Introduction
What is the pancreas?
The pancreas (also known as the sweetbread gland) is an 18cm to 25 cm long organ located behind the stomach in the back of the abdomen near the spine. It is spongy and shaped somewhat like a fish (about the size and shape of a kipper) that is lying horizontally across the abdomen.
The head of the pancreas is the largest part. It lies on the right side of the abdomen where the stomach is attaches to the first part of the small intestine. It is here that the stomach empties partially digested food into the small intestine and this mixes with the secretions from the pancreas.
The tail or body of the pancreas (its narrowest part) extends to the left side of the abdomen next to the spleen. There is a duct that runs the length of the pancreas. Several small branches join from the glandular tissue.
What does the pancreas do?
The pancreas has two main functions.
What is chronic pancreatitis?
Chronic pancreatitis is inflammation of the pancreas that does not heal or improve, gets worse over time, and leads to permanent damage by fibrosis (the production of scar tissue).
As a result of prolonged damage to the substance of the gland, the pancreas fails to produce enough digestive enzymes to permit adequate digestion of food. This leads to weight loss and the frequent passage of pale greasy stools which contain excess amounts of fat (called steatorrhoea).
The destruction of the cells which produce insulin may eventually lead to the development of diabetes. This happens in more than a half of the patients with chronic pancreatitis.
There are several causes of chronic pancreatitis and although the most common is alcohol, there are a number of others including problems relating to gallstones, genetic disorders and damage to the pancreatic duct.
Sometimes it may not always be possible to attribute a specific cause to the condition. It is then known as idiopathic.
Causes of chronic pancreatitis
There are several causes of chronic pancreatitis. Although the most common is alcohol there are a number of others including problems relating to gallstones, genetic disorders and damage to the pancreatic duct.
Sometimes it may not always be possible to attribute a specific cause to the condition and it is then known as idiopathic.
Genetic disorders
Genetic disorders related to pancreatitis are when there is an abnormality in a gene, or several genes an individual carries which can predispose individuals to pancreatitis.
These genes can be inherited and when this is the case it is known as hereditary pancreatitis. The genes most associated with hereditary pancreatitis are the PRSS1, SPINK1 and CTFR gene.
To determine whether your pancreatitis is caused by one of these genetic disorders your consultant may refer you for genetic testing and counselling.
There is an increased risk of developing pancreatic cancer for individuals with chronic pancreatitis and this risk is increased further in hereditary pancreatitis patients.
Sometimes it is impossible to tell if there is any cancer in your pancreas if you have one of these gene defects.
Every effort is made to exclude it but there is a possible small risk of it presenting after your transplant when the islets are transplanted into your liver. It is hard to be accurate and so far this has never been reported in the UK.
The risk worldwide is about 1-2 cases per 1500 6 auto-transplants. If this did happen it meant that you already had cancer in your pancreas at the time of the total pancreatectomy which we were unable to identify.
What is the treatment for chronic pancreatitis?
Treatment for chronic pancreatitis depends on the symptoms. Most treatments focus on pain management and nutritional support. Oral pancreatic enzyme supplements are used to aid in the digestion of food. Patients who develop diabetes require tablets or insulin to control their blood sugar levels.
However a number of patients continue to experience severe pain and have to undergo surgery to treat this. One surgical option is to remove part of the pancreas, although these patients may continue to experience pain.
If pain does continue to be a problem, you may require further surgery. At this stage removing the whole pancreas completely. This is a preferred option and known as a total pancreatectomy. The problem with removing the whole pancreas is that this removed the islet cells (that produce insulin) causing you to have diabetes.
Diabetes occurs because both hormones controlling blood sugar are lost. If you diabetes you have will then have to control your blood sugar using insulin injections.
Often blood sugar levels can swing rapidly from too high to too low. Low blood sugar can cause confusion, incoordination, drowsiness and in extreme cases even seizures or death.
High blood glucose over time can lead to complications of diabetes. This includes blindness, kidney failure and nerve damage that can lead to amputations.
What is total pancreatectomy and islet auto transplantation programme?
What do we remove in the surgical procedure?
There are a number of centres around the world that regularly perform total pancreatectomy combined with islet auto transplantation for chronic pancreatitis.
This procedure allows us to isolate (separate) the islets from the diseased pancreas. This happens immediately after we remove it in the operating theatre.
We then seperate the islet cells from the diseased pancreas. These are given back to the you by injecting them into the liver.
