Improving on Pancreatectomy

Beth Schrope, MD, PhD | Photo Jörg Meyer

The pancreas, tucked discretely between the stomach and the spine, does not get much attention—until something goes wrong. For people with pancreatitis, a noncancerous inflammation of the tiny ducts within the 6-inch organ, the discomfort can be devastating.

“Patients describe unrelenting pain in the abdomen and back that’s exacerbated by eating, so they’re often malnourished as well,” says Beth Schrope, MD, PhD, assistant professor of surgery. “Many can’t work or enjoy a normal life because of the significant narcotics they take to control the pain.”

In certain cases, it may be appropriate for a patient to undergo a total pancreatectomy, removal of the entire pancreas, but the surgery comes with a high cost. “We only recommend it if the condition has made the patient’s life intolerable,” says Dr. Schrope, who dedicates half of her clinical time to patients with pancreatitis and pancreatic cancer. “More than 90 percent get major, if not entire, relief of their symptoms, but some say that they are trading one disease for another—painful, debilitating pancreatitis for insulin-dependent diabetes. The latter is manageable, and livable, especially with new advances, but obviously not ideal.”

Removal of the pancreas necessarily eliminates the islet cells nestled deep within the organ that manufacture insulin and glucagon, the hormones that regulate blood sugar. The form of disease that develops after pancreatectomy—known as brittle diabetes—can be particularly challenging to control. “Because of the loss of glucagon, the counterregulatory hormone, people with brittle diabetes can lack an ability to sense the low blood sugar caused by the absence of insulin,” says Dr. Schrope. “It can lead to coma, seizures, and death. Many say the quality of life improvement associated with a pancreatectomy far outweighs the long-term challenges of managing diabetes, but it is a last-ditch effort.”

Dr. Schrope and her team are using autologous islet cell transplants to improve the outcomes of a pancreatectomy. During an autologous transplant, the pancreas is removed as it is in a pancreatectomy. While the patient is still anesthetized, the Cell Therapy Laboratory staff of NewYork-Presbyterian Hospital and the Department of Pathology & Cell Biology isolate the islet cells from the patient’s own pancreas and return them to the operating room. There, Dr. Schrope and her team infuse the cells into the patient’s liver. Within weeks to months of the procedure, the patient’s islet cells—now in the liver—should resume insulin production. More than one-third of patients can forgo insulin injections entirely, while another third are able to significantly reduce their dependence on injections.

The first transplant at NewYork-Presbyterian/Columbia was done in April 2014. Of two patients who have undergone the procedure, both are making insulin and one has been able to forgo insulin injections. “The first patient waited for us to do the procedure because his insurance only allows treatment in New York state,” says Dr. Schrope. Becoming insulin-dependent—a certainty with conventional pancreatectomy—would have put him on permanent disability. He waited to schedule his pancreatectomy until he could have the autologous islet cell transplant.”

Dr. Schrope and her team plan to continue to refine autologous islet cell transplants and investigate the procedure’s promise for patients at high risk for developing pancreatic cancer. “The best way to treat cancer is to prevent it. Among patients in whom we identify high risk of cancer, perhaps total pancreatectomy followed by autologous islet cell transplant will prove appropriate as a prophylactic treatment.”

Dr. Schrope is a member of Columbia’s Pancreas Center, which is directed by John A. Chabot, MD, the David V. Habif Professor of Surgery at CUMC.