Genetic issues in pediatric pancreatitis

Liver Doppler Findings in Pediatric Patients After Total Pancreatectomy and Islet Autotransplantation

OBJECTIVES

This study was intended to establish normal values for velocities in the hepatic artery and portal veins in pediatric patients after total pancreatectomy and islet autotransplantation (TPIAT).

METHODS

A retrospective review was performed of liver Doppler studies in pediatric patients after TPIAT over 6 years at an academic children's hospital. Doppler velocities in the liver vasculature and the hepatic artery resistive index were recorded.

RESULTS

Sixty-five pediatric patients were evaluated. There were no cases of portal vein thrombosis or other hepatic vascular complications. The mean hepatic artery peak systolic velocity was 157.6 cm/s (SE, 60.9 cm/s), with a mean resistive index of 0.57 (SE, 0.09). The mean main portal vein velocity was 31.9 cm/s (SE, 12.9 cm/s).

CONCLUSIONS

Portal vein thrombosis is rare in pediatric patients after TPIAT. A wide range of hepatic artery and portal vein velocities are encountered in children immediately after TPIAT without hepatic vascular complications and can be considered normal.

The Etiology and Clinical Course of Chronic Pancreatitis in Children With Early Onset of the Disease

OBJECTIVES

The etiological factors of chronic pancreatitis (CP) in children differ from those in adults. To date, no study has assessed the clinical course of CP in young children. The aim of our study was to evaluate the etiology and the clinical presentation of the disease in children with disease onset before 5 years of age in comparison to later-onset of CP.

METHODS

A total of 276 children with CP, hospitalized from 1988 to 2015, were enrolled in the study. Data on presentation, diagnostic findings, and treatment were reviewed. Two hundred sixty patients were screened for the most frequent mutations in major pancreatitis-associated genes, such as cationic trypsinogen/serine protease gene (PRSS1), serine protease inhibitor, Kazal type 1 gene (SPINK1), and cystic fibrosis transmembrane conductance regulator gene (CFTR).

RESULTS

The disease onset before the age of 5 years occurred in 51 patients (group 1), the later onset in 225 patients (group 2). We found no significant discrepancies in distribution of the etiological factors between groups. The youngest patients (group 1) had more pancreatitis episodes (median 5.0 vs 3.00; P < 0.05) and underwent surgeries more frequently (25.5% vs 8.9%; P < 0.05). It could be associated with significantly longer follow-up in early onset group (median 6 vs 4 years; P < 0.05). There were no differences in nutritional status or exocrine and endocrine pancreatic function.

CONCLUSIONS

Early- and later-onset pancreatitis have similar etiological factors with predominance of gene mutations. The most frequent mutation found was p.Asn34Ser (N34S) in SPINK1 gene. The clinical presentation differed in number of pancreatitis episodes and frequency of surgeries.

Genetic Mutations in Pediatric Pancreatitis

OBJECTIVES

The aim of our study was to describe the prevalence, characteristics, and outcomes of children with acute recurrent (ARP) or chronic (CP) pancreatitis with or without mutations in PRSS1, CFTR or SPINK1.

METHODS

Retrospective chart review of children with ARP or CP with and without testing for PRSS1, CFTR, and SPINK1. Demographics, clinical features, management, and outcome were collected. Analysis of variance was used to compare continuous variables and χ or Fisher exact test for categorical variables.

RESULTS

Ninety-one subjects with ARP (n = 77) or CP (n = 14) were identified and included in this study. Of these, 37 (41%) were male, 44 were white, and 30 were Hispanic. Thirty-three (36%) had at least 1 mutation identified (Pan-Mut): PRSS1 (7), CFTR (21), SPINK1 (3), SPINK/CFTR (2). Thirty-six were tested but had no mutation, and 22 were not tested. The Pan-Mut subjects were more likely to have a family history of pancreatitis but there were no differences in the clinical features, imaging or outcome.

CONCLUSIONS

Mutations in CFTR, SPINK1 or PRSS1 are present in one third of pediatric ARP and CP with no other cause. No clinical features or outcomes differentiated between the Pan-Mut group and the no-mutation group. The Pan-Mut subjects were more likely to have a family history of pancreatitis. Pediatric ARP and CP without identified cause should undergo genetic testing.

