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Thavamani A, Sterling N, Umapathi KK, Sankararaman S. Prevalence and impact of psychiatric disorders on hospitalized pediatric patients with chronic pancreatitis. Pancreatology 2023; 23:574-581. [PMID: 37391358 DOI: 10.1016/j.pan.2023.06.012] [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: 11/13/2022] [Revised: 06/03/2023] [Accepted: 06/21/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Patients with chronic pancreatitis (CP) often have a debilitating clinical course characterized by high disease burden, and poor quality of life and these factors adversely affect mental health. However, there is paucity of literature on the prevalence and impact of psychiatric disorders on hospitalized pediatric patients with CP. METHOD ology: We analyzed the Kids Inpatient Database, and National Inpatient Sample, between 2003 and 2019 and included patients up to 21 years of age. Pediatric CP patients with psychiatric disorders were compared with patients without any of the psychiatric disorders using the ICD diagnostic codes. Various demographic and clinical factors were compared between the groups. Length of hospitalization and total hospital charges were used as surrogates to compare the hospital resource utilization between the groups. RESULTS We analyzed a total of 9,808 hospitalizations with CP and the overall prevalence rate of psychiatric disorders was 19.8%. The prevalence rate increased from 19.1% in 2003 to 23.4% in 2019, p = 0.006. The peak prevalence rate of 37.2% was noted at 20 years of age. Depression was noted at 7.6% of the total hospitalizations followed by substance abuse (6.5%), and anxiety (4.4%). Multivariate linear regression analysis showed that among CP patients, psychiatric disorders were independently associated with 1.3 additional days of stay and incurred $15,965 higher charges. CONCLUSIONS The prevalence of psychiatric disorders is increasing in pediatric CP. The concomitant presence of psychiatric disorders was found to be associated with prolonged hospital stay and incurred higher healthcare charges than those CP patients without psychiatric disorders.
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Affiliation(s)
- Aravind Thavamani
- Department of Pediatrics (Division of Pediatric Gastroenterology), UH Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA.
| | - Neya Sterling
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA.
| | | | - Senthilkumar Sankararaman
- Department of Pediatrics (Division of Pediatric Gastroenterology), UH Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA.
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Pediatric-to-Adult Transfer of Care in Patients With Pancreas Disease: Recommendations for Care and Research Opportunities. Am J Gastroenterol 2023; 118:443-451. [PMID: 35862827 PMCID: PMC10147498 DOI: 10.14309/ajg.0000000000001910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/15/2022] [Indexed: 12/11/2022]
Abstract
Young adults who have experienced recurrent acute pancreatitis and chronic pancreatitis as children or adolescents are vulnerable to poor follow-up and disease management during the transfer from the pediatric to adult healthcare system. Although formalized transition programs for young adults have been developed and described for other disease conditions, no such program has been described for young adults with pancreatic disease. This document is the first expert opinion outlining the important aspects of a transitional care and transfer program tailored to youth with recurrent acute and chronic pancreatitis. We emphasize the unique needs of these patients as they transfer to adult health care and the need for further research. The goal of improved transitional care and transfer is to enhance the services provided to adolescents/young adults with pancreatic disease in both healthcare settings and improve continuity of follow-up care.
