TPIAT is a surgical option for people with debilitating pain and impaired quality of life from acute recurrent or chronic pancreatitis. It is an innovative surgical procedure that combines a total pancreatectomy (removal of the whole pancreas) with islet autotransplantation (isolation of the islets that help manage blood sugar from the pancreas, followed by their transplantation into the liver via the portal vein).
What is total pancreatectomy with islet auto transplantation?
TPIAT removes the diseased pancreas, purifies and concentrates the islet cells (crucial for producing insulin), and then places those cells into the liver. Unlike other transplant procedures, TPIAT does not require immune suppression since it is your own islet cells being used. While it is a serious operation with significant risk and ramifications, over 90% of patients who have TPIAT show elimination or significant reduction in pain, and up to 30-40% don’t need to use insulin every day and are able to return to normal daily life.
TPIAT is discussed when treatment options such as medical management and endoscopic treatments do not relieve the symptoms of pancreatitis. It is an option only when other treatments have failed to relieve the pain and suffering related to the disease. The goal of the TPIAT is to provide pain relief and improve quality of life. TPIAT involves two steps in one operation:
- Total Pancreatectomy (“TP”) – This involves removing the entire pancreas and reconstructing the gastrointestinal tract. To prevent postsurgical complications, the appendix and gallbladder
are removed. The spleen is removed because of shared blood vessels with the pancreas. - Islet AutoTransplantation (“IAT”) – After the pancreas has been removed, an “islet isolation team” takes the pancreas to a laboratory where the islets are isolated and recovered. The islets have beta cells inside them. The beta cells are responsible for producing insulin. The team returns the islets to the operating room. The surgeon transplants them into your child’s liver. The hope is that these cells will continue to produce insulin as they did in the pancreas. We want the islet cells to make insulin and provide good blood glucose control. We will not know for several months if this will happen.
Patients who undergo TPIAT typically have been experiencing this type of abdominal pain for more than six months. They are unable to go to school or be active and have been hospitalized one or more times for the pain.
Who is A Candidate for TPIAT?
Patients with severe, debilitating pain caused by chronic or acute recurrent pancreatitis may benefit from TPIAT.
Patients who undergo TPIAT typically have been experiencing this type of abdominal pain for more than six months. They are unable to go to work or school or be active and have been hospitalized one or more times for the pain.
TPIAT Evaluation
Your care team will provide a full evaluation to decide whether TPIAT is the best way to treat your pancreatic problems. They will provide an overview about what the pancreas is supposed to do and explain how TPIAT may help people who are suffering from acute recurrent pancreatitis or chronic pancreatitis.
The evaluation visit can be time consuming. It usually takes multiple days to complete. It can include appointments with:
- Gastroenterology (GI)
- Surgery
- Endocrinology
- Pain Management
- Behavioral Medicine and Clinical Psychology (BMCP)
- Physical Therapy
- Social Work
- Infectious Disease
During the evaluation, your care team will collect all the information they need about your condition. It is a chance for your care team to get to know you and your family, and for you, to learn more about them. Goals for this visit are:
- Get to know you
- Evaluate your cause for pancreatic disease and assess the severity of the disease
- Test the function of the pancreas
- Understand what can expect from our team
- Share our thoughts about your pancreatic disease stage
- Give you a chance to ask questions and share concerns
- Decide if further testing is needed
- Determine whether TPIAT is a good option for you
You will most likely need testing as part of the evaluation visit. These tests might include:
- Blood tests
- Genetic testing
- Mixed meal test (MMT)
- Imaging tests, such as magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Endoscopic ultrasound (EUS)
You will meet with the surgeon to talk about what the operation involves, what the surgeon expects the outcome to be, and what your recovery will look like. You will also meet with an infectious disease doctor. This is because the TPIAT operation involves removing your spleen. It is important that have certain immunizations before the TPIAT to reduce the risk of getting a serious infection called sepsis. The infectious disease provider will discuss this with you.
After the evaluation is complete and all of your test results are available, your team will meet to decide what course of treatment is best for you.
Recovering after TPIAT
The weeks and months following surgery are very important for your long-term success.
During those first four to six weeks, you will return to the Pancreas Care Center for frequent follow-up appointments with your multidisciplinary care team. Your team will:
- Monitor your blood glucose control and islet function.
- Adjust medications as necessary.
- Make sure you’re getting the nutrition needed before and after the feeding tube is removed.
- Wean yourself from pain medications.
After this initial follow-up period, you will return to the clinic less frequently for check ups.
What to Expect Long Term
Most patients report significant pain relief and an improvement in their quality-of-life following TPIAT. In the months following surgery, they typically can return to school, social activities and even sports. Many patients are able to dramatically reduce or eliminate their need for narcotic pain relief.
Knowing whether you will remain on insulin therapy takes longer—up to a few months to a year or more.
Facts About Children Who Receive TPIAT
At Cincinnati Children’s their data for patients one year after the operation shows:
- 30 percent of children produce enough insulin on their own (no longer need insulin)
- 50 percent of children need to take a low amount of insulin (your child’s body is producing some or most of the insulin on its own)
- 20 percent of children need to take a moderate to high amount of insulin (your child’s body is producing little or no insulin on its own)
Younger children are more likely to stop needing insulin completely. Approximately two-thirds of children under age 8 do not need to take insulin at one year after their operation. During your TPIAT evaluation, your endocrinologist and surgeon will discuss your child’s possible insulin needs. Even if your child stops needing insulin, you will still stay in contact with your endocrinology team.
From now on, your child will have to take medication to replace certain digestive enzymes that are normally produced in the pancreas (pancreatic enzyme replacement therapy). However, your child will not need to take anti-rejection drugs after TPIAT, since the islets are transplanted from his or her own body and not from a donor.
