1
|
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; 30:752-757. [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] [MESH Headings] [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.
Collapse
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.
| |
Collapse
|
2
|
Downs EM, Brun A, Bellin MD. Nutrition support in the pediatric total pancreatectomy with islet autotransplantation recipient. Nutr Clin Pract 2024; 39:100-108. [PMID: 38073153 DOI: 10.1002/ncp.11101] [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: 09/01/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 01/13/2024] Open
Abstract
For children with diminished quality of life and chronic pain caused by acute recurrent or chronic pancreatitis who are undergoing total pancreatectomy with islet autotransplantation, postoperative nutrition support has several unique characteristics. Surgical complications may lead to delays in nutrition support initiation or require modifications to the regimen. Early postoperative dysmotility requires the use of temporary enteral nutrition until this improves. The resultant complete exocrine pancreatic insufficiency necessitates lifelong pancreatic enzyme replacement therapy and fat-soluble vitamin supplementation. A low-oxalate diet is recommended to prevent kidney stones. Carbohydrate counting is needed for the provision of short-term insulin dosing and possibly long-term as well, depending on the transplanted islet yield. Children should have careful nutrition assessment and monitoring at several follow-up visits during the first year, then annually, and at any time with concerns.
Collapse
Affiliation(s)
- Elissa M Downs
- Pediatric Gastroenterology, Hepatology, and Nutrition, M Health Fairview, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Amanda Brun
- Nutrition Services, M Health Fairview, Minneapolis, Minnesota, USA
| | - Melena D Bellin
- Pediatric Endocrinology and Transplant Surgery, M Health Fairview, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| |
Collapse
|
3
|
Khazaaleh S, Babar S, Alomari M, Imam Z, Chadalavada P, Gonzalez AJ, Kurdi BE. Outcomes of total pancreatectomy with islet autotransplantation: A systematic review and meta-analysis. World J Transplant 2023; 13:10-24. [PMID: 36687559 PMCID: PMC9850868 DOI: 10.5500/wjt.v13.i1.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/24/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite the increased use of total pancreatectomy with islet autotransplantation (TPIAT), systematic evidence of its outcomes remains limited.
AIM To evaluate the outcomes of TPIAT.
METHODS We searched PubMed, EMBASE, and Cochrane databases from inception through March 2019 for studies on TPIAT outcomes. Data were extracted and analyzed using comprehensive meta-analysis software. The random-effects model was used for all variables. Heterogeneity was assessed using the I2 measure and Cochrane Q-statistic. Publication bias was assessed using Egger’s test.
RESULTS Twenty-one studies published between 1980 and 2017 examining 1011 patients were included. Eighteen studies were of adults, while three studied pediatric populations. Narcotic independence was achieved in 53.5% [95% Confidence Interval (CI): 45-62, P < 0.05, I2 = 81%] of adults compared to 51.9% (95%CI: 17-85, P < 0.05, I2 = 84%) of children. Insulin-independence post-procedure was achieved in 31.8% (95%CI: 26-38, P < 0.05, I2 = 64%) of adults with considerable heterogeneity compared to 47.7% (95%CI: 20-77, P < 0.05, I2 = 82%) in children. Glycated hemoglobin (HbA1C) 12 mo post-surgery was reported in four studies with a pooled value of 6.76% (P = 0.27). Neither stratification by age of the studied population nor meta-regression analysis considering both the study publication date and the islet-cell-equivalent/kg weight explained the marked heterogeneity between studies.
CONCLUSION These results indicate acceptable success for TPIAT. Future studies should evaluate the discussed measures before and after surgery for comparison.
Collapse
Affiliation(s)
- Shrouq Khazaaleh
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Cleveland, OH 44126, United States
| | - Sumbal Babar
- Department of Internal Medicine-Infectious Diseases Division, University of Texas Health Science Center at San Antonio, San Antonio, TX 78249, United States
| | - Mohammad Alomari
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FI 33324, United States
| | - Zaid Imam
- Department of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Pravallika Chadalavada
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FI 33331, United States
| | - Adalberto Jose Gonzalez
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FI 33331, United States
| | - Bara El Kurdi
- Department of Gastroenterology and Hepatology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78249, United States
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Hughes DL, Hughes I, Silva MA. A meta-analysis of the long-term outcomes following surgery or endoscopic therapy for chronic pancreatitis. Langenbecks Arch Surg 2022; 407:2233-2245. [PMID: 35320380 PMCID: PMC9468079 DOI: 10.1007/s00423-022-02468-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 02/11/2022] [Indexed: 11/28/2022]
Abstract
Purpose Refractory abdominal pain is a cardinal symptom of chronic pancreatitis (CP). Management strategies revolve around pain mitigation and resolution. Emerging evidence from observational studies highlights that surgery may result in superior pain relief when compared to endoscopic therapy; however, its impact on long-term quality of life or functional outcome has yet to be determined. Methods A search through MEDLINE, PubMed and Web of Science was performed for RCTs that compared endoscopic treatment with surgery for the management of CP. The main outcome measure was the impact on pain control. Secondary outcome measures were the effect on quality of life and the incidence rate of new onset exocrine and endocrine failure. Data was pooled for analysis using either an odds ratio (OR) or mean difference (MD) with a random effects model. Results Three RCTs were included with a total of 267 patients. Meta-analysis demonstrated that operative treatment was associated with a significantly higher rate of complete pain control (37%) when compared to endoscopic therapy (17%) [OR (95% confidence interval (CI)) 2.79 (1.53–5.08), p = 0.0008]. No difference was noted in the incidence of new onset endocrine or exocrine failure between treatment strategies. Conclusion Surgical management of CP results in a greater extent of complete pain relief during long-term follow-up. Further research is required to evaluate the impact of the time interval between diagnosis and intervention on exocrine function, combined with the effect of early up-front islet auto-transplantation in order to determine whether long-term endocrine function can be achieved. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-022-02468-x.
