Pancreatectomy and autologous islet transplantation for painful chronic pancreatitis: indications and outcomes

Factors associated with favourable 5 year outcomes in islet transplant alone recipients with type 1 diabetes complicated by severe hypoglycaemia in the Collaborative Islet Transplant Registry

AIMS/HYPOTHESIS

Islet transplantation has been studied in small cohorts of recipients with type 1 diabetes complicated by severe hypoglycaemic events (SHEs). We determined factors associated with favourable outcomes in a large cohort of recipients reported to the Collaborative Islet Transplant Registry (CITR).

METHODS

In 398 non-uraemic islet transplant alone (ITA) recipients with type 1 diabetes and SHEs, transplanted between 1999 and 2015 and with at least 1 year follow-up, we analysed specified favourable outcomes against each of all available characteristics of pancreas donors, islet grafts, recipients and immunosuppressive regimens, as well as immunosuppression and procedure-related serious adverse events (SAEs).

RESULTS

Four factors were associated with the highest rates of favourable outcomes: recipient age ≥35 years; total infused islets ≥325,000 islet equivalents; induction immunosuppression with T cell depletion and/or TNF-α inhibition; and maintenance with both mechanistic target of rapamycin (mTOR) and calcineurin inhibitors. At 5 years after the last islet infusion, of the recipients meeting these four common favourable factors (4CFF; N=126), 95% were free of SHEs, 76% had HbA_1c <53 mmol/mol (7.0%), 73% had HbA_1c <53 mmol/mol (7.0%) and absence of SHEs, and 53% were insulin independent, significantly higher rates than in the remaining recipients (<4CFF; N=272). The incidence of procedural and immunosuppression-related SAEs per recipient that resulted in sequelae, disability or death was low in both the 4CFF (0.056 per person) and <4CFF (0.074 per person) groups.

CONCLUSIONS/INTERPRETATION

In recipients with type 1 diabetes complicated by SHEs, islet transplantation meeting 4CFF protected 95% from SHEs at 5 years after the last islet infusion and exerted a large and significant benefit on glycaemic control, with an acceptable safety profile for this subgroup of type 1 diabetes.

The role of total pancreatectomy with islet autotransplantation in the treatment of chronic pancreatitis: A report from the International Consensus Guidelines in chronic pancreatitis

BACKGROUND

Advances in our understanding of total pancreatectomy with islet autotransplantation (TPIAT) have been made. We aimed to define indications and outcomes of TPIAT.

METHODS

Expert physician-scientists from North America, Asia, and Europe reviewed the literature to address six questions selected by the writing group as high priority topics. A consensus was reached by voting on statements generated from the review.

RESULTS

Consensus statements were voted upon with strong agreement reached that (Q1) TPIAT may improve quality of life, reduce pain and opioid use, and potentially reduce medical utilization; that (Q3) TPIAT offers glycemic benefit over TP alone; that (Q4) the main indication for TPIAT is disabling pain, in the absence of certain medical and psychological contraindications; and that (Q6) islet mass transplanted and other disease features may impact diabetes mellitus outcomes. Conditional agreement was reached that (Q2) the role of TPIAT for all forms of CP is not yet identified and that head-to-head comparative studies are lacking, and that (Q5) early surgery is likely to improve outcomes as compared to late surgery.

CONCLUSIONS

Agreement on TPIAT indications and outcomes has been reached through this working group. Further studies are needed to answer the long-term outcomes and maximize efforts to optimize patient selection.

Islet Harvest in Carbon Monoxide-Saturated Medium for Chronic Pancreatitis Patients Undergoing Islet Autotransplantation

Stresses encountered during human islet isolation lead to unavoidable β-cell death after transplantation. This reduces the chance of insulin independence in chronic pancreatitis patients undergoing total pancreatectomy and islet autotransplantation. We tested whether harvesting islets in carbon monoxide-saturated solutions is safe and can enhance islet survival and insulin independence after total pancreatectomy and islet autotransplantation. Chronic pancreatitis patients who consented to the study were randomized into carbon monoxide (islets harvested in a carbon monoxide-saturated medium) or control (islets harvested in a normal medium) groups. Islet yield, viability, oxygen consumption rate, β-cell death (measured by unmethylated insulin DNA), and serum cytokine levels were measured during the peri-transplantation period. Adverse events, metabolic phenotypes, and islet function were measured prior and at 6 months post-transplantation. No adverse events directly related to the infusion of carbon monoxide islets were observed. Carbon monoxide islets showed significantly higher viability before transplantation. Subjects receiving carbon monoxide islets had less β-cell death, decreased CCL23, and increased CXCL12 levels at 1 or 3 days post transplantation compared with controls. Three in 10 (30%) of the carbon monoxide subjects and none of the control subjects were insulin independent. This pilot trial showed for the first time that harvesting human islets in carbon monoxide-saturated solutions is safe for total pancreatectomy and islet autotransplantation patients.

