Total pancreatectomy, accompanied by auto-transplantation of islet cells, increases the quality of life for children with severe chronic pancreatitis, according to Melena Bellin et al. in the September issue of Clinical Gastroenterology and Hepatology.
Chronic pancreatitis is rare among children, but is painful and progressive and can lead to narcotic dependence and exocrine and endocrine insufficiencies; it also increases risk for pancreatic adenocarcinoma. Although there are medical and surgical treatments available, they do not always reduce pain or the risk for diabetes and cancer.
A recently developed treatment option is total pancreatectomy (removal of the entire pancreas) along with autotransplantation of islets cells, which produce insulin and other important factors, into the portal vein (TP/AICT). The islet cells engraft in the liver and secrete insulin in response to glucose, without need for immunosuppression. This technique has been reported to be successful in adults with severe chronic pancreatitis, but there is little data on its efficacy in children.
Bellin et al. report outcomes of 19 children (an average of 14.5 years old) who underwent TP/AICT between 2006 and 2009. All had endured repeated hospitalizations and required narcotic therapy for pain before the procedure. They also had below average health-related quality of life scores from a standardized health survey; their mean physical component summary score was 30 and mental component summary score was 34.
By 1 year after the TP/AICT procedure, these scores improved to 50 and 46, respectively—mean scores improved for all 8 component subscales evaluated (see figure).
Furthermore, 18 of the 19 patients no longer needed narcotics for pain (or had large reductions in their use); 7 became insulin independent and another 4 required only small amounts of insulin (≤0.25 U/kg/d). The patients who were most likely to remain insulin dependent were those who had prior surgical interventions on their pancreas,“…highlighting the need to consider earlier time to pancreatectomy in patients with severe disease,” said Bellin in a video abstract that accompanies the article.
The mean length of hospitalization was 20 days and 3 patients developed complications that required additional operations. Another patient required percutaneous drainage of an abscess.
In an accompanying editorial, Nathan Schmulewitz states that it is noteworthy that physical and emotional summary component scores, which had preoperative values that were almost 2 standard deviations below the population average, normalized after surgery. Furthermore, improvements were sustained from the 3-month to the 12-month postoperative values.
However, the procedure is not for everyone with chronic pancreatitis—Schmulewitz emphasizes that proper patient selection was one of the most important factors for this study. He adds that Bellin et al. clearly described their criteria for study inclusion and their center’s organized approach to patient evaluation. Another strength of the study was the standard surgical technique and processes for islet isolation and perfusion, which reduced procedural variables.
Schmulewitz warns that although the low need for analgesics and rehospitalization observed in the ﬁrst 2 years are reasonable predictors for long-term palliation of pain, prediction of endocrine outcomes is more complex. He states that 5- and 10-year follow-up studies are needed, along with studies of islet cell growth factors and ways to promote islet uptake and survival in the liver.
More Information on Chronic Pancreatitis:
- National Library of Medicine Website on Chronic Pancreatitis
- Schulze Diabetes Institute at the University of Minnesota
- University of California at San Francisco Website on Pancreatitis and Treatment
Read the article online:
Bellin MD, Freeman ML, Schwarzenberg SJ, et al. Quality of life improves for pediatric patients after total pancreatectomy and islet autotransplant for chronic pancreatitis. Clin Gastroenterol and Hepatol 2011; 9:793–799.
Read the accompanying editorial:
Schmulewitz N. Total pancreatectomy with autologous islet cell transplantation in children: making a difference. Clin Gastroenterol and Hepatol 2011; 9:725–726.