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The incidence of new mental health disorders after acute pancreatitis: A large, propensity-matched, observational study. Pancreatology 2023; 23:163-170. [PMID: 36710225 DOI: 10.1016/j.pan.2023.01.008] [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: 07/21/2022] [Revised: 11/29/2022] [Accepted: 01/16/2023] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The prevalence of acute pancreatitis (AP) and mental health disorders (MHDs) are rising. While the association between chronic pancreatitis (CP) and MHDs is established, it is unknown whether there is a risk of MHDs after an index episode of AP. The aim of this study was to evaluate the incidence of MHDs and pharmacotherapy use after an episode of AP. METHODS This was a large observational study using the TriNetX research network, an electronic health record dataset containing inpatient and outpatient data from more than 50 healthcare organizations. Patients with AP from 2015-2020 were identified. Four cohorts were created: acute necrotizing pancreatitis (ANP), acute pancreatitis without necrosis (AP-WON), acute appendicitis, and healthy controls without pancreatitis. The cohorts were matched by age, sex, race, ethnicity, and nicotine and alcohol use. The primary outcome was new composite MHDs at one-year. Secondary outcomes included stratified MHDs, psychiatric medication use, opioid analgesic use, and all-cause mortality. RESULTS The ANP, AP-WON, appendicitis, and healthy control cohorts contained 11,806, 177,266, 27,187, and 561,833 patients, respectively. Patients with AP-WON had significantly higher rates of composite MHDs compared with those hospitalized for appendicitis (9.7% vs 4.7%, HR 1.9, 95% CI 1.7-1.9). This association was augmented when comparing ANP to appendicitis (12.8% vs 5.2%, HR 2.4, 95% CI 2.1-2.7). All secondary outcomes were observed at significantly higher rates in the AP-WON cohort when compared to appendicitis. Again, these associations were augmented comparing ANP to appendicitis. CONCLUSION Compared with controls, patients with AP had significantly higher rates of new MHDs and their associated pharmacotherapies at one-year, suggesting that a single episode of AP may independently place patients at risk for developing MHDs irrespective of whether they go on to develop CP.
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Uc A, Cress GA, Wang F, Abu-El-Haija M, Ellery KM, Fishman DS, Gariepy CE, Gonska T, Lin TK, Liu QY, Mehta M, Maqbool A, McFerron BA, Morinville VD, Ooi CY, Perito ER, Schwarzenberg SJ, Sellers ZM, Serrano J, Shah U, Troendle DM, Wilschanski M, Zheng Y, Yuan Y, Lowe ME. Analysis of INSPPIRE-2 Cohort: Risk Factors and Disease Burden in Children With Acute Recurrent or Chronic Pancreatitis. J Pediatr Gastroenterol Nutr 2022; 75:643-649. [PMID: 35976273 PMCID: PMC9617760 DOI: 10.1097/mpg.0000000000003590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The objective of this study is to investigate risk factors and disease burden in pediatric acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP). METHODS Data were obtained from INternational Study group of Pediatric Pancreatitis: In search for a cuRE-2 (INSPPIRE-2), the largest multi-center prospective cohort study in pediatric patients with ARP or CP. RESULTS Of 689 children, 365 had ARP (53%), 324 had CP (47%). CP was more commonly associated with female sex, younger age at first acute pancreatitis (AP) attack, Asian race, family history of CP, lower BMI%, genetic and obstructive factors, PRSS1 mutations and pancreas divisum. CFTR mutations, toxic-metabolic factors, medication use, hypertriglyceridemia, Crohn disease were more common in children with ARP. Constant or frequent abdominal pain, emergency room (ER) visits, hospitalizations, medical, endoscopic or surgical therapies were significantly more common in CP, episodic pain in ARP. A total of 33.1% of children with CP had exocrine pancreatic insufficiency (EPI), 8.7% had diabetes mellitus. Compared to boys, girls were more likely to report pain impacting socialization and school, medical therapies, cholecystectomy, but no increased opioid use. There was no difference in race, ethnicity, age at first AP episode, age at CP diagnosis, duration of disease, risk factors, prevalence of EPI or diabetes between boys and girls. Multivariate analysis revealed that family history of CP, constant pain, obstructive risk factors were predictors of CP. CONCLUSIONS Children with family history of CP, constant pain, or obstructive risk factors should raise suspicion for CP.
