Surgical management of chronic pancreatitis and the role of islet cell autotransplantation

Interventional Radiological Management and Prevention of Complications after Pancreatic Surgery: Drainage, Embolization and Islet Auto-Transplantation

Pancreatic surgery still remains burdened by high levels of morbidity and mortality with a relevant incidence of complications, even in high volume centers. This review highlights the interventional radiological management of complications after pancreatic surgery. The current literature regarding the percutaneous drainage of fluid collections due to pancreatic fistulas, percutaneous transhepatic biliary drainage due to biliary leaks and transcatheter embolization (or stent–graft) due to arterial bleeding is analyzed. Moreover, also, percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also examined. Moreover, a topic not usually treated in other similar reviewsas percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also one of our areas of focus. In islet auto-transplantation, the patient is simultaneously donor and recipient. Differently from islet allo-transplantation, it does not require immunosuppression, has no risk of rejection and is usually efficient with a small number of transplanted islets.

Pancreatectomy, Islet Cell Transplantation, and Nutrition Considerations

Pancreatic islet transplantation is a reliable approach for treating insulin-deficient diabetes. This established β-cell replacement approach has shown considerable improvements in the last 2 decades. It has helped achieve metabolic homeostasis and safe outcomes for a subset of patients with type 1 diabetes and severe pancreatitis. Nutrition support, until recently, was considered as a secondary factor, merely identified as a means of providing all the necessary nutrients for such patients. However, new literature suggests that several factors, such as the route, timing, quantity, and composition of all the nutrients administered, have key disease-altering properties and are vital during the perioperative management of such patients. This review will highlight the benefits of performing the clinical islet transplantation on a subgroup of patients with type 1 diabetes and pancreatitis and summarize new data that identify the pivotal role of nutrition support as a critical intervention in their management.

Allo- and auto-percutaneous intra-portal pancreatic islet transplantation (PIPIT) for diabetes cure and prevention: the role of imaging and interventional radiology

Although the life expectancy of patients with type 1 diabetes mellitus (T1DM) has improved since the introduction of insulin therapy, the acute life-threatening and long-term complications from diabetes mellitus are significant causes of both mortality and morbidity. Percutaneous intra-portal pancreatic islet transplantation (PIPIT) is a minimally invasive, repeatable procedure which allows a β-cell replacement therapy through a liver islet engraftment, leading to insulin release and glycaemic control restoration in patients with diabetes. Allo-PIPIT, in which isolated and purified islets from cadaveric donor are used, does not require major surgery, and is potentially less expensive for the recipient. In case of long-term T1DM, islet-after-kidney (IAK) transplantation can simultaneously cure diabetes and chronic renal failure, while islet-transplant-alone (ITA) is performed in brittle, short-term T1DM, based on the infusion of an adequate islet mass and on a steroid-free immunosuppressive regimen according to the Edmonton protocol. Results of the Collaborative Islet Transplant Registry (CITR) demonstrate that allo-PIPIT reduces episodes of hypoglycemia and diabetic complications, and improves quality of life of diabetic patients. Auto-PIPIT, in which the own patient's islets are used, has been investigated as a preventive treatment for pancreatogenic diabetes in patients who undergo extensive pancreatectomy for malignant and non-malignant disease. This Review outlines the role of imaging and interventional radiology in allo- and auto-PIPIT.

Single-centre experience of extending indications for percutaneous intraportal islet autotransplantation (PIPIAT) after pancreatic surgery to prevent diabetes: feasibility, radiological aspects, complications and clinical outcome

OBJECTIVE

Islet allotransplantation is a less invasive alternative to surgical pancreas transplantation for Type 1 diabetes, while percutaneous intraportal islet autotransplantation (PIPIAT) is usually performed after pancreatic surgery to prevent diabetes. Our aim was to assess the feasibility, radiological aspects, complications and clinical outcome of PIPIAT following pancreatic surgery for not only chronic pancreatitis but also benign and malignant nodules.

METHODS

From 2008 to 2012, 41 patients were enrolled for PIPIAT 12-48 h after pancreatic surgery (extended pancreatic surgery for chronic pancreatitis and benign/malignant neoplasms). PIPIAT was performed using a combined ultrasonography and fluoroscopy-guided technique (4-F catheter). PIPIAT feasibility, median follow-up and metabolic (insulin independence rate, graft function based on C-peptide levels) and oncologic outcomes were recorded.

RESULTS

PIPIAT was not performed in 7/41 patients (4 cases for an inadequate islet mass, 2 cases for haemodynamic instability and 1 case for islet culture contamination), while it was successfully performed in 34/34 patients. Procedure-related major complications occurred in four patients: two bleedings requiring transfusions, one patient with left portal vein thrombosis and one patient with sepsis. Median follow-up duration was 546 days. Insulin independence was achieved in 15/34 (44%) patients, partial graft function in 16/34 (47%) patients and no function in 3/34 (9%) patients. None of the 17 patients with malignant nodules developed liver metastases during follow-up.

CONCLUSION

PIPIAT, performed under ultrasound and fluoroscopy combined guidance and not requiring immunosuppression, is feasible, with a relatively low complication rate and a better metabolic outcome than allotransplantation.

