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Darden CM, Mohammed ARH, Kirkland J, Kuncha J, Lawrence MC, Danobeitia JS, Beecherl E, Lee SHS, Gupta A, Naziruddin B. Total pancreatectomy with islet autotransplantation outcomes in patients with pancreatitis of genetic etiology: A single-center experience with a large cohort of patients. J Gastrointest Surg 2024:S1091-255X(24)00481-5. [PMID: 38834105 DOI: 10.1016/j.gassur.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/15/2024] [Accepted: 05/27/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE Total pancreatectomy with islet autotransplantation (TPIAT) is an effective treatment for patients with chronic pancreatitis (CP) when other interventions are unsuccessful. CP has many etiologies including heredity. Metabolic and pain relief outcomes after TPIAT are presented among patients with a genetic CP etiology compared with those with a nongenetic etiology in a large cohort of patients who underwent this procedure at our center. METHODS A retrospective analysis was performed of 237 patients undergoing TPIAT between 2006 and 2023. We analyzed the differences in patients with genetic (n = 56) vs nongenetic CP etiologies (n = 181) in terms of pre-TPIAT factors including patient characteristics and disease state, results from the isolation process, and outcomes such as long-term glycemic and pain control. RESULTS Patients with genetic CP underwent TPIAT at a significantly younger age (32.3 vs 41.3 years nongenetic; P < .0001) and endured symptoms for a significantly longer period (10 vs 6 years; P < .01). A significantly lower mass of islets was isolated from patients with genetic CP (P < .01), which increased with body mass index in both groups. Despite lower yields, patients with genetic CP maintained metabolic function similar to patients with nongenetic CP, as indicated by insulin independence and C-peptide, blood glucose, and hemoglobin A1C levels after TPIAT. Post-transplant narcotic usage and pain scores significantly decreased compared with those before TPIAT, and more patients with genetic CP were pain free and narcotic free after TPIAT. CONCLUSION Our data validate TPIAT as a beneficial procedure for patients enduring CP of genetic etiology. Pain that is inevitably recurrent after minor interventions owing to the nature of the disease and favorable TPIAT outcomes should be considered in the decision to perform early TPIAT in cases of genetic CP.
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Affiliation(s)
- Carly M Darden
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | | | - Jeffrey Kirkland
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Jayachandra Kuncha
- Islet Cell Laboratory, Baylor Scott & White Research Institute, Dallas, TX, United States
| | - Michael C Lawrence
- Islet Cell Laboratory, Baylor Scott & White Research Institute, Dallas, TX, United States
| | - J Sebastian Danobeitia
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Ernest Beecherl
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Seung Hee S Lee
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Amar Gupta
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Bashoo Naziruddin
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States.
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Gaglia JL, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Selvin E, Stanton RC, Gabbay RA. 2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S20-S42. [PMID: 38078589 PMCID: PMC10725812 DOI: 10.2337/dc24-s002] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Cusi K, Ekhlaspour L, Fleming TK, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Napoli N, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Verduzco-Gutierrez M, Younossi ZM, Gabbay RA. 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S52-S76. [PMID: 38078591 PMCID: PMC10725809 DOI: 10.2337/dc24-s004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Nanno Y, Hodges JS, Freeman ML, Trikudanathan G, Schwarzenberg SJ, Downs EM, Ramanathan K, Pruett TL, Beilman GJ, Chinnakotla S, Hering BJ, Bellin MD. Early Metabolic Measures Predict Long-term Insulin Independence in Recipients of Total Pancreatectomy and Islet Autotransplantation. Transplant Direct 2024; 10:e1561. [PMID: 38094130 PMCID: PMC10715795 DOI: 10.1097/txd.0000000000001561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 01/05/2024] Open
Abstract
Background Although diabetes after total pancreatectomy and islet autotransplantation (TP-IAT) is one of the biggest concerns for TP-IAT recipients and physicians, reliable prediction of post-TP-IAT glycemic control remains unestablished. This study was conducted to identify early predictors of insulin independence and goal glycemic control by hemoglobin A1c (HbA1c) ≤ 6.5% after TP-IAT. Methods In this single-center, retrospective study, patients who underwent TP-IAT (n = 227) were reviewed for simple metabolic markers or surrogate indices of β-cell function obtained 3 mo after TP-IAT as part of standard clinical testing. Long-term metabolic success was defined as (1) insulin independence and (2) HbA1c ≤ 6.5% 1, 3, and 5 y after TP-IAT. Single- and multivariate modeling used 3-mo markers to predict successful outcomes. Results Of the 227 recipients, median age 31 y, 30% male, 1 y after TP-IAT insulin independence, and HbA1c ≤ 6.5% were present in 39.6% and 72.5%, respectively. In single-predictor analyses, most of the metabolic markers successfully discriminated between those attaining and not attaining metabolic goals. Using the best model selected by random forests analysis, we accurately predicted 1-y insulin independence and goal HbA1c control in 77.3% and 86.4% of the patients, respectively. A simpler "clinically feasible" model using only transplanted islet dose and BETA-2 score allowed easier prediction at a small accuracy loss (74.1% and 82.9%, respectively). Conclusions Metabolic testing measures performed 3 mo after TP-IAT were highly associated with later diabetes outcomes and provided a reliable prediction model, giving valuable prognostic insight early after TP-IAT and help to identify recipients who require early intervention.
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Affiliation(s)
- Yoshihide Nanno
- Department of Surgery, University of Minnesota, Minneapolis, MN
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - James S. Hodges
- Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | | | | | | | - Elissa M. Downs
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | | | | | | | - Srinath Chinnakotla
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Bernhard J. Hering
- Department of Surgery, University of Minnesota, Minneapolis, MN
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
| | - Melena D. Bellin
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
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Turner KM, Wahab SA, Delman AM, Brunner J, Smith MT, Choe KA, Patel SH, Ahmad SA, Wilson GC. Predicting endocrine function after total pancreatectomy and islet cell autotransplantation: A novel approach utilizing computed tomography texture analysis. Surgery 2023; 173:567-573. [PMID: 36241471 DOI: 10.1016/j.surg.2022.06.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/13/2022] [Accepted: 06/27/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Islet cell autotransplantation is an effective method to prevent morbidity associated with type IIIc diabetes after total pancreatectomy. However, there is no valid method to predict long-term endocrine function. Our aim was to assess computed tomography texture analysis as a strategy to predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation. METHODS All patients undergoing total pancreatectomy and islet cell autotransplantation from 2007 to 2020 who had high-quality preoperative computed tomography imaging available for texture analysis were included. The primary outcome was optimal long-term endocrine function, defined as stable glycemic control with <10 units of insulin/day. RESULTS Sixty-three patients met inclusion criteria. Median yield was 6,111 islet equivalent/kg body weight. At a median follow-up of 64.2 months, 12.7% (n = 8) of patients were insulin independent and 39.7% (n = 25) demonstrated optimal endocrine function. Neither total islet equivalent nor islet equivalent/kg body weight alone were associated with optimal endocrine function. To improve endocrine function prediction, computed tomography texture analysis parameters were analyzed, identifying an association between kurtosis (odds ratio, 2.32; 95% confidence interval, 1.08-4.80; P = .02) and optimal endocrine function. Sensitivity analysis discovered a cutoff for kurtosis = 0.60, with optimal endocrine function seen in 66.7% with kurtosis ≥0.60, compared with only 26.2% with kurtosis <0.60 (P < .01). On multivariate logistic regression including islet equivalent yield, only kurtosis ≥0.60 (odds ratio, 5.61; 95% confidence interval, 1.56-20.19; P = .01) and fewer small islet equivalent (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .02) were associated with optimal endocrine function, with the whole model demonstrating excellent prediction of long-term endocrine function (area under the curve, 0.775). CONCLUSION Computed tomography texture analysis can provide qualitative data, that when used in combination with quantitative islet equivalent yield, can accurately predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH. https://twitter.com/KevinTurnerMD
| | - Shaun A Wahab
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH. https://twitter.com/ShaunWahabMD
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - John Brunner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Milton T Smith
- Department of Internal Medicine, Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH. https://twitter.com/SyedAAhmad5
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH.