Collapse
Affiliation(s)
- Daniel Ll Hughes
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Old Road Campus, Off, Roosevelt Dr, Headington, Oxford, OX3 7DQ, UK. .,Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Ioan Hughes
- Queen's University Belfast, University Road, Belfast, Northern Ireland
| | - Michael A Silva
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
6
|
Elnashar M, Vaccarezza M, Al-Salami H. Cutting-edge biotechnological advancement in islet delivery using pancreatic and cellular approaches. Future Sci OA 2020; 7:FSO660. [PMID: 33552541 PMCID: PMC7849926 DOI: 10.2144/fsoa-2020-0105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
There are approximately 1 billion prediabetic people worldwide, and the global cost for diabetes mellitus (DM) is estimated to be $825 billion. In regard to Type 1 DM, transplanting a whole pancreas or its islets has gained the attention of researchers in the last few decades. Recent studies showed that islet transplantation (ILT) containing insulin-producing β cells is the most notable advancement cure for Type 1 DM. However, this procedure has been hindered by shortage and lack of sufficient islet donors and the need for long-term immunosuppression of any potential graft rejection. The strategy of encapsulation may avoid the rejection of stem-cell-derived allogeneic islets or xenogeneic islets. This review article describes various biotechnology features in encapsulation-of-islet-cell therapy for humans, including the use of bile acids.
Collapse
Affiliation(s)
- Magdy Elnashar
- Biotechnology & Drug Development Research Laboratory, School of Pharmacy & Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia.,Centre of Excellence, Department of Polymers, National Research Centre, Cairo, Egypt
| | - Mauro Vaccarezza
- School of Pharmacy & Biomedical Science, Faculty of Health Sciences, Curtin University, Bentley, Perth, WA 6102, Australia
| | - Hani Al-Salami
- Biotechnology & Drug Development Research Laboratory, School of Pharmacy & Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
7
|
Abstract
Chronic pancreatitis is a complex and irreversible disease of the pancreas and is associated with significant morbidity and mortality. Nutrition deficiencies in chronic pancreatitis are common and can be atypical in nature. As such, the management of these deficiencies can be individualized for patients. The aim of this review is to discuss the components of nutrition deficiencies in chronic pancreatitis, their management, and the current areas of research that are being explored. The clinical guidelines of major national and international societies were analyzed for recommendations on the nutrition management of chronic pancreatitis. The etiology of nutrition deficiencies in chronic pancreatitis is multifactorial and includes aspects of exocrine and/or endocrine dysfunction, significant abdominal pain, often persistent alcohol consumption, and increased metabolic activity. A large number of patients with nutrition deficiencies are underrecognized and undertreated. Although the majority of these patients can be managed by oral and pancreatic enzyme supplementation, some patients may require enteral tube feeding and, in rare cases, parenteral feeding. Current areas of research include the accurate identification of patients at risk for nutrition deficiencies, optimization of feeding regimens, and research into islet cell autotransplantation.
Collapse
Affiliation(s)
- Stephen J O'Brien
- Price Institute of Surgical Research, The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Endashaw Omer
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
| |
Collapse
|
8
|
Schaschkow A, Sigrist S, Mura C, Barthes J, Vrana NE, Czuba E, Lemaire F, Neidl R, Dissaux C, Lejay A, Lavalle P, Bruant-Rodier C, Bouzakri K, Pinget M, Maillard E. Glycaemic control in diabetic rats treated with islet transplantation using plasma combined with hydroxypropylmethyl cellulose hydrogel. Acta Biomater 2020; 102:259-272. [PMID: 31811957 DOI: 10.1016/j.actbio.2019.11.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/15/2019] [Accepted: 11/22/2019] [Indexed: 12/18/2022]
Abstract
Islet transplantation is one of the most efficient cell therapies used in clinics and could treat a large proportion of patients with diabetes. However, it is limited by the high requirement of pancreas necessary to provide the sufficient surviving islet mass in the hepatic tissue and restore normoglycaemia. Reduction in organ procurement requirements could be achieved by extrahepatic transplantation using a biomaterial that enhances islet survival and function. We report a plasma-supplemented hydroxypropyl methylcellulose (HPMC) hydrogel, engineered specifically using a newly developed technique for intra-omental islet infusion, known as hOMING (h-Omental Matrix Islet filliNG). The HPMC hydrogel delivered islets with better performance than that of the classical intrahepatic infusion. After the validation of the HPMC suitability for islets in vivo and in vitro, plasma supplementation modified the rheological properties of HPMC without affecting its applicability with hOMING. The biomaterial association was proven to be more efficient both in vitro and in vivo, with better islet viability and function than that of the current clinical intrahepatic delivery technique. Indeed, when the islet mass was decreased by 25% or 35%, glycaemia control was observed in the group of plasma-supplemented hydrogels, whereas no regulation was observed in the hepatic group. Plasma gelation, observed immediately post infusion, decreased anoïkis and promoted vascularisation. To conclude, the threshold mass for islet transplantation could be decreased using HPMC-Plasma combined with the hOMING technique. The simplicity of the hOMING technique and the already validated use of its components could facilitate its transfer to clinics. STATEMENT OF SIGNIFICANCE: One of the major limitations for the broad deployment of current cell therapy for brittle type 1 diabetes is the islets' destruction during the transplantation process. Retrieved from their natural environment, the islets are grafted into a foreign tissue, which triggers massive cell loss. It is mandatory to provide the islets with an 3D environment specifically designed for promoting isletimplantation to improve cell therapy outcomes. For this aim, we combined HPMC and plasma. HPMC provides suitable rheological properties to the plasma to be injectable and be maintained in the omentum. Afterwards, the plasma polymerises around the graft in vivo, thereby allowing their optimal integration into their transplantation site. As a result, the islet mass required to obtain glycaemic control was reduced by 35%.
