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Chen ME, Desai CS. Current practices in islet cell autotransplantation. Expert Rev Endocrinol Metab 2023; 18:419-425. [PMID: 37680038 DOI: 10.1080/17446651.2023.2256407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Chronic pancreatitis and recurrent acute pancreatitis comprise a spectrum of disease that results in complications related to exocrine and endocrine insufficiency and chronic pain with narcotic dependence and poor quality of life. The mainstay of therapy has been medical and endoscopic therapy; surgery, especially total pancreatectomy, was historically reserved for few select patients as the obligate exocrine insufficiency and pancreatogenic diabetes (type 3C) are challenging to manage. The addition of islet cell autotransplantation after total pancreatectomy helps to mitigate brittle type 3c diabetes and prevents mortality related to severe hypoglycemic episodes and hypoglycemic unawareness. There have been more recent data demonstrating the safety of surgery and the beneficial long-term outcomes. AREAS COVERED The purpose of this review is to describe the current practices in the field of islet cell autotransplantation including the selection and evaluation of patients for surgery, their preoperative work up and management, surgical approach, post-operative management and outcomes. EXPERT OPINION Total pancreatectomy and islet cell autotransplantation has the ability to drastically improve quality of life and prevent brittle diabetes for patients suffering with chronic pancreatitis.
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Affiliation(s)
- Melissa E Chen
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Chirag S Desai
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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Reid TD, Madduri SS, Agala CB, Weng C, McEwan S, Desai CS. Perioperative Management of Patients Undergoing Total Pancreatectomy with/without Islet Cell Autotransplantation: A Single Center Experience. J Clin Med 2023; 12:3993. [PMID: 37373687 DOI: 10.3390/jcm12123993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/04/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
Total pancreatectomy (TP) and islet cell autotransplantation (IAT) are complex operations that require intensive postoperative monitoring with standardized protocols. There are few studies detailing immediate perioperative management. The purpose of this study was to describe the perioperative management of post-pancreatectomy patients in the first week following surgery to guide clinicians in addressing salient points from different organ systems. This is a retrospective cohort review of prospectively collected data from September 2017 to September 2022 at a single institution, including patients 16 years and older who underwent TP or TPIAT for chronic pancreatitis. Patients were maintained on a heparin drip (TPIAT), insulin drip, and ketamine infusion. Primary outcomes were complications in the first 5 days following surgery and ICU length of stay (LOS). Secondary outcomes included overall LOS and mortality. Of 31 patients, 26 underwent TPIAT, and 5 underwent TP. Median ICU LOS was five days (IQR 4-6). The most common immediate postoperative complications were reintubation [n = 5 (16%)] and bleeding [n = 2 (6%)]. Median insulin drip use was 70 h (IQR 20-124). There was no mortality. Patients were extubated quickly and progressed well on the protocol. Immediate postoperative complications were generally minor and without long-term effects.
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Affiliation(s)
- Trista D Reid
- Department of Surgery, Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Supradeep S Madduri
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Chris B Agala
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Chengyu Weng
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sasha McEwan
- Department of Surgery, Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Chirag S Desai
- Department of Surgery, Division of Abdominal Transplantation, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Szempruch KR, Walter K, Ebert N, Bridgens K, Desai CS. Pharmacological management of patients undergoing total pancreatectomy with auto-islet transplantation. Pancreatology 2022; 22:656-664. [PMID: 35490122 DOI: 10.1016/j.pan.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/17/2022] [Accepted: 04/15/2022] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis results in permanent parenchymal destruction of the pancreas gland leading to anatomical and physiological consequences for patients. Surgical management varies, and some patients require total pancreatectomy with autologous islet cell transplantation (TPIAT). Patients undergoing TPIAT require complex and diligent management after surgery. This encompasses the management of glucose control (endocrine function of the pancreas) and supplementing loss of exocrine function of the pancreas with digestive enzymes. Other areas of management include optimizing pain relief while reducing narcotic usage, providing antimicrobial prophylaxis, and reducing loss of islet cells by improving its integrity through anticoagulation and use of anti-inflammatory agents. Each aspect of care is unique to this population. However, comprehensive reviews on its pharmacological management are scarce. This review will discuss the available literature to date surrounding all aspects of pharmacological management of patients undergoing TPIAT.
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Affiliation(s)
- Kristen R Szempruch
- Pharmacy Department, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Krysta Walter
- Pharmacy Department, Michigan Medicine, Ann Arbor, MI, USA
| | - Natassha Ebert
- Pharmacy Department, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Kathryn Bridgens
- Department of Nutrition and Food Services, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Chirag S Desai
- Department of Surgery, Transplant, University of North Carolina Medical Center, Chapel Hill, NC, USA.
