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Spleen-preserving total pancreatectomy and islet autotransplantation with complete preservation of the splenic arterial and venous supply does not impact islet yield and function

      Highlights

      • Total pancreatectomy with islet autotransplantation (TPIAT) is an effective treatment for refractory chronic pancreatitis.
      • Currently more than 90% of the surgical procedure involves splenectomy which may contribute to postoperative complications.
      • We report that complete spleen preservation during surgical procedure does not affect islet yield and graft function.
      • Results from this analysis should advance the current practice of TPIAT and guide surgeons and scientists in the field.

      Abstract

      Background

      Standard total pancreatectomy and islet autotransplantation (TPIAT) for chronic pancreatitis includes splenectomy, but TPIAT can be performed without splenectomy by full preservation of the blood supply to the spleen.

      Methods

      We compared the metabolic and clinical outcomes of patients who underwent TPIAT at our center between 2015 and 2021 with or without splenectomy. A total of 89 patients were included in the study, and 17 of them underwent spleen-preserving total pancreatectomy (SPTP).

      Results

      The two study groups had similar demographic and metabolic parameters. Short-term morbidity and long-term outcomes were similar. The operative time was significantly shorter with splenectomy: a median of 9.91 h (interquartile range [IQR] 8.89–10.83) compared to 10.78 h (IQR 10.2–11.6) for SPTP (P = 0.021). There was no difference between the groups in postoperative morbidity. Metabolic outcomes at 1 year were better in the SPTP group compared to the splenectomy group, with a median daily insulin requirement of 7 units (IQR 4–12) vs 15 units (IQR 7–26; P = 0.049) and a median C-peptide at 1 year of 0.65 (IQR 0.40–1.26) vs 1.00 (IQR 0.80–1.90; P = 0.63). The reduction in morphine milligram equivalents per day over time was significantly better in the SPTP group (P < 0.001), as was the decrease in pain score (P < 0.001).

      Conclusion

      TPIAT with full arterial and venous preservation of the spleen had no adverse impact on islet yield or function. TPIAT can be safely and effectively performed with preservation of the spleen and the entire splenic artery and vein. The spleen should be preserved when feasible in every TPIAT surgery.

