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.

• Rubber red top blood tube to send C-peptide intraop

• 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. Arms likely out (if Dr. He, both arms out and will use the robot). 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. Islet cell coordinator will check on their POCT machine, and these values will be used (instead of our labs checks - recommend continuing to send

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

your tech to ensure that this is possible ahead of time.

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

- Current recommended endocrine protocol attached as Appendix A.

- Endocrine service is available for any discussions (Rita Kalyani, MD or

Erica Hall, NP).

• Concurrent dextrose source (D20 at 20-40ml/hr w/ central lines, D10 at 40-

80ml/hr w/ peripheral) is needed to prevent hypog

Islet-cell Autotransfusion:

- Check C-peptide once just prior to starting islet-cell autotransfusion (red rubber top blood tube, you need to order the C-peptide and send it)

- 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).

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.

Procedure variants

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