Total pancreatectomy and islet cell autotransplantation as a means of treating patients with genetically linked pancreatitis

Total pancreatectomy with islet autotransplantation outcomes in patients with pancreatitis of genetic etiology: A single-center experience with a large cohort of patients

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.

Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach

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.

Outcomes of total pancreatectomy with islet autotransplantation: A systematic review and meta-analysis

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 (HbA_1C) 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.

Total pancreatectomy and islet cell autotransplantation: a 10-year update on outcomes and assessment of long-term durability

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 HbA_1C (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.

Intraportal Islet Autotransplantation Independently Improves Quality of Life After Total Pancreatectomy in Patients With Chronic Refractory Pancreatitis

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.

Cell Therapy for Type 1 Diabetes: From Islet Transplantation to Stem Cells

The field of cell therapy of type 1 diabetes is a particularly interesting example in the scenario of regenerative medicine. In fact, β-cell replacement has its roots in the experience of islet transplantation, which began 40 years ago and is currently a rapidly accelerating field, with several ongoing clinical trials using β cells derived from stem cells. Type 1 diabetes is particularly suitable for cell therapy as it is a disease due to the deficiency of only one cell type, the insulin-producing β cell, and this endocrine cell does not need to be positioned inside the pancreas to perform its function. On the other hand, the presence of a double immunological barrier, the allogeneic one and the autoimmune one, makes the protection of β cells from rejection a major challenge. Until today, islet transplantation has taught us a lot, pioneering immunosuppressive therapies, graft encapsulation, tissue engineering, and test of different implant sites and has stimulated a great variety of studies on β-cell function. This review starts from islet transplantation, presenting its current indications and the latest published trials, to arrive at the prospects of stem cell therapy, presenting the latest innovations in the field.

Outpatient Pain Management in Children With Chronic Pancreatitis: A Scoping Systematic Review

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."

Total pancreatectomy sequelae and quality of life: results of islet autotransplantation as a possible mitigation strategy

Total pancreatectomy (TP) is a procedure weighed down not only by postoperative morbidity and mortality but also by long-term effects as a consequence of endocrine and exocrine pancreatic insufficiency. While the latter is now managed quite effectively with pancreatic enzyme replacement therapy, the former remains a challenge. The diabetes resulting after TP, with the complete loss of endogenous insulin and contraregulatory hormones, is characterized by important glycemic variations and is, therefore, frequently referred to as "brittle diabetes". One method to reduce the impact of brittle diabetes in patients undergoing TP is the re-infusion of autologous pancreatic islets isolated from the resected pancreas. Indications to islet autotransplantation (IAT), originally described for patients undergoing TP for chronic pancreatitis, have since been extended to selected patients with other benign and malignant diseases of pancreas. This review recaps on the literature regarding long-term postoperative complications, their impact on quality of life after TP and the role of IAT.

Efficacy and safety of islet autotransplantation after total pancreatectomy in chronic pancreatitis: A systematic review and meta-analysis including 17 studies

AIMS

Islet autotransplantation (IAT), in conjunction with total pancreatectomy (TP), is used to relieve pain in patients with chronic pancreatitis (CP), while reducing the incidence of brittle diabetes. We aimed to evaluate the efficacy and safety of IAT after TP (TPIAT) in this setting.

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials since 1977. Data were extracted from published papers. Random-effects meta-analysis and meta-regression models were built to assess the outcomes and effect of different factors. Subgroup and sensitivity analyses were conducted to examine the between-study heterogeneity, which was assessed using Cochrane's Q and I² statistic.

RESULTS

A total of 17 studies, including 1024 patients, met the eligibility criteria. The median cohort size was 21 patients (range: 5-409). The pooled incidence rates of insulin independence, narcotic independence and mortality at last follow-up were 11.47 per 100 patient-years (95% CI: 6.79-21.60, I²=91.0%), 18.11 per 100 patient-years (95% CI: 5.29-62.04, I²=98.8%) and 2.88 per 100 patient-years (95% CI: 1.75-4.74, I²=46.8%), respectively. However, the heterogeneity level of our results was high, which was due to differences in research methods and definitions of outcomes between studies. Therefore, our results should be interpreted with caution.

CONCLUSIONS

TPIAT can effectively relieve pain and reduce the risk of surgical diabetes with no increase in mortality or morbidity. Prospective, randomized, clinical trials are required to further evaluate selection of patients and the timing of TPIAT.

Islet cell transplantation in children

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.

Pilot study: deficiency of mannose-binding lectin-dependent lectin pathway, a novel modulator in outcome from pancreatic islet auto-transplantation

Background

Numerous factors influence pancreatic islet survival following auto-transplantation. Of these, the host immune response in the early peri-operative period is one of the most important. In this study we investigated the role of the mannose-binding lectin (MBL)-dependent pathway in a group of total pancreatectomy (TP) islet auto-transplantation (TPIAT) patients and classified them as competent or deficient in MBL activity. Complement pathway activities, MBL protein and inflammatory cytokine concentrations were evaluated from eleven pancreatic islet auto-transplant patients from two institutions.

Methods

Eleven patients from two institutions were prospectively recruited. Serum was screened at different time points for 29 different cytokines and compared according to their MBL deficient or competent status. Twelve patients from previous TPIAT patients also underwent screening of MBL pathway activity.

Results

A total nine of twenty three patients (39%) were MBL pathway deficient. MCP-1, IL-7 and IL-1a concentrations were significantly lower in the MBL deficient cohort compared to the normal MBL group (P=0.0237, 0.0001 and 0.0051 respectively). IL-6 and IL-8 concentrations were significantly raised in the normal MBL group. MBL functional activity was lower in insulin-independent group compared to the insulin-dependent group.

Conclusions

Complement activation is an important, possibly damaging response during intra-portal islet infusion. MBL pathway deficiency appears common in this population and the cytokine response was attenuated in MBL pathway deficient patients. Therapeutic MBL pathway blockade during and following islet auto-transplantation (IAT) may improve islet survival and function and thereby clinical outcome.

Geographical variance in reporting of elective surgery for chronic pancreatitis

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.

