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Szempruch KR, Lachiewicz AM, Williams BM, Kumar A, Baldwin X, Desai CS. Microbiological cultures and antimicrobial prophylaxis in patients undergoing total pancreatectomy with islet cell autotransplantation. Hepatobiliary Pancreat Dis Int 2023; 22:426-429. [PMID: 36990838 DOI: 10.1016/j.hbpd.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/08/2023] [Indexed: 03/31/2023]
Affiliation(s)
- Kristen R Szempruch
- Pharmacy Department, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Anne M Lachiewicz
- Division of Infectious Disease, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Brittney M Williams
- Department of Surgery, Transplant, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Aman Kumar
- Department of Surgery, Transplant, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Xavier Baldwin
- Department of Surgery, Transplant, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Chirag S Desai
- Department of Surgery, Transplant, University of North Carolina Medical Center, Chapel Hill, NC, USA.
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Chaouch MA, Leon P, Cassese G, Aguilhon C, Khayat S, Panaro F. Total pancreatectomy with intraportal islet autotransplantation for pancreatic malignancies: a literature overview. Expert Opin Biol Ther 2021; 22:491-497. [PMID: 34747305 DOI: 10.1080/14712598.2022.1990261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION 'Brittle Diabetes' (BD) is a life-threatening metabolic complication after total pancreatectomy (TP). More than 500 Intraportal islet autotransplantation (IAT) have been performed to prevent this complication, with almost 70% insulin independence after 3 years. Even when insulin independence was not achieved, IAT successfully prevented severe hypoglycemia. Currently, preliminary results for oncologic situations are promising, but their oncological outcomes are still a matter of debate. AREAS COVERED We performed a bibliographic research of the last 25 years of data. Articles published in English in peer-reviewed journals were retained. In France, auto- and allo-islet transplantation was recently recognized as a valuable treatment for BD by the national health authority. While accepted for benign diseases, the risk of tumor spreading after IAT in oncologic situations is a source of concern. EXPERT OPINION Preliminary results of IAT in oncological situations are very encouraging. So far, there is no evidence of tumor dissemination. In our opinion, to overcome BD TP with IAT for resectable pancreatic malignancies in patients with a higher risk of postoperative pancreatic fistula and extended pancreatic cancers can be safely performed. Diagnosis of malignancy should not be considered as an exclusion criterion for IAT.
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Affiliation(s)
- Mohamed Ali Chaouch
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
| | - Piera Leon
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
| | - Gianluca Cassese
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France.,Department of Clinical Medicine and Surgery, Federico Ii University, Naples, Italy
| | - Caroline Aguilhon
- Division of Endocrinology, Diabetology and Clinical Nutrition, Montpellier University Hospital, Montpellier, France
| | - Salah Khayat
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
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Naples R, Perlmutter BC, Thomas JD, McMichael J, Bottino R, Solomina J, Trucco M, Augustin T, Simon R, Walsh RM. Clinical Significance of Postoperative Antibiotic Treatment for Positive Islet Cultures After Total Pancreatectomy With Islet Autotransplantation. Pancreas 2021; 50:1000-1006. [PMID: 34629454 DOI: 10.1097/mpa.0000000000001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Islet cultures are routinely performed in total pancreatectomy with islet autotransplantation (TPIAT), and the need for empiric antibiotic treatment based on culture results is unknown. We evaluated the effect of postoperative antibiotic treatment for positive islet cultures on clinical infection. METHODS Seventy-nine patients undergoing TPIAT were reviewed. Prophylactic perioperative ceftriaxone and metronidazole were administered, and transplanted islet preparations included ciprofloxacin. Postoperative antibiotics were not routinely given for positive cultures unless a clinical infection was suspected. The primary end point was 30-day infectious complications. RESULTS Fifty-one patients (65%) had a positive culture. Overall, 39 patients (87%) had organisms susceptible to our perioperative antibiotic regimen. There was no difference in the infectious complication rate between those with positive compared with negative cultures (16% vs 29%, P = 0.17). Patients with a positive culture had similar 30-day postoperative infectious complication rates whether receiving postoperative antibiotics (n = 7) or not (14% vs 16%, P = 0.91). Only 1 patient had a correlation of clinical and islet cultures. CONCLUSIONS Beyond prophylactic antibiotics, empiric antibiotic treatment for a positive culture is not warranted and provides a rationale for the abandonment of routine cultures in TPIAT.
