In preparation for the procedure, patients should meet with the endocrinology team to establish baseline endocrine function and to receive diabetes education, as they will require an insulin taper following the surgery as the islet cells recover. A referral with the transplant surgery team should also be made to review the procedure risks as well as receive prophylactic vaccination in anticipation of the splenectomy that will occur with removal of the pancreas; these include the pneumococcal, H. Influenza type b, meningococcal, and annual influenza immunizations [3].

Technical aspects of the procedure will vary depending on the patient’s prior surgical history as well as the performing surgeon. In general, pancreatectomy for TP-IAT is unique in that blood flow to the organ must be preserved throughout the dissection to minimize warm ischemia time [4]. The spleen is removed with the distal pancreas, while the head and uncinate can be removed en bloc with duodenum, antrum, and distal portions of bile duct. Following explant, the organ is placed in static preservation solution to be prepped for islet isolation (Fig. 17.1). While some centers are equipped to perform the isolation intraoperatively, others may need to ship the preserved organ to a remote facility. The isolated islet suspension is then infused directly into the portal vein with heparin. Portal pressures should be measured throughout the infusion to minimize the risk of thrombosis, which becomes significantly elevated if pressures exceed 25 mm H₂O [5]. If maximal pressures prevent completion of portal vein infusion, excess islets can be injected into the omentum or peritoneum; these sites also enable engraftment, but to date, the portal vein remains the gold standard for islet infusion [6]. Lastly, we prefer to place a jejunostomy tube for enteral feeding as this can reduce rates of readmission, vomiting, and use of TPN, though comes with the risk of increased morbidity related to site infection and other complications [7, 8].

Postoperatively, patients will require strict glucose monitoring and control, as hyperglycemia has been shown to decrease beta cell graft mass in islet cell transplanted animal models [9]. Fingerstick blood glucose should be evaluated every hour, with a target range of 80–130 mg/dL. Nearly all patients will require an insulin drip during this phase, typically at rates between 1.0 and 3.0 units/h. Additionally, sliding scale bolus may be required with each tube feed to prevent hyperglycemia. Once the patient’s sugars are well controlled, they can be switched to a basal-bolus regimen with subcutaneous insulin, and fingerstick frequency can be reduced to every 4 h.

Patients will require tube feeds until they are able to tolerate an oral diet, and pancreatic enzyme supplementation will be required with every feed. In our experience, patients can often escalate to liquids within a few days and solids within weeks. It is critical they work with a dietician throughout this phase to ensure adequate nutrition and education is provided. Additionally, fat-soluble vitamin supplementation should also be considered, particularly vitamin D, as many patients are deficient prior to TP-IAT. For more detailed information on nutrition management with pancreaticoduodenectomy-induced exocrine insufficiency, see Chap. 12 – “Optimizing Nutrition for the Patient after Pancreaticoduodenectomy: Pancreatic Insufficiency.”