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Ludwig S, Distler M, Schubert U, Schmid J, Thies H, Welsch T, Hempel S, Tonn T, Weitz J, Bornstein SR, Ludwig B. Quality of life and metabolic outcomes after total pancreatectomy and simultaneous islet autotransplantation. COMMUNICATIONS MEDICINE 2022; 2:24. [PMID: 35603294 PMCID: PMC9053265 DOI: 10.1038/s43856-022-00087-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 02/07/2022] [Indexed: 12/16/2022] Open
Abstract
Background Pancreas surgery remains technically challenging and is associated with considerable morbidity and mortality. Identification of predictive risk factors for complications have led to a stratified surgical approach and postoperative management. The option of simultaneous islet autotransplantation (sIAT) allows for significant attenuation of long-term metabolic and overall complications and improvement of quality of life (QoL). The potential of sIAT to stratify a priori the indication for total pancreatectomy is yet not adequately evaluated. Methods The aim of this analysis was to evaluate the potential of sIAT in patients undergoing total pancreatectomy to improve QoL, functional and overall outcome and therefore modify the surgical strategy towards earlier and extended indications. A center cohort of 24 patients undergoing pancreatectomy were simultaneously treated with IAT. Patients were retrospectively analyzed regarding in-hospital and overall mortality, postoperative complications, ICU stay, hospital stay, metabolic outcome, and QoL. Results Here we present that all patients undergoing primary total pancreatectomy or surviving complicated two-stage pancreas resection and receiving sIAT show excellent metabolic outcome (33% insulin independence, 66% partial graft function; HbA1c 6,1 ± 1,0%) and significant benefit regarding QoL. Primary total pancreatectomy leads to significantly improved overall outcome and a significant reduction in ICU- and hospital stay compared to a two-stage completion pancreatectomy approach. Conclusions The findings emphasize the importance of risk-stratified pancreas surgery. Feasibility of sIAT should govern the indication for primary total pancreatectomy particularly in high-risk patients. In rescue completion pancreatectomy sIAT should be performed whenever possible due to tremendous metabolic benefit and associated QoL.
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Affiliation(s)
- Stefan Ludwig
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Technische Universität Dresden, D-01307 Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Technische Universität Dresden, D-01307 Dresden, Germany
- Paul Langerhans Institute Dresden of the Helmholtz Center Munich at The University Hospital Carl Gustav Carus and Faculty of Medicine of the Technische Universität Dresden, D-01307 Dresden, Germany
- Center for Diabetes Research (DZD e.V.), D-85764 Neuherberg, Germany
| | - Undine Schubert
- Paul Langerhans Institute Dresden of the Helmholtz Center Munich at The University Hospital Carl Gustav Carus and Faculty of Medicine of the Technische Universität Dresden, D-01307 Dresden, Germany
- Center for Diabetes Research (DZD e.V.), D-85764 Neuherberg, Germany
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, D-01307 Dresden, Germany
| | - Janine Schmid
- Paul Langerhans Institute Dresden of the Helmholtz Center Munich at The University Hospital Carl Gustav Carus and Faculty of Medicine of the Technische Universität Dresden, D-01307 Dresden, Germany
- Center for Diabetes Research (DZD e.V.), D-85764 Neuherberg, Germany
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, D-01307 Dresden, Germany
| | - Henriette Thies
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, D-01307 Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Technische Universität Dresden, D-01307 Dresden, Germany
| | - Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Technische Universität Dresden, D-01307 Dresden, Germany
| | - Torsten Tonn
- Experimental Transfusion Medicine, Faculty of Medicine of the Technische Universität Dresden, D-01307 Dresden, Germany
- DFG-Center for Regenerative Therapies Dresden, Technische Universität Dresden, D-01307 Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus Technische Universität Dresden, D-01307 Dresden, Germany
- Paul Langerhans Institute Dresden of the Helmholtz Center Munich at The University Hospital Carl Gustav Carus and Faculty of Medicine of the Technische Universität Dresden, D-01307 Dresden, Germany
- Center for Diabetes Research (DZD e.V.), D-85764 Neuherberg, Germany
| | - Stefan R. Bornstein
- Paul Langerhans Institute Dresden of the Helmholtz Center Munich at The University Hospital Carl Gustav Carus and Faculty of Medicine of the Technische Universität Dresden, D-01307 Dresden, Germany
- Center for Diabetes Research (DZD e.V.), D-85764 Neuherberg, Germany
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, D-01307 Dresden, Germany
- DFG-Center for Regenerative Therapies Dresden, Technische Universität Dresden, D-01307 Dresden, Germany
- Division of Diabetes & Nutritional Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, SE1 1UL UK
| | - Barbara Ludwig
- Paul Langerhans Institute Dresden of the Helmholtz Center Munich at The University Hospital Carl Gustav Carus and Faculty of Medicine of the Technische Universität Dresden, D-01307 Dresden, Germany
- Center for Diabetes Research (DZD e.V.), D-85764 Neuherberg, Germany
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, D-01307 Dresden, Germany
- DFG-Center for Regenerative Therapies Dresden, Technische Universität Dresden, D-01307 Dresden, Germany
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