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Turan A, Tarique M, Zhang L, Kazmi S, Ulker V, Tedla MG, Badal D, Yolcu ES, Shirwan H. Engineering Pancreatic Islets to Transiently Codisplay on Their Surface Thrombomodulin and CD47 Immunomodulatory Proteins as a Means of Mitigating Instant Blood-Mediated Inflammatory Reaction following Intraportal Transplantation. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2024; 212:1971-1980. [PMID: 38709159 PMCID: PMC11160431 DOI: 10.4049/jimmunol.2300743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/01/2024] [Indexed: 05/07/2024]
Abstract
Most pancreatic islets are destroyed immediately after intraportal transplantation by an instant blood-mediated inflammatory reaction (IBMIR) generated through activation of coagulation, complement, and proinflammatory pathways. Thus, effective mitigation of IBMIR may be contingent on the combined use of agents targeting these pathways for modulation. CD47 and thrombomodulin (TM) are two molecules with distinct functions in regulating coagulation and proinflammatory responses. We previously reported that the islet surface can be modified with biotin for transient display of novel forms of these two molecules chimeric with streptavidin (SA), that is, thrombomodulin chimeric with SA (SA-TM) and CD47 chimeric with SA (SA-CD47), as single agents with improved engraftment following intraportal transplantation. This study aimed to test whether islets can be coengineered with SA-TM and SA-CD47 molecules as a combinatorial approach to improve engraftment by inhibiting IBMIR. Mouse islets were effectively coengineered with both molecules without a detectable negative impact on their viability and metabolic function. Coengineered islets were refractory to destruction by IBMIR ex vivo and showed enhanced engraftment and sustained function in a marginal mass syngeneic intraportal transplantation model. Improved engraftment correlated with a reduction in intragraft innate immune infiltrates, particularly neutrophils and M1 macrophages. Moreover, transcripts for various intragraft procoagulatory and proinflammatory agents, including tissue factor, HMGB1 (high-mobility group box-1), IL-1β, IL-6, TNF-α, IFN-γ, and MIP-1α, were significantly reduced in coengineered islets. These data demonstrate that the transient codisplay of SA-TM and SA-CD47 proteins on the islet surface is a facile and effective platform to modulate procoagulatory and inflammatory responses with implications for both autologous and allogeneic islet transplantation.
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Affiliation(s)
- Ali Turan
- Department of Pediatrics and Department of Molecular Microbiology and Immunology, NextGen Precision Health Institute, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO
| | - Mohammad Tarique
- Department of Pediatrics and Department of Molecular Microbiology and Immunology, NextGen Precision Health Institute, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO
| | - Lei Zhang
- Department of Pediatrics and Department of Molecular Microbiology and Immunology, NextGen Precision Health Institute, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO
| | - Shadab Kazmi
- Department of Pediatrics and Department of Molecular Microbiology and Immunology, NextGen Precision Health Institute, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO
| | - Vahap Ulker
- Department of Pediatrics and Department of Molecular Microbiology and Immunology, NextGen Precision Health Institute, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO
| | - Mebrahtu G Tedla
- Department of Pediatrics and Department of Molecular Microbiology and Immunology, NextGen Precision Health Institute, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO
| | - Darshan Badal
- Department of Pediatrics and Department of Molecular Microbiology and Immunology, NextGen Precision Health Institute, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO
| | - Esma S Yolcu
- Department of Pediatrics and Department of Molecular Microbiology and Immunology, NextGen Precision Health Institute, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO
| | - Haval Shirwan
- Department of Pediatrics and Department of Molecular Microbiology and Immunology, NextGen Precision Health Institute, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO
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Haddad EN, Lansang MC, Xiao H, Walsh RM, Simon R, Hatipoglu BA, Zhou K. Preoperative and Postoperative Predictors of Insulin Independence From Total Pancreatectomy and Islet Autotransplantation. Endocr Pract 2024:S1530-891X(24)00550-0. [PMID: 38871053 DOI: 10.1016/j.eprac.2024.05.013] [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: 03/19/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVE This study examined the preoperative and postoperative variables associated with 1 year and long-term insulin independence following total pancreatectomy and islet autotransplantation (TPIAT). METHODS 46 TPIAT patients from 2010 to 2022 in a single hospital system were retrospectively analyzed. Pre- and postoperative variables were compared between short-term (1 year) and long-term (last follow-up after year 1) insulin-independent versus -dependent patients. RESULTS Nine (20%) and seven (15%) patients achieved short- and long-term insulin independence, respectively. The patients were followed up for a median of 2.8 years (interquartile range [IQR] 1.0, 4.7). Short-term insulin independence was associated with higher median transplanted islet equivalents (IEQ) per kg (6981 vs 4493, P = .02), lower units of basal insulin on discharge (7 vs 12, P = .009), and lower rates of discharge with an insulin regimen (67% vs 100%, P = .006). Odds of short-term insulin independence increased by 80% for every 1000 increase in IEQ per kg (OR 1.80, CI 1.18-3.12, P = .005) and decreased by 32% for every additional basal unit of insulin on discharge (OR 0.68, CI 0.42-0.91, P = .003) on average. Long-term insulin independence was also associated with transplanted IEQ per kg. No patient on antihyperglycemic medication before surgery achieved insulin independence. CONCLUSION Short- and long-term insulin independence after TPIAT is associated with higher transplanted IEQ per kg and immediate postoperative variables that can be used to inform the discussions clinicians have with their patients regarding glycemic prognosis following TPIAT.