Collapse
|
9
|
Microbial Contamination, Infection, and Antimicrobial Use During Total Pancreatectomy With Islet Autotransplantation. Pancreas 2019; 48:1050-1055. [PMID: 31404027 DOI: 10.1097/mpa.0000000000001378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Total pancreatectomy with islet autotransplantation can relieve pain associated with chronic pancreatitis while preserving islet function. Islet preparations are often contaminated by enteric flora. We assessed the impact of contaminated islet preparations on the prevalence of postoperative infection. METHODS Electronic health records for patients who underwent total pancreatectomy with islet autotransplantation from August 1, 2011, to November 15, 2017 were retrospectively reviewed to compare the prevalence of postoperative infection in patients with a positive islet culture and islet culture negative patients. RESULTS Sixty-one patients were included. Twenty-nine patients (47.5%) had a positive islet culture, and 23 (79.3%) of these patients received antimicrobial prophylaxis. The prevalence of postoperative infection did not differ between the islet culture positive and islet culture negative groups (41% vs 34%, P = 0.57). No infections occurred in the 6 islet culture positive patients who did not receive prophylaxis. No difference in intensive care unit or hospital length of stay or in 30-day or 90-day readmission rates were observed. CONCLUSIONS Despite the common use of postoperative systemic antimicrobials, we observed no difference in the prevalence of postoperative infection, length of stay, or hospital readmission in patients receiving a contaminated islet preparation. If prophylactic antimicrobials are used, the duration should be minimized.
Collapse
|
10
|
Berman A, Wszola M, Gorski L, Serwanska-Swietek M, Ostaszewska A, Lipinska A, Chmura A, Kwiatkowski A. Islet Autotransplantation in Diabetic Patients. Transplant Proc 2019; 51:2781-2786. [PMID: 31439326 DOI: 10.1016/j.transproceed.2019.04.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/02/2019] [Accepted: 04/13/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Painful chronic pancreatitis (CP) is the main indication for analgesic pancreatectomy with simultaneous islet autotransplantation to prevent postoperative diabetes mellitus (DM). However, advanced CP may lead to insulin secretion disorders and DM. There are doubts as to whether islet autotransplantation in such cases is an appropriate procedure. The aim of this study was to analyze the results of islet autotransplantation in patients with CP with already diagnosed with DM. METHOD Between 2008 and 2015, at the Department of General and Transplantation Surgery, patients with CP and unsatisfying pain treatment with positive fasting C-peptide ( > 0.3 ng/mL) level were qualified for simultaneous pancreatectomy and islet autotransplantation. Eight procedures were performed. In 5 cases patients had DM diagnosed prior to the procedure (DM group n = 5). Three patients without DM diagnosed prior to surgery were the control group (n = 3). RESULT There were no cases of procedure-related deaths in either group. Pain relief without analgesics was reported by all patients. Good islet function was observed in 80% (4/5) of the DM group vs 100% (3/3) in the control group (P = ns). Brittle diabetes was diagnosed in 1 patient in the DM group as a result of islet primary non-function. CONCLUSION Patients with CP-related severe pain and DM patients with positive C-peptides should be considered for pancreatectomy and islet autotransplantation.
Collapse
Affiliation(s)
- Andrzej Berman
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland; Foundation of Research and Science Development, Warsaw, Poland
| | - Michal Wszola
- Foundation of Research and Science Development, Warsaw, Poland.
| | - Lukasz Gorski
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | | | - Agata Ostaszewska
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Anna Lipinska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Chmura
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Artur Kwiatkowski
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW While there has been a growing utilization of total pancreatectomy with islet autotransplantation (TPIAT) for patients with medically refractory chronic pancreatitis over the past few decades, there remains a lack of consensus clinical guidelines to inform the counseling and management of patients undergoing TPIAT. In this article, we review the current clinical practice and published experience of several TPIAT centers, outline key aspects in managing patients undergoing TPIAT, and discuss the glycemic outcomes of this procedure. RECENT FINDINGS Aiming for lower inpatient glucose targets immediately after surgery (usually 100-120 mg/dl), maintaining all patients on subcutaneous insulin for at least 3 months to "rest" islets before an attempt is made to wean insulin, and close outpatient endocrinology follow-up after TPIAT particularly in the first year is common and related to better outcomes. Although TPIAT procedures and glycemic outcomes may differ across surgical centers, overall, approximately one third of patients are insulin independent at 1 year after TPIAT. Higher islet yield and lower preoperative glucose levels are among the strongest predictors of short-term post-operative insulin independence. Beyond 1 year post-operatively, the clinical management and long-term glycemic outcomes of patients after TPIAT are more variable. A multidisciplinary approach is essential in optimizing the preoperative, inpatient, and post-operative management and counseling of patients about the expected glycemic outcomes after surgery. Consensus guidelines for the clinical management of diabetes after TPIAT and harmonization of data collection protocols among TPIAT centers are needed to address the current knowledge gaps in clinical care and research and to optimize glycemic outcomes after TPIAT.
