Intrathecal Narcotic Infusion Pumps (ITNP) for Intractable Chronic Pancreatitis Pain: A Larger Pilot Series

Abstract

Introduction: Pain management remains the largest clinical problem for many chronicpancreatitis (CP) patients. Escalating narcotic requirements often make the clinicianseek alternatives such as pancreas rest via jejunal feedings, surgical pancreaticdenervation or pancreatectomy. Intrathecal narcotics pump (ITNP) is an alternative which offers the advantages of 1) reversibility; 2) lower total narcotic dose; 3) pancreas remainsintact. Aim: We herein report our experience with 13 such patients. Methods: 13 CP patients (F 8, M 5) (mean age 40.62 ± 9.62 yrs) (etiology idiopathic 3, cystic fibrosis 2, alcoholic 2, pancreas divisum 6) with intractable upper abdominal pain, daily narcotic use, frequent hospitalizations and failed pain relief with jejunal feedings and ERCP sphincter therapy were offered ITNP after a successful temporary intrathecal block. An intrathecal catheter was placed at L2-L3 interspace and subcutaneous pump placed in lower abdomen. Results: Median pain period prior to ITNP was 6 years (2-22 years). ITNP median follow up time period was 739 days (range 68-3096 days). Median duration of ITNP in situ was 739 days (range 16-2523 days). Median narcotic dose before ITNP: 405 morphine equivalent mg per day (range 67.5-1320); median and mean narcotic dose after ITNP: 0.0 and 28.9 mg per day, respectively (range 0-180) (p value < 0.001). Global pain score (0-10) before and after ITNP was 8.2 (± 1.3) and 2.5 (± 2.1), respectively (p value < 0.001). For the 12 evaluable patients, one patient was able to work prior and after ITNP; 9 patients are unemployed after ITNP but perform most daily activity or work at least part time; 2 additional patients were able to work full time after ITNP. Major complications were: CNS infection requiring pump removal (1), CSF leak requiring laminectomy (1) and perispinal abscess requiring pump removal (1). Minor complications were: catheter displacement (1), pump displacement (1) (both repositioned via surgery) and incisional infection (1). No patient developed diabetes or worse steatorrhea. Four pumps were removed (and 3 replaced) for pump expiration after 4, 6, 7 and 7 years. Summary: In this pilot series, ITNP use in CP patients with high narcotic requirement and intractable pain resulted in improved pain control and much less daily narcotic use. Nearly all patients had improvement in performance of daily activities. Major complications occurred in 3/13 requiring pump removal in 2/13. Conclusions: ITNPs are an acceptable alternative for CP patients with high narcotic requirements and intractable pain and frequent hospitalization.