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Surgical Management of Severely Inflamed Chronic Pancreatitis With Total Pancreatectomy Followed by Islet Autotransplantation
Rauf Shahbazov*1, Morihito Takita1, Mazhar a. Kanak2, Gumpei Yoshimatsu1, Michael C. Lawrence1, Ali H. Dabous3, Peter T. Kim3, Nicholas Onaca3, Bashoo Naziruddin3, Marlon F. Levy3
1Islet Cell Laboratory, Baylor Research Institute, Dallas, TX; 2Institute of Biomedical Studies, Baylor University, Waco, TX; 3Baylor Annette C. and Harold C. Simmons Transplant Institute, Dallas, TX
Introduction: Total pancreatectomy (TP) with islet autotransplantation (IAT) has been recognized as an effective surgical procedure for patients with intractable chronic pancreatitis (CP) although severe cases of CP occasionally develop dense adhesion among chronically inflamed pancreas and peri-pancreatic tissue, which potentially cause abortion of TP.
Methods: We performed a retrospective review of all patients who were selected for TPIAT since 2006 at our institute. Main indications for TPIAT includes patients with established diagnosis of CP, narcotic dependence for severe abdominal pain due to CP, history of failed endoscopic treatments and positive serum C-peptide during glucose tolerance test.
Results: In a total of 107 chronic pancreatitis patients who were admitted for TPIAT, completion of total pancreatectomy was aborted in 11 cases (10 %). The reasons were extensive adhesion at peri-pancreas tissue (n = 9), findings of acute inflammation such as edema (n = 5; four patients showed mixed pancreatic lesion with both dense adhesion involving peri-pancreatic tissue and acute inflammation) and liver cirrhosis that was macrographically identified in the operation (n = 1). No operative mortality was reported in both aborted TP and completed TPIAT groups. The history of acute necrotizing pancreatitis was seen in 3 patients in aborted TP groups which is significantly higher proportion when compared to control group without cancellation of TP (27 and 3% in aborted TP and control groups, respectively: p = 0.01). Three patients (27%) had past history of distal pancreatectomy or surgical debridement of pancreatic tail in aborted TP group while past history of pancreatic surgery was found in 13 out of 98 patients (13%) in control (p = 0.20). Three patients in aborted TP group underwent second surgery of TPIAT after resting gastrointestinal with tube feeding for 124 ± 11 days. No significant difference in the weight of procured pancreas was found between TP aborted and the control groups (79.3 ± 12.4 and 83.2 ± 26.9 g, respectively: p = 0.80). TP aborted group was, however, isolated with islet mass of 1,329 ± 597 IEQ/kg, which is significantly less than control group (5,494 ± 3,103 IEQ/kg: p =0.02). A patient achieved insulin independence while the other two have been treated with insulin pump or long-acting insulin injection.
Conclusions: TPIAT is performed for selected patients with refractory CP. TP could not be completed in approximately 10% of the patients due to strong adhesion among peri-pancreatic tissue or prolonged inflammation. History of acute necrotizing pancreatitis is a risk factor of aborted TP. TPIAT can recover islets even when the pancreas is severely inflamed although the patients should be carefully followed up for sufficient period to rest gastrointestinal status.
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