Preventing Surgically Induced Diabetes After Total Pancreatectomy via Autologous Islet Cell Reimplantation

Article Outline

• Abstract
• Anatomy
• Pancreatic Functions
  • Exocrine Functions
    • Cephalic Phase
    • Gastric Phase
    • Intestinal Phase
  • Endocrine Functions
    • Alpha Cells
    • Beta Cells
    • Delta Cells
    • F Cells
• Pancreatitis
• Diagnosis
• Treatment
• Pancreatectomy
  • Preoperative Phase
  • Intraoperative Phase
• Organ Preparation
• Islet Cell Harvesting
• Autologous Islet Cell Reimplantation
• Prognosis
• Conclusion
• Acknowledgement
• Examination. Continuing Education Program
  • Preventing Surgically Induced Diabetes After Total Pancreatectomy via Autologous Islet Cell Reimplantation
    • Purpose/Goal
    • Objectives
    • Questions
• Learner Evaluation. Continuing Education Program
  • Preventing Surgically Induced Diabetes After Total Pancreatectomy via Autologous Islet Cell Reimplantation
    • Objectives
    • Content
• References
• Biography
• Copyright

Abstract 

Total pancreatectomy may be the only treatment option that relieves pain and tissue destruction for patients with chronic pancreatitis, but this procedure causes surgically induced diabetes, which is difficult to manage because of the absence of insulin-producing beta cells. Some patients may benefit from autologous islet cell reimplantation, a procedure that involves collecting and purifying the islets of Langerhans from the patient's own resected pancreas and reinfusing them into the patient via the portal vein. Typically, candidates for this procedure are younger adults with nondilated pancreatitis that has yet to develop into glucose intolerance. Islet cell transplantation success varies and is directly related to the quality and quantity of the patient's pancreas and the damage caused by the chronic pancreatitis.

Key words: chronic pancreatitis, total pancreatectomy, islets of Langerhans, portal vein embolization, interventional radiology

Patients with chronic pancreatitis experience intractable abdominal pain. Traditionally, total pancreatectomy has been the only solution for treating this pain, but the procedure causes the patient to have brittle diabetes. “The term brittle diabetes refers to patients who have dramatic, recurrent swings in glucose levels that often occur for no apparent reason. Patients experience disabling episodes of hyperglycemia or hypoglycemia that typically lead to recurrent emergency department visits and hospitalizations.”¹ With the advent of autologous islet cell transplantation, patients undergoing total pancreatectomy have a more optimistic future: relief from the pain and tissue destruction, without loss of endocrine pancreatic function.

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Anatomy 

The pancreas is located in the retroperitoneal space, directly behind the stomach. The anatomical head of the pancreas is connected to the duodenum, with the tail of the pancreas terminating near the spleen. The unpalpable location of the pancreas tends to complicate the diagnosis and treatment of diseases that affect the pancreas (eg, cancer).

The pancreas begins to form at the fifth week of embryonic development and is capable of producing insulin by the 10th week of gestation.² A ductal system emerges as the pancreas matures during gestation. A normally developed pancreas consists of the main pancreatic duct (ie, the duct of Wirsung) and the accessory duct (ie, the duct of Santorini).³ The ductal system can have several anatomical variations, such as the formation of separate dorsal and ventral ducts (ie, pancreas divisum). In a small number of patients, pancreas divisum can be an anatomical cause of pancreatitis. A more likely anatomical culprit, however, is thought to be ductal stenosis.³ The arterial blood flow of the pancreas is mainly supplied by the posterior and anterior pancreaticoduodenals and by the superior, inferior, and greater pancreatic arteries.⁴

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Pancreatic Functions 

The pancreas has dual functionality, as both an exocrine and an endocrine digestive organ. The exocrine functions of the pancreas facilitate digestion. The endocrine, or hormone-producing, functions aid in digestion and other metabolic processes.

