Elsevier

Pancreatology

Volume 14, Issue 1, January–February 2014, Pages 27-35
Pancreatology

Original article
Total pancreatectomy and islet autotransplantation in chronic pancreatitis: Recommendations from PancreasFest

https://doi.org/10.1016/j.pan.2013.10.009Get rights and content

Abstract

Description

Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure used to treat severe complications of chronic pancreatitis or very high risk of pancreatic cancer while reducing the risk of severe diabetes mellitus. However, clear guidance on indications, contraindications, evaluation, timing, and follow-up are lacking.

Methods

A working group reviewed the medical, psychological, and surgical options and supporting literature related to TPIAT for a consensus meeting during PancreasFest.

Results

Five major areas requiring clinical evaluation and management were addressed: These included: 1) indications for TPIAT; 2) contraindications for TPIAT; 3) optimal timing of the procedure; 4) need for a multi-disciplinary team and the roles of the members; 5) life-long management issues following TPIAP including diabetes monitoring and nutrition evaluation.

Conclusions

TPIAT is an effective method of managing the disabling complications of chronic pancreatitis and risk of pancreatic cancer in very high risk patients. Careful evaluation and long-term management of candidate patients by qualified multidisciplinary teams is required. Multiple recommendations for further research were also identified.

Section snippets

Rationale

Recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) (ICD-9 577.9) are related progressive inflammatory syndromes of the pancreas associated with complications that can be disabling and life threatening. In many cases, standard medical and endoscopic treatment is ineffective, while total pancreatectomy alone leads to brittle diabetes with hypoglycemia linked to loss of counter-regulatory pancreatic glucagon. An alternative is total pancreatectomy with islet autotransplantation

Guideline focus

The PancreasFest working group framed the development of their discussion questions and guidance statements around three areas of concern: 1) Indications and contraindications for TPIAT; 2) Evaluation and timing of TPIAT; and 3) Following patients after TPIAT.

Target population

The clinical recommendations guide the evaluation and management of pediatric and adult patients who are potential candidates for TPIAT or who have undergone TPIAT and require ongoing care.

Guideline development process

PancreasFest is an annual meeting that brings together physicians and scientists with interests in the pancreas: pancreatologists, endoscopists, surgeons, radiologists, molecular biologists, geneticists, epidemiologists, statisticians, systems biologists, and experts in biomarkers (typically 150 + attendees).

At PancreasFest 2009, an expert working group convened to identify the most important clinical questions related to TPIAT and prepared state-of-the-art lectures and case studies for

Evidence review and grading

Methods of developing consensus were based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Grid to reach decisions on clinical practice guidelines [20] and the Surviving Sepsis Campaign report [21].

Evidence and modification

The discussion questions presented to attendees of PancreasFest 2012 were followed by one or more guidance statements intended to provide a concise summary and, if indicated, a clinical recommendation. Conference attendees (Appendix A and B) discussed the initial questions and guidance statements of the working group, which were projected for the entire conference to see and revise in real-time. The conference participants then voted on the level of agreement with the statements, with the

Clinical recommendations

Discussion Question 1: What are the indications for considering TPIAT to manage chronic pancreatitis?

Guidance Statement 1: The primary indication for TPIAT is to treat intractable pain in patients with impaired quality of life due to CP or RAP in whom medical, endoscopic, or prior surgical therapy have failed.

Evidence Level: 2a.

Grade of recommendation: B.

Level of Agreement: A 76%; B 19%; C 5%; D 0%; E 0%

Evidence: In patients with CP, pancreatectomy and islet autotransplantation should be

Research recommendations

Areas of potential research related to TPIAT were identified by the guideline coauthors and PancreasFest participants. These included additional research on mechanisms and management of pain, psychological assessment and care of the TPIAT recipient, diabetes evaluation, and the role of cancer risk in selecting candidates for TPIAT, and are summarized below.

Guidance Statement 1: A better understanding of pain mechanisms in CP is needed, which could aid in selection of TPIAT candidates. In

Summary

Total pancreatectomy and islet autotransplant is a potential treatment option for select patients with severe painful chronic or recurrent acute pancreatitis. Among the PancreasFest participants, there was high consensus (>90% agreement) that the indication for the procedure is intractable pain despite other appropriate treatment modalities in selected patients lacking psychosocial or medical contraindications, that candidates should be evaluated by a multidisciplinary team, and that assessment

Disclosure statement

The authors have no relevant conflicts of interest related to this material.

Author contributions

Developed the concept and the consensus process: M.A.A., R.E.B, L.F. and D.C.W.

TPIAP Working Group: J.B.M. (chair), M.L.F., A.G, M.E.L., A.S., A.H.

Wrote the Manuscript: M.D.B and D.C.W.

Participated in discussion of statements, reviewed and approved manuscript: All authors and participants.

Acknowledgments

This work was supported in part by conference grants from the National Institute of Diabetes and Digestive and Kidney Diseases [R13DK083216 (2009), R13DK088452 (2010), and R13DK09604 (2012)] and accredited physician education supported by Abbott Laboratories, Aptalis Pharma, Boston Scientific, Cook Medical, Lilly, and Olympus through the University of Pittsburgh office of Continuing Medical Education. The authors thank Ms. Michelle Kienholz, Ms. Joy Jenko Merusi, and Ms. Marianne Davis for

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    1

    Working group members; a complete list of participants in the voting process are in the Appendix.

    2

    Co-Authors who participated in the guidance conference and/or helped developed the guidance and evidence statements, and who critically reviewed the paper.

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