Background and Aims:
TPIAT is considered in chronic pancreatitis (CP) and recurrent acute pancreatitis (RAP) to mitigate pain and improve quality of life (QOL) when medical and endoscopic therapy fail. Herein, we report the pain and QOL outcomes prospectively collected following TPIAT in the large multicenter POST consortium, and identify predictors for outcome using regression modelling.
Methods:
We included 384 well-phenotyped patients enrolled in POST and undergoing TPIAT for CP and/or RAP at 12 centers. Numeric pain scores, opioid use, and health-related QOL (SF-12) with physical component score (PCS) and mental component score (MCS) were collected at baseline (pre TPIAT), 6 months and 1 year post TPIAT. Multivariate logistic regression was used to estimate associations between baseline characteristics and 1 year outcomes. Depression, anxiety, duration of pancreatitis and the baseline value of the outcome of interest were included as predictors in all models; additional variables were selected based on variable importance measures from random forests.
Results:
Patients were 29.6 years (66% adult/ 34% children), 62% female. Any opioid use in a 14-day period decreased from 61% pre-TPIAT to 32% at 6 months and 24% at 1 year (p<0.001), and daily opioid use decreased from 46% to 24% and 20% respectively (p<0.001). Daily abdominal pain was reported by 65% pre-TPIAT but only 24% at 1 year (p<0.001), while median pain score decreased from 5 (1Q=3, 3Q=6) to 1 (0, 4) (p<0.001). PCS and MCS score improved by ≥5 points in 71% and 45%, by ≥10 points in 54% and 21% respectively. Hospitalizations were reduced (p<0.001), with fewer participants limited in work/school at 1 year (50% pre-TPIAT, 31% post-TPIAT, p<0.001). In multivariate models, pre TPIAT daily opioid use [OR 9.2 (4.2-20.1)], current smoking [OR 4.1 (1.1-14.8)], and former smoking [OR 2.3 (1.1-4.7)] independently predicted higher odds of daily opioid use at 1 year post TPIAT. Genetic disease [OR 1.92 (1.1-3.4)], higher pre TPIAT pain [OR 1.3 (1.1-1.5)] and daily opioid use [OR 0.5 (0.3-0.9)] were independent predictors for ≥50% decreased pain score.
Conclusion:
This is the first prospective multicenter study to establish that TPIAT significantly reduces pain burden and improves quality of life at 1 year. Those participants who were using daily opioids at pre-TPIAT enrollment and who were current or former smokers were most likely to remain on opioids at 1 year, even after adjustment for other variables. These ‘high risk’ patients may need more intensive pain management post-operatively, or alternatively, may be considered for other non-surgical treatment options.

Figure 1 showing reduction in daily opioid use and multivariate model results

Figure 2 showing pain outcomes in children and adults 1 year post TPIAT

Piotr Witkowski

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