Tag Archives: TPIAT

Big Study: Total Pancreatectomy with Islet Autotransplantation (TPIAT) for Chronic Pancreatitis

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T Guru et al. Gastroenterology 2025: 169:1499 – 1509. Total Pancreatectomy With Islet Autotransplantation for Chronic Pancreatitis

This prospective multicenter study included 384 patients with a mean age of 30 years (34% pediatric).

Key findings:

  • Daily abdominal pain decreased from 65% to 23%, whereas the mean pain score decreased from 4.9 (SD, 2.3) to 2.3 (SD, 2.5; both P < .001)
  • Opioid use decreased (assessed over a 14-day interval) from 61% before to 24% at 1 year after TPIAT (P < .001)
  • Improved physical and mental health: Physical component summary and mental component summary scores improved by ≥10 points in 58% and 35%, respectively
  • Mean hemoglobin A1c was 7% (SD, 1.9%) with 20% insulin independent at 1 year
  • Young age was associated with better outcomes, whereas duration and etiology of disease did not predict response to TPIAT

In their discussion, the authors note that it had been “widely hypothesized that after several years of pain, mechanism shift to solely neuropathic pain, such that surgery would be unlikely to offer benefit. Our results suggest this is not true.”

My take: This study provides robust data supporting TPIAT as average pain scores declined by more than 50%, the need for opioid analgesics decreased substantially, and mental health/physical health/QOL all improved. Most maintained glycemic control.

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    NASPGAN Paper: Surgery for Chronic Pancreatitis: Choose Your Operation and Surgeon Carefully

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    JD Nathan et al. JPGN 2022; 74: 706-719. Open Access: The Role of Surgical Management in Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee

    This society paper provides a terrific review of potential operations and rationale in children with chronic pancreatitis. Some of the highlights from this open access article include figures detailing the anatomical considerations of the operations (eg. Frey, Modified Puestow, TPIAT, Berger, Whipple, and Berne) and an algorithm in choosing which procedure should be considered.

    Key points:

    • Surgery is indicated for children with debilitating CP who have failed maximal medical and endoscopic interventions.
    • A conventional surgical approach (eg, drainage operation, partial resection, combination drainage-resection) may be considered in the presence of significant and uniform pancreatic duct dilation or an inflammatory head mass.
    • Total pancreatectomy with islet autotransplantation is the best surgical option in patients with small duct disease.
    • The presence of genetic risk factors often portends a suboptimal outcome following a conventional operation.

    My take: Fortunately, very few children need operations for chronic pancreatitis. As such, surgical expertise/judgement is particularly important.

    Figure 1

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    Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

    Pancreatitis Update (part 1)

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    Our group received a very helpful update on pancreatitis from Maisam Abu-El-Haija (GI) and Jaime Nathan (surgery). My notes may include some errors in transcription and errors of omission. Some pictures of the slides are included below as well.

    Key points:

    • About 30% of acute pancreatitis patients have a 2nd bout of pancreatitis. Obesity is a risk factor for recurrence.
    • There has been a recent increase in incidence of acute pancreatitis.
    • Cincinnati has a gene panel to examine the four most common mutations which cause hereditary pancreatitis (PRSS1, SPINK1, CFTR, and CRTC) along with 6 other relevant genes. (28 day turnaround) In addition, there is a pancreatitis insufficiency panel.
    • Discussed screening for pancreatic insufficiency.  Directly measuring pancreatic enzymes are more sensitive for early insufficiency, but may be unnecessary if good growth and normal stool elastase.
    • There are NO proven medical/dietary therapies to prevent recurrent or chronic pancreatitis and eliminate pain symptoms.

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    Total Pancreatectomy with Islet Autotransplantation for Refractory Recurrent Pancreatitis

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    A recent study (MD Bellin et al. Clin Gastroenterol Hepatol 2016; 14: 1317-23) describes the use of Total Pancreatectomy with Islet Autotransplantation (TPIAT) in 49 patients (mean age 32.8 years).  This study included 6 children.

    All of these patients met strict criteria for recurrent acute pancreatitis and lacked imaging or functional evidence for chronic pancreatitis.  All 49 required narcotics for pain management prior to TPIAT.

    The surgical technique for TPIAT is well-described in the report.  Patients underwent total pancreatectomy, splenectomy, cholecystectomy and partial duodenectomy with continuity restored via doudenoduodenostomy or Roux-en-Y duodenojejunostomy.  The islets were isolated and then infused intraportally.

    Key findings:

    • At 1 year following TPIAT, 22 (46%) reported no use of narcotic pain medications.
    • Health-related quality of life scores improved (see Figure 3)
    • Diabetes is a common post-op concern.  Approximately half were insulin-independent at 1 and 2 years out from surgery, with one-third remaining so at 5 years.
    • Histopathology was consistent with chronic pancreatitis in 37 (76%) indicating that current imaging/functional features do not reliably identify chronic pancreatitis with adequate sensitivity.

    In the discussion, the authors note the selected patients, due to having normal caliber pancreatitis ducts, were not candidates for surgical drainage procedures like the Puestow procedure.  They also note that the Puestow procedure can compromise later islet cell isolation.

    My take: TPIAT is an important option in those with severe recurrent or persistent pancreatitis disease.

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