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Chinnakotla S, Beilman GJ, Vock D, Freeman ML, Kirchner V, Dunn TB, Pruett TL, Amateau SK, Trikudanathan G, Schwarzenberg SJ, Downs E, Armfield M, Ramanathan K, Sutherland DE, Bellin MD. Intraportal Islet Autotransplantation Independently Improves Quality of Life After Total Pancreatectomy in Patients With Chronic Refractory Pancreatitis. Ann Surg 2022; 276:441-449. [PMID: 35762611 PMCID: PMC9388605 DOI: 10.1097/sla.0000000000005553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine if islet autotransplantation (IAT) independently improves the quality of life (QoL) in patients after total pancreatectomy and islet autotransplantation (TP-IAT). BACKGROUND TP-IAT is increasingly being used for intractable chronic pancreatitis. However, the impact of IAT on long-term islet function and QoL is unclear. METHODS TP-IAT patients at our center >1 year after TP-IAT with ≥1 Short Form-36 QoL measure were included. Patients were classified as insulin-independent or insulin-dependent, and as having islet graft function or failure by C-peptide. The associations of insulin use and islet graft function with QoL measures were analyzed by using a linear mixed model, accounting for time since transplant and within-person correlation. RESULTS Among 817 islet autograft recipients, 564 patients [median (interquartile range) age: 34 (20, 45) years, 71% female] and 2161 total QoL surveys were included. QoL data were available for >5 years after TP-IAT for 42.7% and for >10 years for 17.3%. Insulin-independent patients exhibited higher QoL in 7 of 8 subscale domains and for Physical Component Summary and Mental Component Summary scores ( P <0.05 for all). Physical Component Summary was 2.91 (SE=0.57) higher in insulin-independent patients ( P <0.001). No differences in QoL were observed between those with and without graft function, but islet graft failure was rare (15% of patients). However, glycosylated hemoglobin was much higher with islet graft failure. CONCLUSIONS QoL is significantly improved when insulin independence is present, and glycosylated hemoglobin is lower with a functioning islet graft. These data support offering IAT, rather than just performing total pancreatectomy and treating with exogenous insulin.
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Affiliation(s)
- Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David Vock
- Division of Biostatistics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Martin L. Freeman
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Varvara Kirchner
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ty B. Dunn
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Timothy L. Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Stuart K. Amateau
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Guru Trikudanathan
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Elissa Downs
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Matthew Armfield
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Karthik Ramanathan
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Melena D. Bellin
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
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Nathan JD, Ellery K, Balakrishnan K, Bhatt H, Ganoza A, Husain SZ, Kumar R, Morinville VD, Quiros JA, Schwarzenberg SJ, Sellers ZM, Uc A, Abu-El-Haija M. The Role of Surgical Management in Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2022; 74:706-719. [PMID: 35258494 PMCID: PMC10286947 DOI: 10.1097/mpg.0000000000003439] [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
OBJECTIVES Chronic pancreatitis (CP) is rare in childhood but impactful because of its high disease burden. There is limited literature regarding the management of CP in children, specifically about the various surgical approaches. Herein, we summarize the current pediatric and adult literature and provide recommendations for the surgical management of CP in children. METHODS The literature review was performed to include the scope of the problem, indications for operation, conventional surgical options as well as total pancreatectomy with islet autotransplantation, and outcomes following operations for CP. RESULTS Surgery is indicated for children with debilitating CP who have failed maximal medical and endoscopic interventions. Surgical management must be tailored to the patient's unique needs, considering the anatomy and morphology of their disease. A conventional surgical approach (eg, drainage operation, partial resection, combination drainage-resection) may be considered in the presence of significant and uniform pancreatic duct dilation or an inflammatory head mass. Total pancreatectomy with islet autotransplantation is the best surgical option in patients with small duct disease. The presence of genetic risk factors often portends a suboptimal outcome following a conventional operation. CONCLUSIONS The morphology of disease and the presence of genetic risk factors must be considered while determining the optimal surgical approach for children with CP. Surgical outcomes for CP are variable and depend on the type of intervention. A multidisciplinary team approach is needed to assure that the best possible operation is selected for each patient, their recovery is optimized, and their immediate and long-term postoperative needs are well-met.
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Affiliation(s)
- Jaimie D. Nathan
- Nationwide Children’s Hospital, Department of Abdominal Transplant and Hepatopancreatobiliary Surgery, The Ohio State University College of Medicine, Department of Surgery, Columbus, Ohio, United States
| | - Kate Ellery
- University of Pittsburgh Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh, Pennsylvania, United States
| | - Keshawadhana Balakrishnan
- Texas Children’s Hospital, Section of Pediatric Gastroenterology, Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States
| | - Heli Bhatt
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Armando Ganoza
- University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation, Pittsburgh, Pennsylvania, United States
| | - Sohail Z. Husain
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Rakesh Kumar
- Promedica Russell J. Ebeid Children’s Hospital, Toledo, Ohio, United States
| | - Veronique D. Morinville
- McGill University Health Center, Montreal Children’s Hospital, Division of Pediatric Gastroenterology and Nutrition, Montreal, Quebec, Canada
| | - J. Antonio Quiros
- Icahn School of Medicine, Mount Sinai Kravis Children’s Hospital, New York, New York, United States
| | - Sarah J. Schwarzenberg
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Zachary M. Sellers
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Aliye Uc
- University of Iowa, Carver College of Medicine, Stead Family Department of Pediatrics, Iowa City, Iowa, United States
| | - Maisam Abu-El-Haija
- Cincinnati Children’s Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, United States
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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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Xu X, Yu H, Sun L, Zheng C, Shan Y, Zhou Z, Wang C, Chen B. Adipose‑derived mesenchymal stem cells ameliorate dibutyltin dichloride‑induced chronic pancreatitis by inhibiting the PI3K/AKT/mTOR signaling pathway. Mol Med Rep 2020; 21:1833-1840. [PMID: 32319628 PMCID: PMC7057804 DOI: 10.3892/mmr.2020.10995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/17/2020] [Indexed: 12/20/2022] Open
Abstract
Adipose-derived mesenchymal stem cells (ASCs) play a positive role in tissue injury repair and regeneration. The aim of this study was to determine whether ASCs could ameliorate chronic pancreatitis (CP) induced by the injection of dibutyltin dichloride (DBTC) and to elucidate its potential mechanisms. Furthermore, this study also explored whether there was a significant difference if the ASCs were injected via the inferior vena cava or the left gastric artery. CP was induced in rats by a single intravenous administration of DBTC, and the accumulation of collagen and apoptotic rates of pancreatic acinar cells were analyzed. According to the results, ASCs markedly reduced DBTC-induced pancreatic damage and collagen deposition in the rat model of CP. Moreover, ASCs significantly decreased pancreatic cell apoptosis by regulating the expression levels of caspase-3, BAX and Bcl-2. These effects were observed regardless of whether the injection was in the inferior vena cava or the left gastric artery. It was also found that the expression levels of phosphorylated PI3K, AKT and mTOR in pancreatic tissues of the DBTC-induced CP model group were significantly increased, while the expression levels of phosphorylated PI3K, AKT and mTOR in the two treatment groups were markedly decreased. ASCs noticeably suppressed the PI3K/AKT/mTOR pathway in the pancreatic tissue of DBTC-induced CP. This study indicated that ASCs protect against pancreatic fibrosis by modulating the PI3K/AKT/mTOR pathway, and have the potential to be a new strategy for the treatment of CP in the future.
