Background & Aims

Chronic pancreatitis (CP) is a condition characterized by severe abdominal pain that is often difficult to manage. In the United States, CP poses a significant cost burden estimated at 3.7 billion dollars per year [1], and the incidence of CP is increasing [2]. Chronic abdominal pain secondary to CP is thought to be of both neuropathic and inflammatory etiologies [3]. Treatment options include medications, endoscopic intervention, surgical intervention. Total pancreatectomy with islet cell transplantation provides a definitive treatment but is associated with increased mortality and risk of insulin dependence [4]. Targeted Drug Delivery (TDD) is a relatively new alternative therapy in CP patients. There are very few studies that evaluated its use in CP patients, and none looked at long term outcomes. The purpose of current study was to perform a retrospective review of CP patients treated with TDD versus Oral Opioid Therapy (OOT) to evaluate long term pain control and opioid use.

Methods

Institutional Review Board approval was obtained. Patients receiving TDD for chronic abdominal pain secondary to CP were included. Patients who had at least 50% pain relief with intrathecal trial underwent pump implantation. All patients were weaned off oral opioids 1 week prior to intrathecal trial and intrathecal catheter and pump implantation. Data were collected while on OOT and at 2 weeks, 3 months and 9 months post-implant. Data were analyzed with Microsoft Excel 365 MSO using means and standard deviations. P-values were calculated using a two tailed student’s t-test which was paired two sample for means.

Results

Twenty-three patients were included in the study. Pre-trial average pain score was 6.5/10 which improved by greater than 71% with intrathecal trial. Mean MME was 188 on OOT and significantly decreased at all timepoints on TTD: 0.36 at 2 weeks, 1.39 at 3 months, and 2.47 at 9 months with respective p-values of 0.000495, 0.00052, 0.0048. Mean pain scores at 2 weeks, 3 months, and 9 months were 6, 4.9, and 5.6 respectively with P-values of 0.048, 0.003 and 0.096 respectively in comparison with mean pain scores on OOT. Pump medicine was changed for 4 patients; 1 switched from morphine to hydromorphone, 2 switched from hydromorphone to morphine, and 1 switched from hydromorphone to fentanyl due to various reasons including allergic reaction, intolerance or inadequate pain relief. Complications were present in 4 patients. Three patients had a post-dural puncture headache, and 1 required a blood patch. There were 2 revisions: 1 for pocket irritation and 1 for catheter migration.

Conclusions

This study constitutes the largest study investigating efficacy and safety of TDD in patients with chronic pancreatitis. Targeted drug delivery provides improved pain control with significantly lower opioid dose and is an effective treatment in patients who have failed multiple treatment modalities including medications and surgical interventions for treatment of chronic abdominal pain secondary to chronic pancreatitis.

References

1.Everhart J. E., Ruhl C. E.: Burden of digestive diseases in the United States Part III: Liver, biliary tract, and pancreas. Gastroenterology. 2009, 136:1134-1144. 10.1053/j.gastro.2009.02.038
2.Yadav D., Timmons L., Benson J. T., et. al: Incidence, prevalence, and survival of chronic pancreatitis: a population-based study. Am J Gastroenterol. 2011, 106:2192-2199. 10.1038/ajg.2011.328
3.Drewes A., Bouwense S., Campbell C., et al.: Working group for the International Consensus Guidelines for Chronic, Pancreatitis. (2017). Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology. 2017, 17:720-731. 10.1016/j.pan.2017.07.006
4.Mokadem M., Noureddine L., Howard T., et al.: Total pancreatectomy with islet cell transplantation vs intrathecal narcotic pump infusion for pain control in chronic pancreatitis. World J Gastroenterol. 2016, 22:4160-4167. 10.3748/wjg.v22.i16.4160

Presenting Author

Raheleh Rahimi Darabad

Poster Authors

Raheleh Rahimi Darabad

MD

Indiana University

Lead Author

E-mail

Topics

  • Treatment/Management: Interventional Therapies – Intrathecal Drug Delivery