Exocrine Functions 

Acini cells perform the exocrine functions of the pancreas, producing both aqueous solution and pancreatic enzymes. This aqueous solution primarily serves to raise the pH within the duodenum, which is lowered by stomach acids. This creates a more neutral pH and a more conducive environment for pancreatic enzyme activity. Three main pancreatic enzymes, amylase, trypsin, and pancreatic lipase, facilitate digestion of carbohydrates, protein, and fat. Enzyme release is stimulated by the parasympathetic system and occurs in three phases: cephalic, gastric, and intestinal.²

The cephalic phase is initiated by appetite and the sight and smell of food. The vagus nerve, in turn, stimulates the stomach to produce gastrin. When the parietal cells within the stomach lining are bathed in gastrin, they begin to produce gastric acid. The presence of this acid triggers pancreatic secretion.²

The gastric phase is defined by release of more gastrin, secondary to the presence of proteins and gastric distension, which again stimulates the parasympathetic system to increase pancreatic enzyme release.²

As chyme (ie, semidigested food) enters the duodenum in the intestinal phase, pancreatic secretion continues. The arrival of chyme into the small intestine initiates the release of two other enzymes: secretin and cholecystokinin-pancreozymin. When the pancreas detects secretin, it releases a generous amount of water and bicarbonate.² As cholecystokinin-pancreozymin continues to trigger the release of pancreatic secretions, it also activates the smooth muscle of the gallbladder to release bile.⁵

Endocrine Functions 

There are four main endocrine-producing cells located in the islets of Langerhans within the pancreas.² The typical adult has roughly 1 million islet cells located throughout the pancreas. The four cell types are alpha, beta, delta, and F.²

Glucagon, an important element in maintaining normal blood glucose levels, is manufactured by the alpha cells. This is accomplished by glycogenolysis and gluconeogenesis.

Beta cells play an important role in the metabolism of sugars, carbohydrates, proteins, and fats. This metabolism is accomplished by the production of insulin. Insulin boosts cell uptake of glucose and other elements, and assists in intracellular enzymatic activity.

Delta cells produce the antagonistic hormone somatostatin. Somatostatin hinders the function of many other hormones, such as thyroid-stimulating hormone, growth hormone, and other gastrointestinal hormones.

The F cells produce pancreatic polypeptides. These polypeptides assist in gallbladder emptying.²

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Pancreatitis 

The pancreas plays a fundamental role in the digestion and metabolism of nutrients at the cellular level. As with any organ, the pancreas is subject to a number of disease processes. The more common diseases of the pancreas are cystic fibrosis, pancreatitis, and cancer.² The most common causes of pancreatitis are associated with gallstones and alcohol abuse; however, numerous other etiologies, such as anatomical anomalies (eg, pancreas divisum, ductal stenosis), autoimmune response, trauma, and sphincter of Oddi dysfunction also can trigger acute pancreatitis.⁶

Pancreatitis is defined as either acute or chronic. In acute pancreatitis, the acinar cells become damaged and trigger the enzyme trypsin to be released within the pancreas. The release of trypsin causes the pancreas to autodigest, which causes inflammation.⁶ Generally, the signs and symptoms are gastrointestinal. The patient may have nausea, vomiting, and abdominal pain. Serum levels of amylase and lipase may be elevated. Imaging studies may reveal inflammation of the pancreas.⁷ Acute pancreatitis is usually self-limiting. During acute pancreatitis, typically only mild to moderate damage is occurring and the pancreas recovers.

Depending on the specific etiology of the pancreatitis, patients may present with varying degrees of onset and pathophysiology. For example, alcohol-induced pancreatitis most often affects men in the second to fifth decade of life, after a long history of alcohol abuse. Idiopathic pancreatitis can be subdivided into two forms: juvenile and senile. Juvenile idiopathic pancreatitis has a median onset in patients aged 23 years and senile idiopathic pancreatitis has a median onset in patients aged 62 years. Pancreatitis is also characterized by varying degrees of exocrine and endocrine insufficiency.⁷ Exocrine insufficiency results in malnutrition secondary to reduced production of pancreatic enzymes. Endocrine insufficiency affects insulin production, and hyperglycemia ensues. Either condition is challenging for the patient. With each acute episode of pancreatitis, the acinar cells can atrophy and become damaged, potentially progressing to chronic pancreatitis.⁷

