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Endocrine Reviews Apr 2019Pancreatic islet transplantation has become an established approach to β-cell replacement therapy for the treatment of insulin-deficient diabetes. Recent progress in... (Review)
Review
Pancreatic islet transplantation has become an established approach to β-cell replacement therapy for the treatment of insulin-deficient diabetes. Recent progress in techniques for islet isolation, islet culture, and peritransplant management of the islet transplant recipient has resulted in substantial improvements in metabolic and safety outcomes for patients. For patients requiring total or subtotal pancreatectomy for benign disease of the pancreas, isolation of islets from the diseased pancreas with intrahepatic transplantation of autologous islets can prevent or ameliorate postsurgical diabetes, and for patients previously experiencing painful recurrent acute or chronic pancreatitis, quality of life is substantially improved. For patients with type 1 diabetes or insulin-deficient forms of pancreatogenic (type 3c) diabetes, isolation of islets from a deceased donor pancreas with intrahepatic transplantation of allogeneic islets can ameliorate problematic hypoglycemia, stabilize glycemic lability, and maintain on-target glycemic control, consequently with improved quality of life, and often without the requirement for insulin therapy. Because the metabolic benefits are dependent on the numbers of islets transplanted that survive engraftment, recipients of autoislets are limited to receive the number of islets isolated from their own pancreas, whereas recipients of alloislets may receive islets isolated from more than one donor pancreas. The development of alternative sources of islet cells for transplantation, whether from autologous, allogeneic, or xenogeneic tissues, is an active area of investigation that promises to expand access and indications for islet transplantation in the future treatment of diabetes.
Topics: Diabetes Mellitus, Type 1; Humans; Islets of Langerhans Transplantation; Outcome and Process Assessment, Health Care; Pancreatectomy; Pancreatic Diseases
PubMed: 30541144
DOI: 10.1210/er.2018-00154 -
The British Journal of Surgery Jul 2018Studies comparing upfront surgery with neoadjuvant treatment in pancreatic cancer may report only patients who underwent resection and so survival will be skewed. The... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Studies comparing upfront surgery with neoadjuvant treatment in pancreatic cancer may report only patients who underwent resection and so survival will be skewed. The aim of this study was to report survival by intention to treat in a comparison of upfront surgery versus neoadjuvant treatment in resectable or borderline resectable pancreatic cancer.
METHODS
MEDLINE, Embase and the Cochrane Library were searched for studies reporting median overall survival by intention to treat in patients with resectable or borderline resectable pancreatic cancer treated with or without neoadjuvant treatment. Secondary outcomes included overall and R0 resection rate, pathological lymph node rate, reasons for unresectability and toxicity of neoadjuvant treatment.
RESULTS
In total, 38 studies were included with 3484 patients, of whom 1738 (49·9 per cent) had neoadjuvant treatment. The weighted median overall survival by intention to treat was 18·8 months for neoadjuvant treatment and 14·8 months for upfront surgery; the difference was larger among patients whose tumours were resected (26·1 versus 15·0 months respectively). The overall resection rate was lower with neoadjuvant treatment than with upfront surgery (66·0 versus 81·3 per cent; P < 0·001), but the R0 rate was higher (86·8 (95 per cent c.i. 84·6 to 88·7) versus 66·9 (64·2 to 69·6) per cent; P < 0·001). Reported by intention to treat, the R0 rates were 58·0 and 54·9 per cent respectively (P = 0·088). The pathological lymph node rate was 43·8 per cent after neoadjuvant therapy and 64·8 per cent in the upfront surgery group (P < 0·001). Toxicity of at least grade III was reported in up to 64 per cent of the patients.
CONCLUSION
Neoadjuvant treatment appears to improve overall survival by intention to treat, despite lower overall resection rates for resectable or borderline resectable pancreatic cancer. PROSPERO registration number: CRD42016049374.
Topics: Aged; Humans; Intention to Treat Analysis; Middle Aged; Neoadjuvant Therapy; Pancreatectomy; Pancreatic Neoplasms; Survival Rate; Time Factors; Treatment Outcome
PubMed: 29708592
DOI: 10.1002/bjs.10870 -
In Vivo (Athens, Greece) 2021Studies on robotic total pancreatectomy (RTP) have been limited regardless of the increasing evidence on robotic pancreatoduodenectomy. The aim of this study was to... (Review)
Review
BACKGROUND/AIM
Studies on robotic total pancreatectomy (RTP) have been limited regardless of the increasing evidence on robotic pancreatoduodenectomy. The aim of this study was to review the current status of RTP in terms of surgical techniques and outcomes.
MATERIALS AND METHODS
A literature search using PubMed was conducted to investigate surgical techniques and outcomes of RTP.