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Affiliation(s)
- Eliot N Haddad
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - M Cecilia Lansang
- Department of Endocrinology and Metabolism, Cleveland Clinic, Cleveland, Ohio
| | - Huijun Xiao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - R Matthew Walsh
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert Simon
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Betul A Hatipoglu
- Center for Diabetes and Metabolic Care, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Keren Zhou
- Department of Endocrinology and Metabolism, Cleveland Clinic, Cleveland, Ohio.
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Hines OJ, Pandol SJ. Management of chronic pancreatitis. BMJ 2024; 384:e070920. [PMID: 38408777 DOI: 10.1136/bmj-2023-070920] [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: 02/28/2024]
Abstract
Chronic pancreatitis results from repeated episodes of pancreatic inflammation and associated fibrosis leading to the loss of functional exocrine and endocrine pancreatic function. The disease is manifested by abdominal pain, deterioration in quality of life, food maldigestion and malabsorption, diabetes, and an increased risk for pancreatic adenocarcinoma. This review summarizes the latest evidence on the diagnosis and management of chronic pancreatitis and its manifestations. In particular, this review discusses advances in understanding of the role of genetic disorders in the mechanisms of the disease and surgical options for patients refractory to medical therapy. Furthermore, clinical trials are under way to develop medical therapeutics.
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Affiliation(s)
- O Joe Hines
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Stephen J Pandol
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Chen ME, Desai CS. Current practices in islet cell autotransplantation. Expert Rev Endocrinol Metab 2023; 18:419-425. [PMID: 37680038 DOI: 10.1080/17446651.2023.2256407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Chronic pancreatitis and recurrent acute pancreatitis comprise a spectrum of disease that results in complications related to exocrine and endocrine insufficiency and chronic pain with narcotic dependence and poor quality of life. The mainstay of therapy has been medical and endoscopic therapy; surgery, especially total pancreatectomy, was historically reserved for few select patients as the obligate exocrine insufficiency and pancreatogenic diabetes (type 3C) are challenging to manage. The addition of islet cell autotransplantation after total pancreatectomy helps to mitigate brittle type 3c diabetes and prevents mortality related to severe hypoglycemic episodes and hypoglycemic unawareness. There have been more recent data demonstrating the safety of surgery and the beneficial long-term outcomes. AREAS COVERED The purpose of this review is to describe the current practices in the field of islet cell autotransplantation including the selection and evaluation of patients for surgery, their preoperative work up and management, surgical approach, post-operative management and outcomes. EXPERT OPINION Total pancreatectomy and islet cell autotransplantation has the ability to drastically improve quality of life and prevent brittle diabetes for patients suffering with chronic pancreatitis.