Chronic pancreatitis is a much more serious condition and, typically, has a poor prognosis. In developed countries, alcohol is the principle factor associated with chronic pancreatitis⁷; however, there are other etiologies associated with chronic pancreatitis, such as genetic factors, that may predispose a person to pancreatitis, autoimmune pancreatitis, pancreatic ductal malformation and obstruction, and idiopathic pancreatitis.⁷

The primary clinical manifestation of chronic pancreatitis is severe abdominal pain. Patients will present with pain in the left upper quadrant and epigastrium. The pathology of the pain is secondary to obstruction of the pancreatic ducts, biliary tree, or both. This obstruction forces the digestive pancreatic enzymes into nearby tissues and the retroperitoneal space. Hypermotility of the gut causes nausea and vomiting. Vomiting tends to worsen the patient's pain because of increased intraductal pressures.²

Diabetes is a complication of chronic pancreatitis. As the pancreas becomes more fibrous and beta cells are destroyed, insulin production is limited. Patients with chronic pancreatitis seldom live long enough to develop neuropathies or vascular disease complications secondary to hyperglycemia.⁷

A severe chronic pancreatic episode can be life threatening because multiple organ systems are affected. Pancreatic hemorrhage can lead to cardiovascular collapse and death. The patient's respiratory system can become compromised because of plural effusion secondary to the location of the pancreas in the retroperitoneal space and the chest wall. Another real concern related to chronic pancreatitis is cancer. Numerous bouts of pancreatitis alter the acini cells and make pancreatic tissue fibrotic, which predisposes the pancreas to malignancy.²

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Diagnosis 

A diagnosis of chronic pancreatitis is made after a thorough physical assessment, which includes imaging studies. Most of the imaging studies, such as upper gastrointestinal endoscopy and abdominal ultrasound, are taken in an effort to rule out other sources of the patient's abdominal pain. The “gold standard” in diagnosing chronic pancreatitis is endoscopic retrograde cholangiopancreatography (ERCP). A health care provider performs an ERCP by advancing a flexible esophagogastroduodenoscope through the patient's mouth into the duodenum. At the duodenum, the provider injects contrast medium into the pancreatic ducts and biliary tree. Using fluoroscopy, the provider can assess the ducts for narrowing, or stenosis, or the presence of stones. Undergoing an ERCP also can predispose the patient to pancreatitis.⁷

Laboratory studies useful in diagnosing pancreatitis include cholestasis parameters, which measure bile secretion and transaminases (ie, a catalytic enzyme for amino acids). An oral glucose tolerance test and fecal elastase-I are used to evaluate pancreatic endocrine and exocrine function.⁸

Other diagnostic tests for pancreatitis are not always reliable or indicative. The patient's serum lipase and amylase may or may not be elevated, depending on the onset of the pancreatitis. Abdominal radiographs have limited diagnostic value because only 30% of patients with pancreatitis have calcifications; furthermore, radiographic films cannot discern malignant changes.⁷

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Treatment 

Treatment strategies include minimizing symptoms and improving the patient's quality of life.⁷ Many symptoms, for example, steatorrhea (ie, high lipid content in stool) and diabetes, can be managed medically. Steatorrhea and weight loss can be controlled with oral pancreatic enzyme supplements, and diabetes is managed with insulin.⁷

Pain, often intractable, is the major presenting symptom for 90% of patients with chronic pancreatitis.⁸ Pain is difficult to manage, and achieving a balance with the patient's pain, quality of life, and activities of daily living is difficult. Opiate addiction, and ultimately dependency, is a real concern for these patients. Initially, basic analgesics are prescribed for pain control, although typically this is not effective. Narcotics, such as fentanyl citrate and meperidine, may be used for pain control. Currently, clinical trials are being performed to evaluate the combination of narcotics and antioxidants, such as selenium, beta-carotene, and vitamins C and E, for treating pancreatitis.⁷

Other pain-control measures, although not as common, include endotherapies that focus on ductal dilatation and celiac plexus blocks.⁷ Celiac plexus blocks involve the injection of steroids or phenol into the celiac plexus or solar plexus located near the abdominal aorta with the aid of fluoroscopy for visualization.⁹