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S19-S40. [PMID: 36507649 PMCID: PMC9810477 DOI: 10.2337/dc23-s002] [Citation(s) in RCA: 585] [Impact Index Per Article: 585.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Total pancreatectomy and islet cell autotransplantation: a 10-year update on outcomes and assessment of long-term durability. HPB (Oxford) 2022; 24:2013-2021. [PMID: 35927127 DOI: 10.1016/j.hpb.2022.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/13/2022] [Accepted: 07/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Total pancreatectomy and islet cell autotransplantation (TPIAT) offers an effective, lasting solution for the management of chronic pancreatitis up to 5-years post-operatively. Our aim was to assess durability of TPIAT at 10-years. METHODS Patients undergoing TPIAT for chronic pancreatitis eligible for 10-year follow-up were included. Primary outcomes, including endocrine function and narcotic requirements, were reported at 5-, 7.5-, and 10-years post-operatively. RESULTS Of the 231 patients who underwent TPIAT, 142 met inclusion criteria. All patients underwent successful TPIAT with an average of 5680.3 islet equivalents per body weight. While insulin independence tended to decrease over time (25.7% vs. 16.0% vs. 10.9%, p = 0.11) with an increase in HbA1C (7.6% vs. 8.2% vs. 8.4%, p = 0.09), partial islet function persisted (64.9% vs. 68.0% vs. 67.4%, p = 0.93). Opioid independence was achieved and remained durable in the majority (73.3% vs. 72.2% vs. 75.5%, p = 0.93). Quality of life improvements persisted, with 85% reporting improvement from baseline at 10-years. Estimated median overall survival was 202.7 months. CONCLUSION This study represents one of the largest series reporting on long-term outcomes after TPIAT, demonstrating excellent long-term pain control and durable improvements in quality of life. Islet cell function declines over time however stable glycemic control is maintained.
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4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2022. Diabetes Care 2022; 45:S46-S59. [PMID: 34964869 PMCID: PMC8935396 DOI: 10.2337/dc22-s004] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Boucher AA, Wastvedt S, Hodges JS, Beilman GJ, Kirchner VA, Pruett TL, Hering BJ, Schwarzenberg SJ, Downs E, Freeman M, Trikudanathan G, Chinnakotla S, Bellin MD. Portal Vein Thrombosis May Be More Strongly Associated With Islet Infusion Than Extreme Thrombocytosis After Total Pancreatectomy With Islet Autotransplantation. Transplantation 2021; 105:2499-2506. [PMID: 33988346 DOI: 10.1097/tp.0000000000003624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Total pancreatectomy with islet autotransplantation (TPIAT) involves pancreatectomy, splenectomy, and reinjection of the patient's pancreatic islets into the portal vein. This process triggers a local inflammatory reaction and increase in portal pressure, threatening islet survival and potentially causing portal vein thrombosis. Recent research has highlighted a high frequency of extreme thrombocytosis (platelets ≥1000 × 109/L) after TPIAT, but its cause and association with thrombotic risk remain unclear. METHODS This retrospective single-site study of a contemporary cohort of 409 pediatric and adult patients analyzed the frequency of thrombocytosis, risk factors for thrombosis, and antiplatelet and anticoagulation strategies. RESULTS Of 409 patients, 67% developed extreme thrombocytosis, peaking around postoperative day 16. Extreme thrombocytosis was significantly associated with infused islet volumes. Thromboembolic events occurred in 12.2% of patients, with portal vein thromboses occurring significantly earlier than peripheral thromboses. Portal vein thromboses were associated with infused islet volumes and portal pressures but not platelet counts or other measures. Most thromboembolic events (82.7%) occurred before the postoperative day of maximum platelet count. Only 4 of 27 (14.8%) of portal vein thromboses occurred at platelet counts ≥500 × 109/L. Perioperative heparin was given to all patients. Treatment of reactive thrombocytosis using aspirin in adults and hydroxyurea in children was not associated with significantly decreased thromboembolic risk. CONCLUSIONS These results suggest that post-TPIAT thrombocytosis and portal vein thromboses may be linked to the islet infusion inflammation, not directly to each other, and further reducing this inflammation may reduce thrombosis and thrombocytosis frequencies simultaneously.
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Affiliation(s)
- Alexander A Boucher
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Solvejg Wastvedt
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN
| | - James S Hodges
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Varvara A Kirchner
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Timothy L Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Bernhard J Hering
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | | | - Elissa Downs
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Martin Freeman
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Guru Trikudanathan
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Srinath Chinnakotla
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Melena D Bellin
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
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Pain resolution and glucose control in pediatric patients with chronic pancreatitis after total pancreatectomy with islet auto-transplantation. Pediatr Surg Int 2021; 37:1383-1392. [PMID: 34245339 DOI: 10.1007/s00383-021-04956-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) in pediatric patients are strongly associated with genetic mutations and lead to pan-parenchymal disease refractory to medical and endoscopic treatment. Our aim was to assess pain resolution and glucose control in patients with CP and ARP following total pancreatectomy with islet auto-transplantation (TPIAT). METHODS We retrospectively analyzed prospectively collected clinical data of 12 children who developed CP and ARP and underwent TPIAT when 21 years old or younger at the University of Chicago between December 2009 and June 2020. Patients with recurrent or persistent abdominal pain attributed to acute or chronic pancreatic inflammation and a history of medical interventions attempted for the relief of pancreatic pain were selected by a multi-disciplinary team for TPIAT. We followed patients post-operatively and reported data for pre-TPIAT, post-operative day 75, and yearly post-TPIAT. RESULTS All 12 patients experienced complete resolution of pancreatic pain. The overall insulin-independence rate after 1 year was 66% (8/12) and 50% (3/6) at 4 years. Shorter duration of CP/ARP pre-TPIAT, higher mass of islets infused, and lower BMI, BMI percentile, and BSA were associated with insulin-independence post-TPIAT. CONCLUSIONS TPIAT is a viable treatment option for pediatric patients with CP and ARP. Pediatric patients undergoing TPIAT for CP achieved resolution of pancreatic-type pain and reduced opioid requirements. The majority were able to achieve insulin-independence which was associated with lower pre-TPIAT BMI and higher islet mass transplanted (i.e., over 2000 IEQ/kg), the latter of which can be achieved by earlier TPIAT. LEVEL OF EVIDENCE Treatment study, Level IV.
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12
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Parsons RF, Baquerizo A, Kirchner VA, Malek S, Desai CS, Schenk A, Finger EB, Brennan TV, Parekh KR, MacConmara M, Brayman K, Fair J, Wertheim JA. Challenges, highlights, and opportunities in cellular transplantation: A white paper of the current landscape. Am J Transplant 2021; 21:3225-3238. [PMID: 34212485 DOI: 10.1111/ajt.16740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 02/05/2023]
Abstract
Although cellular transplantation remains a relatively small field compared to solid organ transplantation, the prospects for advancement in basic science and clinical care remain bountiful. In this review, notable historical events and the current landscape of the field of cellular transplantation are reviewed with an emphasis on islets (allo- and xeno-), hepatocytes (including bioartificial liver), adoptive regulatory immunotherapy, and stem cells (SCs, specifically endogenous organ-specific and mesenchymal). Also, the nascent but rapidly evolving field of three-dimensional bioprinting is highlighted, including its major processing steps and latest achievements. To reach its full potential where cellular transplants are a more viable alternative than solid organ transplants, fundamental change in how the field is regulated and advanced is needed. Greater public and private investment in the development of cellular transplantation is required. Furthermore, consistent with the call of multiple national transplant societies for allo-islet transplants, the oversight of cellular transplants should mirror that of solid organ transplants and not be classified under the unsustainable, outdated model that requires licensing as a drug with the Food and Drug Administration. Cellular transplantation has the potential to bring profound benefit through progress in bioengineering and regenerative medicine, limiting immunosuppression-related toxicity, and providing markedly reduced surgical morbidity.