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Affiliation(s)
- Robert Naples
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Breanna C Perlmutter
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Jonah D Thomas
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - John McMichael
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Rita Bottino
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Julia Solomina
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Massimo Trucco
- Institute of Cellular Therapeutics, Allegheny-Singer Research Institute, Allegheny Health Network, Pittsburgh, PA
| | - Toms Augustin
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Robert Simon
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - R Matthew Walsh
- From the Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Jabłońska B, Mrowiec S. Total Pancreatectomy with Autologous Islet Cell Transplantation-The Current Indications. J Clin Med 2021; 10:jcm10122723. [PMID: 34202998 PMCID: PMC8235694 DOI: 10.3390/jcm10122723] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022] Open
Abstract
Total pancreatectomy is a major complex surgical procedure involving removal of the whole pancreatic parenchyma and duodenum. It leads to lifelong pancreatic exocrine and endocrine insufficiency. The control of surgery-induced diabetes (type 3) requires insulin therapy. Total pancreatectomy with autologous islet transplantation (TPAIT) is performed in order to prevent postoperative diabetes and its serious complications. It is very important whether it is safe and beneficial for patients in terms of postoperative morbidity and mortality, and long-term results including quality of life. Small duct painful chronic pancreatitis (CP) is a primary indication for TPAIT, but currently the indications for this procedure have been extended. They also include hereditary/genetic pancreatitis (HGP), as well as less frequent indications such as benign/borderline pancreatic tumors (intraductal papillary neoplasms, neuroendocrine neoplasms) and “high-risk pancreatic stump”. The use of TPAIT in malignant pancreatic and peripancreatic neoplasms has been reported in the worldwide literature but currently is not a standard but rather a controversial management in these patients. In this review, history, technique, indications, and contraindications, as well as short-term and long-term results of TPAIT, including pediatric patients, are described.
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Cortez AR, Kassam AF, Lin TK, Paulsen GC, Brunner J, Jenkins TM, Danziger-Isakov LA, Ahmad SA, Abu-El-Haija M, Nathan JD. Sterility Cultures Following Pancreatectomy with Islet Autotransplantation in the Pediatric Population: Do They Matter? J Gastrointest Surg 2020; 24:2526-2535. [PMID: 31745897 DOI: 10.1007/s11605-019-04413-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatectomy with islet autotransplantation (IAT) is a treatment option for children with debilitating chronic pancreatitis. Sterility cultures from preservation solutions are often positive, yet their impact has not been well studied in children. METHODS A retrospective review of all patients who underwent IAT from 2015 to 2018 at a single institution was performed. Sterility culture data were obtained from both the pancreas transport and islet transplant media. All patients received prophylactic perioperative meropenem and vancomycin for 72 h per our protocol. If cultures resulted positive, antibiotics were extended for a total of 7 days. Primary outcomes were postoperative fever and 30-day infectious complications. RESULTS Forty-one patients underwent IAT during the study period. Seventeen (41.5 %) patients had negative cultures of both the transport and transplant media, while 24 (58.5 %) patients had a positive culture from either sample. Of these patients, 13 (31.7 %) were positive in both, 10 (24.4 %) were positive in only the transport media, and 1 (2.4 %) was positive in only the transplant media. Patients with positive transplant media were similar with regard to age, gender, etiology, and disease duration compared to those with negative transplant media (all p > 0.05), but the positive group was more likely to have a pancreatic stent in place at the time of surgery (38.5 % vs. 4.2 %, p = 0.01). The overall postoperative infectious complication rate was 31.2 % (n = 13). No difference was detected between the transplant positive and negative culture groups in postoperative fever or 30-day infectious complications (p > 0.05 for each). CONCLUSION An existing pancreatic stent at the time of pancreatectomy with IAT is a risk factor for positive sterility cultures. However, positive islet transplant media culture was not associated with increased risk of post-IAT infection or morbidity in the setting of an empiric antibiotic protocol. Future work is necessary to study the optimal perioperative antibiotic regimen in pediatric IAT.
