Faculty Bibliography

BACKGROUND:In selected patients, total pancreatectomy with islet autotransplantation (TPIAT) effectively relieves pain caused by chronic pancreatitis and ameliorates the brittle diabetes of the apancreatic state. Patients often undergo multiple endoscopic and surgical interventions prior to TPIAT, increasing the risk for pancreas colonization with enteric microorganisms. Little is known of the safety of transplanting islet cells with microbial contamination. METHODS:A prospectively collected database of 80 patients submitted to TPIAT at the Medical University of South Carolina from March 2009 to February 2012 was retrospectively reviewed. Patient charts were reviewed for postoperative infectious complications and organisms identified were compared with those identified in pre-transplant islet cultures. RESULTS:A total of 35 patients (43.8%) had a positive pre-transplant islet cell Gram stain or islet cell culture from the final islet preparation solution. Of these 35 patients, 33 (94.3%) were given antibiotics prophylactically post-transplant for a positive islet Gram stain or culture. Twenty patients (57.1%) receiving Gram stain- or culture-positive islets developed postoperative infectious complications, but only four patients (11.4%) developed infections that concorded with their pre-transplant islet product. CONCLUSIONS:Islet transplant solutions are frequently culture-positive, presumably as a result of prior pancreas intervention. Microbial contamination of islet preparations should not preclude autotransplantation.

Previous studies have shown that total pancreatectomy with islet cell autotransplantation improves quality of life in chronic pancreatitis. A significant number of these patients develop postoperative hyperglycemia and daily insulin requirements or increase in daily insulin requirements. Our study investigates whether increased insulin requirements postoperatively have a negative impact on quality of life. A prospectively collected database of 74 patients undergoing extensive pancreatectomy with islet autotransplantation for pancreatitis was reviewed. Data pertaining to daily requirements and quality of life (QOL), as measured by the SF-12 questionnaire, in the preoperative and postoperative period were reviewed. Approval from the Institutional Review Board for the evaluation of human subjects was obtained. Seventy-four patients underwent extensive pancreatectomy with islet autotransplantation for pancreatitis. The majority of these patients required new daily insulin or an increase in daily insulin requirements postoperatively. Mean preoperative HA1c in this group was 5.6 with an increase to 7.3 at 6 months postoperatively (P < 0.001), a mean of 8.1 at 12 months, and 8.9 at 2 years. Mean preoperative daily insulin requirements for this group were five units/day with average increase to 19 units/day at 6 months, 21 units/day at 12 months, and 26 units/day at 2 years. Preoperative QOL scores were a mean of 26 for the physical component and 36 for the mental health component. Postoperatively, physical component scores averaged 33 at 6 months (p < 0.001), 36 at 12 months, and 36 at 2 years; the mental health component scores averaged 42 at 6 months (p = 0.007), 41 at 12 months, and 41 at 2 years. There is no correlation between physical component score or mental component score QOL scores and daily insulin requirements (r = -0.016 and r = 0.039, respectively). Total pancreatectomy with islet cell autotransplantation is an effective surgery for end-stage chronic pancreatitis. Quality of life significantly improves in physical and mental health components regardless of a postoperative increase in daily insulin requirements.

BACKGROUND:Pain is common and multifactorial among patients with chronic pancreatitis. Underrecognized and undertreated psychosocial comorbidity can exacerbate pain experience. Excess inpatient service utilization within this patient population prompted a performance improvement initiative at a large academic medical center. METHODS:An interprofessional treatment approach with programmatic medical, surgical, and psychological and psychiatric interventions was rolled-out in January 2007 and length of stay (LOS) was measured on a quarterly basis for a 2-year period. Trends in resource utilization (LOS, estimated opportunity costs) were assessed with a novel modified bootstrapping technique, Simulation Modeling Analysis (SMA). RESULTS:From January 1, 2007, through December 31, 2008, SMA revealed a linear downward trend in LOS (ρ = -0.857, p = .0170), and the interprofessional treatment approach was associated with estimated opportunity cost savings of $670,750.27. There were no associated changes in 7-, 14-, and 30-day readmission rates, p > .05. CONCLUSION/CONCLUSIONS:Interprofessional care that combines behavioral approaches to pain management; behavioral contingency management for opioid medication management; psychological and psychotropic treatments for depression, anxiety, and addiction in addition to standard medical and surgical treatments for pancreatitis appears to be associated with lower healthcare costs. Future research should examine patient reported outcomes of this model.

