Laparoscopic total pancreatectomy with islet autotransplantation and intraoperative islet separation as a treatment for patients with chronic pancreatitis

Caleb J. Fan, Kenzo Hirose, Christi M. Walsh, Michael Quartuccio, Niraj M Desai, Vikesh Singh, Rita R. Kalyani, Daniel Warren, Zhao Li Sun, Marie Hanna, Martin A Makary

Research output: Contribution to journalArticle

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.

Original languageEnglish (US)
Pages (from-to)550-556
Number of pages7
JournalJAMA Surgery
Volume152
Issue number6
DOIs
StatePublished - Jun 1 2017

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Pancreatectomy
Autologous Transplantation
Chronic Pancreatitis
Therapeutics
Operative Time
Insulin
Opioid Analgesics
Warm Ischemia
Length of Stay
C-Peptide
Glycosylated Hemoglobin A
Pancreatitis
Laparoscopy
Surgical Wound Infection
Pain
Pain Measurement
Pain Management
Hernia
Postoperative Pain
Tertiary Care Centers

ASJC Scopus subject areas

  • Surgery

Cite this

@article{db192ac9039a4f7b96f251bf0b00f009,
title = "Laparoscopic total pancreatectomy with islet autotransplantation and intraoperative islet separation as a 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.",
author = "Fan, {Caleb J.} and Kenzo Hirose and Walsh, {Christi M.} and Michael Quartuccio and Desai, {Niraj M} and Vikesh Singh and Kalyani, {Rita R.} and Daniel Warren and Sun, {Zhao Li} and Marie Hanna and Makary, {Martin A}",
year = "2017",
month = "6",
day = "1",
doi = "10.1001/jamasurg.2016.5707",
language = "English (US)",
volume = "152",
pages = "550--556",
journal = "JAMA Surgery",
issn = "2168-6254",
publisher = "American Medical Association",
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}

TY - JOUR

T1 - Laparoscopic total pancreatectomy with islet autotransplantation and intraoperative islet separation as a treatment for patients with chronic pancreatitis

AU - Fan, Caleb J.

AU - Hirose, Kenzo

AU - Walsh, Christi M.

AU - Quartuccio, Michael

AU - Desai, Niraj M

AU - Singh, Vikesh

AU - Kalyani, Rita R.

AU - Warren, Daniel

AU - Sun, Zhao Li

AU - Hanna, Marie

AU - Makary, Martin A

PY - 2017/6/1

Y1 - 2017/6/1

N2 - 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.

AB - 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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