycemic control with half of all patients experiencing severe hypoglycemia, many requiring medical intervention or hospitalization. Pancreas transplantation has the potential to manage both the endocrine and the exocrine insufficiency in this patient population. METHODS Between June 1, 2005, and July 1, 2016, 8 patients with brittle diabetes following total pancreatectomy underwent pancreas transplantation. All grafts had systemic venous and enteric exocrine drainage. Data included demographics, graft and patient survival, pre- and post-transplant supplementation with pancreatic enzymes, and narcotic usage. RESULTS Patient survival rate at 1 and 3 years was 88%. Pancreas graft survival rate of those alive at 1 year was 100% and 86%, respectively. About 75% of these patients remained insulin-free until their time of death, loss of follow-up, or present day. Of the patients with maintained graft function at 3 years, none required further hospitalization for glycemic control. About 75% of these patients have also maintained exocrine function without pancreatic enzyme supplementation. CONCLUSIONS Pancreas transplant can treat both exocrine and endocrine insufficiency and give long-term insulin-free survival and should be considered as a viable treatment option for patients who have undergone total pancreatectomy for chronic pancreatitis.
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Affiliation(s)
- Adam Cerise
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Santosh Nagaraju
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrew Lutz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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