Long-term Outcomes After Total Pancreatectomy and Islet Cell Autotransplantation

Is It a Durable Operation?

Gregory C. Wilson, MD; Jeffrey M. Sutton, MD; Daniel E. Abbott, MD; Milton T. Smith, MD; Andrew M. Lowy, MD; Jeffrey B. Matthews, MD; Horacio L. R. Rilo, MD; Nathan Schmulewitz, MD; Marzieh Salehi, MD; Kyuran Choe, MD; John Brunner, RN; Dennis J. Hanseman, PhD; Jeffrey J. Sussman, MD; Michael J. Edwards, MD; Syed A. Ahmad, MD

Disclosures

Annals of Surgery. 2014;260(4):659-667. 

In This Article

Abstract and Introduction

Abstract

Objective: Total pancreatectomy and islet cell autotransplantation (TPIAT) has been increasingly utilized for the management of chronic pancreatitis (CP) with early success. However, the long-term durability of this operation remains unclear.

Methods: All patients undergoing TPIAT for the treatment of CP with 5-year or greater follow-up were identified for inclusion in this single-center observational study. End points included narcotic requirements, glycemic control, islet function, quality of life (QOL), and survival.

Results: Between 2000 and 2013, 166 patients underwent TPIAT; 112 of these patients had 5-year follow-up data to analyze. All patients underwent successful IAT with a mean of 6027 ± 595 islet equivalents per body weight. There was no perioperative mortality and actuarial survival at 5 years was 94.6%. The narcotic independence rate at 1 year was 55% and continued to improve to 73% at 5-year follow-up (P < 0.05). The insulin independence rate declined over time (38% at 1 year vs 27% at more than 5 years), but insulin requirements remained similar (21.4 vs 24.3 units per day, P = 0.6). All patients achieved stable glycemic control with a median hemoglobin A1C (HgA1C) of 6.9% (range: 5.85%–8.3%). The short form 36-item QOL assessment of a subset of patients available for contact demonstrated continued improvements in all tested modules in patients with at least 5-year follow-up. Two patients developed diabetic complications requiring whole organ pancreas transplant for salvage.

Conclusions: This represents one of the largest series examining long-term outcomes after TPIAT. This operation produces durable pain relief and improvement in QOL parameters. Insulin independence rates decline over time, but most patients maintain stable glycemic control.

Introduction

The clinical presentation of chronic pancreatitis (CP) can vary with respect to the degree of exocrine and endocrine manifestations, but most CP patients seek medical attention for symptoms of debilitating abdominal pain. Clinical management of these patients can be quite complicated, as the degree of pain does not always correlate with the morphologic abnormalities demonstrated on radiographic imaging. Furthermore, a multidisciplinary approach incorporating the expertise of several specialists is often necessary for the optimal medical management of these patients.

Over time, approximately 50% of patients develop progressive symptoms and require additional surgical intervention.[1] Most patients can be managed with traditional operations such as a pancreaticoduodenectomy, duodenal sparing head resections, or decompressive procedures.[2,3] A subset of patients, however, suffer from CP in the absence of demonstrable main duct pathology, have relapsing recurrent acute pancreatitis, or have established dysgenetic causes of their pancreatitis. These patients have minimal benefit or fail to respond to pancreatic resections or drainage procedures. Over the last decade, these latter groups are now increasingly considered for total pancreatectomy and islet cell autotransplantation (TPIAT).

Historically, this operation has been considered a nontraditional option for the management of CP. In the modern era, however, this therapy is part of the treatment algorithm for the properly selected patient, as evidenced by the growing number of centers devoting considerable resources toward the development of TPIAT programs.[4–6] The rationale behind this operation is that by removing the inciting organ and its inflammation, and in the process preventing type 3c diabetes by transplanting the patient's own islet cells into the liver, pain and narcotic dependence can be minimized while also preventing the risk of cancer development. Many institutions have reported short-term results, detailing pain relief, quality of life (QOL), and insulin independence.[4–6] Few reports document long-term results after TPIAT, which primarily focus on endocrine function but do not concentrate on narcotic requirements or QOL parameters.[7] These latter 2 outcomes are critical metrics in comprehensively assessing success after TPIAT. Therefore, we undertook this study to evaluate long-term outcomes in our cohort of patients undergoing TPIAT for treatment of CP.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....