Our group received a very helpful update on pancreatitis from Maisam Abu-El-Haija (GI) and Jaime Nathan (surgery). These notes focus on the surgical perspective. My notes may include some errors in transcription and errors of omission. Some pictures of the slides are included below as well.
Several surgical procedures can be considered in chronic pancreatitis. Prior surgical procedures, though, could reduce islet cells if TPIAT needed later.
TPIAT –Cincinnati experience: 17 cases in last 2 years. Highly selected group. Operation time takes about 10 hours (or more). GJ tube placed due to anticipated poor gastric emptying for 4-6 weeks. Fevers expected during 1st post-operative week due to systemic inflammatory response. ~15% of children remain on opioids after TPIAT, likely due to long-standing problems prior to TPIAT.
Post-TPIAT care: PERT, vitamins, insulin (may wean off). During 1st year, anticoagulation, hydroxyurea/aspirin (if high platelets), and penicillin prophylaxis. Prior to TPIAT, patients receive vaccines (due to anticipated splenectomy).
A recent study (MD Bellin et al. Clin Gastroenterol Hepatol 2016; 14: 1317-23) describes the use of Total Pancreatectomy with Islet Autotransplantation (TPIAT) in 49 patients (mean age 32.8 years). This study included 6 children.
All of these patients met strict criteria for recurrent acute pancreatitis and lacked imaging or functional evidence for chronic pancreatitis. All 49 required narcotics for pain management prior to TPIAT.
The surgical technique for TPIAT is well-described in the report. Patients underwent total pancreatectomy, splenectomy, cholecystectomy and partial duodenectomy with continuity restored via doudenoduodenostomy or Roux-en-Y duodenojejunostomy. The islets were isolated and then infused intraportally.
At 1 year following TPIAT, 22 (46%) reported no use of narcotic pain medications.
Health-related quality of life scores improved (see Figure 3)
Diabetes is a common post-op concern. Approximately half were insulin-independent at 1 and 2 years out from surgery, with one-third remaining so at 5 years.
Histopathology was consistent with chronic pancreatitis in 37 (76%) indicating that current imaging/functional features do not reliably identify chronic pancreatitis with adequate sensitivity.
In the discussion, the authors note the selected patients, due to having normal caliber pancreatitis ducts, were not candidates for surgical drainage procedures like the Puestow procedure. They also note that the Puestow procedure can compromise later islet cell isolation.
My take: TPIAT is an important option in those with severe recurrent or persistent pancreatitis disease.