Total Pancreatectomy with Islet Autotransplantation
The Total Pancreatectomy with Islet Autotransplantation (TPIAT) is a surgery for patients with chronic pancreatitis (CP) or recurrent acute pancreatitis (RAP) who suffer from severe pain and reduced quality of life. The procedure includes removing the entire pancreas and transplanting islet cells into the liver. This surgery should be done by a surgeon who is experienced in TPIAT. Not all pancreatitis patients are candidates for this type of surgery.
What is the Total Pancreatectomy with Islet Autotransplantation (TPIAT)?
The Total Pancreatectomy with Islet Autotransplantation (TPIAT) is a type of pancreas removal surgery, in which the pancreas, duodenum, and spleen are removed and islet cells (insulin-producing cells) from the pancreas are isolated and transplanted into the liver.
The TPIAT is a major surgery. It involves many hours under anesthesia and about a year of recovery.
The TPIAT involves two steps in one operation:
- Total Pancreatectomy (TP). The first step in the TPIAT involves removing the entire pancreas, duodenum (part of the intestine), and oftentimes, the spleen. The bile duct and stomach are then reconnected to the intestines.
- Islet Autotransplantation (IAT). After the pancreas is removed, the second step in the TPIAT involves taking your removed pancreas and isolating its islet cells, which are the cells that make insulin. These islet cells are then transplanted into your liver through the portal vein, which carries blood to the liver. This is done so the islet cells will start making insulin in the liver as they normally would in the pancreas, preventing lifelong diabetes.
The main goal of the TPIAT is to relieve pain, improve quality of life, and reduce the chances of developing diabetes in people suffering from severe chronic or recurrent acute pancreatitis. TPIAT addresses pancreas pain by surgically removing the pancreas, which is the source of pain. About 85% of patients who have had TPIAT report significantly less pain after surgery.
Listen to Dr. Melena Bellin of the University of Minnesota explain:
- Who should consider the TPIAT
- What’s involved in the TPIAT procedure
- TPIAT recovery and outcomes
Who is eligible for the TPIAT?
The TPIAT is a surgery available to chronic pancreatitis patients who experience severe, debilitating pain and reduced quality of life. Those with recurrent acute pancreatitis may also be considered for the TPIAT if the repeated episodes pose significant challenges to their daily life.
Certain hospitals or surgical centers may have different requirements, but generally, to be considered for the TPIAT, a patient should meet these requirements:
- Pancreatitis (chronic or recurrent acute) is the cause of abdominal pain
- The pain is severe enough to cause disability (missing school, work, family life, etc.) and/or results in opioid dependence
- There are functioning islet cells (ideally, the patient is not diabetic)
- Any other physical and mental health issues are managed
- The patient is a non-smoker or is able to completely stop smoking before and after the surgery
- The patient is willing to commit to a long and difficult recovery
- The patient is willing to commit to lifelong pancreatic enzyme replacement therapy, monitoring of complications, and likely diabetes
Listen to Amy, chronic pancreatitis patient, share her experience after getting the TPIAT.
What To Expect
TPIAT Evaluation
In order to determine if you qualify for the Total Pancreatectomy with Islet Autotransplantation, a care team will first provide a full evaluation to see if the TPIAT is the best option for treating your pancreatitis. The evaluation process is lengthy and can span over multiple days.
While each medical institution may have different evaluation processes, patients can typically expect to have appointments with the following:
- Medical Directors
- Surgeons
- Gastroenterologists
- Endocrinologists
- Pain Physicians
- Psychologists
- Physical Therapists
- Dieticians
- Islet Team
- Nurse Coordinators
- Local Primary Care Physician
- and more (anesthesiologist, pulmonologist, hematologist)
During the evaluation phase, your care team will ask you questions to better understand you, your condition, and why you’re considering the TPIAT. They’ll also explain the extent of the surgery, and what you can expect before, after, and during surgery. As part of your evaluation, you will also most likely need testing, such as blood tests, genetic testing, and imaging.
Day of TPIAT Surgery
On the day of the TPIAT surgery, you will be prepped and taken into an operating room. Here, you will be put under anesthesia, and surgeons will begin removing your pancreas, part of your duodenum, and, possibly, your spleen. Once these are removed, another team will come in to take the pancreas and begin isolating the islet cells. As this is being done, the surgeons will simultaneously reconnect the bile duct and stomach to the small intestine.
Once the islet cells are ready, the surgeon will transplant the islets back into your body by placing an IV into the portal vein, where they will flow into the liver. After this is done, the surgery is complete. You will then be taken to the recovery area and, later, your hospital bed. Altogether, the estimated length of the TPIAT is between 6 to 10 hours, although it can be longer.
