Islet autotransplantation combined with total pancreatectomy for treatment of pancreatic adenocarcinoma

Total pancreatectomy sequelae and quality of life: results of islet autotransplantation as a possible mitigation strategy

Total pancreatectomy (TP) is a procedure weighed down not only by postoperative morbidity and mortality but also by long-term effects as a consequence of endocrine and exocrine pancreatic insufficiency. While the latter is now managed quite effectively with pancreatic enzyme replacement therapy, the former remains a challenge. The diabetes resulting after TP, with the complete loss of endogenous insulin and contraregulatory hormones, is characterized by important glycemic variations and is, therefore, frequently referred to as "brittle diabetes". One method to reduce the impact of brittle diabetes in patients undergoing TP is the re-infusion of autologous pancreatic islets isolated from the resected pancreas. Indications to islet autotransplantation (IAT), originally described for patients undergoing TP for chronic pancreatitis, have since been extended to selected patients with other benign and malignant diseases of pancreas. This review recaps on the literature regarding long-term postoperative complications, their impact on quality of life after TP and the role of IAT.

Total Pancreatectomy with Autologous Islet Cell Transplantation-The Current Indications

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.

Autologous Islet Transplantation in Patients Requiring Pancreatectomy: A Broader Spectrum of Indications Beyond Chronic Pancreatitis

Islet autotransplantation (IAT) is usually performed in patients undergoing pancreatic surgery for chronic pancreatitis. In the present series, IAT was offered also to patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, having either completion pancreatectomy as treatment for severe pancreatic fistulas (n = 21) or extensive distal pancreatectomy for neoplasms of the pancreatic neck (n = 19) or pancreatoduodenectomy because of the high risk of pancreatic fistula (n = 32). Fifty-eight of 72 patients who were eligible to this broader spectrum of indication actually received IAT. There was no evidence of a higher-than-expected rate of major complications for pancreatectomy. Forty-five patients receiving IAT were still alive at the time of the last scheduled follow-up (1375 ± 365 days). Eighteen (95%) of 19 and 11 (28%) of 39 patients reached insulin independence after partial or total pancreatectomy, respectively. The metabolic results were dependent on the transplanted islet mass. Thirty-one of 58 patients had malignant diseases of the pancreas or periampullary region, and only three patients developed ex novo liver metastases after IAT (median follow-up 914 ± 382 days). Our data demonstrate the feasibility, efficacy, and safety of IAT for a broader spectrum of clinical indications beyond chronic pancreatitis.

Autologous islet transplantation in patients requiring pancreatectomy for neoplasm

Autologous islet cell transplantation is a procedure performed to prevent or reduce the severity of diabetes after pancreatic resection. Autologous islet cell transplantation is being used almost exclusively in patients undergoing pancreatectomy because of painful, chronic pancreatitis, or multiple recurrent episodes of pancreatitis that is not controlled by standard medical and surgical treatments. Here, we discuss the possibility of extending the clinical indications for this treatment on the basis of our experience in patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, including patients undergoing completion pancreatectomy because of anastomosis leakage after pancreaticoduodenectomy and those with pancreatic anastomosis deemed at high risk for failure.

A new surgical technique of pancreaticoduodenectomy with splenic artery resection for ductal adenocarcinoma of the pancreatic head and/or body invading splenic artery: impact of the balance between surgical radicality and QOL to avoid total pancreatectomy

For pancreatic ductal adenocarcinoma (PDAC) of the head and/or body invading the splenic artery (SA), we developed a new surgical technique of proximal subtotal pancreatectomy with splenic artery and vein resection, so-called pancreaticoduodenectomy with splenic artery resection (PD-SAR). We retrospectively reviewed a total of 84 patients with curative intent pancreaticoduodenectomy (PD) for PDAC of the head and/or body. These 84 patients were classified into the two groups: conventional PD (n = 66) and PD-SAR (n = 18). Most patients were treated by preoperative chemoradiotherapy (CRT). Postoperative MDCT clearly demonstrated enhancement of the remnant pancreas at 1 and 6 months in all patients examined. Overall survival rates were very similar between PD and PD-SAR (3-year OS: 23.7% versus 23.1%, P = 0.538), despite the fact that the tumor size and the percentages of UICC-T4 determined before treatment were higher in PD-SAR. Total daily insulin dose was significantly higher in PD-SAR than in PD at 1 month, while showing no significant differences between the two groups thereafter. PD-SAR with preoperative CRT seems to be promising surgical strategy for PDAC of head and/or body with invasion of the splenic artery, in regard to the balance between operative radicality and postoperative QOL.

