Gianpaolo Balzano

Università Vita-Salute San Raffaele, Milano, Lombardy, Italy

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Publications (94)338.99 Total impact

  • Gastrointestinal Endoscopy 05/2015; 81(5):AB537. DOI:10.1016/j.gie.2015.03.1083 · 4.90 Impact Factor
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    ABSTRACT: In the developed world, pancreatic surgery is becoming more common, with an increasing number of patients developing diabetes because of either partial or total pancreatectomy, with a significant impact on quality of life and survival. Although these patients are expected to consume increasing health care resources in the near future, many aspects of diabetes after pancreatectomy are still not well defined. The treatment of diabetes in these patients takes advantage of the therapies used in type 1 and 2 diabetes; however, no specific guidelines for its management, both immediately after pancreatic surgery or in the long term, have been developed. In this article, on the basis of both the literature and our clinical experience, we address the open issues and discuss the most appropriate therapeutic options for patients with diabetes after pancreatectomy.
    Current Diabetes Reports 04/2015; 15(4):589. DOI:10.1007/s11892-015-0589-2 · 3.38 Impact Factor
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    ABSTRACT: No data are available about distal pancreatectomy (DP) in Italy, regarding variability of care among centers, and outcome of minimally invasive distal pancreatectomy (MIDP) in a multicenter setting. Hence, a survey was conducted among 20 institutions experienced in pancreatic surgery by the Italian Association for Study of Pancreas. Centers were asked to fill in two questionnaires about (1) general approach and perioperative protocols for DP and MIDP; (2) detailed operative results of MIDP in the period 2010-2011. Results of questionnaire 1: a great variability in perioperative approach was observed: octreotide was used in 50 % of centers, enzyme supplementation in 35 %, postoperative gastric suction in 80 % and oral liquids on day 1 in 55 %. All hospitals used at least one drain and its removal ranged between days 3-5 (in absence of fistula). Differences in type and timing of post-splenectomy vaccinations were recorded. As regards MIDP, 17/20 centers performed laparoscopic or robotic DP. MIDP rate on overall DP varied among centers (range 0-82 %) and it doubled from 2007 (14 %) to 2011 (28 %). Results of questionnaire 2: in the period 2010-2011, 171 MIDP were performed (140 laparoscopic, 31 robotic). Overall conversion rate was 17 %, mean operative time was 230 min and blood loss 285 ml. Mortality was nil and morbidity was 62 %, with 4 % relaparotomies. Pancreatic fistula occurred in 49 % (grade A 35 %, B 14 %). Mean postoperative stay was 9.8 days with 10 % readmission rate. The results indicated a great variability in DP management among Italian centers. Most centers performed MIDP, but MIDP rate on overall DP largely varied among centers. As regards MIDP conversion rate and hospital stay were found to be worse than those in single-institution series.
    Updates in Surgery 11/2014; DOI:10.1007/s13304-014-0273-0
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    ABSTRACT: Pancreatic cancer patients underwent surgical resection often present distant metastases early after surgery. Detection of circulating tumor cells (CTCs) has been correlated to a worse oncological outcome in patients with advanced pancreatic cancer. The objective of this pilot study is to investigate the possible prognostic role of CTCs in patients undergoing surgery for pancreatic cancer. In 20 patients undergoing pancreatic resection, 10 mL blood sample was collected intraoperatively from both systemic circulation (SC) and portal vein (PV). Blood sample was analyzed for CTCs with CellSearch® system. All patients underwent an oncologic follow-up for at least 3 years, quarterly. CTCs were detected in nine (45 %) patients: five patients had CTCs in PV only, three patients in both SC and PV, and one patient in SC only. CTC-positive and CTC-negative patients were similar for demographics and cancer stage pattern. No significant differences were found in both overall and disease-free survival between CTC-positive and CTC-negative patients. At 3-year follow-up, portal vein CTC-positive patients presented a higher rate of liver metastases than CTC-negative patients (53 vs. 8 %, p = 0.038). CTCs were found in 45 % of the patients. No correlation between CTCs and survival was found. The presence of CTCs in portal vein has been associated to higher rate of liver metastases after surgery.