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Affiliation(s)
- Aliye Uc
- University of Iowa, Stead Family Children’s Hospital, Iowa City, IA
| | | | - Fuchenchu Wang
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Maisam Abu-El-Haija
- Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH
| | | | - Douglas S. Fishman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX
| | | | | | - Tom K. Lin
- Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Quin Y. Liu
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - Megha Mehta
- University of Texas Southwestern Medical School, Dallas, TX
| | - Asim Maqbool
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Brian A. McFerron
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | | | - Chee Y. Ooi
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales and Sydney Children’s Hospital Randwick Sydney, Sydney, Australia
| | | | | | | | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD
| | - Uzma Shah
- Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA
| | | | | | - Yuhua Zheng
- Children’s Hospital Los Angeles, Los Angeles, CA
| | - Ying Yuan
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Mark E. Lowe
- Washington University School of Medicine, St. Louis, MO
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Abstract
RECENT FINDINGS Early initiation of feeds is safe and possible in mild to moderate pediatric acute pancreatitis (AP) and is not associated with increased pain or increased serum lipase level. Enteral nutrition within 48 h of admission compared to no feeds within 48 h (NPO) is associated with a significant reduction in length of stay, reduced progression to severe acute pancreatitis, decreased ICU transfers, and increased weight gain at follow-up. Early standard fat meals did not worsen pain or serum lipase levels in children with mild to moderate AP. PURPOSE OF REVIEW Nutrition is essential in the management of AP in children. Diet before, during, and after an attack of AP can affect outcomes. Here, we highlight recent advances that have been made in the last decade on nutritional interventions in pediatric acute pancreatitis and provide future directions for research. SUMMARY Early enteral nutrition is safe and feasible in pediatric mild to moderate AP and is associated with improved outcomes. There are only a handful of studies on nutritional interventions in pediatric mild to moderate AP. Further studies are needed to understand the effects of early enteral nutrition in pediatric severe AP.
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Affiliation(s)
- Chinenye R Dike
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center, and Children's Hospital and Medical Center Omaha, NE
| | - Maisam Abu-El-Haija
- Division of Gastroenterology Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center
- Pediatric Department, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
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Multidisciplinary Approach to the Care of Children With Acute Recurrent Pancreatitis and Chronic Pancreatitis. Pancreas 2022; 51:256-260. [PMID: 35584383 DOI: 10.1097/mpa.0000000000002008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of this article is to provide guidance to centers and organizations on the personnel (both physician and nonphysician) needed to create and sustain an optimal team, along with potential alternatives, to provide care to children with acute recurrent pancreatitis and chronic pancreatitis. METHODS This document was developed in collaboration with the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Pancreas Committee and the National Pancreas Foundation (NPF) after several meetings. RESULTS This document highlights both physician and nonphysician personnel needed to provide multidisciplinary care to children with pancreatitis per the recommendation of the NASPGHAN Pancreas Committee members in year 2021 and added to the currently published NPF criteria. We summarize how the NPF criteria would fit with the recently published pediatric pancreatitis society articles from the NASPGHAN. CONCLUSIONS It is important to manage children with acute recurrent pancreatitis and chronic pancreatitis in a multidisciplinary setting. There is need to study the impact of these personnel on the outcomes of children with pancreatitis.
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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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8
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Abstract
PURPOSE OF REVIEW In children, chronic pancreatitis is infrequent but may be associated with serious complications, including severe pain that limits activities, exocrine and endocrine pancreatic insufficiency and malnutrition. Investigation into pediatric chronic pancreatitis has transitioned from single center reports to multicenter, protocol-driven studies. As a result, we now have information on much larger numbers of children with chronic pancreatitis, allowing a more reliable understanding of the complications of chronic pancreatitis. RECENT FINDINGS A high percentage of children with chronic pancreatitis use opioids frequently to control pain. About a quarter of children with chronic pancreatitis have exocrine pancreatic insufficiency, and about 6% have pancreatogenic diabetes. Mild malnutrition and low bone density are both common in children with chronic pancreatitis. SUMMARY Large multicenter and single-center observational studies have allowed us to more accurately assess complications of chronic pancreatitis in children. These studies demonstrate the need for examination of therapies for these complications in children.
