Islet Cell Autografts Relieve Chronic Pancreatitis Pain

HOT SPRINGS, VA. – Despite the predominant view that islet cell transplantation is a radical procedure, it is effective for chronic pancreatitis when endoscopic duct drainage does not relieve the pain, according to researchers at the University of Minnesota, where the standard is to perform islet autotransplants in almost all cases of chronic pancreatitis.

The university began islet transplantation in 1977, but 60% of the procedures have been performed in the past 5 years. The total is now 374 adult cases and 57 pediatric cases. Dr. David Sutherland, professor of surgery at the university, presented data on the adult cases at the annual meeting of the Southern Surgical Association.

Islet autografts are still both a science and an art, said Dr. Sutherland. The pancreas is removed; importantly, the blood supply has to be preserved to the point of removal to avoid warm ischemia, he said. The islets are then isolated in a processing center. Each isolation must be adjusted to each individual’s diseased pancreas. The cells are then infused into the liver.

Minnesota’s case mix is very different from what is typical for pancreatitis. Seventy-three percent of the patients in the analysis were female, and only 7% of cases were due to alcoholism. In an interview after the presentation, Dr. Timothy Pruett, chief of the division of transplantation at the University of Minnesota, said that patients seem to be learning about the Minnesota procedure online and self-selecting to come to the university.

Some 41% of the cases were idiopathic in origin. Ninety-two percent did not have diabetes before transplantation.

Pain was a predominant factor for most patients. The average duration of pain was 9 years, and the duration of narcotic use was almost 4 years on average. This has many implications, including the central sensitization of pain and opioid-induced hyperalgesia.

The mortality rate for autotransplants has been low, with 97% of the most recent cohort (2006-2011) alive at 1 year. At 5 years, 86%-88% of the earlier transplant patients were still alive. Twenty-year survival is 66%, said Dr. Sutherland. Overall, 16% of patients have required reoperation; of those, about 10% needed surgery because of bleeding.

To assess the effectiveness of the islet autografts, the researchers looked at the 201 patients who had more than 1 year of follow-up. Regardless of the islet yield, 91% of the patients are C-peptide positive and 83% have a hemoglobin A_1c level in the desired range of 7% or less. Higher islet yields produce better results, with fewer patients becoming diabetic.

At 3 years, 70% of patients who had a high yield of islet cells were insulin independent. Only 10%-20% of the patients who had lower yields of cells did not need insulin, however.

Pancreatitis pain resolved in 80%-90% of patients overall. In 60% of patients, narcotics were withdrawn by 2 years. It is a slow process, noted Dr. Sutherland.

The pain rating went down for most patients – from a 66 to a 44 on a 100-point scale. There was also improvement in all eight categories on the Short Form-36 quality of life survey, said Dr. Sutherland. Although pain scores improved more in the insulin-independent patients, significant pain improvement was also seen in the insulin-dependent group.

"There’s no doubt in my mind that this procedure is safe and effective in the management of intractable chronic pain associated with pancreatitis in selected patients," said Dr. David B. Adams, who commented on the presentation. However, it is not clear how to best identify patients who would benefit from the procedure, said Dr. Adams, a professor of surgery at the Medical University of South Carolina in Charleston. Calling the Minnesota report a "landmark paper," he added that while the procedure does not cure patients, it does improve quality of life, which is crucial in this group.

Dr. Kenneth L. Brayman, division chief of transplant surgery at the University of Virginia, Charlottesville, said that "islet autotransplantation has emerged as successful therapy." At his institution, 40%-50% of autograft patients are insulin free and 80% are pain free.

Noting the success at Virginia and in other programs, Dr. Brayman said that "it remains curious to me and others, why the management of chronic pancreatitis remains so controversial."

"The question of whether this is a radical procedure or not is in the eyes of the beholder," said Dr. Pruett. "It’s not radical in our hands. It is what we do."