TPIAT Recovery
After your TPIAT, you can expect to be in the hospital for 10 to 14 days; however, the recovery time is much longer and continues when you return home. The full TPIAT recovery time is estimated to be about 1 year. For some people, recovery may be even longer.
TPIAT recovery involves the following:
- Weaning off pain medications
- Weaning off insulin (if possible)
- Transitioning to a regular diet
- Adjusting the dose and timing of pancreatic enzymes
- Monitoring nutritional markers, fat-soluble vitamins, and other lab markers
Lifelong monitoring is required after the TPIAT. All patients after the TPIAT will be short-term diabetics and require insulin. Some patients may develop life-long diabetes.
Medical Management After TPIAT
Because the TPIAT removes the pancreas, medical management is required to replace normal pancreatic functions. Medical management can vary from person to person based on their needs and any complications that may arise.
Medical management after the TPIAT includes:
- Taking pancreatic enzymes with every meal/snack (lifelong)
- Taking multivitamins (recommended, preferably lifelong)
- Asplenia vaccines (to prevent spleen-related infections)
- Proton pump inhibitors (can be up to a year or longer)
- Insulin therapy (short-term or long-term)
- Pain medications (short-term)
- Frequent lab assessments (nutritional, diabetes, liver enzymes, etc.)
TPIAT Risks
TPIAT is a major surgery that carries significant risks. It’s important to talk to your healthcare team regarding the possible short-term and long-term complications associated with the TPIAT and to be prepared for any potential challenges.
Immediate Risks
Up to one month after the TPIAT, patients are at the highest risk for certain complications. As a result, if you traveled for the TPIAT, your surgeon may ask you to stay locally for some time to monitor you closely.
The immediate risks after TPIAT include:
- Infections
- Bleeding
- Acute surgical complications
Long-Term Risks
Those who have the TPIAT are also at risk of long-term complications. These complications include:
- Diabetes. About 60% of TPIAT patients will develop lifelong insulin-dependent diabetes, which is influenced by the number of successfully transplanted islets. Higher islet transplant quantities decrease the likelihood of insulin independence, while lower quantities raise the risk of diabetes.
- Pain. About 15% of patients who had the TPIAT report the same level of pain they experienced pre-surgery. This may be due to a different non-pancreas cause of pain, a surgical complication, or changes in the nervous system.
Learn more about pain management for chronic pancreatitis.
TPIAT Centers
Not every hospital performs the TPIAT. Medical Centers offering the TPIAT in the United States include:
- University of Minnesota
- University of Chicago
- Dartmouth
- Johns Hopkins
- Baylor University
- Cleveland Clinic
- University of Pittsburgh
- Virginia Commonwealth
- University of Virginia
- University of Alabama
- University of Louisville
- Ohio State University
- Cincinnati Children’s
- UCLA
- UC San Francisco
- MUSC Medical Center
- Columbia University
Frequently Asked Questions
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. How early TPIAT should be considered depends on the person. 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, leaving 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.
It’s important to wean off opioids after the TPIAT, which will improve outcomes when it comes to recovery of the nervous system and the pain nerves in your body. If this will be challenging, your care team can help you wean off opioids over time.
Partial resections and drainage procedures can make TPIAT less effective. The reason for this is that islet autotransplantation is less successful if other surgeries are performed first, which can lead to lifelong diabetes.
The estimated length of the TPIAT is between 6 to 10 hours, but it may be longer.
The spleen is a small organ that stores and filters blood. It also makes white blood cells that protect you from infections. It is removed during the TPIAT because it shares blood vessels with the pancreas.
The duodenum is the first part of your small intestine. Here, pancreatic enzymes from your pancreas and bile from your liver mix together to help break down food. It is removed during the TPIAT to help reconstruct your digestive tract.
Key Takeaways
- The Total Pancreatectomy with Islet Autotransplantation (TPIAT) is a major surgery where the pancreas, duodenum, and, sometimes, spleen are removed. Islet cells from the pancreas are then separated and transplanted into the liver.
- TPIAT aims to alleviate pain, improve quality of life, and reduce the risk of diabetes in individuals with severe chronic or recurrent acute pancreatitis.
- TPIAT candidates should have functioning islet cells, commit to a challenging recovery, and be willing to handle lifelong complications.
- TPIAT evaluation requires appointments with many medical specialists to determine whether it is right for a specific person.
- TPIAT surgery lasts approximately 6 to 10 hours or more, and recovery takes up to a year or more.
- Post-TPIAT recovery includes tapering off pain medications, managing insulin needs, transitioning to a regular diet, and more.
- Lifelong medical management is necessary after TPIAT, including pancreatic enzyme supplementation, vitamin intake, vaccinations, and potential insulin therapy.
- TPIAT carries immediate risks such as infections, bleeding, and surgical complications, as well as long-term risks like diabetes and persistent pain in certain cases.
