It certainly wasn't a gourmet feast, but to Clara Clements it seemed like one. There was soup and chicken, rice and bread. And, Clements recounted with delight, "There was coffee cake. I had a piece of cake."
For 20 years since coming down with diabetes, Clements, a 40-year-old Glendale resident, had been on a restricted diet in which sugars and starchy foods were taboo.
Then last month, she had a pancreas transplant at UCLA Medical Center, the first such operation performed on the West Coast. On Thursday, Clements was well enough to leave the hospital after a 3 1/2-week stay.
First Unrestricted Dinner
After the operation, Clements had something most diabetics don't even dare hope for--a healthy pancreas capable of producing sufficient insulin to control her blood-sugar levels. Several days after the operation she ate her first unrestricted dinner.
"When she saw that first meal, her eyes gleamed," said Dr. Patrick Soon-Shiong, the UCLA surgeon who performed Clements' transplant. "She told me she had been waiting for that day for 20 years. That is what this operation is all about--improving the quality of life for patients with severe diabetes."
Pancreas transplant surgery is still in its infancy. To date, only about 900 pancreas transplants have been performed worldwide. Currently, four pancreas transplant centers are operating in the United States, and UCLA is the only center on the West Coast performing the procedure.
The pancreas, a six-inch-long organ located behind the stomach, regulates the body's conversion of sugars and carbohydrates to energy by secreting the enzyme insulin to adjust the level of sugar in the blood.
In diabetics, the pancreas either does not manufacture sufficient quantities of insulin or the insulin it manufactures does not do an adequate job of metabolizing sugars and carbohydrates. Patients like Clements, with severe cases of diabetes, must therefore inject themselves regularly with insulin.
But daily insulin injections cannot mimic the way a normal pancreas secretes the appropriate amount of insulin during the day in response to rising and falling blood-sugar levels. Because injections are less effective, diabetics can develop serious complications such as heart disease, blindness, stroke, kidney failure and severe circulatory problems which can lead to limb amputation.
Soon-Shiong said that pancreas transplants are the most difficult type of organ transplant. "The pancreas is an extremely delicate organ," he said. "To harvest the organ from the donor requires a four- to five-hour operation." If the pancreas is damaged during the operation, it can secrete the digestive juices which, in effect, cause the pancreas to destroy itself."
Implanting the pancreas in the patient requires another four- to five-hour operation, during which numerous small blood vessels must be connected. The patient's old pancreas is left in place, and the new pancreas is placed lower in the abdomen near the groin area.
Performing the transplant on Clements was difficult but very exciting, Soon-Shiong said. "After we (connected blood vessels to) the organ, we saw it literally come to life and pulsate on the operating table," he said.
A successful connection of the organ is not the only obstacle with pancreas transplants. After surgery, the patient must be carefully monitored, because, as with other types of organ transplants, there is a chance the new organ will be rejected.
No Signs of Rejection
Indeed, two weeks after receiving her new organ, Clements showed signs of rejecting it. "We caught it early, and were able to treat the rejection episode (with drugs) in the hospital," Soon-Shiong said. Until her new organ recovers fully, Clements is taking some insulin again, but Soon-Shiong estimates that within several weeks her pancreas will again be fully functional.
"She is progressing very rapidly," he said. "I estimated that after one week I could halve the dose of insulin she required after the rejection episode. Instead, I was able to halve it after two days."
The one-year patient survival rate after a pancreatic transplant is about 95%, a UCLA spokesman said. After two years, between 65% and 70% of transplant patients have a successfully functioning new pancreas.
Long-term success rates are unknown because the procedure is so new. Although the first pancreas transplant was performed at the University of Minnesota in 1966, it has only been recently that such transplants have been widely available. The majority of pancreas transplants have been performed in Minnesota. The procedure is also done at the University of Iowa and the University of Wisconsin at Madison.
Not Recommended for All
Soon-Shiong is quick to point out that the surgery is not recommended for all diabetics. At UCLA, pancreas transplants will only be performed on people with the most severe form of the disease who've already had a kidney transplant operation. Cancer patients are not candidates for the operation at this times.
Significant numbers of diabetic have needed kidney transplants, Soon-Shiong said, estimating that 25% to 30% of all kidney transplants are necessitated by kidney failure due to severe diabetes.
Patients who previously had kidney transplants are already taking drugs to suppress their immune systems to minimize the chance of rejection. These immunosuppressants can have serious side effects, including increasing the risk of infection in patients taking them. Therefore patients who are already taking the drugs are considered better candidates for pancreas transplants. Otherwise, we would be "simply substituting anti-rejection drugs for insulin," Soon-Shiong said.
With the addition of a pancreas transplant program, UCLA has become one of the few centers in the country to provide all four types of major organ transplants. Heart, liver and kidney transplants are the other types of organ transplants.
UCLA began performing the procedure, Soon-Shiong said, as part of a continuing program to provide the best possible medical care to diabetes sufferers.
In addition to its transplant program, UCLA is studying alternative ways of stimulating insulin production in patients with severe diabetes. Researchers are currently focusing on transplanting islet cells from the pancreas, the cells specifically responsible for producing insulin. The procedure has been tried unsuccessfully nationwide on about 115 patients.
UCLA doctors plan to continue performing pancreas transplants as organs become available and as patients need them.