Institutional Outcomes following Total Pancreatectomy and Islet Autotransplantation in Children

Purpose: Total pancreatectomy with islet autotransplantation (TPIAT) is used to treat debilitating chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) that has failed medical and endoscopic therapy. There is limited knowledge about perioperative management and outcomes in pediatric patients. We describe our institutional experience with pediatric TPIAT. Methods: A retrospective review of TPIAT patients at a free-standing children’s hospital was performed to determine preoperative pancreatitis course and perioperative outcomes of TPIAT. Results: Twenty patients [median age 13, (range 4-19); 65% female] underwent TPIAT (2015-2017). Ninety-five percent had CP; one patient underwent TPIAT for ARP. Eighty-five percent had a pancreatitis-associated genetic mutation; 40% had pancreas divisum. Partial or full parenteral nutrition (PN) was used in 25% preoperatively. Patients had a median of 4.5 hospitalizations (0-20) and 1 ERCP (0- 4) in the year preceding TPIAT. Preoperatively, 75% were taking opioids for pain control (60% daily). Three had preoperative diabetes; 11 had exocrine pancreatic insufficiency. All underwent TPIAT with Roux-en- Y duodenojejunostomy and Roux- en-Y biliary reconstruction. Median operative duration was 803 minutes (406- 1147). Median total islet equivalent count (IEQ) and dose (IEQ/kg) were 448,500 (228,000-927,000) and 6403 (1,904-14,242), respectively. Median length of stay was 27 days. Postoperative complications included percutaneous drainage of fluid collections (n=5), re-exploration for bleeding (n=1) and bowel obstruction (n=1). At 90 days postoperatively, all patients were off PN (p=0.01). There were significantly fewer patients on opioids at 90 days postoperatively, compared to preoperatively (42% vs. 75%, p=0.007). Reflecting beta cell function, median stimulated c-peptide was 1.95 (range 0.5-4.3) at 90 days, with a median insulin requirement of 0.47 units/kg/day (range 0-0.82). Conclusion: Pediatric ARP/CP can be treated with TPIAT when debilitating disease persists in spite of maximal medical and endoscopic therapy. Opioid and PN use can successfully be weaned in the ninety days after surgery, while insulin weans require a longer period