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Affiliation(s)
- Alexander R Cortez
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2023, Cincinnati, OH, 45229, USA
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Al-Faraaz Kassam
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2023, Cincinnati, OH, 45229, USA
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Tom K Lin
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Grant C Paulsen
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John Brunner
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Todd M Jenkins
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2023, Cincinnati, OH, 45229, USA
| | - Lara A Danziger-Isakov
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2023, Cincinnati, OH, 45229, USA.
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
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Kumano K, Takita M, Vasu S, Darden C, Lawrence M, Beecherl E, Gupta A, Onaca N, Naziruddin B. Impact of microbial contamination of the islet product during total pancreatectomy with islet autotransplantation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:211-218. [PMID: 31944603 DOI: 10.1002/jhbp.709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/22/2019] [Accepted: 01/08/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The combined use of interleukin-1β and tumor necrosis factor-α blockers in the peritransplant period has improved outcomes of total pancreatectomy with islet autotransplantation (TPIAT). However, these drugs may suppress the immune system, resulting in severe infection. METHODS We retrospectively investigated the impact of microbial-contaminated islet product on posttransplant complications and metabolic outcomes of TPIAT patients receiving the IL-1β and TNF-blockade treatment at our center. RESULTS Among 108 TPIAT patients, 37 patients (34%) received contaminated products. Preoperative stent treatment and fibrosis score were independent risk factors for the contamination. There were no significant differences between the contaminated and noncontaminated product groups in posttransplant infectious complication rate, length of hospitalization, or readmission rate. However, islet equivalents (P < .0001) and insulin independence rate (P = .036) at 6 months were significantly lower for patients receiving contaminated product. CONCLUSIONS These results suggest that combined anti-inflammatory drug use is safe and well tolerated in TPIAT patients who receive contaminated islet product and does not increase the rate of infectious complications; however, contaminated islet product is associated with poor metabolic outcomes.
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Affiliation(s)
- Kenjiro Kumano
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | | | - Srividya Vasu
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | | | | | | | - Amar Gupta
- Baylor Simmons Transplant Institute, Dallas, TX, USA
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Gołębiewska JE, Bachul PJ, Fillman N, Kijek MR, Basto L, Para M, Perea L, Gołąb K, Wang LJ, Tibudan M, Dębska-Ślizień A, Matthews JB, Fung J, Witkowski P. Early Infectious Complications After Total Pancreatectomy with Islet Autotransplantation: a Single Center Experience. J Gastrointest Surg 2019; 23:2201-2210. [PMID: 30719679 DOI: 10.1007/s11605-019-04118-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/09/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION We assessed whether positive microbiological cultures from the islet preparation had any effect on the risk of infectious complications (IC) after total pancreatectomy with islet autotransplantation (TPIAT) in our center. METHODS We analyzed preservation fluid and final islet product surveillance cultures with reference to clinical data of patients undergoing TPIAT. All patients received routine prophylactic broad-spectrum antibiotics. RESULTS The study involved 10 men and 18 women with a median age of 39 years. Over 30% of surveillance cultures during pancreas processing grew bacterial strains with predominantly polymicrobial contaminations (13 of 22 (59%)). At least one positive culture was identified in almost half of the patients (46%) undergoing TPIAT and a third had both surveillance cultures positive. Infectious complications affected 50% of patients. After excluding cases of PICC line-associated bacteremia/fungemia present on admission, incidence of IC was higher in cases of positive final islet product culture than in those with negative result (57% vs. 21%), which also corresponded with the duration of chronic pancreatitis (p = 0.04). Surgical site infections were the most common IC, followed by fever of unknown origin. There was no concordance between pathogens isolated from the pancreas and those identified during the infection. CONCLUSIONS While IC was common among TPIAT patients, we found no concordance between pathogens isolated from the pancreas and those identified during infection. Contamination of the final islet product was of clinical importance and could represent a surrogate marker for higher susceptibility to infection.