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Affiliation(s)
- Xiangxiang Xu
- Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato‑Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Huajun Yu
- Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato‑Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Linxiao Sun
- Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato‑Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Chenlei Zheng
- Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato‑Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Yunfeng Shan
- Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato‑Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Zhenxu Zhou
- Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato‑Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Cheng Wang
- Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato‑Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Bicheng Chen
- Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato‑Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
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5
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Efficacy of total pancreatectomy with islet autotransplantation on opioid and insulin requirement in painful chronic pancreatitis: A systematic review and meta-analysis. Surgery 2019; 166:263-270. [DOI: 10.1016/j.surg.2019.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 03/12/2019] [Accepted: 03/18/2019] [Indexed: 12/15/2022]
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Wang J, Zhang Y, Cloud C, Duke T, Owczarski S, Mehrotra S, Adams DB, Morgan K, Gilkeson G, Wang H. Mesenchymal Stem Cells from Chronic Pancreatitis Patients Show Comparable Potency Compared to Cells from Healthy Donors. Stem Cells Transl Med 2019; 8:418-429. [PMID: 30680957 PMCID: PMC6477001 DOI: 10.1002/sctm.18-0093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 11/07/2018] [Indexed: 12/27/2022] Open
Abstract
Mesenchymal stem cells (MSCs) are proven to be beneficial in islet transplantation, suggesting a potential therapeutic role of them in total pancreatectomy with islet autotransplantation (TP-IAT) for chronic pancreatitis (CP) patients. We investigated whether MSCs derived from CP patients are suitable for use in autologous cell therapy. MSCs from healthy donors (H-MSCs) and CP patients (CP-MSCs) were studied for phenotype, colony formation potential, multilineage differentiation ability, proliferation, senescence, secretory characters, and immunosuppressive functions. The potential protective effect of CP-MSCs was evaluated on hypoxia-induced islet cell death. Cell surface markers were similar between H-MSCs and CP-MSCs, as well as the ability of colony formation, multilineage differentiation, secretion of vascular endothelial growth factor and transforming growth factor (TGF-β), senescence, and inhibition of T cells proliferation in vitro. We found that growth differentiation factor 6 and hepatocyte growth factor (HGF) were significantly downregulated, whereas TGFβ and matrix metalloproteinase-2 were significantly upregulated in CP-MSCs compared with H-MSCs, among 84 MSC-related genes investigated in this study. MSCs from CP patients secreted less HGF, compared with the H-MSCs. A higher interferon-γ-induced indoleamine 2,3-dioxygenase expression was observed in CP-MSCs compared to H-MSCs. Moreover, CP-MSCs prevented hypoxia-induced β cell deaths to a similar extent as H-MSCs. Regardless of moderate difference in gene expression, CP-MSCs possess similar immunomodulatory and prosurvival functions to H-MSCs, and may be suitable for autologous cell therapy in CP patients undergoing TP-IAT. Stem Cells Translational Medicine 2019;8:418-429.
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Affiliation(s)
- Jingjing Wang
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Yong Zhang
- College of Life ScienceQingdao Agricultural UniversityQingdaoPeople's Republic of China
| | - Colleen Cloud
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Tara Duke
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Stefanie Owczarski
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Shikhar Mehrotra
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - David B. Adams
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Katherine Morgan
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Gary Gilkeson
- Department of MedicineMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Hongjun Wang
- Department of SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
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Saravanan PB, Kanak MA, Chang CA, Darden C, Yoshimatsu G, Lawrence MC, Naziruddin B. Islet damage during isolation as assessed by miRNAs and the correlation of miRNA levels with posttransplantation outcome in islet autotransplantation. Am J Transplant 2018; 18:982-989. [PMID: 29210193 DOI: 10.1111/ajt.14615] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/21/2017] [Accepted: 11/24/2017] [Indexed: 02/06/2023]
Abstract
High-quality pancreatic islets are essential for better posttransplantation endocrine function in total pancreatectomy with islet autotransplantation (TPIAT), yet stress during the isolation process affects quality and yield. We analyzed islet-enriched microRNAs (miRNAs) -375 and -200c released during isolation to assess damage and correlated the data with posttransplantation endocrine function. The absolute concentration of miR-375, miR-200c, and C-peptide was measured in various islet isolation steps, including digestion, dilution, recombination, purification, and bagging, in 12 cases of TPIAT. Posttransplantation glycemic control was monitored through C-peptide, hemoglobin A1c , insulin requirement, and SUITO index. The amount of miR-375 released was significantly higher during enzymatic digestion followed by the islet bagging (P < .001). Mir-200c mirrored these changes, albeit at lower concentrations. In contrast, the C-peptide amount was significantly higher in the purification and bagging steps (P < .001). Lower amounts of miR-375 were associated with a lower 6-month insulin requirement (P = .01) and lower hemoglobin A1c (P = .04). Measurement of the absolute quantity of miRNA-375 and -200c released during islet isolation is a useful tool to assess islet damage. The quantity of released miRNA is indicative of posttransplantation endocrine function in TPIAT patients.