    Tumor Biology 10/2014; 36(2). DOI:10.1007/s13277-014-2716-0 · 2.84 Impact Factor
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    ABSTRACT: Laparoscopic distal pancreatectomy (LDP) has been recently proposed as the procedure of choice for lesions of the pancreatic body and tail in experienced centres. The purpose of this study is to assess the potential advantages of LDP in a consecutive series of 100 patients.
    Surgical Endoscopy 10/2014; DOI:10.1007/s00464-014-3879-x · 3.31 Impact Factor
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    Gianpaolo Balzano, Lorenzo Piemonti
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    ABSTRACT: Autologous islet cell transplantation is a procedure performed to prevent or reduce the severity of diabetes after pancreatic resection. Autologous islet cell transplantation is being used almost exclusively in patients undergoing pancreatectomy because of painful, chronic pancreatitis, or multiple recurrent episodes of pancreatitis that is not controlled by standard medical and surgical treatments. Here, we discuss the possibility of extending the clinical indications for this treatment on the basis of our experience in patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, including patients undergoing completion pancreatectomy because of anastomosis leakage after pancreaticoduodenectomy and those with pancreatic anastomosis deemed at high risk for failure.
    Current Diabetes Reports 08/2014; 14(8):512. DOI:10.1007/s11892-014-0512-2 · 3.38 Impact Factor
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    ABSTRACT: To characterize the clinical signature and etiopathogenetic factors of diabetes associated with pancreas disease [type 3 diabetes mellitus (T3cDM)]. To estimate incidence and identify predictors of both diabetes onset and remission after pancreatic surgery. A prospective observational study was conducted. From January 2008 to December 2012, patients (n = 651) with new diagnosis of pancreatic disease admitted to the Pancreatic Surgery Unit of the San Raffaele Scientific Institute were evaluated. Hospital and/or outpatient medical records were reviewed. Blood biochemical values including fasting blood glucose, insulin and/or C-peptide, glycosylated hemoglobin and anti-islet antibodies were determined. Diabetes onset was assessed after surgery and during follow-up. At baseline, the prevalence of diabetes was 38 % (age of onset 64 ± 11 years). In most cases, diabetes occurred within 48 months from pancreatic disease diagnosis. Among different pancreatic diseases, minor differences were observed in diabetes characteristics, with the exception of the prevalence. Diabetes appeared associated with classical risk factors for type 2 diabetes (i.e., age, sex, family history of diabetes and body mass index), and both beta-cell dysfunction and insulin resistance appeared relevant determinants. The prevalence of adult-onset autoimmune diabetes was as previously reported within type 2 diabetes. Within a few days after surgery, either diabetes remission or new-onset diabetes was observed. In patients with pancreatic cancer, no difference in diabetes remission was observed after palliative or resective surgery. Classical risk factors for type 2 diabetes were associated with the onset of diabetes after surgery. T3cDM appeared as a heterogeneous entity strongly overlapped with type 2 diabetes.
    Acta Diabetologica 06/2014; 51(5). DOI:10.1007/s00592-014-0614-y · 3.68 Impact Factor
  • Pancreatology; 06/2014
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    ABSTRACT: Enhanced recovery after surgery (ERAS(A (R))) pathways have reduced morbidity and length of hospital stay (LOS) in orthopedics, bariatric, and colorectal surgery. New perioperative care protocols have been tested in patients undergoing pancreaticoduodenectomy (PD), with controversial results on morbidity. Incomplete data about ERAS items compliance have been reported. The aim of this study was to assess compliance with an ERAS protocol and its impact on short-term outcome in patients undergoing PD. A comprehensive ERAS protocol was applied in 115 consecutive patients undergoing PD. Each ERAS patient was matched with one patient who received standard perioperative care. Match criteria were age, gender, malignant/benign disease, and PD-specific prognostic score. No adverse effect related to ERAS items occurred. Compliance with postoperative items ranged between 38 and 66 %. The ERAS group had an earlier recovery of mobilization (p < 0.001), oral feeding (p < 0.001), gut motility (p < 0.001), and an earlier suspension of intravenous fluids (p = 0.041). No difference between ERAS and control group was found in mortality, overall morbidity, and major complication rates. Subgroup analysis showed that 43/60 (71 %) patients with early postoperative low compliance with the ERAS pathway had complications. The ERAS pathway significantly shortened LOS in uneventful patients or those with minor complications (11.2 vs. 13.7 days, p = 0.001). The ERAS pathway was feasible and safe, yielding an earlier postoperative recovery. An ERAS protocol should be implemented in patients undergoing PD; however, patients with early postoperative low compliance should be carefully managed.