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Affiliation(s)
- Justyna E Gołębiewska
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Piotr J Bachul
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Natalie Fillman
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - Mark R Kijek
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - Lindsay Basto
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - Monica Para
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - Laurencia Perea
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - Karolina Gołąb
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - Ling-Jia Wang
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - Martin Tibudan
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Jeffrey B Matthews
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - John Fung
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA
| | - Piotr Witkowski
- Department of Surgery, University of Chicago Medical Center, Transplantation Institute, 5841 S. Maryland Ave. MC5027, Room J-517, Chicago, IL, 60637, USA.
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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.
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Rickels MR, Robertson RP. Pancreatic Islet Transplantation in Humans: Recent Progress and Future Directions. Endocr Rev 2019; 40:631-668. [PMID: 30541144 PMCID: PMC6424003 DOI: 10.1210/er.2018-00154] [Citation(s) in RCA: 165] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/26/2018] [Indexed: 12/11/2022]
Abstract
Pancreatic islet transplantation has become an established approach to β-cell replacement therapy for the treatment of insulin-deficient diabetes. Recent progress in techniques for islet isolation, islet culture, and peritransplant management of the islet transplant recipient has resulted in substantial improvements in metabolic and safety outcomes for patients. For patients requiring total or subtotal pancreatectomy for benign disease of the pancreas, isolation of islets from the diseased pancreas with intrahepatic transplantation of autologous islets can prevent or ameliorate postsurgical diabetes, and for patients previously experiencing painful recurrent acute or chronic pancreatitis, quality of life is substantially improved. For patients with type 1 diabetes or insulin-deficient forms of pancreatogenic (type 3c) diabetes, isolation of islets from a deceased donor pancreas with intrahepatic transplantation of allogeneic islets can ameliorate problematic hypoglycemia, stabilize glycemic lability, and maintain on-target glycemic control, consequently with improved quality of life, and often without the requirement for insulin therapy. Because the metabolic benefits are dependent on the numbers of islets transplanted that survive engraftment, recipients of autoislets are limited to receive the number of islets isolated from their own pancreas, whereas recipients of alloislets may receive islets isolated from more than one donor pancreas. The development of alternative sources of islet cells for transplantation, whether from autologous, allogeneic, or xenogeneic tissues, is an active area of investigation that promises to expand access and indications for islet transplantation in the future treatment of diabetes.
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Affiliation(s)
- Michael R Rickels
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - R Paul Robertson
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Division of Endocrinology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Pacific Northwest Diabetes Research Institute, Seattle, Washington
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Berger MG, Majumder K, Hodges JS, Bellin MD, Schwarzenberg SJ, Gupta S, Dunn TB, Beilman GJ, Pruett TL, Freeman ML, Wilhelm JJ, Sutherland DER, Chinnakotla S. Microbial contamination of transplant solutions during pancreatic islet autotransplants is not associated with clinical infection in a pediatric population. Pancreatology 2016; 16:555-62. [PMID: 27134135 DOI: 10.1016/j.pan.2016.03.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/08/2016] [Accepted: 03/28/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Total pancreatectomy and islet autotransplant (TP-IAT) is a potential treatment for children with severe refractory chronic pancreatitis. Cultures from the resected pancreas and final islet preparation are frequently positive for microbes. It is unknown whether positive cultures are associated with adverse outcomes in pediatric patients. METHODS We reviewed the medical records of children (n = 86) who underwent TP-IAT from May 2006-March 2015 with emphasis on demographics, previous pancreatic interventions, culture results, islet yield, hospital days, posttransplant islet function, and posttransplant infections. We compared outcomes in patients with positive (n = 57) and negative (n = 29) cultures. RESULTS Patients with positive cultures had higher rates of previous pancreas surgery (P = 0.007) and endoscopic retrograde cholangiopancreatography (P < 0.0001). Positive cultures were not associated with posttransplant infections (P = 1.00) or prolonged hospital length of stay (P = 0.29). Patients with positive final islet preparation culture showed increased rates of graft failure at 2 years posttransplant (P = 0.041), but not when adjusted for islet mass transplanted (P = 0.39). CONCLUSIONS Positive cultures during pediatric TP-IATs do not increase the risk of posttransplant infections or prolong hospital length of stay. Endocrine function depends on islet mass transplanted.