The Role of Genetics in Pancreatitis

Individuals with acute recurrent and chronic pancreatitis may have an inherited predisposition to the development of the disease. Pancreatitis in the setting of a significant family history of the disease can be classified as hereditary or familial pancreatitis. In this article, the authors closely examine the specific genes implicated in pancreatitis, investigate the role of genetic testing for diagnosis, and describe the impact of genetic testing results on clinical management.

Glycemic Outcomes of Islet Autotransplantation

PURPOSE OF REVIEW

While there has been a growing utilization of total pancreatectomy with islet autotransplantation (TPIAT) for patients with medically refractory chronic pancreatitis over the past few decades, there remains a lack of consensus clinical guidelines to inform the counseling and management of patients undergoing TPIAT. In this article, we review the current clinical practice and published experience of several TPIAT centers, outline key aspects in managing patients undergoing TPIAT, and discuss the glycemic outcomes of this procedure.

RECENT FINDINGS

Aiming for lower inpatient glucose targets immediately after surgery (usually 100-120 mg/dl), maintaining all patients on subcutaneous insulin for at least 3 months to "rest" islets before an attempt is made to wean insulin, and close outpatient endocrinology follow-up after TPIAT particularly in the first year is common and related to better outcomes. Although TPIAT procedures and glycemic outcomes may differ across surgical centers, overall, approximately one third of patients are insulin independent at 1 year after TPIAT. Higher islet yield and lower preoperative glucose levels are among the strongest predictors of short-term post-operative insulin independence. Beyond 1 year post-operatively, the clinical management and long-term glycemic outcomes of patients after TPIAT are more variable. A multidisciplinary approach is essential in optimizing the preoperative, inpatient, and post-operative management and counseling of patients about the expected glycemic outcomes after surgery. Consensus guidelines for the clinical management of diabetes after TPIAT and harmonization of data collection protocols among TPIAT centers are needed to address the current knowledge gaps in clinical care and research and to optimize glycemic outcomes after TPIAT.

Patient and Procedural Factors Associated With Increased Islet Cell Yield in Total Pancreatectomy With Islet Autotransplantation

OBJECTIVES

Total pancreatectomy with islet autotransplantation (TPIAT) offers symptom relief to highly selected patients with recurrent acute and/or chronic pancreatitis. However, with variable clinical response, it is important to refine islet manipulation technique and patient selection criteria. This study explores the variables associated with high islet cell yield, a driver of success in TPIAT.

METHODS

This study evaluated patients who underwent TPIAT at Dartmouth-Hitchcock Medical Center from 2012 to 2016. Odds ratios were calculated for various patient and procedural characteristics. The primary clinical outcome was the number of isolated islet equivalents per kilogram body weight.

RESULTS

Thirty-eight patients met inclusion criteria. Patients with no computed tomography or magnetic resonance imaging evidence of chronic pancreatitis, without pancreatic duct stones, and without parenchymal stones were associated with higher odds of success (P = 0.02, P = 0.02, and P = 0.002, respectively). Patients with preoperative glycated hemoglobin greater than 5.6, with islet cell suspensions positive for cultures, and with positive gram stains were associated with lower odds of success (P = 0.02, P = 0.01, and P = 0.02, respectively).

CONCLUSIONS

Factors that diminish a successful islet cell harvest during TPIAT include the presence of infected islets, an elevated preoperative glycated hemoglobin, and the presence of pancreatic duct stones.

Total Pancreatectomy With Intraportal Islet Autotransplantation as a Treatment of Chronic Pancreatitis in Patients With CFTR Mutations

OBJECTIVES

Chronic pancreatitis (CP) is an infrequent but debilitating complication associated with CFTR mutations. Total pancreatectomy with islet autotransplantation (TPIAT) is a treatment option for CP that provides pain relief and preserves β-cell mass, thereby minimizing the complication of diabetes mellitus. We compared outcomes after TPIAT for CP associated with CFTR mutations to CP without CTFR mutations.

METHODS

All TPIATs performed between 2002 and 2014 were retrospectively reviewed: identifying 20 CFTR homozygotes (cystic fibrosis [CF] patients), 19 CFTR heterozygotes, and 20 age-/sex-matched controls without CFTR mutations. Analysis of variance and χ tests were used to compare groups.

RESULTS

Baseline demographics were not different between groups. Postoperative glycosylated hemoglobin and C-peptide levels were similar between groups, as were islet yield and rate of postoperative complications. At 1 year, 40% of CF patients, 22% of CFTR heterozygotes, and 35% of control patients were insulin independent.

CONCLUSION

Total pancreatectomy with islet autotransplantation is a safe, effective treatment option for CF patients with CP, giving similar outcomes for those with other CP etiologies.

Patient Selection for Total Pancreatectomy with Islet Autotransplantation in the Surgical Management of Chronic Pancreatitis

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.

Pediatric pancreas transplantation, including total pancreatectomy with islet autotransplantation

Unlike other solid-organ transplants, whole pancreas transplantation in children is relatively rare, and it occurs more frequently in the context of multivisceral or composite organ transplantation. Because children only infrequently suffer severe sequelae of type 1 diabetes mellitus, pancreas transplantation is rarely indicated in the pediatric population. More commonly, pediatric pancreas transplant occurs in the setting of incapacitating acute recurrent or chronic pancreatitis, specifically islet autotransplantation after total pancreatectomy. In this clinical scenario, total pancreatectomy removes the nidus of chronic pain and debilitation, while autologous islet transplantation aims to preserve endocrine function. The published experiences with pediatric total pancreatectomy with islet autotransplantation (TPIAT) in children has demonstrated excellent outcomes including liberation from chronic opioid use, as well as improved mental and physical quality of life with good glycemic control. Given the complexity of the operation, risk of postoperative complication, and long-term physiologic changes, appropriate patient selection and comprehensive multidisciplinary care teams are critical to ensuring optimal outcomes.