A total pancreatectomy (removal of the pancreas) is performed during open surgery. This is through a large cut (incision) across the top of the abdomen. Sometimes we may remove the spleen too.
As soon as we remove your pancreas, we take it to a cell isolation laboratory at the Centre for Life. Specialised enzymes (proteins) are then used to digest the gland and separate out the islets. These are a clusters of cells which produce insulin (which keeps sugars low). They also produce the hormones glucagon and pancreatic polypeptide (which keep sugars high).
We then process the islet cells (purified if necessary) and return them to the operating room as quickly as possible. This process can take anything from 4-6 hours.
While we process the pancreas the surgeon reconnects the bile tube and the bowel. The surgeon inserts a tube into a suitable vein ready for the injection of the islets into the liver. Reconstructions may vary depending on the extent of any previous surgery.
In this new and healthy environment they can recover from the isolation process and develop a new blood supply. They resume their production of the necessary insulin and hormones to maintain normal blood sugar levels.
What are the potential results of surgery?
Patients who have undergone this surgery have experienced a dramatic improvement in their quality of life after the procedure.
In the most successful cases, patients are insulin-free with normal glucose tolerance and have excellent relief of abdominal pain.
The remaining patients have usually required minimal insulin to treat high blood sugars (hyperglycaemia) or have easy to control blood sugars.
However not every patient is a success as some patients may develop a complication from surgery and some still have abdominal pain.
This amounts to about 30% (3 in 10) of patients. Nevertheless it is important to mention that within this 30% the extent of variation is wide in terms of seriousness of complications and improvement in quality of life.
For example, most patients have been successfully weaned off all their painkillers (often morphine based). This is usually between six months to a year as this has to be done in a controlled manner. Others have greatly reduced the need for painkillers but from time to time may still have episodes of pain.
Combining the total pancreatectomy with islet auto transplantation. This allows a patient to be treated for the pain of pancreatitis without the very serious side-effects of a total pancreatectomy.
This includes “brittle diabetes” when a person’s blood sugar levels often swing quickly from high to low and from low to high which makes it very difficult to control.
Alternatives to having the transplant would include 3-4 times daily insulin injections with regular blood monitoring or a continuous insulin infusion pump if deemed appropriate.
Having an islet auto transplant is the only way to become insulin independent after total pancreatectomy.
Pancreatic assessment work-up protocol
If your consultant feels that you should be considered for a total pancreatectomy and islet auto transplantation we will ask you to undergo a formal pancreatic assessment.
Why do I need a pancreatic assessment?
Total pancreatectomy and islet auto transplantation is clearly a major undertaking and is considered only as a “last resort” treatment when all else has failed to relieve your symptoms. The surgery itself can take between 8-12 hours.
This involves a comprehensive pancreatic work-up and treatment plan.
Being assessed for the procedure does not necessarily mean that you will be offered this surgery.
Pancreatic assessment allows a multi-disciplinary (MDT) team of consultants and medical personnel to assess your suitability and at the same time makes sure that you fully understand what is involved.
Who will co-ordinate the pancreatic assessment?
The aim of the assessment and workup is to ensure that you fully understand the procedure and the long-term results.
Your assessment process is a streamlined service which will be co-ordinated by a pancreatic nurse specialist.
The role of the nurse specialist is to explain the assessment process and to provide you with as much information as possible to enable you to make an informed decision as to whether or not you wish go ahead with the surgery should it be offered to you.
As part of your assessment you will see Professor White who leads the program who will organise a number of special investigations.
This is all done in a consultation which may initially take up to 1 hour to complete.
The pancreatic nurse specialist or Professor White’s Secretary will be a permanent contact point for you throughout your assessment.
The nurse specialist will then arrange appointments for you with various consultants who are part of the assessment team. In addition you will be introduced to a patient who has had the procedure done.
On completion of the assessment the nurse specialist will arrange for you to see Professor White again in an outpatient clinic with some of your family, if you wish, to discuss the outcome of your assessment.
What tests will I have and why?
Pancreatic function tests
In order to test the function of the pancreas we need to do two important tests which are as follows:
- Mixed meal tolerance test (MMTT)
- Faecal elastase stool test
Anaesthetic assessment
You will also be reviewed in our pre-assessment clinic (clinic H). Here your fitness for surgery will be assessed and this may involve a cardiopulmonary exercise test on a stationary bicycle.