Collapse
Affiliation(s)
- Mohammed E Al-Sofiani
- Division of Endocrinology, Diabetes & Metabolism, The Johns Hopkins University, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
- Endocrinology Division, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Michael Quartuccio
- Division of Endocrinology, Diabetes & Metabolism, The Johns Hopkins University, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
| | - Erica Hall
- Division of Endocrinology, Diabetes & Metabolism, The Johns Hopkins University, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
| | - Rita Rastogi Kalyani
- Division of Endocrinology, Diabetes & Metabolism, The Johns Hopkins University, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA.
| |
Collapse
|
12
|
Abstract
PURPOSE OF REVIEW We reviewed the current state of total pancreatectomy with islet autotransplantation (TPIAT) for chronic pancreatitis and recurrent acute pancreatitis (RAP). RECENT FINDINGS An increasing number of centers in the United States and internationally are performing TPIAT. In selected cases, TPIAT may be performed partially or entirely laparoscopically. Islet isolation is usually performed at the same center as the total pancreatectomy surgery, but new data suggest that diabetes outcomes may be nearly as good when a remote center is used for islet isolation. Ongoing clinical research is focused on patient and disease factors that predict success or failure to respond to TPIAT. Causes of persistent abdominal pain after TPIAT may include gastrointestinal dysmotility and central sensitization to pain. Several clinical trials are underway with anti-inflammatory or other islet protective strategies to better protect islets at the time of infusion and thereby improve the diabetes results of the procedure. SUMMARY In summary, there is an increasing body of literature emerging from multiple centers highlighting the benefits and persistent challenges of TPIAT for chronic pancreatitis and RAP. Ongoing study will be critical to optimizing the success of this procedure.
Collapse
|
13
|
Nassar A, Quintini C, Costa G, Lennon E, Bottino R, Hatipoglu B, Hashimoto K, Fujiki M, Kandeel F, Walsh RM, Abu-Elmagd K. Total pancreaticoduodenectomy with autologous islet transplantation 14 years after liver-contained composite visceral transplantation. Am J Transplant 2018; 18:2068-2074. [PMID: 29673066 DOI: 10.1111/ajt.14880] [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: 02/06/2018] [Revised: 03/18/2018] [Accepted: 04/03/2018] [Indexed: 01/25/2023]
Abstract
Chronic pancreatitis (CP) is a severely disabling disorder with potential detrimental effects on quality of life, gut function, and glucose homeostasis. Disease progression often results in irreversible morphological and functional abnormalities with development of chronic pain, mechanical obstruction, and pancreatic insufficiency. Along with comprehensive medical management, the concept of total pancreatectomy and islet autotransplantation (TP-AIT) was introduced 40 years ago for patients with intractable pain and preserved beta-cell function. With anticipated technical difficulties, total excision of the inflamed-disfigured gland is expected to alleviate the incapacitating visceral pain and correct other associated abdominal pathology. With retrieval of sufficient islet-cell mass, the autologous transplant procedure has the potential to maintain an euglycemic state without exogenous insulin requirement. The reported herein case of CP-induced recalcitrant pain and foregut obstruction is exceptional because of the technical challenges in performing native pancreaticoduodenectomy in close proximity to the composite visceral allograft with complex vascular and gut reconstructions. Equally novel is transplanting the auto-islets in the liver-contained visceral allograft. Despite intravenous nutrition shortly after birth, liver transplantation at age 13, retransplantation with liver-contained visceral allograft at age 17 and TP-AIT at age 31, the 38-year-old recipient is currently pain free with full nutritional autonomy and normal glucose homeostasis.
Collapse
Affiliation(s)
- Ahmed Nassar
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Guilherme Costa
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth Lennon
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rita Bottino
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
| | - Betul Hatipoglu
- Department of Endocrinology, Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fouad Kandeel
- Department of Internal Medicine, City of Hope Health System, Los Angeles, CA, USA
| | - R Matthew Walsh
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kareem Abu-Elmagd
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
14
|
|
15
|
Tillou JD, Tatum JA, Jolissaint JS, Strand DS, Wang AY, Zaydfudim V, Adams RB, Brayman KL. Operative management of chronic pancreatitis: A review. Am J Surg 2017; 214:347-357. [PMID: 28325588 DOI: 10.1016/j.amjsurg.2017.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/26/2016] [Accepted: 03/08/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pain secondary to chronic pancreatitis is a difficult clinical problem to manage. Many patients are treated medically or undergo endoscopic therapy and surgical intervention is often reserved for those who have failed to gain adequate pain relief from a more conservative approach. RESULTS There have been a number of advances in the operative management of chronic pancreatitis over the last few decades and current therapies include drainage procedures (pancreaticojejunostomy, etc.), resection (pancreticoduodenectomy, etc.) and combined drainage/resection procedures (Frey procedure, etc.). Additionally, many centers currently perform total pancreatectomy with islet autotransplantation, in addition to minimally invasive options that are intended to tailor therapy to individual patients. DISCUSSION Operative management of chronic pancreatitis often improves quality of life, and is associated with low rates of morbidity and mortality. The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience.