Total Pancreatectomy With Islet Autotransplantation Resolves Pain in Young Children With Severe Chronic Pancreatitis

OBJECTIVES

Fear of diabetes and major surgery may prohibit referral of young children severely affected by pancreatitis for total pancreatectomy with islet autotransplant (TPIAT). We evaluated outcomes in our youngest TPIAT recipients, 3 to 8 years of age at surgery.

METHODS

Medical records were reviewed for 17 children (9 girls) ages 8 years or younger undergoing TPIAT from 2000 to 2014. Most (14/17) had genetic risk factors for pancreatitis. Since 2006, TPIAT recipients were followed prospectively with health questionnaires including assessments of pain and narcotic use, and scheduled hemoglobin A1c (HbA1c) and mixed-meal tolerance tests (6 mL/kg Boost HP) before surgery, and at regular intervals after. Patients are 1 to 11 years post-TPIAT (median 2.2 years). Data are reported as median (25th, 75th percentile).

RESULTS

All had relief of pain, with all 17 patients off narcotics at most recent follow-up. Hospitalization rates decreased from 5.0 hospitalization episodes per person-year of follow-up before TPIAT, to 0.35 episodes per person-year of follow-up after TPIAT. Fourteen (82%) discontinued insulin, higher than the observed insulin independence rate of 41% in 399 patients older than 8 years of age undergoing TPIAT over the same interval (P = 0.004). Median post-TPIAT HbA1c was 5.9% (5.6%, 6.3%), and within patient post-TPIAT mean HbA1c was ≤6.5% for all but 2 patients.

CONCLUSIONS

Young children with severe refractory chronic pancreatitis may be good candidates for TPIAT, with high rates of pain relief and insulin independence, and excellent glycemic control in the majority.

Islet Cell Yield Following Remote Total Pancreatectomy With Islet Autotransplant is Independent of Cold Ischemia Time

OBJECTIVES

Total pancreatectomy with islet autotransplantation is increasingly being performed remotely, that is, removing the pancreas in 1 location, isolating the islet cells in another location, then returning the islets to the original location for reimplantation into the patient. We determined the influence of extended cold ischemia time on key clinical outcomes in remote islet autotransplantation.

METHODS

We evaluated patients who underwent remote islet autotransplantation at 2 centers from 2011 to 2014. Patients were divided into 2 groups: those with and those without a decrease in C-peptide greater than 50% from baseline. The primary clinical outcome was the quantity of isolated islet equivalents per kilogram body weight (IEQs/kg).

RESULTS

Twenty-five patients met inclusion criteria; 15 had a decrease in C-peptide greater than 50% from baseline and had lower corresponding IEQs/kg compared with those without a decrease greater than 50% (4045 vs 6654 IEQs/kg, P = 0.01). There was no difference in cold ischemia time between the 2 groups (664 vs 600 minutes, P = 0.25). Daily insulin use at 1 year nearly met statistical significance (25.3 vs 8 U, P = 0.06), as did glycated hemoglobin (8.07 vs 6.69 mmol/L, P = 0.06).

CONCLUSIONS

Cold ischemia time does not influence islet yield in patients undergoing pancreatectomy with remote isolation.

Total Pancreatectomy With Islet Autotransplantation Improves Quality of Life in Patients With Refractory Recurrent Acute Pancreatitis

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.

Completion pancreatectomy and islet cell autotransplantation as salvage therapy for patients failing previous operative interventions for chronic pancreatitis

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.

Diabetes after pancreatic surgery: novel issues

In the developed world, pancreatic surgery is becoming more common, with an increasing number of patients developing diabetes because of either partial or total pancreatectomy, with a significant impact on quality of life and survival. Although these patients are expected to consume increasing health care resources in the near future, many aspects of diabetes after pancreatectomy are still not well defined. The treatment of diabetes in these patients takes advantage of the therapies used in type 1 and 2 diabetes; however, no specific guidelines for its management, both immediately after pancreatic surgery or in the long term, have been developed. In this article, on the basis of both the literature and our clinical experience, we address the open issues and discuss the most appropriate therapeutic options for patients with diabetes after pancreatectomy.

Total pancreatectomy with islet cell autotransplantation as the initial treatment for minimal-change chronic pancreatitis

OBJECTIVES

Patients with minimal-change chronic pancreatitis (MCCP) are traditionally managed medically with poor results. This study was conducted to review outcomes following total pancreatectomy with islet cell autotransplantation (TP/IAT) as the initial surgical procedure in the treatment of MCCP.

METHODS

All patients submitted to TP/IAT for MCCP were identified for inclusion in a single-centre observational study. A retrospective chart review was performed to identify pertinent preoperative, perioperative and postoperative data.

RESULTS

A total of 84 patients with a mean age of 36.5 years (range: 15-60 years) underwent TP/IAT as the initial treatment for MCCP. The most common aetiology of chronic pancreatitis in this cohort was idiopathic (69.0%, n = 58), followed by aetiologies associated with genetic mutations (16.7%, n = 14), pancreatic divisum (9.5%, n = 8), and alcohol (4.8%, n = 4). The most common genetic mutations pertained to CFTR (n = 9), SPINK1 (n = 3) and PRSS1 (n = 2). Mean ± standard error of the mean preoperative narcotic requirements were 129.3 ± 18.7 morphine-equivalent milligrams (MEQ)/day. Overall, 58.3% (n = 49) of patients achieved narcotic independence and the remaining patients required 59.4 ± 10.6 MEQ/day (P < 0.05). Postoperative insulin independence was achieved by 36.9% (n = 31) of patients. The Short-Form 36-Item Health Survey administered postoperatively demonstrated improvement in all tested quality of life subscales.

CONCLUSIONS

The present report represents one of the largest series demonstrating the benefits of TP/IAT in the subset of patients with MCCP.

Total pancreatectomy with islet autologous transplantation: the cure for chronic pancreatitis?

