Pancreatic islet cell autotransplantation as a therapeutic option in chronic pancreatitis complicated by pancreatic pseudocyst

Abstract

Introduction. In the management of chronic pancreatitis (CP), pancreatic pseudocyst (PCP) is a complication that requires the attention of surgeons, provided that it is non-neoplastic, recurrent, >6 cm in size, persists >4 weeks, has calcifications, causes ductal strictures, is refractory to endoscopic drainage and endoscopic ductal decompression. When CP is complicated by such a PCP, which progressively destroys the parenchyma, total pancreatectomy with pancreatic islet cell autotransplantation (PACT) can be opted for. Objectives. To analyze the relevance of using PACT in patients with PCP who opt for total pancreatectomy, to evaluate the clinical success and post-operative risks. Materials and methods. Research of scientific literature, from electronic databases such as PubMed, Web of Science and ScienceDirect, was conducted for the last decade. Results. ACIP represents the last therapeutic step when all other medical alternatives fail. The nonfunctional pancreas is completely removed, the islets are isolated from the extracted pancreas, and the islets are retransplanted into the portal vein, thus preserving the reserve of insulin and C-peptide secretion . To increase the therapeutic yield, it is necessary to comply with several clinical conditions: severe CP, basal glycemia <200 mg/dL, HbA1c <8%, islet-positive patient, age <60 years, absence of terminal diseases and advanced cirrhosis. The major contraindication is the presence of type 1 diabetes, since there is a risk of immune rejection of the islet transplant. Post-ACIP results are promising with clinical improvement of up to 90%. Beneficial effects include: reduced risk of insulin dependence and avoidance of severe hyperglycemia, maintenance of normal HbA1c for at least 12 months, pain relief and opioid withdrawal (59%), and total insulin independence when IEQ/kg > 5000 (48%). Post-ACIP risks include: endocrine morbidity (18.6%), postoperative hemorrhage (10%), exocrine symptoms (43.5%), postpancreatectomy pancreatogenic diabetes (<1%), portal vein thrombosis (5%) and mortality (1.6%). Perioperative morbidity is 50%, with the need for surgical reintervention in 16% of patients. Conclusions. ACIP offers an advantageous therapeutic combination for patients with pancreatic complications, such as PCP: it relieves pain, allows preservation of endocrine function and the perioperative risk is minimal.