    World Journal of Surgery 05/2014; 38(11). DOI:10.1007/s00268-014-2653-5 · 2.35 Impact Factor
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    ABSTRACT: This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.
    Digestive and Liver Disease 05/2014; 46(6). DOI:10.1016/j.dld.2013.12.019 · 2.89 Impact Factor
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    ABSTRACT: To evaluate the safety and feasibility of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with autologous islet transplantation (AIT) for benign tumors of the pancreatic body-neck. Three non-diabetic, female patients (age 37, 44 and 35 years, respectively) were declared candidates for surgery, between May and September 2011, because of pancreatic body/neck cystic lesions. The planned operation was an LSPDP associated with AIT from the normal pancreas distal to the neoplasm. Islets isolation was performed on the residual pancreatic parenchyma after frozen section examination of the margin. Purified autologous islets were infused into the portal vein by a percutaneous transhepatic approach the day after surgery. The procedure was performed successfully in all the three cases, and the spleen was preserved along with its vessels. Mean operation time was 283 ± 52 min and average blood loss was 133 ± 57 mL. Residual pancreas weights were 33, 22 and 30 g, and 105.200, 40.390 and 94.790 islet equivalents were isolated, respectively. Surgical complications occurred in one patient (grade A pancreatic fistula). Postoperative stays were 6, 6 and 7 d, respectively. Histopathological evaluation revealed mucinous cystic neoplasm in cases 1 and 3, and serous cystic neoplasm in patient 2. No postoperative insulin administration was required. One patient developed a transient partial portal thrombosis 2 mo after islet infusion. Patients are insulin independent at a mean follow up of 8 ± 2 mo. Combination of LSPDP and AIT is feasible and could be effective to minimize the surgical impact for benign neoplasm of pancreatic body-neck.
    World Journal of Gastroenterology 04/2014; 20(14):4030-6. DOI:10.3748/wjg.v20.i14.4030 · 2.43 Impact Factor
  • Pancreatology 03/2014; 13(3):S3. DOI:10.1016/j.pan.2013.04.007 · 2.50 Impact Factor
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    Diabetes 12/2013; 63(1):377-377. DOI:10.2337/db14-er01 · 8.47 Impact Factor
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    ABSTRACT: PURPOSE Percutaneous islet allo-transplantation, needing immunosuppression, is a traditional less invasive alternative to surgical pancreas transplantation for brittle type-1 diabetes, while PIPIAT, not needing immunosuppression, is usually performed after pancreatic surgery for chronic pancreatitis to prevent diabetes. Our aim was to assess feasibility, technical aspects, complications and clinical outcome of PIPIAT following pancreatic surgery, not only for chronic pancreatitis but also for benign and malignant nodules. METHOD AND MATERIALS From 2008 to 2012, 41 patients were enrolled for PIPIAT 24/48 hours after pancreatic surgery (total pancreatectomy, distal pancreatectomy for benign/borderline neoplasms of pancreatic body-neck). PIPIAT was performed using a combined US and fluoroscopy-guided technique (4-F catheter): portography and portal vein pressure assessment were performed before and after islet transplantation. Intrahepatic tract embolization was performed before final catheter removal. PIPIAT feasibility, complications, median-follow-up, metabolic (insulin independence rate, graft function based on β-score, marker of islet function ) and oncologic (malignant and metastatic diseases) outcomes were recorded. RESULTS PIPIAT wasn’t performed in 7/41 patients (4 for inadequate islet mass, 2 for hemodynamic instability, 1 for islet culture contamination), while it was successfully performed in 34/34 patients. PIPIAT-related complications occurred in 8 patients (23.5%): 4 bleedings (2 requiring transfusions), 3 portal thromboses (1 complete, 2 partial), 1 sepsis. Median follow-up duration was 546 days. Insulin independence was achieved in 15/34 patients (44%), partial graft function in 16/34 patients (47%), no function in 3/34 patients (6%). Seventeen patients had malignancy; none of them developed liver metastases during follow-up. CONCLUSION PIPIAT, performed under a combined US and fluoroscopy guidance and not requiring immunosuppression, is feasible, with a relatively low complication rate and a better metabolic outcome than allo-transplantation. CLINICAL RELEVANCE/APPLICATION PIPIAT indications can be extended to selected patients with neoplasm, both benign and malignant. An increased islet mass may lead to the improvement of the metabolic outcome.