After all other conservative measures for pain control have been exhausted, surgical intervention may be necessary. There are several surgical options for the patient with chronic pancreatitis. One option is the Partington-Rochelle procedure, a drainage procedure. The surgeon creates a pancreaticojejunostomy with a Roux-en-Y loop, which allows the pancreatic (ie, Wirsung and Santorini) ducts to drain freely, reducing pancreatic congestion and pain. Only a limited portion of the pancreas is resected, so endocrine and exocrine function is maintained. This surgical procedure only has short-term effects on pain control, lasting about two years, Typically, pancreatic inflammation and destruction continue.⁸ The final surgical option is a total pancreatectomy. Unfortunately, this procedure gives the patient brittle diabetes, which will require scrutinized dietary and insulin control.

With the advent of autologous islet cell transplantation in the late 1990s, patients undergoing total pancreatectomy have a better long-term prognosis.¹⁰ The ideal candidate for total pancreatectomy and islet cell transplantation is typically a younger adult with nondilated ductal pancreatitis who has not yet developed diabetes (David B. Adams, MD, e-mail communication, January 12, 2010).

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Pancreatectomy 

Patients with chronic pancreatitis can be medically challenging, especially if they develop glucose intolerance.⁴ The physician may place the patient on several days of parenteral nutrition and vitamins before surgery.⁴

Preoperative Phase 

While the patient is undergoing parenteral nutrition, the preoperative nurse begins to prepare the patient for surgery. The nurse ensures that the patient's blood has been typed and cross matched because of the bleeding risks associated with pancreatic dissection and ligation of vessels, for example, the splenic artery.⁴ The physician inserts a nasogastric tube, and the preoperative nurse applies continuous gastric suctioning.⁴ The nurse reviews the patient's medical record and confirms laboratory values (eg, glucose, hemoglobin, hematocrit).⁴ During the preoperative interview, the nurse confirms with the patient that the patient is informed regarding the procedure and has signed the surgical consent. The consent should include terminology related to the pancreatectomy, islet cell transplantation and reimplantation, and interventional radiographic studies related to portal vein catheterization. The preoperative nurse helps the patient put on thromboembolic device hose if the patient is not already wearing them. Hair should only be removed from the surgical site if necessary, and then only by using electric clippers. The use of manual razors can cause small nicks in the skin and increase the patient's risk for developing a surgical site infection.¹¹

As with all surgeries, the perioperative nurse ensures that the Surgical Care Improvement Project (SCIP) initiatives are followed. These initiatives set forth by the Centers for Medicare and Medicaid Services play an important role in preventing postoperative surgical complications.¹¹ One SCIP quality measure concerns the administration of prophylactic antibiotics within one hour before making the surgical incision and appropriate antibiotic selection related to the surgical procedure.¹¹

Intraoperative Phase 

The circulating nurse and scrub person ensure that the OR is properly set up for the procedure by using the surgical preference card (Table 1). The circulating nurse then goes to the preoperative area to meet and assess the patient. After reviewing the patient's medical record (eg, consent form, laboratory test results, medical and surgical history, physical examination), the circulating nurse introduces himself or herself to the patient and family members. The nurse reviews the intraoperative phase of care by describing expected activities. After confirming the anticipated surgical procedure with the patient, the OR schedule, and the signed consent form, the circulating nurse checks the patient's surgical site marking. After answering the patient's and the family members' questions, the circulating nurse prepares a care plan specific to this patient (Table 2).

TABLE 1. Preference Card for Total Pancreatectomy With Islet Cell Transplantation

TABLE 2. Nursing Care Plan for a Patient Undergoing Total Pancreatectomy With Autologous Islet Cell Reimplantation

The circulating nurse then transports the patient to the OR and positions the patient supine on the OR bed. The circulating nurse assists the anesthesia care provider in placing an upper-body temperature-regulating blanket over the patient's arms and chest. The circulating nurse applies and activates intermittent compression devices on the patient's lower extremities before anesthesia induction and intubation. Use of thromboembolic device hose in conjunction with intermittent compression devices helps prevent the most common postoperative complications, deep vein thrombosis and venous thromboembolism, and is another SCIP quality measure.¹¹

Before induction of anesthesia, the entire surgical team and the patient participate in the time-out procedure. The surgical team members focus their direct attention on the patient and verify the procedure, surgical site, and patient position, and confirm the presence of all needed equipment and radiographs. When all are in agreement, the circulating nurse assists the anesthesia care provider with induction of anesthesia.

