Groene John,  Wieck Minna,  Ong Seng,  Zaritzky Mario,  Feinstein Kate

Final Pr. ID: Poster #: EDU-024

In this exhibit we will describe a fairly new surgical procedure - total pancreatectomy and islet autotransplant (TPIAT). TPIAT is an uncommon procedure performed in children who suffer from chronic or recurrent acute pancreatitis. The purpose of the exhibit is to learn about the selection criteria, the surgery itself, and the imaging features of surgical complications.

Candidates are selected for surgery based on a multitude of factors including severity and chronicity of pain, laboratory evaluation of pancreatic exocrine and endocrine function, and imaging features of chronic pancreatitis on MRCP and/or endoscopic ultrasound.

In the surgical procedure, the pancreas and duodenum are resected, islet cells are isolated and then infused through the portal vein into the liver. A splenectomy is performed and continuity of the GI tract restored. Patients may spend three weeks in the hospital after surgery. Months after the infusion, the islet cells will be embedded within the liver and begin to produce insulin.

The primary goal of this procedure is to relieve debilitating pain and improve quality of life, for which this procedure is around 90% successful. The secondary goal of the procedure is to retain islet cell function. In this regard, approximately 40% of the pediatric patients will regain complete islet cell function, 30% will regain partial function while 30% will have no islet cell function.

Follow up imaging may also be performed on these patients for evaluation of complications such as delayed gastric emptying, small bowel obstruction, surgical site infections, bile leak, and intra-abdominal hemorrhage. Complications seen in our hospital, including small bowel obstruction, delayed gastric emptying, and prolonged ileus will be highlighted.
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Authors:  Groene John , Wieck Minna , Ong Seng , Zaritzky Mario , Feinstein Kate

Keywords:  total pancreatectomy and islet autotransplant, TPIAT, islet cell transplantation

Ames Jeff,  Holm Tara,  Murati Michael,  Hoggard Eric,  Dietz Kelly

Final Pr. ID: Poster #: EDU-025

Chronic pancreatitis (CP) is characterized by permanent damage to the pancreas resulting in endocrine and exocrine deficiencies. CP is often associated with a history of acute recurrent pancreatitis. Pediatric CP is most commonly linked to known genetic mutations, such as PRSS1 or CFTR, and there is an increased risk of pancreatic adenocarcinoma in patients with hereditary pancreatitis. The mainstay of CP management involves controlling chronic pain and preserving quality of life.

Total pancreatectomy and islet auto-transplantation (TPIAT) is an option for managing pain in pediatric patients with uncontrollable pain or pancreatitis secondary to genetic causes. TPIAT was first performed at the University of Minnesota in 1971. Currently there are more than 15 academic institutions in the US performing TPIAT and that number continues to rise. TPIAT has been shown to be effective for pain relief as well as maintaining insulin independence in adults and young pediatric patients. The timing of TPIAT in a patient’s disease course is critical because islet cell yield is inversely correlated with pancreatic fibrosis, and postoperative diabetes outcomes depend on islet yield.

Imaging prior to transplant is aimed at assessing changes of pancreatitis, vessel patency, and identifying vessel and pancreatic ductal anatomic variants. Preoperative imaging can also confirm adequate liver volume for the procedure and identify postoperative changes from previous procedures such as distal pancreatectomy or Puestow procedure (pancreaticojejunostomy).

Routine postoperative imaging consists of liver Doppler ultrasound screening because elevated infusion pressures during autotransplantation can result in endothelial injury and portal vein thrombosis. Delayed gastric emptying and small bowel ileus are common postsurgical complications, and targeted cross-sectional imaging, radiography, and fluoroscopy may be performed based on patient symptoms. Once bowel function has returned, enteral feeds are started via gastrojejunostomy tube and can sometimes be complicated by GJ tube-related intussusception. The largest retrospective review in pediatric patients showed a 20% surgical complication rate, with the most common complication being post-splenectomy thrombocytosis.

We present pertinent imaging findings for surgical planning in patients with CP prior to TPIAT, expected postoperative imaging findings, and imaging of postoperative complications. Read More

Authors:  Ames Jeff , Holm Tara , Murati Michael , Hoggard Eric , Dietz Kelly

Keywords:  Chronic pancreatitis, Islet autotransplant, Total pancreatectomy