Collapse
Affiliation(s)
- John D Tillou
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jacob A Tatum
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Joshua S Jolissaint
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Victor Zaydfudim
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Reid B Adams
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Kenneth L Brayman
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA.
| |
Collapse
|
16
|
Kilburn DJ, Chiow AKH, Leung U, Siriwardhane M, Cavallucci DJ, Bryant R, O'Rourke NA. Early Experience with Laparoscopic Frey Procedure for Chronic Pancreatitis: a Case Series and Review of Literature. J Gastrointest Surg 2017; 21:904-909. [PMID: 28025771 DOI: 10.1007/s11605-016-3343-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 12/15/2016] [Indexed: 01/31/2023]
Abstract
The Frey procedure has been demonstrated to be an effective surgical technique to treat patients with painful large duct chronic pancreatitis. More commonly reported as an open procedure, we report our experience with a minimally invasive approach to the Frey procedure. Four consecutive patients underwent a laparoscopic Frey procedure at our institution from January 2012 to July 2015. We herein report our technique and describe short- and medium-term outcomes. The median age was 40 years old. The median duration of pancreatic pain prior to surgery was 12 years. Median operative time and intraoperative blood loss was 130 min (100-160 min) and 60 mL (50-100 mL), respectively. The median length of stay was 7 days (3-40 days) and median follow-up was 26 months (12-30 months). There was one major postoperative complication requiring reoperation. Within 6 months, in all four patients, frequency of pain and analgesic requirement reduced significantly. Two patients appeared to have resolution of pancreatic exocrine insufficiency. The Frey procedure is possible laparoscopically with acceptable short- and medium-term outcomes in well-selected patients.
Collapse
Affiliation(s)
- Daniel J Kilburn
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia
| | - Adrian K H Chiow
- Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore, Singapore
| | - Universe Leung
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia
| | - Mehan Siriwardhane
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia
| | - David J Cavallucci
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia
| | - Richard Bryant
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia
| | - Nicholas A O'Rourke
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia. .,School of Medicine, The University of Queensland, Brisbane, Australia. .,, Wesley Medical Centre Suite 47, 40 Chasely Street, Auchenflower, Brisbane, Queensland, 4066, Australia.
| |
Collapse
|
17
|
|
18
|
Del Chiaro M, Rangelova E, Segersvärd R, Arnelo U. Are there still indications for total pancreatectomy? Updates Surg 2016; 68:257-263. [PMID: 27605208 PMCID: PMC5123621 DOI: 10.1007/s13304-016-0388-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/19/2016] [Indexed: 12/16/2022]
Abstract
Total pancreatectomy is associated with short- and long-term high complication rate and without evidence of oncologic advantages. Several metabolic consequences are co-related with the apancreatic state. The unstable diabetes related to the total resection of the pancreas expose the patients to short- and long-term life-threatening complications. Severe hypoglycemia is a short-term dangerous complication that can also cause patients’ death. Chronic complications of severe diabetes (cardiac and vascular diseases, neuropathy, nephropathy, and retinopathy) are also cause of morbidity, mortality and worsening of quality of life. For this reasons the number of total pancreatectomies performed has certainly decreased over time. However, today there are still some indications for this kind of procedures. Chronic pancreatitis untreatable with conventional treatments, surgical treatment of precancerous pancreatic lesions, surgical treatment of locally advanced pancreatic cancer and the management of patients with extraordinary high-risk pancreatic texture after pancreaticoduodenectomy represent possible indications for total pancreatectomy and are analyzed in the present paper.
Collapse
Affiliation(s)
- Marco Del Chiaro
- Pancreatic Surgery Unit-Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases-Karolinska University Hospital, K53-14186, Stockholm, Sweden.
| | - Elena Rangelova
- Pancreatic Surgery Unit-Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases-Karolinska University Hospital, K53-14186, Stockholm, Sweden
| | - Ralf Segersvärd
- Pancreatic Surgery Unit-Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases-Karolinska University Hospital, K53-14186, Stockholm, Sweden
| | - Urban Arnelo
- Pancreatic Surgery Unit-Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases-Karolinska University Hospital, K53-14186, Stockholm, Sweden
| |
Collapse
|
19
|
Fazlalizadeh R, Moghadamyeghaneh Z, Demirjian AN, Imagawa DK, Foster CE, Lakey JR, Stamos MJ, Ichii H. Total pancreatectomy and islet autotransplantation: A decade nationwide analysis. World J Transplant 2016; 6:233-238. [PMID: 27011922 PMCID: PMC4801800 DOI: 10.5500/wjt.v6.i1.233] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/14/2015] [Accepted: 02/16/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate outcomes and predictors of in-hospital morbidity and mortality after total pancreatectomy (TP) and islet autotransplantation.
METHODS: The nationwide inpatient sample (NIS) database was used to identify patients who underwent TP and islet autotransplantation (IAT) between 2002-2012 in the United States. Variables of interest were inherent variables of NIS database which included demographic data (age, sex, and race), comorbidities (such as diabetes mellitus, hypertension, and deficiency anemia), and admission type (elective vs non-elective). The primary endpoints were mortality and postoperative complications according to the ICD-9 diagnosis codes which were reported as the second to 25th diagnosis of patients in the database. Risk adjusted analysis was performed to investigate morbidity predictors. Multivariate regression analysis was used to identify predictors of in-hospital morbidity.
RESULTS: We evaluated a total of 923 patients who underwent IAT after pancreatectomy during 2002-2012. Among them, there were 754 patients who had TP + IAT. The most common indication of surgery was chronic pancreatitis (86%) followed by acute pancreatitis (12%). The number of patients undergoing TP + IAT annually significantly increased during the 11 years of study from 53 cases in 2002 to 155 cases in 2012. Overall mortality and morbidity of patients were 0% and 57.8 %, respectively. Post-surgical hypoinsulinemia was reported in 42.3% of patients, indicating that 57.7% of patients were insulin independent during hospitalization. Predictors of in-hospital morbidity were obesity [adjusted odds ratio (AOR): 3.02, P = 0.01], fluid and electrolyte disorders (AOR: 2.71, P < 0.01), alcohol abuse (AOR: 2.63, P < 0.01), and weight loss (AOR: 2.43, P < 0.01).
