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Sunday, December 1, 2013
Pancreatitis causes excruciating abdominal pain that may severely impair quality of life. Patients commonly become addicted to the narcotics prescribed to treat the chronic pain and undergo repeat surgeries to remove parts of the pancreas causing the pain. These surgeries, as well as the general course of the disease, decrease the quantity and efficiency of the insulin-producing islets in the pancreas, contributing to insulin dependence and diabetes. Massachusetts General Hospital’s Pancreas/Islet Transplant Program now offers an innovative procedure aimed at addressing this challenge for patients in New England.
A Dual Procedure
Traditionally, the rationale for surgically treating chronic pancreatitis has been twofold: to relieve pain while preserving as much pancreatic function as possible in order to prevent diabetes. When other efforts to relieve a patient’s pain fail, physicians may recommend a total pancreatectomy (TP). TP appears to achieve the first pain relief goal while undermining the second goal of preventing the onset of diabetes.
An innovative dual procedure follows TP with islet autotransplantation (IAT), intended to restore islet cell function and reduce the risk of diabetes. Together, the treatment is called total pancreatectomy/islet autotransplantation (TP-IAT). Minimally invasive islet transplantation is generally preferable to a pancreas organ transplant, and autotransplantation of islets is more effective at maintaining insulin levels than islet allotransplantation from cadavers—and it does not require lifelong immunosuppression, since the islets are not foreign. TP-IAT is intended to achieve both the goal of relieving pain and the goal of reducing diabetes risk.
Massachusetts General Hospital’s Pancreas/Islet Transplant Program now offers the TP-IAT procedure as a regional service, which is overseen by Chief of Surgery Keith Lillemoe, MD, and islet transplant surgeon James Markmann, MD, PhD.
There are a number of criteria for selecting patients for TP-IAT. Typically, the patient’s quality of life has diminished because of severe abdominal pain attributed to the pancreas for at least six months. Also, the patient has a constant need for narcotics despite exhausting all other surgical, medical and non-procedure-based options. The patient must not resume any prior alcoholism following the treatment. Patients who are already diabetic will not benefit from islet autotransplantation. Age and sex are not selection criteria, and children are also eligible.
Surgery and Islet Processing
Patients first undergo a total pancreatectomy. The pancreatic tissue is sent to the islet transplantation lab, where the islet cells are isolated from the excised tissue and prepared for transplantation back into the patient through the portal vein of the liver.
When performed at Mass General, the patient remains in the operating room while the islet preparation is under way, which takes about three to five hours. As part of the regional service, patients may undergo the pancreatectomy at their home hospital, which sends the excised pancreatic tissue to the Mass General islet transplantation lab. The home hospital may receive the islet preparation later the same day or early the next day, depending on the distance from Mass General. In the latter case, the patient returns to the OR the following day for the brief infusion procedure.
Measures of Success
The combined TP-IAT procedure was pioneered at the University of Minnesota in 1977, but it is currently offered only at selected hospitals, because of the specialization required to perform islet preparation and the cost of the lab to perform it. Mass General has the only active human islet isolation facility in New England offering this service. A 2012 study in the Journal of the American College of Surgeons reviews the outcomes in 409 patients (including 53 children) who underwent TP-IAT at the University of Minnesota over a 34-year period, from 1977 to 2011. Eighty-five percent of patients experienced pain improvement and 59 percent had ceased narcotic use. After three years, about a third were insulin independent, a third required medication or insulin to control blood sugar levels and a third were diabetic.
An Evolving Goal
Determining when to offer TP-IAT is challenging. Dr. Markmann sees a trend toward intervening earlier. When the pancreas is less diseased and the patient has had less of it removed in earlier procedures, the islet transplantation team can rescue a greater mass of healthily functioning islet cells, reducing the risk of diabetes. Work in animal studies is leading to improved islet processing and allotransplantation techniques that may also lead to improvements in autotransplantation outcomes in patients.
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