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(December 15, 2009) - A 21-year-old airman severely injured while serving his country in a remote area of Afghanistan is recovering at Walter Reed Army Medical Center (WRAMC) in Washington, D.C. after several surgeries and an unprecedented transplant.
The extraordinary care is an example of military and civilian medical experts working together in the first known case of a successful isolation and transplantation of insulin-producing cells following a severe trauma requiring complete removal of the pancreas. Camillo Ricordi M.D. and his team at the Diabetes Research Institute played a major role in the life-saving effort.
The airman, Tre Porfirio, was struck by three high velocity bullets on November 21 and was operated on twice by surgeons in forward combat medical bases in Salerno and Bagram, both in Afghanistan.
The surgeries included a rare but life-saving trauma Whipple, in which the head of the pancreas, a portion of the stomach, gallbladder, and entire duodenum were removed. In addition, a portion of the airman’s large and small bowels were also removed.
A procedure to prevent infection was later performed at a military base in Germany, before the wounded warrior was transferred by the Air Force Critical Care Air Transport teams to Walter Reed four days after the initial injury.
The airman was taken back to the operating room at Walter Reed by Dr. Craig Shriver, chief of general surgery, to have his entire intra-abdominal structure reconstructed. During this operation, what was remaining of the airman’s pancreas was found to be damaged beyond repair from the gunshot wounds.
“The optimal procedure at this point was to remove his entire remaining pancreas to prevent further leakage of the pancreatic enzymes and control the bleeding, which could be fatal,” said Dr. Shriver. “We knew that the procedure would lead to the most severe and life-threatening form of diabetes, which tends to be very brittle and difficult to control in this type of situation.”
At this point in the operation, Dr. Shriver sought the opinion of Dr. Rahul Jindal, a transplant surgeon at Walter Reed and a clinical professor of surgery at George Washington University in Washington, D.C. Dr. Jindal had training and experience in islet cell transplantation, which is considered the best hope for curing diabetes.
In islet cell transplantation, the insulin-producing islets are isolated from a donor pancreas and then reinfused in a patient’s liver where they later begin to produce insulin.
“Isolation and purification of pancreatic islets is a very intricate procedure which requires a specialized laboratory, and there are only a few such facilities in the United States,” said Dr. Jindal. “I knew the Diabetes Research Institute at the University of Miami Miller School of Medicine had such a facility and I put a call in to its director, Dr. Camillo Ricordi, for his assistance in isolating the islets from our airman’s removed pancreas.”
Dr. Ricordi, scientific director at the DRI, developed the method for isolating the islet cells from the pancreas and is considered a pioneer in the field. He immediately agreed to help, in his words, “anything to help a wounded warrior.”
Dr. Shriver proceeded to remove the remaining portion of the pancreas; and Drs. Jindal and Eric Elster, a Navy transplant surgeon, flushed the harvested pancreas and intact spleen with a special preservation solution, packed it in ice and transported it by courier to Miami.
“The organ arrived at 11 o’clock the night before Thanksgiving, and my cell processing team at the Diabetes Research Institute spent the next six hours performing the islet isolation and purification procedure,” explains Dr. Ricordi. “More than 220,000 purified islets were then suspended in a specialized cold solution and flown back to Walter Reed.”
Late in the afternoon on Thanksgiving Day, the cells were successfully injected into the patient’s portal vein into his liver with Dr. Ricordi and his team coordinating the procedure via an internet connection with surgeons at Walter Reed.
Less than one week after surgery, there was clear evidence of pancreas islet function in the wounded warrior's liver, as shown by the presence of a specialized blood test called c-peptide. Fifteen days after the procedure, that same blood test indicated the transplanted islet cells were functioning in the normal range.
As time goes on, the pancreatic islets in the liver will take up new blood supply and the patient's requirement of exogenous insulin is expected to further decrease, facilitating diabetes management and preventing the onset of complications of the disease, and improving his overall quality of life.
Teamwork and close coordination between the many professionals in the entire Military Trauma System at Walter Reed and at the Diabetes Research Institute at the University of Miami made this possible.
This procedure may allow for more cases of islet transplantation following traumatic injury to the pancreas, where purification and transplantation of the insulin producing cells from even a segment of the rescued organ could prevent the development of severe diabetes and its complications.
Why is this an important first worldwide?
- It was the first post-traumatic autologous pancreatic islet transplant ("Autologous" means transplanting from one part of the body to another in the same individual.)
- It was the first islet cell product shipment to a remote site with the islets already prepared in the Ricordi Infusion Bag kit ready for infusion (since WRAMC did not have the facility and local expertise to reprocess and package an islet cell product for transplant following shipment with a conventional protocol).
- It was the first time islet shipment was performed at cool temperature instead of room temperature (in an attempt to minimize metabolic activation of the concentrated islet cell product).
- It was the first time the transplant was done via Telemedicine assisted live communication between Dr. Camillo Ricordi and the WRAMC team in the operating room.