TPIAT benefits some patients with chronic pancreatitis

Last Updated: 2018-01-11

By Will Boggs MD

NEW YORK (Reuters Health) - Total pancreatectomy with islet autotransplantation (TPIAT) is a durable treatment for selected chronic pancreatitis patients, according to a database study.

"The most significant finding is that patients with genetic pancreatitis have superior outcomes and clearly benefit from TPIAT," Dr. Katherine A. Morgan from Medical University of South Carolina, in Charleston, told Reuters Health by email. "Other patients benefit as well, but selection is less clear and the results are less perfect."

TPIAT can relieve pain and improve quality of life for patients with chronic pancreatitis, but the best method of patient selection for surgery remains unclear.

Dr. Morgan and colleagues used data from a prospectively maintained database of 195 consecutive patients (mean age, 40; 72% women; 27% smokers) undergoing TPIAT at their institution to evaluate long-term outcomes after TPIAT and to identify factors that might enable optimal patient selection.

Surgery time averaged 240 minutes, and postoperative length of stay was a median 9 days. Major complications occurred after surgery in 19% of patients; two perioperative deaths (day 9 and day 24) resulted from hepatic failure or respiratory failure.

Only 29% of patients did not require insulin at 1 year, 28% at 2 years, and 23% at 5 years postoperatively, according to the December 28 Journal of the American College of Surgeons online report.

Insulin independence was more likely in patients who did not smoke, who did not have prior pancreatic surgery, and whose duration of pancreatitis was 5 years or less.

Quality of life improved, and emergency department visits and oral morphine use decreased, following surgery.

Patients with hereditary pancreatitis experienced greater improvements in quality of life and greater reductions in daily oral morphine use after surgery, compared to other patients with chronic pancreatitis.

Overall, the 5-year actuarial survival was 92.3%.

"Genetic pancreatitis patients should be offered TPIAT early in their course," Dr. Morgan said. "Smoking should be considered a relative contraindication to surgery."

Dr. Vikesh K. Singh, director of the TPIAT program at Johns Hopkins University School of Medicine, in Baltimore, told Reuters Health by email, "It is being increasingly recognized that patients with genetic pancreatitis have better outcomes with regards to pain when compared to patients with a non-genetic etiology."

"From our experience, patients with unequivocal acute recurrent pancreatitis and/or calcifications of the pancreas (many of whom have pathogenic genetic mutations) tend to do well, whereas patients whose etiology is alcohol and/or smoking tend to not do well," he said.

"Potentially most important is that nearly 45% of their patients carry etiologies of pancreatitis that are highly controversial," Dr. Singh explained. "Pancreas divisum, the most common congenital anomaly in the world, is not a cause of pancreatitis or abdominal pain. Most divisum patients have an established etiology for their pancreatitis identified after a thorough evaluation, including genetic testing, recognition of the causative role of smoking, etc. Similarly, papillary stenosis is also highly problematic as an 'etiology' for pancreatitis. This study would have been stronger if they had further elucidated whether these divisum and papillary stenosis patients have a history of acute recurrent pancreatitis and/or calcifications in their pancreata."

Dr. Singh expressed hope that the "ongoing, 5-year NIH/NIDDK-funded prospective observational registry study of patients undergoing TPIAT at 12-15 centers across the country" will identify patients "who do the best with this highly morbid procedure."

Dr. Timothy B. Gardner from Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, who recently reported on glycemic control in patients undergoing TPIAT, told Reuters Health by email, "This validates what other studies have shown - patients with hereditary pancreatitis have improved quality of life compared with those patients with other etiologies (of) their pancreatitis. Patients should be counseled that if they have a non-hereditary form of chronic pancreatitis and have had symptoms for greater than five years and are on opiates, the chances of an improved quality of life and subsequent insulin independence are not as robust."

"It is critical that any patient being evaluated for TPAIT be seen by a multidisciplinary team in a center very experienced with this type of surgery," he added, noting that even for patients severely debilitated by their disease, clinicians need to be ready to deny surgery to those whose preoperative risk factors stand in the way of achieving insulin independence and better quality of life.

SOURCE: http://bit.ly/2m9qSyB

J Am Coll Surg 2017.