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Affiliation(s)
- Ronald F Parsons
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, Georgia
| | - Angeles Baquerizo
- Scripps Center for Cell and Organ Transplantation, La Jolla, California
| | - Varvara A Kirchner
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Sayeed Malek
- Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chirag S Desai
- Division of Transplantation, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Austin Schenk
- Division of Transplantation, Department of Surgery, Ohio State University, Columbus, Ohio
| | - Erik B Finger
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Todd V Brennan
- Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kalpaj R Parekh
- Division of Cardiothoracic Surgery, Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Malcolm MacConmara
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kenneth Brayman
- Division of Transplantation, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Jeffrey Fair
- Division of Transplant Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Jason A Wertheim
- Departments of Surgery and Biomedical Engineering, University of Arizona Health Sciences, Tucson, Arizona
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Landstra CP, Andres A, Chetboun M, Conte C, Kelly Y, Berney T, de Koning EJP, Piemonti L, Stock PG, Pattou F, Vantyghem MC, Bellin MD, Rickels MR. Examination of the Igls Criteria for Defining Functional Outcomes of β-cell Replacement Therapy: IPITA Symposium Report. J Clin Endocrinol Metab 2021; 106:3049-3059. [PMID: 34061967 PMCID: PMC8571711 DOI: 10.1210/clinem/dgab386] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT The Igls criteria were developed to provide a consensus definition for outcomes of β-cell replacement therapy in the treatment of diabetes during a January 2017 workshop sponsored by the International Pancreas & Islet Transplant Association (IPITA) and the European Pancreas & Islet Transplant Association. In July 2019, a symposium at the 17th IPITA World Congress was held to examine the Igls criteria after 2 years in clinical practice, including validation against continuous glucose monitoring (CGM)-derived glucose targets, and to propose future refinements that would allow for comparison of outcomes with artificial pancreas system approaches. EVIDENCE ACQUISITION Utilization of the criteria in various clinical and research settings was illustrated by population as well as individual outcome data of 4 islet and/or pancreas transplant centers. Validation against CGM metrics was conducted in 55 islet transplant recipients followed-up to 10 years from a fifth center. EVIDENCE SYNTHESIS The Igls criteria provided meaningful clinical assessment on an individual patient and treatment group level, allowing for comparison both within and between different β-cell replacement modalities. Important limitations include the need to account for changes in insulin requirements and C-peptide levels relative to baseline. In islet transplant recipients, CGM glucose time in range improved with each category of increasing β-cell graft function. CONCLUSIONS Future Igls 2.0 criteria should consider absolute rather than relative levels of insulin use and C-peptide as qualifiers with treatment success based on glucose assessment using CGM metrics on par with assessment of glycated hemoglobin and severe hypoglycemia events.
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Affiliation(s)
- Cyril P Landstra
- Division of Endocrinology & Division of Nephrology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Axel Andres
- Divison of Transplantation and Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Mikael Chetboun
- Department of General and Endocrine Surgery, Centre Hospitalier Universitaire de Lille, and Inserm, Translational Research for Diabetes, Université de Lille, Lille, France
| | - Caterina Conte
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, and Vita-Salute San Raffaele University, Milan, Italy
| | - Yvonne Kelly
- Division of Transplantation, Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Thierry Berney
- Divison of Transplantation and Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Eelco J P de Koning
- Division of Endocrinology & Division of Nephrology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, and Vita-Salute San Raffaele University, Milan, Italy
| | - Peter G Stock
- Division of Transplantation, Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - François Pattou
- Department of General and Endocrine Surgery, Centre Hospitalier Universitaire de Lille, and Inserm, Translational Research for Diabetes, Université de Lille, Lille, France
| | - Marie-Christine Vantyghem
- Department of Endocrinology, Diabetology and Metabolism, Centre Hospitalier Universitaire de Lille, and Inserm, Translational Research for Diabetes, Université de Lille, Lille, France
| | - Melena D Bellin
- Division of Endocrinology, Department of Pediatrics, and the Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN, USA
| | - Michael R Rickels
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, and Institute for Diabetes, Obesity & Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Correspondence: Michael R. Rickels, MD, MS, Institute for Diabetes, Obesity & Metabolism, University of Pennsylvania Perelman School of Medicine, 12-134 Smilow Center for Translational Research, 3400 Civic Center Boulevard, Philadelphia, PA, USA 19104-5160.
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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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15
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Lara LF, Wastvedt S, Hodges JS, Witkowski P, Wijkstrom M, Walsh RM, Singh VK, Schwarzenberg SJ, Pruett TL, Posselt A, Naziruddin B, Nathan JD, Morgan KA, Mitchell R, Kirchner VA, Mokshagundam SL, Hatipoglu B, Gardner TB, Freeman ML, Chinnakotla S, Beilman GJ, Abu-El-Haija M, Conwell DL, Bellin MD. The Association of Smoking and Alcohol Abuse on Anxiety and Depression in Patients With Recurrent Acute or Chronic Pancreatitis Undergoing Total Pancreatectomy and Islet Autotransplantation: A Report From the Prospective Observational Study of TPIAT Cohort. Pancreas 2021; 50:852-858. [PMID: 34347725 PMCID: PMC8373657 DOI: 10.1097/mpa.0000000000001850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Smoking and alcohol use are risk factors for acute and chronic pancreatitis, and their role on anxiety, depression, and opioid use in patients who undergo total pancreatectomy and islet autotransplantation (TPIAT) is unknown. METHODS We included adults enrolled in the Prospective Observational Study of TPIAT (POST). Measured variables included smoking (never, former, current) and alcohol abuse or dependency history (yes vs no). Using univariable and multivariable analyses, we investigated the association of smoking and alcohol dependency history with anxiety and depression, opioid use, and postsurgical outcomes. RESULTS Of 195 adults studied, 25 were current smokers and 77 former smokers, whereas 18 had a history of alcohol dependency (of whom 10 were current smokers). A diagnosis of anxiety was associated with current smoking (P = 0.005), and depression was associated with history of alcohol abuse/dependency (P = 0.0001). However, active symptoms of anxiety and depression at the time of TPIAT were not associated with smoking or alcohol status. Opioid use in the past 14 days was associated with being a former smoker (P = 0.005). CONCLUSIONS Active smoking and alcohol abuse history were associated with a diagnosis of anxiety and depression, respectively; however, at the time of TPIAT, symptom scores suggested that they were being addressed.
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Affiliation(s)
- Luis F. Lara
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, OH
| | - Solvejg Wastvedt
- School of Public Health, University of Minnesota Minneapolis, MN
| | - James S. Hodges
- School of Public Health, University of Minnesota Minneapolis, MN
| | | | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Vikesh K. Singh
- Department of Medicine, Division of Gastroenterology, John Hopkins Medical Institutions, Baltimore, MD
| | | | - Timothy L. Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Andrew Posselt
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Bashoo Naziruddin
- Department of Surgery, Islet Cell Processing Laboratory, Baylor Health, Dallas, TX
| | - Jaimie D. Nathan
- Division of Surgery, Cincinnati Children’s Hospital Medical Center
- Department of Surgery, University of Cincinnati, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Katherine A. Morgan
- Department of Surgery, Division of GI and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC
| | - Rebecca Mitchell
- School of Public Health, University of Minnesota Minneapolis, MN
| | - Varvara A. Kirchner
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | | | - Betul Hatipoglu
- Department of Medicine, Division of Clinical and Molecular Endocrinology, University Hospitals, Cleveland, OH
| | - Timothy B. Gardner
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Martin L. Freeman
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical School, Minneapolis, MN
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Maisam Abu-El-Haija
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital
| | - Darwin L. Conwell
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, OH
| | - Melena D. Bellin
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN
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16
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Robbins AJ, Lusczek E, Bellin MD, Alwan FS, Hodges JS, Chapman SA, Beilman GJ. Gastrointestinal Bleed After Total Pancreatectomy With Islet Autotransplant. Pancreas 2021; 50:841-846. [PMID: 34347732 PMCID: PMC8373743 DOI: 10.1097/mpa.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Gastrointestinal bleeding (GIB) is an uncommon complication after abdominal surgery. Given the unique risks in the total pancreatectomy with islet autotransplant (TPIAT) population, we aimed to describe this population's incidence of postoperative GIB. METHODS Prospectively collected data on patients who underwent a TPIAT from 2001 to 2018 at the University of Minnesota were reviewed for postoperative GIB. Each GIB patient was matched to a control patient and compared for medical, medication, and social history and for clinical outcomes. RESULTS Sixty-eight patients developed a GIB (12.4%) at median time after surgery of 17 months. Etiologies included the following: anastomotic ulcer (35%), Clostridium difficile (4%), gastric or duodenal ulcers (9%), esophagitis/gastritis (10%), hemorrhoids (3%), inflammatory bowel disease (4%), Mallory-Weiss tears (1%), and unknown (29%). During diagnostic workup, 87% had an endoscopic procedure and 3% underwent imaging. Seven patients required an operation (10%), 1 required an open embolization (1%), and 13 required endoscopic treatments (19%). Patients with a GIB were more likely to die (15% vs 5%, P = 0.055). CONCLUSIONS Twelve percent of patients developed a GIB after TPIAT. One third of those had an undefined etiology despite endoscopy. The need for intervention was high (30%).
