Total pancreatectomy for recurrent acute and chronic pancreatitis: a critical review of patient selection criteria

Abstract

Purpose of review Critical review of the indications for total pancreatectomy and highlight limitations in current diagnostic criteria for chronic pancreatitis. Recent findings The diagnosis of noncalcific chronic pancreatitis remains controversial because of an overreliance on nonspecific imaging and laboratories findings. Endoscopic ultrasound, s-magnetic resonance cholangiopancreatography, and/or endoscopic pancreatic function testing are often used to diagnose noncalcific chronic pancreatitis despite the fact that there is no gold standard for this condition. Abdominal pain is not specific for chronic pancreatitis and is more likely to be encountered in patients with functional gastrointestinal disorders based on the high incidence of these conditions. The duration of pain and opioid analgesic use results in central sensitization that adversely affects pain outcomes after total pancreatectomy. An alcoholic cause is associated with poorer pain outcomes after total pancreatectomy. Summary The lack of a gold standard for noncalcific chronic pancreatitis limits the diagnostic accuracy of imaging and laboratory tests. The pain of chronic pancreatitis is nonspecific and is affected by duration, preoperative opioid use, and cause. These factors will need to be considered in the development of future selection criteria for this morbid surgery.

The state of the art in acute pancreatitis research

“…Opioid analgesics: such as morphine and hydrocodone. Opioids [14] can be used for severe pain, but should be closely monitored, as they may cause respiratory depression and dependence. Proton pump inhibitors (PPI): such as omeprazole and esomeprazole.…”

Current status of total pancreatectomy with islet autotransplantation for chronic and recurrent acute pancreatitis

“…Patients with hereditary/genetic pancreatitis are suitable candidates for TPIAT, with consideration of its efficacy in inhibiting pain and preventing recurrent pancreatitis and pancreatic cancer. 25,26 Contraindications for TPIAT vary by institution, for example, the University of Minnesota lists alcoholism, the presence of pancreatic cancer, IPMN, and uncontrolled mental illness as contraindications for TPIAT. 22 In some institutions, patients with diabetes or pre-diabetes can undergo TPIAT, which improves residual pancreatic islet and alpha cell functions, 27 if there is endogenous islet function.…”

“…Intractable pain is the common primary indication for TPIAT in patients with impaired QoL due to CP or RAP that was not successfully managed with medical, endoscopic, or prior surgical therapy. Patients with hereditary/genetic pancreatitis are suitable candidates for TPIAT, with consideration of its efficacy in inhibiting pain and preventing recurrent pancreatitis and pancreatic cancer 25,26 . Contraindications for TPIAT vary by institution, for example, the University of Minnesota lists alcoholism, the presence of pancreatic cancer, IPMN, and uncontrolled mental illness as contraindications for TPIAT 22 .…”