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Affiliation(s)
- Emily Perito
- Department of Pediatrics, University of California, San Francisco
| | - Tanja Gonska
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melena D. Bellin
- Department of Pediatrics, University of Minnesota Medical Center and Schulze Diabetes Institute, Minneapolis, MN
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Uc A, Andersen DK, Apkarian AV, Bellin MD, Colloca L, Drewes AM, Dunbar EK, Forsmark CE, Goodman MT, Kapural L, Koob GF, Palermo TM, Pandol SJ, Pasricha P, Phillips AE, Piomelli D, Saloman JL, Schwarzenberg SJ, Singh VK, Sowa G, Strouse T, Treisman GJ, Windsor JA, Yadav D. Pancreatic Pain-Knowledge Gaps and Research Opportunities in Children and Adults: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2021; 50:906-915. [PMID: 34643606 PMCID: PMC10273134 DOI: 10.1097/mpa.0000000000001899] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT A workshop was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases to focus on research gaps and opportunities in pancreatic pain. The event was held on July 21, 2021, and structured into 4 sessions: (1) pathophysiology; (2) biomarkers, mediators, and pharmacology of pain; (3) pain assessment; and (4) pain treatment challenges and opportunities. The current state of knowledge was reviewed; many knowledge gaps and research needs were identified that require further investigation. Common themes included the need to better understand the underlying mechanisms of pain in pancreatic diseases, the relationship of visceral neural pathways and central pain centers, the role of behavioral factors and disorders on the perception of pain, and differences in pain perception and processes in children when compared with adults. In addition, the role of genetic risk factors for pain and the mechanisms and role of placebos in pain treatment were discussed. Methods of pain assessment including quantitative sensory testing were examined, as well as the process of central sensitization of pain. Finally, newer approaches to pain management including cognitive behavioral therapy, nerve stimulation, experimental (nonopioid) drugs, and cannabinoid compounds were covered.
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Affiliation(s)
- Aliye Uc
- From the Division of Gastroenterology, Hepatology, Pancreatology and Nutrition, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - A Vania Apkarian
- Departments of Physiology, Anesthesiology, Physical Medicine and Rehabilitation, and Center for Translational Pain Research, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Melena D Bellin
- Departments of Pediatrics and Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | | | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Florida, Gainesville, FL
| | - Marc T Goodman
- Cancer Prevention and Control Program, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - George F Koob
- National Institute on Alcohol Abuse and Alcoholism and Intramural Research Program, National Institute on Drug, National Institutes of Health, Bethesda, MD
| | | | - Stephen J Pandol
- Division of Gastroenterology, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Pankaj Pasricha
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anna E Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
| | - Daniele Piomelli
- Departments of Anatomy and Neurobiology, Biological Chemistry, and Pharmacology, University of California, Irvine School of Medicine, Irvine, CA
| | - Jami L Saloman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
| | - Sarah Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gwendolyn Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas Strouse
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Glenn J Treisman
- Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
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Suzuki M, Minowa K, Isayama H, Shimizu T. Acute recurrent and chronic pancreatitis in children. Pediatr Int 2021; 63:137-149. [PMID: 32745358 DOI: 10.1111/ped.14415] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/27/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022]
Abstract
Acute recurrent pancreatitis (ARP) is defined as two distinct episodes of acute pancreatitis (AP), whereas chronic pancreatitis (CP) is caused by persistent inflammation of the pancreas. In children they are caused by genetic mutations, autoimmune pancreatitis, congenital pancreatic abnormalities, and other conditions. Acute recurrent pancreatitis is frequently a precursor to CP, and both are thought to be on the same disease continuum. In particular, genetic factors are associated with early progression of ARP to CP. The diagnosis of CP, as in AP, is based on clinical findings, biochemical tests, and imaging studies. Findings of exocrine pancreatic dysfunction are also important in the diagnosis of CP. A step-up strategy has become increasingly standard for the treatment of patients with CP. This strategy starts with endoscopic treatment, such as pancreatic sphincterotomy and stenting, and progresses to surgery should endoscopic therapy fail or prove technically impossible. Non-opioid (e.g. ibuprofen / naproxen) and opioid (e.g. oxycodone) forms of analgesia are widely used in pediatric patients with AP or CP, whereas pancreatic enzyme replacement therapy may be beneficial for patients with abdominal pain, steatorrhea, and malnutrition. Despite the disparity in the age of onset, pediatric CP patients display some similarities to adults in terms of disease progress. To reduce the risk of developing pancreatic exocrine inefficiency, diabetes and pancreatic cancer in the future, clinicians need to be aware of the current diagnostic approach and treatment methods for ARP and CP and refer them to a pediatric gastroenterologist in a timely manner.