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Affiliation(s)
| | - Mazhar A Kanak
- Transplantation Division, Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Charles A Chang
- Institute of Biomedical Studies, Baylor University, Waco, TX, USA
| | - Carly Darden
- Institute of Biomedical Studies, Baylor University, Waco, TX, USA
| | - Gumpei Yoshimatsu
- Islet Cell Laboratory, Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Michael C Lawrence
- Islet Cell Laboratory, Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Bashoo Naziruddin
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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Bellin MD, Kerdsirichairat T, Beilman GJ, Dunn TB, Chinnakotla S, Pruett TL, Radosevich DR, Schwarzenberg SJ, Sutherland DER, Arain MA, Freeman ML. Total Pancreatectomy With Islet Autotransplantation Improves Quality of Life in Patients With Refractory Recurrent Acute Pancreatitis. Clin Gastroenterol Hepatol 2016; 14:1317-23. [PMID: 26965843 PMCID: PMC5538725 DOI: 10.1016/j.cgh.2016.02.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Therapeutic options are limited for patients with recurrent acute pancreatitis who have intractable symptoms despite maximal endoscopic and medical treatment, but equivocal or no morphologic or functional evidence of chronic pancreatitis. We performed a prospective observational cohort study to determine the efficacy of total pancreatectomy with islet autotransplantation (TPIAT) for these patients. METHODS We collected data from all patients undergoing TPIAT at the University of Minnesota from 2007 through 2013; 49 patients (42 female; mean age, 32.8 ± 7.8 years) had a diagnosis of recurrent acute pancreatitis not provoked by intervention, with negative or equivocal findings from nondiagnostic imaging or pancreatic function tests for chronic pancreatitis, and intractable pain between episodes. Data on insulin use, narcotic requirements, pain scores, and health-related quality of life were collected before TPIAT; 3 months, 6 months, and 1 year afterward; and then yearly. RESULTS All 49 patients studied required narcotics before TPIAT (45 daily users and 4 intermittent users); 2 had insulin-treated diabetes. At 1 year after TPIAT, 22 out of 48 patients (46%) reported no use of narcotic pain medications (P < .001 vs baseline). Health-related quality of life score, measured by the physical and mental component summary score, increased by approximately 1 standard deviation from the population mean (P < .001 for the physical component summary; P = .019 for the mental component summary). At 1 year after TPIAT, 21 out of 48 patients (45%) were insulin independent; their mean percent glycosylated hemoglobin A1c at 1 year after TPIAT was 6.0% ± 0.9% (5.2% ± 0.6% pre-TPIAT). CONCLUSIONS Patients with recurrent acute pancreatitis but lacking clear chronic pancreatitis benefit from TPIAT, with outcomes similar to those previously described for patients with chronic pancreatitis (improved quality of life and reduced narcotic use). For these patients who have otherwise limited surgical treatment options, TPIAT can be considered when medical and endoscopic therapies have failed.
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Kumar R, Chung WY, Dennison AR, Garcea G. Current principles and practice in autologous intraportal islet transplantation: a meta-analysis of the technical considerations. Clin Transplant 2016; 30:344-56. [DOI: 10.1111/ctr.12695] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Rohan Kumar
- Department of Hepato-Pancreato-Biliary Surgery; University Hospitals of Leicester; Leicester UK
| | - Wen Yuan Chung
- Department of Hepato-Pancreato-Biliary Surgery; University Hospitals of Leicester; Leicester UK
| | - Ashley Robert Dennison
- Department of Hepato-Pancreato-Biliary Surgery; University Hospitals of Leicester; Leicester UK
| | - Giuseppe Garcea
- Department of Hepato-Pancreato-Biliary Surgery; University Hospitals of Leicester; Leicester UK
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10
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Factors Predicting Outcomes After a Total Pancreatectomy and Islet Autotransplantation Lessons Learned From Over 500 Cases. Ann Surg 2015; 262:610-22. [PMID: 26366540 DOI: 10.1097/sla.0000000000001453] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Our objective was to analyze factors predicting outcomes after a total pancreatectomy and islet autotransplantation (TP-IAT). BACKGROUND Chronic pancreatitis (CP) is increasingly treated by a TP-IAT. Postoperative outcomes are generally favorable, but a minority of patients fare poorly. METHODS In our single-centered study, we analyzed the records of 581 patients with CP who underwent a TP-IAT. Endpoints included persistent postoperative "pancreatic pain" similar to preoperative levels, narcotic use for any reason, and islet graft failure at 1 year. RESULTS In our patients, the duration (mean ± SD) of CP before their TP-IAT was 7.1 ± 0.3 years and narcotic usage of 3.3 ± 0.2 years. Pediatric patients had better postoperative outcomes. Among adult patients, the odds of narcotic use at 1 year were increased by previous endoscopic retrograde cholangiopancreatography (ERCP) and stent placement, and a high number of previous stents (>3). Independent risk factors for pancreatic pain at 1 year were pancreas divisum, previous body mass index >30, and a high number of previous stents (>3). The strongest independent risk factor for islet graft failure was a low islet yield-in islet equivalents (IEQ)-per kilogram of body weight. We noted a strong dose-response relationship between the lowest-yield category (<2000 IEQ) and the highest (≥5000 IEQ or more). Islet graft failure was 25-fold more likely in the lowest-yield category. CONCLUSIONS This article represents the largest study of factors predicting outcomes after a TP-IAT. Preoperatively, the patient subgroups we identified warrant further attention.
