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What You Need to Know About TPIAT (Total Pancreatectomy and Islet Auto-Transplantation)

TPIAT, or Total Pancreatectomy with Islet Autotransplantation, is a surgery primarily for people with recurrent acute and chronic pancreatitis. It involves the full removal of the pancreas and the storage of the patient’s own islet cells. If you suffer from pancreatitis, you might have questions regarding TPIAT surgery.

Considering TPIAT

I Suffer from Chronic Pancreatitis. Should I Get TPIAT Surgery?

Pancreatitis causes extreme pain and injury to the pancreas. People with acute, recurrent acute, or chronic pancreatitis may have pain due to strictures or stones that obstruct the pancreatic duct, inflammation, or anatomic changes like pseudocysts. Causes of pancreatitis can vary. Many patients have genetic factors that put them at a higher risk for pancreatitis. 

Pancreatitis is treated through a step-up approach. This means that the first step for treatment is medical therapy and surgical therapy is not considered unless medical therapy fails. Unfortunately, medical therapy for pancreatitis is limited. However, it includes supportive therapy for flares, a chronic pancreatitis pain management program, pancreatic enzyme replacement therapy (PERT), and antioxidant therapies. 

For patients with strictures or stones, endoscopic therapy might be considered as the second treatment option for pancreatitis if medical therapies fail and pain persists. Endoscopic therapy, also known as ERCP, uses a scope that goes down to the pancreatic duct to remove stones or place stents across strictures. 

If medical and endoscopic therapies fail, it might be appropriate to take surgical procedures into account. For patients with a disease that involves all of the pancreas, TPIAT is seen as the main surgical procedure. TPIAT might be the only surgical option for patients with a small or normal-sized pancreatic duct because certain procedures to drain the duct are not feasible.

Who should consider TPIAT? 

TPIAT may be considered when:

  • Pancreatitis (severe chronic pancreatitis or acute recurrent pancreatitis) is the cause of abdominal pain 
  • The pain is severe enough to cause disability
    • This includes missing school, work, or family life
  • The pain is severe enough to result in opioid dependence 
  • There are functioning islets
  • Surgery is ideal for non-diabetic patients
  • Any physical and mental health comorbidities are managed, so that surgery can be performed safely
  • Patient must be able to stop smoking before the surgery and long-term
  • The patient is willing to commit to a difficult recovery, a lifelong dependence on pancreatic enzymes, risk of diabetes, and lifelong monitoring for complications

At What Time Should TPIAT be Considered?

How early TPIAT should be considered depends on the individual. Factors like the course of pancreatitis and the cause of the disease are important when thinking about surgical intervention. Undergoing TPIAT surgery early on can have disadvantages: it is a major surgery that comes with risks and lifelong monitoring and treatment. However, an early intervention also has advantages. For example, it is possible that islet masses can be preserved better which leaves patients with less risk of long-term insulin dependence. Also, the earlier the intervention is done, the less the nerves are damaged and patients have a chance of complete pain relief. 

If TPIAT is an option, patients should avoid partial resections and drainage procedures. The reason for this is that islet autotransplantation is less successful if other surgeries are performed first.

Pain Relief, Removal of the Pancreas, and Islet Autotransplantation – What does TPIAT surgery involve?

For severe chronic pancreatitis patients, the main goal of TPIAT is pain relief. TPIAT surgery involves the removal of the pancreas, which relieves pain and improves quality of life. Also, through islet autotransplantation, the patient receives their own islet cells. This is done to prevent or minimize diabetes. If the pancreas is removed with no islet autotransplant, the patient would be an insulin-dependent diabetic after the surgery.

During a total pancreatectomy (TP), the entire pancreas is removed as well as the duodenum and spleen. The intestines and bile duct are then connected and some patients may need nutritional supplementation via a feeding tube.

During the islet autotransplant (IAT), the patient’s own islet cells are infused into the portal vein of the liver. This infusion triggers an inflammatory response, which will initially damage the cells which is why all patients are insulin dependent initially after surgery. If everything works well, the islets will engraft over time in the liver, and once engrafted, they will respond to glucose in the liver by releasing insulin.