RESULTS
A total of eight case series with 56 patients were included. The indications for RTP consisted of benign or pre-malignant tumors in 43 patients and malignant tumors in 13 patients. Surgical techniques included the "dividing technique" and "en-bloc technique". Regarding surgical outcomes, the rate of conversion to open total pancreatectomy was 3.6% and the incidence of major complications was 10.7%.
CONCLUSION
Although evidence for RTP is still lacking, RTP is feasible for selected patients when performed in specialized centers. Further studies are essential to investigate the effectiveness of RTP compared to open total pancreatectomy.
Topics: Humans; Laparoscopy; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Robotic Surgical Procedures; Robotics
PubMed: 34182462
DOI: 10.21873/invivo.12456 -
Surgery Feb 2017Recent literature suggests that chyle leak may complicate up to 10% of pancreatic resections. Treatment depends on its severity, which may include chylous ascites. No... (Review)
Review
BACKGROUND
Recent literature suggests that chyle leak may complicate up to 10% of pancreatic resections. Treatment depends on its severity, which may include chylous ascites. No international consensus definition or grading system of chyle leak currently is available.
METHODS
The International Study Group on Pancreatic Surgery, an international panel of pancreatic surgeons working in well-known, high-volume centers, reviewed the literature and worked together to establish a consensus on the definition and classification of chyle leak after pancreatic operation.
RESULTS
Chyle leak was defined as output of milky-colored fluid from a drain, drain site, or wound on or after postoperative day 3, with a triglyceride content ≥110 mg/dL (≥1.2 mmol/L). Three different grades of severity were defined according to the management needed: grade A, no specific intervention other than oral dietary restrictions; grade B, prolongation of hospital stay, nasoenteral nutrition with dietary restriction, total parenteral nutrition, octreotide, maintenance of surgical drains, or placement of new percutaneous drains; and grade C, need for other more invasive in-hospital treatment, intensive care unit admission, or mortality.
CONCLUSION
This classification and grading system for chyle leak after pancreatic resection allows for comparison of outcomes between series. As with the other the International Study Group on Pancreatic Surgery consensus statements, this classification should facilitate communication and evaluation of different approaches to the prevention and treatment of this complication.
Topics: Anastomosis, Surgical; Anastomotic Leak; Chylous Ascites; Consensus; Female; Humans; Internationality; Male; Pancreatectomy; Pancreatic Neoplasms; Postoperative Complications; Prognosis; Risk Assessment; Severity of Illness Index; Treatment Outcome
PubMed: 27692778
DOI: 10.1016/j.surg.2016.06.058 -
Updates in Surgery Sep 2016Total pancreatectomy is associated with short- and long-term high complication rate and without evidence of oncologic advantages. Several metabolic consequences are... (Review)
Review
Total pancreatectomy is associated with short- and long-term high complication rate and without evidence of oncologic advantages. Several metabolic consequences are co-related with the apancreatic state. The unstable diabetes related to the total resection of the pancreas expose the patients to short- and long-term life-threatening complications. Severe hypoglycemia is a short-term dangerous complication that can also cause patients' death. Chronic complications of severe diabetes (cardiac and vascular diseases, neuropathy, nephropathy, and retinopathy) are also cause of morbidity, mortality and worsening of quality of life. For this reasons the number of total pancreatectomies performed has certainly decreased over time. However, today there are still some indications for this kind of procedures. Chronic pancreatitis untreatable with conventional treatments, surgical treatment of precancerous pancreatic lesions, surgical treatment of locally advanced pancreatic cancer and the management of patients with extraordinary high-risk pancreatic texture after pancreaticoduodenectomy represent possible indications for total pancreatectomy and are analyzed in the present paper.
Topics: Decision Making; Humans; Pancreatectomy; Pancreatic Neoplasms; Pancreatitis, Chronic; Quality of Life; Treatment Outcome
PubMed: 27605208
DOI: 10.1007/s13304-016-0388-6 -
Current Diabetes Reports Oct 2015A total pancreatectomy and islet autotransplant (TPIAT) offers substantial pain relief and improved quality of life for children who are severely affected by chronic or... (Review)
Review
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.
Topics: Child; Diabetes Mellitus; Humans; Islets of Langerhans Transplantation; Pancreatectomy; Pancreatitis; Quality of Life; Transplantation, Autologous
PubMed: 26275441
DOI: 10.1007/s11892-015-0639-9 -
Current Opinion in Gastroenterology Sep 2018We reviewed the current state of total pancreatectomy with islet autotransplantation (TPIAT) for chronic pancreatitis and recurrent acute pancreatitis (RAP). (Review)
Review
PURPOSE OF REVIEW
We reviewed the current state of total pancreatectomy with islet autotransplantation (TPIAT) for chronic pancreatitis and recurrent acute pancreatitis (RAP).