Chronic pancreatitis (CP) is a debilitating disease that leads to varying degrees of pancreatic endocrine and exocrine dysfunction. One of the most difficult symptoms of CP is severe abdominal pain, which is often challenging to control with available analgesics and therapies. In the last decade, total pancreatectomy with autologous islet cell transplantation has emerged as a promising treatment for the refractory pain of CP and is currently performed at approximately a dozen centers in the United States. While total pancreatectomy is not a new procedure, the endocrine function-preserving autologous islet cell isolation and re-implantation have made the prospect of total pancreatectomy more acceptable to patients and clinicians. This review will focus on the current status of total pancreatectomy with autologous islet cell transplant including patient selection, technical considerations, and outcomes. As the procedure is performed at an increasing number of centers, this review will highlight opportunities for quality improvement and outcome optimization.

Long-term outcomes after total pancreatectomy and islet cell autotransplantation: is it a durable operation?

OBJECTIVE

Total pancreatectomy and islet cell autotransplantation (TPIAT) has been increasingly utilized for the management of chronic pancreatitis (CP) with early success. However, the long-term durability of this operation remains unclear.

METHODS

All patients undergoing TPIAT for the treatment of CP with 5-year or greater follow-up were identified for inclusion in this single-center observational study. End points included narcotic requirements, glycemic control, islet function, quality of life (QOL), and survival.

RESULTS

Between 2000 and 2013, 166 patients underwent TPIAT; 112 of these patients had 5-year follow-up data to analyze. All patients underwent successful IAT with a mean of 6027 ± 595 islet equivalents per body weight. There was no perioperative mortality and actuarial survival at 5 years was 94.6%. The narcotic independence rate at 1 year was 55% and continued to improve to 73% at 5-year follow-up (P < 0.05). The insulin independence rate declined over time (38% at 1 year vs 27% at more than 5 years), but insulin requirements remained similar (21.4 vs 24.3 units per day, P = 0.6). All patients achieved stable glycemic control with a median hemoglobin A1C (HgA1C) of 6.9% (range: 5.85%-8.3%). The short form 36-item QOL assessment of a subset of patients available for contact demonstrated continued improvements in all tested modules in patients with at least 5-year follow-up. Two patients developed diabetic complications requiring whole organ pancreas transplant for salvage.

CONCLUSIONS

This represents one of the largest series examining long-term outcomes after TPIAT. This operation produces durable pain relief and improvement in QOL parameters. Insulin independence rates decline over time, but most patients maintain stable glycemic control.

Total pancreatectomy and islet autotransplantation in children for chronic pancreatitis: indication, surgical techniques, postoperative management, and long-term outcomes

OBJECTIVE

Describe the surgical technique, complications, and long-term outcomes of total pancreatectomy and islet autotransplantation (TP-IAT) in a large series of pediatric patients.

BACKGROUND

Surgical management of childhood pancreatitis is not clear; partial resection or drainage procedures often provide transient pain relief, but long-term recurrence is common due to the diffuse involvement of the pancreas. Total pancreatectomy (TP) removes the source of the pain, whereas islet autotransplantation (IAT) potentially can prevent or minimize TP-related diabetes.

METHODS

Retrospective review of 75 children undergoing TP-IAT for chronic pancreatitis who had failed medical, endoscopic, or surgical treatment between 1989 and 2012.

RESULTS

Pancreatitis pain and the severity of pain statistically improved in 90% of patients after TP-IAT (P < 0.001). The relief from narcotics was sustained. Of the 75 patients undergoing TP-IAT, 31 (41.3%) achieved insulin independence. Younger age (P = 0.032), lack of prior Puestow procedure (P = 0.018), lower body surface area (P = 0.048), higher islet equivalents (IEQ) per kilogram body weight (P = 0.001), and total IEQ (100,000) (P = 0.004) were associated with insulin independence. By multivariate analysis, 3 factors were associated with insulin independence after TP-IAT: (1) male sex, (2) lower body surface area, and (3) higher total IEQ per kilogram body weight. Total IEQ (100,000) was the single factor most strongly associated with insulin independence (odds ratio = 2.62; P < 0.001).

CONCLUSIONS

Total pancreatectomy and islet autotransplantation provides sustained pain relief and improved quality of life. The β-cell function is dependent on islet yield. Total pancreatectomy and islet autotransplantation is an effective therapy for children with painful pancreatitis that failed medical and/or endoscopic management.

Autologous islet transplantation in patients requiring pancreatectomy for neoplasm

Autologous islet cell transplantation is a procedure performed to prevent or reduce the severity of diabetes after pancreatic resection. Autologous islet cell transplantation is being used almost exclusively in patients undergoing pancreatectomy because of painful, chronic pancreatitis, or multiple recurrent episodes of pancreatitis that is not controlled by standard medical and surgical treatments. Here, we discuss the possibility of extending the clinical indications for this treatment on the basis of our experience in patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, including patients undergoing completion pancreatectomy because of anastomosis leakage after pancreaticoduodenectomy and those with pancreatic anastomosis deemed at high risk for failure.

Total pancreatectomy with islet cell auto-transplantation: update and outcomes from major centers

OPINION STATEMENT

Chronic pancreatitis is the result of irreversible damage to pancreatic acinar cells, and can result in debilitating chronic pain for patients. Treatment centers on pain relief, often with chronic narcotic use. Surgical therapy consists of both resection procedures to remove affected pancreatic parenchyma and drainage procedures to facilitate drainage of the main pancreatic duct. Total pancreatectomy historically was utilized in extreme cases due to the brittle glucose control that followed from the total loss of islet cells. Total pancreatectomy with islet cell auto-transplantation (TP-AIT) is gaining in popularity due to the maintenance of beta cell mass and the ability of patients to potentially be insulin independent post-operatively. TP-AIT is very helpful in the treatment of pain for patients with chronic pancreatitis. The overall majority of patients have an improvement in pain and quality-of-life scores. AIT also allows the majority of patients to have minimal insulin requirements post-operatively. With proper patient selection, these outcomes can be achieved.

Chronic pancreatitis and primary sclerosing cholangitis--first report of intrahepatic autologous islet transplantation

BACKGROUND

We are reporting first successful intrahepatic autologous islet transplantation after total pancreatectomy in a patient with chronic pancreatitis and primary sclerosing cholangitis.