CONCLUSION: TP + IAT is a safe procedure with no mortality, acceptable morbidity, and achieved high rate of early insulin independence. Obesity is the most significant predictor of in-hospital morbidity.
Collapse
|
20
|
Kumar R, Chung WY, Dennison AR, Garcea G. Current principles and practice in autologous intraportal islet transplantation: a meta-analysis of the technical considerations. Clin Transplant 2016; 30:344-56. [DOI: 10.1111/ctr.12695] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Rohan Kumar
- Department of Hepato-Pancreato-Biliary Surgery; University Hospitals of Leicester; Leicester UK
| | - Wen Yuan Chung
- Department of Hepato-Pancreato-Biliary Surgery; University Hospitals of Leicester; Leicester UK
| | - Ashley Robert Dennison
- Department of Hepato-Pancreato-Biliary Surgery; University Hospitals of Leicester; Leicester UK
| | - Giuseppe Garcea
- Department of Hepato-Pancreato-Biliary Surgery; University Hospitals of Leicester; Leicester UK
| |
Collapse
|
21
|
Tanhehco YC, Weisberg S, Schwartz J. Pancreatic islet autotransplantation for nonmalignant and malignant indications. Transfusion 2015; 56:761-70. [DOI: 10.1111/trf.13417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 10/02/2015] [Accepted: 10/08/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Yvette C. Tanhehco
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
| | - Stuart Weisberg
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
| | - Joseph Schwartz
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
| |
Collapse
|
22
|
Hata T, Sakata N, Yoshimatsu G, Tsuchiya H, Fukase M, Ishida M, Aoki T, Katayose Y, Egawa S, Unno M. Cholestatic Liver Injury After Biliary Reconstruction Impairs Transplanted Islet Viability and Function. Am J Transplant 2015; 15:2085-95. [PMID: 25908212 DOI: 10.1111/ajt.13266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 02/03/2015] [Accepted: 02/11/2015] [Indexed: 01/25/2023]
Abstract
Islet autotransplantation following total pancreatectomy differs from allograft transplantation with respect to the requirement of biliary reconstruction. Although it is known that careful consideration should be given to postoperative cholestatic liver injury after biliary reconstruction, its direct effects on transplanted islets have not been completely elucidated. In this study, we developed a murine model of postoperative cholestatic liver injury after biliary reconstruction with islet autotransplantation that involved syngeneic intraportal islet transplantation into chemically induced diabetic mice and common bile duct ligation. We assessed the viability and function of the transplanted islets. The impaired viability of transplanted islets and increased blood glucose levels indicated restoration of the diabetic state after common bile duct ligation in this murine model. Furthermore, impaired islet viability and function occurred earlier in the transplanted islets than in the surrounding liver tissues, which was consistent with the faster and higher expression of oxidative stress markers in the transplanted islets. Transplanted islets may be more vulnerable to oxidative stress caused by cholestatic liver injury than the surrounding liver tissue. Therefore, patients should be intensively managed after total pancreatectomy with islet autotransplantation to preserve viability and function of the transplanted islets.
Collapse
Affiliation(s)
- T Hata
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - N Sakata
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - G Yoshimatsu
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - H Tsuchiya
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - M Fukase
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - M Ishida
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - T Aoki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Y Katayose
- Division of Integrated Surgery and Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - S Egawa
- Division of International Cooperation for Disaster Medicine, International Research Institute of Disaster Science, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - M Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Integrated Surgery and Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
23
|
Total pancreatectomy with islet cell auto-transplantation: update and outcomes from major centers. ACTA ACUST UNITED AC 2014; 12:350-8. [PMID: 25053231 DOI: 10.1007/s11938-014-0026-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OPINION STATEMENT Chronic pancreatitis is the result of irreversible damage to pancreatic acinar cells, and can result in debilitating chronic pain for patients. Treatment centers on pain relief, often with chronic narcotic use. Surgical therapy consists of both resection procedures to remove affected pancreatic parenchyma and drainage procedures to facilitate drainage of the main pancreatic duct. Total pancreatectomy historically was utilized in extreme cases due to the brittle glucose control that followed from the total loss of islet cells. Total pancreatectomy with islet cell auto-transplantation (TP-AIT) is gaining in popularity due to the maintenance of beta cell mass and the ability of patients to potentially be insulin independent post-operatively. TP-AIT is very helpful in the treatment of pain for patients with chronic pancreatitis. The overall majority of patients have an improvement in pain and quality-of-life scores. AIT also allows the majority of patients to have minimal insulin requirements post-operatively. With proper patient selection, these outcomes can be achieved.