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Affiliation(s)
| | | | | | | | - James S Hodges
- Division of Biostatistics, University of Minnesota School of Public Health
| | - Scott A Chapman
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN
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Yoshimatsu G, Kanak MA, Vasu S, Kumano K, Lawrence M, Onaca N, Takita M, Levy MF, Naziruddin B. Outcomes of Islet Autotransplantation in Chronic Pancreatitis Patients with Complete Acinar Atrophy. Cell Transplant 2021; 29:963689720949242. [PMID: 32878466 PMCID: PMC7784518 DOI: 10.1177/0963689720949242] [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] [Indexed: 11/16/2022] Open
Abstract
Total pancreatectomy with islet autotransplantation (TPIAT) is a promising treatment for refractory chronic pancreatitis (CP). Pathological features of CP include progressive fibrosis in pancreas parenchyma, atrophy, and/or ductal occlusion. Complete acinar atrophy (CAA) caused by chronic fibrosis and necroinflammation results in exocrine sufficiency and may influence islet isolation characteristics during TPIAT. In this analysis of patients who underwent TPIAT at our center, we compared transplant outcomes among those with CAA (n = 5) vs non-acinar atrophy (NAA; matching controls, n = 36). Data were analyzed using one-way analysis of variance with Bonferroni post hoc test or Student's t test. Pancreas digestion was longer in CAA than in NAA cases (18.6 vs 14.6 min) despite a lower pancreas weight (55.2 vs 91.2 g). Obtained tissue volume was 1.0 ml in the CAA group and 12.1 ml in the NAA group. Both groups had similar islet viability (96%) and islet dose (CAA, 3,391 IEQ/kg; NAA, 4141.1 IEQ/kg). During islet infusion, serum cytokine (IL-6, IL-8, and MCP-1) levels and plasma hsa-miR-375 levels were lower in the CAA group than in the NAA group, but not significantly. Serum tumor necrosis factor α levels at 3 h after infusion were significantly higher in CAA group than in NAA group. After TPIAT, the metabolic outcomes of the CAA group were comparable with that of the NAA group. Narcotics usage decreased significantly over 24 months in both groups, with the CAA group reporting being pain free at 12 months. Complete atrophy of acinar cells of pancreas did not significantly impact islet yield or endocrine function after TPIAT.
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Affiliation(s)
| | - Mazhar A Kanak
- Department of Surgery, 2397Virginia Commonwealth University, Richmond, VA, USA
| | - Srividya Vasu
- Islet Cell Laboratory, 22683Baylor Scott and White Health Research Institute, Dallas, TX, USA
| | - Kenjiro Kumano
- Islet Cell Laboratory, 22683Baylor Scott and White Health Research Institute, Dallas, TX, USA
| | - Michael Lawrence
- Islet Cell Laboratory, 22683Baylor Scott and White Health Research Institute, Dallas, TX, USA
| | - Nicholas Onaca
- Annette C. and Harold C. Simmons Transplant Institute, 22683Baylor University Medical Center, Dallas, TX, USA
| | - Morihito Takita
- Islet Cell Laboratory, 22683Baylor Scott and White Health Research Institute, Dallas, TX, USA
| | - Marlon F Levy
- Department of Surgery, 2397Virginia Commonwealth University, Richmond, VA, USA
| | - Bashoo Naziruddin
- Annette C. and Harold C. Simmons Transplant Institute, 22683Baylor University Medical Center, Dallas, TX, USA
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18
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Maatman TK, Zyromski NJ. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2020.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Factors Associated With Morbidity Following Total Pancreatectomy and Islet Autotransplantation: A NSQIP Analysis. Transplant Proc 2021; 53:705-711. [PMID: 33563474 DOI: 10.1016/j.transproceed.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/28/2020] [Accepted: 11/23/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Total pancreatectomy with islet autotransplantation is a therapeutic surgical option for patients with chronic pancreatitis leading to significant reduction in pain, improvement in quality of life, and potential for preservation of partial to full endocrine function. Data on the factors associated with short-term morbidities are limited. METHODS We queried the American College of Surgeons National Surgery Quality Improvement Project for patients undergoing total pancreatectomy with islet autotransplantation from 2005 to 2015. We determined 30-day morbidity and mortality and performed univariate and multivariate analysis to determine the preoperative and intraoperative factors associated with development of postoperative infectious complications. RESULTS The rate of 30-day postoperative morbidity in 384 patients undergoing total pancreatectomy with islet autotransplantation was 36% with an overall mortality of 1%. Postoperative infectious complications developed in 29% of patients and were associated with increased operative time (P = .016),and higher postoperative wound class (P = .045). After risk adjustment, only increased operative time was independently associated with increased rates of infectious complications (OR=1.1, 95% CI = 1.01-1.13, P = .02). CONCLUSIONS Total operative time is independently associated with increased postoperative infectious complications in total pancreatectomy with islet autotransplantation. Future interventions aimed at optimizing islet isolation, surgical approach, and refinement of patient selection criteria present opportunities for reducing operative time and potentially reducing the morbidity of this surgical procedure.
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20
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4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2021. Diabetes Care 2021; 44:S40-S52. [PMID: 33298415 DOI: 10.2337/dc21-s004] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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22
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Fat-soluble Vitamin Deficiency is Common in Children With Chronic Pancreatitis Undergoing Total Pancreatectomy With Islet Autotransplantation. J Pediatr Gastroenterol Nutr 2021; 72:123-126. [PMID: 32960829 DOI: 10.1097/mpg.0000000000002950] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The prevalence of fat-soluble vitamin (FSV) deficiency in children undergoing total pancreatectomy with islet autotransplantation (TPIAT) for chronic pancreatitis (CP) is unknown. We quantified FSV deficiency in 100 children (age ≤18) undergoing TPIAT. FSV levels (vitamins A, E, D) and clinical history were abstracted from medical records. Vitamin A was low in 4% before and 7% at 1 year after TPIAT, vitamin E in 17% and 18%, and vitamin D in 22% and 24%, respectively, regardless of pancreatic enzyme or vitamin supplement dosing. Longer duration of CP was associated with pre-TPIAT vitamin D insufficiency (P = 0.0002). This remained significant in a multivariate regression model (adjusted P = 0.01). On multivariate analysis, there were no significant predictors of low FSV levels post-TPIAT. FSV deficiencies are common among children undergoing TPIAT and patients who have had longer disease duration may be at increased risk. All children should be monitored for FSV deficiency after TPIAT.