ADVANCES IN KNOWLEDGE

PIPIAT can prevent pancreatogenic diabetes. Ultrasound is a useful tool for the guidance and monitoring of PIPIAT.

Preservation of Beta Cell Function after Pancreatic Islet Autotransplantation: University of Chicago Experience

The aim of the study was to assess the rate of insulin independence in patients after total pancreatectomy (TP) and islet autotransplantation in our center. TP followed by islet auto-transplantation was performed in 10 patients. Severe unrelenting pain associated with chronic pancreatitis was the major indication for surgery. Islets were isolated using the modified Ricordi method and infused through the portal vein. Exogenous insulin therapy was implemented for at least two months posttransplant to support islet engraftment and was subsequently weaned off, if possible. Median follow-up was 26 months (range, 2 to 60 months). Median islet yield was 158,860 islet equivalents (IEQ) (range, 40,203 to 330,472 IEQ) with an average islet yield of 2,478 IEQ/g (range, 685 to 6,002 IEQ/g) of processed pancreas. One patient developed transient partial portal vein thrombosis, which resolved without sequela. Five (50%) patients are currently off insulin with excellent glucose control and HbA1c below 6. Patients who achieved and maintained insulin independence were transplanted with significantly more islets (median, 202,291 IEQ; range, 145,000 to 330,474 IEQ) than patients who required insulin support (64,348 IEQ; range, 40,203 to 260,476 IEQ; P < 0.05). Patient body mass index and time of chronic pancreatitis prior transplant procedure did not correlate with the outcome. The remaining five patients, who require insulin support, had present C-peptide in blood and experience good glucose control without incidence of severe hypoglycemic episodes. Islet autotransplantation efficiently preserved beta cell function in selected patients with chronic pancreatitis and the outcome correlated with transplanted islet mass.

Implication of pancreatic image findings in total pancreatectomy with islet autotransplantation for chronic pancreatitis

OBJECTIVE

To clarify the implication of pancreatic findings on transabdominal ultrasound and/or abdominal computed tomographic scan on outcomes of islet isolation and endocrine function after total pancreatectomy (TP) with islet autotransplantation (IAT).

METHODS

Retrospective review of islet isolations and graft functions in a cohort of patients with chronic pancreatitis who received TP with IAT from December 2007 to September 2009. Patients were categorized into the following 2 groups on the basis of their transabdominal ultrasound or computed tomographic findings before IAT: early group (normal or equivocal of Cambridge classification) and advanced group (mild to marked).

RESULTS

A total of 12 patients (early group, n=6; advanced group, n=6) were included. Total islet yield per pancreas weight and per patient body weight in the early group was significantly higher compared with that in the advanced group (6989±659 vs 3567±615 islet equivalents per gram, P<0.01; 8556±953 vs 3847±739 islet equivalents per kilogram, P<0.01, respectively). Four patients (67%) in the early group became insulin-free, whereas 2 patients (33%) in the advanced group obtained insulin independence. However, both groups maintained islet graft function and similar glycated hemoglobin levels after transplantation.

CONCLUSIONS

Excellent glycemic control was observed in both groups of patients who received TP with IAT, although the early group showed a significantly better outcome of islet isolation.

Total pancreatectomy with islet autotransplantation: an overview

Pain control is one of the most challenging aspects in the management of chronic pancreatitis. Total pancreatectomy can successfully relieve the intractable abdominal pain in these patients but will inevitably result in insulin-dependent diabetes. Islet autotransplantation aims to preserve, as far as possible, the insulin secretory function of the islet cell mass thereby reducing (or even removing) the requirement for exogenous insulin administration after a total pancreactomy. Despite the relatively small number of centres able to perform these procedures, there are important technical variations in the details of their approaches. The aim of this review is to provide details of the current surgical practice for total pancreatectomy combined with islet autotransplantation, and outline the potential advantages and disadvantages of the variations adopted in each centre.

How much of the pancreatic head should we resect in Frey's procedure?

PURPOSE

Frey's procedure for chronic pancreatitis (CP) has been minimized gradually in our institution in recent years. We compared the functional outcome of minimized Frey's procedure with that of modified Frey's procedure to establish how deeply and widely we should cut into the head of the pancreas.

METHODS

Between January 1992 and December 2006, we performed Frey's procedure on 57 patients; as modi-fied Frey's procedure from 1992 to 2001, then as minimized Frey's procedure from 2002 to 2006. The patients' pre- and postoperative pain scores (PS), rates of readmission, body mass indexes (BMI), plasma glucose levels (PG), hemoglobin A1c, daily insulin use (DIU), and pancreatic function diagnostant were systematically reviewed and compared between the two groups.

RESULTS

Frey's procedure resulted in a significant decrease in PS (P < 0.001) and a significant increase in BMI (P = 0.01). There were no significant differences in the pre- and postoperative PG or DIU. The outcome of the late group was similar to that of the early group in terms of pain relief and preservation of endocrine function. There was no early postoperative mortality.

