Total pancreatectomy and islet autotransplantation in chronic pancreatitis: Recommendations from PancreasFest

Abstract

Description Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure used to treat severe complications of chronic pancreatitis or very high risk of pancreatic cancer while reducing the risk of severe diabetes mellitus. However, clear guidance on indications, contraindications, evaluation, timing, and follow-up are lacking. Methods A working group reviewed the medical, psychological, and surgical options and supporting literature related to TPIAT for a consensus meeting during PancreasFest. Results Five major areas requiring clinical evaluation and management were addressed: These included: 1) indications for TPIAT; 2) contraindications for TPIAT; 3) optimal timing of the procedure; 4) need for a multi-disciplinary team and the roles of the members; 5) life-long management issues following TPIAP including diabetes monitoring and nutrition evaluation. Conclusions TPIAT is an effective method of managing the disabling complications of chronic pancreatitis and risk of pancreatic cancer in very high risk patients. Careful evaluation and long-term management of candidate patients by qualified multidisciplinary teams is required. Multiple recommendations for further research were also identified.

Clinical Islet Cell Transplantation – Recent Advances

“…The exact mechanism(s) for CP is still unclear; however, the main causes have been proposed as alcohol consumption, autoimmunity and also genetic mutations 79 . In most of the cases, the standard treatments for CP such as celiac blocks and administration of antiinflammatory drugs have been unsuccessful, and whereas removal of entire pancreas by total pancreatectomy leads to brittle diabetes or SHEs that cause substantial morbidity and mortality due to the loss of counter-regulatory pancreatic glucagon 80 . The alternative treatment is total pancreatectomy with islet transplantation (TPIAT).…”

Total pancreatectomy and islet autotransplantation for chronic pancreatitis: spectrum of postoperative CT findings

“…It typically involves resection of the entire pancreas along with part or the entire duodenum and the gallbladder, while removal of the pylorus and spleen are optional, and a choledochojejunal anastomosis is constructed. Given the irreversibility of the procedure, pain recurrence in up to 20% of patients, and a variable control of resulting diabetes, the procedure is reserved for high riskpatients only [11]. Although a variety of etiologies are treated with TPIAT, patients with hereditary pancreatitis benefit the most from this procedure due to the early onset and increased severity of disease and symptoms requiring intervention.…”

ERCP in children

“…It appears that the combination of pancreas divisum with minor papilla stenosis would lead to a real functional obstruction. In children with recurrent pancreatitis, pancreas divisum has been found in 9.5% of patients [1,54,55,68,69].…”

“…ERCP demonstrates evidence of these abnormalities that can be treated endoscopically [1-5, 18, 55, 79]. Children with chronic pancreatitis frequently have an underlying genetic mutation (PRSS1, CFTR, SPINK1, CTRC, and others) as etiological factor, and endotherapy may be of help but a group of nonresponders with debilitating pain may benefit from total pancreatectomy with islet autotransplantation [69].…”