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Narayanan S, Bhutiani N, Adamson DT, Jones CM. Pancreatectomy, Islet Cell Transplantation, and Nutrition Considerations. Nutr Clin Pract 2020; 36:385-397. [PMID: 33002260 DOI: 10.1002/ncp.10578] [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] [Indexed: 12/13/2022] Open
Abstract
Pancreatic islet transplantation is a reliable approach for treating insulin-deficient diabetes. This established β-cell replacement approach has shown considerable improvements in the last 2 decades. It has helped achieve metabolic homeostasis and safe outcomes for a subset of patients with type 1 diabetes and severe pancreatitis. Nutrition support, until recently, was considered as a secondary factor, merely identified as a means of providing all the necessary nutrients for such patients. However, new literature suggests that several factors, such as the route, timing, quantity, and composition of all the nutrients administered, have key disease-altering properties and are vital during the perioperative management of such patients. This review will highlight the benefits of performing the clinical islet transplantation on a subgroup of patients with type 1 diabetes and pancreatitis and summarize new data that identify the pivotal role of nutrition support as a critical intervention in their management.
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Affiliation(s)
- Siddharth Narayanan
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Neal Bhutiani
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Dylan T Adamson
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Christopher M Jones
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
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Pre-operative Sarcopenia Predicts Low Islet Cell Yield Following Total Pancreatectomy with Islet Autotransplantation for Chronic Pancreatitis. J Gastrointest Surg 2020; 24:2423-2430. [PMID: 32557018 DOI: 10.1007/s11605-020-04687-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 06/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Sarcopenia defined as degenerative loss of skeletal muscle mass associated with aging, represents an objective parameter to measure frailty and to estimate patient's physiologic reserves. It is a robust predictor of post-operative complications in transplantation and major oncologic surgeries. There is no data regarding the prevalence of sarcopenia in chronic pancreatitis or its impact on the outcome of patients undergoing TPIAT for CP. We sought to estimate the prevalence of sarcopenia, its impact on post-operative morbidity and prediction of islet yield and metabolic outcomes in patients undergoing TPIAT. METHODS Adult patients undergoing TPIAT between 2008 and 2018 were identified from our prospectively maintained database and were included if they had CT within 6 months before TPIAT. Skeletal muscle index (SMI) was evaluated by pre-operative CT at the level of L3 vertebra. Sarcopenia was defined as SMI < 52.4 in males and < 38.5 in females. Post-operative morbidity occurring within 90 days after TPIAT was graded as per the validated Clavien-Dindo score. Major post-surgical morbidity was defined as Clavien-Dindo score of IIIa or more. The yield of islets was quantified as islet equivalents (IEQ) and IEQ/kg recipient body weight was calculated. RESULTS One hundred and thirty-eight patients underwent TPIAT, with 46 (one-third) being classified as having pre-operative sarcopenia based on CT. No significant differences were observed in the incidence of any major surgical complications, length of hospital stay (median (range in days) 111-8 vs. 122-9; p = 0.6) and 30-day readmission rate (7 (15.2%) vs, 2 (2.2%); p = 0.5) between sarcopenic and non-sarcopenic patients. More patients with sarcopenia needed to be discharged to residential rehabilitation facility compared with non-sarcopenic patients (7 (15.2%) vs. 2 (2.2%), p = 0.007). Sarcopenia (OR 7.4 (95% CI 1.32-41.24); p = 0.023) and presence of calcification (OR 5.5 (95% CI 0.94-32.19); p = 0.05) were independent predictors of low islet yield (< 2500 IEQ/kg) on multivariate analysis. CONCLUSION Sarcopenia is frequent in CP patients undergoing TPIAT, but not readily recognized by standard anthropometric measurement. Sarcopenia was associated with increased chance of discharge to a residential rehabilitation facility and with a poor islet yield during TPIAT. It is therefore critical to optimize nutrition prior to TPIAT surgery in CP patients.
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25
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Zhang YJ, Duan DD, Yuan H. Efficacy and safety of islet autotransplantation after total pancreatectomy in chronic pancreatitis: A systematic review and meta-analysis including 17 studies. Clin Res Hepatol Gastroenterol 2020; 44:598-608. [PMID: 31523018 DOI: 10.1016/j.clinre.2019.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023]
Abstract
AIMS Islet autotransplantation (IAT), in conjunction with total pancreatectomy (TP), is used to relieve pain in patients with chronic pancreatitis (CP), while reducing the incidence of brittle diabetes. We aimed to evaluate the efficacy and safety of IAT after TP (TPIAT) in this setting. METHODS We searched PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials since 1977. Data were extracted from published papers. Random-effects meta-analysis and meta-regression models were built to assess the outcomes and effect of different factors. Subgroup and sensitivity analyses were conducted to examine the between-study heterogeneity, which was assessed using Cochrane's Q and I2 statistic. RESULTS A total of 17 studies, including 1024 patients, met the eligibility criteria. The median cohort size was 21 patients (range: 5-409). The pooled incidence rates of insulin independence, narcotic independence and mortality at last follow-up were 11.47 per 100 patient-years (95% CI: 6.79-21.60, I2=91.0%), 18.11 per 100 patient-years (95% CI: 5.29-62.04, I2=98.8%) and 2.88 per 100 patient-years (95% CI: 1.75-4.74, I2=46.8%), respectively. However, the heterogeneity level of our results was high, which was due to differences in research methods and definitions of outcomes between studies. Therefore, our results should be interpreted with caution. CONCLUSIONS TPIAT can effectively relieve pain and reduce the risk of surgical diabetes with no increase in mortality or morbidity. Prospective, randomized, clinical trials are required to further evaluate selection of patients and the timing of TPIAT.
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Affiliation(s)
- Ya-Jun Zhang
- Department of Pharmacy, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, 24 Jinghua Road, Jianxi District, Luoyang 471003, China.
| | - Dan-Dan Duan
- Department of Pharmacy, Henan Provincial Corps Hospital of Chinese People's Armed Police Force, Zhengzhou 450000, China
| | - Hang Yuan
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
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26
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Maatman TK, Zyromski NJ. Chronic Pancreatitis. Curr Probl Surg 2020; 58:100858. [PMID: 33663691 DOI: 10.1016/j.cpsurg.2020.100858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas K Maatman
- Resident in General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas J Zyromski
- Professor of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA..
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Abstract
OBJECTIVE When total pancreatectomy with islet autotransplantation (TPIAT) is performed for chronic pancreatitis, the pancreas and most of the duodenum are removed, with Roux-en-Y reconstruction of the gastrointestinal tract. Enteroendocrine cells in the intestines and pancreas secrete hormones coordinating digestion and motility, but anatomic reconstruction alters transit of nutrients to these cells. We hypothesized that TPIAT leads to changes in enteroendocrine hormones. METHODS Glucagon-like peptide 1 (GLP-1), peptide YY (PYY), and pancreatic polypeptide (PP) were measured from mixed-meal tolerance tests of 34 clinical trial participants before and 18 months after TPIAT. Area under the curve of GLP-1 and PYY-stimulated responses were calculated by trapezoidal method, and the PP response was measured as the stimulated max minus baseline (ΔPP). RESULTS Area under the curve of GLP-1 and PYY increased significantly after TPIAT (GLP-1 average +553.1 pg/mL per minute, P = 0.004; PYY average +4647.9 pg/mL per minute, P = 0.02). ΔPP trended toward lower after TPIAT (average, -52.2 pg/mL, P = 0.06). CONCLUSIONS In this novel study of enteroendocrine hormones in TPIAT patients, stimulated levels of GLP-1 and PYY were significantly higher after versus before TPIAT. ΔPP was lower after TPIAT, but not significantly. These hormone changes have potential clinical implications that warrant further research.
