Total pancreatectomy with islet autotransplant in pediatric chronic pancreatitis significantly improves quality of life and largely obviates the need for narcotics post procedure, wrote Dr. Melena D. Bellin and colleagues.
“This procedure should be considered in children with [chronic pancreatitis] when medical and endoscopic modalities have failed” and may be a better alternative to the current surgical standard of care – partial resection and drainage, the authors said.
Dr. Bellin of the endocrinology division in the department of pediatrics at the University of Minnesota, Minneapolis, and her associates studied 19 consecutive children aged 5–18 years who underwent total pancreatectomy with islet autotransplant into the portal vein during 2006–2009 at her institution (Clin. Gastroenterol. Hepatol. 2011 September [doi:10.1016/j.cgh.2011.04.024].
According to the authors, only three centers around the world have completed more than 50 of these procedures, with the bulk of the experience occurring in the adult population.
All patients had a diagnosis of chronic pancreatitis (CP), and had previously failed medical treatment, endoscopic treatment or both.
With their parents' help, patients completed the Medical Outcomes Study 36-item short form (SF-36) questionnaire at 1 week before and at 3, 6, and 12 months after surgery, and then annually. The scores range between 0 and 100 and are divided into eight subscales which in turn make up a Physical Component Summary (PCS) and a Mental Component Summary (MCS) score, with higher numbers signifying better health.
At baseline, all 13 patients required daily or intermittent narcotics. All patients had also had multiple hospitalizations for pain management. Two were dependent on jejunal tube feedings and two on total parenteral nutrition. “Prior to surgery, all patients had below average HRQOL [health related quality of life] based on the SF-36, with a mean PCS score of 30 and a mean MCS score of 34,” Dr. Bellin and her associates wrote. These scores were equivalent to 2 and 1.5 standard deviations, respectively, below the norm for the U.S. population.
By 1 year, wrote the authors, the PCS improved significantly, to a mean of 50. Similarly, the MCS improved to a mean of 46, although the increase just missed statistical significance. Both postsurgery scores were equivalent to normal HRQOL values in this population.
Looking at postprocedure narcotics use, the authors found that by 1 year, 14 patients had stopped using narcotics for pain management entirely, “2 reported rare narcotic use (a few times a year), 1 used tramadol, and 2 used daily narcotics at a reduced dose.”
After surgery, all of the patients received insulin initially, with a goal of weaning them off insulin if possible. At a mean of 18 months following the islet graft, seven patients were insulin independent, and four more were reporting minimal insulin use.
However, the study showed that patients who had undergone prior drainage procedures were more likely to be insulin dependent and have variable HbA1c levels, perhaps necessitating a “shift in the current management of CP, with avoidance of partial resections without islet autotransplantation and of surgical drainage procedures,” they recommended.