    Radiological Society of North America 2013 Scientific Assembly and Annual Meeting; 12/2013
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    ABSTRACT: PURPOSE Despite the improvement in technique/expertise, pancreatic surgery remains burdened with a high complication rate. Our aim was to report our 10-year single-centre experience about the clinical relevance and the interventional-radiological management of the postoperative complications (treatment/prevention) on 1292 patients submitted to pancreatic surgery. METHOD AND MATERIALS In 2000-2012, 1292 patients were submitted to pancreatic surgery (total pancreatectomy, duodeno-cephalo-pancreatectomy, distal pancreatectomy). Patients were classified on the basis of the complication severity in 5 classes (Clavien-Dindo classification): 0=none, class1-2=conservative treatment, 3a=endoscopic/radiological interventional, 3b=surgery, 4=intensive care, 5=death. Interventional-radiological management consisted of: PTC/biliary drainage in case of biliary fistula (bile in surgical drainage, normal bilirubin levels/undilated biliary ducts at US) under US/fluoroscopic guidance (right approach, puncturing along the course of the sixth-segment portal branch (Chiba needle 21G), or left approach if aerobilia/adequate volume of left hepatic lobe); embolization (microcoils/PVA-particles) or covered-stenting (Viabahn-Gore) in case of bleeding; percutaneous drainage (US/CT-guidance) in case of liquid/infected collection. Percutaneous intra-portal islet auto-transplantation (PIPIAT) was performed in case of total pancreatectomy to prevent diabetes. RESULTS Patients were classified as follows: 524/1292 (40%) class 0; 210/1292 (16%) class 1; 361/1292 (28%) class 2; 79/1292 (6%) class 3a; 55/1292 (4%) class 3b; 24/1292 (2%) class 4; 39/1292 (3%) class 5. Among the 79 class-3a-patients, 74/79 required radiological-interventional management, 5/79 endoscopic management. The 74 interventional procedures were the following: 32 drainages of liquid/fluid infected collections, 30 biliary drainages, 12 bleeding management (9/12 embolization; 3/12 covered-stenting). 25/1292 underwent PIPIAT. CONCLUSION In centres of excellence pancreatic surgery has a low rate of complications, usually successfully managed and prevented by interventional-radiological procedures. In particular PIPIAT is an advanced, non invasive technique in the prevention of postsurgical diabetes. CLINICAL RELEVANCE/APPLICATION In centres of excellence, interventional-radiological procedures take part in the management/prevention of the complications of pancreatic surgery, reducing the morbidity/mortality.
    Radiological Society of North America 2013 Scientific Assembly and Annual Meeting; 12/2013
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    ABSTRACT: To determine the maximum tolerated radiation dose (MTD) of an integrated boost to the tumor subvolume infiltrating vessels, delivered simultaneously with radical dose to the whole tumor and concomitant capecitabine in patients with pretreated advanced pancreatic adenocarcinoma. Patients with stage III or IV pancreatic adenocarcinoma without progressive disease after induction chemotherapy were eligible. Patients underwent simulated contrast-enhanced four-dimensional computed tomography and fluorodeoxyglucose-labeled positron emission tomography. Gross tumor volume 1 (GTV1), the tumor, and GTV2, the tumor subvolume 1 cm around the infiltrated vessels, were contoured. GTVs were fused to generate Internal Target Volume (ITV)1 and ITV2. Biological tumor volume (BTV) was fused with ITV1 to create the BTV+Internal Target Volume (ITV) 1. A margin of 5/5/7 mm (7 mm in cranium-caudal) was added to BTV+ITV1 and to ITV2 to create Planning Target Volume (PTV) 1 and PTV2, respectively. Radiation therapy was delivered with tomotherapy. PTV1 received a fixed dose of 44.25 Gy in 15 fractions, and PTV2 received a dose escalation from 48 to 58 Gy as simultaneous integrated boost (SIB) in consecutive groups of at least 3 patients. Concomitant chemotherapy was capecitabine, 1250 mg/m(2) daily. Dose-limiting toxicity (DLT) was defined as any treatment-related G3 nonhematological or G4 hematological toxicity occurring during the treatment or within 90 days from its completion. From June 2005 to February 2010, 25 patients were enrolled. The dose escalation on the SIB was stopped at 58 Gy without reaching the MTD. One patient in the 2(nd) dose level (50 Gy) had a DLT: G3 acute gastric ulcer. Three patients had G3 late adverse effects associated with gastric and/or duodenal mucosal damage. All patients received the planned dose of radiation. A dose of 44.25 Gy in 15 fractions to the whole tumor with an SIB of 58 Gy to small tumor subvolumes concomitant with capecitabine is feasible in chemotherapy-pretreated patients with advanced pancreatic cancer.
