Pancreatectomy and islet transplant can boost QOL in chronic pancreatitis

Last Updated: 2015-01-16

By Will Boggs MD

NEW YORK (Reuters Health) - Patients with chronic pancreatitis have improved physical and psychological quality of life (QOL) after total pancreatectomy with islet autotransplantation (TPIAT), researchers say.

"Patient selection is essential to the success of TPIAT, yet we are really just beginning to understand which patients are the best candidates," Dr. Katherine A. Morgan, of the Medical University of South Carolina in Charleston told Reuters Health by email.

"The preoperative behavioral health evaluation is helpful to us and more importantly to the patients and their families by enhancing preparation for surgery, which undoubtedly leads to greater success postoperatively," she said.

Some patients who appear to have disease that would be expected to improve after TPIAT do not benefit from the surgery, suggesting that factors other than clinical course and anatomy play a role in the success of the intervention.

Dr. Morgan's team analyzed preoperative psychometric parameters to potentially identify predictive factors for success or failure of TPIAT in a prospective study of 127 patients who underwent the procedure for debilitating pain from chronic pancreatitis.

Preoperative quality of life was generally poor but improved after surgery, the researchers reported January 6 online in the Journal of the American College of Surgeons.

Mean improvements in the physical QOL score were 7.1 points (on a 100-point scale) at one year, 5.8 points at two years, and 7.8 points at three years after surgery, while mean improvements in psychological QOL score were 3.9, 4.9, and 6.6 points, respectively.

Around two-thirds of patients experienced at least a three-point (clinically meaningful) improvement in physical QOL score at one year, but only about half showed at least a 3-point improvement in psychological QOL score.

The 78 patients (68%) who had significant depressive symptoms preoperatively had lower QOL scores preoperatively, but their improvements were similar to those of nondepressed patients postoperatively.

Higher opioid misuse scores at baseline predicted greater improvements in physical QOL (but not psychological QOL) at two and three years postoperatively.

In an exploratory multiple regression analysis, patient demographics were not associated with postoperative changes in QOL, although higher opioid misuse scores at baseline remained associated with greater improvements in physical QOL at two years.

"We were hopeful that the preoperative psychometric evaluations would be a nice objective tool to help us in the patient selection process," Dr. Morgan said. "They certainly remain an important component of the evaluation, but are not a yes/no answer."

"Carefully selected patients can expect significant improvements in quality of life and pain improvement from TPIAT," Dr. Morgan said. "The process of patient selection, however, is a work in progress and needs further study."

"The chronic pancreatitis-related pain syndrome is complicated and multifaceted," Dr. Morgan added. "These patients need multidisciplinary teams for successful management, importantly including behavioral health specialists."

Dr. Jeffrey B. Matthews, surgeon-in-chief at the University of Chicago, told Reuters Health by email, "I was not surprised at the failure of psychometric tests to predict outcomes, which confirms my own experience with TPIAT. Potential patients are very different in their clinical situations and show widely different adaptive emotional and physical responses to their illness."

"TPIAT should be considered in patients who are severely affected by the pain of chronic pancreatitis and who have no conventional alternative," he explained. "Patients with so-called 'small duct' disease, or who have failed prior surgical interventions may be good candidates so long as they are not yet diabetic. Patients with genetic predisposition (e.g., hereditary pancreatitis), particularly younger patients, are very well suited to this procedure."

"The outcomes for TPIAT are best when performed in a center that has deep, multidisciplinary experience in caring for the spectrum of benign and malignant pancreatic diseases," Dr. Matthews said. "In addition to a significant institutional commitment to an islet isolation laboratory, a successful program requires close collaboration between medical pancreatologists, advanced endoscopists, and pancreatic surgeons in addition to experts in surgical nursing, nutrition, and pain management."

Dr. Syed Ahmad, director of the Pancreas Disease Center at the University of Cincinnati Medical Center in Ohio, told Reuters Health by email, "The most important metric of success to patients is QOL. Patients who have this operation can be on pain meds and require insulin after the operation, but if their QOL is improved they will think the operation was worth it."

"As expected, physical QOL is immediate as pancreatectomy improves some pain; however, not all the pain goes away right away," Dr. Ahmad said. "As the remaining pain gets better psychological QOL improves. In addition, weaning from narcotics takes time and this is also related to improvement of psychological QOL."

Dr. Ahmad said, "Our indications (for TPIAT) at University of Cincinnati are: Debilitating abdominal pain not responding to medical management in a patient who does not qualify for traditional subtotal resections or decompression operations (and) debilitating abdominal pain in patients with minimal change pancreatitis, recurrent acute pancreatitis without anatomic defect, genetic related pancreatitis."

Dr. Horacio Rilo, director of the Pancreatic Disease Center at North Shore-Long Island Jewish Hospital in Manhasset, New York, told Reuters Health by email, "The majority of patients improve with time posttransplant but the road to recovery takes time and includes weaning patients from pain medications to teaching patients the importance of monitoring their blood glucose frequently, especially during the first year. It is also important to reiterate to patients that recovery will take time. So many patients focus on pain relief (understandably) and less on the prospect of potentially having to take insulin for the rest of their lives."

"Comorbidities also play an important role in the depression and anxiety presented by these patients," Dr. Rilo said. "It is important to understand that despite a pancreatectomy and auto islet transplant, a lot of problems may remain due to years of the inflammatory milieu that affects other organs. In addition these patients consumed heavy doses of opioid analgesics for years, sometimes for decades, and it can be very difficult to wean these patients."

The authors report no external funding or disclosures.

SOURCE: http://bit.ly/141c9dG

J Am Coll Surg 2015.