Collapse
|
24
|
Bellin MD, Freeman ML, Gelrud A, Slivka A, Clavel A, Humar A, Schwarzenberg SJ, Lowe ME, Rickels MR, Whitcomb DC, Matthews JB, Amann S, Andersen DK, Anderson MA, Baillie J, Block G, Brand R, Chari S, Cook M, Cote GA, Dunn T, Frulloni L, Greer JB, Hollingsworth MA, Kim KM, Larson A, Lerch MM, Lin T, Muniraj T, Robertson RP, Sclair S, Singh S, Stopczynski R, Toledo FGS, Wilcox CM, Windsor J, Yadav D. Total pancreatectomy and islet autotransplantation in chronic pancreatitis: recommendations from PancreasFest. Pancreatology 2014; 14:27-35. [PMID: 24555976 PMCID: PMC4058640 DOI: 10.1016/j.pan.2013.10.009] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 10/23/2013] [Accepted: 10/25/2013] [Indexed: 12/11/2022]
Abstract
DESCRIPTION Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure used to treat severe complications of chronic pancreatitis or very high risk of pancreatic cancer while reducing the risk of severe diabetes mellitus. However, clear guidance on indications, contraindications, evaluation, timing, and follow-up are lacking. METHODS A working group reviewed the medical, psychological, and surgical options and supporting literature related to TPIAT for a consensus meeting during PancreasFest. RESULTS Five major areas requiring clinical evaluation and management were addressed: These included: 1) indications for TPIAT; 2) contraindications for TPIAT; 3) optimal timing of the procedure; 4) need for a multi-disciplinary team and the roles of the members; 5) life-long management issues following TPIAP including diabetes monitoring and nutrition evaluation. CONCLUSIONS TPIAT is an effective method of managing the disabling complications of chronic pancreatitis and risk of pancreatic cancer in very high risk patients. Careful evaluation and long-term management of candidate patients by qualified multidisciplinary teams is required. Multiple recommendations for further research were also identified.
Collapse
Affiliation(s)
- Melena D. Bellin
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Martin L. Freeman
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pennsylvania, USA
| | - Alfred Clavel
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pennsylvania, USA
| | | | - Mark E. Lowe
- Department of Pediatrics, University of Pittsburgh, Pennsylvania, USA,Children’s Hospital of Pittsburgh, Pennsylvania, USA
| | - Michael R. Rickels
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
|
26
|
Prior surgery determines islet yield and insulin requirement in patients with chronic pancreatitis. Transplantation 2013; 95:1051-7. [PMID: 23411743 DOI: 10.1097/tp.0b013e3182845fbb] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Total pancreatectomy with islet autotransplantation (TP-IAT) is safe and effective in the management of intractable pain associated with chronic pancreatitis (CP). Prevention of pancreatogenic diabetes after TP-IAT is related to islet yield from the diseased pancreas. The purpose of this study is to compare islet yield and insulin requirement in the 76 patients who underwent different surgical procedures before TP-IAT at the Medical University of South Carolina between 2009 and 2011. METHODS Patients were grouped into four categories based on the operation they had before TP-IAT: transduodenal sphincteroplasty/no prior surgery (n=50), Whipple or Beger procedure (n=14), distal pancreatectomy (n=8), or lateral pancreaticojejunostomy (n=4). Islets were harvested from pancreases of those patients at our current good manufacturing practice facility. Total unpurified islets were transplanted into patients via portal vein infusion. Pancreatic fibrosis, islet yield, cell viability, and insulin requirement were measured. RESULTS The pancreases of transduodenal sphincteroplasty/no prior surgery and Whipple or Beger procedure patients were less fibrotic and had higher islet yield compared with those who had distal pancreatectomy or lateral pancreaticojejunostomy. Higher islet yield also correlated with a greater diabetes-free rate and a lesser insulin requirement at the following intervals: preoperative, postoperative, and 6 months after TP-IAT. CONCLUSIONS Prior surgery is strongly correlated with the extent of pancreatic fibrosis, islet yield, and insulin requirements in CP patients undergoing TP-IAT. The history of prior pancreatic resection and drainage procedures may be used to predict postoperative islet function and help to determine the optimal timing for TP-IAT in CP patients.
Collapse
|
27
|
Islet autotransplantation to preserve beta cell mass in selected patients with chronic pancreatitis and diabetes mellitus undergoing total pancreatectomy. Pancreas 2013; 42:317-21. [PMID: 23146918 PMCID: PMC3573248 DOI: 10.1097/mpa.0b013e3182681182] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Islet autotransplantation (IAT) is performed in nondiabetic patients with chronic pancreatitis at the time of total pancreatectomy (TP) to minimize risk of postoperative diabetes. The role of TP-IAT in patients with chronic pancreatitis and C-peptide-positive diabetes is not established. We postulate that IAT can preserve beta cell mass and thereby benefit patients with preexisting diabetes undergoing TP. METHODS Preoperative metabolic testing, islet isolation outcomes, and subsequent islet graft function were reviewed for 27 patients with diabetes mellitus and chronic pancreatitis undergoing TP-IAT. The relationships between the results of preoperative metabolic testing and islet isolation outcomes were explored using regression analysis. RESULTS Mean islet yield was 2060 (SD, 2408) islet equivalents/kg. Peak C-peptide (from mixed meal tolerance testing) was the strongest predictor of islet yield, with higher stimulated C-peptide levels associated with greater islet mass. Half of the patients who had C-peptide levels measured after transplantation demonstrated C-peptide production at a level that conveys protective benefit in type 1 diabetes (≥ 0.6 ng/mL). CONCLUSIONS These findings provide proof of concept that significant islet mass can be isolated in patients with chronic pancreatitis and C-peptide-positive diabetes mellitus undergoing TP-IAT. Stimulated C-peptide may be a useful marker of islet mass before transplantation in these patients.