Dr. Sutherland and Dr. Pruett reported no conflicts.

HOT SPRINGS, VA. – Despite the predominant view that islet cell transplantation is a radical procedure, it is effective for chronic pancreatitis when endoscopic duct drainage does not relieve the pain, according to researchers at the University of Minnesota, where the standard is to perform islet autotransplants in almost all cases of chronic pancreatitis.

The university began islet transplantation in 1977, but 60% of the procedures have been performed in the past 5 years. The total is now 374 adult cases and 57 pediatric cases. Dr. David Sutherland, professor of surgery at the university, presented data on the adult cases at the annual meeting of the Southern Surgical Association.

Islet autografts are still both a science and an art, said Dr. Sutherland. The pancreas is removed; importantly, the blood supply has to be preserved to the point of removal to avoid warm ischemia, he said. The islets are then isolated in a processing center. Each isolation must be adjusted to each individual’s diseased pancreas. The cells are then infused into the liver.

Minnesota’s case mix is very different from what is typical for pancreatitis. Seventy-three percent of the patients in the analysis were female, and only 7% of cases were due to alcoholism. In an interview after the presentation, Dr. Timothy Pruett, chief of the division of transplantation at the University of Minnesota, said that patients seem to be learning about the Minnesota procedure online and self-selecting to come to the university.

Some 41% of the cases were idiopathic in origin. Ninety-two percent did not have diabetes before transplantation.

Pain was a predominant factor for most patients. The average duration of pain was 9 years, and the duration of narcotic use was almost 4 years on average. This has many implications, including the central sensitization of pain and opioid-induced hyperalgesia.

The mortality rate for autotransplants has been low, with 97% of the most recent cohort (2006-2011) alive at 1 year. At 5 years, 86%-88% of the earlier transplant patients were still alive. Twenty-year survival is 66%, said Dr. Sutherland. Overall, 16% of patients have required reoperation; of those, about 10% needed surgery because of bleeding.

To assess the effectiveness of the islet autografts, the researchers looked at the 201 patients who had more than 1 year of follow-up. Regardless of the islet yield, 91% of the patients are C-peptide positive and 83% have a hemoglobin A_1c level in the desired range of 7% or less. Higher islet yields produce better results, with fewer patients becoming diabetic.

At 3 years, 70% of patients who had a high yield of islet cells were insulin independent. Only 10%-20% of the patients who had lower yields of cells did not need insulin, however.

Pancreatitis pain resolved in 80%-90% of patients overall. In 60% of patients, narcotics were withdrawn by 2 years. It is a slow process, noted Dr. Sutherland.

The pain rating went down for most patients – from a 66 to a 44 on a 100-point scale. There was also improvement in all eight categories on the Short Form-36 quality of life survey, said Dr. Sutherland. Although pain scores improved more in the insulin-independent patients, significant pain improvement was also seen in the insulin-dependent group.

"There’s no doubt in my mind that this procedure is safe and effective in the management of intractable chronic pain associated with pancreatitis in selected patients," said Dr. David B. Adams, who commented on the presentation. However, it is not clear how to best identify patients who would benefit from the procedure, said Dr. Adams, a professor of surgery at the Medical University of South Carolina in Charleston. Calling the Minnesota report a "landmark paper," he added that while the procedure does not cure patients, it does improve quality of life, which is crucial in this group.

Dr. Kenneth L. Brayman, division chief of transplant surgery at the University of Virginia, Charlottesville, said that "islet autotransplantation has emerged as successful therapy." At his institution, 40%-50% of autograft patients are insulin free and 80% are pain free.

Noting the success at Virginia and in other programs, Dr. Brayman said that "it remains curious to me and others, why the management of chronic pancreatitis remains so controversial."

"The question of whether this is a radical procedure or not is in the eyes of the beholder," said Dr. Pruett. "It’s not radical in our hands. It is what we do."

Dr. Sutherland and Dr. Pruett reported no conflicts.