After intubation, the circulating nurse preps the surgical area, the lower chest, and abdomen from table edge to table edge.⁴ The nurse ensures that no prep solution has pooled under the patient. After the prep is complete, the scrub person and surgeon drape the patient.

Typically, the surgeon makes a midline incision from the xiphoid process to below the umbilicus.⁴ After dissecting into the peritoneum, the surgeon places a self-retaining retractor, mobilizes the pancreas, and dissects the pancreas with a variety of stapling devices, clips, and the ultrasonic scalpel. When the pancreas is resected, the scrub person places it in a basin of cold transplant preservation fluid. The basin is kept cold by placing it in slushed saline solution. One physician begins prepping the pancreas on a separate, sterile back table in preparation for the islet harvest team as the surgeon completes the pancreatectomy and removes the gallbladder.⁴ The surgeon then performs a gastrojejunal anastomosis.⁴ When the anastomosis is complete, the surgeon closes the surgical incision.

After the procedure, the anesthesia care provider and circulating nurse transport the patient to the digestive disease intensive care unit (DDICU), where the patient remains intubated for five to six hours until the islet cells are harvested. The anesthesia care provider and circulating nurse review the patient's postoperative needs (eg, pain management, beta-blocker therapy) with the assigned DDICU nurse.

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Organ Preparation 

The surgeon examines and cleans the resected pancreas and removes extra tissue. The surgeon then cannulates each of the two pancreatic ducts with 22-gauge IV catheters (Figure 1) and secures these in place with a 4-0 polydioxanone suture (Figure 2). After the catheters are secured, the surgeon injects transplant preservation fluid through the catheters to perfuse the ductal system of the pancreas. The surgeon places the pancreas in a sterile plastic drawstring bag filled with transplant preservation fluid. The scrub person then double bags the pancreas, places it in a sterile specimen container, and passes it off the sterile field to the harvest team. The circulating nurse places the specimen container in a cooler to be transported to a sterile cellular therapy laboratory.

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• Figure 1. 

  The distal resected pancreas; one pancreatic duct is cannulated with a 22-gauge catheter.

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• Figure 2. 

  The transected head of the pancreas with ductal cannulation.

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Islet Cell Harvesting 

When the cooler that contains the pancreas arrives at the laboratory, the transport person places it in a “pass-through” window box. This pass-through window allows the technician within the sterile laboratory to retrieve the specimen without cross contamination of the laboratory environment.

The technician removes the pancreas from the container by using sterile technique and places the pancreas under a biosafe laboratory hood to begin the harvesting process. The technician removes any fat and extraneous tissue and then infuses a digestive enzymatic cocktail into the pancreas via the 22-gauge catheters. This cocktail consists of a purified enzyme blend of collagenase isoforms I and II and a thermostable neutral metalloproteinase enzyme.¹² This infusion engorges the organ and begins to break it down. The technician then dissects the pancreas into 1-cm cubes.

The technician places the pancreatic cubes in a sterile disposable bowl. The bowl also contains polytetrafluoroethylene (ie, Teflon™) coated marbles, and the lid contains a filter screen. The technician fits the lid with sterile tubing on either side (ie, an in and an out) to create a continuous, closed-loop system. The technician then places the tubing in a pump filtration system that collects the islet cells and primes the tubing and bowl with Roswell Park Memorial Institute cellular medium solution. When the bowl is sealed, the technician places it into a shaker apparatus. As the container is shaken, the Teflon marbles begin to pulverize the cubed pancreas. As the pancreas is broken down to the cellular level and pumped through the filtration system, a computer monitors pressure, temperature, and pH. This islet cell purification process can take four to six hours. The technician takes samples throughout the process to evaluate the condition, quality, and quantity of the islet cells.

