Auto-islet transplantation after pancreatectomy

Robotic total pancreatectomy with or without autologous islet cell transplantation: replication of an open technique through a minimal access approach

BACKGROUND

Total pancreatectomy (TP) is a morbid but sometimes necessary operation. Robotic TP is not often reported but may harbor some advantages compared to the open approach. This manuscript details a single institution's outcomes and technique of robotic TP. An accompanying video demonstrates a robotic TP with auto islet cell transplantation (IAT) in which (1) the arterial blood supply and venous drainage are kept intact until the last step of the TP to minimize warm ischemia time and (2) extirpation of the entire pancreas is performed without dividing the pancreatic neck to maximize islet recovery.

METHODS

This study is a retrospective review of a prospective database of perioperative outcomes of all consecutive robotic TPs at a single institution. This included a single robotic TP with IAT performed on a twenty-year-old patient with chronic pancreatitis.

RESULTS

Between 2010 and January 2014, ten robotic TPs were performed (7 males, mean age 58 years), one of which included an IAT. Median body mass index was 28. Indications were intraductal papillary mucinous neoplasms (6), pancreatic adenocarcinoma (1), and chronic pancreatitis (3). The median operative time was 560 min with a median estimated blood loss of 650 ml. One case was converted to laparotomy. Ninety days mortality and Clavien III-IV complication rate were 0 and 20 %, respectively. The average length of stay was 10 ± 3 days, with only 1 readmission within 90 days. The single TP and IAT were completed successfully without conversion, and were achieved without division of the pancreatic neck thereby maintaining vascular inflow to an entire specimen up until extraction.

CONCLUSION

This represents the largest series of robotic TP, demonstrating its safety and feasibility. Additionally, TP and IAT using the technique described above can be recapitulated using the robotic approach.

Prior surgery determines islet yield and insulin requirement in patients with chronic pancreatitis

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.

Sustained reversal of diabetes following islet transplantation to striated musculature in the rat

BACKGROUND

There is an increasing emphasis in the islet transplant community on the development of alternative sites for islet implantation. Striated musculature constitutes a potential alternative, which has been successfully employed in autotransplantation of parathyroid glands for decades. In the present study, a technique for intramuscular islet transplantation was developed and compared with intraportal islet transplantation in a syngeneic rat model.

MATERIALS AND METHODS

Lewis rats were used. Pancreata were digested using Liberase. Islets were either transplanted into m. biceps femoris in a pearls-on-a-string fashion or intraportally, and the ability to reverse diabetes was compared. Eight weeks after transplantation an IVGTT was performed. Real-time quantitative RT-PCR was employed on muscle biopsies to investigate mRNA levels of cytokines in response to the transplant procedure. Explanted livers, muscles, and pancreata were harvested at the end of the experiment for histopathological analyses.

RESULTS

2000 IEQ repeatedly cured diabetic rats at the intraportal site, while 4000 IEQ was required at the intramuscular site. Time to reversal of diabetes, post-transplant weight development, and IVGTT curves did not differ between the groups. Normoglycemia was sustainable to the end of the study (>100 days) for all animals. The transplant procedure upregulated pro-inflammatory cytokines (IL-6 and IL-8) in striated muscle, and peri-islet fibrosis was observed in intramuscular grafts.

CONCLUSIONS

Islet transplantation into striated musculature is feasible; however, in its present form the intramuscular site is less efficient compared with the liver in rats. The intramuscular site allows manipulation of the graft and implantation site prior to transplantation and may therefore have implications for islet transplantation in humans.

Ultrasound changes within the liver after total pancreatectomy and intrahepatic islet cell autotransplantation

OBJECTIVE

Intrahepatic infusion is the most common method of islet autotransplantation. Structural and functional changes within the liver may result from a number of factors, including embolization of the terminal branches of the portal vein, the effects of high insulin concentration on surrounding hepatocytes or responses to the death of admixed exocrine tissue. Awareness of the potential changes in the appearance of the liver on ultrasonography (USS), together with an assessment of liver function, is important in the postoperative surveillance of these patients.

METHODS

We retrospectively reviewed 83 patients who underwent total pancreatectomy between 1993 and 2006. Thirty-three patients had total pancreatectomy alone (control group) and 50 patients underwent total pancreatectomy and islet autotransplantation (islet group). The islets were infused into the left lobe of the liver through the middle colic or recannalated umbilical vein. All patients underwent USS as part of their hepaticojejunostomy surveillance (initially every 6 months and then yearly).

RESULTS

"Echogenic nodularity" of the liver was observed in 25% of the islet group of patients and in none of the control group patients (P=0.03). These USS changes occurred from 6 to 12 months after islet autotransplantation and were not associated with any significant loss of liver function or increase in insulin requirements. The islet group had significantly less insulin requirement compared with the control group (P<0.01).

CONCLUSION

Echogenicity with a nodular appearance is a common ultrasonographic finding in the liver after intrahepatic islet autotransplantation. These changes do not seem to adversely affect liver function or insulin requirement. Appreciating these changes is important to avoid misinterpretation or over-interpretation of postoperative USS images.