Diagnosis and treatment in chronic pancreatitis: an international survey and case vignette study

BACKGROUND

The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research.

METHODS

An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG.

RESULTS

A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Büchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment.

CONCLUSION

Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged.

Vasculogenic hydrogel enhances islet survival, engraftment, and function in leading extrahepatic sites

Islet transplantation is a promising alternative therapy for insulin-dependent patients, with the potential to eliminate life-threatening hypoglycemic episodes and secondary complications of long-term diabetes. However, widespread application of this therapy has been limited by inadequate graft function and longevity, in part due to the loss of up to 60% of the graft in the hostile intrahepatic transplant site. We report a proteolytically degradable synthetic hydrogel, functionalized with vasculogenic factors for localized delivery, engineered to deliver islet grafts to extrahepatic transplant sites via in situ gelation under physiological conditions. Hydrogels induced differences in vascularization and innate immune responses among subcutaneous, small bowel mesentery, and epididymal fat pad transplant sites with improved vascularization and reduced inflammation at the epididymal fat pad site. This biomaterial-based strategy improved the survival, engraftment, and function of a single pancreatic donor islet mass graft compared to the current clinical intraportal delivery technique. This biomaterial strategy has the potential to improve clinical outcomes in islet autotransplantation after pancreatectomy and reduce the burden on donor organ availability by maximizing graft survival in clinical islet transplantation for type 1 diabetes patients.

Paediatric pancreatitis

PURPOSE OF REVIEW

The purpose of this review is to describe recent developments in paediatric pancreatitis and to discuss causes and current management.

RECENT FINDINGS

Although recent studies have estimated the annual incidence of paediatric acute pancreatitis approaching that of adults, there are no established guidelines about its diagnosis and treatment in children. Genetic and structural/congenital abnormalities are emerging as the primary risk factors for paediatric acute recurrent and chronic pancreatitis. Specifically, chronic pancreatitis is associated with a significant socioeconomic burden in children. Both medical and surgical therapies are proposed for paediatric chronic pancreatitis, but there is little evidence that they are beneficial.

SUMMARY

Acute recurrent and chronic pancreatitis create significant health issues in the paediatric population. Medical and surgical therapies exist to potentially treat these conditions, but the paediatric data are limited and the cohorts are small. A multidisciplinary and multicentre approach is necessary to better determine pancreatic disease processes and treatment options in children.

Metabolic assessment prior to total pancreatectomy and islet autotransplant: utility, limitations and potential

Islet autotransplant (IAT) may ameliorate postsurgical diabetes following total pancreatectomy (TP), but outcomes are dependent upon islet mass, which is unknown prior to pancreatectomy. We evaluated whether preoperative metabolic testing could predict islet isolation outcomes and thus improve assessment of TPIAT candidates. We examined the relationship between measures from frequent sample IV glucose tolerance tests (FSIVGTT) and mixed meal tolerance tests (MMTT) and islet mass in 60 adult patients, with multivariate logistic regression modeling to identify predictors of islet mass ≥2500 IEQ/kg. The acute C-peptide response to glucose (ACRglu) and disposition index from FSIVGTT correlated modestly with the islet equivalents per kilogram body weight (IEQ/kg). Fasting and MMTT glucose levels and HbA1c correlated inversely with IEQ/kg (r values -0.33 to -0.40, p ≤ 0.05). In multivariate logistic regression modeling, normal fasting glucose (<100 mg/dL) and stimulated C-peptide on MMTT ≥4 ng/mL were associated with greater odds of receiving an islet mass ≥2500 IEQ/kg (OR 0.93 for fasting glucose, CI 0.87-1.0; OR 7.9 for C-peptide, CI 1.75-35.6). In conclusion, parameters obtained from FSIVGTT correlate modestly with islet isolation outcomes. Stimulated C-peptide ≥4 ng/mL on MMTT conveyed eight times the odds of receiving ≥2500 IEQ/kg, a threshold associated with reasonable metabolic control postoperatively.