Postoperative pain control with paravertebral catheters after pediatric total pancreatectomy and islet autotransplantation: a retrospective cohort study

BACKGROUND

Total pancreatectomy and islet autotransplantation (TPIAT) has been used to treat pediatric patients with chronic pancreatitis. The primary symptom of this disease is extreme poorly controlled pain. This results in significant alterations in the quality of life of the patient. We sought to determine if the addition of bilateral thoracic paravertebral catheters with continuous ropivacaine infusion would improve postoperative opioid use and pain control.

METHODS

The medical records of 32 patients who underwent TPIAT from March 2011 to July 2014 were analyzed retrospectively (15 without paravertebral catheters and 17 with paravertebral catheters). Maximum and minimum pain scores, opioid use (mg · kg(-1) · day(-1)), percent opioid use above baseline, length of stay, and complications were recorded.

RESULTS

Those patients who had bilateral thoracic paravertebral catheters had decreased total opioid use in the first 7 days postoperatively when compared to those who did not (612 (95% CI: 432-792) vs 943.7 (95% CI: 650-1237) mg of morphine equivalents; P = 0.043). The total opioid use remained significantly decreased when corrected for weight (12.53 (95% CI: 9.19-15.44) vs 18.85 (95% CI: 13.69-24.03) mg · kg(-1) of morphine equivalents; P = 0.03). In addition, those on preoperative opioids had less percent opioid use above baseline on postoperative days 1, 2, and 7 as well as decreased opioid use (mg · kg(-1) · day(-1)) on postoperative days 1, 2, 3, and 7. There were no differences in complications or length of stay.

CONCLUSIONS

Bilateral paravertebral catheters may provide decreased opioid use and improved postoperative pain control after TPIAT.

Pediatric Autologous Islet Transplantation

A total pancreatectomy and islet autotransplant (TPIAT) offers substantial pain relief and improved quality of life for children who are severely affected by chronic or recurrent acute pancreatitis and for whom the usual medical and endoscopic therapies have failed. The pancreas is entirely resected, and the pancreatic islets are isolated from the pancreas and infused back into the patient's liver. Because this is an autologous transplant, no immunosuppression is required. Over several months, the islets engraft in the liver; the patient is then slowly weaned off insulin therapy. Slightly more than 40 % of patients become and remain insulin independent, yet even among patients who remain on insulin, most have some islet function, permitting easier diabetes control. The majority of patients experience pain relief, with significant improvements in health-related quality of life. A TPIAT should be considered for children who are significantly disabled by chronic pancreatitis.

Paediatric pancreatitis

PURPOSE OF REVIEW

The purpose of this review is to describe recent developments in paediatric pancreatitis and to discuss causes and current management.

RECENT FINDINGS

Although recent studies have estimated the annual incidence of paediatric acute pancreatitis approaching that of adults, there are no established guidelines about its diagnosis and treatment in children. Genetic and structural/congenital abnormalities are emerging as the primary risk factors for paediatric acute recurrent and chronic pancreatitis. Specifically, chronic pancreatitis is associated with a significant socioeconomic burden in children. Both medical and surgical therapies are proposed for paediatric chronic pancreatitis, but there is little evidence that they are beneficial.

SUMMARY

Acute recurrent and chronic pancreatitis create significant health issues in the paediatric population. Medical and surgical therapies exist to potentially treat these conditions, but the paediatric data are limited and the cohorts are small. A multidisciplinary and multicentre approach is necessary to better determine pancreatic disease processes and treatment options in children.

Quality of life improves for pediatric patients after total pancreatectomy and islet autotransplant for chronic pancreatitis

BACKGROUND & AIMS

Total pancreatectomy (TP) and islet autotransplant (IAT) have been used to treat patients with painful chronic pancreatitis. Initial studies indicated that most patients experienced significant pain relief, but there were few validated measures of quality of life. We investigated whether health-related quality of life improved among pediatric patients undergoing TP/IAT.

METHODS

Nineteen consecutive children (aged 5-18 years) undergoing TP/IAT from December 2006 to December 2009 at the University of Minnesota completed the Medical Outcomes Study 36-item Short Form (SF-36) health questionnaire before and after surgery. Insulin requirements were recorded.

RESULTS

Before TP/IAT, patients had below average health-related quality of life, based on data from the Medical Outcomes Study SF-36; they had a mean physical component summary (PCS) score of 30 and mental component summary (MCS) score of 34 (2 and 1.5 standard deviations, respectively, below the mean for the US population). By 1 year after surgery, PCS and MCS scores improved to 50 and 46, respectively (global effect, PCS P < .001, MCS P = .06). Mean scores improved for all 8 component subscales. More than 60% of IAT recipients were insulin independent or required minimal insulin. Patients with prior surgical drainage procedures (Puestow) had lower yields of islets (P = .01) and greater incidence of insulin dependence (P = .04).