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Affiliation(s)
- Melissa E Chen
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Chirag S Desai
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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Kalsi RS, Kreger AM, Saleh M, Yoshida S, Sharma K, Fusco J, Saloman JL, Zhang T, Thomas M, Sehrawat A, Wang Y, Reif J, Mills J, Raad S, Zengin B, Gomez A, Singhi A, Tadros S, Slivka A, Esni F, Prasadan K, Gittes G. Chemical pancreatectomy in non-human primates ablates the acini and ducts and enhances beta-cell function. Sci Rep 2023; 13:9113. [PMID: 37277426 PMCID: PMC10241801 DOI: 10.1038/s41598-023-35820-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/24/2023] [Indexed: 06/07/2023] Open
Abstract
Chronic pancreatitis is a debilitating disease affecting millions worldwide. These patients suffer from bouts of severe pain that are minimally relieved by pain medications and may necessitate major surgeries with high morbidity and mortality. Previously, we demonstrated that "chemical pancreatectomy," a pancreatic intraductal infusion of dilute acetic acid solution, ablated the exocrine pancreas while preserving the endocrine pancreas. Notably, chemical pancreatectomy resolved chronic inflammation, alleviated allodynia in the cerulein pancreatitis model, and improved glucose homeostasis. Herein, we extensively tested the feasibility of a chemical pancreatectomy in NHPs and validated our previously published pilot study. We did serial computed tomography (CT) scans of the abdomen and pelvis, analyzed dorsal root ganglia, measured serum enzymes, and performed histological and ultrastructural assessments and pancreatic endocrine function assays. Based on serial CT scans, chemical pancreatectomy led to the loss of pancreatic volume. Immunohistochemistry and transmission electron microscopy demonstrated exocrine pancreatic ablation with endocrine islet preservation. Importantly, chemical pancreatectomy did not increase pro-nociceptive markers in harvested dorsal root ganglia. Also, chemical pancreatectomy improved insulin secretion to supranormal levels in vivo and in vitro. Thus, this study may provide a foundation for translating this procedure to patients with chronic pancreatitis or other conditions requiring a pancreatectomy.
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Affiliation(s)
- Ranjeet S Kalsi
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Alexander M Kreger
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Mohamed Saleh
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Division of Pediatric Endocrinology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Shiho Yoshida
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Kartikeya Sharma
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Joseph Fusco
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Jami L Saloman
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Department of Neurobiology, Pittsburgh Center for Pain Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ting Zhang
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Madison Thomas
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Anuradha Sehrawat
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Yan Wang
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Jason Reif
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Juliana Mills
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Sarah Raad
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Bugra Zengin
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Ana Gomez
- Division of Pediatric Pathology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Aatur Singhi
- Divisions of Anatomic Pathology and Molecular Genomic Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sameh Tadros
- Department of Pediatric Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Farzad Esni
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Krishna Prasadan
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - George Gittes
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
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Kalsi RS, Kreger AM, Saleh M, Yoshida S, Sharma K, Fusco J, Saloman JL, Zhang T, Thomas M, Sehrawat A, Wang Y, Reif J, Mills J, Raad S, Zengin B, Gomez A, Singhi A, Tadros S, Slivka A, Esni F, Prasadan K, Gittes G. Chemical pancreatectomy in non-human primates ablates the acini and ducts and enhances beta-cell function. RESEARCH SQUARE 2023:rs.3.rs-2618133. [PMID: 36945494 PMCID: PMC10029118 DOI: 10.21203/rs.3.rs-2618133/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Chronic pancreatitis is a debilitating disease affecting millions worldwide. These patients suffer from bouts of severe pain that are minimally relieved by pain medications and may necessitate major surgeries with high morbidity and mortality. Previously, we demonstrated that "chemical pancreatectomy," a pancreatic intraductal infusion of dilute acetic acid solution, ablated the exocrine pancreas while preserving the endocrine pancreas. Notably, chemical pancreatectomy resolved chronic inflammation, alleviated allodynia in the cerulein pancreatitis model, and improved glucose homeostasis. Herein, we extensively tested the feasibility of a chemical pancreatectomy in NHPs and validated our previously published pilot study. We did serial computed tomography (CT) scans of the abdomen and pelvis, analyzed dorsal root ganglia, measured serum enzymes, and performed histological and ultrastructural assessments and pancreatic endocrine function assays. Based on serial CT scans, chemical pancreatectomy led to the loss of pancreatic volume. Immunohistochemistry and transmission electron microscopy demonstrated exocrine pancreatic ablation with endocrine islet preservation. Importantly, chemical pancreatectomy did not increase pro-nociceptive markers in harvested dorsal root ganglia. Also, chemical pancreatectomy improved insulin secretion to supranormal levels in vivo and in vitro. Thus, this study may provide a foundation for translating this procedure to patients with chronic pancreatitis or other conditions requiring a pancreatectomy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Yan Wang