    International journal of radiation oncology, biology, physics 12/2013; 87(5):1000-1006. DOI:10.1016/j.ijrobp.2013.09.012 · 4.18 Impact Factor
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    ABSTRACT: This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas (AISP). We covered the main diseases associated with exocrine pancreatic insufficiency (EPI) which are of common interest to internists/gastroenterologists, oncologists and surgeons, fully aware that EPI may also occur together with many other diseases, but less frequently. A preliminary manuscript based on an extended literature search (Medline/PubMed, Cochrane Library and Google Scholar) of published reports was prepared, and key recommendations were proposed. The evidence was discussed at a dedicated meeting in Bologna during the National Meeting of the Association in October 2012. Each of the proposed recommendations and algorithms was discussed and an initial consensus was reached. The final draft of the manuscript was then sent to the AISP Council for approval and/or modification. All concerned parties approved the final version of the manuscript in June 2013.
    World Journal of Gastroenterology 11/2013; 19(44):7930-7946. DOI:10.3748/wjg.v19.i44.7930 · 2.43 Impact Factor
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    ABSTRACT: Context Pancreatic surgery can be related to new onset diabetes, but also with diabetes remission. Postoperative reversion of diabetes has been attributed to the removal of pancreatic cancer. Objective To evaluate changes of diabetic status and the determinants of diabetes reversion after pancreatic surgery. Methods Prospective observational study. Patients candidate to pancreatic surgery, admitted from Jan 2008 to Oct 2012, were evaluated. Clinical variables were recorded and blood biochemistry (including fasting blood glucose, insulin and C-peptide) were evaluated pre- and post-operatively with regular follow-up. Patients were defined as diabetic if fasting plasma glucose was ≥126 mg/dL or HbA1C was ≥6.5% or if taking diabetes medications. Results Study group included 624 patients. 523 underwent pancreatectomy (264 pancreatico­duodenectomy (PD), 174 distal, 66 total, 17 enucleation, 2 segmental), 78 had palliative surgical interventions and 23 were discharged without surgery. Among 297 non-diabetic patients who underwent partial pancreatectomy, 44 (14.8%) developed diabetes postoperatively (median of 30 days). Univariate analysis showed higher HbA1c level, higher fasting glycemia, higher BMI, pancreatic cancer and distal pancreatectomy strongly associated with new onset diabetes. Multivariate analysis confirmed fasting glycemia (OR=1.63, 95% CI: 1.06-2.49; P=0.024), BMI (OR=1.19, 95% CI: 1.09-1.30; P<0.0001) and cancer (OR=2.855, 95% CI: 1.19-6.84; P=0.019) as variables independently associated with post surgical new onset diabetes. Among 160 diabetic patients who underwent partial pancreatectomy, 29 (18.1%) presented reverted diabetes post-operatively (median of 16 days). A similar behavior was seen in patients who did not undergo pancreatectomy. Among 47 diabetic patients who underwent palliative surgery, 8 (17.0%) presented reverted diabetes postoperatively (median of 7 days). Surgical procedures bypassing the duodenum (both PD and gastro-jejunostomy) were associated with reversion in univariate Cox regression analysis. Multivariate analysis confirmed surgical procedures bypassing the duodenum (OR=2.36, 95% CI: 1.02-5.42; P=0.44), but not cancer removal, to be independently associated with diabetes reversion. Conclusions Diabetes changes are frequent after pancreatic surgery, with a 14.8% rate of new onset diabetes and 18.1% of diabetes reversion. Reversion occurred within a few days after surgery before significant weight loss takes place, and surgical procedures which bypass duodenum appeared major determinants. This suggests that, as for bariatric surgery, gastrointestinal anatomic changes more than cancer removal may play a relevant role in remission of diabetes.    