METHODS

Total pancreatectomy and subsequent islet autotransplantation were performed in a 16-year-old boy with intractable pain due to chronic pancreatitis in the setting of ulcerative colitis and primary sclerosing cholangitis (PSC). Liver biopsy revealed PSC with focal bridging fibrosis. The pancreas was surgically removed and digested, and islets were isolated, highly purified, and infused intraportally.

RESULTS

Over 18-month follow-up, the patient did not show progression of chronic liver disease or signs of portal hypertension. Magnetic resonance cholangiopancreatography revealed no new changes, and liver biopsy did not show progression of the periportal fibrosis. Pain medication was weaned over 12 months at which time glycemic control was excellent without exogenous insulin supplementation. HbgA1c was 5.9. Fifteen months after the procedure, stimulation with a mixed meal led to a fourfold increase of serum C-peptide and an eightfold increase of insulin level.

CONCLUSION

Pancreatic autologous islets can be successfully transplanted into a liver affected by PSC without compromising hepatic or graft function. Durability of the procedure may be limited in the future by the natural course of the liver injury caused by PSC.

Long-term outcomes of total pancreatectomy and islet auto transplantation for hereditary/genetic pancreatitis

BACKGROUND

Chronic pancreatitis is a debilitating disease resulting from many causes. The subset with hereditary/genetic pancreatitis (HGP) not only has chronic pain, but also an increased risk for pancreatic cancer. Long-term outcomes of total pancreatectomy (TP) and islet autogeneic transplantation (IAT) for chronic pancreatitis due to HGP are not clear.

STUDY DESIGN

We reviewed a prospectively maintained database of 484 TP-IATs from 1977 to 2012 at a single center. The outcomes (eg, pain relief, narcotic use, β-cell function, health-related quality of life measures) of patients who received TP-IAT for HGP (protease trypsin 1, n = 38; serine protease inhibitor Kazal type 1, n = 9; cystic fibrosis transmembrane conductance regulator, n = 14; and familial, n = 19) were evaluated and compared with those with non-hereditary/nongenetic causes.

RESULTS

All 80 patients with HGP were narcotic dependent and failed endoscopic management or direct pancreatic surgery. Post TP-IAT, 90% of the patients were pancreatitis pain free with sustained pain relief; >65% had partial or full β-cell function. Compared with nonhereditary causes, HGP patients were younger (22 years old vs 38 years old; p ≤ 0.001), had pancreatitis pain of longer duration (11.6 ± 1.1 years vs 9.0 ± 0.4 years; p = 0.016), had a higher pancreas fibrosis score (7 ± 0.2 vs 4.8 ± 0.1; p ≤ 0.001), and trended toward lower islet yield (3,435 ± 361 islet cell equivalent vs 3,850 ± 128 islet cell equivalent; p = 0.28). Using multivariate logistic regression, patients with non-HGP causes (p = 0.019); lower severity of pancreas fibrosis (p < 0.001); shorter duration of years with pancreatitis (p = 0.008); and higher transplant islet cell equivalent per kilogram body weight (p ≤ 0.001) were more likely to achieve insulin independence (p < 0.001). There was a significant improvement in health-related quality of life from baseline by RAND 36-Item Short Form Health Survey and in physical and mental component health-related quality of life scores (p < 0.001). None of the patients in the entire cohort had cancer of pancreatic origin in the liver or elsewhere develop during 2,936 person-years of follow-up.

CONCLUSIONS

Total pancreatectomy and IAT in patients with chronic pancreatitis due to HGP cause provide long-term pain relief (90%) and preservation of β-cell function. Patients with chronic painful pancreatitis due to HGP with a high lifetime risk of pancreatic cancer should be considered earlier for TP-IAT before pancreatic inflammation results in a higher degree of pancreatic fibrosis and islet cell function loss.

Long-term outcomes of total pancreatectomy and islet auto transplantation for hereditary/genetic pancreatitis

BACKGROUND

Chronic pancreatitis is a debilitating disease resulting from many causes. The subset with hereditary/genetic pancreatitis (HGP) not only has chronic pain, but also an increased risk for pancreatic cancer. Long-term outcomes of total pancreatectomy (TP) and islet autogeneic transplantation (IAT) for chronic pancreatitis due to HGP are not clear.

STUDY DESIGN

We reviewed a prospectively maintained database of 484 TP-IATs from 1977 to 2012 at a single center. The outcomes (eg, pain relief, narcotic use, β-cell function, health-related quality of life measures) of patients who received TP-IAT for HGP (protease trypsin 1, n = 38; serine protease inhibitor Kazal type 1, n = 9; cystic fibrosis transmembrane conductance regulator, n = 14; and familial, n = 19) were evaluated and compared with those with non-hereditary/nongenetic causes.

RESULTS

All 80 patients with HGP were narcotic dependent and failed endoscopic management or direct pancreatic surgery. Post TP-IAT, 90% of the patients were pancreatitis pain free with sustained pain relief; >65% had partial or full β-cell function. Compared with nonhereditary causes, HGP patients were younger (22 years old vs 38 years old; p ≤ 0.001), had pancreatitis pain of longer duration (11.6 ± 1.1 years vs 9.0 ± 0.4 years; p = 0.016), had a higher pancreas fibrosis score (7 ± 0.2 vs 4.8 ± 0.1; p ≤ 0.001), and trended toward lower islet yield (3,435 ± 361 islet cell equivalent vs 3,850 ± 128 islet cell equivalent; p = 0.28). Using multivariate logistic regression, patients with non-HGP causes (p = 0.019); lower severity of pancreas fibrosis (p < 0.001); shorter duration of years with pancreatitis (p = 0.008); and higher transplant islet cell equivalent per kilogram body weight (p ≤ 0.001) were more likely to achieve insulin independence (p < 0.001). There was a significant improvement in health-related quality of life from baseline by RAND 36-Item Short Form Health Survey and in physical and mental component health-related quality of life scores (p < 0.001). None of the patients in the entire cohort had cancer of pancreatic origin in the liver or elsewhere develop during 2,936 person-years of follow-up.

