Pancreatectomy Raised Quality of Life in Pediatric Chronic Pancreatitis

Total pancreatectomy with islet autotransplant in pediatric chronic pancreatitis significantly improves quality of life and largely obviates the need for narcotics post procedure, according to a report by Dr. Melena D. Bellin and colleagues in the September issue of Clinical Gastroenterology and Hepatology.

"This procedure should be considered in children with [chronic pancreatitis] when medical and endoscopic modalities have failed," and may be a better alternative to the current surgical standard of care – partial resection and drainage, wrote the authors.

Dr. Bellin, of the endocrinology division in the department of pediatrics at the University of Minnesota, Minneapolis, studied 19 consecutive children aged 5-18 years who underwent total pancreatectomy with islet autotransplant into the portal vein during 2006-2009 at her institution (Clin. Gastroenterol. Hepatol. 2011 September [doi:10.1016/j.cgh.2011.04.024]).

According to the authors, only three centers around the world have completed more than 50 of these procedures, with the bulk of the experience occurring in the adult population.

All patients had a diagnosis of chronic pancreatitis (CP), and had previously failed medical treatment, endoscopic treatment or both.

With their parents’ help, patients completed the Medical Outcomes Study 36-item short form (SF-36) questionnaire at 1 week before and at 3, 6, and 12 months after surgery, and then annually. The scores range between 0 and 100 and are divided into eight subscales which in turn make up a Physical Component Summary (PCS) and a Mental Component Summary (MCS) score, with higher numbers signifying better health.

At baseline, all patients required narcotics, either on a daily basis (n = 13) or intermittently. All patients had also had multiple hospitalizations for pain management. Two were dependent on jejunal tube feedings and two on total parenteral nutrition. Seven patients also had undergone prior pancreatic surgery at outside institutions.

"Prior to surgery, all patients had below average HRQOL [health related quality of life] based on the SF-36, with a mean PCS score of 30 and a mean MCS score of 34," wrote Dr. Bellin. These scores were equivalent to 2 and 1.5 standard deviations, respectively, below the norm for the U.S. population.

By 1 year, wrote the authors, the PCS improved significantly, to a mean of 50 (P less than .001). Similarly, the MCS improved to a mean of 46, although the increase just missed statistical significance (P = .06). Both postsurgery scores were equivalent to normal HRQOL values in this population.

Looking at postprocedure narcotics use, the authors found that by 1 year, 14 patients had stopped using narcotics for pain management entirely.

"Of the remaining 5 patients, 2 reported rare narcotic use (a few times a year), 1 used tramadol, and 2 used daily narcotics at a reduced dose," they added.

After surgery, all of the patients received insulin initially, with a goal of weaning them off insulin if possible. At a mean of 18 months following the islet graft, seven patients were insulin independent, and four more were reporting minimal insulin use; all of them had hemoglobin A_1c levels less than or equal to 6.5%.

However, the study showed that patients who had undergone prior drainage procedures were more likely to be insulin-dependent (P = .04) and to have variable HbA_1c levels, perhaps necessitating "a paradigm shift in the current management of CP, with avoidance of partial resections without islet autotransplantation and of surgical drainage procedures," recommended Dr. Bellin.

"Although optimal timing of surgery needs to be elucidated, for those who will go on to [total pancreatectomy with islet autotransplantation], earlier surgery may avoid progressive damage to the endocrine pancreas and the hyperalgesia associated with chronic narcotic use," concluded Dr. Bellin.

The authors reported no individual conflicts of interest related to this study, which was supported in part by the National Pancreas Foundation.

Total pancreatectomy with islet autotransplant in pediatric chronic pancreatitis significantly improves quality of life and largely obviates the need for narcotics post procedure, according to a report by Dr. Melena D. Bellin and colleagues in the September issue of Clinical Gastroenterology and Hepatology.

"This procedure should be considered in children with [chronic pancreatitis] when medical and endoscopic modalities have failed," and may be a better alternative to the current surgical standard of care – partial resection and drainage, wrote the authors.

Dr. Bellin, of the endocrinology division in the department of pediatrics at the University of Minnesota, Minneapolis, studied 19 consecutive children aged 5-18 years who underwent total pancreatectomy with islet autotransplant into the portal vein during 2006-2009 at her institution (Clin. Gastroenterol. Hepatol. 2011 September [doi:10.1016/j.cgh.2011.04.024]).

According to the authors, only three centers around the world have completed more than 50 of these procedures, with the bulk of the experience occurring in the adult population.

All patients had a diagnosis of chronic pancreatitis (CP), and had previously failed medical treatment, endoscopic treatment or both.

With their parents’ help, patients completed the Medical Outcomes Study 36-item short form (SF-36) questionnaire at 1 week before and at 3, 6, and 12 months after surgery, and then annually. The scores range between 0 and 100 and are divided into eight subscales which in turn make up a Physical Component Summary (PCS) and a Mental Component Summary (MCS) score, with higher numbers signifying better health.

At baseline, all patients required narcotics, either on a daily basis (n = 13) or intermittently. All patients had also had multiple hospitalizations for pain management. Two were dependent on jejunal tube feedings and two on total parenteral nutrition. Seven patients also had undergone prior pancreatic surgery at outside institutions.