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Grafting Islets to a Dissected Peritoneal Pouch to Improve Transplant Survival and Function. Transplantation 2020; 104:2307-2316. [PMID: 32541557 DOI: 10.1097/tp.0000000000003355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Although the liver is the primary site for clinical islet transplantation, it poses several restrictions, especially limited tissue volume due to portal vein pressure. We evaluated the preperitoneal space as an extrahepatic islet transplant site to deliver high tissue volumes and sustain long-term graft function. METHODS A peritoneal pouch was formed by dissecting the parietal peritoneum from the transversalis fascia of mice. Syngeneic C57BL/6 donor islets were transplanted into the peritoneal pouch of diabetic mouse recipients. Blood glucose was monitored for islet function, and miR-375 was analyzed for islet damage. Islet graft morphology and vascularization were evaluated by immunohistochemistry. [F] fluoro-D-glucose positron emission tomography/computed tomography was used to image islet grafts. RESULTS Transplantation of 300 syngeneic islets into the peritoneal pouch of recipients reversed hyperglycemia for >60 days. Serum miR-375 was significantly lower in the peritoneal pouch group than in the peritoneal cavity group. Peritoneal pouch islet grafts showed high neovascularization and sustained insulin and glucagon expression up to 80 days posttransplantation. A peritoneal pouch graft with high tissue volume (1000 islets) could be visualized by positron emission tomography/computed tomography imaging. Human islets transplanted into the peritoneal pouch of diabetic nude mice also reversed hyperglycemia successfully. CONCLUSIONS Islets transplanted into a dissected peritoneal pouch show high efficiency to reverse diabetes and sustain islet graft function. The preperitoneal site has the advantages of capacity for high tissue volume, enriched revascularization and minimal inflammatory damage. It can also serve as an extrahepatic site for transplanting large volume of islets necessitated in islet autotransplantation.
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Abu-El-Haija M, Anazawa T, Beilman GJ, Besselink MG, Del Chiaro M, Demir IE, Dennison AR, Dudeja V, Freeman ML, Friess H, Hackert T, Kleeff J, Laukkarinen J, Levy MF, Nathan JD, Werner J, Windsor JA, Neoptolemos JP, Sheel ARG, Shimosegawa T, Whitcomb DC, Bellin MD. The role of total pancreatectomy with islet autotransplantation in the treatment of chronic pancreatitis: A report from the International Consensus Guidelines in chronic pancreatitis. Pancreatology 2020; 20:762-771. [PMID: 32327370 DOI: 10.1016/j.pan.2020.04.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 03/18/2020] [Accepted: 04/06/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Takayuki Anazawa
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Ashley R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, University of Leicester, UK
| | - Vikas Dudeja
- Department of Surgery, University of Miami, Miami, FL, USA
| | - Martin L Freeman
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Helmut Friess
- Department of Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Jorg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Marlon F Levy
- Division of Transplant Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, University of Munich, LMU, Germany
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - John P Neoptolemos
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Andrea R G Sheel
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - David C Whitcomb
- Department of Medicine, Cell Biology & Physiology, and Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melena D Bellin
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA; Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.
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Kumano K, Lawrence MC, Onaca N, Levy MF, Naziruddin B. Successful allogeneic islet transplantation after total pancreatectomy with islet autotransplantation to restore normoglycemia: a case report. Acta Diabetol 2020; 57:619-622. [PMID: 31773266 DOI: 10.1007/s00592-019-01457-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Kenjiro Kumano
- Baylor Scott and White Research Institute, 3410 Worth Street, Suite 950, Dallas, TX, 75246, USA
| | - Michael C Lawrence
- Baylor Scott and White Research Institute, 3410 Worth Street, Suite 950, Dallas, TX, 75246, USA
| | | | - Marlon F Levy
- Division of Transplantation, Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, 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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4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2020. Diabetes Care 2020; 43:S37-S47. [PMID: 31862747 DOI: 10.2337/dc20-s004] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Shahbazov R, Naziruddin B, Salam O, Saracino G, Levy MF, Beecherl E, Onaca N. The impact of surgical complications on the outcome of total pancreatectomy with islet autotransplantation. Am J Surg 2020; 219:99-105. [DOI: 10.1016/j.amjsurg.2019.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 02/07/2023]
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee (https://doi.org/10.2337/dc20-SPPC), a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Lara LF, Luthra A, Conwell DL, Krishna SG. Pancreatic Cysts in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:457-469. [PMID: 31707690 DOI: 10.1007/s11938-019-00260-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Incidental pancreatic cysts are common, and management strategies continue to evolve. This review summarizes diagnostic and management recommendations in older patients with these lesions based on guidelines and best clinical evidence. RECENT FINDINGS Diagnosis of cyst type has been enhanced with improved imaging and cyst fluid analysis and visualization. Recent outcome studies indicate that certain cyst types should be followed independent of patient age as long as certain criteria which are reviewed are met. Differentiation of pancreatic cyst type is important as this dictates the need for long-term follow-up. Because most cyst-related neoplasia occurs in older patients, surveillance should continue within certain guidelines.
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Affiliation(s)
- Luis F Lara
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA.
| | - Anjuli Luthra
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
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Lara LF, Bellin MD, Ugbarugba E, Nathan JD, Witkowski P, Wijkstrom M, Steel JL, Smith KD, Singh VK, Schwarzenberg SJ, Pruett TL, Naziruddin B, Long-Simpson L, Kirchner VA, Gardner TB, Freeman ML, Dunn TB, Chinnakotla S, Beilman GJ, Adams DB, Morgan KA, Abu-El-Haija MA, Ahmad S, Posselt AM, Hughes MG, Conwell DL. A Study on the Effect of Patient Characteristics, Geographical Utilization, and Patient Outcomes for Total Pancreatectomy Alone and Total Pancreatectomy With Islet Autotransplantation in Patients With Pancreatitis in the United States. Pancreas 2019; 48:1204-1211. [PMID: 31593020 PMCID: PMC7952005 DOI: 10.1097/mpa.0000000000001405] [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] [Indexed: 02/07/2023]
Abstract
OBJECTIVES A selective therapy for pancreatitis is total pancreatectomy and islet autotransplantation. Outcomes and geographical variability of patients who had total pancreatectomy (TP) alone or total pancreatectomy with islet autotransplantation (TPIAT) were assessed. METHODS Data were obtained from the Healthcare Cost and Utilization Project National Inpatient Sample database. Weighed univariate and multivariate analyses were performed to determine the effect of measured variables on outcomes. RESULTS Between 2002 and 2013, there were 1006 TP and 825 TPIAT in patients with a diagnosis of chronic pancreatitis, and 1705 TP and 830 TPIAT for any diagnosis of pancreatitis. The majority of the TP and TPIAT were performed in larger urban hospitals. Costs were similar for TP and TPIAT for chronic pancreatitis but were lower for TPIAT compared with TP for any type of pancreatitis. The trend for TP and TPIAT was significant in all geographical areas during the study period. CONCLUSIONS There is an increasing trend of both TP and TPIAT. Certain groups are more likely to be offered TPIAT compared with TP alone. More data are needed to understand disparities and barriers to TPIAT, and long-term outcomes of TPIAT such as pain control and glucose intolerance need further study.