Who are the multi-disciplinary (MDT) team?
The MDT is a team of specialist medical personnel who are experienced in the management of patients with complex, long-term diseases of the pancreas.
They see all patients being considered for a pancreatectomy and islet auto transplant and decide which patients are most suitable and should have the operation.
This procedure is a major undertaking and can only be performed by surgeons with experience of complicated pancreatic surgery.
The surgeons also work with a team of doctors with experience in isolating and transplanting islet cells back into the liver and also specialist doctors who look after the control of blood sugar in these complicated patients.
As with any major operation there are risks and complications do occur and very occasionally these can be fatal.
Although the risk of the complications (particularly the major ones) is small and it is essential that you are assessed and consented appropriately understanding the risks involved.
The MDT consists of the following consultants:
- Pancreatic surgeons
- Diabetologist
- Gastroenterologists
- Clinical psychologists
- Pain specialist (anaesthetist)
- Clinical nurse specialist
- Clinical nurse specialist
The role of the members of the MDT is to assess the appropriateness of the proposed surgery together with the your suitability, and to discuss the procedure in detail.
They will examine you and complete a comprehensive clinical assessment of your condition. Each consultant will focus on their particular specialist area and ask you important questions related to your chronic pancreatitis to assess how you manage your condition and what effect it has on your quality of life.
It is important that you give a clear history to each consultant on how your pancreatitis impacts on your life and what you do to manage it. Each consultant will then complete an individual report on your suitability to be put forward for the surgery.
It is important to know that any member of the MDT team is able to say if the procedure should not go ahead if they have concerns about your diagnosis, appropriateness of the surgical procedure or your suitability for a combined islet auto transplantation. If they do then this decision will be explained to you and discussed further when you meet Professor White.
Why do I need to see other patients who have also had pancreatic surgery?
As part of the assessment process you will also be introduced to a patient who has previously undergone the procedure.
It is important to discuss with a patient who has gone through the same assessment process and can give you an accurate insight as to what to expect, how they prepared themselves for the procedure and give you advice you may find useful.
They will make you understand that your recovery will be a long process and generally can take a good two years before you truly feel the full benefit of what you have been through.
Also maintaining a positive attitude with help and support from your family and friends is a vital part of the recovery process and is easier if you know what to expect at each stage.
What is islet auto transplantation?
Islet transplantation can be used for patients with diabetes (islets from a donor) and when patients have their pancreas removed for the treatment of chronic pancreatitis.
The Freeman hospital already performs both islet cell transplants and whole pancreas transplants from organ donors . The surgical removal of the pancreas will automatically cause diabetes, because the islets scattered within the pancreas are the only site of insulin production in the body.
Islet transplantation is used for diabetic patients and the islets are separated from another person’s pancreas and injected into the patient.
For islet autotransplantation, the same methods are used to isolate and transplant the islets but the islets are isolated from the patient’s own pancreas, rather than a donated pancreas.
Because the patient’s own islets are being transplanted, the body will not see the tissue as ‘foreign’ as is the case with donated tissue from another person and this will avoid problems associated with rejection.
This means that the powerful drugs that diabetic patients use to prevent the body rejecting the donated tissue are not required.
Additionally, the islet autotransplantation is done at the same time as the removal of the pancreas, with no ‘waiting list’ for a suitable donor.
If successful, islet autotransplantation will prevent you from having to inject yourself with insulin. In many cases, although the islets are working, the numbers that are isolated and transplanted are often too small to allow you to be completely free of insulin injections.
However, the doses of insulin necessary to control blood glucose levels tend to be much lower than if the islet transplantation had not been done. Even if you make some of your own insulin this will be of great benefit in the long-term giving you better control of your blood glucose.
Why do I need to see other patients who have also had pancreatic surgery?
As part of the assessment process you will also be introduced to a patient who has previously undergone the procedure. It is important to discuss with a patient who has gone through the same assessment process and can give you an accurate insight as to what to expect, how they prepared themselves for the procedure and give you advice you may find useful.
They will make you understand that your recovery will be a long process and generally can take a good two years before you truly feel the full benefit of what you have been through. Also maintaining a positive attitude (with help and support from your family and friends) is a vital part of the recovery process and is easier if you know what to expect at each stage.
The operation
How are the islets isolated?
During the operation the pancreas will be removed and then taken to the islet isolation laboratory.
The pancreas is then injected with an enzyme called collagenase, which digests it and separates it into acinar tissue and islets.