CONCLUSIONS

Quality of life (physical and emotional components) significantly improve after TP/IAT in subsets of pediatric patients with severe chronic pancreatitis. Minimal or no insulin was required for most patients, although islet yield was reduced in patients with previous surgical drainage operations.

The etiology of acute recurrent pancreatitis in children: a challenge for pediatricians

OBJECTIVES

To assess specific etiologies of acute recurrent pancreatitis at a single Italian pediatric cystic fibrosis (CF) center.

METHODS

We studied, retrospectively, 78 young patients (39 female subjects; mean age at diagnosis, 8.8 ± 5.1 years) affected by acute recurrent episodes of pancreatitis, remained etiologically undiagnosed at first-level assessment. All patients were submitted to endoscopic retrograde cholangiopancreatography to exclude biliopancreatic malformations and tested for CF by a sweat chloride test. Most patients also were studied for the research of CFTR, PRSS1, and SPINK1 gene mutations.

RESULTS

A high percentage of family history for chronic pancreatitis was observed (20.5%). The sweat test identified 8 subjects (10.3%) with classic CF (2 patients) or at risk for CF (6 patients). Genetic analysis showed mutations in CFTR, SPINK1, and PRSS1 genes in 39.6%, 7.1%, and 4.5% of patients, respectively. A biliopancreatic malformation was diagnosed in 15 patients (19.2%). We also observed biliary lithiasis (5 patients [6.5%]), congenital pancreatic polycystosis (2 patients), a case of dyslipidemia, and 1 patient with a posttransplantation, drug-induced pancreatitis.

CONCLUSIONS

Recurrent pancreatitis in children has several etiologies. Genetic testing confirms the high frequency of CFTR mutations. This suggests that it is of some value to identify patients with late-onset CF and CFTR-related disorders.

Hereditary pancreatitis

Hereditary chronic pancreatitis (HCP) is a rare disease in which chronic pancreatitis develops in childhood. HCP has autosomal dominant inheritance with approximately 80% penetrance. Diagnostic criteria are not universally agreed upon but the EUROPAC trial defined it as two first-degree relatives or at least 3 second-degree relatives in two or more generations, with chronic pancreatitis for which there is no other etiology. The gene for HCP was originally identified on chromosome 7 and subsequently many other genes have been reported to be associated with HCP. To date, no single genetic alteration has been found that is necessary for the development of HCP. In a recent study, 81% of patients with HCP were found to have a mutation of the PRSS1 gene. Patients with HCP are at risk for developing exocrine and endocrine insufficiency and there is a 50-fold increased risk of pancreatic cancer in HCP patients as compared with the general population.

Pediatric islet autotransplantation: indication, technique, and outcome

Chronic pancreatitis is a rare disease in childhood. However, when severe, a total pancreatectomy may be the only option to relieve pain and restore quality of life. An islet autotransplant performed at the time of pancreatectomy can prevent or minimize the postsurgical diabetes that would otherwise result from pancreatectomy alone. In this procedure, the resected pancreas is mechanically disrupted and enzymatically digested to separate the islets from the surrounding exocrine tissue, and the isolated islets are infused into the portal vein and engraft in the liver. Because patients are receiving their own tissue, no immunosuppression is required. Islet autotransplant is successful in two thirds of children-these patients are insulin independent or require little insulin to maintain euglycemia. Factors associated with a more successful outcome include a younger age at transplant (<13 years), more islets transplanted, and lack of prior surgical procedures on the pancreas (partial pancreatectomy or surgical drainage procedures).

Pancreatitis in children and adolescents

Several clinical and methodologic difficulties occur when diagnosing acute pancreatitis in the pediatric age group. Due to its uncommonness and heterogeneous symptoms, acute pancreatitis in children is often misdiagnosed, and prospective studies are lacking. Guidelines for classifying, diagnosing, and managing acute pancreatitis are frequently based on standards that are developed and validated in adult patients. Among the broad range of etiologies of pediatric acute pancreatitis in children, gallstones and biliary disease may play a greater role than previously believed. Although it is typically a benign disease in the pediatric population, complications such as pseudocysts may occur. When there are fatalities, they are usually attributed to systemic illness rather than the pancreatitis itself. Improvements in diagnostic and imaging methods and growing awareness cannot account for the recent increases in the observed incidence of pediatric acute pancreatitis.