DISTAL PANCREATECTOMY WITH ISLET AUTOTRANSPLANT FOR MANAGEMENT OF DISCONNECTED PANCREATIC DUCT SYNDROME (DPDS) FROM NECROTIZING PANCREATITIS (NP)- A LARGE TERTIARY CARE CENTER EXPERIENCE
Guru Trikudanathan*, Gaurav Suryawanshi, Karthik Ramanathan, Gregory Beilman, Martin L. Freeman, Melena Bellin
Gastroenterology, University of Minnesota, Minneapolis, MN
Background and Aim:
Disconnected pancreatic duct syndrome (DPDS) is characterized by complete transection of the main pancreatic duct by central pancreatic necrosis, leading to discontinuity between viable secreting pancreatic tissue upstream and the gastrointestinal tract. Manifestations include high output external pancreatic fistula, symptomatic pseudocyst and recurrent acute pancreatitis/chronic pancreatitis impacting quality of life. Standard surgical management for persistent DPDS involves resection of the upstream gland (distal pancreatectomy), but may result in brittle insulin dependent post surgical diabetes. Islet cell autotransplantation is an increasingly available adjunctive measure to reduce risk of of diabetes that has been shown to improve quality of life (QOL) after total pancreatectomy, but has not been reported after DP for DPDS. We report our single center experience on DPIAT as a novel management for DPDS in necrotizing pancreatitis (NP).
Methods:
All NP patients with DPDS undergoing DPIAT from 2005-22 were included in the study. Baseline demographics, indications for DPIAT, HbA1c, opioid requirements and quality of life (QOL) metrics at baseline and at 6 months, insulin requirement and graft function at 6 months were recorded. Patients were classified as insulin independent or dependent, and as having islet graft function or graft failure (meal-stimulated C-peptide <0.6 ng/mL).
Results:
Among 676 patients with NP managed during this period, 10 patients [males 6, median (IQR) age-47.5 (35-51) years] who underwent DPIAT for DPDS were included in the study. Management of NP involved endoscopic approach in 5, percutaneous drainage in 1, open necrosectomy in 4. The site of disconnection was in the neck 6 (60%), body 3(30%) and tail 1 (10%). Indications for DPIAT were recurrent pancreatitis in 6 (60%), chronic pancreatitis in 3 (30%) and fistula 1(10%). 1 had diabetes prior to surgery and 8/10 (80%) patients were on long standing opioids. Median (IQR) islet equivalents/kg infused intraportally was 1224 (705-2818). No periprocedural complications were reported. 2 patients did not have long term follow up. At 6 months after DPIAT, only 2/10 (20%) required opioids and the majority showed improvement in QOL. All patients had preserved islet graft function with median (IQR) C-peptide of 6.4 (5.5-9.9), median (IQR) HbA1c of 6.05 (5.8-6.6) with 8/10 (80%) requiring baseline insulin and 6/10 (60%) required pancreatic enzymes.
Conclusion:
DPIAT for DPDS is associated with improvement in pain and QOL with discontinuation of opioids in most. Although majority required baseline insulin, all patients had graft function which could potentially lower the HbA1c and long term risk of microvascular complications. Long term data in larger cohort is needed to validate our conclusions.
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