The pancreas is placed in a specialised chamber and a solution is circulated through it. This special chamber is in a circuit containing the digestion fluid and this is known as the digestion process.
The digested pancreatic tissue is then washed several times to remove any remaining enzyme and dead acinar tissue. Samples are then taken to allow the number of islets to be counted and their size measured.
This is important, as it allows a calculation to be made about the total amount of islet tissue which is going to be transplanted. The islets are then put into an infusion bag and taken back to theatre to be transplanted into your liver.
How are islets transplanted?
Islets are normally scattered within the pancreas. However, as your pancreas will be removed, an alternative place to transplant the islets into has to be found.
Information gathered from studies around the world has shown that the best pace to transplant the islets is into the liver.
In order for your islets to be infused into your liver, the surgeon will place a small tube into one of the blood vessels that supplies the liver with blood. Once this is in place, the tube is attached to the infusion bag containing the islets.
These are then infused slowly into your liver while the anaesthetist keeps a careful check on the blood pressure going into the liver.
The whole process from the time the pancreas arrives in the laboratory to the time the islets go back into your liver takes between two and three hours.
Once the islets have been infused the operation is completed and your wound will be closed. You will then be transferred to the recovery room and then to the intensive care unit.
Is it definite that the islets will be isolated from my pancreas?
The methods used for isolating islets from the pancreas have been undertaken for many years and scientists with training and experience will be performing this part of the procedure.
If the pancreas has been severely damaged by the chronic pancreatitis process or you have had a previous drainage operation it may not be feasible to inject the enzyme/protein required to digest the pancreas and it will then be impossible to recover any islets to transplant back into your liver.
Every effort will be made to try to isolate the islets but sometimes this is just not possible. Also rarely there are technical failures with the isolation equipment which can lead to no islets being isolated but reasonable steps will be taken to try and keep this risk to a minimum.
Unfortunately, it is not possible to tell whether the islet isolation will be successful until the pancreas has been taken back to the laboratory and the isolation process is completed. Your surgeon and or nurse specialist will be able to discuss the possibility of this happening to you.
Is islet auto transplantation always successful?
The aim of islet autotransplantation is to preserve and restore as much of the insulin producing islet tissue as possible.
Over time, if left untreated, the damage from your chronic pancreatitis will cause your pancreas to “fail” and you will most likely develop diabetes anyway.
You will need to take injections of large doses of insulin to control your blood glucose levels and will have to prick your finger 4-5 times a day to check your blood glucose.
If the islet autotransplant works and you receive enough islet cells, the transplanted islets should produce enough insulin to allow you to maintain your normal blood sugar levels without having to inject insulin.
In some cases, the islets work partially, which means that you will need a little bit if insulin to “top-up”, but your blood sugar levels will be quite stable and much easier to control.
Even having partial function means that you are at a much lower risk of low blood glucose and that diabetes is much easier to control.
If the autotransplant fails, or we are not able to isolate the islets from your pancreas, you will be completely reliant on insulin. Without insulin you cannot live it is a vital hormone to maintain life.
In the UK and abroad, islet autotransplantation has had very good success, with most patients achieving full or partial function of their transplant. However, it is important to remember that there is no guarantee that once the islet autotransplantation has been performed that your islets will function normally.
It is usually the case that the islets take some time, generally 2 to 3 weeks before they start to secret insulin fully and in some cases there is a further improvement a lot later (sometimes as long as 1 and 2 years).
During that time, you will have to inject yourself with insulin, but as your islets start to work, the dose you need to inject will gradually decrease.
Scheduling your total pancreatectomy and islet auto transplantation operation
If you are suitable to have surgery, it will be scheduled to take place as soon as possible.
If you need any additional investigations they will be organised by either your surgeon or nurse specialist. You will be asked to attend a pre-assessment clinic before your admission to hospital.
What does pre-assessment testing involve?
A nurse will ask you questions check your blood pressure, pulse and temperature and take routine swabs for MRSA screening.
A doctor will complete all relevant documentation and any further tests that you will need. These include further blood tests, a heart recording (ECG) and chest X-ray (to check your lungs) and a cardiopulmonary exercise test.
Consent
You will be asked to give your consent to allow the surgeon to operate on you.
Before any operation, make sure that you have discussed it fully with your surgeon so that you understand what is involved. This is the time when you should ask further questions about the risks involved.