HOT SPRINGS, VA. – Despite the predominant view that islet cell transplantation is a radical procedure, it is effective for chronic pancreatitis when endoscopic duct drainage does not relieve the pain, according to researchers at the University of Minnesota, where the standard is to perform islet autotransplants in almost all cases of chronic pancreatitis.

The university began islet transplantation in 1977, but 60% of the procedures have been performed in the past 5 years. The total is now 374 adult cases and 57 pediatric cases. Dr. David Sutherland, professor of surgery at the university, presented data on the adult cases at the annual meeting of the Southern Surgical Association.

Islet autografts are still both a science and an art, said Dr. Sutherland. The pancreas is removed; importantly, the blood supply has to be preserved to the point of removal to avoid warm ischemia, he said. The islets are then isolated in a processing center. Each isolation must be adjusted to each individual’s diseased pancreas. The cells are then infused into the liver.

Minnesota’s case mix is very different from what is typical for pancreatitis. Seventy-three percent of the patients in the analysis were female, and only 7% of cases were due to alcoholism. In an interview after the presentation, Dr. Timothy Pruett, chief of the division of transplantation at the University of Minnesota, said that patients seem to be learning about the Minnesota procedure online and self-selecting to come to the university.

Some 41% of the cases were idiopathic in origin. Ninety-two percent did not have diabetes before transplantation.

Pain was a predominant factor for most patients. The average duration of pain was 9 years, and the duration of narcotic use was almost 4 years on average. This has many implications, including the central sensitization of pain and opioid-induced hyperalgesia.

The mortality rate for autotransplants has been low, with 97% of the most recent cohort (2006-2011) alive at 1 year. At 5 years, 86%-88% of the earlier transplant patients were still alive. Twenty-year survival is 66%, said Dr. Sutherland. Overall, 16% of patients have required reoperation; of those, about 10% needed surgery because of bleeding.

To assess the effectiveness of the islet autografts, the researchers looked at the 201 patients who had more than 1 year of follow-up. Regardless of the islet yield, 91% of the patients are C-peptide positive and 83% have a hemoglobin A_1c level in the desired range of 7% or less. Higher islet yields produce better results, with fewer patients becoming diabetic.

At 3 years, 70% of patients who had a high yield of islet cells were insulin independent. Only 10%-20% of the patients who had lower yields of cells did not need insulin, however.

Pancreatitis pain resolved in 80%-90% of patients overall. In 60% of patients, narcotics were withdrawn by 2 years. It is a slow process, noted Dr. Sutherland.

The pain rating went down for most patients – from a 66 to a 44 on a 100-point scale. There was also improvement in all eight categories on the Short Form-36 quality of life survey, said Dr. Sutherland. Although pain scores improved more in the insulin-independent patients, significant pain improvement was also seen in the insulin-dependent group.

"There’s no doubt in my mind that this procedure is safe and effective in the management of intractable chronic pain associated with pancreatitis in selected patients," said Dr. David B. Adams, who commented on the presentation. However, it is not clear how to best identify patients who would benefit from the procedure, said Dr. Adams, a professor of surgery at the Medical University of South Carolina in Charleston. Calling the Minnesota report a "landmark paper," he added that while the procedure does not cure patients, it does improve quality of life, which is crucial in this group.

Dr. Kenneth L. Brayman, division chief of transplant surgery at the University of Virginia, Charlottesville, said that "islet autotransplantation has emerged as successful therapy." At his institution, 40%-50% of autograft patients are insulin free and 80% are pain free.

Noting the success at Virginia and in other programs, Dr. Brayman said that "it remains curious to me and others, why the management of chronic pancreatitis remains so controversial."

"The question of whether this is a radical procedure or not is in the eyes of the beholder," said Dr. Pruett. "It’s not radical in our hands. It is what we do."

Dr. Sutherland and Dr. Pruett reported no conflicts.