RECENT FINDINGS
An increasing number of centers in the United States and internationally are performing TPIAT. In selected cases, TPIAT may be performed partially or entirely laparoscopically. Islet isolation is usually performed at the same center as the total pancreatectomy surgery, but new data suggest that diabetes outcomes may be nearly as good when a remote center is used for islet isolation. Ongoing clinical research is focused on patient and disease factors that predict success or failure to respond to TPIAT. Causes of persistent abdominal pain after TPIAT may include gastrointestinal dysmotility and central sensitization to pain. Several clinical trials are underway with anti-inflammatory or other islet protective strategies to better protect islets at the time of infusion and thereby improve the diabetes results of the procedure.
SUMMARY
In summary, there is an increasing body of literature emerging from multiple centers highlighting the benefits and persistent challenges of TPIAT for chronic pancreatitis and RAP. Ongoing study will be critical to optimizing the success of this procedure.
Topics: Abdominal Pain; Acute Disease; Diabetes Mellitus; Humans; Islets of Langerhans Transplantation; Pancreatectomy; Pancreatitis; Pancreatitis, Chronic; Recurrence; Transplantation, Autologous
PubMed: 29901515
DOI: 10.1097/MOG.0000000000000458 -
Updates in Surgery Aug 2021Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was... (Review)
Review
Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was to critically analyze current evidence supporting the use of total pancreatectomy (TP) to prevent the development of POPF in patients with high-risk pancreas, and to explore the role of completion total pancreatectomy (CP) in the management of severe POPF. Considering the encouraging perioperative outcomes, TP may represent a promising tool to avoid the morbidity related to an extremely high-risk pancreatic anastomosis in selected patients. Surgical management of severe POPF is only required in few critical scenarios. In this context, even if anecdotal, CP might play a role as last resort in expert hands.
Topics: Humans; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 34363601
DOI: 10.1007/s13304-021-01130-3 -
Digestive Surgery 2017Total pancreatectomy (TP) is not more beneficial than less aggressive resection techniques for the treatment of pancreatic neoplasms and is associated with high... (Review)
Review
BACKGROUND
Total pancreatectomy (TP) is not more beneficial than less aggressive resection techniques for the treatment of pancreatic neoplasms and is associated with high morbidity and mortality. However, with advances in surgical techniques and glycemic monitoring, and the development of synthetic insulin and pancreatic enzymes for postoperative treatment, TP has been increasingly indicated. This is a review of the recent literature reporting the clinical outcomes after TP.
METHODS
We reviewed the publications reporting the use of TP starting 2007. The clinicophysiological and survival data were analyzed.
RESULTS
Few studies evaluated the differences in clinical outcomes between TP and pancreaticoduodenectomy (PD) with inconsistent results. It was reported that while the perioperative morbidity did not decrease, the mortality decreased compared to previous literature. All patients who underwent TP required insulin and high dose of pancreatic enzyme supplements. The 5-year survival rates after TP and PD for pancreatic cancer were similar.
CONCLUSION
The perioperative mortality decreased in patients who underwent TP with advances in the operative procedures and perioperative care. The long-term survival rates were similar for TP and PD. Therefore, treating pancreatic neoplasms using TP is feasible. Patients undergoing TP should receive adequate treatment with synthetic insulin and pancreatic enzyme supplements.
Topics: Dietary Supplements; Enzyme Therapy; Humans; Insulin; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Patient Selection; Survival Rate; Treatment Outcome
PubMed: 27701159
DOI: 10.1159/000449234 -
Asian Journal of Surgery Mar 2018This review describes the recent advances in, and current status of, minimally invasive pancreatic surgery (MIPS). Typical MIPS procedures are laparoscopic... (Comparative Study)
Comparative Study Review
This review describes the recent advances in, and current status of, minimally invasive pancreatic surgery (MIPS). Typical MIPS procedures are laparoscopic pancreaticoduodenectomy (LPD), laparoscopic distal pancreatectomy (LDP), laparoscopic central pancreatectomy (LCP), and laparoscopic total pancreatectomy (LTP). Some retrospective studies comparing LPD or LDP and open procedures have demonstrated the safety and feasibility as well as the intraoperative outcomes and postoperative recovery of these procedures. In contrast, LCP and LTP have not been widely accepted as common laparoscopic procedures owing to their complicated reconstruction and limited indications. Nevertheless, our concise review reveals that LCP and LTP performed by expert laparoscopic surgeons can result in good short-term and long-term outcomes. Moreover, as surgeons' experience with laparoscopic techniques continues to grow around the world, new innovations and breakthroughs in MIPS will evolve. Well-designed and suitably powered randomized controlled trials of LPD, LDP, LCP, and LTP are now warranted to demonstrate the superiority of these procedures.
Topics: Disease-Free Survival; Female; Humans; Laparoscopy; Length of Stay; Male; Operative Time; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Prognosis; Risk Assessment; Survival Analysis; Treatment Outcome
PubMed: 27688035
DOI: 10.1016/j.asjsur.2016.09.003