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11
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Wu Q, Zhang M, Qin Y, Jiang R, Chen H, Xu X, Yang T, Jiang K, Miao Y. Systematic review and meta-analysis of islet autotransplantation after total pancreatectomy in chronic pancreatitis patients. Endocr J 2015; 62:227-34. [PMID: 25735805 DOI: 10.1507/endocrj.ej14-0510] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Islet autotransplantation (IAT) is a viable treatment for patients with severe chronic pancreatitis, this modality may prevent brittle diabetes mellitus after pancreatectomy. This systematic review and meta-analysis was performed to evaluated the outcomes of IAT after TP and discuss the factors that may affect the efficacy of this procedure. MEDLINE, Embase, Web of Science and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1977 to 30 April 2014. Cohort Studies reported patients with IAT after TP were included. The studies and data were identified and extracted by two reviewers independently. Data were analyzed using STATA 12.0 and Comprehensive Meta AnalysisV2 software. Random effects model, meta-regression analysis, sensitivity analysis and publication bias were conducted to improve the comprehensive analysis. Twelve studies reporting the outcomes of 677 patients were included in this review. The insulin independent rate for IAT after TP at last follow-up was 3.72 per 100 person-years (95% CI: 1.00-6.44). The 30-day mortality was 2.1% (95% CI: 1.2-3.8%). The mortality at last follow-up was 1.09 per 100 person-years (95% CI: 0.21-1.97). Factors associated with incidence density of insulin independence in univariate meta-regression analyses included islet equivalents per kg body weight (IEQ/kgBW) (P=0.026). Our systematic review suggests that IAT is a safe modality for patients with CP need to undergo TP. A significant number of patients will achieve insulin independence for a long time after receiving enough IEQ/kgBW.
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Affiliation(s)
- Qian Wu
- Department of Endocrinology, the First Affiliated Hospital with Nanjing Medical University, Nanjing Medical University, China
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12
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Total pancreatectomy and islet autotransplantation in children for chronic pancreatitis: indication, surgical techniques, postoperative management, and long-term outcomes. Ann Surg 2014; 260:56-64. [PMID: 24509206 DOI: 10.1097/sla.0000000000000569] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Describe the surgical technique, complications, and long-term outcomes of total pancreatectomy and islet autotransplantation (TP-IAT) in a large series of pediatric patients. BACKGROUND Surgical management of childhood pancreatitis is not clear; partial resection or drainage procedures often provide transient pain relief, but long-term recurrence is common due to the diffuse involvement of the pancreas. Total pancreatectomy (TP) removes the source of the pain, whereas islet autotransplantation (IAT) potentially can prevent or minimize TP-related diabetes. METHODS Retrospective review of 75 children undergoing TP-IAT for chronic pancreatitis who had failed medical, endoscopic, or surgical treatment between 1989 and 2012. RESULTS Pancreatitis pain and the severity of pain statistically improved in 90% of patients after TP-IAT (P < 0.001). The relief from narcotics was sustained. Of the 75 patients undergoing TP-IAT, 31 (41.3%) achieved insulin independence. Younger age (P = 0.032), lack of prior Puestow procedure (P = 0.018), lower body surface area (P = 0.048), higher islet equivalents (IEQ) per kilogram body weight (P = 0.001), and total IEQ (100,000) (P = 0.004) were associated with insulin independence. By multivariate analysis, 3 factors were associated with insulin independence after TP-IAT: (1) male sex, (2) lower body surface area, and (3) higher total IEQ per kilogram body weight. Total IEQ (100,000) was the single factor most strongly associated with insulin independence (odds ratio = 2.62; P < 0.001). CONCLUSIONS Total pancreatectomy and islet autotransplantation provides sustained pain relief and improved quality of life. The β-cell function is dependent on islet yield. Total pancreatectomy and islet autotransplantation is an effective therapy for children with painful pancreatitis that failed medical and/or endoscopic management.
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Johnson CN, Morgan KA, Owczarski SM, Wang H, Fried J, Adams DB. Autotransplantation of culture-positive islet product: is dirty always bad? HPB (Oxford) 2014; 16:665-9. [PMID: 24308511 PMCID: PMC4105905 DOI: 10.1111/hpb.12198] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 10/15/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND In selected patients, total pancreatectomy with islet autotransplantation (TPIAT) effectively relieves pain caused by chronic pancreatitis and ameliorates the brittle diabetes of the apancreatic state. Patients often undergo multiple endoscopic and surgical interventions prior to TPIAT, increasing the risk for pancreas colonization with enteric microorganisms. Little is known of the safety of transplanting islet cells with microbial contamination. METHODS A prospectively collected database of 80 patients submitted to TPIAT at the Medical University of South Carolina from March 2009 to February 2012 was retrospectively reviewed. Patient charts were reviewed for postoperative infectious complications and organisms identified were compared with those identified in pre-transplant islet cultures. RESULTS A total of 35 patients (43.8%) had a positive pre-transplant islet cell Gram stain or islet cell culture from the final islet preparation solution. Of these 35 patients, 33 (94.3%) were given antibiotics prophylactically post-transplant for a positive islet Gram stain or culture. Twenty patients (57.1%) receiving Gram stain- or culture-positive islets developed postoperative infectious complications, but only four patients (11.4%) developed infections that concorded with their pre-transplant islet product. CONCLUSIONS Islet transplant solutions are frequently culture-positive, presumably as a result of prior pancreas intervention. Microbial contamination of islet preparations should not preclude autotransplantation.
