Endocrine Abstracts

Total pancreatectomy for chronic pancreatic pain is often deferred because it leaves the patient with unstable insulin-dependent diabetes. NICE (2008) has recently approved pancreatectomy with simultaneous islet autotransplantation and we here describe our first case. A 49-year-old female with a 6-year history of intractable, opioid requiring abdominal pain had become depressed to the point of suicide attempts. Imaging showed pancreatic atrophy and duct irregularity (subsequent histology confirmed exocrine acinar atrophy and fibrosis). Glucose levels were normal (HbA1C=5.2%) and glucagon stimulation showed adequate β-cell function (C-peptide 1046 nmol/l basally, 2572 at 6 min). A total pancreatectomy was performed with simultaneous splenectomy. Following pancreatic digestion with Serva collagenase and neutral protease, 433 000 islet equivalents were infused into the portal system via the umbilical vein. Postoperatively, she was given oxygen, tinzaparin and insulin. She was discharged 2 weeks post-transplant with greatly reduced pain. However, 4 days later, she developed right upper quadrant pain and vomiting. Platelets had risen to 1000×10⁹/l and a CT scan demonstrated partial portal vein thrombosis. She was anticoagulated with heparin, followed by warfarin for 6 months. C-peptide levels rose transiently within 1 h post-transplant, probably due to release from dying β-cell, fell to undetectable levels by day 3 but a glucagon stimulation test at 4 months demonstrated basal and stimulated C-peptide levels of 357 and 540 pmol/l respectively indicating satisfactory β-cell engraftment. Her glycaemic control was stabilised on small amounts of insulin. A real time subcutaneous glucose sensor showed stable glucose levels as seen in Type 2 diabetes and insulin is being gradually replaced by exenatide. Our patient underwent successful simultaneous pancreatectomy and islet autotransplantation resulting in satisfactory pain relief and stable glycaemia. This procedure should be considered earlier in the course of painful chronic pancreatitis. However, if the spleen has to be removed, portal vein thrombosis due to the consequent thrombocythaemia is a risk.