BACKGROUND:Total pancreatectomy with islet autotransplantation (TP-IAT) is safe and effective in the management of intractable pain associated with chronic pancreatitis (CP). Prevention of pancreatogenic diabetes after TP-IAT is related to islet yield from the diseased pancreas. The purpose of this study is to compare islet yield and insulin requirement in the 76 patients who underwent different surgical procedures before TP-IAT at the Medical University of South Carolina between 2009 and 2011. METHODS:Patients were grouped into four categories based on the operation they had before TP-IAT: transduodenal sphincteroplasty/no prior surgery (n=50), Whipple or Beger procedure (n=14), distal pancreatectomy (n=8), or lateral pancreaticojejunostomy (n=4). Islets were harvested from pancreases of those patients at our current good manufacturing practice facility. Total unpurified islets were transplanted into patients via portal vein infusion. Pancreatic fibrosis, islet yield, cell viability, and insulin requirement were measured. RESULTS:The pancreases of transduodenal sphincteroplasty/no prior surgery and Whipple or Beger procedure patients were less fibrotic and had higher islet yield compared with those who had distal pancreatectomy or lateral pancreaticojejunostomy. Higher islet yield also correlated with a greater diabetes-free rate and a lesser insulin requirement at the following intervals: preoperative, postoperative, and 6 months after TP-IAT. CONCLUSIONS:Prior surgery is strongly correlated with the extent of pancreatic fibrosis, islet yield, and insulin requirements in CP patients undergoing TP-IAT. The history of prior pancreatic resection and drainage procedures may be used to predict postoperative islet function and help to determine the optimal timing for TP-IAT in CP patients.

Chronic pain and obesity are significant public health concerns in the United States associated with significant levels of health-care expenses and lost productivity. Previous research suggests that obesity is a risk factor for chronic pain, mainly due to excessive weight placed on the joints. However, the obesity-pain relationship appears to be complex and reciprocal. Little work to date has focused on the relationship between weight and pain among patients undergoing gastric bypass surgery for weight loss. Patients scheduled to undergo bariatric surgery for weight loss at a large southeastern academic medical center (N = 115) completed the Brief Pain Inventory (BPI), the Center for Epidemiological Studies 10-item Depression scale (CESD-10), and the Beck Anxiety Inventory (BAI). Higher presurgical weight was associated with higher pain-on-average ratings, higher functional impairment due to pain across the domains of physical activity, mood, walking ability, relationships, and enjoyment of life. Higher presurgical weight was associated with higher BAI scores, but weight was not related to depression. Findings suggest that bariatric surgery candidates report a moderate amount of pain prior to surgery and that presurgical weight is associated with higher pain, increased functional impairment due to pain, and increased anxiety. Anxiety was found to mediate the relationship between increased weight and pain.

Total pancreatectomy with immediate islet autotransplantation (IAT) can be an effective therapy in patients with chronic pancreatitis. Patient selection criteria for radical resection are not well defined. The impact of prior pancreatic surgery on quality of life outcomes in patients undergoing IAT is evaluated. A retrospective review of a prospectively collected database of patients undergoing pancreatectomy with islet autotransplantation was undertaken. Patients having undergone prior pancreatic resection and/or drainage procedures were compared with those without prior pancreatic operative history. Sixty-one patients underwent pancreatectomy with IAT for pancreatitis. Twenty-three patients had a prior history of pancreatic surgery (Group S); 38 had no prior history of pancreatic surgery (Group NS). Demographics between the groups were similar. Patients in Group S took more daily oral morphine equivalents and had a lower psychological quality of life preoperatively. Operative times and blood loss were similar between the patient groups. Islet yields were lower for patients in Group S. Postoperatively, daily insulin requirements at 6 months and 1 year trended higher in Group S. Postoperative quality of life scores at 6 months were improved and similar between the groups. Quality of life metrics continued to improve beyond 1 year of follow-up, with a trend toward greater improvement in the NS Group. Total pancreatectomy for chronic pancreatitis improves quality of life in patients with and without a prior history of pancreatic surgery. This study demonstrates that IAT without preceding pancreatic surgery may enhance outcomes measured by long term insulin requirements and quality of life.

