Total Pancreatectomy with Islet Cell Autotransplantation

Total Pancreatectomy with Islet Cell Autotransplantation

Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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A total pancreatectomy with three stages: 1) resection of head of pancreas (where islet cells will be extracted from), 2) distal pancreatectomy, and 3) implantation of patient's islet cells into liver (autotransplantation).

Overview

Indications

Significant morbidity secondary to chronic pancreatitis, refractory to medical therapy.

Surgical procedure

• A total pancreatectomy ± splenectomy

• Removed pancreas processed by auto-islet team to isolate the islet cells (this is performed in the OR and can take 2-4 hours)

• Purified islets are placed in an IV bag and then infused into the portal vein hopefully taking up residence in the liver

Preoperative management

Patient evaluation

System	Considerations
Airway	GETA
Neurologic	Neuropathies secondary to diabetes
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal	Nephropathy secondary to diabetes
Endocrine	Diabetes mellitus; severe blood glucose derangements
Other

Labs and studies

Recent CBC and CMP. Current type and screen. POCT glucose check in preop.

Operating room setup

Overview: Prepare for GETA. PIV x2, arterial line, central line, hotline. Ultrasound as needed.

Details:

• Due to potential for significant blood loss requiring transfusions, large bore peripheral IVs are necessary. Given these patients frequently have poor peripheral

access, can consider a cordis as indicated.

• A central line will be required for ongoing access needs like medication infusions through the peri-operative period.

• An arterial line is required for frequent blood draws (especially blood sugar checks) and potential for intraoperative hemodynamic instability.

• Appropriate blood products should be matched and available.

• An extra pressure bag/transducer setup is necessary to transduce portal pressures from surgical field during auto-islet infusion. Can use CVP transducer if available.

• Plenty of heparinized 3 cc syringes for hourly glucose monitoring

Patient preparation and premedication

Labs as above. Order insulin drip, dextrose 10% in NS, and ertapenem (if indicated) night prior. Patient's should take their home pain medications (many are on chronic pain meds). Consider adjunctive preop pain medications such as gabapentin.

Regional and neuraxial techniques

Pain management is a significant issue in these patients, and they often have significant narcotic requirements and tolerance. Peri-operative management tends to be difficult.

• Acute pain service (APS) should be consulted prior to surgery, ideally seeing the patient in pre-op holding. Can discuss general management plan, consider

adjuvants/modulators like Gabapentin pre-operatively.

• The use of an epidural for postoperative analgesia must consider the intraoperative heparin bolus from the auto-islet cell preparation, as well as additional heparin possibly

being required acutely for portal vein thrombosis. An epidural can be placed in the ICU and should be discussed with APS.

• A Transverse Abdominis Plane block has been used in other institutions with excellent results. Can discuss with surgeon. Best potential time for this are the 2-3 hours once

pancreas is explanted, and waiting for auto-islets to be prepared.

Intraoperative management

Monitoring and access

Standard monitors

Positioning

Supine. Pad arms/upper body well given length of case.

Maintenance and surgical considerations

- Volatile, TIVA, or combined. May use vecuronium infusion if preferred.

Blood Glucose Management:

- Hourly glucose checks throughout

- Tight glucose control is essential for this procedure to prevent stress on the newly transplanted auto-islet cells which can potentially kill them:

- Tight glucose control started once pancreas is removed:

- Check glucose Q1 hour during case. Islet cell coordinator will check on their POCT machine once pancreas is out, and these values will be used to drive glucose control (instead

of our labs). Need to have glucose <120 prior to start of auto-islet infusion. Check glucose Q15-20min once auto-islet infusion is started.

- Goal glucose range is 100-120 once auto-islets infusion has started. Use insulin or dextrose 10% to achieve.

- Current recommended endocrine protocol attached as Appendix A.

- Concurrent dextrose source (D20 at 20-40ml/hr for central lines, D10 at 40-80ml/hr for peripheral) may be needed to prevent

hypoglycemia. Communication with islet cell coordinator on whether this must be started, or whether okay to start for hypoglycemia

only.

Islet-Cell Autotransfusion:

- Check C-peptide once just prior to starting islet-cell autotransfusion

- Surgery will ask for patient end of additional pressure bag/transducer during islet-cell autotransfusion to measure portal pressures.

Be ready with the line zeroed and with a pressure tubing extension on the end. This will be used to periodically check portal

pressure to monitor for evidence of portal vein thrombosis (risk during the auto transfusion).

Considerations during auto-islet transfusion include:

- Elevation of portal vein pressure. Monitor portal vein pressures intermittently every 5 minutes during the auto-islet transfusion. Goal is < 22 mmHg. Female end of pressure line

from field is connected to transducer. If pressure > 22 mmHg, surgeons will stop transfusion & recheck in 5-10 mins. Infusion restarted < 18 mmHg. If portal vein pressure

doubles on consecutive readings with second reading >15 mmHg, will hold transfusion for 5-10 mins.

- Acute blood glucose drop: Significant drop in glucose may occur when starting auto-islet transfusion secondary to insulin in transfusate from the preparation

process and from lyzed Islet cells.

- Thrombosis of portal vein: Auto-islet infusion contains heparin so coagulopathy might occur. LFTs and coagulation studies typically obtained in the ICU, could also check

intraop. Heparin infusion may be requested if the patient is at high risk for thrombosis.

- Systemic hypotension: May occur during the auto-islet transfusion. Usually responsive to volume, minimize vasopressors.

Postoperative management

Disposition

ICU

Pain management

See above regarding regional adjuncts. Can add in other opioids, precedes, ketamine as needed. Discuss Tylenol with surgical team given possibility of liver ischemia introp.

Potential complications

Hemodynamic instability, significant hypo- or hyperglycemia, portal vein thrombosis.

Procedure variants

	Variant 1	Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

https://livejohnshopkins.sharepoint.com/sites/ACCM/best_practices/Best%20Practices/Autoislet%20Transplant%20Anesthesia%20Guidelines.pdf