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Affiliation(s)
- Luis F. Lara
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Melena D. Bellin
- Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN
| | - Emmanuel Ugbarugba
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jaimie D. Nathan
- Department of Surgery, Cincinnati Children’s Hospital, Cincinnati, OH
| | | | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jennifer L. Steel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kerrington D. Smith
- Division of Surgical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Center, Baltimore, MD
| | | | - Timothy L. Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Bashoo Naziruddin
- Islet Cell Laboratory, Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | | | - Varvara A. Kirchner
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Timothy B. Gardner
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Martin L. Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical School, Minneapolis, MN
| | - Ty B. Dunn
- Division of Transplant Surgery, The University of Pennsylvania, Philadelphia, PA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - David B. Adams
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | | | | | - Syed Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Andrew M. Posselt
- Department of Surgery, University of California-San Francisco, San Francisco, CA
| | | | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
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Bellin MD, Beilman GJ, Sutherland DER, Ali H, Petersen A, Mongin S, Kirchner V, Schwarzenberg SJ, Trikudanathan G, Freeman ML, Pruett TL, Chinnakotla S. How Durable Is Total Pancreatectomy and Intraportal Islet Cell Transplantation for Treatment of Chronic Pancreatitis? J Am Coll Surg 2019; 228:329-339. [DOI: 10.1016/j.jamcollsurg.2018.12.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/17/2018] [Indexed: 12/18/2022]
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Andersen DK, Forsmark CE, Pandol SJ. The Agenda for Accelerating Pancreatic Research. Pancreas 2019; 47:1177-1179. [PMID: 30325854 PMCID: PMC6193268 DOI: 10.1097/mpa.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Dana K. Andersen
- Division of Digestive Diseases and Nutrition, National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD
| | - Christopher E. Forsmark
- Division of Gastroenterology, Department of Medicine, University of Florida Health Sciences Center, Gainesville, FL
| | - Stephen J. Pandol
- Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2019. Diabetes Care 2019; 42:S34-S45. [PMID: 30559230 DOI: 10.2337/dc19-s004] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Giorgakis E, Mathur AK, Chakkera HA, Reddy KS, Moss AA, Singer AL. Solid pancreas transplant: Pushing forward. World J Transplant 2018; 8:237-251. [PMID: 30596031 PMCID: PMC6304337 DOI: 10.5500/wjt.v8.i7.237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 11/10/2018] [Accepted: 11/15/2018] [Indexed: 02/05/2023] Open
Abstract
Pancreas transplant has evolved significantly in recent years. It has now become a viable treatment option on type 1 diabetic patients with poorly controlled diabetes on conventional treatment, insulin intolerance, hypoglycaemia unawareness, brittle diabetes and/ or end-stage kidney disease. The purpose of this review is to provide an overview of pancreas transplant historical origins and current barriers to broader utilization of pancreata for transplant, with a focus on areas for future improvement to better pancreas transplant care. Donor pancreata remain underutilized; pancreatic allograft discard rates remain close to 30% in the United States. Donations after cardiac death (DCD) pancreata are seldom procured. Study groups from Europe and the United Kingdom showed that procurement professionalization and standardization of technique, as well as development of independent regional procurement teams might increase organ procurement efficiency, decrease discards and increase pancreatic allograft utilization. Pancreas transplant programs should consider exploring pancreas procurement opportunities on DCD and obese donors. Selected type 2 diabetics should be considered for pancreas transplant. Longer follow-up studies need to be performed in order to ascertain the long-term cardiovascular and quality of life benefits following pancreas transplant; the outcomes of which might eventually spearhead advocacy towards broader application of pancreas transplant among diabetics.
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Affiliation(s)
- Emmanouil Giorgakis
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
- Department of Transplant, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Amit K Mathur
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Harini A Chakkera
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Kunam S Reddy
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Adyr A Moss
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Andrew L Singer
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
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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.
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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.
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Abstract
PURPOSE OF REVIEW Patients suffering from chronic pancreatitis often require surgical intervention to treat their disease. This review discusses surgical options as well as reviews current trends and research in the operative management of chronic pancreatitis. RECENT FINDINGS Relevant current topics in the field include the appropriate timing of surgery as well as the relative benefits of various procedures, particularly duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy. Multiple studies have found that surgery earlier in the disease course results in improved outcomes. Furthermore, the recent literature reports similar outcomes of duodenum-preserving pancreatic head resection when compared with pancreaticoduodenectomy. SUMMARY It is important for treating clinicians to be well versed on the interplay of medical, endoscopic, and surgical strategies to carefully tailor a patient's treatment plan. Each patient warrants careful consideration and an individualized approach in collaboration with multidisciplinary colleagues.
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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.
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Naziruddin B, Kanak MA, Chang CA, Takita M, Lawrence MC, Dennison AR, Onaca N, Levy MF. Improved outcomes of islet autotransplant after total pancreatectomy by combined blockade of IL-1β and TNFα. Am J Transplant 2018; 18:2322-2329. [PMID: 29862647 DOI: 10.1111/ajt.14961] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/20/2018] [Accepted: 05/28/2018] [Indexed: 01/25/2023]
Abstract
The efficacy of islet transplant is compromised by a significant loss of islet mass posttransplant due to an innate inflammatory reaction. We report the use of a combination of etanercept and anakinra (ANA+ETA) to block inflammatory islet damage in 100 patients undergoing total pancreatectomy with islet autotransplant. The patients were divided into 3 groups: no treatment (control [CTL]), etanercept alone (ETA), or a combination of etanercept and anakinra (ANA+ETA). Peritransplant serum samples were analyzed for protein markers of islet damage and for inflammatory cytokines. Graft function was assessed by fasting blood glucose, basal C-peptide, secretory unit of islet transplant objects (SUITO) index, and hemoglobin A1c . Administration of both antiinflammatory drugs was well tolerated without any major adverse events. Reductions in interleukin-6, interleukin-8, and monocyte chemoattractant protein 1 were observed in patients receiving ANA+ETA compared with the CTL group, while also showing a modest improvement in islet function as assessed by basal C-peptide, glucose, hemoglobin A1c , and SUITO index but without differences in insulin dose. These results suggest that double cytokine blockade (ANA+ETA) reduces peritransplant islet damage due to nonspecific inflammation and may represent a promising strategy to improve islet engraftment, leading to better transplant outcomes.
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Affiliation(s)
- B Naziruddin
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Dallas, TX, USA.,Islet Cell Laboratory, Baylor Research Institute, Dallas, TX, USA
| | - M A Kanak
- Division of Transplantation, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - C A Chang
- Institute of Biomedical Studies, Baylor University, Waco, TX, USA
| | - M Takita
- Islet Cell Laboratory, Baylor Research Institute, Dallas, TX, USA
| | - M C Lawrence
- Islet Cell Laboratory, Baylor Research Institute, Dallas, TX, USA
| | - A R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Leicester, Leicester, UK
| | - N Onaca
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Dallas, TX, USA
| | - M F Levy
- Division of Transplantation, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Liu L, Zhu Y, Noë M, Li Q, Pasricha PJ. Neuronal Transforming Growth Factor beta Signaling via SMAD3 Contributes to Pain in Animal Models of Chronic Pancreatitis. Gastroenterology 2018; 154:2252-2265.e2. [PMID: 29505748 PMCID: PMC5985212 DOI: 10.1053/j.gastro.2018.02.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 02/15/2018] [Accepted: 02/26/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND & AIMS Chronic pancreatitis (CP) is characterized by pancreatic inflammation and fibrosis, associated with increased pancreatic expression of transforming growth factor beta (TGFB). It is not clear how these might contribute to pain. We investigated whether TGFB signaling via SMAD induces sensitization of pancreatic sensory neurons to increase nociception. METHODS CP was induced in Sprague-Dawley rats by infusion of trinitrobenzene sulfonic acid; some rats were given intrathecal infusions of TGFB1. CP was induced in control mice by administration of cerulein; we also studied β1glo/Ptf1acre-ER mice, which on induction overexpress TGFB1 in pancreatic acinar cells, and TGFBr1f/f-CGRPcreER mice, which have inducible disruption of TGFBr1 in calcitonin gene-related peptide-positive neurons. Dominant negative forms of human TGFBR2 and SMAD3 were overexpressed from viral vectors in rat pancreas. Some rats were given the SMAD3 inhibitors SIS3 or halofuginone. After induction of CP, mice were analyzed for pain in behavior tests or electrophysiologic studies of sensory neurons. Pancreatic nociceptor excitability was examined by patch-clamp techniques and nociception was measured by Von Frey Filament tests for referred somatic hyperalgesia and behavioral responses to pancreatic electrical stimulation. Pancreata were collected from mice and rats and analyzed histologically and by enzyme-linked immunosorbent assay and immunohistochemistry. RESULTS Overexpression of TGFB in pancreatic acinar cells of mice and infusion of TGFB1 into rats resulted in sensory neuron hyperexcitability, SMAD3 activation, and increased nociception. This was accompanied by a reduction in the transient A-type current in pancreas-specific sensory neurons in rats, a characteristic of nociceptive sensitization in animal models of CP. Conversely, pancreata from TGFBr1f/f-CGRPcreER mice, rats with pancreatic expression of dominant negative forms of human TGFBR2 or SMAD3, and rats given small molecule inhibitors of SMAD3 had attenuated neuronal sensitization and pain behavior following induction of CP. In contrast to findings from peripheral administration of TGFB1, intrathecal infusion of TGFB1 reduced hyperalgesia in rats with CP. CONCLUSIONS In pancreata of mice and rats, TGFB promotes peripheral nociceptive sensitization via a direct effect on primary sensory neurons mediated by intra-neuronal SMAD3. This is distinct from the central nervous system, where TGFB reduces nociception. These results provide an explanation for the link between fibrosis and pain in patients with CP. This signaling pathway might be targeted therapeutically to reduce pain in patients with CP.
