Total Pancreatectomy and Islet Autotransplantation for Chronic Pancreatitis

Abstract

Background Total-pancreatectomy (TP) with intraportal-islet-auto-transplantation (IAT) can relieve pain and preserve beta-cell-mass in patients with chronic-pancreatitis (CP) when other-therapies fail. Reported is a >30-year-single-center-series. Study Design 409 patients (53 children, 5–18 yrs) with CP underwent TP-IAT from Feb/1977–Sept/2011; (etiology idiopathic-41%; SOD/biliary-9%; genetic-14%; divisum-17%; alcohol-7%; other-12%); mean age-35.3 yrs,); 74% female; prior-surgeries 21%--Puestow procedure 9%, Whipple 6%, distal pancreatectomy 7%; other 2%). Islet-function was classified as insulin-independent for those on no insulin; partial if known C-peptide positive or euglycemic on once-daily-insulin; and insulin-dependent if on standard basal–bolus diabetic regimen. An SF-36-survey for Quality-of-Life (QOL)) was completed before and in serial follow-up by patients done since 2007 with an integrated-survey that added in 2008. Results Actuarial-patient-survival post-TP-IAT was 96% in adults and 98% in children (1-year) and; 89% and 98% (5-years). Complications requiring relaparotomy occurred in 15.9%, bleeding (9.5%) being most common. IAT-function is achieved in 90% (C-peptide >0.6 ng/ml). At 3 years, 30% were insulin-independent (25% in adults, 55% in children) and 33% had partial-function. Mean HbA1C was <7.0% in 82%. Prior pancreas surgery lowered islet-yield (2712vs4077/kg, p=.003). Islet yield [<2500/kg (36%); 2501–5000/kg (39%); >5000/kg (24%)] correlated with degree of function with insulin-independent rates at 3 yrs of 12, 22 and 72%, partial function 33, 62 and 24%. All patients had pain before TP-IAT and nearly all were on daily-narcotics. After TP-IAT, 85% had pain-improvement. By two years 59% had ceased-narcotics. All children were on narcotics before, 39% at follow-up; pain improved in 94%; 67% became pain-free. In the SF-36 survey, there was significant improvement from baseline in all dimensions including the Physical and Mental Component Summaries (P<0.01), whether on narcotics or not. Conclusions TP can ameliorate pain and improve QOL in otherwise-refractory-CP-patients, even if narcotic-withdrawal is delayed or incomplete because of prior long-term use. IAT preserves meaningful islet function in most patients and substantial islet function in >2/3 of patients with insulin-independence occurring in one-quarter of adults and half the children.

Systematic review and meta-analysis of islet autotransplantation after total pancreatectomy in chronic pancreatitis patients [Review]

“…For the patients not achieved insulin independent, they also had partial functions of beta cells for a long time which was indicated by the high rates of C-peptide positive and no morbidity of brittle diabetes mellitus [15] and have an improved quality of life because of the intractable pain controlled, return to a normal diet, low insulin requirement than patients with TP alone and a decreasing frequency of hospital admissions. To further characterize the efficacy of IAT after CP, we performed univariate meta-regression analysis.…”

“…2). The insulin independence rate at 1 year follow-up was 28.4% (95% CI: 15.7-46.0) of 362 patients reported by five studies [7,8,10,15,17]. The insulin independence rate at 2 year follow-up was 19.7% (95% CI: 5.1-52.6%) of 297patients reported by three studies [10,15,17].…”

“…1. 12 studies reporting the outcomes of 677 patients met the inclusion and exclusion criteria [7][8][9][10][11][12][13][14][15][16][17][18]. Main study characteristics were described in Table 1.…”

“…C-peptide level at 6 month was reported by two studies with mean being 1.7 ng/mL (SD 0.57 ng/mL) [12], 1.4 ng/mL (SD 0.36 ng/mL) [14], respectively. Sutherland et al reported 90% of the patients were C-peptide positive (>0.6 ng/dL) at 3 years postoperative [15]. Walsh et al reported the median postoperative C-peptide level was 0.40 (IQR 0.27-1.00) at the last follow-up [16].…”

Trying to Prevent the Clogged Drain: Optimizing the Yield and Function of Portal Vein-Infused Islets

“…To avoid complications it is desirable to minimize the total volume of tissue transplanted intraportally [1]. Embolization via intra portal (IP) infusion of islets in auto and allo-transplantation can be associated with portal hypertension (PH), hepatic infarction, elevation of liver enzyme levels (transaminitis), disseminated intravascular coagulation, and portal venous thrombosis (PVT) [2][3][4][5].…”