P APERS OF THE 134TH ASA ANNUAL MEETING Long-Term Outcomes After Total Pancreatectomy and Islet Cell Autotransplantation Is It a Durable Operation? Gregory C. Wilson, MD, ∗ Jeffrey M. Sutton, MD, ∗ Daniel E. Abbott, MD, ∗ Milton T. Smith, MD,† Andrew M. Lowy, MD,¶ Jeffrey B. Matthews, MD,|| Horacio L. R. Rilo, MD, ∗∗ Nathan Schmulewitz, MD,† Marzieh Salehi, MD,‡ Kyuran Choe, MD,§ John Brunner, RN, ∗ Dennis J. Hanseman, PhD, ∗ Jeffrey J. Sussman, MD, ∗ Michael J. Edwards, MD, ∗ and Syed A. Ahmad, MD ∗ Objective: Total pancreatectomy and islet cell autotransplantation (TPIAT) has been increasingly utilized for the management of chronic pancreatitis (CP) with early success. However, the long-term durability of this operation remains unclear. Methods: All patients undergoing TPIAT for the treatment of CP with 5-year or greater follow-up were identified for inclusion in this single-center obser- vational study. End points included narcotic requirements, glycemic control, islet function, quality of life (QOL), and survival. Results: Between 2000 and 2013, 166 patients underwent TPIAT; 112 of these patients had 5-year follow-up data to analyze. All patients underwent successful IAT with a mean of 6027 ± 595 islet equivalents per body weight. There was no perioperative mortality and actuarial survival at 5 years was 94.6%. The narcotic independence rate at 1 year was 55% and continued to improve to 73% at 5-year follow-up (P < 0.05). The insulin independence rate declined over time (38% at 1 year vs 27% at more than 5 years), but insulin re- quirements remained similar (21.4 vs 24.3 units per day, P = 0.6). All patients achieved stable glycemic control with a median hemoglobin A 1C (HgA 1C ) of 6.9% (range: 5.85%–8.3%). The short form 36-item QOL assessment of a subset of patients available for contact demonstrated continued improvements in all tested modules in patients with at least 5-year follow-up. Two patients developed diabetic complications requiring whole organ pancreas transplant for salvage. Conclusions: This represents one of the largest series examining long-term outcomes after TPIAT. This operation produces durable pain relief and im- provement in QOL parameters. Insulin independence rates decline over time, but most patients maintain stable glycemic control. Keywords: chronic pancreatitis, insulin independence, islet cell autotrans- plantation, long-term outcomes, narcotic independence, total pancreatectomy, TPIAT (Ann Surg 2014;260:659–667) From the Departments of ∗ Surgery, †Gastroenterology, ‡Endocrinology, §Radiology, University of Cincinnati Medical Center; ¶Department of Surgery, University of California San Diego School of Medicine; ||Department of Surgery, University of Chicago Medical Center; and ∗∗ Department of Surgery, University of Arizona Medical Center. Presented at the 2014 Annual Meeting of the American Surgical Association, Boston, MA. Disclosure: No funding was received in support of this work. The authors declare no conflicts of interest. Reprints: Syed A. Ahmad, MD, Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH 45219. E-mail: ahmadsy@ucmail.uc.edu. Copyright C  2014 by Lippincott Williams & Wilkins ISSN: 0003-4932/14/26004-0659 DOI: 10.1097/SLA.0000000000000920 T he clinical presentation of chronic pancreatitis (CP) can vary with respect to the degree of exocrine and endocrine manifestations, but most CP patients seek medical attention for symptoms of debili- tating abdominal pain. Clinical management of these patients can be quite complicated, as the degree of pain does not always correlate with the morphologic abnormalities demonstrated on radiographic imaging. Furthermore, a multidisciplinary approach incorporating the expertise of several specialists is often necessary for the optimal medical management of these patients. Over time, approximately 50% of patients develop progres- sive symptoms and require additional surgical intervention. 1 Most patients can be managed with traditional operations such as a pan- creaticoduodenectomy, duodenal sparing head resections, or decom- pressive procedures. 2,3 A subset of patients, however, suffer from CP in the absence of demonstrable main duct pathology, have relapsing recurrent acute pancreatitis, or have established dysgenetic causes of their pancreatitis. These patients have minimal benefit or fail to re- spond to pancreatic resections or drainage procedures. Over the last decade, these latter groups are now increasingly considered for total pancreatectomy and islet cell autotransplantation (TPIAT). Historically, this operation has been considered a nontradi- tional option for the management of CP. In the modern era, however, this therapy is part of the treatment algorithm for the properly selected patient, as evidenced by the growing number of centers devoting con- siderable resources toward the development of TPIAT programs. 4–6 The rationale behind this operation is that by removing the inciting organ and its inflammation, and in the process preventing type 3c diabetes by transplanting the patient’s own islet cells into the liver, pain and narcotic dependence can be minimized while also prevent- ing the risk of cancer development. Many institutions have reported short-term results, detailing pain relief, quality of life (QOL), and in- sulin independence. 4–6 Few reports document long-term results after TPIAT, which primarily focus on endocrine function but do not con- centrate on narcotic requirements or QOL parameters. 7 These latter 2 outcomes are critical metrics in comprehensively assessing success after TPIAT. Therefore, we undertook this study to evaluate long-term outcomes in our cohort of patients undergoing TPIAT for treatment of CP. METHODS Patient Selection This study was approved by and performed according to the guidelines outlined by the University of Cincinnati institutional re- view board. The University of Cincinnati Pancreatic Disease Cen- ter patient database was queried to identify all patients undergoing TPIAT from 2000 to 2013. Before surgical intervention, all patients were previously diagnosed with CP after a thorough multidisciplinary team evaluation that included gastroenterology, endocrinology, Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Annals of Surgery  Volume 260, Number 4, October 2014 www.annalsofsurgery.com | 659