The technician places a small sample of the collected islet cells on a slide with stain. The beta cells within the islets pick up the stain and appear red under the microscope. An average islet cell is 150 micrometers. When sampling yields only one to two islet cells per sample, the harvest is complete (Figure 3).

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• Figure 3. 

  The islets of Langerhans pick up the stain and appear red under the microscope (150 micrometers).

Photograph courtesy of Gina Scurti and the Center for Cellular Therapy at the Medical University of South Carolina, Charleston.

The technician then places the collected islet cells into a centrifuge. During the centrifuge process, the islets or “pellets” collect in the bottom of the containers. The technician uses a pipette to transfer the islet cells into another container in which the cells are suspended in transplant preservation solution. This container is placed in the shaker apparatus, which rotates and shakes the container for 30 minutes. The islets are now ready to be washed and centrifuged again three more times.

When this process is complete, the technician takes a sample to quantify the yielded cells. An average harvest yields 600,000 to 800,000 islet cells. This number is dependent on the condition of the patient's pancreas. Typically, a pancreas that is more fibrous and has had extensive acinar damage secondary to the disease process yields fewer islet cells. After the technician suspends the washed islet cells in a solution of 5% human albumin, the cells are ready for reinfusion.

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Autologous Islet Cell Reimplantation 

Pancreatic islet cell reimplantation has been practiced since the late 1990s with different embolization sites. In the United Kingdom, transplant sites have included the splenic sinusoids, the spleen, and the liver, with varying degrees of success.¹⁰ The liver is a much quicker and easier site to embolize (ie, implant) because of the ease of vascular access. Percutaneous access to the spleen is difficult.¹⁰ Embolization of the liver via the portal vein is not without risk. The major complication of this procedure is portal vein occlusion as a result of thrombosis, which results in portal vein hypertension.¹⁰

When the patient's islet cells are purified and ready for reimplantation, the patient, still anesthetized, is transported from the DDICU to an interventional radiology suite. The interventional radiologist guides a catheter into the patient's abdomen and then into the portal vein by using ultrasound and fluoroscopy. The radiologist confirms placement of the catheter and infuses the islet cells through the catheter. As the islet cells travel through the portal vein toward the liver, the islets “seed” the liver vasculature.¹³ When the islet cells have embolized the liver and begin functioning, the liver, in essence, becomes an endocrine insulin-producing organ. As glucose-laden blood bathes the islets, the beta cells begin to produce insulin in an effort to normalize blood glucose levels.

The patient is then transported back to the DDICU. When the patient is stable, a respiratory therapist and the DDICU nurse wean the patient from the ventilator and remove the endotracheal tube when the patient is ready. After the patient's condition has stabilized and the patient is extubated, he or she is transferred to a regular nursing floor bed. Most patients remain in the hospital for 10 to 14 days, during which nurses check the patient's blood sugar often, and the patient may require insulin injections. The goal of this procedure is to avoid the need for lifelong insulin injections, but all the patients will still need to follow a diabetic diet. Nursing staff members instruct the patient to avoid any heavy lifting or straining for six to eight weeks after surgery. The patient is discharged with narcotic pain medications; the doses are decreased over several weeks according to the patient's perceived pain level.¹⁴

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Prognosis 

The patient who has undergone total pancreatectomy with islet cell reimplantation has almost immediate relief from the irretractable pain caused by the pancreatitis. Patients who undergo most other transplant procedures require immunosuppressive medications to prevent rejection. Patients who have islet cell reimplantation, however, receive their own cells, so immunosuppressive therapy is not necessary.¹³

The patient's islets cells should start producing insulin within two or three days, although the process can take six months to a year. To monitor islet cell function, the surgeon orders daily monitoring of glucose, c-peptide, and insulin requirements. Islet cell transplantation success varies and is directly related to the quality and quantity of the patient's pancreas and the damage caused by the preexisting chronic pancreatitis. Thirty percent of patients who undergo this procedure will not have to take insulin, but 70% will have to take varying amounts of insulin. The five-year mortality rate for patients with chronic pancreatitis is 25%. As research continues and more patients undergo this procedure, these rates are expected to decrease (David B. Adams, MD, e-mail communication, January 12, 2010).