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Affiliation(s)
- Crystal N Johnson
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
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Chhabra P, Brayman KL. Overcoming barriers in clinical islet transplantation: current limitations and future prospects. Curr Probl Surg 2014; 51:49-86. [PMID: 24411187 DOI: 10.1067/j.cpsurg.2013.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Bellin MD, Freeman ML, Gelrud A, Slivka A, Clavel A, Humar A, Schwarzenberg SJ, Lowe ME, Rickels MR, Whitcomb DC, Matthews JB, Amann S, Andersen DK, Anderson MA, Baillie J, Block G, Brand R, Chari S, Cook M, Cote GA, Dunn T, Frulloni L, Greer JB, Hollingsworth MA, Kim KM, Larson A, Lerch MM, Lin T, Muniraj T, Robertson RP, Sclair S, Singh S, Stopczynski R, Toledo FGS, Wilcox CM, Windsor J, Yadav D. Total pancreatectomy and islet autotransplantation in chronic pancreatitis: recommendations from PancreasFest. Pancreatology 2014; 14:27-35. [PMID: 24555976 PMCID: PMC4058640 DOI: 10.1016/j.pan.2013.10.009] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 10/23/2013] [Accepted: 10/25/2013] [Indexed: 12/11/2022]
Abstract
DESCRIPTION Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure used to treat severe complications of chronic pancreatitis or very high risk of pancreatic cancer while reducing the risk of severe diabetes mellitus. However, clear guidance on indications, contraindications, evaluation, timing, and follow-up are lacking. METHODS A working group reviewed the medical, psychological, and surgical options and supporting literature related to TPIAT for a consensus meeting during PancreasFest. RESULTS Five major areas requiring clinical evaluation and management were addressed: These included: 1) indications for TPIAT; 2) contraindications for TPIAT; 3) optimal timing of the procedure; 4) need for a multi-disciplinary team and the roles of the members; 5) life-long management issues following TPIAP including diabetes monitoring and nutrition evaluation. CONCLUSIONS TPIAT is an effective method of managing the disabling complications of chronic pancreatitis and risk of pancreatic cancer in very high risk patients. Careful evaluation and long-term management of candidate patients by qualified multidisciplinary teams is required. Multiple recommendations for further research were also identified.
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Affiliation(s)
- Melena D. Bellin
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Martin L. Freeman
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pennsylvania, USA
| | - Alfred Clavel
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pennsylvania, USA
| | | | - Mark E. Lowe
- Department of Pediatrics, University of Pittsburgh, Pennsylvania, USA,Children’s Hospital of Pittsburgh, Pennsylvania, USA
| | - Michael R. Rickels
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pennsylvania, USA
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Prior surgery determines islet yield and insulin requirement in patients with chronic pancreatitis. Transplantation 2013; 95:1051-7. [PMID: 23411743 DOI: 10.1097/tp.0b013e3182845fbb] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Total pancreatectomy with islet autotransplantation (TP-IAT) is safe and effective in the management of intractable pain associated with chronic pancreatitis (CP). Prevention of pancreatogenic diabetes after TP-IAT is related to islet yield from the diseased pancreas. The purpose of this study is to compare islet yield and insulin requirement in the 76 patients who underwent different surgical procedures before TP-IAT at the Medical University of South Carolina between 2009 and 2011. METHODS Patients were grouped into four categories based on the operation they had before TP-IAT: transduodenal sphincteroplasty/no prior surgery (n=50), Whipple or Beger procedure (n=14), distal pancreatectomy (n=8), or lateral pancreaticojejunostomy (n=4). Islets were harvested from pancreases of those patients at our current good manufacturing practice facility. Total unpurified islets were transplanted into patients via portal vein infusion. Pancreatic fibrosis, islet yield, cell viability, and insulin requirement were measured. RESULTS The pancreases of transduodenal sphincteroplasty/no prior surgery and Whipple or Beger procedure patients were less fibrotic and had higher islet yield compared with those who had distal pancreatectomy or lateral pancreaticojejunostomy. Higher islet yield also correlated with a greater diabetes-free rate and a lesser insulin requirement at the following intervals: preoperative, postoperative, and 6 months after TP-IAT. CONCLUSIONS Prior surgery is strongly correlated with the extent of pancreatic fibrosis, islet yield, and insulin requirements in CP patients undergoing TP-IAT. The history of prior pancreatic resection and drainage procedures may be used to predict postoperative islet function and help to determine the optimal timing for TP-IAT in CP patients.
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Bellin M, Balamurugan A, Pruett TL, Sutherland DE. No islets left behind: islet autotransplantation for surgery-induced diabetes. Curr Diab Rep 2012; 12:580-6. [PMID: 22777430 PMCID: PMC3432727 DOI: 10.1007/s11892-012-0296-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
For patients with severe chronic pancreatitis refractory to medical interventions, total pancreatectomy can be considered to relieve the root cause of pain. The goal of a simultaneous islet autotransplant is to prevent or minimize the otherwise inevitable surgical diabetes. Islet autotransplant can successfully preserve some endogenous islet function in the majority of recipients, which mediates protection against brittle diabetes. Most maintain reasonably good glycemic control, while 30 %-40 % successfully discontinue insulin therapy. With islet autotransplants reaching a wider clinical audience, refinements in islet isolation techniques and strategies to protect islet grafts post-transplant may further improve the success of this procedure.
