How Durable Is Total Pancreatectomy and Intraportal Islet Cell Transplantation for Treatment of Chronic Pancreatitis?

Abstract

BACKGROUND:A total pancreatectomy and intraportal islet cell autotransplant (TPIAT) is increasingly being offered to patients with chronic pancreatitis (CP). The benefits include removal of the root cause of pain and amelioration of diabetes. However, the long-term durability of this operation remains unclear. STUDY DESIGN:Of the 742 patients who have undergone a TPIAT at our center, 215 who did so between 1998 and 2008 now have at least 10 years of follow-up time and were eligible for this single-center observational study. Our outcomes measures included abdominal pain relief, narcotic use, islet graft function (subdivided into 3 groups: insulin independence; partial graft function, defined by C-peptide level > 0.6 mg/dL; and no function, defined by C-peptide level < 0.6 mg/dL), and health-related quality of life. RESULTS:The 10-year actuarial survival rate was 72%. A BMI > 30 kg/m 2 (p = 0.04) predicted 10-year mortality. The rates of pain relief were 82% at 10 years and 90% at 15 years. Narcotic use declined with time: the rates were 50% at 5 years and 37% at 10 years. At 10 years, the rate of insulin independence was 20%; the rate of partial graft function, 32%. Transplantation of islet equivalents/kg > 4,000 was the strongest predictor of islet graft function at 10 years. Pediatric patients were more likely to have islet function than adults (p = 0.01). Health-related quality of life continued to improve at 10 years, even in patients on narcotics.

Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons!

“…A single-centre observational study has reported on 215/742 TPIAT patients with at least a 10-year follow-up. Complete and sustained pain relief was present in 82% at 10 years and 90% at 15 years, with either full or partial islet graft function in nearly 50% patients 82…”

Total pancreatectomy with islet autotransplantation in diabetic and pre-diabetic patients with intractable chronic pancreatitis

“…TP can provide long-term relief from pancreatic pain and improves the quality of daily life, while IAT allows for preservation of beta cell mass, improving glucose control in patients with postpancreatectomy diabetes. [ 1 ] Since a larger islet mass may be isolated from and transplanted into TP with IAT (TPIAT) candidates with normal glucose control and islet function before surgery, these individuals are more likely to maintain better postsurgical endocrine function than those with pre-procedural islet dysfunction. [ 2 ] However, the clinical decision to proceed with TPIAT is based mainly on the need for pain control and should not, in general, be driven by assumptions about outcomes for ultimate glycemic control.…”

Robot‐Assisted Total Pancreatectomy With Autologous Islet Cell Transplantation: Perioperative Nursing Considerations

“… analgesics, lifestyle modifications (eg, diet therapy), pancreatic enzyme replacement therapy, endoscopic decompression of the pancreatic duct, stent placement for ductal strictures, celiac plexus nerve blocks, percutaneous radiofrequency splanchnic nerve ablation, and pancreatectomy …”

“…It is a technically challenging procedure because of the complex anatomy of the pancreas and surrounding structures . Total pancreatectomy can alleviate pain from CP but is associated with significant morbidity because resecting the pancreas results in diabetes that is difficult to control …”

“…Therefore, one of the goals of TPAIT is for the patient to achieve insulin independence, which is associated with an improved QOL . In a single‐center study of 215 patients who underwent TPAIT, 27% achieved insulin independence within one year after the procedure; however, this percentage decreased to 22.3% within five years after the procedure . Most patients who underwent TPAIT reported a marked decrease in pain …”