INTRODUCTION/BACKGROUND:In selected patients with chronic pancreatitis, total pancreatectomy with islet autotransplantation can be effective for the treatment of intractable pain while ameliorating postoperative diabetes. Improved quality of life scores and decreased daily narcotic use, as indicators of successful pain relief, are expected after total pancreatectomy. These outcomes and their relationship have not been well examined in this patient group. METHODS:A prospectively collected database of patients undergoing extensive pancreatectomy with islet autotransplantation for pancreatitis was reviewed. Data pertaining to daily oral morphine equivalents (MEs) and quality of life (QOL), as measured by the SF-12 questionnaire, in the preoperative and postoperative period were reviewed. Approval from the IRB for the evaluation of human subjects was obtained. RESULTS:Over a 20-month period, 33 patients (25 women, median age 42) underwent extensive pancreatectomy with islet autotransplantation for pancreatitis. Mean follow-up was 9 months with a range of 6-12 months. Postoperative complications occurred in 16 patients (48%). Preoperative QOL scores were a mean 25 for physical component and 32 for mental health component. Postoperatively, physical component scores averaged 33 at 6 months (p = 0.025) and 36 at 12 months (mean increase of 11); the mental health component scores averaged 43 at 6 months (p = 0.007) and 44 at 12 months (mean increase of 12). Preoperative MEs averaged 357 mg daily. At discharge from the hospital, this number increased to 536 mg average MEs daily, a 50% increase, as expected after major surgery in the chronic pain patient. At 6 months, 15 out of 31 patients (48%) required less daily MEs than preoperatively and averaged 161 mg daily (-55%). By 12 months, 11 out of 17 patients (65%) required less daily MEs than preoperatively and averaged 128 mg daily (-64%); four were narcotic-free (23%). Of the six patients who did not decrease their analgesic requirements at 1 year, five (83%) still had an improved physical QOL score (one patient was unchanged) and all six had an improved mental health QOL. CONCLUSION/CONCLUSIONS:Total pancreatectomy with islet autotransplant is an effective surgery for end-stage chronic pancreatitis. Quality of life improves early postoperatively while decreased narcotic analgesia requirements occur later. Both improved quality of life and decreased narcotic analgesia requirements continue to occur at least up to 1 year postoperatively. Further investigation is needed to assess the durability of total pancreatectomy with islet autotransplantation for severe chronic pancreatitis with respect to pain relief and improved quality of life.

BACKGROUND:Hemoglobin A1c (HbA1c) is a reliable marker for long-term glycemic control in obese diabetic patients. Roux-en-Y gastric bypass improves HbA1c levels over time. However, it is not clear whether the preoperative HbA1c level is a predictor of the outcome in these patients. Our objectives were to understand the predictive capacity of the preoperative HbA1c level in gastric bypass patients at a single university-based Bariatric Center of Excellence. METHODS:We performed a retrospective review of 468 charts from 2006 to 2009 of patients who had undergone Roux-en-Y gastric bypass. Using their preoperative HbA1c status, the patients were categorized and the postoperative outcomes compared. RESULTS:Of the 468 patients reviewed, 310 (66.2%) had a HbA1c of <6.5% (group 1), 92 (19.4%) had a HbA1c of 6.5-7.9% (group 2), and 66 (14.1%) had a HbA1c level of >8.0% (group 3). No difference was found among the 3 groups in baseline body mass index, race, procedure type, length of stay, hospital cost, and smoking status. Groups 2 and 3 were associated with older age, male gender, and higher baseline creatinine. Groups 2 and 3 also had a proportionally greater inpatient postoperative blood glucose level. An elevated postoperative glucose level was independently associated with wound infection (P = .008) and acute renal failure (P = .04). Also, group 3 experienced worse outcomes, including less weight loss at 18 months and fewer diabetic remissions. Over time, however, the vast majority in all groups achieved excellent chronic glycemic control, with HbA1c <6.5% after Roux-en-Y gastric bypass. CONCLUSION/CONCLUSIONS:Poor preoperative glycemic control is associated with worse glucose level control postoperatively, fewer diabetic remissions, and less weight loss. An elevated mean postoperative glucose level is independently associated with increased morbidity.

Objective. The present study was conducted to determine if depressive symptoms were associated with variability in pain perception and quality of life among patients with nonalcohol-related chronic pancreatitis. Methods. The research design was cross-sectional, and self-report data was collected from 692 patients with nonalcohol-related, intractable pancreatitis. The mean age of the sample was 52.6 (SD = 14.7); 41% of the sample were male. Participants completed the MOS SF12 Quality of Life Measure, the Center for Epidemiological Studies 10-item Depression Scale (CESD), and a numeric rating scale measure of "pain on average" from the Brief Pain Inventory. Results. Depressive symptoms were significantly related to participants' reports of increased pain and decreased quality of life. The mean CESD score of the sample was 10.6 (SD = 6.5) and 52% of the sample scored above the clinical cutoff for the presence of significant depressive symptomology. Patients scoring above the clinical cutoff on the depression screening measure rated their pain as significantly higher than those below the cutoff (P < 0.0001) and had significantly lower physical quality of life (P < 0.0001) and lower mental quality of life (P < 0.0001). Conclusion. Although causality cannot be determined based on cross-sectional, correlational data, findings suggest that among patients with nonalcoholic pancreatitis, the presence of depressive symptoms is common and may be a risk factor associated with increased pain and decreased quality of life. Thus, routine screening for depressive symptomology among patients with nonalcoholic pancreatitis may be warranted.