title: Laparoscopic Total Pancreatectomy With Islet Autotransplantation and Intraoperative Islet Separation as a Treatment for Patients With Chronic Pancreatitis.
abstract: 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).
  
  
  
  To examine the feasibility of using laparoscopic TPIAT (L-TPIAT) in the treatment of CP.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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%).
  
  
  
  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.
authors.affiliation: School of Medicine, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Caleb J
authors.initials: CJ
authors.lastname: Fan
authors.affiliation: Department of Surgery, Johns Hopkins University, Baltimore, Maryland3Department of Surgery, University of California, San Francisco.
authors.forename: Kenzo
authors.initials: K
authors.lastname: Hirose
authors.affiliation: Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Christi M
authors.initials: CM
authors.lastname: Walsh
authors.affiliation: Department of Medicine, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Michael
authors.initials: M
authors.lastname: Quartuccio
authors.affiliation: Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Niraj M
authors.initials: NM
authors.lastname: Desai
authors.affiliation: Department of Medicine, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Vikesh K
authors.initials: VK
authors.lastname: Singh
authors.affiliation: Department of Medicine, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Rita R
authors.initials: RR
authors.lastname: Kalyani
authors.affiliation: Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Warren
authors.affiliation: Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Zhaoli
authors.initials: Z
authors.lastname: Sun
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Marie N
authors.initials: MN
authors.lastname: Hanna
authors.affiliation: Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Martin A
authors.initials: MA
authors.lastname: Makary
mesh_terms: D000328:Adult; D064592:Autografts; D002423:Cause of Death; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007515:Islets of Langerhans / Q000601:surgery*; D016381:Islets of Langerhans Transplantation / Q000379:methods* / Q000401:mortality; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods*; D050500:Pancreatitis, Chronic / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D055815:Young Adult