- UPMC Children's Hospital of Pittsburgh
| | | | | | | | | | - Ana Gomez
- UPMC Children's Hospital of Pittsburgh
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de Rijk FEM, van Veldhuisen CL, Besselink MG, van Hooft JE, van Santvoort HC, van Geenen EJM, van Werkhoven CH, de Jonge PJF, Bruno MJ, Verdonk RC. Implementation of an evidence-based management algorithm for patients with chronic pancreatitis (COMBO trial): study protocol for a stepped-wedge cluster-randomized controlled trial. Trials 2023; 24:18. [PMID: 36611202 PMCID: PMC9824955 DOI: 10.1186/s13063-022-07044-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Chronic pancreatitis (CP) is an inflammatory disease that may be complicated by abdominal pain, pancreatic dysfunction, nutritional deficiencies, and diminished bone density. Importantly, it is also associated with a substantially impaired quality of life and reduced life expectancy. This may partly be explained by suboptimal treatment, in particular the long-term management of this chronic condition, despite several national and international guidelines. Standardization of care through a structured implementation of guideline recommendations may improve the level of care and lower the complication rate of these patients. Therefore, the aim of the present study is to evaluate to what extent patient education and standardization of care, through the implementation of an evidence-based integrated management algorithm, improve quality of life and reduce pain severity in patients with CP. METHODS The COMBO trial is a nationwide stepped-wedge cluster-randomized controlled trial. In a stepwise manner, 26 centers, clustered in 6 health regions, cross-over from current practice to care according to an evidence-based integrated management algorithm. During the current practice phase, study participants are recruited and followed longitudinally through questionnaires. Individual patients contribute data to both study periods. Co-primary study endpoints consist of quality of life (assessed by the PANQOLI score) and level of pain (assessed by the Izbicki questionnaire). Secondary outcomes include process measure outcomes, clinical outcomes (e.g., pancreatic function, nutritional status, bone health, interventions, medication use), utilization of healthcare resources, (in) direct costs, and the level of social participation. Standard follow-up is 35 months from the start of the trial. DISCUSSION This is the first stepped-wedge cluster-randomized controlled trial to investigate whether an evidence-based integrated therapeutic approach improves quality of life and pain severity in patients with CP as compared with current practice. TRIAL REGISTRATION ISRCTN, ISRCTN13042622. Registered on 5 September 2020.
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Affiliation(s)
- Florence E. M. de Rijk
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands ,grid.415960.f0000 0004 0622 1269Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Charlotte L. van Veldhuisen
- grid.415960.f0000 0004 0622 1269Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands ,grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Marc G. Besselink
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Jeanin E. van Hooft
- grid.10419.3d0000000089452978Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hjalmar C. van Santvoort
- grid.415960.f0000 0004 0622 1269Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands ,grid.7692.a0000000090126352Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erwin J. M. van Geenen
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelis H. van Werkhoven
- grid.7692.a0000000090126352Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Pieter Jan F. de Jonge
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Marco J. Bruno
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Robert C. Verdonk
- grid.415960.f0000 0004 0622 1269Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Sordi V, Monaco L, Piemonti L. Cell Therapy for Type 1 Diabetes: From Islet Transplantation to Stem Cells. Horm Res Paediatr 2022; 96:658-669. [PMID: 36041412 DOI: 10.1159/000526618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 08/08/2022] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Valeria Sordi
- Diabetes Research Institute, San Raffaele Hospital, Milan, Italy,
| | - Laura Monaco
- Diabetes Research Institute, San Raffaele Hospital, Milan, Italy
| | - Lorenzo Piemonti
- Diabetes Research Institute, San Raffaele Hospital, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Coluzzi M, Naziruddin B, Kumano K, Saracino G, Testa G, Beecherl E, Onaca N. Spleen-preserving total pancreatectomy and islet autotransplantation with complete preservation of the splenic arterial and venous supply does not impact islet yield and function. Am J Surg 2022; 224:1295-1300. [PMID: 35781373 DOI: 10.1016/j.amjsurg.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/10/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Standard total pancreatectomy and islet autotransplantation (TPIAT) for chronic pancreatitis includes splenectomy, but TPIAT can be performed without splenectomy by full preservation of the blood supply to the spleen. METHODS We compared the metabolic and clinical outcomes of patients who underwent TPIAT at our center between 2015 and 2021 with or without splenectomy. A total of 89 patients were included in the study, and 17 of them underwent spleen-preserving total pancreatectomy (SPTP). RESULTS The two study groups had similar demographic and metabolic parameters. Short-term morbidity and long-term outcomes were similar. The operative time was significantly shorter with splenectomy: a median of 9.91 h (interquartile range [IQR] 8.89-10.83) compared to 10.78 h (IQR 10.2-11.6) for SPTP (P = 0.021). There was no difference between the groups in postoperative morbidity. Metabolic outcomes at 1 year were better in the SPTP group compared to the splenectomy group, with a median daily insulin requirement of 7 units (IQR 4-12) vs 15 units (IQR 7-26; P = 0.049) and a median C-peptide at 1 year of 0.65 (IQR 0.40-1.26) vs 1.00 (IQR 0.80-1.90; P = 0.63). The reduction in morphine milligram equivalents per day over time was significantly better in the SPTP group (P < 0.001), as was the decrease in pain score (P < 0.001). CONCLUSION TPIAT with full arterial and venous preservation of the spleen had no adverse impact on islet yield or function. TPIAT can be safely and effectively performed with preservation of the spleen and the entire splenic artery and vein. The spleen should be preserved when feasible in every TPIAT surgery.