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Affiliation(s)
- Liansheng Liu
- Johns Hopkins Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yaohui Zhu
- Johns Hopkins Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michaël Noë
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Qian Li
- Johns Hopkins Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pankaj Jay Pasricha
- Johns Hopkins Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Age and Disease Duration Impact Outcomes of Total Pancreatectomy and Islet Autotransplant for PRSS1 Hereditary Pancreatitis. Pancreas 2018. [PMID: 29517634 DOI: 10.1097/mpa.0000000000001028] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES We investigated the impact of patient age and disease duration on islet isolation results, diabetes outcomes, and pain outcomes after total pancreatectomy with islet autotransplant (TPIAT) performed in 64 patients with hereditary pancreatitis due to PRSS1 gene mutation. METHODS We evaluated the association of patient age and disease duration on islet isolation results and opioid use at 1 year using logistic regression and on graft function using 1-way analysis of variance. RESULTS Islet mass was negatively associated with increasing age and longer disease duration, with a 13% reduction (95% confidence interval [CI], 3%-22%) and 22% (95% CI, 14%-29%) reduction in islet equivalents per kilogram body weight (IEQ/kg) for each 5 years of age and disease duration, respectively. Full graft function was associated with younger age and shorter duration of disease (P < 0.01). Persistent opioid use (15% of patients at 1 year) increased with age (P = 0.05) and disease duration (P = 0.04). CONCLUSIONS The TPIAT outcomes were adversely impacted by older age and prolonged disease. In particular, islet mass is lower and risk of diabetes high in older patients with prolonged disease. This should be considered when counseling this subgroup of TPIAT recipients on expected outcomes.
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Bellin MD, Abu-El-Haija M, Morgan K, Adams D, Beilman GJ, Chinnakotla S, Conwell DL, Dunn TB, Freeman ML, Gardner T, Kirchner VA, Lara LF, Long-Simpson L, Nathan JD, Naziruddin B, Nyman JA, Pruett TL, Schwarzenberg SJ, Singh VK, Smith K, Steel JL, Wijkstrom M, Witkowski P, Hodges JS. A multicenter study of total pancreatectomy with islet autotransplantation (TPIAT): POST (Prospective Observational Study of TPIAT). Pancreatology 2018; 18:286-290. [PMID: 29456124 PMCID: PMC5879010 DOI: 10.1016/j.pan.2018.02.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Total pancreatectomy with islet autotransplantation (TPIAT) is considered for managing chronic pancreatitis in selected patients when medical and endoscopic interventions have not provided adequate relief from debilitating pain. Although more centers are performing TPIAT, we lack large, multi-center studies to guide decisions about selecting candidates for and timing of TPIAT. METHODS Multiple centers across the United States (9 to date) performing TPIAT are prospectively enrolling patients undergoing TPIAT for chronic pancreatitis into the Prospective Observational Study of TPIAT (POST), a NIDDK funded study with a goal of accruing 450 TPIAT recipients. Baseline data include participant phenotype, pancreatitis history, and medical/psychological comorbidities from medical records, participant interview, and participant self-report (Medical Outcomes Survey Short Form-12, EQ-5D, andPROMIS inventories for pain interference, depression, and anxiety). Outcome measures are collected to at least 1 year after TPIAT, including the same participant questionnaires, visual analog pain scale, pain interference scores, opioid requirements, insulin requirements, islet graft function, and hemoglobin A1c. Health resource utilization data are collected for a cost-effectiveness analysis. Biorepository specimens including urine, serum/plasma, genetic material (saliva and blood), and pancreas tissue are collected for future study. CONCLUSIONS This ongoing multicenter research study will enroll and follow TPIAT recipients, aiming to evaluate patient selection and timing for TPIAT to optimize pain relief, quality of life, and diabetes outcomes, and to measure the procedure's cost-effectiveness. A biorepository is also established for future ancillary studies.
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Affiliation(s)
- Melena D Bellin
- University of Minnesota Medical School, Minneapolis, MN, United States.
| | | | - Katherine Morgan
- The Medical University of South Carolina, Charleston, SC, United States
| | - David Adams
- The Medical University of South Carolina, Charleston, SC, United States
| | - Gregory J Beilman
- University of Minnesota Medical School, Minneapolis, MN, United States
| | | | - Darwin L Conwell
- The Ohio State Wexner University Medical Center, Columbus, OH, United States
| | - Ty B Dunn
- University of Minnesota Medical School, Minneapolis, MN, United States
| | - Martin L Freeman
- University of Minnesota Medical School, Minneapolis, MN, United States
| | - Timothy Gardner
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | | | - Luis F Lara
- The Ohio State Wexner University Medical Center, Columbus, OH, United States
| | | | - Jaimie D Nathan
- Cincinnati Children's Hospital, Cincinnati, OH, United States
| | | | - John A Nyman
- University of Minnesota Medical School, Minneapolis, MN, United States
| | - Timothy L Pruett
- University of Minnesota Medical School, Minneapolis, MN, United States
| | | | - Vikesh K Singh
- John Hopkins Medical Institutions, Baltimore, MD, United States
| | | | - Jennifer L Steel
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Martin Wijkstrom
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | | | - James S Hodges
- University of Minnesota School of Public Health, Minneapolis, MN, United States
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Bellin MD. A Role for Total Pancreatectomy and Islet Autotransplant in the Treatment of Chronic Pancreatitis. Am J Gastroenterol 2018; 113:324-326. [PMID: 29460919 DOI: 10.1038/ajg.2017.425] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Melena D Bellin
- Departments of Pediatrics and Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Shahbazov R, Naziruddin B, Yadav K, Saracino G, Yoshimatsu G, Kanak MA, Beecherl E, Kim PT, Levy MF. Risk factors for early readmission after total pancreatectomy and islet auto transplantation. HPB (Oxford) 2018; 20:166-174. [PMID: 28993044 DOI: 10.1016/j.hpb.2017.08.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/09/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little published data exist examining causes of hospital readmission following total pancreatectomy with islet autotransplantation (TPIAT). METHODS A retrospective analysis was performed of a prospectively collected institutional TPIAT database. Primary outcome was unplanned readmission to the hospital within 30 days from discharge. Reasons and risk factors for readmission as well as islet function were evaluated and compared by univariate and multivariate analysis. RESULTS 83 patients underwent TPIAT from 2006 to 2014. 21 patients (25.3%) were readmitted within 30 days. Gastrointestinal problems (52.4%) and surgical site infection (42.8%) were the most common reasons for readmission. Initial LOS and reoperation were risk factors for early readmission. Patients with delayed gastric emptying (DGE) were three times more likely to get readmitted. In multivariate analysis, patients undergoing pylorus preservation surgery were nine times more likely to be readmitted than the antrectomy group. CONCLUSION Early readmission after TPIAT is common (one in four patients), underscoring the complexity of this procedure. Early readmission is not detrimental to islet graft function. Patients undergoing pylorus preservation are more likely to get readmitted, perhaps due to increased incidence of delayed gastric emptying. Decision for antrectomy vs. pylorus preservation needs to be individualized.
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Affiliation(s)
- Rauf Shahbazov
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Bashoo Naziruddin
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Dallas-Fort Worth, TX, USA.
| | - Kunal Yadav
- Division of Transplantation, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Giovanna Saracino
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Dallas-Fort Worth, TX, USA
| | | | - Mazhar A Kanak
- Division of Transplantation, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Ernest Beecherl
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Dallas-Fort Worth, TX, USA
| | - Peter T Kim
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Dallas-Fort Worth, TX, USA
| | - Marlon F Levy
- Division of Transplantation, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
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3. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2018. Diabetes Care 2018; 41:S28-S37. [PMID: 29222374 DOI: 10.2337/dc18-s003] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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