Factors Predicting Outcomes After a Total Pancreatectomy and Islet Autotransplantation Lessons Learned From Over 500 Cases

Srinath Chinnakotla, MD; Gregory Beilman, J. MD; Ty B. Dunn, MD, MS; Melena D. Bellin, MD; Martin L. Freeman, MD; David M. Radosevich, RN, PhD; Mustafa Arain, MD; Stuart Amateau, K. MD, PhD; Shawn J. Mallery, MD; Sarah Schwarzenberg, J. MD; Alfred Clavel, MD; Joshua Wilhelm, MS; Paul R. Robertson, MD; Louise Berry, RN; Marie Cook, MPH; Bernhard J. Hering, MD; David E.R. Sutherland, MD, PhD; Timothy L. Pruett, MD

Disclosures

Annals of Surgery. 2015;262(4):610-622. 

In This Article

Abstract and Introduction

Abstract

Objective: Our objective was to analyze factors predicting outcomes after a total pancreatectomy and islet autotransplantation (TP-IAT).

Background: Chronic pancreatitis (CP) is increasingly treated by a TP-IAT. Postoperative outcomes are generally favorable, but a minority of patients fare poorly.

Methods: In our single-centered study, we analyzed the records of 581 patients with CP who underwent a TP-IAT. Endpoints included persistent postoperative "pancreatic pain" similar to preoperative levels, narcotic use for any reason, and islet graft failure at 1 year.

Results: In our patients, the duration (mean ± SD) of CP before their TP-IAT was 7.1 ± 0.3 years and narcotic usage of 3.3 ± 0.2 years. Pediatric patients had better postoperative outcomes. Among adult patients, the odds of narcotic use at 1 year were increased by previous endoscopic retrograde cholangiopancreatography (ERCP) and stent placement, and a high number of previous stents (>3). Independent risk factors for pancreatic pain at 1 year were pancreas divisum, previous body mass index >30, and a high number of previous stents (>3). The strongest independent risk factor for islet graft failure was a low islet yield—in islet equivalents (IEQ)—per kilogram of body weight. We noted a strong dose-response relationship between the lowest-yield category (<2000 IEQ) and the highest (≥5000 IEQ or more). Islet graft failure was 25-fold more likely in the lowest-yield category.

Conclusions: This article represents the largest study of factors predicting outcomes after a TP-IAT. Preoperatively, the patient subgroups we identified warrant further attention.

Introduction

Chronic pancreatitis (CP) is a disorder that is challenging to patients and physicians alike. Its incidence is estimated at 0.2% to 0.6% in the United States.[1,2] The economic impact of the disease is notable with total estimated annual health care expenditures of $2.6 billion.[3]

The initial treatment of CP is directed towards relieving pain and restoring quality of life. Interventions are aimed at correcting the inciting mechanical, metabolic, immunologic, or pharmacologic events, with the use of options such as narcotic analgesics, pancreatic enzymes (to reduce pancreatic stimulation and treat pancreatic exocrine insufficiency), and, occasionally, nerve block procedures.[4,5] If these medical and endoscopic interventions fail, patients may be candidates for surgery.

Surgical techniques include partial pancreatic resection and drainage procedures such as lateral pancreaticojejunostomy or variants. Patients often have transient pain relief, but given the diffuse nature of CP and the involvement of the entire pancreas, pain eventually recurs in up to 50% patients,[6,7] in addition, exocrine and endocrine insufficiency often develops, over time.[8]

A total pancreatectomy (TP) completely removes the root cause of pain. However, a TP alone, in the absence of preservation of any beta-cell function, results in diabetes that is often difficult to manage, similar to type 1 diabetes mellitus but with the added problem of exocrine pancreatic insufficiency. Thus, a combination procedure—that is, a TP along with an intraportal islet autotransplant (TP-IAT)—was designed to preserve beta-cell mass and insulin secretory capacity as much as possible and to mitigate diabetic complications. Most CP patients are not diabetic when they first seek treatment for their intractable pain, and thus have some degree of beta-cell mass worth preserving (even though, eventually, CP typically results in diabetes by progressively destroying islets).

The world's first TP-IAT was performed at the University of Minnesota in 1977 to treat a patient with painful CP.[9] Since then, nearly 600 TP-IATs have been performed in adults and children. We previously reported the Minnesota series with an emphasis on the efficacy of TP-IATs in terms of islet function, pain relief, narcotic use, and quality of life.[10–12] Postoperative outcomes are generally favorable but a substantial minority of patients fare poorly. Over time, we have attempted to standardize our approach, yet we still have very limited data on factors predicting outcomes after a TP-IAT. In this study, our objective was to analyze factors predicting outcomes, particularly poor outcomes, after a TP-IAT with an ultimate goal of improving the patient selection process.

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