P97
TOTAL PANCREATECTOMY WITH ISLET CELL AUTO-TRANSPLANTATION (TPIAT) IN A 13 YEAR-OLD WITH CHRONIC PANCREATITIS: A CASE REPORT
M. Kellner1, S. Y. Ong2
1NHS GGC, Glasgow, UK
2NHS Lothian, Edinburgh, UK
Description:
Chronic pancreatitis (CP) in children is rare, yet can lead to significant morbidity (chronic pain, frequent admissions, poor nutritional state, poor quality of life). [1]
TPIAT is a surgical procedure involving pancreatectomy and auto-transplantation of islet cells into the patient's liver.
We present the youngest reported UK case of TPIAT for CP. Full written consent was obtained to present the case.
The patient was a 13 year-old male with a background of CP, pancreatic insufficiency (gastrostomy fed) and non-verbal autism with significant learning difficulties.
A decision to perform TPIAT was made following local, regional and national MDT discussion.
The patient was premedicated and anaesthetised via inhalational induction with parental presence. IV access was gained and nasal intubation performed. Thoracic epidural, central venous catheter, arterial line and urinary catheter were sited. Maintenance was using TIVA. Intra-operative analgesia comprised of paracetamol, magnesium, thoracic epidural.
Monitoring (standard plus CVP, core temperature, Narcotrend) was supplemented by arterial blood gases hourly for glucose and lactate levels.
An insulin sliding scale was commenced immediately post-pancreatectomy, glucose measured every 15 minutes and sliding scale adjusted accordingly. At end of operation glucose was 7.5.
Post-operatively the patient was transferred to PICU. Analgesia was thoracic epidural, Ketamine and Fentanyl infusions and IV paracetamol. Sedation was Dexmedetomidine and Propofol.
Discussion:
Surgically, this case is similar to adult practice, however anaesthetically there are additional considerations. The patient’s autism/learning difficulties added complexity and affected pre-operative assessment, induction of anaesthesia, airway management, analgesia and post-operative sedation. Significant involvement of the Learning Disability Liaison Nurse, pre-medication and inhalational induction facilitated a smooth induction. Decision for nasal intubation was made to optimise sedation post-operatively.
Tight blood glucose control (4-7) was paramount for the long-term success of the islet auto-transplant. A much higher rate of insulin was required than expected, before it plateaued, to control the glucose. This was done with input from the endocrinologist.
Total anaesthetic time was 18 hours. The time between pancreatectomy and islet cell transplant was almost 9 hours, a long time for both patient and anaesthetist. Theatre teams swapped at their usual shift hours and the surgical team had a prolonged break whilst waiting for islet cells, however the anaesthetists remained throughout the case.
Conclusion:
We present the youngest case of TPIAT in the UK. Autism/learning difficulties can create challenges and alter our approach to intra-operative and post-operative management. Time taken between pancreatectomy and infusion of islet cells was long and may in future warrant an anaesthetic team changeover. Tight glucose control is paramount. We would like to highlight the importance of the MDT approach in the management of this complex paediatric case.
Acknowledgements:
We would like to thank the patient and his family, and the whole multidisciplinary team.
Reference:
[1] Ellery KM, Uc A. Recurrent Pancreatitis in Children: Past, Present, and Future. Journal of Pediatric Gastroenterology and Nutrition. 70(4):p 413-416, April 2020. DOI: 10.1097/MPG.0000000000002619