CONCLUSIONS

Total pancreatectomy and IAT in patients with chronic pancreatitis due to HGP cause provide long-term pain relief (90%) and preservation of β-cell function. Patients with chronic painful pancreatitis due to HGP with a high lifetime risk of pancreatic cancer should be considered earlier for TP-IAT before pancreatic inflammation results in a higher degree of pancreatic fibrosis and islet cell function loss.

Islet autotransplantation and total pancreatectomy

The goal of IAT is the preservation of beta-cell mass at the time of pancreatectomy. The majority of recipients have significant endogenous beta-cell function with positive blood C-peptide after surgery, even if only approximately one third achieve insulin independence. In appropriately selected patients, total pancreatectomy combined with IAT achieves relief of pain and improves quality of life with relatively easier-to-manage glycemic control and avoidance of hyper- and hypoglycemic episodes. Current research is focused on improving techniques of islet isolation and engraftment as well as long-term survival of autografted islets.

Total pancreatectomy and islet autotransplantation in chronic pancreatitis: recommendations from PancreasFest

DESCRIPTION

Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure used to treat severe complications of chronic pancreatitis or very high risk of pancreatic cancer while reducing the risk of severe diabetes mellitus. However, clear guidance on indications, contraindications, evaluation, timing, and follow-up are lacking.

METHODS

A working group reviewed the medical, psychological, and surgical options and supporting literature related to TPIAT for a consensus meeting during PancreasFest.

RESULTS

Five major areas requiring clinical evaluation and management were addressed: These included: 1) indications for TPIAT; 2) contraindications for TPIAT; 3) optimal timing of the procedure; 4) need for a multi-disciplinary team and the roles of the members; 5) life-long management issues following TPIAP including diabetes monitoring and nutrition evaluation.

CONCLUSIONS

TPIAT is an effective method of managing the disabling complications of chronic pancreatitis and risk of pancreatic cancer in very high risk patients. Careful evaluation and long-term management of candidate patients by qualified multidisciplinary teams is required. Multiple recommendations for further research were also identified.

Surgical outcomes after total pancreatectomy and islet cell autotransplantation in pediatric patients

BACKGROUND

This study aims to review surgical outcomes of pediatric patients undergoing total pancreatectomy with islet cell autotransplantation (TP/IAT) for the treatment of chronic pancreatitis (CP).

METHODS

All pediatric patients (≤18 years old) undergoing TP/IAT over a 10-year period (December 2002-June 2012) were identified for inclusion in a single-center, observational cohort study. Retrospective chart review was performed to identify pertinent preoperative, perioperative, and postoperative data, including narcotic usage, insulin requirements, etiology of pancreatitis, previous operative interventions, operative times, islet cell yields, duration of hospital stay, and overall quality of life. Quality of life was assessed using the Short Form-36 health questionnaire.

RESULTS

Fourteen pediatric patients underwent TP/IAT for the treatment of CP at the University of Cincinnati with a mean age of 15.9 years (range, 14-18) and a mean body mass index of 21.8 kg/m(2) (range, 14-37). Of the patients, 50% (n = 7) were male and 29% had undergone previous pancreatic operations (1 each of Whipple, Puestow, Frey, and Berne procedures). Etiology of pancreatitis was idiopathic for 57% (n = 8); the remainder had identified genetic mutations predisposing to pancreatitis (CFTR, n = 4; SPINK1, n = 1; PRSS1, n = 1). Mean operative time was 532 minutes (range, 360-674) with an average hospital duration of stay of 16 days (range, 7-37). Islet cell isolation resulted in mean islet cell equivalents (IEQ) of 500,443 in patients without previous pancreatic surgery versus 413,671 IEQ in patients with prior pancreatic surgery (P = .12). Median patient follow-up was 9 months from surgery (range, 1-78). Preoperatively, patients required on average 32.7 morphine equivalent mg per day (MEQ), which improved to 13.9 MEQ at most recent follow-up. Eleven patients (79%) were narcotic independent. None of the patients were diabetic preoperatively. All of the patients were discharged after the operation with scheduled insulin requirements (mean, 17 U/d). This requirement decreased to a mean of 10.1 U/d at most recent follow-up visit. Four patients (29%) progressed to insulin independence. All patients in this series achieved stable glycemic control postoperatively and there was no incidence of "brittle" diabetes. Quality-of-life surveys showed improvement in all tested modules.

CONCLUSION

This study represents one of the largest series examining TP/IAT in the pediatric population. Pediatric patients benefitted from TP/IAT with a decrease in postoperative narcotic requirements, stable glycemic control, and improved quality of life.

A replacement for islet equivalents with improved reliability and validity

Islet equivalent (IE), the standard estimate of isolated islet volume, is an essential measure to determine the amount of transplanted islet tissue in the clinic and is used in research laboratories to normalize results, yet it is based on the false assumption that all islets are spherical. Here, we developed and tested a new easy-to-use method to quantify islet volume with greater accuracy. Isolated rat islets were dissociated into single cells, and the total cell number per islet was determined by using computer-assisted cytometry. Based on the cell number per islet, we created a regression model to convert islet diameter to cell number with a high R2 value (0.8) and good validity and reliability with the same model applicable to young and old rats and males or females. Conventional IE measurements overestimated the tissue volume of islets. To compare results obtained using IE or our new method, we compared Glut2 protein levels determined by Western Blot and proinsulin content via ELISA between small (diameter≤100 μm) and large (diameter≥200 μm) islets. When normalized by IE, large islets showed significantly lower Glut2 level and proinsulin content. However, when normalized by cell number, large and small islets had no difference in Glut2 levels, but large islets contained more proinsulin. In conclusion, normalizing islet volume by IE overestimated the tissue volume, which may lead to erroneous results. Normalizing by cell number is a more accurate method to quantify tissue amounts used in islet transplantation and research.

