TOTAL PANCREATECTOMY WITH ISLET AUTOTRANSPLANT AFTER REMOTE ISLET PROCESSING: A VIABLE PARADIGM?
Kyle A. Lewellen*2, Kathleen A. McGreevy1, Michael G. House2, Melissa K. Cavaghan2, Michael Dorwart2, Evan L. Fogel2, Paul Haste2, Anne Mary Montero2, Nicholas J. Zyromski2
1Indiana University Health Inc, Indianapolis, IN; 2Indiana University School of Medicine, Indianapolis, IN
Introduction
Total pancreatectomy with islet autotransplant (TPIAT) is an important therapeutic option for select chronic pancreatitis (CP) patients. The challenge of islet isolation limits widespread TPIAT use. We recently established a TPIAT program with remote islet isolation and sought to evaluate initial perioperative outcomes. We hypothesized that remote islet isolation provides satisfactory islet yield and perioperative outcomes.
Methods
Retrospective review of TPIAT patients treated between 2020 to 2022. Islet isolation occurred at an off-site laboratory, with percutaneous, intraportal islet autotransplant (IAT) the morning following pancreatectomy. Demographic and perioperative outcomes data were analyzed with descriptive statistics as appropriate.
Results
Eleven patients (10 female) underwent TPIAT. Median age at operation was 42 years (IQR 17 years), including one pediatric patient. Operation occurred a median of 9 (15) years from diagnosis of CP. Genetic causes were the most common pancreatitis etiology (64%), followed by pancreas divisum (18%), alcohol (9%), and idiopathic (9%). Three patients were prior smokers, one was diabetic on partial insulin replacement, and ten (91%) required exogenous pancreatic enzyme supplementation preoperatively. All patients had undergone endoscopic therapy (endoscopic retrograde cholangiopancreatography or endoscopic ultrasound evaluation with celiac plexus block) for CP (median number of endoscopic procedures 9 [4.5]). Two had prior pancreatic surgery; one patient had a drainage procedure, one underwent prior pancreaticoduodenectomy.
Median operative time was 251 (54) minutes, estimated blood loss was 100 (50) mL. The median islet equivalent (IEQ) yield was 3869 (3888) IEQ/kg (Table 1). Median IAT procedural time was 79 (31) minutes. Opening portal pressures were 11 (4) mmHg, median change in pressure was 5 (5) mmHg. Eight patients were treated for positive islet cultures and had no resultant infectious complications. The most common postoperative complications observed were thromboembolic (n=2). No cardiac, pulmonary, renal, or percutaneous portal venous access complications were observed. No patient required parenteral nutrition, but 10 (91%) patients had feeding access placed at time of pancreatectomy.
Median postoperative length of stay was 15 (4) days. Four patients (36%) were readmitted within 90 days, most commonly for pain. All patients were discharged on insulin; median discharge basal requirement was 0.40 (0.17) units/kg. No mortality was observed, and all patients were discharged to home.
Conclusion
Total pancreatectomy with islet autotransplant with remote islet isolation provides excellent islet yield and perioperative outcomes.
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