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Affiliation(s)
- Melena Bellin
- University of Minnesota Amplatz Children’s Hospital, East Building, Rm MB-671, 2450 Riverside Ave E, Minneapolis, MN 55454
| | - A.N. Balamurugan
- University of Minnesota, Schulze Diabetes Institute, Department of Surgery, 420 Delaware St SE, Minneapolis, MN 55455, Phone 651-253-0656, Fax 612-626-5855,
| | - Timothy L. Pruett
- University of Minnesota, 420 Delaware St. S.E., Minneapolis, MN 55455, 612-626-7282 Phone, 612-624-7168 Fax,
| | - David E.R. Sutherland
- University of Minnesota, 420 Delaware St. S.E., Minneapolis, MN 55455, 612-625-7600 Phone, 612-624-7168 Fax,
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Wang H, Wu H, Rocuts F, Gu Z, Bach FH, Otterbein LE. Activation of Peroxisome Proliferator-Activated Receptor γ Prolongs Islet Allograft Survival. Cell Transplant 2012; 21:2111-8. [DOI: 10.3727/096368911x637399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Exposing donor mice to carbon monoxide (CO) protects transplanted islet allografts from immune rejection after transplantation (referred as the “donor” effect). In an attempt to understand the mechanisms of the donor effect of CO, we found that donor treatment with CO upregulates expression of peroxisome proliferatoractivated receptor γ (PPARγ), a transcriptional regulator, in isolated islets. In this study, we evaluated whether PPARγ contributes to the survival and function of transplanted islets and whether PPARγ mediates the protective effect of CO in a major mismatch islet allogeneic transplantation model. BALB/c (H-2d) islets in which PPARγ activity was induced by its agonists, 15-deoxy-Δ12–14-prostaglandin J2 (15d-PGJ2) or troglitazone were transplanted into C57BL/6 (H-2b) recipients that had been rendered diabetic by streptozotocin (STZ). Blood glucose levels of recipients were monitored to determine the function of transplanted islets. Our data indicated that PPARγ activation in islets led to a high percentage of BALB/c islets survived long-term in C57BL/6 recipients. Activation of PPARγ in the donor suppresses expressions of proinflammatory cytokines including tumor necrosis factor-α (TNF-α) and inducible nitric oxide synthase (iNOS) in transplanted islets. Blocking PPARγ activity by its antagonist, GW9662, abrogated the donor effect of CO in vivo and in vitro. Our data demonstrate that PPARγ plays a critical role in the survival and function of transplanted islets after transplantation in the recipient. The protective effects of CO are at least in part mediated by PPARγ.
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Affiliation(s)
- Hongjun Wang
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hongju Wu
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Fredy Rocuts
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zhuoying Gu
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Fritz H. Bach
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Leo E. Otterbein
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Bellin MD, Sutherland DER, Robertson RP. Pancreatectomy and autologous islet transplantation for painful chronic pancreatitis: indications and outcomes. Hosp Pract (1995) 2012; 40:80-87. [PMID: 23086097 DOI: 10.3810/hp.2012.08.992] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Total pancreatectomy with intrahepatic autoislet transplantation (TP/IAT) is a definitive treatment for relentlessly painful chronic pancreatitis. Pain relief is reported to be achieved in approximately 80% of patients. Overall, 30% to 40% achieve insulin independence, and 70% of recipients remain insulin independent for > 2 years, sometimes longer if > 300 000 islets are successfully transplanted. Yet, this approach to chronic pancreatitis is underemphasized in the general medical and surgical literature and vastly underused in the United States. This review emphasizes the history and metabolic outcomes of TP/IAT and considers its usefulness in the context of other, more frequently used approaches, such as operative intervention with partial pancreatectomy and/or lateral pancreaticojejunostomy (Puestow procedure), as well as endoscopic retrograde cholangiopancreatography with pancreatic duct modification and stent placement. Distal pancreatectomy and Puestow procedures compromise isolation of islet mass, and adversely affect islet autotransplant outcomes. Therefore, when endoscopic measures fail to relieve pain in severe chronic pancreatitis, we recommend early intervention with TP/IAT.
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Affiliation(s)
- Melena D Bellin
- The Division of Endocrinology, Department of Pediatrics, University of Minnesota, St. Paul, MN
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Sutherland DER, Radosevich DM, Bellin MD, Hering BJ, Beilman GJ, Dunn TB, Chinnakotla S, Vickers SM, Bland B, Balamurugan AN, Freeman ML, Pruett TL. Total pancreatectomy and islet autotransplantation for chronic pancreatitis. J Am Coll Surg 2012. [PMID: 22397977 DOI: 10.1016/j.jamcollsurg.2011.12.040s1072-7515(12)00014-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Total pancreatectomy (TP) with intraportal islet autotransplantation (IAT) can relieve pain and preserve β-cell mass in patients with chronic pancreatitis (CP) when other therapies fail. We report on a >30-year single-center series. STUDY DESIGN Four hundred and nine patients (including 53 children, 5 to 18 years) with CP underwent TP-IAT from February 1977 to September 2011 (etiology: idiopathic, 41%; Sphincter of Oddi dysfunction/biliary, 9%; genetic, 14%; divisum, 17%; alcohol, 7%; and other, 12%; mean age was 35.3 years, 74% were female; 21% has earlier operations, including 9% Puestow procedure, 6% Whipple, 7% distal pancreatectomy, and 2% other). Islet function was classified as insulin independent for those on no insulin; partial, if known C-peptide positive or euglycemic on once-daily insulin; and insulin dependent if on standard basal-bolus diabetic regimen. A 36-item Short Form (SF-36) survey for quality of life was completed by patients before and in serial follow-up since 2007, with an integrated survey that was added in 2008. RESULTS Actuarial patient survival post TP-IAT was 96% in adults and 98% in children (1 year) and 89% and 98% (5 years). Complications requiring relaparotomy occurred in 15.9% and bleeding (9.5%) was the most common complication. IAT function was achieved in 90% (C-peptide >0.6 ng/mL). At 3 years, 30% were insulin independent (25% in adults, 55% in children) and 33% had partial function. Mean hemoglobin A1c was <7.0% in 82%. Earlier pancreas surgery lowered islet yield (2,712 vs 4,077/kg; p = 0.003). Islet yield (<2,500/kg [36%]; 2,501 to 5,000/kg [39%]; >5,000/kg [24%]) correlated with degree of function with insulin-independent rates at 3 years of 12%, 22%, and 72%, and rates of partial function 33%, 62%, and 24%. All patients had pain before TP-IAT and nearly all were on daily narcotics. After TP-IAT, 85% had pain improvement. By 2 years, 59% had ceased narcotics. All children were on narcotics before, 39% at follow-up; pain improved in 94%; and 67% became pain-free. In the SF-36 survey, there was significant improvement from baseline in all dimensions, including the Physical and Mental Component Summaries (p < 0.01), whether on narcotics or not. CONCLUSIONS TP can ameliorate pain and improve quality of life in otherwise refractory CP patients, even if narcotic withdrawal is delayed or incomplete because of earlier long-term use. IAT preserves meaningful islet function in most patients and substantial islet function in more than two thirds of patients, with insulin independence occurring in one quarter of adults and half the children.