Factors associated with insulin and narcotic independence after islet autotransplantation in patients with severe chronic pancreatitis

BACKGROUND

For patients who suffer from severe chronic pancreatitis, total pancreatectomy can alleviate pain, and islet autotransplantation (IAT) might preserve endocrine function and circumvent the complications of diabetes. Factors that determine success after this operation have not been clearly defined.

STUDY DESIGN

From 2000 to 2004, 45 total or subtotal pancreatectomies with IAT were performed. Patient characteristics, narcotic usage and insulin requirements were recorded at routine followup. Narcotic usage was standardized by conversion to morphine equivalents (MEs). Univariate and multivariate statistical analyses were performed to determine factors associated with insulin and narcotic independence.

RESULTS

Forty-five patients (30 women, 15 men), with a mean age of 39 years (range 16 to 62 years) underwent total or completion (n=41) or subtotal (n=4) pancreatectomies with IAT. Forty percent of patients were insulin free after a mean followup of 18months (range 1 to 46months). Factors associated in univariate analyses with insulin independence included female gender (p=0.004), lower body weight (kg) (p=0.04), more islet equivalents per kg body weight (IEQ/kg) transfused (<0.05), lower mean insulin requirement for the first 24hours postoperation (p=0.002), and lower mean insulin requirement at discharge (p=0.0005). A multiple logistic regression using gender, body mass index, and IEQ/kg identified female gender as the only notable variable associated with insulin independence. There was a notable reduction (p < 0.0001) of postoperative MEs (mean 90 mg) compared with preoperative MEs (mean 206 mg) for the entire cohort; 58% of patients are narcotic independent. In the subset of patients with>5months followup (n=32), 23 (72%) are narcotic free, with a substantial decrease in ME usage (p=0.01).

CONCLUSIONS

The likelihood of glycemic control after IAT is related to both patient characteristics and islet cell mass. Based on these data, more islet cells may be required for insulin independence than previously thought.

Cell therapies for type 1 diabetes mellitus

Type 1 diabetes is caused by autoimmune destruction of pancreatic beta-cells and is characterised by absolute insulin insufficiency. The monocellular nature of this disease and endocrine action of insulin make this disease an excellent candidate for cellular therapy. Furthermore, precedent for cellular therapies has been set by successful cadaveric whole pancreas and islet transplantation. In order to expand the supply of cells to meet current and future needs, several novel cell sources have been proposed, including human beta-cells or islets expanded in culture, islet xenografts and pancreatic ductal progenitor cells. Surrogate beta-cells derived from hepatocytes, intestinal K cells or non-endodermal cell types have also been suggested. Stem cells found in bone marrow and umbilical cord blood have been used extensively to repopulate the haematopoietic system and offer the possibility of autologous transplantation. Recent studies have suggested that these stem cells may also have a broader capacity to differentiate, possibly into beta-cells. Stem cells from embryonic sources, such as human embryonic stem and embryonic germ cells, have the ability to proliferate extensively in culture and have an inherent developmental plasticity that may make them a potentially unlimited source of cells that can sense glucose and produce mature insulin. The wide range of proposed cell sources and our increasingly clear picture of pancreatic development suggest that novel cellular therapies might one day compete with non-cellular glucose sensing and insulin delivery devices.

The surgical management of congenital hyperinsulinemic hypoglycemia in infancy

BACKGROUND

Congenital hyperinsulinism (CHI) is characterized by profound hypoglycaemia caused by inappropriate insulin secretion. CHI is a heterogeneous disorder with at least 2 histologic lesions and several implicated genes. If CHI is caused by a focal lesion, elective surgery is the only treatment because it leads to complete recovery without diabetes; on the contrary, diffuse CHI can only be cured by near-total pancreatectomy, and medical treatment, if efficient, is preferable. It is therefore mandatory to distinguish the 2 forms of CHI, and the surgeon has to fullfill his role in the multidisciplinary team that deals with CHI.

METHODS

A total of 134 patients with CHI were investigated both radiologically and with molecular biology. Pathology was the only proof of focal or diffuse lesions, and the pancreatic tissue could be studied by electrophysiology (Katp and Ca channels) and gene study.

RESULTS

In 59 infants with CHI, a focal lesion was suspected by radiology and proved by extemporaneous pathology; partial pancreatectomy (33 tail +/- body, 19 head, 5 isthmus resections) was performed, and molecular biology and histochemistry confirmed the genetic lesion specific to the focal disease; 75 near-total pancreatectomies were necessary in diffuse disease to prevent brain damage.

CONCLUSIONS

CHI is a severe brain-threatening disease. Surgery is indicated in all focal diseases, providing they are diagnosed preoperatively. In diffuse disease with resistance to medical treatment, near-total pancreatectomy is a last resort option that hopefully will be improved in the future with culture of beta cells and genetic modification of the beta cell disease before autograft.