      Keywords

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      References

        • Sutherland D.E.R.
        • Matas A.J.
        • Najarian J.S.
        Pancreatic islet cell transplantation.
        Surg Clin North Am. 1978; 58: 365-382https://doi.org/10.1016/S0039-6109(16)41489-1
        • Abu-El-Haija M.
        • Anazawa T.
        • Beilman G.J.
        • et al.
        The role of total pancreatectomy with islet autotransplantation in the treatment of chronic pancreatitis: a report from the International Consensus Guidelines in chronic pancreatitis.
        Pancreatology. 2020; 20: 762-771https://doi.org/10.1016/j.pan.2020.04.005
        • Forsmark C.E.
        Management of chronic pancreatitis.
        Gastroenterology. 2013; 144 (e3): 1282-1291https://doi.org/10.1053/j.gastro.2013.02.008
        • Chinnakotla S.
        • Bellin M.D.
        • Schwarzenberg S.J.
        • et al.
        Total pancreatectomy and islet autotransplantation in children for chronic pancreatitis: indication, surgical techniques, postoperative management, and long-term outcomes.
        Ann Surg. 2014; 260: 56-64https://doi.org/10.1097/SLA.0000000000000569
        • Kesseli S.J.
        • Smith K.A.
        • Gardner T.B.
        Total pancreatectomy with islet autologous transplantation: the cure for chronic pancreatitis?.
        Clin Transl Gastroenterol. 2015; 6: e73https://doi.org/10.1038/ctg.2015.2
        • Bhayani N.H.
        • Enomoto L.M.
        • Miller J.L.
        • et al.
        Morbidity of total pancreatectomy with islet cell auto-transplantation compared to total pancreatectomy alone.
        HPB. 2014; 16: 522-527https://doi.org/10.1111/hpb.12168
        • Fazlalizadeh R.
        • Moghadamyeghaneh Z.
        • Demirjian A.N.
        • et al.
        Total pancreatectomy and islet autotransplantation: a decade nationwide analysis.
        World J Transplant. 2016; 6: 233-238https://doi.org/10.5500/wjt.v6.i1.233
        • Nathan J.D.
        • Yang Y.
        • Eaton A.
        • et al.
        Surgical approach and short-term outcomes in adults and children undergoing total pancreatectomy with islet autotransplantation: a report from the Prospective Observational Study of TPIAT.
        Pancreatology. 2022; 22: 1-8https://doi.org/10.1016/j.pan.2021.09.011
        • Di Sabatino A.
        • Carsetti R.
        • Corazza G.R.
        Post-splenectomy and hyposplenic states.
        Lancet. 2011; 378: 86-97https://doi.org/10.1016/S0140-6736(10)61493-6
        • Sun N.
        • Lu G.
        • Zhang L.
        • et al.
        Clinical efficacy of spleen-preserving distal pancreatectomy with or without splenic vessel preservation: a meta-analysis.
        Medicine (Baltim). 2017; 96e8600https://doi.org/10.1097/MD.0000000000008600
        • Sutherland D.E.
        • Radosevich D.M.
        • Bellin M.D.
        • et al.
        Total pancreatectomy and islet autotransplantation for chronic pancreatitis.
        J Am Coll Surg. 2012; 214: 409-424https://doi.org/10.1016/j.jamcollsurg.2011.12.040
        • Naples R.
        • Walsh R.M.
        • Thomas J.D.
        • et al.
        Short- and long-term surgical outcomes of total pancreatectomy with islet autotransplantation: a comparative analysis of surgical technique and intraoperative heparin dosing to optimize outcomes.
        Pancreatology. 2021; 21: 291-298https://doi.org/10.1016/j.pan.2020.11.013
        • White S.A.
        • London N.J.M.
        • Johnson P.R.V.
        • et al.
        The risks of total pancreatectomy and splenic islet autotransplantation.
        Cell Transplant. 2000; 9: 19-24https://doi.org/10.1177/096368970000900103
        • Warshaw A.L.
        Conservation of the spleen with distal pancreatectomy.
        Arch Surg. 1988; 123: 550-553https://doi.org/10.1001/archsurg.1988.01400290032004
        • Kimura W.
        • Inoue T.
        • Futakawa N.
        • Shinkai H.
        • Han I.
        • Muto T.
        Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein.
        Surgery. 1996; 120: 885-890https://doi.org/10.1016/S0039-6060(96)80099-7
        • Shahbazov R.
        • Naziruddin B.
        • Salam O.
        • et al.
        The impact of surgical complications on the outcome of total pancreatectomy with islet autotransplantation.
        Am J Surg. 2020; 219: 99-105https://doi.org/10.1016/j.amjsurg.2019.04.007
        • Shahbazov R.
        • Yoshimatsu G.
        • Haque W.Z.
        • et al.
        Clinical effectiveness of a pylorus-preserving procedure on total pancreatectomy with islet autotransplantation.
        Am J Surg. 2017; 213: 1065-1071https://doi.org/10.1016/j.amjsurg.2016.09.051
        • Naziruddin B.
        • Matsumoto S.
        • Noguchi H.
        • et al.
        Improved pancreatic islet isolation outcome in autologous transplantation for chronic pancreatitis.
        Cell Transplant. 2012; 21: 553-558https://doi.org/10.3727/096368911X605475
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240 (ae): 205-213https://doi.org/10.1097/01.sla.0000133083.54934
        • Kimura W.
        • Moriya T.
        • Ma J.
        • et al.
        Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein.
        World J Gastroenterol. 2007; 13: 1493-1499https://doi.org/10.3748/wjg.v13.i10.1493
        • Butturini G.
        • Inama M.
        • Malleo G.
        • et al.
        Perioperative and long-term results of laparoscopic spleen-preserving distal pancreatectomy with or without splenic vessels conservation: a retrospective analysis.
        J Surg Oncol. 2012; 105: 387-392https://doi.org/10.1002/jso.22117
        • Yoon Y.S.
        • Lee K.H.
        • Han H.S.
        • Cho J.Y.
        • Ahn K.S.
        Patency of splenic vessels after laparoscopic spleen and splenic vessel-preserving distal pancreatectomy.
        Br J Surg. 2009; 96: 633-640https://doi.org/10.1002/bjs.6609
        • Inama M.
        • Butturini G.
        • Bassi C.
        Warshaw's technique: what's the point?.
        HPB. 2012; 14: 279https://doi.org/10.1111/j.1477-2574.2011.00434.x
        • Matsushima H.
        • Kuroki T.
        • Adachi T.
        • et al.
        Laparoscopic spleen-preserving distal pancreatectomy with and without splenic vessel preservation: the role of the Warshaw procedure.
        Pancreatology. 2014; 14: 530-535https://doi.org/10.1016/j.pan.2014.09.007
        • Li B.Q.
        • Qiao Y.X.
        • Li J.
        • Yang W.Q.
        • Guo J.C.
        Preservation or ligation of splenic vessels during spleen-preserving distal pancreatectomy: a meta-analysis.
        J Invest Surg. 2019; 32: 654-669https://doi.org/10.1080/08941939.2018.1449918
        • Zhou Z.Q.
        • Kim S.C.
        • Song K.B.
        • Park K.M.
        • Lee J.H.
        • Lee Y.J.
        Laparoscopic spleen-preserving distal pancreatectomy: comparative study of spleen preservation with splenic vessel resection and splenic vessel preservation.
        World J Surg. 2014; 38: 2973-2979https://doi.org/10.1007/s00268-014-2671-3
        • Yu X.
        • Li H.
        • Jin C.
        • et al.
        Splenic vessel preservation versus Warshaw's technique during spleen-preserving distal pancreatectomy: a meta-analysis and systematic review.
        Langenbeck's Arch Surg. 2015; 400: 183-191https://doi.org/10.1007/s00423-015-1273-3
        • Takaori K.
        • Uemoto S.
        Artery-first distal pancreatectomy.
        Dig Surg. 2016; 33: 314-319https://doi.org/10.1159/000445016
        • Ong S.L.
        • Gravante G.
        • Pollard C.A.
        • Webb M.A.
        • Illouz S.
        • Dennison A.R.
        Total pancreatectomy with islet autotransplantation: an overview.
        HPB. 2009; 11: 613-621https://doi.org/10.1111/j.1477-2574.2009.00113.x
        • Kimura W.
        • Yano M.
        • Sugawara S.
        • et al.
        Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein: techniques and its significance.
        J Hepatobiliary Pancreat Sci. 2010; 17: 813-823https://doi.org/10.1007/s00534-009-0250-z
        • Kempeneers M.A.
        • Scholten L.
        • Verkade C.R.
        • et al.
        • Dutch Pancreatitis Study Group
        Efficacy of total pancreatectomy with islet autotransplantation on opioid and insulin requirement in painful chronic pancreatitis: a systematic review and meta-analysis.
        Surgery. 2019; 166: 263-270https://doi.org/10.1016/j.surg.2019.03.014