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Affiliation(s)
- Mitsuyoshi Suzuki
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kei Minowa
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
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11
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Wilhelm JJ, Balamurugan AN, Bellin MD, Hodges JS, Diaz J, Jane Schwarzenberg S, Swanson ZA, Cook ME, Downs EM, Sutherland DER, Hering BJ, Chinnakotla S. Progress in individualizing autologous islet isolation techniques for pediatric islet autotransplantation after total pancreatectomy in children for chronic pancreatitis. Am J Transplant 2021; 21:776-786. [PMID: 32678932 DOI: 10.1111/ajt.16211] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/29/2020] [Accepted: 07/07/2020] [Indexed: 01/25/2023]
Abstract
Total pancreatectomy with islet autotransplantation is performed to treat chronic pancreatitis in children. Successful islet isolation must address the challenges of severe pancreatic fibrosis and young donor age. We have progressively introduced modifications to optimize enzymatic and mechanical dissociation of the pancreas during islet isolation. We evaluated 2 islet isolation metrics in 138 children-digest islet equivalents per gram pancreas tissue (IEQ/g) and digest IEQ per kilogram body weight (IEQ/kg), using multiple regression to adjust for key disease and patient features. Islet yield at digest had an average 4569 (standard deviation 2949) islet equivalent (IEQ)/g and 4946 (4009) IEQ/kg, with 59.1% embedded in exocrine tissue. Cases with very low yield (<2000 IEQ/g or IEQ/kg) have decreased substantially over time, 6.8% and 9.1%, respectively, in the most recent tertile of time compared to 19.2% and 23.4% in the middle and 34.1% and 36.4% in the oldest tertile. IEQ/g and IEQ/kg adjusted for patient and disease factors improved in consistency and yield in the modern era. Minimal mechanical disruption during digestion, warm enzymatic digestion using enzyme collagenase:NP activity ratio < 10:1, coupled with extended distension and trimming time during islet isolation of younger and fibrotic pediatric pancreases, gave increased islet yield with improved patient outcomes.
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Affiliation(s)
- Joshua J Wilhelm
- Schulze Diabetes Institute, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | | | - Melena D Bellin
- Schulze Diabetes Institute, University of Minnesota Medical School, Minneapolis, Minnesota, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - James S Hodges
- Division of Biostatistics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jessica Diaz
- Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | | | - Zachary A Swanson
- Schulze Diabetes Institute, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Marie E Cook
- Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Elissa M Downs
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - David E R Sutherland
- Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Bernhard J Hering
- Schulze Diabetes Institute, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Srinath Chinnakotla
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA.,Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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12
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Kassam AF, Cortez AR, Johnston ME, Zang H, Fei L, Lin TK, Abu-El-Haija M, Nathan JD. Total pancreatectomy with islet autotransplantation reduces resource utilization in pediatric patients. Am J Surg 2021; 222:786-792. [PMID: 33541688 PMCID: PMC10123923 DOI: 10.1016/j.amjsurg.2021.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/03/2021] [Accepted: 01/21/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic pancreatitis (CP) is associated with poor quality of life. Total pancreatectomy with islet autotransplantation (TPIAT) has traditionally been reserved for patients with refractory disease. We hypothesized TPIAT would lead to decreased costs and resource utilization after operation in children. METHODS Retrospective review of 39 patients who underwent TPIAT at a single children's hospital was performed. All inpatient admissions, imaging, endoscopic procedures, and operations were recorded for the year prior to and following operation. Costs were determined from Centers for Medicare and Medicaid Services. RESULTS Median hospital admissions before operation was 5 (IQR:2-7) and decreased to 2 (IQR:1-3) after (p < 0.01). Median total cost for the year before operation was $36,006 (IQR:$19,914-$47,680), decreasing to $24,900 postoperatively (IQR:$17,432-$44,005, p = 0.03). Removing cost of TPIAT itself, total cost was further reduced to $10,564 (IQR:$3096-$29,669, p < 0.01). CONCLUSION In children with debilitating CP, TPIAT has favorable impact on cost reduction, hospitalizations, and invasive procedures. Early intervention at a specialized pancreas center of excellence should be considered to decrease future resource utilization and costs among children.
