Martin L. Freeman

Background: Total pancreatectomy with islet auto‐transplantation (TPIAT) alleviates pain and preserves islet function in patients with severe pancreatitis. Although approximately one third of recipients achieve insulin independence, spontaneous hypoglycemia has been observed in this population. Its frequency, risk factors, and management remain poorly characterized. Methods: Using prospectively collected data on insulin‐independent (TPIAT) recipients at the University of Minnesota (2010–2023), we compared patients who developed hypoglycemia (defined as documented blood glucose < 70 mg/dL) to those with no reported hypoglycemia. Demographic, clinical, surgical, and metabolic variables were evaluated, and treatment strategies were reviewed. Results: Among 503 TPIAT recipients, 156 (31%) achieved insulin independence; of these, 45 (28.8%) experienced hypoglycemia, including 32 (20.5%) with level 2 hypoglycemia (< 54 mg/dL). Severe hypoglycemia events requiring external assistance occurred in 25% of affected individuals. Hypoglycemia developed a mean of 2.4 ± 2.2 years posttransplant, most commonly postprandial or exercise‐related. Patients who developed hypoglycemia were older at the time of TPIAT ( p = 0.036) and had higher preoperative BMI ( p = 0.016) and a greater prevalence of malabsorptive disorders ( p < 0.001), whereas islet yield and metabolic testing results were similar between patients with and without hypoglycemia. Most patients with hypoglycemia (78%) were managed with non‐pharmacological interventions (dietary, continuous glucose monitoring); pharmacologic therapies included acarbose (22%), diazoxide (13%), and minidose glucagon (7%). Conclusions: Spontaneous hypoglycemia is a frequent, clinically relevant complication among insulin‐independent TPIAT recipients. Older age, higher BMI, and malabsorptive disorders were associated with increased susceptibility. Routine surveillance, dietary counseling, and continuous glucose monitoring (CGM) are common components of management.

INTRODUCTION: Hospital readmission rate is a key hospital metric and represents a substantial burden to patients and the healthcare system. Necrotizing pancreatitis (NP) patients are at high risk of unplanned readmission. The aim of this study was to determine the incidence and predictors of 30-day unplanned readmission after index hospitalization for NP. METHODS: Adult NP patients who were managed at a single tertiary referral center between 2009 and 2022 were identified from a prospective database and categorized into 2 groups based on 30-day unplanned readmission after index hospitalization. Patients with no follow-up who died during index admission or within 30 days of discharge were excluded. Baseline data on admission including demographic, clinical, interventional, imaging, and discharge characteristics were compared. Multivariable analysis was completed to identify independent predictors of 30-day readmission. RESULTS: Among 505 patients with NP (male patients—347 [69%], median age—50 years [inter quartile range 37–63]) 191 (37.8%) had at least 1 unplanned readmission. The most common causes of readmission were abdominal pain (40%) and sepsis (27%). On multivariable analysis, independent predictors for early readmission were necrosis collection size ≥ 6 cm (adjusted odds ratio [aOR] 1.91 [1.11–3.30], P < 0.03), stay at outside hospital ≥ 14 days before transfer to tertiary center (aOR 2.89 [1.27–6.60], P < 0.01), and need for percutaneous feeding tube at the time of discharge (aOR 2.06 [1.01–4.21], P < 0.05). DISCUSSION: Readmission after NP is common and associated with greater mortality at 6 months. Expedited transfer to tertiary center for timely intervention, assiduous follow-up of other high-risk patients (large collections and those who need enteral nutrition) could help avoid readmissions and optimize outcomes.

Alterations in the gut microbiome have been implicated in various pathologies. Fecal microbiota transplantation (FMT) has been offered as a novel treatment for conditions implicated in the disruption of the gut-microbiota axis. This case report details the successful treatment of recurrent nonobstructive cholangitis following a single FMT application in a patient who had previously undergone a hepatobiliary tract surgical diversion. Cholangitis was suspected secondary to reflux of an altered microbiome into the surgically reanastomosed biliary tract, and FMT was justified based on the history of recurrent Clostridioides difficile infections. This case supports the further evaluation of the utility of FMT as one potential treatment of post hepatobiliary surgical diversion cholangitis.

Background.: Although diabetes after total pancreatectomy and islet autotransplantation (TP-IAT) is one of the biggest concerns for TP-IAT recipients and physicians, reliable prediction of post-TP-IAT glycemic control remains unestablished. This study was conducted to identify early predictors of insulin independence and goal glycemic control by hemoglobin A1c (HbA1c) ≤ 6.5% after TP-IAT. Methods.: In this single-center, retrospective study, patients who underwent TP-IAT (n = 227) were reviewed for simple metabolic markers or surrogate indices of β-cell function obtained 3 mo after TP-IAT as part of standard clinical testing. Long-term metabolic success was defined as (1) insulin independence and (2) HbA1c ≤ 6.5% 1, 3, and 5 y after TP-IAT. Single- and multivariate modeling used 3-mo markers to predict successful outcomes. Results.: Of the 227 recipients, median age 31 y, 30% male, 1 y after TP-IAT insulin independence, and HbA1c ≤ 6.5% were present in 39.6% and 72.5%, respectively. In single-predictor analyses, most of the metabolic markers successfully discriminated between those attaining and not attaining metabolic goals. Using the best model selected by random forests analysis, we accurately predicted 1-y insulin independence and goal HbA1c control in 77.3% and 86.4% of the patients, respectively. A simpler “clinically feasible” model using only transplanted islet dose and BETA-2 score allowed easier prediction at a small accuracy loss (74.1% and 82.9%, respectively). Conclusions.: Metabolic testing measures performed 3 mo after TP-IAT were highly associated with later diabetes outcomes and provided a reliable prediction model, giving valuable prognostic insight early after TP-IAT and help to identify recipients who require early intervention.

Purpose of Review Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP. Literature Findings CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. Summary The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.