ATC 2012 Report – Pancreatectomy and auto islet transplantation works well in children

by Thomas R. Collins –  Total pancreatectomy and auto islet transplantation among children can bring about good results, with many able to stay insulin-free and almost all of them with pain eased enough that they don’t have to take narcotics to treat it, researchers from a leading centre for the procedure said here at the 2012 American Transplant Congress.

Children with crippling pain due to pancreatitis that hasn’t been helped enough with medical treatment pose a tough medical problem. The children can develop a dependence on narcotics, can miss a lot of school and generally suffer a poor quality of life.

“Also, there is a risk of pancreatic cancer long term in children with hereditary forms,” said Srinath Chinnakotla, MD, a Paediatric Transplant Surgeon at the University of Minnesota Medical Center.

The children have a risk of pancreatic cancer with hereditary forms of pancreatitis, and because of their small duct size, endoscopic management of the disease does not work well. When ducts are drained and portions of the pancreas are resected, there is about a 50 percent rate of recurrence of the pain.

But a total pancreatectomy, along with auto islet transplantation, can work in children, Dr Chinnakotla said.

The University of Minnesota Medical Center was the first institution to perform the procedure, back in 1977. Since then, the centre has performed more than 400 of the procedures, 54 of them on children.

To be eligible for the procedure, children must have pancreatitis that has caused narcotic dependence or repeated relapsing, along with pain that affects their quality of life. Also, endoscopic stenting must have already failed, imaging studies must have demonstrated chronic pancreatitis, and they must be non-diabetic or C peptide-positive.

In the procedure, the entire pancreas is removed. Then, in order to prevent almost certain diabetes, islet cells are removed from the pancreas and re-introduced to the body.

Among the 54 paediatric patients, one suffered an early death, within 30 days, because of sepsis. And two more deaths occurred after one year — one because of acute respiratory distress syndrome after a subsequent spinal procedure and one due to a cause that isn’t known.

The most encouraging result was that just 4 of the patients were using narcotics for pain after the procedure, with 4 additional patients getting weaned from narcotics. The rest were narcotics-free, even though all of the patient had been using narcotics before the procedure.

Twenty of the patients, or 44 percent, were off insulin.

While 80 percent of the children reported missing school because of health problems before the procedure, less than 20 percent reported this 24 months or more after the procedure. Patients also reported that the number of days they had their activity limited after the procedure was just a third of the number of days they reported limited activity before the procedure.

Overall, 25 percent of the patients had early surgical complications, but none were long-term complications.

“Clearly any previous operation — and especially Puestow (procedure in which the pancreas is made to drain directly into the intestines),” Dr Chonnikotla said, “results in low islet yield and less insulin.”