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Affiliation(s)
- Megan G Berger
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Kaustav Majumder
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - James S Hodges
- Department of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Melena D Bellin
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA; Schulze Diabetes Institute, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Sameer Gupta
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ty B Dunn
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Timothy L Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Martin L Freeman
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Joshua J Wilhelm
- Schulze Diabetes Institute, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David E R Sutherland
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA; Schulze Diabetes Institute, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA; Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
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Pouch SM. Infectious complications of pancreatic islet transplantation: clinical experience and unanswered questions. Curr Infect Dis Rep 2015; 17:482. [PMID: 25896753 DOI: 10.1007/s11908-015-0482-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pancreatic islet transplantation is an evolving treatment modality for type I diabetes mellitus. While the field has advanced significantly over the course of the past three decades, our understanding of the infectious complications of pancreatic islet transplantation remains quite limited. This review aims to describe the current literature relating to infectious complications of pancreatic islet transplantation, including the role of microbiologically contaminated islet preparations in disease pathogenesis, our current understanding of the epidemiology and outcomes of cytomegalovirus and other infectious complications of pancreatic islet transplantation, and infectious concerns related to the use of porcine pancreatic islet cell xenografts. This review also highlights unanswered clinical questions and suggests areas of future research to mitigate infectious complications in recipients of islet transplantation.
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Affiliation(s)
- Stephanie M Pouch
- Transplant Infectious Diseases Service, Division of Infectious Diseases, Ohio State University Wexner Medical Center, 410 W. 10th Avenue, N1123 Doan Hall, Columbus, OH, 43210, USA,
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12
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Colling KP, Blondet JJ, Balamurugan AN, Wilhelm JJ, Dunn T, Pruett TL, Sutherland DER, Chinnakotla S, Bellin M, Beilman GJ. Positive sterility cultures of transplant solutions during pancreatic islet autotransplantation are associated infrequently with clinical infection. Surg Infect (Larchmt) 2015; 16:115-23. [PMID: 25668050 DOI: 10.1089/sur.2013.224] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic pancreatitis is a painful and often debilitating disease. Total pancreatectomy with intra-portal islet autotransplantation (TP-IAT) is a treatment option that allows for pain relief and preservation of beta-cell mass, thereby minimizing the complication of diabetes mellitus. Cultures of harvested islets are often positive for bacteria, possibly due to frequent procedures prior to TP-IAT, such as endoscopic retrograde cholangiopancreatography (ERCP), stenting, or other operative drainage procedures. It is unclear if these positive cultures contribute to post-operative infections. HYPOTHESIS We hypothesized that positive cultures of transplant solutions will not be associated with increased infection risk. METHODS We reviewed retrospectively the sterility cultures from both the pancreas preservation solution used to transport the pancreas and the final islet preparation for intra-portal infusion of patients who underwent TP-IAT between April 2006 and November 2012. Two hundred fifty-one patients underwent total, near-total, or completion pancreatectomy with IAT and had complete sterility cultures. All patients received prophylactic peri-operative antibiotics. Patients with positive pancreas preservation solution or islet sterility cultures received further antibiotics for 5-7 d. Patients' medical records were reviewed for post-operative infections and causative organisms. RESULTS Of the 251 patients included, 151 (61%) had one or more positive bacterial cultures from the pancreas preservation solution or final islet product. Seventy-three of the 251 patients (29%) had an infectious complication. Thirty-four of the 73 (22%) patients with a post-operative infectious complication also had positive cultures. Only seven of 151 patients with positive cultures (4.7%) had an infectious complication caused by the same organism as that isolated from their pancreas or islet cell preparation. CONCLUSIONS In autologous islet preparations, isolation solutions frequently have positive cultures, but this finding is associated infrequently with clinical infection.