"Prior to surgery, all patients had below average HRQOL [health related quality of life] based on the SF-36, with a mean PCS score of 30 and a mean MCS score of 34," wrote Dr. Bellin. These scores were equivalent to 2 and 1.5 standard deviations, respectively, below the norm for the U.S. population.

By 1 year, wrote the authors, the PCS improved significantly, to a mean of 50 (P less than .001). Similarly, the MCS improved to a mean of 46, although the increase just missed statistical significance (P = .06). Both postsurgery scores were equivalent to normal HRQOL values in this population.

Looking at postprocedure narcotics use, the authors found that by 1 year, 14 patients had stopped using narcotics for pain management entirely.

"Of the remaining 5 patients, 2 reported rare narcotic use (a few times a year), 1 used tramadol, and 2 used daily narcotics at a reduced dose," they added.

After surgery, all of the patients received insulin initially, with a goal of weaning them off insulin if possible. At a mean of 18 months following the islet graft, seven patients were insulin independent, and four more were reporting minimal insulin use; all of them had hemoglobin A_1c levels less than or equal to 6.5%.

However, the study showed that patients who had undergone prior drainage procedures were more likely to be insulin-dependent (P = .04) and to have variable HbA_1c levels, perhaps necessitating "a paradigm shift in the current management of CP, with avoidance of partial resections without islet autotransplantation and of surgical drainage procedures," recommended Dr. Bellin.

"Although optimal timing of surgery needs to be elucidated, for those who will go on to [total pancreatectomy with islet autotransplantation], earlier surgery may avoid progressive damage to the endocrine pancreas and the hyperalgesia associated with chronic narcotic use," concluded Dr. Bellin.

The authors reported no individual conflicts of interest related to this study, which was supported in part by the National Pancreas Foundation.

Total pancreatectomy with islet autotransplant in pediatric chronic pancreatitis significantly improves quality of life and largely obviates the need for narcotics post procedure, according to a report by Dr. Melena D. Bellin and colleagues in the September issue of Clinical Gastroenterology and Hepatology.

"This procedure should be considered in children with [chronic pancreatitis] when medical and endoscopic modalities have failed," and may be a better alternative to the current surgical standard of care – partial resection and drainage, wrote the authors.

Dr. Bellin, of the endocrinology division in the department of pediatrics at the University of Minnesota, Minneapolis, studied 19 consecutive children aged 5-18 years who underwent total pancreatectomy with islet autotransplant into the portal vein during 2006-2009 at her institution (Clin. Gastroenterol. Hepatol. 2011 September [doi:10.1016/j.cgh.2011.04.024]).

According to the authors, only three centers around the world have completed more than 50 of these procedures, with the bulk of the experience occurring in the adult population.

All patients had a diagnosis of chronic pancreatitis (CP), and had previously failed medical treatment, endoscopic treatment or both.

With their parents’ help, patients completed the Medical Outcomes Study 36-item short form (SF-36) questionnaire at 1 week before and at 3, 6, and 12 months after surgery, and then annually. The scores range between 0 and 100 and are divided into eight subscales which in turn make up a Physical Component Summary (PCS) and a Mental Component Summary (MCS) score, with higher numbers signifying better health.

At baseline, all patients required narcotics, either on a daily basis (n = 13) or intermittently. All patients had also had multiple hospitalizations for pain management. Two were dependent on jejunal tube feedings and two on total parenteral nutrition. Seven patients also had undergone prior pancreatic surgery at outside institutions.

"Prior to surgery, all patients had below average HRQOL [health related quality of life] based on the SF-36, with a mean PCS score of 30 and a mean MCS score of 34," wrote Dr. Bellin. These scores were equivalent to 2 and 1.5 standard deviations, respectively, below the norm for the U.S. population.

By 1 year, wrote the authors, the PCS improved significantly, to a mean of 50 (P less than .001). Similarly, the MCS improved to a mean of 46, although the increase just missed statistical significance (P = .06). Both postsurgery scores were equivalent to normal HRQOL values in this population.

Looking at postprocedure narcotics use, the authors found that by 1 year, 14 patients had stopped using narcotics for pain management entirely.

"Of the remaining 5 patients, 2 reported rare narcotic use (a few times a year), 1 used tramadol, and 2 used daily narcotics at a reduced dose," they added.

After surgery, all of the patients received insulin initially, with a goal of weaning them off insulin if possible. At a mean of 18 months following the islet graft, seven patients were insulin independent, and four more were reporting minimal insulin use; all of them had hemoglobin A_1c levels less than or equal to 6.5%.

However, the study showed that patients who had undergone prior drainage procedures were more likely to be insulin-dependent (P = .04) and to have variable HbA_1c levels, perhaps necessitating "a paradigm shift in the current management of CP, with avoidance of partial resections without islet autotransplantation and of surgical drainage procedures," recommended Dr. Bellin.

"Although optimal timing of surgery needs to be elucidated, for those who will go on to [total pancreatectomy with islet autotransplantation], earlier surgery may avoid progressive damage to the endocrine pancreas and the hyperalgesia associated with chronic narcotic use," concluded Dr. Bellin.

The authors reported no individual conflicts of interest related to this study, which was supported in part by the National Pancreas Foundation.