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Affiliation(s)
- Al-Faraaz Kassam
- Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery, Cincinnati, OH, USA; University of Cincinnati Medical Center, Department of Surgery, Cincinnati, OH, USA
| | - Alexander R Cortez
- Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery, Cincinnati, OH, USA; University of Cincinnati Medical Center, Department of Surgery, Cincinnati, OH, USA
| | - Michael E Johnston
- Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery, Cincinnati, OH, USA; University of Cincinnati Medical Center, Department of Surgery, Cincinnati, OH, USA
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center, Division of Biostatistics and Epidemiology, Cincinnati, OH, USA
| | - Lin Fei
- Cincinnati Children's Hospital Medical Center, Division of Biostatistics and Epidemiology, Cincinnati, OH, USA
| | - Tom K Lin
- Cincinnati Children's Hospital Medical Center, Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH, USA
| | - Maisam Abu-El-Haija
- Cincinnati Children's Hospital Medical Center, Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH, USA
| | - Jaimie D Nathan
- Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery, Cincinnati, OH, USA; University of Cincinnati Medical Center, Department of Surgery, Cincinnati, OH, USA.
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13
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Valente R, Waldthaler A, Scandavini CM, Vujasinovic M, Del Chiaro M, Arnelo U, Löhr JM. Conservative Treatment of Chronic Pancreatitis: A Practical Approach. Scand J Surg 2021; 109:59-68. [PMID: 32192418 DOI: 10.1177/1457496920905559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chronic pancreatitis is a long-standing, inflammatory condition of the pancreas that leads to the progressive damage and loss of function of pancreatic parenchyma and to the development of possible locoregional and systemic medical complications. MATERIALS AND METHODS In this review, we tried to summarize the current evidence on non-surgical treatment trying to suggest a practical approach to the management of chronic pancreatitis. RESULTS Besides the unclear pathophysiological mechanism and a poorly unknown epidemiology, chronic pancreatitis is a complex syndrome that displays different possible challenges for physicians. Despite being traditionally considered as a benign disease, chronic pancreatitis encompasses 10-year mortality rates which are superior to the ones reported for some of the most common cancers. CONCLUSIONS Chronic pancreatitis encompasses the management of multiple and complex medical co-morbidities that needs to be understood and addressed in a multidisciplinary specialist context.
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Affiliation(s)
- R Valente
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - A Waldthaler
- Endoscopy Unit, Karolinska University Hospital, Stockholm, Sweden
| | - C M Scandavini
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - M Vujasinovic
- CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Endoscopy Unit, Karolinska University Hospital, Stockholm, Sweden
| | - M Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - U Arnelo
- CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - J-M Löhr
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
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14
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Abstract
Recurrent acute and chronic pancreatitis are increasingly recognized in childhood. Etiologies are vastly different in children compared with adults and mostly involve genetic and anatomical factors with negligible contribution of environmental risks. Pediatric acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) have significant impact on quality of life with high healthcare costs. Children with these conditions suffer from recurrent acute or chronic abdominal pain and they endure multiple emergency room visits, hospitalizations, procedures, and surgeries. Diagnostic methods are being developed; treatment options are limited. This review summarizes the most recent developments in pediatric ARP and CP. These discoveries will help physicians provide optimal care for children with these conditions.
