title: Completion pancreatectomy and islet cell autotransplantation as salvage therapy for patients failing previous operative interventions for chronic pancreatitis.
abstract: OBJECTIVE
  Traditional decompressive and/or pancreatic resection procedures have been the cornerstone of operative therapy for refractory abdominal pain secondary to chronic pancreatitis. Management of patients that fail these traditional interventions represents a clinical dilemma. Salvage therapy with completion pancreatectomy and islet cell autotransplantation (CPIAT) is an emerging treatment option for this patient population; however, outcomes after this procedure have not been well-studied.
  
  
  METHODS
  All patients undergoing CPIAT after previous decompressive and/or pancreatic resection for the treatment of chronic pancreatitis at our institution were identified for inclusion in this single-center observational study. Study end points included islet yield, narcotic requirements, glycemic control, and quality of life (QOL). QOL was assessed using the Short Form (SF)-36 health questionnaire.
  
  
  RESULTS
  Sixty-four patients underwent CPIAT as salvage therapy. The median age at time of CPIAT was 38 years (interquartile range [IQR], 14.7-65.4). The most common etiology of chronic pancreatitis was idiopathic pancreatitis (66%; n = 42) followed by genetically linked pancreatitis (9%; n = 6) and alcoholic pancreatitis (8%; n = 5). All of these patients had previously undergone prior limited pancreatic resection or decompressive procedure. The majority of patients (50%; n = 32) underwent prior pancreaticoduodenectomy, whereas the remainder had undergone distal pancreatectomy (17%; n = 11), Frey (13%; n = 8), Puestow (13%; n = 8), or Berne (8%; n = 5) procedures. Median time from initial surgical intervention to CPIAT was 28.1 months (IQR, 13.6-43.0). All of these patients underwent a successful CPIAT. Mean operative time was 502.2 minutes with average hospital duration of stay of 13 days. Islet cell isolation was feasible despite previous procedures with a mean islet yield of 331,304 islet cell equivalents, which totaled an islet cell autotransplantation of 4,737 ± 492 IEQ/kg body weight. Median patient follow-up was 21.2 months (IQR, 7.9-36.8). Before CPIAT, all patients required a mean of 120.8 morphine equivalent milligrams per day (MEQ/d), which improved to 48.5 MEQ (P < .001 compared with preoperative requirements) at most recent follow-up. Of these patients, 44% (n = 28) achieved narcotic independence. All patients were able to achieve stable glycemic control with a mean insulin requirement of 16 units per day. Of these patients, 20% (n = 13) were insulin independent after CPIAT. Mean postoperative glycosylated hemoglobin was 7.8% (range, 4.6-12.5). Islet cell viability was confirmed with endocrine testing and mean C-peptide levels 6 months after CPIAT were 0.91 ng/mL (range, 0.1-3.0). The SF-36 QOL survey administered postoperatively demonstrated improvement in all tested modules.
  
  
  CONCLUSIONS
  This study is the first to examine the results of salvage therapy with CPIAT for patients with refractory chronic pancreatitis. Patients undergoing CPIAT achieved improved postoperative narcotic requirements, stable glycemic control, and improved QOL.
authors.affiliation: Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Gregory C
authors.initials: GC
authors.lastname: Wilson
authors.affiliation: Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Sutton
authors.affiliation: Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Milton T
authors.initials: MT
authors.lastname: Smith
authors.affiliation: Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Nathan
authors.initials: N
authors.lastname: Schmulewitz
authors.affiliation: Department of Endocrinology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Marzieh
authors.initials: M
authors.lastname: Salehi
authors.affiliation: Department of Radiology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Kyuran A
authors.initials: KA
authors.lastname: Choe
authors.affiliation: Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Nick C
authors.initials: NC
authors.lastname: Levinsky
authors.affiliation: Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: John E
authors.initials: JE
authors.lastname: Brunner
authors.affiliation: Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Abbott
authors.affiliation: Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Sussman
authors.affiliation: Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Edwards
authors.affiliation: Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH. Electronic address: ahmadsy@uc.edu.
authors.forename: Syed A
authors.initials: SA
authors.lastname: Ahmad
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016381:Islets of Langerhans Transplantation / Q000379:methods; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods*; D016577:Pancreaticoduodenectomy; D050500:Pancreatitis, Chronic / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods*; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D055815:Young Adult