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Affiliation(s)
- Kristin P Colling
- 1 Department of Surgery, University of Minnesota , Minneapolis, Minnesota
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Johnson CN, Morgan KA, Owczarski SM, Wang H, Fried J, Adams DB. Autotransplantation of culture-positive islet product: is dirty always bad? HPB (Oxford) 2014; 16:665-9. [PMID: 24308511 PMCID: PMC4105905 DOI: 10.1111/hpb.12198] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 10/15/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND In selected patients, total pancreatectomy with islet autotransplantation (TPIAT) effectively relieves pain caused by chronic pancreatitis and ameliorates the brittle diabetes of the apancreatic state. Patients often undergo multiple endoscopic and surgical interventions prior to TPIAT, increasing the risk for pancreas colonization with enteric microorganisms. Little is known of the safety of transplanting islet cells with microbial contamination. METHODS A prospectively collected database of 80 patients submitted to TPIAT at the Medical University of South Carolina from March 2009 to February 2012 was retrospectively reviewed. Patient charts were reviewed for postoperative infectious complications and organisms identified were compared with those identified in pre-transplant islet cultures. RESULTS A total of 35 patients (43.8%) had a positive pre-transplant islet cell Gram stain or islet cell culture from the final islet preparation solution. Of these 35 patients, 33 (94.3%) were given antibiotics prophylactically post-transplant for a positive islet Gram stain or culture. Twenty patients (57.1%) receiving Gram stain- or culture-positive islets developed postoperative infectious complications, but only four patients (11.4%) developed infections that concorded with their pre-transplant islet product. CONCLUSIONS Islet transplant solutions are frequently culture-positive, presumably as a result of prior pancreas intervention. Microbial contamination of islet preparations should not preclude autotransplantation.
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Affiliation(s)
- Crystal N Johnson
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
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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.
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Maruyama M, Kenmochi T, Akutsu N, Otsuki K, Ito T, Matsumoto I, Asano T. A Review of Autologous Islet Transplantation. CELL MEDICINE 2013; 5:59-62. [PMID: 26858866 DOI: 10.3727/215517913x666558] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autologous islet transplantation after total or semitotal pancreatectomy aims to preserve insulin secretory function and prevent the onset of diabetes. The major indication for pancreatectomy is chronic pancreatitis with severe abdominal pain, a benign pancreatic tumor, and trauma. The metabolic outcome of autologous islet transplantation is better than that of allogeneic transplantation and depends on the number of transplanted islets. Achieving islet isolation from a fibrous or damaged pancreas is one of the biggest challenges of autologous islet transplantation; a major complication is portal vein thrombosis after crude islet infusion. However, the incidence of portal vein thrombosis has decreased as islet preparation techniques have improved over time.
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Affiliation(s)
- Michihiro Maruyama
- Department of Surgery, NHO Chiba-East National Hospital , Chiba City, Chiba , Japan
| | - Takashi Kenmochi
- Department of Surgery, NHO Chiba-East National Hospital , Chiba City, Chiba , Japan
| | - Naotake Akutsu
- Department of Surgery, NHO Chiba-East National Hospital , Chiba City, Chiba , Japan
| | - Kazunori Otsuki
- Department of Surgery, NHO Chiba-East National Hospital , Chiba City, Chiba , Japan
| | - Taihei Ito
- Department of Surgery, NHO Chiba-East National Hospital , Chiba City, Chiba , Japan
| | - Ikuko Matsumoto
- Department of Surgery, NHO Chiba-East National Hospital , Chiba City, Chiba , Japan
| | - Takehide Asano
- Department of Surgery, NHO Chiba-East National Hospital , Chiba City, Chiba , Japan
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Isolation of human islets for autologous islet transplantation in children and adolescents with chronic pancreatitis. J Transplant 2012; 2012:642787. [PMID: 22461976 PMCID: PMC3306977 DOI: 10.1155/2012/642787] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 10/11/2011] [Indexed: 01/29/2023] Open
Abstract
Chronic pancreatitis is an inflammatory disease of the pancreas that causes permanent changes in the function and structure of the pancreas. It is most commonly a complication of cystic fibrosis or due to a genetic predisposition. Chronic pancreatitis generally presents symptomatically as recurrent abdominal pain, which becomes persistent over time. The pain eventually becomes disabling. Once specific medical treatments and endoscopic interventions are no longer efficacious, total pancreatectomy is the alternative of choice for helping the patient achieve pain control. While daily administrations of digestive enzymes cannot be avoided, insulin-dependent diabetes can be prevented by transplanting the isolated pancreatic islets back to the patient. The greater the number of islets infused, the greater the chance to prevent or at least control the effects of surgical diabetes. We present here a technical approach for the isolation and preservation of the islets proven to be efficient to obtain high numbers of islets, favoring the successful treatment of young patients.
