Background. Surgical resection of the pancreas is considered a final resort in the treatment of chronic pancreatitis. However, the opportunity to perform an islet autotransplant at the same time provides the potential to prevent the onset of diabetes.
Methods. Pancreatectomy together with islet autotransplantation has been offered in our center since 1994. A total of 40 patients have now undergone this procedure. The follow-up times range from 6 months to 7 years. The data presented here include the annual postoperative oral glucose tolerance test and glycosylated hemoglobin (HbA1c) results, together with insulin and opiate requirements.
Results. Nineteen male and 21 female patients (median age 44, range 21-65) have been transplanted. Pancreatitis was related to alcohol in 45% and was idiopathic in 40%. A median of 130,108 (24,332-1, 165,538) islet equivalent (IEQ) were transplanted, which related to 2,020 (320-23,311) IEQ per kilogram of body weight. At 2 years posttransplant, 18 patients had a median HbA1c of 6.6% (5.2-19.3%), fasting C-peptide of 0.66 ng/mL (0.26-2.65 ng/mL), and required a median of 12 (0-45) units of insulin per day. At 6 years, these figures were 8% (6.1-11.1%), 1.68 ng/mL (0.9-2.78 ng/ml) and 43 U/day (6-86 U/day), respectively. The majority of patients no longer require opiate analgesia, 68% have been able to return to work, and one patient has had a baby.
Conclusions. Islet autotransplantation offers a valuable addition to surgical resection of the pancreas, as a treatment for chronic pancreatitis; and even in cases in which insulin independence is not achieved, the potential beneficial effects of C-peptide make the procedure worthwhile.
The problematic clinical course of chronic pancreatitis (CP) and the final resort of surgical resection of all or part of the pancreas have been previously documented (1,2). One of the major disadvantages with pancreatectomy is that the patient will become diabetic if a total resection is performed or may be at risk of developing diabetes following partial resection. However, it should also be taken into consideration that a relatively high proportion of patients with CP will go on to develop diabetes, with various studies quoting between one third to one half of CP patients developing either insulin-dependent diabetes mellitus (IDDM), noninsulin-dependent diabetes mellitus (NIDDM), or impaired glucose tolerance (IGT) (3-5).
Diabetes associated with pancreatic resection is termed pancreatogenic diabetes and differs from the symptoms normally associated with IDDM and NIDDM in that ketoacidosis is infrequent, hypoglycemia is common, and control of normal blood glucose levels is difficult (6). In addition, this type of diabetes is associated with the loss of glucagon and pancreatic polypeptide (PP) secreting cells, both present in the islets of Langerhans and which have a role in maintaining glucose homeostasis. Because of the destructive nature of CP, the loss of glucagon and PP secretion means that the type of diabetes that develops in CP is similar to that following pancreatic resection (7).
The potential severity of the problems following pancreatic resection requires these problems to be weighed against the benefits that pancreatic resection can provide for CP patients. These include improved quality of life, the eradication or reduction of previously intractable pain, weight gain caused by being able to eat normally, and a reduction in the number of hospital admissions. However, the option of offering islet autotransplantation (IAT) to patients undergoing total or partial pancreatectomy, in center where there are facilities for islet isolation, provides the potential to prevent the onset of diabetes (2,8,9). It has also been reported that transportation of the pancreas to an islet-isolation laboratory at a distant location allows IAT to be undertaken when such services are not available on site (10).
IAT has been undertaken in our center since 1994. A total of 40 patients have now completed this form of treatment, with 7-year follow-up data becoming available for some of these individuals. A previous publication from this group has given details of the nature of the operation undertaken in this center (9), and the purpose of this article is to concentrate on the follow-up data relating to posttransplant islet function.