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Affiliation(s)
- David E R Sutherland
- Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN 55455, USA.
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Sutherland DER, Radosevich DM, Bellin MD, Hering BJ, Beilman GJ, Dunn TB, Chinnakotla S, Vickers SM, Bland B, Balamurugan AN, Freeman ML, Pruett TL. Total pancreatectomy and islet autotransplantation for chronic pancreatitis. J Am Coll Surg 2012; 214:409-24; discussion 424-6. [PMID: 22397977 DOI: 10.1016/j.jamcollsurg.2011.12.040] [Citation(s) in RCA: 298] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 12/15/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Total pancreatectomy (TP) with intraportal islet autotransplantation (IAT) can relieve pain and preserve β-cell mass in patients with chronic pancreatitis (CP) when other therapies fail. We report on a >30-year single-center series. STUDY DESIGN Four hundred and nine patients (including 53 children, 5 to 18 years) with CP underwent TP-IAT from February 1977 to September 2011 (etiology: idiopathic, 41%; Sphincter of Oddi dysfunction/biliary, 9%; genetic, 14%; divisum, 17%; alcohol, 7%; and other, 12%; mean age was 35.3 years, 74% were female; 21% has earlier operations, including 9% Puestow procedure, 6% Whipple, 7% distal pancreatectomy, and 2% other). Islet function was classified as insulin independent for those on no insulin; partial, if known C-peptide positive or euglycemic on once-daily insulin; and insulin dependent if on standard basal-bolus diabetic regimen. A 36-item Short Form (SF-36) survey for quality of life was completed by patients before and in serial follow-up since 2007, with an integrated survey that was added in 2008. RESULTS Actuarial patient survival post TP-IAT was 96% in adults and 98% in children (1 year) and 89% and 98% (5 years). Complications requiring relaparotomy occurred in 15.9% and bleeding (9.5%) was the most common complication. IAT function was achieved in 90% (C-peptide >0.6 ng/mL). At 3 years, 30% were insulin independent (25% in adults, 55% in children) and 33% had partial function. Mean hemoglobin A1c was <7.0% in 82%. Earlier pancreas surgery lowered islet yield (2,712 vs 4,077/kg; p = 0.003). Islet yield (<2,500/kg [36%]; 2,501 to 5,000/kg [39%]; >5,000/kg [24%]) correlated with degree of function with insulin-independent rates at 3 years of 12%, 22%, and 72%, and rates of partial function 33%, 62%, and 24%. All patients had pain before TP-IAT and nearly all were on daily narcotics. After TP-IAT, 85% had pain improvement. By 2 years, 59% had ceased narcotics. All children were on narcotics before, 39% at follow-up; pain improved in 94%; and 67% became pain-free. In the SF-36 survey, there was significant improvement from baseline in all dimensions, including the Physical and Mental Component Summaries (p < 0.01), whether on narcotics or not. CONCLUSIONS TP can ameliorate pain and improve quality of life in otherwise refractory CP patients, even if narcotic withdrawal is delayed or incomplete because of earlier long-term use. IAT preserves meaningful islet function in most patients and substantial islet function in more than two thirds of patients, with insulin independence occurring in one quarter of adults and half the children.
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Affiliation(s)
- David E R Sutherland
- Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN 55455, USA.
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Induction of protective genes leads to islet survival and function. J Transplant 2011; 2011:141898. [PMID: 22220267 PMCID: PMC3246756 DOI: 10.1155/2011/141898] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 09/01/2011] [Indexed: 12/16/2022] Open
Abstract
Islet transplantation is the most valid approach to the treatment of type 1 diabetes. However, the function of transplanted islets is often compromised since a large number of β cells undergo apoptosis induced by stress and the immune rejection response elicited by the recipient after transplantation. Conventional treatment for islet transplantation is to administer immunosuppressive drugs to the recipient to suppress the immune rejection response mounted against transplanted islets. Induction of protective genes in the recipient (e.g., heme oxygenase-1 (HO-1), A20/tumor necrosis factor alpha inducible protein3 (tnfaip3), biliverdin reductase (BVR), Bcl2, and others) or administration of one or more of the products of HO-1 to the donor, the islets themselves, and/or the recipient offers an alternative or synergistic approach to improve islet graft survival and function. In this perspective, we summarize studies describing the protective effects of these genes on islet survival and function in rodent allogeneic and xenogeneic transplantation models and the prevention of onset of diabetes, with emphasis on HO-1, A20, and BVR. Such approaches are also appealing to islet autotransplantation in patients with chronic pancreatitis after total pancreatectomy, a procedure that currently only leads to 1/3 of transplanted patients being diabetes-free.