Inherited pancreatic cancer syndromes

Pancreatic cancer remains one of the most challenging of all cancers. Genetic risk factors are believed to play a major role, but other than genes coding for blood group, genetic risks for sporadic cases remain elusive. However, several germline mutations have been identified that lead to hereditary pancreatic cancer, familial pancreatic cancer, and increased risk for pancreatic cancer as part of a familial cancer syndrome. The most important genes with variants increasing risk for pancreatic cancer include BRCA1, BRCA2, PALB2, ATM, CDKN2A, APC, MLH1, MSH2, MSH6, PMS2, PRSS1, and STK11. Recognition of members of high-risk families is important for understanding pancreatic cancer biology, for recommending risk reduction strategies and, in some cases, initiating cancer surveillance programs. Because the best methods for surveillance have not been established, the recommendation to refer at-risk patients to centers with ongoing research programs in pancreatic cancer surveillance is supported.

No islets left behind: islet autotransplantation for surgery-induced diabetes

For patients with severe chronic pancreatitis refractory to medical interventions, total pancreatectomy can be considered to relieve the root cause of pain. The goal of a simultaneous islet autotransplant is to prevent or minimize the otherwise inevitable surgical diabetes. Islet autotransplant can successfully preserve some endogenous islet function in the majority of recipients, which mediates protection against brittle diabetes. Most maintain reasonably good glycemic control, while 30 %-40 % successfully discontinue insulin therapy. With islet autotransplants reaching a wider clinical audience, refinements in islet isolation techniques and strategies to protect islet grafts post-transplant may further improve the success of this procedure.

Pancreatectomy and autologous islet transplantation for painful chronic pancreatitis: indications and outcomes

Total pancreatectomy with intrahepatic autoislet transplantation (TP/IAT) is a definitive treatment for relentlessly painful chronic pancreatitis. Pain relief is reported to be achieved in approximately 80% of patients. Overall, 30% to 40% achieve insulin independence, and 70% of recipients remain insulin independent for > 2 years, sometimes longer if > 300 000 islets are successfully transplanted. Yet, this approach to chronic pancreatitis is underemphasized in the general medical and surgical literature and vastly underused in the United States. This review emphasizes the history and metabolic outcomes of TP/IAT and considers its usefulness in the context of other, more frequently used approaches, such as operative intervention with partial pancreatectomy and/or lateral pancreaticojejunostomy (Puestow procedure), as well as endoscopic retrograde cholangiopancreatography with pancreatic duct modification and stent placement. Distal pancreatectomy and Puestow procedures compromise isolation of islet mass, and adversely affect islet autotransplant outcomes. Therefore, when endoscopic measures fail to relieve pain in severe chronic pancreatitis, we recommend early intervention with TP/IAT.

Improved quality of life following total pancreatectomy and auto-islet transplantation for chronic pancreatitis

BACKGROUND

Total pancreatectomy (TP) with auto-islet transplant (AIT) is an extreme treatment for chronic pancreatitis, and we reviewed our experience to assess the impact on quality of life (QOL).

METHODS

A prospective cohort study from 2007 through 2010 with pre- and postoperative assessments of the Depression Anxiety Stress Scale, Pain Disability Index, and visual analogue pain scale was performed.

RESULTS

Twenty patients underwent TP-AIT with a median follow-up of 12 months (6.75-24 months). All patients reported moderate (45 %) to severe (55 %) pain prior to surgery. TP-AIT resulted in significant decreases in abdominal pain (p < 0.001), 80 % reporting no or mild pain. Despite pain improvement, only 30 % discontinued narcotics. Improvements in all PDI QOL domains improved from 79 to 90 % (p = 0.002), with greatest improvements seen in those without prior pancreatic surgery, younger patients, and in those with higher levels of preoperative pain. Patients were less affected by depression and anxiety prior to surgery, but 60 and 70 % did show improvement in depression and anxiety, respectively (p = 0.033). Sixteen patients (80 %) required exogenous insulin at last follow-up (mean total dose of insulin 11.6 U/day).

CONCLUSIONS

TP-AIT significantly improves pain and QOL measures in appropriately selected patients with CP.

What is personalized medicine and what should it replace?

Personalized medicine is a new framework for medical care that involves modelling and simulation of a disease on the basis of its underlying mechanisms. This strategy must replace the 20(th) century paradigm of defining disease by pathology or associated signs and symptoms and conducting outcomes research that is based on the presence or absence of the disease syndrome. New technologies, including next-generation sequencing, the 'omics' and powerful computers provide massive amounts of accurate data. However, attempts to understand complex disorders by applying these new technologies within the 20(th) century framework have failed to produce the expected medical advances. To help physicians embrace a paradigm shift, the limitations of the old framework and major advantages of the new framework must be demonstrated. Chronic pancreatitis is an ideal complex disorder to study to consider the pros and cons of the two frameworks, because the pancreas is such a simple organ for disease modelling, and the advantages of personalized medicine are so profound.

Total pancreatectomy and islet autotransplantation for chronic pancreatitis

BACKGROUND

Total pancreatectomy (TP) with intraportal islet autotransplantation (IAT) can relieve pain and preserve β-cell mass in patients with chronic pancreatitis (CP) when other therapies fail. We report on a >30-year single-center series.

STUDY DESIGN

Four hundred and nine patients (including 53 children, 5 to 18 years) with CP underwent TP-IAT from February 1977 to September 2011 (etiology: idiopathic, 41%; Sphincter of Oddi dysfunction/biliary, 9%; genetic, 14%; divisum, 17%; alcohol, 7%; and other, 12%; mean age was 35.3 years, 74% were female; 21% has earlier operations, including 9% Puestow procedure, 6% Whipple, 7% distal pancreatectomy, and 2% other). Islet function was classified as insulin independent for those on no insulin; partial, if known C-peptide positive or euglycemic on once-daily insulin; and insulin dependent if on standard basal-bolus diabetic regimen. A 36-item Short Form (SF-36) survey for quality of life was completed by patients before and in serial follow-up since 2007, with an integrated survey that was added in 2008.

