Once considered a “last resort” in patients with chronic pancreatitis, a new study shows that a total pancreatectomy with islet autotransplantation, sooner rather than later, can stave off the onset of diabetes and improve quality of life.
A diagnosis of chronic pancreatitis (CP) once doomed a patient to significantly diminished quality of life (QOL) at best and full-blown diabetes to eventual death at worst. These dire prognoses are not necessarily the case any longer, due to the enormous success of the nearly 40-year-old procedure known as total pancreatectomy with islet autotransplantation (TP/IAT). The twofold problem is, many clinicians are unaware that the procedure exists, and many of those who do know about it mistakenly believe that they do not have access to a facility that can implement it.
In the May 2015 issue of The Journal of Clinical Endocrinology & Metabolism (JCEM), the manuscript entitled “Factors Associated With Islet Yield and Insulin Independence After Total Pancreatectomy and Islet Cell Autotransplantation in Patients With Chronic Pancreatitis Utilizing Off-site Islet Isolation: Cleveland Clinic Experience,” reveals just how mistaken that latter notion is. “In our study, we show that patients can get this care at a lot of places without too much cost involved,” says the article’s lead author, Betul A. Hatipoglu, MD, in the Department of Endocrinology, Diabetes and Metabolism at the Cleveland Clinic Foundation in Ohio. “We improved both quality of care and patient QOL in the long term, and we are very happy about that.”
Without islet transplantation, total pancreatectomy invariably causes diabetes. Although the patient’s pain may wax and wane, in a large segment of patients with chronic, relentless pain, overall QOL will continue to deteriorate due to chronic pain, narcotic addiction, weight loss, diarrhea, and general disability. As a result of the inflammatory process in the pancreas, islet destruction ensues and the islet mass diminishes, leading ultimately to diabetes. TP/IAT removes the patient’s own islets from the resected pancreas and transplants them into the patient’s liver. This effectively gives the patient a new lease on life. But because laboratories that are equipped to isolate the islet cells from the removed pancreas are very expensive to establish and therefore scarce, TP/IAT has been regrettably underutilized.
“Another reason not to wait to operate is that the ultimate outcome of [chronic pancreatitis] is diabetes in most cases. That is not a great reward at the end of the road. My message is, get [total pancreatectomy with islet autotransplantation] done as soon as you realize that the disease course is chronic and irreversible to relieve pain — that is the main reason — but also to prevent diabetes.” — R. Paul Robertson, MD, editor-in-chief, The Journal of Clinical Endocrinology & Metabolism
To reverse this unfortunate and unnecessary trend, Hatipoglu and team sought to determine whether the IAT component of TP/IAT could be conducted off-site — in this case at the University of Pittsburgh’s islet isolation lab. In a cohort of 18 male and 18 female patients averaging age 38 years, they achieved rates of islet yields and insulin independence commensurate with those that centers with on-site labs report, about 33%. “The most important point I want to get out there is that it would be impossible and not at all cost effective for every institution performing pancreatectomies to run an islet isolation lab,” Hatipoglu says. “With our study, we were able to show that collaborating with another lab capable of isolating the islets for us yielded very similar outcomes, which means that one lab can serve many hospitals. This kind of networking will allow clinicians to serve their patients the best possible way. Not every patient can afford to go to one of the larger centers, and we showed that it is okay to treat them locally.”
Don’t Wait to Operate
In “Total Pancreatectomy and Islet Autotransplantation for Chronic Pancreatitis: Breaking Down Barriers,” an accompanying editorial by JCEM editor-in-chief, R. Paul Robertson, MD, at the University of Washington in Seattle, the cause of publicizing the success and accessibility of TP/IAT is further heralded. “Transplantation centers should understand that they do not need their own islet isolation facility and can learn how to work with an existing one — like the Cleveland Clinic has done with the University of Pittsburgh. That demonstration opens the door — because now, when healthcare providers make the diagnosis of chronic, irreversible pancreatitis, they can realistically consider taking the entire pancreas out.” In other words, delaying the procedure — which was once considered routine for this disease — is not going to improve anything, and could potentially make the patient’s condition much worse. The patient will continue to suffer pain and disability as long as the pancreas stays inside the body.
“In our study we show that patients can get this care at a lot of places without too much cost involved. We improved both quality of care and patient QOL in the long term, and we are very happy about that.” — Betul A. Hatipoglu, MD, Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, Ohio
Moreover, many of these patients have been forced to leave their jobs or forfeit care of their families because of the debilitating nature of their disease.
“Another reason not to wait to operate is that the ultimate outcome of CP is diabetes in most cases. That is not a great reward at the end of the road,” Robertson says. “My message is, get [TP/IAT] done as soon as you realize that the disease course is chronic and irreversible to relieve pain — that is the main reason — but also to prevent diabetes.” Although no strict definition of “irreversible course” exists, what Robertson calls “clinical common sense” indicates that the condition of a pancreatitis patient with significantly reduced QOL for the prior couple of years is likely going to worsen, leaving no good reason to try to retain the pancreas. “Some surgeons will take out progressively more of the pancreas over time, but each time they take out a little more, the patient is that much closer to diabetes. Those surgeons are not just removing the inflamed non-islet tissue, they are also taking out functional islets with each piece of the pancreas,” he says.
Hatipoglu agrees that delaying can mean a less favorable outcome for the patient. “If you are too late, then the patient’s pain management might not be as good as if the procedure had been done earlier, and the islet mass will not be in great shape. Timing of the surgery is therefore very important and should be a decision made by a multidisciplinary team,” she says.
The bottom line is, there appears to be no good reason not to perform TP/IAT with a chronic, irreversible disease course and several important reasons in favor of doing it. It can resolve the pain and reduced QOL associated with CP, it is becoming widely accessible in terms of location and cost, and it prevents the eventual downslide to diabetes the patient would otherwise likely face. “[TP/IAT] is gaining momentum, but this snowball needs to roll down the hill a little faster,” said Robertson. Patients should not have to suffer unnecessarily, and the heathcare system could certainly benefit from a lighter diabetes burden.
—Horvath is a freelance writer based in Baltimore, Md. She wrote about how EDCs affect female reproduction in the July issue.