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Dong M, Parsaik AK, Erwin PJ, Farnell MB, Murad MH, Kudva YC. Systematic review and meta-analysis: islet autotransplantation after pancreatectomy for minimizing diabetes. Clin Endocrinol (Oxf) 2011; 75:771-9. [PMID: 21605156 DOI: 10.1111/j.1365-2265.2011.04121.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Islet autotransplantation (IAT) may decrease the morbidity and mortality of postpancreatectomy diabetes mellitus. The current systematic review and meta-analysis examined the rate of insulin independence (II) and mortality after IAT post-total (TP) or partial pancreatectomy (PP). METHODS Ovid MEDLINE, EMBASE, Web of Science, SCOPUS and reference lists were searched until 31 January 2011. Eligible studies enrolled adult patients with IAT post-TP or PP, regardless of study design, sample size and language. Two investigators identified eligible studies and extracted data independently. From each study, 95% confidence intervals (CIs) were estimated and pooled using random effects meta-analysis. RESULTS Fifteen observational studies were eligible (11 IAT post-TP, two post-PP and two including both). The II rates for IAT post-TP at last follow-up and transiently during the study were 4·62 per 100 person-years (95% CI: 1·53-7·72) and 8·34 per 100 person-years (95% CI: 3·32-13·37), respectively. In the later group, patients achieved transient II lasting 15·57 months (95% CI: 10·35-20·79). The II rate at last follow-up for IAT post-PP was 24·28 per 100 person-years (95% CI: 0·00-48·96). Whereas the 30-day mortality for IAT post-TP and post-PP was 5% (95% CI: 2-10%) and 0, respectively, the long-term mortality was 1·38 per 100 person-years (95% CI: 0·66-2·11) and 0·70 per 100 person-years (95% CI: 0·00-1·80) respectively. CONCLUSIONS IAT postpancreatectomy offers some patients a chance for insulin independence. Better data reporting are essential to establish the risks and benefits of IAT after pancreatic surgery.
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Affiliation(s)
- Ming Dong
- Endocrinology, Diabetes, Metabolism, & Nutrition, Mayo Clinic, Rochester, MN 55902, USA
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Abstract
Autologous islet transplantation (AIT) is performed to prevent surgical diabetes after total or semi-total pancreatectomy for the treatment of chronic pancreatitis with severe abdominal pain. In addition, AIT is used in cases of benign pancreatic tumors and pancreatic trauma. It has been shown that AIT results in better outcomes in terms of glycemic control compared with allogeneic islet transplantation. The reasons for the favorable outcomes of AIT are thought to be: (i) patients have no autoimmune diseases; (ii) the transplanted islets do not suffer allogeneic rejection; (iii) diabetogenic antirejection drugs are not required; (iv) pancreata do not undergo a cytokine storm as a result of periods of brain death; (v) the period of cold preservation of retrieved pancreata is short; (vi) the isolated islets are immediately transplanted without culture; and (vii) pancreata with pancreatitis may contain more progenitor cells. Further research into AIT would help improve the results of allogeneic islet transplantation. Conversely, the technical difficulties associated with islet isolation appear to be the largest hurdle for AIT; therefore, remote center islet isolation may prove to be key in the promotion of this treatment.
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Affiliation(s)
- Shinichi Matsumoto
- Baylor All Saints Islet Cell Laboratory, Baylor Research Institute Fort Worth Campus, Fort Worth, Texas 76104, USA.
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Quality of life improves for pediatric patients after total pancreatectomy and islet autotransplant for chronic pancreatitis. Clin Gastroenterol Hepatol 2011; 9:793-9. [PMID: 21683160 PMCID: PMC3163759 DOI: 10.1016/j.cgh.2011.04.024] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2010] [Revised: 04/13/2011] [Accepted: 04/24/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Total pancreatectomy (TP) and islet autotransplant (IAT) have been used to treat patients with painful chronic pancreatitis. Initial studies indicated that most patients experienced significant pain relief, but there were few validated measures of quality of life. We investigated whether health-related quality of life improved among pediatric patients undergoing TP/IAT. METHODS Nineteen consecutive children (aged 5-18 years) undergoing TP/IAT from December 2006 to December 2009 at the University of Minnesota completed the Medical Outcomes Study 36-item Short Form (SF-36) health questionnaire before and after surgery. Insulin requirements were recorded. RESULTS Before TP/IAT, patients had below average health-related quality of life, based on data from the Medical Outcomes Study SF-36; they had a mean physical component summary (PCS) score of 30 and mental component summary (MCS) score of 34 (2 and 1.5 standard deviations, respectively, below the mean for the US population). By 1 year after surgery, PCS and MCS scores improved to 50 and 46, respectively (global effect, PCS P < .001, MCS P = .06). Mean scores improved for all 8 component subscales. More than 60% of IAT recipients were insulin independent or required minimal insulin. Patients with prior surgical drainage procedures (Puestow) had lower yields of islets (P = .01) and greater incidence of insulin dependence (P = .04). CONCLUSIONS Quality of life (physical and emotional components) significantly improve after TP/IAT in subsets of pediatric patients with severe chronic pancreatitis. Minimal or no insulin was required for most patients, although islet yield was reduced in patients with previous surgical drainage operations.
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Implication of pancreatic image findings in total pancreatectomy with islet autotransplantation for chronic pancreatitis. Pancreas 2011; 40:103-8. [PMID: 20881896 DOI: 10.1097/mpa.0b013e3181f749bc] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To clarify the implication of pancreatic findings on transabdominal ultrasound and/or abdominal computed tomographic scan on outcomes of islet isolation and endocrine function after total pancreatectomy (TP) with islet autotransplantation (IAT). METHODS Retrospective review of islet isolations and graft functions in a cohort of patients with chronic pancreatitis who received TP with IAT from December 2007 to September 2009. Patients were categorized into the following 2 groups on the basis of their transabdominal ultrasound or computed tomographic findings before IAT: early group (normal or equivocal of Cambridge classification) and advanced group (mild to marked). RESULTS A total of 12 patients (early group, n=6; advanced group, n=6) were included. Total islet yield per pancreas weight and per patient body weight in the early group was significantly higher compared with that in the advanced group (6989±659 vs 3567±615 islet equivalents per gram, P<0.01; 8556±953 vs 3847±739 islet equivalents per kilogram, P<0.01, respectively). Four patients (67%) in the early group became insulin-free, whereas 2 patients (33%) in the advanced group obtained insulin independence. However, both groups maintained islet graft function and similar glycated hemoglobin levels after transplantation. CONCLUSIONS Excellent glycemic control was observed in both groups of patients who received TP with IAT, although the early group showed a significantly better outcome of islet isolation.
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