Does Pancreatectomy With Islet Autotransplantation Benefit Patients With Recurrent Acute Pancreatitis?
In patients with recurrent acute pancreatitis, total pancreatectomy with islet autotransplantation (TPIAT) reduces pain and requirements for narcotic therapy, and increases quality of life, researchers report in the September issue of Clinical Gastroenterology and Hepatology. This treatment should be considered when medical and endoscopic therapies have failed.
Recurrent acute pancreatitis, caused by a variety of risk factors, often progresses to chronic pancreatitis or intractable pain without clear evidence of chronic pancreatitis. Medical, endoscopic, and surgical treatments are not always effective and are controversial. Patients have frequent hospitalizations, opioid analgesic dependency, disability, and reduced quality of life.
In this procedure, the pancreas is completely resected and the pancreatic islets are isolated and infused back into the recipient’s portal vein. They engraft in the liver and produce insulin to prevent or minimize post-surgical diabetes. Overall, about 90% of patients with chronic pancreatitis who undergo TPIAT have endogenous islet function, and one-third discontinue insulin therapy.
TPIAT has never been evaluated specifically as a treatment for refractory recurrent acute pancreatitis.
Melena D. Bellin et al investigated the effects of TPIAT in 48 patients with recurrent acute pancreatitis, not provoked by endoscopic retrograde cholangiopancreatogram (ERCP), who had not responded to endoscopic or medical pain management. The patients had progressed to frequent or daily intractable severe pain but lacked definitive evidence of chronic pancreatitis.
Their median pain duration was 7.9 ± 7.8 years, and interval since first documented episode of acute pancreatitis was 5.3 ± 6.3 years. The patients had been hospitalized for pancreatitis a median of 4 times in the year before TPIAT.
The patients underwent TPIAT and were followed for a mean 4.5 ± 1.8 years.
At the time of TPIAT, 45 patients (92%) were using narcotic analgesics daily and 4 received narcotics intermittently with hospitalizations. One year after TPIAT, 22 patients (46%) reported no use of narcotic pain medications.
Before surgery, the median daily pain score was 5.5. After TPIAT, applying a Bonferroni adjustment for multiple comparisons, median pain scores were significantly reduced at 3 months (score, 2.5), 1 year (score, 2.0), and 2 years (score, 3.0) after surgery.
Health-related quality of life scores, measured by the physical and mental component summary score, increased by approximately 1 standard deviation from the mean.
Before surgery, 2 patients had diabetes that was treated with insulin. One year post-TPIAT, however, 21 patients (44%) were insulin independent, whereas another 14 (29%) used once-daily basal insulin. The authors say that only one-third were still insulin dependent 5 years after TPIAT.
Bellin et al state that, although diabetes is an obvious concern when considering total pancreatectomy, most patients that underwent TPIAT had well controlled blood glucose, based on levels of hemoglobin A1c, 5 years after TPIAT.
The authors noticed a trend of increasing median pain scores at 3–4 years after TPIAT, indicating possible recurrent or persistent pain caused by complications or comorbidities such as gastrointestinal motility disorders. In addition, central sensitization from chronic or repeated episodes of pain, and opioid-induced hyperalgesia, could all contribute to ongoing pain symptoms.
Bellin et al propose that patients undergoing TPIAT be followed by pain management and health psychology specialists, and eventually transition back to their physician for local pain management.
Further studies are needed to determine the optimal timing for TPIAT and whether etiology of pancreatitis affects long-term outcome.