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Physician Update - No pancreas?
Date: June 15, 2012
Last summer, Hopkins began offering islet autotransplants for men and women with intractable chronic pancreatitis. It’s a path worth walking, say the patients who, despite removal of the entire pancreas, can now produce insulin.
The new capability makes The Johns Hopkins Hospital the Northeast’s high volume center for islet autotransplants.
“For certain patients, a total pancreatectomy is their last option to escape the lasting, severe pain of chronic pancreatitis,” says Vikesh Singh, medical director of the islet autotransplant program. “And while we can indeed replace digestive enzymes that the body no longer secretes without a pancreas, compensating for the lost islets is another story.” The “brittle diabetes” that can result resists control.
Fortunately, recent research has refined the ability to isolate living islets from a damaged pancreas and raise their survival after transplant to the liver.
“And we found ourselves with a happy confluence of expertise and support,” says Singh, gastroenterologist for the team that includes pancreatic surgeons, transplant surgeons, cell biologists, endocrinologists and pain specialists.
Choosing patients for both pancreatectomy and transplant is complicated. In his role as “selector,” Singh must, for example, carefully assess how advanced the disease is—no simple matter when biopsy of the pancreas, with its risks, is rarely an option. “There’s a fine balance point,” Singh says. “You want to remove a pancreas because there’s pain. But you hesitate to take out an organ with mostly good function. Yet wait too long and there’s nothing to transplant. In the long run, we do a lot of evaluating, most of it as a team.”
“We bring a rich experience to treating pancreatitis,” says pancreatic surgeon Martin Makary, the program’s surgical director. Makary and his surgical team perform some 400 pancreas operations a year, more than any hospital worldwide. Having introduced a laparoscopic version of the Whipple procedure to Hopkins, he’s readying a minimally invasive total pancreatectomy to pair with the islet transplants.
Once a pancreas is removed, Makary explains, the transplant surgery team performs “a massive laboratory endeavor”—within the OR—to retrieve its islets. A good harvest is crucial, as transplanted islet cells no longer reproduce. Once Makary injects them via catheter into the liver, they’re free to set up shop.
“A lot of our patients whose lives were on hold are able to return to their jobs,” Singh says. “It made my day when a patient called to tell me, I ate a grilled cheese sandwich for the first time in years!”
410-502-2650 to refer a patient.