An Update on Diabetes Outcomes of Total Pancreatectomy with Islet Autologous Transplant (TP-IAT) at Dartmouth, Using Off-Site and on-Site Intra-Operative Islet Isolation

Presentation Number: SAT 612
Date of Presentation: April 1st, 2017

Sushela S Chaidarun*, Chantal Lewis, Deepa Philip, Kerrington D. Smith and Timothy B. Gardner
Dartmouth-Hitchcock Medical Center, Lebanon, NH

Abstract

The advent of islet auto-transplantation can help transition patients from brittle post-pancreatectomy insulin dependent diabetes to type 2-like diabetes, pre-diabetes, or in some cases, no diabetes at all. Here we described our experience at Dartmouth, where we initially used off-site and then transitioned to intra-operative islet isolation for patients with severe medically refractory chronic pancreatitis with preserved islet function.

Results: In 2012 Dartmouth-Hitchcock Medical Center developed a collaborative program for total pancreatectomy with islet auto-transplant, initially using off-site islet isolation at Massachusetts General Hospital and then transitioned to on-site intra-operative islet isolation. We have successfully treated 39 patients thus far, and have had encouraging results from a diabetes perspective. Before the surgery, 20% (8/39) of the patients already had diabetes requiring treatment (metformin and/or insulin), 10% had prediabetes, and 70% had no diabetes (A1c<5.7%). The average A1c was 5.1+2.0% (+SD) with a range of 4.6-8.4%. All patients had normal pre-operative stimulated c-peptide (3.1+1.9 ng/ml, normal range 1.1-4.4 ng/ml), suggestive of preserved endogenous insulin production. Average islet equivalent (IEq) yields was 3,499 IEq/Kg (range 21-10,214); 28% of patients had low yields (<2,500), 51% had moderate yields (2,500-5,000), and 21% had high yields (>5,000 IEq/kg). Three months after the surgery, 24% of patients required no insulin with near normal mean A1c 6.0% while 81% had A1c at target (<7%). Six months post-operatively, the average A1c had risen to 6.9+1.2%, but 66% of the patients still had glycemic control at target, and 12 of 34 (35%) of patients required no insulin at all. Twelve months post-operatively, the average A1c was stable at 7.3+1.8%, and 57% of the patients continued to have glycemic control at target, and 12 of 28 (42%) of patients required no insulin at all. Since most of the patients maintained reasonable islet function with normal c-peptide levels, we typically started treatment with oral agents (e.g. metformin and then DPP-4 inhibitor) for patients who subsequently had suboptimal diabetic control. Some patients had low c-peptide requiring insulin but their glucose control was less brittle than those with total pancreatectomy alone.

Conclusion: TP-IAT techniques, either using off-site or on-site intra-operative isolation, resulted in a lower rate of insulin-dependent diabetes, and should be seen as a viable treatment option for patients with intractable chronic pancreatitis. Furthermore, patients generally experienced much less pain and returned to work with a better quality of life. Therefore, islet auto-transplantation either on-site or off-site islet isolation can be used to avert the burden of complicated and costly diabetic care for carefully selected patients requiring total or sub-total pancreatectomy.

 

Nothing to Disclose: SSC, CL, DP, KDS, TBG