Results of Open and Robot-Assisted Pancreatectomies With Autologous Islet Transplantations: Treating Chronic Pancreatitis and Preventing Surgically Induced Diabetes

For patients with chronic pancreatitis (CP), standard surgical procedures (eg, partial or total resections, drainage procedures) are inadequate treatment options, because they do not confer pain relief and they leave patients prone to brittle diabetes and hypoglycemia. The combination of total pancreatectomy and islet autotransplantation (TP-IAT), however, can create insulin-independent and pain-free states. At our center, from August 2009 through August 2013, 61 patients with CP underwent either open or robot-assisted TP-IAT. The 30-day mortality rate was 0%. The transplanted islet equivalents per body weight ranged from 10,000 to 17,770. In all, 19% of the patients became insulin independent (after a range of 1–24 months); 27% of patients required <10 units of insulin. Moreover, at 12 months after surgery, 71% of the patients were pain free and no longer required analgesics. Our metabolic outcomes could have been even better if most patients had been referred at an earlier disease stage; instead, ∼80% had already undergone surgical procedures, and 91% had abnormal results on preoperative continuous glucose monitoring tests. Only if patients with CP are referred early for a TP-IAT—rather than being subjected to additional inadequate endoscopic and surgical procedures—can insulin-independent and pain-free states be accomplished in most.     

Radiographic evaluation of marginal bone maintenance around tissue level implant and bone level implant: a randomised controlled trial. A 1‐year follow‐up

The etiologic factors associated with crestal bone loss have not been comprehensively clarified. Several theories exist as to the reason for the observed changes in crestal bone height following implant restoration. In the 1990s, the wide‐diameter implants were commercially introduced. Initially, the implants were restored with standard‐diameter abutments because of lack of matching prosthetic components. Long‐term radiographic follow‐up of these ‘platform‐switched’ restored wide‐diameter dental implants has demonstrated a smaller‐than‐expected vertical change in the crestal bone height around these implants that is typically observed around implants restored conventionally with prosthetic components of matching diameters. The aim of this randomised controlled study was to assess radiographically marginal bone level alterations in implants restored according to the platform‐switching concept compared with traditionally restored implants. Fifty‐four subjects to participate in this randomised controlled study were selected. Two groups were assigned at random: control group (56 implants were restored with standard matching‐diameter abutments) and test group (58 implants were restored with medialised abutments). X‐ray explorations were taken for peri‐implant bone level at the minute the last cementing of the prosthesis and at 1‐year follow‐up. NHI Image was used to digitally process and manipulate the radiographic images and perform the measurements. Mean of bone loss with platform‐switching implants was ?0·01 mm, and the mean of bone loss with standard platform implant was 0·42 mm. Outcomes of this study indicated that the platform‐switching design could preserve the crestal bone levels to 1‐year follow‐up. There was a statistically significant difference in marginal bone loss.     

A Simplified Palatal Lift Prosthesis for Neurogenic Velopharyngeal Incompetence

Velopharyngeal incompetence is a contributing factor to speech disorders and implies the presence of hypernasality, inappropriate nasal escape, and decreased air pressure during speech. One prosthetic treatment is a rehabilitative procedure employing a palatal lift prosthesis (PLP), which reduces hypernasality by approximating the incompetent soft palate to the posterior pharyngeal wall and consists of two parts, the anterior denture base and the palatal lifting plate, which are connected with steel wires; however, it seems difficult to reproduce the mobility of the soft palate in speaking, and it is therefore likely that the palatal lifting plate stimulates or oppresses the tissue of the soft palate and hinders rather than assists articulatory function. To avoid these disturbances we devised an adjustable PLP with a flexible conjunction between the denture base and the palatal lifting plate to obtain the optimal vertical lifting angle. The palatal plate was adapted to conform in a passive manner to the soft palate with light‐cured resin. The designed PLP simplified the procedure and reduced the number of adjustments and visits.     

