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Autologous Islet Transplantation with Remote Islet Isolation After Pancreas Resection for Chronic Pancreatitis

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Autologous Islet Transplantation with Remote Islet Isolation After Pancreas Resection for Chronic Pancreatitis Research Original Investigation | PACIFIC COAST SURGICAL ASSOCIATION Autologous Islet Transplantation With Remote Islet Isolation After Pancreas Resection for Chronic Pancreatitis Denise S. Tai, MD; Na Shen, MD; Gregory L. Szot, MS; Andrew Posselt, MD, PhD; Nicholas J. Feduska, MS; Andrew Habashy, BS; Barbara Clerkin, RN; Erin Core, RN; Ronald W. Busuttil, MD, PhD; O. Joe Hines, MD; Howard A. Reber, MD; Gerald S. Lipshutz, MD, MS IMPORTANCE Autologous islet transplantation is an elegant and effective method for preserving euglycemia in patients undergoing near-total or total pancreatectomy for severe chronic pancreatitis. However, few centers worldwide perform this complex procedure, which requires interdisciplinary coordination and access to a sophisticated Food and Drug Administration–licensed islet-isolating facility. OBJECTIVE To investigate outcomes from a single institutional case series of near-total or total pancreatectomy and autologous islet transplantation using remote islet isolation. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study between March 1, 2007, and December 31, 2013, at tertiary academic referral centers among 9 patients (age range, 13-47 years) with chronic pancreatitis and reduced quality of life after failed medical management. INTERVENTIONS Pancreas resection, followed by transport to a remote facility for islet isolation using a modified Ricordi technique, with immediate transplantation via portal vein infusion. MAIN OUTCOMES AND MEASURES Islet yield, pain assessment, insulin requirement, costs, and transport time. RESULTS Eight of nine patients had successful islet isolation after near-total or total pancreatectomy. Four of six patients with total pancreatectomy had islet yields exceeding 5000 islet equivalents per kilogram of body weight. At 2 months after surgery, all 9 patients had significantly reduced pain or were pain free. Of these patients, 2 did not require insulin, and 1 required low doses. The mean transport cost was $16 527, and the mean transport time was 3½ hours. CONCLUSIONS AND RELEVANCE Pancreatic resection with autologous islet transplantation for severe chronic pancreatitis is a safe and effective final alternative to ameliorate debilitating Author Affiliations: Department of pain and to help prevent the development of surgical diabetes. Because many centers lack Surgery, David Geffen School of access to an islet-isolating facility, we describe our experience using a regional 2-center Medicine at the University of California, Los Angeles (Tai, Feduska, collaboration as a successful model to remotely isolate cells, with outcomes similar to those Habashy, Clerkin, Core, Busuttil, of larger case series. Hines, Reber, Lipshutz); Division of Endocrinology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles (Shen, Lipshutz); Department of Surgery, University of California, San Francisco (Szot, Posselt); UCLA Center for Pancreatic Diseases, University of California, Los Angeles (Clerkin, Hines, Reber, Lipshutz). Corresponding Author: Gerald S. Lipshutz, MD, MS, Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Room 77-120, Center for the Health Sciences, Los JAMA Surg. 2015;150(2):118-124. doi:10.1001/jamasurg.2014.932 Angeles, CA 90095 (glipshutz Published online December 10, 2014. @mednet.ucla.edu). 118 (Reprinted) jamasurgery.com Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://archsurg.jamanetwork.com/ by a Bibl. IRCCS Fond. Centro S. Raffaele Monte Tabor User on 03/18/2015 Autologous Islet Transplantation for Pancreatitis Original Investigation Research hronic pancreatitis (CP) is an inflammatory disease of Despite the effective pain relief and insulin indepen- the pancreas that over time leads to irreversible fibro- dence reported in many patients after pancreatectomy and C sis and loss of function. Such repeated and progres- AIT,10 few medical centers worldwide offer such treatment op- sive injury commonly manifests with intractable pain, mal- tions for patients with CP. Possible reasons include the lim- absorption, and diabetes mellitus.1,2 During a period of decades, ited access to and cost of maintaining an islet-isolating facil- the risk of malignant conversion is up to 50 times greater in ity, a lack of consensus regarding indications for and timing patients with CP than in the general population, particularly of surgical intervention, and the paucity of data on long-term among those with a history of smoking or hereditary outcomes. etiology.3 For many, the debilitating abdominal pain often At the University of California, Los Angeles (UCLA), we leads to a diminished quality of life due to multiple hospi- have performed pancreatic resection and AIT on a series of pe- talizations, invasive interventions, and potential narcotic diatric and adult patients with CP during 7 years. To circum- dependency. vent the limitation of direct access to an islet-isolating facil- Although CP is a prevalent disorder, it can be difficult to ity, we developed a unique regional collaboration to remotely diagnose because of its progressive nature and nonspecific process islets after pancreas resection. The objectives of this symptoms that overlap with many conditions. Epidemio- study were to report the results of our case series and collab- logic data are limited in the United States, but the economic orative experience and to contribute to the growing body of burden of all pancreatitis cases was estimated at $3.7 billion literature on TP and AIT as a promising strategy to treat pa- in 2004, with CP-related discharges from hospitals estimated tients with unremitting symptoms of pancreatitis. at 8.1 per 100 000 persons.4,5 Excessive alcohol consumption is the most common etiology in the United States; less com- mon causes include hypertriglyceridemia, pancreas divisum, Methods and autoimmune and familial pancreatitis, with known mu- tations in several genes, including the cystic fibrosis trans- Patients and Data Collection membrane receptor (CFTR) (OMIM 602421), trypsin inhibitor This study was approved by the Committee for Human Re- (SPINK1) (OMIM 167790), and trypsin 1 gene (PRSS1) (OMIM search at UCLA. All patients were fully informed of the risks 276000). and uncertain efficacy of AIT and provided written consent. Chronic pain is often the most challenging symptom to Between March 1, 2007, and December 31, 2013, nine patients treat, and its pathogenesis remains poorly defined. Evidence with a diagnosis of CP were referred to the UCLA Center for Pan- suggests that ductal obstruction via stricture or stones and the creatic Diseases for pancreatic resection and AIT. The diagno- concomitant rise of intraductal pressure lead to parenchymal sis was made by a history of chronic abdominal pain requir- ischemia and neuronal injury that may contribute to pain in ing narcotics, recurrent episodes of acute pancreatitis, and pancreatitis.1 Although medical management and pain con- radiographic or endoscopic findings consistent with CP. Medi- trol are the initial approaches to CP, a subset of patients de- cal records were retrospectively reviewed to collect preopera- velop intractable pain that requires more invasive interven- tive, operative, posttransplantation, and financial data. tion via endoscopy to relieve elevated ductal pressure.6 When such interventions fail, surgical management is often the next Preoperative Assessment logical approach to management. Before surgery, patients were evaluated by a local endocri- Selecting the optimal surgical procedure depends largely nologist or by the UCLA endocrinology service. Glycated he- on the extent and complication of disease, as well as ductal size. moglobin level, fasting C-peptide level, and a metabolic panel Options have traditionally included procedures to improve were obtained. Patients were evaluated by teams from the drainage such as lateral pancreaticojejunostomy, resection, or UCLA Center for Pancreatic Diseases (B.C., O.J.H., H.A.R., and a combination of drainage and resection. Pancreatic resec- G.S.L.) and the UCLA transplantation services (G.S.L.). All pa- tion with total pancreatectomy (TP) or pancreatoduodenec- tients were offered the option of a Whipple procedure or TP tomy (Whipple procedure) has been shown to provide pain re- and possible AIT. All patients who decided to undergo a lief in up to 80% of patients.7 However, pancreatectomy Whipple procedure also elected to receive AIT to preserve func- invariably produces brittle diabetes by removal of insulin- tional islet tissue. secreting beta cells that reside in the islets of Langerhans and by loss of glucagon counterregulation.2 Operative and Autologous Islet Transplantation Procedures Autologous islet transplantation (AIT) was first described Patients who underwent pancreatic resection received a duo- in the 1970s as a method for preserving long-term euglyce- denum-preserving pancreatoduodenectomy or TP with sple- mia after near-total or TP for CP.8 In a specialized islet- nectomy by standard technique. Effort was made to maintain isolating facility, islets are procured from the resected pan- arterial perfusion and unimpeded venous outflow from the creas by enzymatic and mechanical digestion.9 After assessing pancreas for as long as possible. The pancreas was removed for quality and quantity, the islet preparation is immediately from the operating table, and a biopsy specimen was ob- transplanted to the patient via portal vein
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