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Affiliation(s)
- Mariagrazia Coluzzi
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA; Unit of General and Emergency Surgery, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - Bashoo Naziruddin
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
| | - Kenjiro Kumano
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Giovanna Saracino
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Giuliano Testa
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Ernest Beecherl
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Nicholas Onaca
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA; LifeGift, Fort Worth, TX, USA
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Szempruch KR, Walter K, Ebert N, Bridgens K, Desai CS. Pharmacological management of patients undergoing total pancreatectomy with auto-islet transplantation. Pancreatology 2022; 22:656-664. [PMID: 35490122 DOI: 10.1016/j.pan.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/17/2022] [Accepted: 04/15/2022] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis results in permanent parenchymal destruction of the pancreas gland leading to anatomical and physiological consequences for patients. Surgical management varies, and some patients require total pancreatectomy with autologous islet cell transplantation (TPIAT). Patients undergoing TPIAT require complex and diligent management after surgery. This encompasses the management of glucose control (endocrine function of the pancreas) and supplementing loss of exocrine function of the pancreas with digestive enzymes. Other areas of management include optimizing pain relief while reducing narcotic usage, providing antimicrobial prophylaxis, and reducing loss of islet cells by improving its integrity through anticoagulation and use of anti-inflammatory agents. Each aspect of care is unique to this population. However, comprehensive reviews on its pharmacological management are scarce. This review will discuss the available literature to date surrounding all aspects of pharmacological management of patients undergoing TPIAT.
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Affiliation(s)
- Kristen R Szempruch
- Pharmacy Department, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Krysta Walter
- Pharmacy Department, Michigan Medicine, Ann Arbor, MI, USA
| | - Natassha Ebert
- Pharmacy Department, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Kathryn Bridgens
- Department of Nutrition and Food Services, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Chirag S Desai
- Department of Surgery, Transplant, University of North Carolina Medical Center, Chapel Hill, NC, USA.
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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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12
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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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13
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OUP accepted manuscript. Br J Surg 2022; 109:363-371. [DOI: 10.1093/bjs/znab473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/16/2021] [Accepted: 12/22/2021] [Indexed: 11/14/2022]
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14
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Yadav D, Palermo TM, Phillips AE, Bellin MD, Conwell DL. Painful chronic pancreatitis - new approaches for evaluation and management. Curr Opin Gastroenterol 2021; 37:504-511. [PMID: 34172622 PMCID: PMC8826115 DOI: 10.1097/mog.0000000000000769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Management of abdominal pain in patients with chronic pancreatitis is often suboptimal. We review recent data on the epidemiology and new approaches for managing pain in chronic pancreatitis. RECENT FINDINGS Chronic pancreatitis duration does not appear to affect the pain experience. Pain pattern in chronic pancreatitis patients frequently changes and is not related to traditional patient and disease-related factors. Psychologic comorbidities, i.e. anxiety and depression, are frequent in patients with chronic pancreatitis, and are associated with more severe pain and pain interference. Adjunctive treatments, such as cognitive behavioral therapy, may positively influence pain management in chronic pancreatitis. Total pancreatectomy with islet autotransplantation (TPIAT) is an increasingly adopted treatment option in painful chronic pancreatitis. Ongoing multicenter studies will help define optimal candidates, predictors of successful pain remission and diabetes outcomes after TPIAT. Pancreatic quantitative sensory testing, a promising technique to interrogate nociception and sensory response, holds promise to identify patients with central sensitization. Initial studies show feasibility to stratify patients into defined pain profiles, and future studies will explore if these can help in prognostication of pain therapy. SUMMARY Several lines of investigations currently under evaluation are likely to have a positive impact on the management of pain in chronic pancreatitis.
