Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Welcome back to an educational video about pancreatic pathologies by the Pancreas Care Center here at Cincinnati Children's Hospital. Today, we are going to dive into the day of the total pancreatectomy with islet auto transplantation. And for that, we are going to follow Dr. Juan Gurrea, a pediatric surgeon and surgical director of the Pancreas Care Center here at Cincinnati Children's Hospital. Hi, my name is Juan Pablo Gurrea. Today we're going to perform a total pancreatectomy with islet auto transplantation. But before going into the surgery, let's hear from him which patients are candidates for receiving this procedure. TPIAT is clearly one of the most complex abdominal surgical procedures we perform in children. The surgical indications for this procedure are uh for patients with either chronic or acute recurrent pancreatitis. These patients are candidates for TPIAT when all medical and endoscopic therapy has failed. These patients usually have a genetic mutation that drives the disease and typically present with chronic debilitating pain that can lead to opioid addiction or severely prevent of their mental health. This specific procedure uh we perform months in advance when we perform a full evaluation by the entire uh uh Pancreas Care Center for excellence in a children's team that includes GI, uh social worker, endocrine, surgery, radiology, genetics, behavioral health, and physical therapy, including also anesthesia and pain team. Also, we need to make sure the patients are ready for a major operation. After we review with the entire team and we vote this patients in for surgery or reviewing them candidates for it, we prepare the patients with vaccinations for potential splectomy. And then we're we're ready to go. Now that we know who is a candidate, let's dive into the surgery. But first, I have to change. So now that we are ready, let's go into the OR. How do you prepare before the surgery? I start my surgery the night before where I review the entire set of laboratory values, the entire imaging pictures of these patients and I review the entire procedure that I'm I'm going to perform the next morning in my head. On the day of the surgery, the surgeons admit the patient in the same day surgery area, and then they get ready. The surgical procedure starts early in the morning. All the necessary equipment by anesthesia set up. We place pain catheters in the erecto spino muscle. Uh that's taken care by our pain specialist. After the team finish with the catheter placement, the surgical team places a central Venus catheter using ultrasound for the being puncture and fluroscopy for the appropriate insertion. Once finished, they place an arterial line and it is then when they are ready to start the procedure. We perform an extensive exploratory laparotomy. We identify uh the pancreas all the way down in the retroperitoneum. And we dissect this pancreas very carefully. Remember this this pancreas has been injured for sometimes years, which makes this procedure quite challenging. The procedure begins by mobilising all the organs from the left side of the abdomen, including the colon, stomach, and spleen. Then we transition to the right side. We mobilize the small intestine, the the beginning of it, which is a dudenum and the liver high. Uh we need to identify very, very important structures including the bowel ducts and the blood supply to the liver. Once they mobilize the pancreas off the retroperitoneum, they disconnect it from the GI tract at two places. One, after the pyoric muscle in the du duodenum, and two, downstream in the dujunum. After this, they string the dujunum off the retroperitoneum behind the colon, and then they disconnect the biliary duct. Once we have that disconnected, we preserve very carefully the blood supply to the head and the entire body until the pancreas until the very last moment because we cannot risk oxing these cells. Uh once we're ready to remove the pancreas, we cut off the blood supply and bring the pancreas outside of the abdomen. So once the pancreas is out, the surgeon prepare the organ for transport and the love physicians and techs start their part of the shop. To explain that to us, we have Dr. Rita Botino, the director of the islet program at Ema Pharma. Okay, I'm a clinical consultant and uh I'm the old stating the lab and probably with more experience in the isolation. What we do is first of all, we clean the pancreas, so we remove blood vessels, we remove fat tissue if there is adipose tissue, connective tissue. And then we isolate and cannulate the pancreatic ducts that we uh utilize as a channel to inject exocrine enzymes like collagenases, neutral proteases, a mixture of these enzymes that will start to break the extracellular matrix that holds all the cells together. So by injecting digestive enzymes into the pancreatic duct, the lab is able to disintegrate the extracellular matrix, releasing islet cells and exocrine cells, turning the organ from solid to a liquid form. If necessary, we can further separate the islets from the asiner cells. The main goal is to bring back to the operating table, the highest number of islets possible because the islet number correlates with the good outcome. As this will be injected into the portal vein, it is important to control the amount we infuse. That is why the maximum is 5 milliliters per bag and three bags per patient. So, depending on how many cells we have, we bring back to the operating room, one, two, or three bags that contains the cells, suspended in medium with albumin, heparin, and antibiotics. So, while all of this is happening in the lab, what it's going on in the OR? Well, they're doing this. Uh me along with my team, we start the reconstruction of the gastrointestinal tract. We bring a loop of uh of theum up uh towards to the to the biloy to perform a reconstruction and then we reconnect back another loop of intestine uh towards the uh uh the dudenum just pass the pyoric muscle. Then we uh hook both uh denal limbs. Along with this, uh we place a feeding tube to allow our patients to be fed while they heal our very important connections. We also leave drains where the spleen was removed and top of our connection with the biliary tract. So now the lab arrives to the OR with the islet cells and they start the infusion. And we transfuse back these islet cells into the portal vein with the hopes of these islet cells to go and implant in the liver and get ready to start producing insulin. While we infuse the islet cells, we're constantly checking the pressures in the portal vein to make sure we don't risk any thrombosis in the portal vein, which could cause a lot of morbidity to the patient. Once we achieve this, we close the abdomen. So now the surgery has ended, but this is not the end of our journey. Now, the patient goes to the ICU for a few days and we have to take care of them very carefully to assure a good recovery, prevent complications and discharge them as soon as possible. So let's hear from Dr. what is the post-operative care? We uh put them in the intensive care unit to control not only uh hemodynamics but uh fluid shift balance. We control their vital signs. We monitor them very closely. We want to make sure their islet cells are healing in a very homeostatic environment. We control uh their insulin, the exogen insulin. We also pay uh very close attention to their nutrition because this is key in the healing of all these important connections between the tract and the gastrointestinal tract as well. After the acute period, they transition to the diabetes floor where they complete their in hospital recovery. Well, once uh our team deemed them ready to be fully discharged, meaning their pain is absolutely well controlled, they're full feeds either via G tube feeds or by mouth, with glucose is well controlled via the continuous lupus monitoring and uh everything is aligned along with their full education that we provide here since children, they're ready to go home. And they go back to their cities where their local GI uh physician continue to follow them along with our team. So in summary, TPIAT is one of the most complex abdominal surgeries in children. Candidates include patients with chronic or acute recurrent pancreatitis. The surgery is a full day procedure that involves multiple specialists. It consists of removing the pancreas along with the duodenum and potentially the spleen with a reconstruction of the intestinal and biliary tract. After an infusion of the islet cells from the pancreas that were processed and recovered in the lab is done. The recovery takes part first in the ICU and then in the surgical floor, making sure to have a close glucose and insulin monitor. And with that, we conclude a day in the life of TPIAT. I hope you enjoy it and come back for more videos about pancreatic pathologies by the Pancreas Care Center here at Cincinnati Children's Hospital. Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.