Total Pancreatectomy and Islet Auto Transplantation for Chronic Pancreatitis

Abstract

Background: For patients with severe chronic pancreatitis refractory to conventional therapy, total pancreatectomy with islet cell auto transplantation can alleviate pain while at the same time avoid the complications of diabetes. Methods: Between 2006 and 2010, 5 patients underwent either total pancreatectomy and splenectomy (n = 4) or splenic preserving total pancreatectomy (n = 1), with islet cell auto transplantation. Pain relief, glycemic control and insulin requirements were assessed post operatively, The pancreas was excised and placed into chilled RPMI 1640 tissue culture medium followed by decontamination with povidone iodine and saline, followed by intraductal perfusion with a solution of collagenase and neutral protease and then transferred to a heated vessel for digestion. Collection of tissue fragments (including free islets) began after 20 minutes and continued 30 minutes longer. The pancreatic fragments were washed, combined, and assessed for islet number, size, quality, and total tissue volume. Islets were placed into RPMI with heparin and returned to surgery for infusion through a 5 Fr. intraportal catheter. Results: The etiology of pancreatitis was: pancreas divisum (2), autoimmune (1), and idiopathic (2). Mean islet yield was 3339 islet equivalents/gm of pancreas (I.E.)/gm, (range 556 to 11,310 (I.E.)/g pancreas). Infusion was interrupted at intervals to allow monitoring of portal pressure, which gradually rose as more tissue was infused. Infusion was discontinued when portal pressures became stable at 20-25 mm/Hg. Because the volume of tissue infused was limited by portal pressure rise, an average of 61% of each patient's islets could be infused. In all cases, robust graft function gradually developed between two and 8 weeks, mean C-peptide levels at 1 month and 6 months were 1.74 and 4.0 respectively, complete insulin independence was achieved in 4 patients. Although one patient continued to suffer from severe intercurrent disease (Lupus, renal failure, sepsis), four patients reported significant or complete pain relief and were completely weaned from narcotic analgesia. Conclusion: Total pancreatectomy with islet auto transplantation should be considered as an early therapeutic option for patients with chronic pancreatitis to alleviate abdominal pain while preserving endocrine function.