Surgical outcomes after total pancreatectomy and islet cell autotransplantation in pediatric patients

Wilson, Gregory C.; Sutton, Jeffrey M.; Salehi, Marzieh; Schmulewitz, Nathan; Smith, Milton T.; Kucera, Stephen; Choe, Kyuran A.; Brunner, John; Abbott, Daniel E.; Sussman, Jeffrey J.; Ahmad, Syed A.

doi:10.1016/j.surg.2013.07.003

Cited by 53 publications

(38 citation statements)

References 28 publications

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“…Surgical therapy may be considered in carefully selected children who have failed appropriate medical and endoscopic treatments. Total pancreatectomy with islet autotransplantation is the preferred surgical approach for most patients with small-duct genetic pancreatitis and diffuse gland involvement (18, 24–26). In our experience with very young children (age 3–8 years) undergoing TPIAT, long-term outcomes are favorable, with successful relief of pain and insulin independence in the majority.…”

Section: Discussionmentioning

confidence: 99%

Total Pancreatectomy With Islet Autotransplantation Resolves Pain in Young Children With Severe Chronic Pancreatitis

Bellin¹,

Forlenza

Majumder³

et al. 2017

J. pediatr. gastroenterol. nutr.

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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.

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Section: Discussionmentioning

confidence: 99%

Total Pancreatectomy With Islet Autotransplantation Resolves Pain in Young Children With Severe Chronic Pancreatitis

Bellin¹,

Forlenza

Majumder³

et al. 2017

J. pediatr. gastroenterol. nutr.

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“…First-line therapies include medical management and endoscopic procedures, but they often fail to provide long-term pain relief [2]. A total pancreatectomy and islet autotransplant (TPIAT) might be the only therapeutic modality available to achieve sustained pain relief for children who are severely affected by chronic pancreatitis or by recurrent acute pancreatitis [3, 4••, 5, 6•]. …”

Section: Introductionmentioning

confidence: 99%

Pediatric Autologous Islet Transplantation

et al. 2015

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A total pancreatectomy and islet autotransplant (TPIAT) offers substantial pain relief and improved quality of life for children who are severely affected by chronic or recurrent acute pancreatitis and for whom the usual medical and endoscopic therapies have failed. The pancreas is entirely resected, and the pancreatic islets are isolated from the pancreas and infused back into the patient’s liver. Because this is an autologous transplant, no immunosuppression is required. Over several months, the islets engraft in the liver; the patient is then slowly weaned off insulin therapy. Slightly more than 40 % of patients become and remain insulin independent, yet even among patients who remain on insulin, most have some islet function, permitting easier diabetes control. The majority of patients experience pain relief, with significant improvements in health-related quality of life. A TPIAT should be considered for children who are significantly disabled by chronic pancreatitis.

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“…This concept is supported by a large body of animal studies as well as ongoing work in clinical islet transplant recipients at our institution. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] Although some conflicting studies have suggested that glucose is a stimulus for the expansion of b-cell mass or survival in the vascularized pancreases, 33,34 one should be cautious in applying these same principles to newly transplanted devascularized islets. Even so, the IIP at our institution does not keep islets devoid of glucose; although physiologic BG is the goal, all patients experience some supraphysiologic excursions (nearly 15% of BG values are >140 mg/dL), and patients are never maintained intentionally in hypoglycemia.…”

Section: Discussionmentioning

confidence: 99%

“…1 Approximately 40% of children discontinue insulin therapy after TPIAT, with islet mass being the most important measurable predictor of subsequent diabetes risk. [2][3][4][5][6] During isolation, islets are stripped of their native arteriolar blood supply. Once transplanted, islets are reliant on diffusion of nutrients and oxygen to the islet core until neovascularization is complete, a process that takes weeks to months.…”

mentioning

confidence: 99%

Near-Euglycemia Can Be Achieved Safely in Pediatric Total Pancreatectomy Islet Autotransplant Recipients Using an Adapted Intravenous Insulin Infusion Protocol

Forlenza

Chinnakotla

Schwarzenberg

et al. 2014

Diabetes Technology & Therapeutics

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Background: Children with severe chronic pancreatitis may undergo total pancreatectomy with islet autotransplantation (TPIAT) to relieve pain while minimizing the risk of postsurgical diabetes. Because overstimulation of transplanted islets by hyperglycemia can result in b-cell loss, we developed a specialized intravenous insulin infusion protocol (IIP) for pediatric TPIAT recipients to maintain euglycemia or near-euglycemia posttransplant. Subjects and Methods: Our objective was to review glucose control using an IIP specific for TPIAT recipients at a single institution. We reviewed postoperative blood glucose (BG) levels for 32 children 4-18 years old with chronic pancreatitis who underwent TPIAT between July 2011 and June 2013. We analyzed the proportion of BG values in the range of 70-140 mg/dL, mean glucose, glucose variability, and occurrence of hypoglycemia during the IIP; we also evaluated the transition to subcutaneous therapy (first 72 h with multiple daily injections [MDI]). Results: During IIP, the mean patient BG level was 116 -27 mg/dL, with 83.1% of all values in the range of 70-140 mg/dL. Hypoglycemia was rare, with only 2.5% of values <70 mg/dL. The more recent era (n = 16) had a lower mean BG and less variability than the early era (first 16 patients) (P £ 0.004). Mean glucose level (116 vs. 128 mg/dL) and glucose variability were significantly lower during the IIP compared with MDI therapy (P < 0.0001). Conclusions: Tight glycemic control without excessive severe hypoglycemia was achieved in children undergoing TPIAT using an IIP specifically designed for this population; the ability to maintain BG in target range improved with experience with the protocol.

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Surgical outcomes after total pancreatectomy and islet cell autotransplantation in pediatric patients

Cited by 53 publications

References 28 publications

Total Pancreatectomy With Islet Autotransplantation Resolves Pain in Young Children With Severe Chronic Pancreatitis

Total Pancreatectomy With Islet Autotransplantation Resolves Pain in Young Children With Severe Chronic Pancreatitis

Pediatric Autologous Islet Transplantation

Near-Euglycemia Can Be Achieved Safely in Pediatric Total Pancreatectomy Islet Autotransplant Recipients Using an Adapted Intravenous Insulin Infusion Protocol

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