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Original Investigation
June 2017

Laparoscopic Total Pancreatectomy With Islet Autotransplantation and Intraoperative Islet Separation as a Treatment for Patients With Chronic Pancreatitis

Author Affiliations
  • 1School of Medicine, Johns Hopkins University, Baltimore, Maryland
  • 2Department of Surgery, Johns Hopkins University, Baltimore, Maryland
  • 3Department of Surgery, University of California, San Francisco
  • 4Department of Medicine, Johns Hopkins University, Baltimore, Maryland
  • 5Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
JAMA Surg. 2017;152(6):550-556. doi:10.1001/jamasurg.2016.5707
Key Points

Question  Is laparoscopic total pancreatectomy with islet autotransplantation and intraoperative islet separation a feasible treatment for patients with chronic pancreatitis?

Findings  In this case series of 20 patients, patients undergoing laparoscopic total pancreatectomy with islet autotransplantation experienced shorter total operative and islet isolation times, reduced length of stay, and quicker opioid independence compared with patients undergoing open or robotic-assisted total pancreatectomy with islet autotransplantation.

Meaning  Laparoscopic total pancreatectomy with islet autotransplantation is a feasible alternative treatment for patients with chronic pancreatitis.

Abstract

Importance  Pain management of patients with chronic pancreatitis (CP) can be challenging. Laparoscopy has been associated with markedly reduced postoperative pain but has not been widely applied to total pancreatectomy with islet autotransplantation (TPIAT).

Objective  To examine the feasibility of using laparoscopic TPIAT (L-TPIAT) in the treatment of CP.

Design, Setting, and Participants  Thirty-two patients with CP presented for TPIAT at a tertiary hospital from January 1, 2013, through December 31, 2015. Of the 22 patients who underwent L-TPIAT, 2 patients converted to an open procedure because of difficult anatomy and prior surgery. Pain and glycemic outcomes were recorded at follow-up visits every 3 to 6 months postoperatively.

Main Outcomes and Measures  Operative outcomes included operative time, islet isolation time, warm ischemia time, islet equivalent (IE) counts, estimated blood loss, fluid resuscitation, and blood transfusions. Postoperative outcomes included length of stay, all-cause 30-day readmission rate, postoperative complications, mortality rate, subjective pain measurements, opioid use, random C-peptide levels, insulin requirements, and glycated hemoglobin level.

Results  Of the 32 patients who presented for TPIAT, 20 underwent L-TPIAT (8 men and 12 women; mean [SD] age, 39 [13] years; age range, 21-58 years). Indication for surgery was CP attributable to genetic mutation (n = 9), idiopathic pancreatitis (n = 6), idiopathic pancreatitis with pancreas divisum (n = 3), and alcohol abuse (n = 2). Mean (SD) operative time was 493 (78) minutes, islet isolation time was 185 (37) minutes, and warm ischemia time was 51 (62) minutes. The mean (SD) IE count was 1325 (1093) IE/kg. The mean (SD) length of stay was 11 (5) days, and the all-cause 30-day readmission rate was 35% (7 of 20 patients). None of the patients experienced postoperative surgical site infection, hernia, or small-bowel obstruction, and none died. Eighteen patients (90%) had a decrease or complete resolution of pain, and 12 patients (60%) no longer required opioid therapy at a median follow-up period of 6 months. Postoperative random insulin C-peptide levels were detectable in 19 patients (95%) at a median follow-up of 10.4 months. At a median follow-up of 12.5 months, 5 patients (25%) were insulin independent, whereas 9 patients (45%) required 1 to 10 U/d, 5 patients (25%) required 11 to 20 U/d, and 1 patient (5%) required greater than 20 U/d of basal insulin. The mean (SD) glycated hemoglobin level was 7.4% (0.5%).

Conclusions and Relevance  This study represents the first series of L-TPIAT, demonstrating its safety and feasibility. Our approach enables patients to experience shorter operative times and the benefits of laparoscopy, including reduced length of stay and quicker opioid independence.

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