As with any surgery there are specific risks that are associated with the anaesthetic, the surgery and islet transplantation and with the recovery. When you sign the consent form, you should ensure that you understand clearly what you are signing for.
Anaesthesia for total pancreatectomy and islet auto transplantation operation
Before your surgery your anaesthetist will visit you. This is the doctor that keeps you unconscious during your operation and looks your breathing and heart function while you have surgery.
The anaesthetist will do everything possible to keep you safe during the operation. Before your surgery they will ask you questions about your general health and examine you.
The anaesthetist will explain what is involved with the anaesthetic and will discuss your options for pain relief. You will be asked not to drink or eat anything for eight hours before the operation to ensure that your stomach is empty so that you can be safely put to sleep with a general anaesthetic.
Total pancreatectomy and islet auto transplantation operation
To enable the surgeon to perform this operation safely, they must be able to see the pancreas clearly.
For this reason a large cut (incision) known as a roof top incision will be made across your upper abdomen under the ribcage. You will not receive a blood transfusion unless it is absolutely necessary but often it is needed during pancreatic surgery.
The length of the operation depends on how diseased your pancreas is. It can take between eight and twelve hours to perform the surgery and the islet auto transplantation.
At the end of the operation your surgeon will telephone a relative or friend of your choice to explain what was found and what has been done.
The whole pancreas is removed usually (but not always) along with the spleen and part of the duodenum.
If the spleen is removed you will need to have immunisations to reduce the risk of any infections such as a flu jab and take low dose penicillin antibiotics. Sometimes the spleen can be preserved.
The average length of stay in hospital after surgery on your pancreas surgery is between 14 and 21 days.
What are the risks of the operation?
As with any operation, complications are always possible and some of them are potentially serious.
With this type of operation, they can include
- 1-2% mortality (death) rate related to pancreas surgery. These figures come from specialist centres across the world including our own
- Bleeding (usually from the pancreatic bed or liver after islets are injected) infection
- Leakage from the areas joined back together with stitches
- Pneumonia
- Heart problems and stroke
- Clots in the legs and lungs (deep vein thrombosis and pulmonary embolism)
- Clots in the liver veins (1%)
What should I expect after the operation?
After your operation you will wake up in the intensive care unit (ITU) and spend a few days there.
This is because after major surgery such as pancreas surgery, the doctors and nurses will need to keep a very close check on your bodily functions. Immediately after the operation you will be on a ventilator (life support machine which helps you breath) to rest your body due to the length of your surgery.
You will usually be taken off this the following morning and allowed to breathe on your own.
As soon as you are well enough a member of the surgical team will discuss your operation in detail with you.
When you wake up after the surgery you will also have the following:
- A tube called a nasogastric tube (NG), in your nose going into your stomach. This tube drains the fluid that naturally accumulates in your stomach. You will have the NG tube for a couple of days and it may be uncomfortable.
- A catheter (a soft, flexible tube) in your bladder to drain urine. This will save you having to get up to pass urine. The catheter is usually taken out after a few days.
- An intravenous (IV) line into a vein in your neck and arm to give you fluids until you begin drinking fluid and eating again.
- Tube drains in your abdomen to remove excess fluid following surgery. The nurses will be regularly measuring the amount of fluid in these drains. The tube drains will be removed within a few days, once they are draining minimal amounts of fluid.
- An intravenous (IV) line into a vein in your neck to give you insulin which is called sliding scale insulin. This is to allow your newly transplanted islet to settle down in your liver and rest until they recover and start to work and produce insulin. The sliding scale insulin will continue for at least seven days and until you begin drinking fluid and eating properly again.
Will I need insulin after my operation?
This will depend on how successful your islet auto transplantation has been and how many islets were transplanted. This information will be given to you after your surgery.
In a few patients, the islets start to secret insulin as soon as they have been transplanted, whereas in others the islets do not function so well and they will always have to inject insulin (although in a small number of cases this may reduce over time).
Pain control
When you wake up you will notice immediately that the pain from your pancreas has gone although you may have some pain (this pain will be different and due to your surgery).
After this type of surgery it is not uncommon to experience significant pain or discomfort in the first few days, which can be quite difficult to control, due to the longstanding need for painkillers for your chronic pancreatitis before your operation.
This is a particular problem in patients who need such high doses of strong painkillers because the condition is so painful and it takes a while after your operation to get your pain under control.
You will be given painkillers for several days after the operation to control the pain due to your operation.