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15
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Palermo TM, Murray C, Aalfs H, Abu-El-Haija M, Barth B, Bellin MD, Ellery K, Fishman DS, Gariepy CE, Giefer MJ, Goday P, Gonska T, Heyman MB, Husain SZ, Lin TK, Liu QY, Mascarenhas MR, Maqbool A, McFerron B, Morinville VD, Nathan JD, Ooi CY, Perito ER, Pohl JF, Schwarzenberg SJ, Sellers ZM, Serrano J, Shah U, Troendle D, Zheng Y, Yuan Y, Lowe M, Uc A. Web-based cognitive-behavioral intervention for pain in pediatric acute recurrent and chronic pancreatitis: Protocol of a multicenter randomized controlled trial from the study of chronic pancreatitis, diabetes and pancreatic cancer (CPDPC). Contemp Clin Trials 2019; 88:105898. [PMID: 31756383 DOI: 10.1016/j.cct.2019.105898] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Abdominal pain is common and is associated with high disease burden and health care costs in pediatric acute recurrent and chronic pancreatitis (ARP/CP). Despite the strong central component of pain in ARP/CP and the efficacy of psychological therapies for other centralized pain syndromes, no studies have evaluated psychological pain interventions in children with ARP/CP. The current trial seeks to 1) evaluate the efficacy of a psychological pain intervention for pediatric ARP/CP, and 2) examine baseline patient-specific genetic, clinical, and psychosocial characteristics that may predict or moderate treatment response. METHODS This single-blinded randomized placebo-controlled multicenter trial aims to enroll 260 youth (ages 10-18) with ARP/CP and their parents from twenty-one INSPPIRE (INternational Study Group of Pediatric Pancreatitis: In search for a cuRE) centers. Participants will be randomly assigned to either a web-based cognitive behavioral pain management intervention (Web-based Management of Adolescent Pain Chronic Pancreatitis; WebMAP; N = 130) or to a web-based pain education program (WebED; N = 130). Assessments will be completed at baseline (T1), immediately after completion of the intervention (T2) and at 6 months post-intervention (T3). The primary study outcome is abdominal pain severity. Secondary outcomes include pain-related disability, pain interference, health-related quality of life, emotional distress, impact of pain, opioid use, and healthcare utilization. CONCLUSIONS This is the first clinical trial to evaluate the efficacy of a psychological pain intervention for children with CP for reduction of abdominal pain and improvement of health-related quality of life. Findings will inform delivery of web-based pain management and potentially identify patient-specific biological and psychosocial factors associated with favorable response to therapy. Clinical Trial Registration #: NCT03707431.
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Affiliation(s)
- Tonya M Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, USA; Center for Child Health, Behavior & Development, Seattle Children's Research Institute, USA.
| | - Caitlin Murray
- Center for Child Health, Behavior & Development, Seattle Children's Research Institute, USA
| | - Homer Aalfs
- Center for Child Health, Behavior & Development, Seattle Children's Research Institute, USA
| | - Maisam Abu-El-Haija
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Bradley Barth
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Melena D Bellin
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Kate Ellery
- Children's Hospital; of Pittsburgh, Pittsburgh, PA, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | | | | | | | | | - Melvin B Heyman
- University of California San Francisco, San Francisco, CA, USA
| | | | - Tom K Lin
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Quin Y Liu
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Asim Maqbool
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian McFerron
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Jaimie D Nathan
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Chee Y Ooi
- School of Women's and Children's Health, Medicine, University of New South Wales and Sydney Children's Hospital Randwick Sydney, Australia
| | - Emily R Perito
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, USA
| | - Uzma Shah
- Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA, USA
| | - David Troendle
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Yuhua Zheng
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Ying Yuan
- The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Mark Lowe
- Washington University School of Medicine, Iowa City, IA, USA
| | - Aliye Uc
- University of Iowa, Stead Family Children's Hospital, Iowa City, IA, USA
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