06:43am Monday 21 August 2017

The Miller School’s Diabetes Research Institute Teams Up with Military Surgeons to Give Wounded Warrior an Historic Islet Cell Transplant

A 21-year-old Georgia airman who was gravely wounded in Afghanistan and faced a future as a severe diabetic may live a normal life after the Miller School’s Diabetes Research Institute helped doctors at Walter Reed Army Medical Center perform an unprecedented transplant of the serviceman’s own insulin-producing cells.
 
The Thanksgiving Day transplant was performed by Walter Reed surgeons in Washington, D.C., under the telemedicine-assisted guidance of DRI Director Camillo Ricordi, M.D., the professor of surgery who invented the machine and method for isolating large numbers of islets and transplanting them into the liver to reverse diabetes.    
 
Just 15 hours earlier, Ricordi and his four-member DRI team began an all-night race against the clock to isolate U.S. Air Force Senior Airman Tre Porfirio’s islets from his damaged pancreas, which had been partially removed after he was shot three times in Afghanistan five days before Thanksgiving. Completely removed at Walter Reed, the organ was rushed to Miami, arriving late Wednesday as most people were readying for bed, and the long holiday weekend.
 
By Thanksgiving afternoon, Walter Reed doctors had more than 220,000 of Porfirio’s re-purified islets suspended in a Ricordi infusion bag and, with Ricordi’s remote guidance, began injecting them into the Air Force enlistee’s liver via his portal vein. Today, the transplanted islet cells are producing insulin in the normal range.

“This was the first successful post-traumatic autologous pancreatic islet transplant performed in an emergency procedure,’’ Ricordi said before a Tuesday afternoon news conference at Walter Reed announcing the historic collaboration and procedure. “To be able to give back to a wounded warrior this way – I couldn’t think of a better way to spend Thanksgiving.’’

Miller School Dean Pascal J. Goldschmidt, M.D., who accompanied Ricordi to Washington, said the Miller School and the entire University of Miami “are extremely proud and honored to be involved in the care of young Tre, a wounded warrior.’’

“It is just one beautiful accomplishment of two teams working to save a life from diabetes,’’ the Dean said. “I can tell you first hand the incredible damage that diabetes creates for individuals.’’

After three long, agonizing weeks, Porfirio’s father, a widower with five sons, finally has reason to be optimistic.

“Three weeks ago, I thought I had lost him forever,’’ Karl Porfirio said. “Now he is recuperating and he will walk out of Walter Reed a new man – minus a few organs. I am ever grateful to all the physicians and scientists who made this happen.’’

Without the pioneering transplant made possible by extraordinary military/civilian teamwork, Porfirio, who is recovering on a general ward, was destined for a grim future.
 
“When you completely remove the pancreas you develop one of the most severe forms of diabetes because not only do you lack any source of insulin, but you also miss the so-called counter-regulatory hormone, glucagon, which helps protect you from low blood glucose levels,’’ Ricordi explained. “That’s why it’s so difficult to manage diabetes following total pancreatectomy.”
 
Now, Ricordi said, the success of the transplant holds great promise for other patients who lose their pancreas in an accident, a shooting or some other trauma. If they are within a six-hour plane ride from Miami, their physicians could take advantage of the emergency procedure he and his team, with help from more than 60 Walter Reed professionals, proved possible for trauma patients and have long performed on patients with chronic pancreatitis who undergo scheduled pancreatectomies to ease intractable pain.
 
“Every physician, surgeon and center should know in cases where the pancreas needs to be removed from chronic pancreatitis or from trauma, it should never be thrown away,’’ Ricordi said. “We can process the pancreas and re-purify the insulin-producing cells and return them to the patients so they will be cured of one of the most severe forms of diabetes. Anyone within a six-hour flight could be assisted.’’
 
Usually, pancreatic islet transplants are conducted with donor cells from a cadaver. Avoiding rejection and immunity issues is a huge advantage of an autologous transplant, Ricordi said.

The race to save Porfirio, who has undergone 11 surgeries in 20 days, began the Saturday before Thanksgiving when an insurgent shot him three times in the back at close range on the remote Army outpost where he was serving. The assailant was killed.

Surgeons in two forward combat medical bases in Afghanistan operated on the airman twice, performing a rare trauma Whipple, which involves the removal of the head of the pancreas, a portion of the stomach, gallbladder, and the entire duodenum. They also removed a portion of the airman’s large and small bowels.

Another procedure to prevent infection was performed at a military base in Germany, before Air Force Critical Care Air Transport airlifted Porfirio to Walter Reed.

Arriving just 72 hours after the shooting, the airman was returned to the OR the day before Thanksgiving. There Col. Craig Shriver, M.D., chief of general surgery at Walter Reed and professor of surgery at the Uniformed Services University in Bethesda, Maryland, began reconstructing his entire intra-abdominal structure. But during the operation, Shriver found the remainder of the airman’s pancreas to be damaged beyond repair, and reluctantly removed it.

“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,” Shriver said. “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.”

Shriver consulted with Rahul Jindal, M.D., a transplant surgeon at Walter Reed and clinical professor of surgery at George Washington University. Jindal, who had training and experience in islet cell transplantation and clinical trials, recommended calling the man who invented the procedure.
 
“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,” Jindal said.  “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.’’

Ricordi didn’t hesitate. “Anything to help a wounded warrior,’’ he said, giving his Walter Reed colleagues the protocols and instructions on how to package and ship the organ.

“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,” Ricordi recalled. “More than 220,000 purified islets were then suspended in a specialized cold solution and flown back to Walter Reed.”

By 3:30 Thanksgiving afternoon, Ricordi established a live telemedicine link with the Walter Reed team, and guided them through the process of injecting the airman’s islets into his liver.

Less than a week later, a c-peptide blood test showed evidence of pancreas islet function in Porfirio’s liver. Fifteen days later, the same test indicated the transplanted islet cells were producing insulin in the normal range, turning the liver, in Ricordi’s words, into “a double organ.’’

As time goes on, the transplanted pancreatic islets are expected to take up new blood supply in the liver, decreasing Porfirio’s dependence on exogenous insulin, preventing complications from the disease and improving his overall quality of life.

“The prospect is they will continue to work for many years and hopefully forever,’’ Ricordi said. “He had several organs removed so if he can recover from that he should have a normal life.’’

Listening in to the news conference by phone, the airman’s father said he was overwhelmed with gratitude – for his son, for his family, which has been touched by diabetes before, and for the millions of people suffering from the disease.

“Again, I can’t thank everyone enough for saving my son’s life and for what you all have done,’’ he said.


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