Martin Makary, MD, MPH, Michol Cooper, MD, PhD, Niraj Desai, MD, Nicole Jiam, Daniel Warren, PhD, Zhaoli Sun, PhD, VIkesh Singh, MD, Anup K Manes, Rita Kalyani, MD, Erica Hall, MSN, CRNP, CDE, Bonny Thul, CRNP, Kenzo Hirose, MD. Johns Hopkins Hospital.
Background: Pain management following surgery for chronic pancreatitis can be very challenging. Pre-existing nerve hypersensitization often magnifies postoperative pain and these episodes can impede improvement of long-term pain outcomes, elevating the importance of minimizing surgical pain in this unique population. We describe a totally laparoscopic pancreatectomy with islet autotransplantation (TP/IAT) to minimize pain outcomes in patients with chronic pancreatitis.
Methods: We attempted a laparoscopic TP/IAT in six patients with chronic pain secondary to small-duct chronic pancreatitis over a six-month period (February 2013-August 2013). Two 5mm ports and three to four 12 mm ports were used with injection of port sites with local anesthetic prior to insertion. To minimize operative time, a laboratory was set up in the operating room to perform the islet isolation immediately upon organ extraction. A laparoscopic hepaticojejunostomy and gastrojejunostomy were performed during the laboratory isolation. Islet autotransplantation was then performed by laparoscopically guiding an infusion catheter into the portal vein under direct visualization (see Figure). We collected data on operative time, baseline and postoperative pain score at follow-up at 6-8 weeks, glycemic outcomes, estimated blood loss, 30-day surgical complications, and mortality.
Results: A totally laparoscopic approach including a laparoscopic islet autotransplantation was successful in all six patients. The mean operative time was 527 minutes (range=471-619 minutes). The median estimated blood loss was 450 cc (range=200-1250cc). Mean preoperative pain score was 8.5 (range 7-10) among the five patients that had pain. One patient had no preoperative pain but underwent the procedure for cancer prevention as she met radiographic criteria and had both the CTFR and PRSS1 gene mutations. Mean postoperative pain score among patients with preoperative pain was 3.5 at their 6-8 week follow-up visit. All patients were insulin C-peptide positive at 6-8 weeks and none required short-acting insulin. Median hospital length of stay was 10.2 days (range=6-21 days). Two patients were readmitted with intra-abdominal abscesses and had a drain placed. One patient developed a UTI post-operatively. There were no postoperative wound infections. The 30-day mortality was zero.
Conclusion: We report outcomes following a novel surgical procedure of a totally laparoscopic TP/IAT with intraoperative islet isolation. In this early series, we observed high feasibility with reasonable operative time and good patient outcomes. The procedure should be considered in appropriate patients with small-duct chronic pancreatitis.