Chronic pancreatitis

PURPOSE OF REVIEW

We review selected important clinical observations reported in 2012.

RECENT FINDINGS

Celiac disease is a risk factor for pancreatitis. Patients with recurrent acute pancreatitis likely have chronic pancreatitis, do not benefit from pancreatic sphincterotomy, and may not benefit from biliary sphincterotomy. Analysis of endoscopic ultrasonography (EUS) images with an artificial neural network (ANN) program may improve chronic pancreatitis diagnosis compared with clinical interpretation of images. In a multicenter, randomized controlled trial of chronic pancreatitis patients, 90 000 USP U of pancreatin with meals decreased fat malabsorption compared with placebo. Detection of visceral pain in chronic pancreatitis predicts pain relief from various treatments, but nonvisceral pain due to altered central pain processing may respond to agents such as pregabalin. Predictors of surgical pain relief include onset of symptoms less than 3 years and preoperatively no opioid use and less than five endoscopic procedures. Total pancreatectomy for presumed painful chronic pancreatitis remains controversial.

SUMMARY

Celiacs are at risk for pancreatitis. The diagnosis of chronic pancreatitis may be enhanced by ANN analysis of EUS imaging. Treatment of fat malabsorption requires 90,000 USP U of lipase with meals. Relief of pain from organ directed treatment of chronic pancreatitis may depend upon timing of interventions and whether pain is visceral or nonvisceral.

Increase in Postoperative Insulin Requirements Does Not Lead to Decreased Quality of Life after Total Pancreatectomy with Islet Cell Autotransplantation for Chronic Pancreatitis

Previous studies have shown that total pancreatectomy with islet cell autotransplantation improves quality of life in chronic pancreatitis. A significant number of these patients develop postoperative hyperglycemia and daily insulin requirements or increase in daily insulin requirements. Our study investigates whether increased insulin requirements postoperatively have a negative impact on quality of life. A prospectively collected database of 74 patients undergoing extensive pancreatectomy with islet autotransplantation for pancreatitis was reviewed. Data pertaining to daily requirements and quality of life (QOL), as measured by the SF-12 questionnaire, in the preoperative and postoperative period were reviewed. Approval from the Institutional Review Board for the evaluation of human subjects was obtained. Seventy-four patients underwent extensive pancreatectomy with islet autotransplantation for pancreatitis. The majority of these patients required new daily insulin or an increase in daily insulin requirements post-operatively. Mean preoperative HA1c in this group was 5.6 with an increase to 7.3 at 6 months postoperatively ( P < 0.001), a mean of 8.1 at 12 months, and 8.9 at 2 years. Mean preoperative daily insulin requirements for this group were five units/day with average increase to 19 units/day at 6 months, 21 units/day at 12 months, and 26 units/day at 2 years. Preoperative QOL scores were a mean of 26 for the physical component and 36 for the mental health component. Postoperatively, physical component scores averaged 33 at 6 months (p < 0.001), 36 at 12 months, and 36 at 2 years; the mental health component scores averaged 42 at 6 months (p = 0.007), 41 at 12 months, and 41 at 2 years. There is no correlation between physical component score or mental component score QOL scores and daily insulin requirements ( r = -0.016 and r = 0.039, respectively). Total pancreatectomy with islet cell autotransplantation is an effective surgery for end-stage chronic pancreatitis. Quality of life significantly improves in physical and mental health components regardless of a postoperative increase in daily insulin requirements.

Endoscopic management of benign bile duct strictures

The use of endoscopic retrograde cholangiopancreatography for treating benign biliary strictures has become the standard of practice, with surgery and percutaneous therapy reserved for selected patients. The gold-standard endoscopic therapy is dilation of the stricture followed by placing and exchanging progressively larger and more numerable plastic stents over a 1-year period. Newer modalities, including the use of fully covered metal stents, are currently under investigation in an effort to improve the treatment of benign biliary strictures.