    AISP - 37th National Congress., Bologna, Italy; 09/2013
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    ABSTRACT: OBJECTIVE:: To assess metabolic and oncologic outcomes of islet autotransplantation (IAT) in patients undergoing pancreatic surgery for either benign or malignant disease. BACKGROUND:: IAT is performed to improve glycemic control after extended pancreatectomy, almost exclusively in patients with chronic pancreatitis. Limited experience is available for other indications or in patients with pancreatic malignancy. METHODS:: In addition to chronic pancreatitis, indications for IAT were grade C pancreatic fistula (treated with completion or left pancreatectomy, as indicated); total pancreatectomy as an alternative to high-risk anastomosis during pancreaticoduodenectomy; and distal pancreatectomy for benign/borderline neoplasm of pancreatic body-neck. Malignancy was not an exclusion criterion. Metabolic and oncologic follow-up is presented. RESULTS:: From November 2008 to June 2012, 41 patients were candidates to IAT (accounting for 7.5% of all pancreatic resections). Seven of 41 did not receive transplantation for inadequate islet mass (4 pts), patient instability (2 pts), or contamination of islet culture (1 pt). IAT-related complications occurred in 8 pts (23.5%): 4 bleeding, 3 portal thromboses (1 complete, 2 partial), and 1 sepsis. Median follow-up was 546 days. Fifteen of 34 patients (44%) reached insulin independence, 16 patients (47%) had partial graft function, 2 patients (6%) had primary graft nonfunction, and 1 patient (3%) had early graft loss. Seventeen IAT recipients had malignancy (pancreatic or periampullary adenocarcinoma in 14). Two of them had already liver metastases at surgery, 13 were disease-free at last follow-up, and none of 2 patients with tumor recurrence developed metastases in the transplantation site. CONCLUSIONS:: Although larger data are needed to definitely exclude the risk of disease dissemination, the present study suggests that IAT indications can be extended to selected patients with neoplasm.
    Annals of surgery 06/2013; DOI:10.1097/SLA.0b013e31829c790d · 7.19 Impact Factor
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    ABSTRACT: The liver is the current site of choice for pancreatic islet transplantation, even though it is far from being ideal. In mice we have recently shown that the bone marrow (BM) may be a valid alternative to the liver and here we report a pilot study to test feasibility and safety of BM as a site for islet transplantation in humans. Four patients who developed diabetes after total pancreatectomy were candidates for the autologous transplantation of pancreatic islet. Since the patients had contraindications for intraportal infusion, islets were infused in the BM. In all recipients islets engrafted successfully, as shown by measurable post-transplantation C-peptide levels and histopathological evidence of insulin producing cells and/or molecular markers of endocrine tissue on BM biopsies performed during follow-up. Thus far we have recorded no adverse events related to the infusion procedure or the presence of islets in the BM. Islet function was sustained up to the maximum follow-up of 944 days. The encouraging results of this pilot study open new perspectives in identifying alternative sites for islet infusion in patients with type 1 diabetes. Moreover, this is the first unequivocal example of successful engraftment of an endocrine tissue in the BM in humans.
    Diabetes 06/2013; 62(10). DOI:10.2337/db13-0465 · 8.47 Impact Factor

Publication Stats

2k Citations
338.99 Total Impact Points

Institutions

  • 2006–2014
    • Università Vita-Salute San Raffaele
      Milano, Lombardy, Italy
  • 2000–2014
    • San Raffaele Scientific Institute
      Milano, Lombardy, Italy
  • 1994–2013
    • University of Milan
      • Department of Internal Medicine
      Milano, Lombardy, Italy
  • 2001–2005
    • Ospedale di San Raffaele Istituto di Ricovero e Cura a Carattere Scientifico
      Milano, Lombardy, Italy