How Durable Is Total Pancreatectomy and Intraportal Islet Cell Transplantation for Treatment of Chronic Pancreatitis?

Abstract

Background: A total pancreatectomy and intraportal islet cell autotransplant (TPIAT) is increasingly being offered to patients with chronic pancreatitis (CP). The benefits include removal of the root cause of pain and amelioration of diabetes. However, the long-term durability of this operation remains unclear.

Study design: Of the 742 patients who have undergone a TPIAT at our center, 215 who did so between 1998 and 2008 now have at least 10 years of follow-up time and were eligible for this single-center observational study. Our outcomes measures included abdominal pain relief, narcotic use, islet graft function (subdivided into 3 groups: insulin independence; partial graft function, defined by C-peptide level > 0.6 mg/dL; and no function, defined by C-peptide level < 0.6 mg/dL), and health-related quality of life.

Results: The 10-year actuarial survival rate was 72%. A BMI > 30 kg/m² (p = 0.04) predicted 10-year mortality. The rates of pain relief were 82% at 10 years and 90% at 15 years. Narcotic use declined with time: the rates were 50% at 5 years and 37% at 10 years. At 10 years, the rate of insulin independence was 20%; the rate of partial graft function, 32%. Transplantation of islet equivalents/kg > 4,000 was the strongest predictor of islet graft function at 10 years. Pediatric patients were more likely to have islet function than adults (p = 0.01). Health-related quality of life continued to improve at 10 years, even in patients on narcotics.

Conclusions: This represents the first and largest series to examine long-term outcomes (10 years or more) in TPIAT patients. In our series, this dual procedure produced durable pain relief and sustained islet graft function, even past 10 years postoperatively.

Figure 1.

Patient survival from 1998 to 2008, Kaplan-Meier curve (n = 215). Kaplan-Meier based on patient survival times censored at last available follow-up. TPIAT, total pancreatectomy and islet autotransplant.

Figure 2.

Predictors of mortality at 10 years. *Significant associations. Reference standards for categorical variables are: <2,000 islet equivalents (IEQ)/kg; no ERCP stenting procedures, no diagnosis of diabetes before surgery, pancreatitis duration < 5 years, BMI 20 to 25 kg/m², female sex, age 35 to 50 years. DM, diabetes mellitus; ERCP, endoscopic retrograde cholangiopancreatography; panc, pancreatitis.

Figure 3.

Pain improvement post-total pancreatectomy and islet autotransplant (TPIAT), per patients’ perception.

Figure 4.

Percent of patients with pancreatic pain and on narcotics (for any reason) post-total pancreatectomy and islet autotransplant.

Figure 5.

Percent of patients with islet graft function. Graft function defined as: graft failure if stimulated C-peptide < 0.6 ng/mL, or in absence of C-peptide testing patient, requires basal-bolus insulin (multiple daily injections); partial function if on insulin therapy with C-peptide ≥ 0.6 ng/mL, or in the absence of C-peptide data, requires only once daily basal insulin or occasional (less than daily) supplemental insulin; and full function if insulin independent.

Figure 6.

Predictors of islet graft function. *Significant associations. Reference standards for categorical variables are: <2,000 islet equivalents (IEQ)/kg; no ERCP stenting procedures, no diagnosis of diabetes before surgery, pancreatitis duration < 5 years, BMI 20 to 25 kg/m², Female sex, Age 35 to 50 years. DM, diabetes mellitus; ERCP, endoscopic retrograde cholangiopancreatography; panc, pancreatitis.