CONCLUSIONS

These findings suggest that minimum Frey's procedure is sufficient for resolving intractable pain and improving nutritional status in most patients with CP.

Pancreatic Resection with Islet Cell Autotransplant for the Treatment of Severe Chronic Pancreatitis

Pancreatic resection can alleviate pain in properly selected patients with severe chronic pancreatitis (CP), although the apancreatic state causes “brittle” diabetes. Islet auto-transplantation (IAT) after resection can decrease diabetes-related morbidity. Twenty-six consecutive patients with CP who underwent 27 pancreatic resections with IAT from April 2005 to December 2007 were evaluated in this retrospective case control study. Data were collected by chart and operative note reviews and query of hospital databases. Subgroup analysis was performed on 21 cases of total pancreatectomy and six cases of pancreaticoduodenectomy (PD). Mean age was 43.8 years and 46.2 per cent of patients were female. The most common etiology of CP was alcoholism (34.6%), followed by idiopathic causes (30.8%) and pancreatic divisum (23.1%). There was no mortality and the complication rate was 56 per cent. Islet equivalents infused and islet equivalents/gram of pancreas were 82,094 and 2,739 respectively. Mean discharge insulin dose was 10.7 units/day. Mean follow-up was 6.5 months. At 6 months, 80 per cent of patients reporting had decreased or eliminated their use of narcotic medication and all total pancreatectomy patients required insulin (mean 23 units/day). In appropriately selected patients, pancreatic resection with IAT is safe and effective for the treatment of intractable pain associated with CP.

Intramuscular autotransplantation of pancreatic islets in a 7-year-old child: a 2-year follow-up

A 7-year-old girl with severe hereditary pancreatitis underwent total pancreatectomy. A total of 160,000 islet equivalents (6400 islet/kg) were transplanted to the brachioradialis muscle of the right forearm. Her plasma C-peptide level was undetectable after pancreatectomy but increased to 1.37 ng/mL after 17 days; at this time point, her insulin requirement was 0.75 units of insulin/kg/day. At 5- and 27-months, her hemoglobin A1c (HbA1c) and insulin requirements were 4.5 and 5.3% and 0.3 and 0.18 units/kg/day, respectively. Basal and stimulated C-peptide levels were 0.67 +/- 0.07 and 3.36 +/- 1.37 ng/mL, respectively. Stimulated insulin levels were 30% higher in the islet-bearing arm compared to the contralateral arm after glucagon stimulation. After surgery and islet transplantation, the quality of life improved dramatically and she gained 8 kg of weight. In summary, a normal HbA1c, a low insulin requirement and the absence of recurrent hypoglycemia and the gradient of insulin between the arms indicate that the intramuscularly transplanted islets contribute to a long-term clinically significant metabolic control.

Estado actual del trasplante de islotes pancreáticos

Due to the numerous advances in islet transplantation in the last few years, clinical outcomes following this procedure are continually improving. Novel immunosuppression protocols, improved donor and recipient selection, and careful attention to the process of organ extraction, preservation and islet isolation have contributed to long-term success. The present article reviews the results of clinical islet transplantation and their relationship with the different advances introduced. The use of new islet sources such as living and non-heart-beating donors, as well as recent advances in our knowledge of the mechanisms of rejection and its prevention, are also reviewed.

Construction of an "artificial beta cell": Modulation of glucose-stimulated insulin secretion from HepG2 cell

AIM: To construct an "artificial beta cell" which exhibit glucose-stimulated insulin secretion from a human hepatoma cell line.

METHODS: HepG2 cells were infected with recombinant retrovirus carrying glucokinase (gk) gene and mutant proinsulin (mpin) gene, then selectively cultured with G418 to obtain the positive clones. gk gene and mpin gene transcription and expression were identified by radio-immunity, SDS-PAGE, Western-blot and RT-PCR techniques. At last, we tested the dose-response effect of glucose on insulin secretion from the "artificial beta cell", and HepG2 cells with mpin gene transferred as control.

RESULTS: HepG2 cells with gk gene and mpin gene transferred were selectively cultured with G418 and the positive clones were obtained in 3 weeks. Four clones with gk gene and mpin gene expression were selected out by radio-immunity, SDS-PAGE, Western-blot from 20 positive clones. We picked up one clone with strong gk gene and mpin gene expression and named it clone "b". It was proved that the clone "b" had gk gene and mpin gene transcription by RT-PCR. In the clone "b", the differences in the insulin secretion at 0.5 mmol/L and 0.75 mmol/L glucose concentration were not significant (P >0.05), and the differences in the insulin secretion at 2.0 mmol/L, 3.0 mmol/L, 4.0 mmol/L, 5.0 mmol/L and 6.0 mmol/L glucose concentration were also not significant (P >0.05), while there were significant differences in the insulin secretion at the other glucose concentration(P <0.05). In HepG2 cells with mpin gene transferred, there were no significant differences in the insulin secretion at any glucose concentration(P >0.05). The "artificial beta cell" obtained a glucose-stimulated insulin secretion with maximal insulin secretion at 1.75-2 mmol/L glucose concentration.

CONCLUSION: An "artificial beta cell" is successfully constructed.