New technologies, designs and materials for removable maxillary obturator prostheses

The size and location for maxillary defects influence the difficulty of prosthetic rehabilitation. In all such cases, specially made obturator prosthesis's necessary to restore masticatory function and improve speech, deglution and esthetics. Obturator prostheses vary in size and shape depending on the extent of the defect. Various methods and techniques have been described for the fabrication of removable obturator prostheses. The aim of the present work was to review the progress made in technologies, designs and materials for prosthesis of this type.     

Fat embolism syndrome after surgery to replace the femoral stem of a hip prosthesis

A 66-year-old woman developed hemodynamic instability, oliguria, prostration, fever, and coagulopathy 4 hours after surgery to replace the femoral stem component of a hip prosthesis under a combined subarachnoid-epidural block. Dyspnea and tachypnea developed, and a petechial rash appeared 24 hours later. The diagnosis was fat embolism after other possible causes were ruled out. Supplementary oxygen, fluid replacement therapy, and inotropic support were started. The patient's condition improved and she was discharged from the postoperative recovery unit 5 days after admission. Although fat embolism usually appears in young men after large bone fractures, it should be considered when symptoms consistent with this diagnosis arise in patients who have undergone orthopedic surgery so that appropriate treatment can be started early.     

Impaired Proinsulin Processing is a Characteristic of Transplanted Islets

We sought to determine whether recipients of islet transplants have defective proinsulin processing. Individuals who had islet allo- or autotransplantation were compared to healthy nondiabetic subjects. Insulin (I), total proinsulin (TP), intact proinsulin and C-peptide (CP) were measured in samples of fasting serum by immunoassay, and the ratios of TP/TP+I and TP/CP were calculated. Islet allotransplant recipients had elevated TP levels relative to nondiabetic controls (16.8 [5.5–28.8] vs. 8.4 [4.0–21.8] pmol/L; p < 0.05) and autologous transplant recipients (7.3 [0.3–82.3] pmol/L; p < 0.05). Islet autotransplant recipients had significantly higher TP/TP+I ratios relative to nondiabetic controls (35.9 ± 6.4 vs. 13.9 ± 1.4%; p < 0.001). Islet allotransplant recipients, some of whom were on insulin, tended to have higher TP/TP+I ratios. The TP/CP ratio was significantly higher in both islet autotransplant (8.9 [0.6–105.2]; p < 0.05) and allotransplant recipients (2.4 [0.8–8.8]; p < 0.001) relative to nondiabetic controls (1.4 [0.5–2.6]%). Consistent with these findings, TP/TP+I and TP/CP values in islet autotransplant recipients increased significantly by 1-year posttransplant compared to preoperative levels (TP/CP: 3.8 ± 0.6 vs. 23.3 ± 7.9%; p < 0.05). Both allo- and autotransplant subjects who received <10 000 IE/kg had higher TP/CP ratios than those who received >10 000 IE/kg. Islet transplant recipients exhibit defects in the processing of proinsulin similar to that observed in subjects with type 2 diabetes manifest as higher levels of total proinsulin and increased TP/TP+I and TP/CP ratios.     

Human islet isolation and allotransplantation in 22 consecutive cases.

This report provides our initial experience in islet isolation and intrahepatic allotransplantation in 21 patients. In group 1, 10 patients underwent combined liver-islet allotransplantation following upper-abdominal exenteration for cancer. In group 2, 4 patients received a combined liver-islet allograft for cirrhosis and diabetes. One patients had plasma C-peptide greater than 3 pM and was therefore excluded from analysis. In group 3, 7 patients received 8 combined cadaveric kidney-islet grafts (one retransplant) for end-stage renal disease secondary to type 1 diabetes mellitus. The islets were separated by a modification of the automated method for human islet isolation and the preparation were infused into the portal vein. Immunosuppression was with FK506 (group 1) plus steroids (groups 2 and 3). Six patients in group 1 did not require insulin treatment for 5 to greater than 16 months. In groups 2 and 3 none of the patients became insulin-independent, although decreased insulin requirement and stabilization of diabetes were observed. Our results indicate that rejection is still a major factor limiting the clinical application of islet transplantation in patients with type 1 diabetes mellitus, although other factors such as steroid treatment may contribute to deteriorate islet engraftment and/or function.