The favorable outcome of human islet transplantation in Korea: experiences of 10 autologous transplantations

BACKGROUND

Cystic neoplasms of the pancreas are an increasingly diagnosed entity, and surgical resection of the pancreas is advocated. Islet autotransplantation is a therapeutic approach used to prevent diabetes in cases of pathologically benign neoplasm after major pancreatectomy.

METHODS

A total of 10 patients underwent pancreatectomy with islet autotransplantation. To evaluate islet transplantation efficiency, the authors compared 23 subjects who did not undergo islet transplantation after partial pancreatectomy with 87 subjects with normal glucose tolerance and with 77 diabetic subjects that did not undergo pancreatectomy.

RESULTS

Ten female patients with nine cystic neoplasms and one patient with pancreatic injury underwent transplantation. Their mean islet equivalents (IEQ) was 3,159 IEQ/kg. During follow-up, two recipients required insulin or oral agents. At the 12-month follow-up, homeostasis model assessment (HOMA)-beta was 77.36+/-17.68, the insulinogenic index (INSindex) was 0.49+/-0.11, and fasting C-peptide and hemoglobin A1c were 1.28+/-0.18 ng/mL and 5.73+/-0.26%, respectively. Islet replacement was found to increase HOMA-beta by approximately 17% compared with distal pancreatectomy in normal glucose tolerance subjects without islet autotransplantation and by 46% compared with distal pancreatectomy diabetes subjects without islet autotransplantation. Factors different in the two insulin and oral hypoglycemic agent (OHA)-requiring recipients and the eight insulin- and OHA-free recipients were pancreatectomy extent, preoperative glucose metabolism insufficiency, age, and underlying cystic neoplasm disease.

CONCLUSIONS

Even partial islet graft function can have a beneficial metabolic effect on the recipient in terms of metabolic parameters such as HOMA-beta and INSindex. This study suggests that islet replacement should be considered for experimental procedures in benign pancreatic conditions.

Islet autotransplantation combined with pancreatectomy for treatment of pancreatic adenocarcinoma: a case report

Extensive pancreatectomy (EP) may increase the resection rate of pancreatic adenocarcinoma (PA). Unfortunately, EP often results in unstable diabetes. Recently, islet autotransplantation (auto-Tx) has offered the potential to prevent this metabolic disorder. Because of the fear of contamination of prepared islets by malignant cells, this procedure has so far not been used as a treatment for PA. We herein report a case of a 63-year-old nondiabetic patient who underwent EP combined with islet auto-Tx in an emergency operation following histologically proved R(0)-resection for PA (pT(3)pN(1)G(2)). Islets were isolated from the excised pancreas using a continuous digestion filtration device. The resultant preparation was injected into the portal vein. Owing to the moderate fasting hyperglycemia, postoperative exogenous insulin therapy was necessary (26 U/d). After discharge, the patient's daily insulin dose was gradually reduced. At 1-year follow-up the fasting C-peptide level was 0.66 ng/mL, and an oral glucose tolerance test (oGTT) and an intravenous (IV) glucagon stimulation (GS) showed functioning engrafted islets. The K-ras mutations were detected in the paraffin-embedded PA, but not in the prepared islets or in the peripheral blood. Computed tomographic (CT) imaging revealed neither local tumor recurrence nor liver metastases. At 2-year follow-up, the patient was on a balanced food regimen and gaining weight. Although he remains insulin-dependent (16 U/d), he is metabolically stable (HbA(1)(c) 5.9%). The fasting C-peptide level is 0.68 ng/mL. The peak value of C-peptide in response to oGTT was 0.92 ng/mL and to GS 0.89 ng/mL. At this time Ca19-9 and CEA are increased to 35.3 U/mL and 19.2 ng/mL, respectively. The patient died 2.5 years after operation owing to tumor recurrence. There was no evidence for liver metastases. We postulate that histologic evaluation (R(0)-resection) and detection of K-ras mutations may be useful techniques. However, islet auto-Tx after EP for adenocarcinoma should only be regarded for rescue therapy. Studies on strategies to exclude possible contamination of islet tissue with carcinoma cells are critically important.