Pain relief after pancreas surgery is usually given in the form of an epidural, which is a method of providing continuous pain relief. The epidural is a fine length of tubing, which is inserted into a small space in your backbone. The epidural tubing is connected to a pump which automatically delivers pain-relieving medication to you and should give continuous pain relief.
When you wake up from your operation you will be connected to a pump and you will receive your painkillers without the need for you to do anything.
You will have pain-relieving epidural for as long as you need it, but most patients move on to tablets after a few days. It is very important that your pain is controlled enough to enable you to walk, cough and breathe deeply.
Physiotherapy
Soon after your operation you will be helped out of bed to a chair and then encouraged to walk a short distance with help from the physiotherapist or nurse.
Walking soon after surgery helps improve circulation, prevents blood clots, and stimulates bowel functions. You will be encouraged to do coughing and deep breathing exercises all of which help to prevent chest infections or pneumonia.
Your diet
Once your bowels begin to work again, you will be allowed to drink sips of clear fluids and gradually advance to a normal diet.
At first you will not be able to eat the same portions of food you did before the surgery. Many patients lose weight before the operation and during the first couple of weeks after surgery.
You will regain the weight slowly as your appetite and capacity for food improves. You will also need to continue taking pancreatic enzymes by mouth to help your digestion.
Going home
Once you tolerate a normal diet, move your bowels, can manage your own blood sugars and give yourself insulin (if necessary) and show no signs of complications, you will be ready to go home.
Your doctor will give you discharge instructions and prescriptions for any medication you need. Your nurse will review these instructions with you. If you need a visit from the district nurse, we will arrange this during your stay in hospital.
Special considerations
Fatigue
Feeling tired (fatigue) is the most common complaint following pancreas surgery. You may need a nap during the day, but try to stay out of bed as much as possible so you will sleep at night.
It usually takes six to twelve weeks until your energy levels return to normal.
Decreased appetite
It is common to have a decreased appetite after surgery. Try eating smaller meals that have each of the four groups (i.e. fruits/vegetables, meat/chicken/fish, breads/grains and dairy products).
Alcohol
You may consume alcohol in moderation but please check with your doctor before doing so.
Pain relief
We will discharge you home on the same amount of painkillers that you were taking before your operation.
This is because over the years your body becomes addicted to the painkillers and weaning them off too soon after your surgery can often set your recovery back.
In many cases it can result in some patients requiring higher does of pain relief in the short term. We will monitor your pain management during your follow-up appointments and advice you when to start reducing them.
It can take between six months to a year before we encourage you to begin this weaning process and we advise that you reduce your painkillers by 25% each month until you have stopped them completely.
Please remember that some painkillers cause constipation so take extra fluids and fibre in your diet.
Numbness
It is normal to have numbness of the skin below the incision as some of the nerves are cut. This sensation will diminish over time but there may be some permanent numbness below the middle of your cut.
Exercise
Exercise will help you gain strength and feel better. We recommend walking. Check with your doctor or clinical nurse specialist before resuming any strenuous exercise. Do not lift anything heavier than 2kg for six weeks.
Driving
It may be a number of weeks before you are able to drive again. We recommend that you contact your insurance company for advice before starting to drive.
Please contact your GP/ diabetes team / nurse specialist if you have any of the below:
- A temperature above 38°C
- Uncontrolled blood sugars
- Redness or leakage from your wound
- Any increase in pain or new pain
- Uncontrolled nausea or vomiting
- Any new or unexplained symptoms
Follow-up appointments
Consultant surgeon
Usually your first appointment after your operation with your consultant should be within 6 to 8 weeks after you leave hospital.
You will receive this appointment through the post. After your first appointment, your next appointments will be every three months up to one year and then every year up to ten years.
At each visit your consultant will organise for you to have an ultrasound scan and blood tests before your next visit. We will discharge you after ten years.
Diabetes care team
The diabetes care team will make the necessary arrangements for you to be followed up in respect of your diabetes management following your discharge from hospital.
Before discharge you will be given the contact numbers of the diabetes care team. Once your blood sugars are stable you will then be discharged back into the care of your general practitioners.
Contact numbers and further information
Main hospital
TPIAT clinical nurse specialist
There is currently no option for voicemail on this number. If you contact the team and there is not a member of staff to help with your query and it is urgent please contact the consultant secretary.
You can also email us and your query will be responded to when we return to work.
