Fear of diabetes and major surgery may prohibit referral of young children severely impacted by pancreatitis for total pancreatectomy and islet autotransplant (TPIAT). We evaluated outcomes in our youngest TPIAT recipients, age 3–8 years at surgery.
Medical records were reviewed for 17 children (9 female) age ≤8 years undergoing TPIAT from 2000–2014. Most (14/17) had genetic risk factors for pancreatitis. Since 2006, TPIAT recipients were followed prospectively with health questionnaires including assessments of pain and narcotic use, and scheduled HbA1c and mixed meal tolerance tests (6 mL/kg Boost HP) before surgery, and at regular intervals after. Patients are 1–11 years post TPIAT (median 2.2 years). Data are reported as median (25th, 75th percentile).
All had relief of pain, with all 17 patients off narcotics at most recent follow up. Hospitalization rates decreased from 5.0 hospitalization episodes per person-year of follow up before TPIAT, to 0.35 episodes per person-year of follow up after TPIAT. Fourteen (82%) discontinued insulin, higher than the observed insulin independence rate of 41% in 399 patients >8 years of age undergoing TPIAT over the same interval (p=0.004). Median post-TPIAT HbA1c was 5.9% (5.6, 6.3%), and within patient post-TPIAT mean HbA1c was ≤6.5% for all but 2 patients.
Very young children with severe refractory chronic pancreatitis may be good candidates for TPIAT, with high rates of pain relief and insulin independence, and excellent glycemic control in the majority.
Background
Tertiary hyperparathyroidism following kidney transplantation is most commonly characterized by 4‐gland hyperplasia, but single and double adenomatous disease has been demonstrated in this population as well. It is unknown whether preoperative imaging can assist in identifying patients who may qualify for focused surgery for adenomatous disease.
Materials and methods
We performed a retrospective review of our patient database from 1998–2018 for patients with tertiary hyperparathyroidism following renal transplant. Patient charts were reviewed for patient demographics, laboratory values, preoperative imaging, operative findings, pathology, and complications.
Results
We identified 113 patients with tertiary hyperparathyroidism following renal transplant who underwent parathyroidectomy. There were 51 females and 62 males with a mean age of 53.4 ± 13.4 years. Median preoperative calcium and PTH were 10.9 mg/dl (IQR 10.3–11.2) and 228 pg/ml (IQR 118–305). Preoperative ultrasound was performed in 60 patients. Of these, 11 (18%) were negative, 38 (63%) showed 1–2 adenomas, and 11 (18%) showed ≥ 3 adenomas. 99mTc‐sestamibi parathyroid scintigraphy was performed in 101/113 patients. Of these, 11 (11%) were negative, 62 (61%) showed 1–2 areas of discordant sestamibi uptake, and 28 (28%) showed ≥ 3 areas of discordant uptake. Ultimately, 19 (17%) patients had a single adenoma removed, 16 (14%) had 2 adenomas removed, and (69%) had multi‐gland disease. There were 26 ectopic glands found in 21 patients, 42.3% of which were identified on preoperative imaging. 94.1% of patients were eucalcemic at last follow‐up, mean (± SD) 5.8 ± 3.6 years. Adenomas that were visualized on ultrasound were larger on pathology than those non‐visualized (997 ± 120 mg (mean ± SE) vs. 388 ± 109 mg, p = 0.0003). This was also true for parathyroid scintigraphy (647 ± 41 mg vs. 355 ± 51 mg, p = 0.0001).
Conclusion
In patients with tertiary hyperparathyroidism, preoperative imaging can aid in predicting which patients will have 1–2 gland disease. In patients with 1–2 gland disease on congruent ultrasound and nuclear medicine imaging studies, the accuracy increases to 59%. Preoperative imaging can help identify ectopic glands. Larger adenomas are more likely to be identified on both imaging modalities.
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