SURGICAL OUTCOMES OF TOTAL PANCREATECTOMY WITH ISLET AUTOTRANSPLANTATION
Robert Naples*, Jonah D. Thomas, Breanna Perlmutter, John McMichael, Toms Augustin, R Matthew Walsh, Robert Simon
Cleveland Clinic, Cleveland, OH
Background: Total pancreatectomy with islet autotransplantation (TP-IAT) can be performed selectively for patients with refractory chronic pancreatitis to alleviate pain, improve quality of life, and preserve endocrine function. We evaluated the short- and long-term surgical outcomes of TP-IAT.
Methods: We performed a retrospective review of 82 patients who underwent TP-IAT at our institution from 2007-2019. All patients had a diagnosis of chronic pancreatitis and were evaluated by a multidisciplinary team prior to surgical intervention. Primary endpoints were morbidity and mortality. Postoperative complications during initial hospital stay were classified by Clavien-Dindo grade. They were further categorized into early (≤30 days) or late (>30 days) and compared between standard (resection of the antrum) and pylorus-preserving approaches. The rate of postoperative hemorrhage was evaluated based on the amount of heparin infused (units/kg) during islet autotransplantation.
Results: All patients underwent an open technique with 55 (67%) and 57 (70%) patients undergoing a pylorus-preserving approach and concomitant splenectomy, respectively. Median follow-up was 36 months (IQR, 14-71). There was no 90-day mortality. Clavien-Dindo grade 1, 2, 3a, 3b, 4a, 4b, and 5 complications was observed in 10%, 33%, 11%, 10%, 4%, 0%, and 0%. Early and late postoperative complications were 32% and 40%, respectively. The most common early complications were intra-abdominal abscess (n=7) and postoperative hemorrhage (n=5). Overall, there were eight (10%) patients who underwent reoperation within 30-days of TP-IAT with five (6%) being related to postoperative hemorrhage. No difference was observed in the rate of postoperative hemorrhage based on amount of heparin infused during islet autotransplantation (<60 units/kg: 2% vs ≥60 units/kg: 11%, p=0.12), and there was no known incidence of portal vein thrombosis. Late complications included marginal ulcer (n=9), small bowel obstruction (n=7), and incisional hernia (n=7). There were 13 (16%) operations related to a late complication, most commonly for incisional hernia repair (n=7) and small bowel obstruction (n=4). The pylorus-preserving approach had a higher rate of marginal ulcer formation compared to the standard approach (11% vs 0%, p=0.03).
Conclusions: Despite the complexity of the operation and patient population, TP-IAT can be performed safely with no 90-day mortality. A pylorus-preserving approach should be universally adopted to achieve optimal outcomes, particularly to prevent the formation of marginal ulcers. When considering the risk of portal vein thrombosis versus postoperative hemorrhage, a lower heparin dose is acceptable. This study can advise surgeons on the expected morbidity and mortality after this operation and highlight potential areas for future improvement.
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