Improved Glycemic Outcomes with Early Initiation of Insulin Pump Therapy in Pediatric Postoperative Total Pancreatectomy with Islet Autotransplantation

Abstract

Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure for patients with chronic pancreatitis and poor quality of life. Euglycemia is critical for islet cell survival and engraftment. We reviewed clinical care practice and hypothesized that early in-hospital transition from intravenous insulin to insulin pump therapy, managed by an endocrine unit trained on post-surgical care, would improve glucose control and impact the length of hospital stay. We completed a retrospective analysis of 40 pediatric patients who underwent TPIAT. Comparative hospitalized postoperative groups included those who received insulin intravenously, followed by multiple daily injections, subsequently managed by pump therapy (n = 14), versus those who received insulin intravenously followed by early pump therapy provided on the endocrine unit trained to manage post-surgical patients (n = 26). The outcomes analyzed included percentage of blood glucoses in target (4.44–6.66 mmol/L (80–120 mg/dL)), hypoglycemia (<3.33 mmol/L (<60 mg/dL)) and hyperglycemia (>7.77 mmol/L (>140 mg/dL)), blood glucose variability, and length of hospital unit stay post-ICU. Hospitalized patients with early transition to pump therapy on a specialized endocrine unit had a higher proportion of glucose values in the target range (61% vs. 51%, p = 0.0003), a lower proportion of hyperglycemia (15% vs. 19%, p = 0.04), and a lower proportion of hypoglycemia, though not statistically significant (3.4% vs. 4.4%, p = 0.33). Early pump users also had lower variability in glucose values over 10 days post-intravenous insulin (p = 0.001), and the post-transition median length of stay was shorter by 5 days (median: 11.5 vs. 16.5 days, p = 0.005). Early in-hospital pump therapy managed by the specialized endocrine unit improved glucose outcomes and reduced the duration of in-unit stay.

Total pancreatectomy with islet autotransplantation reduces opioid use and improves nutritional support in children with debilitating pancreatitis

“…A p value of <0.05 was considered statistically significant. A subset of these patients was published in other studies with different study design and divergent goals and aims [10,[20][21][22][23][24][25][26][27]. A subset of these patients was enrolled in the Consortium for the Study of Chronic Pancreatitis, Diabetes and Pancreatic Cancer (CPDPC) and in the Prospective Observational Study of TPIAT (POST) multicenter study, also under different goals and objectives.…”

Metabolic Outcomes in Pediatric Patients One-Year Post-Total Pancreatectomy with Islet Autotransplantation after Early Pump Initiation

“…A retrospective review of patients post-TPIAT who were previously studied at 10-days post-surgery were reviewed at 12-months post-TPIAT. This cohort of patients included individuals who were managed on MDI within the first 10-days post-ICU before transitioning to an insulin pump, and individuals who were managed on insulin pumps directly post-ICU [6]. In the early years of the program, all TPIAT recipients were transitioned from IV insulin in the ICU to MDI while they recovered on a surgical unit, and then transitioned from MDI to an insulin pump while they completed post-surgical recovery and education on an endocrine unit [6].…”

“…We previously published findings on the improved glycemic outcomes of pediatric post-TPIAT patients who transitioned from IV insulin directly to insulin pump therapy during the first 10-days post-ICU compared to those who were managed with multiple daily injections (MDI) and then transitioned to pump use [6]. We hypothesized that not only would using insulin pump therapy for post-TPIAT glycemic management improve glycemic outcomes in the critical immediate post-operative period, but those benefits would extend to longer-term metabolic outcomes.…”

Nutrition support in the pediatric total pancreatectomy with islet autotransplantation recipient

“…Once children are tolerating full enteral nutrition, they are generally able to transition to an insulin pump and continuous glucose monitoring system. 62,63 When advancing oral intake, they are instructed on carbohydrate counting and mealtime insulin coverage.…”

“…An insulin drip is used for tight glycemic control immediately after the operation to minimize functional stress on the islets 61 while feeds are slowly advanced to meet full nutrition needs. Once children are tolerating full enteral nutrition, they are generally able to transition to an insulin pump and continuous glucose monitoring system 62,63 . When advancing oral intake, they are instructed on carbohydrate counting and mealtime insulin coverage.…”