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Abstract
Autologous islet transplantation (AIT) is performed to prevent surgical diabetes after total or semi-total pancreatectomy for the treatment of chronic pancreatitis with severe abdominal pain. In addition, AIT is used in cases of benign pancreatic tumors and pancreatic trauma. It has been shown that AIT results in better outcomes in terms of glycemic control compared with allogeneic islet transplantation. The reasons for the favorable outcomes of AIT are thought to be: (i) patients have no autoimmune diseases; (ii) the transplanted islets do not suffer allogeneic rejection; (iii) diabetogenic antirejection drugs are not required; (iv) pancreata do not undergo a cytokine storm as a result of periods of brain death; (v) the period of cold preservation of retrieved pancreata is short; (vi) the isolated islets are immediately transplanted without culture; and (vii) pancreata with pancreatitis may contain more progenitor cells. Further research into AIT would help improve the results of allogeneic islet transplantation. Conversely, the technical difficulties associated with islet isolation appear to be the largest hurdle for AIT; therefore, remote center islet isolation may prove to be key in the promotion of this treatment.
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Affiliation(s)
- Shinichi Matsumoto
- Baylor All Saints Islet Cell Laboratory, Baylor Research Institute Fort Worth Campus, Fort Worth, Texas 76104, USA.
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Lehec SC, Hughes RD, Mitry RR, Graver MA, Verma A, Wade JJ, Dhawan A. Experience of Microbiological Screening of Human Hepatocytes for Clinical Transplantation. Cell Transplant 2009; 18:941-7. [DOI: 10.3727/096368909x471323] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Hepatocyte transplantation is being used in patients with liver-based metabolic disorders and acute liver failure. Hepatocytes are isolated from unused donor liver tissue under GMP conditions. Cells must be free of microbiological contamination to be safe for human use. The experience of microbiological screening during 72 hepatocyte isolation procedures at one center is reported. Samples were taken at different stages of the process and tested using a blood culture bottle system and Gram stain. Bacterial contamination was detected in 37.5% of the UW organ preservative solutions used to transport the liver tissue to the Cell Isolation Unit. After tissue processing the contamination was reduced to 7% overall in the final hepatocyte product, irrespective of the presence of initial contamination of the transport solution. The most common organisms recovered were coagulase-negative staphylococci, a skin commensal. A total of 41 preparations of fresh or cryopreserved hepatocytes were used for cell transplantation in children with liver-based metabolic disorders without any evidence of sepsis due to infusion of hepatocytes. In conclusion, the incidence of bacterial contamination of the final product was low, confirming the suitability of the organs used, hepatocyte isolation procedure, and the environmental conditions of the clean room.
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Affiliation(s)
- Sharon C. Lehec
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, London, UK
| | - Robin D. Hughes
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, London, UK
| | - Ragai R. Mitry
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, London, UK
| | - Michelle A. Graver
- Health Protection Agency London Region Laboratory, King's College Hospital, London, UK
| | - Anita Verma
- Health Protection Agency London Region Laboratory, King's College Hospital, London, UK
| | - Jim J. Wade
- Health Protection Agency London Region Laboratory, King's College Hospital, London, UK
| | - Anil Dhawan
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, London, UK
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