Total Pancreatectomy with Islet Cell Auto-transplant Anesthesia Pearls

Vs 1.0; 8/2020

Total Pancreatectomy with Islet Cell Auto-transplant Anesthesia Pearls

Kate Kronish MD and Andrew Posselt MD

Background

Total pancreatectomy with islet cell auto-transplant is performed for patients with chronic pancreatitis who have failed medical treatment. They frequently have significant chronic opioid use. The spleen is also removed. The patient's own islet cells are preserved, isolated and purified, and then injected back into the patient's portal vein to ameliorate the surgical diabetes that is produced by a total pancreatectomy. Because the patient's own islet cells are used, immunosuppression is not required. Post-op over a period of months, about 80% of patients are able to wean fully off opioids, and 50-75% of patients achieve insulin independence.

Surgical notes

Surgeons make a midline incision from xiphoid to below umbilicus. The right arm is usually tucked and left arm out.  The pancreatectomy takes about 3 hours, after which there is a period of about 1.5 – 2h where we wait (with patient under GA) for the islet cells to be processed.  There is no surgical stimulation during this time. 

Islet cell infusion

Infusion of the islets takes about 20 mins. Surgeons will measure portal pressures during the infusion – have an extra pressure transducer zeroed and ready. There may be some transient hypotension at the start of the infusion but this usually resolves. A total of 70 units/kg heparin is given at the start of the infusion – 35 units/kg are in the islet mix and 35 units/kg are given IV by the anesthesia provider.

Anesthetic plan

-GETA with neuromuscular blockade. NG Tube. Consider A-line or use large PIV for frequent blood glucose monitoring. 

-Usual EBL 200-300. Chance of blood loss (if surgically difficult with extensive scarring). Consider ordering RBCs, but not necessary in the OR. 2 PIVs.

-Fluid goals for the entire case are around 2-3 L. 

-BG should be checked every 20-30 mins after pancreas is out. Always communicate BG and insulin treatment plan with surgeon. OK to use Decadron for PONV.

-Pain management: ESP bilateral catheters (placed in pre-op by the regional team). Dose the catheters intra-op + IV opioids + adjuncts (gabapentin + acetaminophen pre-op, consider ketamine, magnesium). Calculate the patient's baseline opioid requirement. Communicate plan with the pain service. 

-Extubate and go to ICU post-op for q1 hour glucose checks.