RESULTS

Actuarial patient survival post TP-IAT was 96% in adults and 98% in children (1 year) and 89% and 98% (5 years). Complications requiring relaparotomy occurred in 15.9% and bleeding (9.5%) was the most common complication. IAT function was achieved in 90% (C-peptide >0.6 ng/mL). At 3 years, 30% were insulin independent (25% in adults, 55% in children) and 33% had partial function. Mean hemoglobin A1c was <7.0% in 82%. Earlier pancreas surgery lowered islet yield (2,712 vs 4,077/kg; p = 0.003). Islet yield (<2,500/kg [36%]; 2,501 to 5,000/kg [39%]; >5,000/kg [24%]) correlated with degree of function with insulin-independent rates at 3 years of 12%, 22%, and 72%, and rates of partial function 33%, 62%, and 24%. All patients had pain before TP-IAT and nearly all were on daily narcotics. After TP-IAT, 85% had pain improvement. By 2 years, 59% had ceased narcotics. All children were on narcotics before, 39% at follow-up; pain improved in 94%; and 67% became pain-free. In the SF-36 survey, there was significant improvement from baseline in all dimensions, including the Physical and Mental Component Summaries (p < 0.01), whether on narcotics or not.

CONCLUSIONS

TP can ameliorate pain and improve quality of life in otherwise refractory CP patients, even if narcotic withdrawal is delayed or incomplete because of earlier long-term use. IAT preserves meaningful islet function in most patients and substantial islet function in more than two thirds of patients, with insulin independence occurring in one quarter of adults and half the children.

Total pancreatectomy and islet autotransplantation for chronic pancreatitis

BACKGROUND

Total pancreatectomy (TP) with intraportal islet autotransplantation (IAT) can relieve pain and preserve β-cell mass in patients with chronic pancreatitis (CP) when other therapies fail. We report on a >30-year single-center series.

STUDY DESIGN

Four hundred and nine patients (including 53 children, 5 to 18 years) with CP underwent TP-IAT from February 1977 to September 2011 (etiology: idiopathic, 41%; Sphincter of Oddi dysfunction/biliary, 9%; genetic, 14%; divisum, 17%; alcohol, 7%; and other, 12%; mean age was 35.3 years, 74% were female; 21% has earlier operations, including 9% Puestow procedure, 6% Whipple, 7% distal pancreatectomy, and 2% other). Islet function was classified as insulin independent for those on no insulin; partial, if known C-peptide positive or euglycemic on once-daily insulin; and insulin dependent if on standard basal-bolus diabetic regimen. A 36-item Short Form (SF-36) survey for quality of life was completed by patients before and in serial follow-up since 2007, with an integrated survey that was added in 2008.

RESULTS

Actuarial patient survival post TP-IAT was 96% in adults and 98% in children (1 year) and 89% and 98% (5 years). Complications requiring relaparotomy occurred in 15.9% and bleeding (9.5%) was the most common complication. IAT function was achieved in 90% (C-peptide >0.6 ng/mL). At 3 years, 30% were insulin independent (25% in adults, 55% in children) and 33% had partial function. Mean hemoglobin A1c was <7.0% in 82%. Earlier pancreas surgery lowered islet yield (2,712 vs 4,077/kg; p = 0.003). Islet yield (<2,500/kg [36%]; 2,501 to 5,000/kg [39%]; >5,000/kg [24%]) correlated with degree of function with insulin-independent rates at 3 years of 12%, 22%, and 72%, and rates of partial function 33%, 62%, and 24%. All patients had pain before TP-IAT and nearly all were on daily narcotics. After TP-IAT, 85% had pain improvement. By 2 years, 59% had ceased narcotics. All children were on narcotics before, 39% at follow-up; pain improved in 94%; and 67% became pain-free. In the SF-36 survey, there was significant improvement from baseline in all dimensions, including the Physical and Mental Component Summaries (p < 0.01), whether on narcotics or not.

CONCLUSIONS

TP can ameliorate pain and improve quality of life in otherwise refractory CP patients, even if narcotic withdrawal is delayed or incomplete because of earlier long-term use. IAT preserves meaningful islet function in most patients and substantial islet function in more than two thirds of patients, with insulin independence occurring in one quarter of adults and half the children.

Chronic pancreatitis and exocrine insufficiency

The evaluation, management, and follow-up of patients with chronic pancreatitis (CP) can be simple, but it can also be complex, so having a good referral network of subspecialists experienced in this field is essential. Identifying the cause of CP requires a systematic review of the many potential causes when the cause is not obvious. The identification of patients with autoimmune CP is particularly important because treatment with steroids may be effective. Alterations in pain or other symptoms in patients with CP should not be attributed to worsening disease before evaluations for complications including malignancy are done.

Remote processing of pancreas can restore normal glucose homeostasis in autologous islet transplantation after traumatic whipple pancreatectomy: technical considerations

An emergency autologous islet transplant after a traumatic Whipple operation and subsequent total pancreatectomy was performed for a 21-year-old patient who was wounded with multiple abdominal gunshot wounds. After Whipple pancreatectomy, the remnant pancreas (63.5 g), along with other damaged organs, was removed by the surgeons at Walter Reed Army Medical Center (WRAMC) and shipped to Diabetes Research Institute (DRI) for islet isolation. The pancreas was preserved in UW solution for 9.25 h prior to islet isolation. Upon arrival, the organ was visually inspected; the pancreatic head was missing, the rest of the pancreas was damaged and full of blood; the tail looked normal. A 16-gauge catheter was inserted into the main duct and directed towards tail of the pancreas after the dissection of main duct in the midbody of the pancreas. The pancreas was distended with collagenase solution (Roche MTF) through the catheter. During 10 min of intraductal delivery of enzyme, the gland was distended uniformly. No leakage of the solution was observed. The pancreas was transferred to a Ricordi chamber for automated mechanical and enzymatic digestion. Islets were purified using a COBE 2991 cell processor. Islet equivalents (IEQ; 221,250) of 40% purity and 90% viability were recovered during the isolation, which were shipped back to WRAMC and infused by intraportal injection into the patient. Immediate islet function was demonstrated by the rapid elevation of serum C peptide followed by insulin independence with near normal oral glucose tolerance test (OGTT) 1 and 2 months later. It is possible to restore near normal glucose tolerance with autologous islet transplantation after total pancreatectomy even with suboptimal number of islets while confirming that islets processed at a remote site are suitable for transplantation.