Overview

Curative management of locally resectable invasive adenocarcinomas located in the cephalic region of the pancreas (pancreas, duodenum and ampulla of Vater) requires a pancreaticoduodenectomy followed by adjuvant chemotherapy. Pancreaticoduodenectomy is a major surgery that often leads to major complications including approximately 20% of relevant clinical postoperative pancreatic fistula.

Postoperative complications following pancreaticoduodenectomy can lead to early discontinuation of the complete oncologic strategy, i.e., chemotherapy for malignancy is performed in only about a third of patients who experienced a grade C fistula.

A total pancreatectomy rather than a pancreaticoduodenectomy is an alternative procedure that involves the complete and definitive resection of all pancreatic tissue, eliminating any risk of postoperative pancreatic fistula but is associated with unavoidable endocrine insufficiency and potentially severe metabolic complications, such as "brittle diabetes".

Total Pancreatectomy following by intraportal Islet AutoTransplantation (TPIAT) can prevent "brittle diabetes" and improve the quality of life. The endocrine islets can be isolated from the pancreatic surgical specimen with standardized procedures and transplanted in the liver through intraportal infusion, in absence of immunosuppression and allow adequate control of glucose metabolism with a reduced need for exogenous insulin and an effective graft function in 70% of cases at 3 years Thereby, the investigators hypothesize that total pancreatectomy with intraportal Islet autotransplantation rather than classical pancreaticuduodenectomy, in patients with high-risk of postoperative fistula will increase the rate of complete access to adjuvant chemotherapy, while maintaining an adequate metabolic control.

Eligibility

Inclusion criteria

        Inclusion criteria are composed of preoperative conditions validated by intraoperative
        confirmation to plan an exit of the protocol if the pancreas does not finally appear with a
        high-risk of CR-POPF.
          -  Age ≥ 18 years
          -  Locale resectable invasive adenocarcinomas located in the cephalic region of the
             pancreas documented by endoscopic ultrasonography with fine-needle aspiration biopsy
          -  pancreatic adenocarcinoma;
          -  duodenal adenocarcinoma;
          -  ampullary adenocarcinoma;
          -  and IPMNs with adenocarcinoma degeneration;
          -  A potentially curative strategy with primary tumor resection approved by a
             multidisciplinary expert team
          -  A high-risk of CR-POPF
               1. Suspected during preoperative evaluation by the presence of 2 or more of the
                  following criteria (screening criteria of inclusion) : sex male;an obesity (BMI ≥
                  30 kg/m2);a main pancreatic duct diameter ≤ 3 mm on preoperative endoscopic
                  ultrasonography a visceral obesity (i.e. a visceral fat area > 84 cm2) ; a
                  sarcopenia (i.e. a skeletal muscle index < 43 cm2/m2 in men with a BMI of <25
                  kg/m2 or <53 cm2/m2 in men with a BMI of ≥25 kg2/m2, and <41 cm2/m2 in women)
               2. and validated during intraoperative evaluation (finale inclusion) by a
                  probability score above or equal to 20% on the validated updated alternative
                  Fistula Risk Score ua-FRS for pancreaticoduodenectomy (ua-FRS) based of pancreas
                  texture, duct size, BMI, sex .
          -  Women of childbearing potential should only be included after a confirmed menstrual
             period, and a negative highly sensitive urine or serum pregnancy test and must agree
             to be subjected to a monthly pregnancy test (urine or blood) until the end of the
             relevant systemic exposure to chemotherapy agents, in accordance with current CTFG
             recommendations (Recommendations related to contraception and pregnancy testing in
             clinical trials);
          -  Women of child-bearing potential and male subjects must agree to use a birth control
             methods which may be considered as highly effective (failure rate of less than 1% per
             year ) as recommended by the CTFG (Cinical Trials Facilitation and Coordination Group,
             version 1.1). These recommandations related to contraception and pregnancy testing in
             clinical trials suggested such method (see below) that will be use during chemotherapy
             exposure for included women of child-bearing potential and woman of child-bearing
             potential when partner of included male : combined (estrogen and progestogen
             containing) hormonal contraception associated with inhibition of ovulation (oral,
             intravaginal or transdermal) ; progestogen-only hormonal contraception associated with
             inhibition of ovulation (oral, injectable or implantable) ; intrauterine device (IUD)
             ; intrauterine hormone-releasing system ( IUS) ; bilateral tubal occlusion;
             vasectomised partner ;sexual abstinence For included male partner of a women of
             child-bearing potential, contraception with condom.
        Contraception will be perform during the relevant systemic exposure to chemotherapy agents
        and will be extended by 6 months for women of childbearing potential and by 1 month for men
        included as recommended by the CTFG
          -  Patient covered by a health insurance system
          -  Patient who provides a written informed consent to participate to the study
        Exclusion criteria
          -  Patient will be screened and excluded if they present a preoperative diabetes defined
             by a stimulated C-peptide < 0.5 ng/mL relative to blood glucose > 2 g/dL, at 2 hours
             in post prandial
          -  Patients with a known or highly suspected genetic syndrome associated with a risk of
             pancreatic adenocarcinoma: familial pancreatic cancer, multiple familial melanoma,
             Peutz-Jeghers syndrome, hereditary chronic pancreatitis, cystic fibrosis, familial
             breast Ovarian Cancer, Lynch syndrome, adenomatous polyposis family, Li Fraumeni
             syndrome, Multi-endocrine disorder type I;
          -  Multifocal pancreatic adenocarcinomas identified during preoperative evaluation;
          -  Performance status and comorbidity profile inappropriate for a major abdominal
             surgery;
          -  Contraindication for autologous islet intraportal transplantation
          -  Current or indicated/scheduled neoadjuvant chemotherapy;
          -  Extra pancreatic metastasis identified during preoperative evaluation (high-definition
             cross-sectional imaging with thorax-abdomen-pelvis multi-detection computed tomography
             or abdominal MRI with T1, T2 and diffusion weighted sequences) or during
             intraoperative assessment (clinical examination and ultrasonography);
          -  Need for complex vascular reconstructions (endovascular treatment or release of the
             arcuate ligament will be not considered as complex vascular reconstructions), major
             vein reconstructions will exclude the patients because of the over-risk of portal
             thrombosis following islet intraportal infusion.
          -  evident macroscopically or biologically proved post biliary drainage pancreatitis that
             jeopardize islet isolation
          -  Known infection or positive serology performed at screening for human immunodeficiency
             virus (HIV) infection, Hepatitis B or C virus infection, HTLV infection or syphilis
             infection.
          -  Active infection for SARS-CoV-2 virus (positive PCR), which will require rescheduling
             of the intervention 30 days later.
          -  Pregnant or breastfeeding woman
          -  Dihydropyrimidine dehydrogenase total deficiency
          -  Ethics / regulatory criteria :
               -  Person unable to understand purposes, benefits and risks of the study and/or
                  unable to provide a written informed consent.
               -  Person unable to comply with the whole study schedule.
               -  Person not covered by a health insurance system.
               -  Person kept in detention and/or receiving psychiatric medical care and/or
                  patients admitted in a social or medical sanatorium.
               -  Person in an emergency situation.