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Conclusion 

Chronic pancreatitis can be a debilitating disease, often characterized by excruciating pain that is difficult to manage. Pain management via opiates tends to lead to dependency, addiction, and a decreased quality of life.⁷ Surgery may be the only alternative for pain relief.

Total pancreatectomy with autologous islet cell reimplantation may be the solution for many patients with chronic pancreatitis. As islet cell harvesting and preservation techniques continue to improve, expanded areas of research could provide treatment for other diseases. Currently, research studies are underway to test islet cell transplants from donors to treat type I diabetes.⁷ Although islet cell harvesting and transplantation is a relatively new science, it holds promise for people with chronic pancreatitis and who have intractable abdominal pain.

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Acknowledgement 

The author thanks David B. Adams, MD, professor and section head of gastrointestinal surgery at the Medical University of South Carolina, Charleston, and Katherine A. Morgan, MD, associate professor, hepatobiliary and pancreatic surgery at the Medical University of South Carolina, Charleston, for providing resource information during the manuscript process, and Gina Scurti, BS; Mingli Li, MS; Kelly Moxley, BS; and Stu Irwin, MS, cellular therapy laboratory staff members at the Medical University of South Carolina, Charleston, for allowing observation of the islet cell purification process.

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Examination. Continuing Education Program 

Preventing Surgically Induced Diabetes After Total Pancreatectomy via Autologous Islet Cell Reimplantation 

To educate perioperative nurses about the caring for patients undergoing autologous islet cell reimplantation after total pancreatectomy.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.

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Learner Evaluation. Continuing Education Program 

Preventing Surgically Induced Diabetes After Total Pancreatectomy via Autologous Islet Cell Reimplantation 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.

To what extent were the following objectives of this continuing education program achieved?

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References 

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6. Kwak SW, Kim S, Lee JW, et al. Evaluation of unusual causes of pancreatitis: role of cross-sectional imaging. Eur J Radiol. 2009;71(2):296–312
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7. Tattersall SJ, Apte MV, Wilson JS. A fire inside: current concepts in chronic pancreatitis. Intern Med J. 2008;38(7):592–598
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8. Mihaljevic AL, Kleeff J, Friess H, Buchler MW, Beger HG. Surgical approaches to chronic pancreatitis. Best Pract Res Clin Gastroenterol. 2008;22(1):167–181
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9. Celiac plexus block. MedCentral Health System http://www.medcentral.org/body.cfm?id=342Accessed April 26, 2010
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10. Johnson PRV, White SA, Robertson GSM, et al. Pancreatic islet autotransplantation combined with total pancreatectomy for the treatment of chronic pancreatitis: the Leicester experience. J Mol Med. 1999;77(1):130–132
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11. Current Specification Manual for National Hospital Quality Measures Version 3.0c. The Joint Commission http://www.jointcommission.org/performancemeasurement/performancemeasurement/current+nhqm+manual.htmAccessed April 26, 2010
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13. MUSC performs state's first islet cell transplant for chronic pancreatitis. Updated March 19, 2009. Medical University of South Carolina http://www.musc.edu/pr/cct.htmAccessed April 26, 2010
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14. MUSC Health Digestive Disease Center. Pancreatic Islet Cell Autologous Transplant Program: Guide for Patients. Charleston, SC: MUSC Health Digestive Disease Center; n.d.:1-36.
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• 1 Understanding pancreatitis. American Gastroenterological Association. http://www.gastro.org/patient-center/digestive-conditions/pancreatitis. Accessed May 27, 2010.
• 2 Pancreatitis—what is chronic pancreatitis. National Digestive Diseases Information Clearinghouse. http://digestive.niddk.nih.gov/ddiseases/pubs/pancreatitis/. Accessed May 24, 2010.
• 1 Understanding pancreatitis. American Gastroenterological Association. http://www.gastro.org/patient-center/digestive-conditions/pancreatitis. Accessed May 27, 2010.
• 2 Pancreatitis—what is chronic pancreatitis. National Digestive Diseases Information Clearinghouse. http://digestive.niddk.nih.gov/ddiseases/pubs/pancreatitis/. Accessed May 24, 2010.