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Affiliation(s)
- Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tonya M. Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Anna E. Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melena D. Bellin
- Division of Endocrinology and Metabolism, University of Minnesota Medical Center, Minneapolis, MN
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
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15
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Naples R, Perlmutter BC, Thomas JD, McMichael J, Bottino R, Solomina J, Trucco M, Augustin T, Simon R, Walsh RM. Clinical Significance of Postoperative Antibiotic Treatment for Positive Islet Cultures After Total Pancreatectomy With Islet Autotransplantation. Pancreas 2021; 50:1000-1006. [PMID: 34629454 DOI: 10.1097/mpa.0000000000001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Islet cultures are routinely performed in total pancreatectomy with islet autotransplantation (TPIAT), and the need for empiric antibiotic treatment based on culture results is unknown. We evaluated the effect of postoperative antibiotic treatment for positive islet cultures on clinical infection. METHODS Seventy-nine patients undergoing TPIAT were reviewed. Prophylactic perioperative ceftriaxone and metronidazole were administered, and transplanted islet preparations included ciprofloxacin. Postoperative antibiotics were not routinely given for positive cultures unless a clinical infection was suspected. The primary end point was 30-day infectious complications. RESULTS Fifty-one patients (65%) had a positive culture. Overall, 39 patients (87%) had organisms susceptible to our perioperative antibiotic regimen. There was no difference in the infectious complication rate between those with positive compared with negative cultures (16% vs 29%, P = 0.17). Patients with a positive culture had similar 30-day postoperative infectious complication rates whether receiving postoperative antibiotics (n = 7) or not (14% vs 16%, P = 0.91). Only 1 patient had a correlation of clinical and islet cultures. CONCLUSIONS Beyond prophylactic antibiotics, empiric antibiotic treatment for a positive culture is not warranted and provides a rationale for the abandonment of routine cultures in TPIAT.
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Affiliation(s)
- Robert Naples
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Breanna C Perlmutter
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Jonah D Thomas
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - John McMichael
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Rita Bottino
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Julia Solomina
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Massimo Trucco
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Toms Augustin
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Robert Simon
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - R Matthew Walsh
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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16
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Jabłońska B, Mrowiec S. Total Pancreatectomy with Autologous Islet Cell Transplantation-The Current Indications. J Clin Med 2021; 10:jcm10122723. [PMID: 34202998 PMCID: PMC8235694 DOI: 10.3390/jcm10122723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022] Open
Abstract
Total pancreatectomy is a major complex surgical procedure involving removal of the whole pancreatic parenchyma and duodenum. It leads to lifelong pancreatic exocrine and endocrine insufficiency. The control of surgery-induced diabetes (type 3) requires insulin therapy. Total pancreatectomy with autologous islet transplantation (TPAIT) is performed in order to prevent postoperative diabetes and its serious complications. It is very important whether it is safe and beneficial for patients in terms of postoperative morbidity and mortality, and long-term results including quality of life. Small duct painful chronic pancreatitis (CP) is a primary indication for TPAIT, but currently the indications for this procedure have been extended. They also include hereditary/genetic pancreatitis (HGP), as well as less frequent indications such as benign/borderline pancreatic tumors (intraductal papillary neoplasms, neuroendocrine neoplasms) and “high-risk pancreatic stump”. The use of TPAIT in malignant pancreatic and peripancreatic neoplasms has been reported in the worldwide literature but currently is not a standard but rather a controversial management in these patients. In this review, history, technique, indications, and contraindications, as well as short-term and long-term results of TPAIT, including pediatric patients, are described.