Collapse
|
28
|
Pancreatic islet autotransplantation with total pancreatectomy for chronic pancreatitis. Surg Today 2012; 43:715-9. [DOI: 10.1007/s00595-012-0382-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 07/26/2012] [Indexed: 12/11/2022]
|
29
|
Walsh RM, Saavedra JRA, Lentz G, Guerron AD, Scheman J, Stevens T, Trucco M, Bottino R, Hatipoglu B. Improved quality of life following total pancreatectomy and auto-islet transplantation for chronic pancreatitis. J Gastrointest Surg 2012; 16:1469-77. [PMID: 22673773 DOI: 10.1007/s11605-012-1914-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Accepted: 05/15/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Total pancreatectomy (TP) with auto-islet transplant (AIT) is an extreme treatment for chronic pancreatitis, and we reviewed our experience to assess the impact on quality of life (QOL). METHODS A prospective cohort study from 2007 through 2010 with pre- and postoperative assessments of the Depression Anxiety Stress Scale, Pain Disability Index, and visual analogue pain scale was performed. RESULTS Twenty patients underwent TP-AIT with a median follow-up of 12 months (6.75-24 months). All patients reported moderate (45 %) to severe (55 %) pain prior to surgery. TP-AIT resulted in significant decreases in abdominal pain (p < 0.001), 80 % reporting no or mild pain. Despite pain improvement, only 30 % discontinued narcotics. Improvements in all PDI QOL domains improved from 79 to 90 % (p = 0.002), with greatest improvements seen in those without prior pancreatic surgery, younger patients, and in those with higher levels of preoperative pain. Patients were less affected by depression and anxiety prior to surgery, but 60 and 70 % did show improvement in depression and anxiety, respectively (p = 0.033). Sixteen patients (80 %) required exogenous insulin at last follow-up (mean total dose of insulin 11.6 U/day). CONCLUSIONS TP-AIT significantly improves pain and QOL measures in appropriately selected patients with CP.
Collapse
Affiliation(s)
- R M Walsh
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Bramis K, Gordon-Weeks AN, Friend PJ, Bastin E, Burls A, Silva MA, Dennison AR. Systematic review of total pancreatectomy and islet autotransplantation for chronic pancreatitis. Br J Surg 2012; 99:761-6. [PMID: 22434330 DOI: 10.1002/bjs.8713] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND Total pancreatectomy and islet autotransplantation (TP/IAT) is a treatment option in a subset of patients with chronic pancreatitis. A systematic review of the literature was performed to evaluate the outcome of this procedure, with an attempt to ascertain when it is indicated. METHODS MEDLINE (1950 to present), Embase (1980 to present) and the Cochrane Library were searched to identify studies of outcomes in patients undergoing TP/IAT. Cohort studies that reported the outcomes following the procedure were included. The MOOSE guidelines were used as a basis for this review. RESULTS Five studies met the inclusion criteria. The techniques reported for pancreatectomy and islet cell isolation varied between studies. TP/IAT was successful in reducing pain in patients with chronic pancreatitis. Comparing morphine requirements before and after the procedure, two studies recorded significant reductions. Concurrent IAT reduced the insulin requirement after TP; the rate of insulin independence ranged from 46 per cent of patients at 5 years' mean follow-up to 10 per cent at 8 years. The impact on quality of life was poorly reported. The studies reviewed did not provide evidence for optimal timing of TP/IAT in relation to the evolution of chronic pancreatitis. CONCLUSION This systematic review showed that TP/IAT had favourable outcomes with regard to pain reduction. Concurrent IAT enabled a significant proportion of patients to remain independent of insulin supplementation.
Collapse
Affiliation(s)
- K Bramis
- Department of Hepatobiliary and Transplant Surgery, Churchill Hospital, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK
| | | | | | | | | | | | | |
Collapse
|
31
|
Affiliation(s)
- Michael B Farnell
- Department of Surgery, College of Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
32
|
Quality of life improves for pediatric patients after total pancreatectomy and islet autotransplant for chronic pancreatitis. Clin Gastroenterol Hepatol 2011; 9:793-9. [PMID: 21683160 PMCID: PMC3163759 DOI: 10.1016/j.cgh.2011.04.024] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2010] [Revised: 04/13/2011] [Accepted: 04/24/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Total pancreatectomy (TP) and islet autotransplant (IAT) have been used to treat patients with painful chronic pancreatitis. Initial studies indicated that most patients experienced significant pain relief, but there were few validated measures of quality of life. We investigated whether health-related quality of life improved among pediatric patients undergoing TP/IAT. METHODS Nineteen consecutive children (aged 5-18 years) undergoing TP/IAT from December 2006 to December 2009 at the University of Minnesota completed the Medical Outcomes Study 36-item Short Form (SF-36) health questionnaire before and after surgery. Insulin requirements were recorded. RESULTS Before TP/IAT, patients had below average health-related quality of life, based on data from the Medical Outcomes Study SF-36; they had a mean physical component summary (PCS) score of 30 and mental component summary (MCS) score of 34 (2 and 1.5 standard deviations, respectively, below the mean for the US population). By 1 year after surgery, PCS and MCS scores improved to 50 and 46, respectively (global effect, PCS P < .001, MCS P = .06). Mean scores improved for all 8 component subscales. More than 60% of IAT recipients were insulin independent or required minimal insulin. Patients with prior surgical drainage procedures (Puestow) had lower yields of islets (P = .01) and greater incidence of insulin dependence (P = .04). CONCLUSIONS Quality of life (physical and emotional components) significantly improve after TP/IAT in subsets of pediatric patients with severe chronic pancreatitis. Minimal or no insulin was required for most patients, although islet yield was reduced in patients with previous surgical drainage operations.
Collapse
|