Introduction

Liver cirrhosis (LC) and common bile duct (CBD) malignancy often require combined liver transplant (LT) and pancreatectomy (PE). Total pancreatectomy (TP) often results in unstable glucose control (GC); hence the surgically more risky pancreaticoduodenectomy (PD) is often preferred. TP and pancreatic islet autotransplantation (IAT) is another option that may offer GC. We report our first experience with IAT after residual PE for pancreatic fistula (PF) following split LT and PD.

Case report

A 64-year-old non-diabetic male with LC due to autoimmune hepatitis was eligible for LT after six weeks on the waiting list. He had been diagnosed with high-grade dysplasia (HGD) in the CBD. At the time of LT, the liver graft was split to give the left lateral segment to a pediatric recipient. Our patient was left with the remaining extended right liver graft. The intraoperative histology assessment (HA) of the CBD margin revealed HGD and PD was then performed. A final HA later confirmed one metastatic lymph node by the CBD. Eleven days postoperative a PF was obvious and a rescue PE and splenectomy were done. The pancreatic remnant was sent to the Rudbeck Laboratory for islet isolation.

Results

A total of 86 grams of pancreatic tissue yielded 71087 islet equivalents (IEQ) with a stimulation index of 4.9. Two days post PE the islet suspension was successfully infused into the portal vein by percutaneous approach. Enbrel® was added to the existing immunosuppressive therapy. The patient underwent multiple reoperations and was finally discharged after seven weeks to his local hospital where he stayed for one month due to recurrent infections, intra-abdominal abscesses, and rehabilitation. Due to fasting hyperglycemia, postoperative exogenous insulin was required at time of discharge (26 U/d), but stable glucose control was achieved with positive C-peptide levels. At our patient's one and six month follow-ups, his fasting C-peptide levels were 147 pmol/L and 219 pmol/L respectively and HbA1c at three months 6.8%.

Conclusion

IAT of residual pancreas in patients with PF after PD and split LT is technically feasible. A relatively low IEQ should not prevent IAT as the short and long term islet loss is considered to be less prominent in the setting of auto transplantation. IAT should be considered whenever a rescue PE is needed as it may provide stable GC and improved quality of life.

CITATION INFORMATION: Horneland R, Guvåg S, Korsgren O, Aandahl E. Pancreatectomy and Islet Autotransplantation After Combined Split Liver Transplantation and Pancreaticoduodenectomy: A Case Report. Am J Transplant. 2017;17 (suppl 3).

« Back to 2017 American Transplant Congress