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17
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Maatman TK, Zyromski NJ. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2020.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Maatman TK, Zyromski NJ. Chronic Pancreatitis. Curr Probl Surg 2020; 58:100858. [PMID: 33663691 DOI: 10.1016/j.cpsurg.2020.100858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas K Maatman
- Resident in General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas J Zyromski
- Professor of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA..
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19
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Miksch RC, D'Haese JG, Werner J. Surgical Therapy of Chronic Alcoholic Pancreatitis: A Literature Review of Current Options. Visc Med 2020; 36:191-197. [PMID: 32775349 PMCID: PMC7383250 DOI: 10.1159/000508174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022] Open
Abstract
Chronic pancreatitis (CP) is associated with alcohol abuse in 80% of cases. The primary treatment goals in CP are pain reduction and avoidance of pancreatitis-associated complications. CP should be treated in an interdisciplinary approach. A recent randomized clinical trial showed that early surgery compared with an endoscopy-first approach resulted in reduced pain levels. Surgical resections are, therefore, the most efficient treatment of pancreatitis-associated pain as well as other complications and should be performed early in the course of the disease. Since most of the patients pre-sent with chronic inflammation of the pancreatic head, pancreatic head resection is the most common treatment option. Duodenum-preserving pancreatic head resections are the surgical procedure of choice, but pancreaticoduodenectomies (Kausch-Whipple procedures) demonstrate similar outcome with regard to pain control, quality of life, and metabolic parameters. Other surgical procedures, including drainage procedures, pancreatic segmental resections, or left resections, are rarely indicated.
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Affiliation(s)
| | | | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilian University Munich, Munich, Germany
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20
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Udd M, Kylänpää L, Kokkola A. The Role of Endoscopic and Surgical Treatment in Chronic Pancreatitis. Scand J Surg 2020; 109:69-78. [DOI: 10.1177/1457496920910009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic pancreatitis is a long-term illness leading to hospital admissions and readmission. This disease is often caused by heavy alcohol consumption and smoking. Patients with chronic pancreatitis suffer from acute or chronic pain episodes, recurrent pancreatitis, and complications, such as pseudocysts, biliary duct strictures, and pancreatic duct fistulas. Pancreatic duct strictures and stones may increase intraductal pressure and cause pain. Endoscopic therapy is aiming at decompressing the pressure and relieving the pain, most commonly with pancreatic duct stents and pancreatic duct stone retrieval. Early surgery is another option to treat the pain. In addition, endotherapy has been successful in treating complications related to chronic pancreatitis. The therapy should be individually chosen in a multidisciplinary meeting. Endoscopic therapy and surgery as treatment options for chronic pancreatitis are discussed in this review.
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Affiliation(s)
- M. Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L. Kylänpää
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A. Kokkola
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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21
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Kempeneers MA, Issa Y, Ali UA, Baron RD, Besselink MG, Büchler M, Erkan M, Fernandez-Del Castillo C, Isaji S, Izbicki J, Kleeff J, Laukkarinen J, Sheel ARG, Shimosegawa T, Whitcomb DC, Windsor J, Miao Y, Neoptolemos J, Boermeester MA. International consensus guidelines for surgery and the timing of intervention in chronic pancreatitis. Pancreatology 2020; 20:149-157. [PMID: 31870802 DOI: 10.1016/j.pan.2019.12.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/03/2019] [Accepted: 12/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Chronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP. METHODS An international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach's alpha reliability coefficient. RESULTS Strong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40-55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients. CONCLUSIONS This international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.
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Affiliation(s)
- M A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Y Issa
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - U Ahmed Ali
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - R D Baron
- Department of Surgery, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - M G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - M Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - M Erkan
- Department of Surgery, Koc University, Istanbul, Turkey
| | | | - S Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Japan
| | - J Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Germany
| | - J Kleeff
- Department of Visceral, Vascular, and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Germany
| | - J Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Finland
| | - A R G Sheel
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - T Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - D C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, PA, USA
| | - J Windsor
- HBP/Upper GI Unit, Auckland City Hospital/Department of Surgery, University of Auckland, New Zealand
| | - Y Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, China
| | - J Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - M A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands.
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22
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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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