Autologous Islet Transplantation in Patients Requiring Pancreatectomy: A Broader Spectrum of Indications Beyond Chronic Pancreatitis

Abstract

Islet autotransplantation (IAT) is usually performed in patients undergoing pancreatic surgery for chronic pancreatitis. In the present series, IAT was offered also to patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, having either completion pancreatectomy as treatment for severe pancreatic fistulas (n = 21) or extensive distal pancreatectomy for neoplasms of the pancreatic neck (n = 19) or pancreatoduodenectomy because of the high risk of pancreatic fistula (n = 32). Fifty-eight of 72 patients who were eligible to this broader spectrum of indication actually received IAT. There was no evidence of a higher-than-expected rate of major complications for pancreatectomy. Forty-five patients receiving IAT were still alive at the time of the last scheduled follow-up (1375 AE 365 days). Eighteen (95%) of 19 and 11 (28%) of 39 patients reached insulin independence after partial or total pancreatectomy, respectively. The metabolic results were dependent on the transplanted islet mass. Thirty-one of 58 patients had malignant diseases of the pancreas or periampullary region, and only three patients developed ex novo liver metastases after IAT (median follow-up 914 AE 382 days). Our data demonstrate the feasibility, efficacy, and safety of IAT for a broader spectrum of clinical indications beyond chronic pancreatitis.

Are there still indications for total pancreatectomy?

“…However, in selected patients in poor general conditions, and with very high-risk pancreas and obese, TP may represent an adequate alternative technique [9]. …”

“…The same authors investigated also the long-term QoL of 27 patients included in the study, showing a decrease of QoL compared with age- and gender-matched controls, but not compared to patients with diabetes from other causes. Even analyzing the recent data from the literature, it is quite evident that TP are associated with a significant postoperative morbidity and mortality, not inferior to partial pancreatectomy, as showed in Table 1 [5, 9, 10, 12–17]. …”

“…In selected cases of very high-risk patients, with a high-risk pancreas and other contributing risk factors, TP may represent an alternative to a pancreatic anastomosis in an attempt to reduce the significant postoperative morbidity and mortality. This approach has been proposed recently, even in a conjunction to auto-islet transplantation [9]. However, this decision should be always weighted against the risks associated with TP, as the postoperative mortality and morbidity (Table 1) of TP are significant as well as the long-term sequels of this operation [3].…”

“…At the same time TP is proposed, with or without simultaneous auto-islet transplantation, for some types of chronic pancreatitis [7] and also for the treatment of locally advanced pancreatic cancer requiring arterial resection and reconstruction [8]. Total pancreatectomy combined with autologous islet transplantation has also been proposed for patients with a high-risk for complications resulting from the pancreatic anastomosis [9]. …”

Diabetes induction by total pancreatectomy in minipigs with simultaneous splenectomy: a feasible approach for advanced diabetes research

“…The induction of a complete insulin and glucagon deficiency represents a major challenge for diabetes management, comparable to the situation in patients with very long duration of diabetes mellitus type 1 or diabetes mellitus type 3c . An intact hypoglycemic counterregulatory system where the anti‐insulin hormone glucagon plays a major role is crucial for successful diabetes management with any non‐biological methods (multiple daily injections, CSII, sensor‐augmented pump therapy, closed‐loop system) and an impairment of it often causes severe metabolic lability and hypoglycemia, the main indications for beta‐cell replacement therapy .…”