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Background/Aims
Total pancreatectomy with islet auto-infusion (TP + IAI) is effective in selected patients with chronic pancreatitis (CP) who have intractable pain unresponsive to medical and interventional therapies. IAI can maintain adequate glycemic control, possibly insulin independence, and has been used in selected cases following total pancreatectomy for IPMN, pancreas trauma or pancreas necrosis with persistent leak. We report our experience with TP + IAI for indications beyond chronic pancreatitis.

Methods
TP + IAI has been performed since 2006 at BUMC. Pancreata are preserved using chilled ET-Kyoto solution and using the oxygen-charged static two layer method. Digestion is by the modified Ricordi method, and purified when over 10 ml of tissue is obtained and then injected into the portal vein. A SUITO index of > 10 and islet yield of 500,000 correlates with increased insulin independence. Patients who had the procedure for a diagnosis other than chronic pancreatitis and intractable pain were selected from the IRB approved database.

Results
Thirty seven patients had a TP + IAI since 2006; 34 patients had CP confirmed by CT/MRI and/or EUS/ERCP, endoscopic secretin stimulated pancreas function testing (ePFT) and histology. Three patients had the procedure for other indications and are reported.
Patient 1: 32 y/o F with idiopathic recurrent acute pancreatitis (IRAP)resulting in multiorgan failure (MOF), ARDS and ventilator dependency with each attack. EUS/ERCP were not diagnostic of CP, ePFT was normal. No evidence of endocrine/exocrine failure. No genetic mutations found. Decision to perform TP + IAI after last admission with 2 month hospitalization with MOF.
Patient 2: 31 y/o M with hereditary chronic pancreatitis (HP) with PRSS1 (R122H) mutation, mother with CP and PRSS1, 2 family members with CP, 2 family members with pancreas cancer (<55 y/o). Intermittent pain exacerbations treated mostly at home. Decision to perform procedure due to known mutation and family history of cancer.
Patient 3: 62 y/o F with ampullary adenoma, recurrent high grade dysplasia despite repeated ampullectomies complicated by pancreas necrosis, and distal pancreatectomy with persistent leak. Decision to perform procedure as a completion pancreatectomy was expected.
The results are summarized in the table.

Conclusions
The pt with IRAP had a higher c-peptide, SUITO index and islet yield compared to the patient with HP, but post-procedure c-peptide and glycemic control were similar. Despite purity of the pancreas extract ductal cells could have been injected into the portal vein, which was explained to the patient with HP and who consented. As TP + IAI becomes more routine studies are needed to understand its application beyond treatment of intractable pain and glycemic control in CP.

TP + IAI for indications other than intractable pain in chronic pancreatitis

	Patient 1	Patient 2	Patient 3
basal c-peptide	1.8 ng/ml	0.9 ng/ml	0.5 ng/ml
basal SUITO index	73	46.6	6.6
Total islet yield (IE)	500,351	212,463	Impossible to remove head of pancreas
IE/kg	4313	3708
post IAI c-peptide	0.7 ng/ml	0.5 ng/ml
post IAI SUITO index	10.5	5.8
Insulin need	*Partial	*Partial

TP=total pancreatectomy; IAI=islet auto-infusion; *Partial=c-peptide measurable but insulin needed for glycemic control