Islet Cell / TPIAT
Also covered as: acute recurrent pancreatitis Β· chronic pancreatitis
Educational content from recorded physician discussions β not medical advice. Always talk to your child's care team about your child's situation.
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Fundamentals
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Welcome and Introductions: Pancreatic Disease
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Dr. Todd Ponsky introduces the event onacute pancreatitis, recurrent and chronic pancreatitis, exocrine insufficiency, interventional procedures as well as surgical indications for the diseased pancreas in children, culminating with a state
video6:04 Β· Jan 2019
Surgical Management
2 items
Total Pancreatectomy with Islet Autotransplantation: Pancreatic Disease
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Dr. Jaimie Nathan introduces the session, covering indications for total pancreatectomy with islet auto-transplantation(TPIAT), pre-TPIAT evaluation, pre- and post-operative management, and long-term follow-up.Dr. Joe Palermopresents a chro
video47:20 Β· Jan 2019
Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center
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In this video, we take you through a Total Pancreatectomy with Islet Autotransplantation (TPIAT)βone of the most complex abdominal surgeries performed in children. Learn about who qualifies for TPIAT, the surgical process, and the critical
video10:19 Β· Dec 2024
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Total pancreatectomy with islet autotransplantation (TPIAT) is indicated for chronic pain unresponsive to medical and endoscopic therapy or significantly impaired quality of life from acute recurrent pancreatitis [e973-c1, e973-c2]. The procedure involves total pancreatectomy with near-total duodenectomy, splenectomy, and portal vein infusion of autologous islets isolated via collagenase digestion [e973-c22, e973-c23, e10147-c21]. Portal pressures exceeding 25 cm HβO carry tenfold increased thrombosis risk . Perioperative protocols include methadone, ketamine, lidocaine infusions, heparin for one week, and dexamethasone to blunt instant blood-mediated inflammatory response [e973-c21, e973-c32, e10147-c23]. Complication rates approximate 15β20%, with bleeding in 5β7% and portal vein thrombosis in a handful of percent . Up to 85β90% achieve opioid independence, and 40% of children reach insulin independence by 12 months, rising to 55% in those under 12 years [e973-c38, e973-c40, e973-c42]. Younger children demonstrate superior beta-cell replicatory capacity and possible ductal neogenesis [e973-c43, e10147-c30]. Prior ductal drainage or resection reduces islet yield by approximately 50%, and genetic factorsβparticularly PRSS1 mutationsβcorrelate with disease severity and cancer risk [e10147-c32, e10147-c41, e10147-c42, e10147-c43]. Insulin independence correlates with islet yield >5000 IEQ/kg, though HOMA-Ξ² and microRNA-375 may offer superior prediction [e10147-c28, e10147-c36, e10147-c37].
- TPIAT achieves 85β90% opioid independence and 40% insulin independence in children, with best glycemic outcomes (55%) in patients under 12 years old.
- Portal vein pressure changes >25 cm HβO during islet infusion carry tenfold increased thrombosis risk; complication rate is 15β20%.
- Prior Puestow or distal pancreatectomy reduces islet yield by ~50%, lowering insulin-independence probability but not contraindicating TPIAT.
- Perioperative dexamethasone and heparin infusions mitigate instant blood-mediated inflammatory response; all patients experience delayed gastric emptying for 3β5 weeks.
- PRSS1 mutations carry 40% cancer risk by age 50, lowering threshold for intervention; genetic screening identifies risk factors in 68% of chronic pancreatitis patients.
For patients & families
When a child has severe, ongoing pancreas pain that doesn't get better with medicine or other treatments, doctors may talk about a surgery called TPIAT β total pancreatectomy and islet auto-transplantation. The main goal is to stop the pain that keeps children from school, activities, and normal life. During the operation, surgeons remove the entire pancreas and collect special cells called islets that make insulin. These islet cells are then put back into the child's liver, where they can start making insulin again. Before surgery, a team of many specialists β doctors, social workers, pain experts, and others β carefully evaluates whether TPIAT is the right choice. After surgery, all children will need insulin at first because the transplanted islets take time to start working. Over the first year, about 40% of children can stop needing insulin shots, and most children are able to stop taking pain medicines. Younger children tend to have better results. The operation is complex and recovery takes several weeks, but for many families it offers hope for a life without constant pain.
When a child has severe, ongoing pancreas pain that doesn't get better with medicine or other treatments, doctors may talk about a surgery called TPIAT β total pancreatectomy and islet auto-transplantation. The main goal is to stop the pain that keeps children from school, activities, and normal life. During the operation, surgeons remove the entire pancreas and collect special cells called islets that make insulin. These islet cells are then put back into the child's liver, where they can start making insulin again. Before surgery, a team of many specialists β doctors, social workers, pain experts, and others β carefully evaluates whether TPIAT is the right choice. After surgery, all children will need insulin at first because the transplanted islets take time to start working. Over the first year, about 40% of children can stop needing insulin shots, and most children are able to stop taking pain medicines. Younger children tend to have better results. The operation is complex and recovery takes several weeks, but for many families it offers hope for a life without constant pain.
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Every expert statement below comes from the recorded discussions, with its speaker and moment.
Welcome and Introductions: Pancreatic Disease
Cincinnati Children's has been leading the world in pediatric surgical education
opinionTodd Ponsky0:28 β
The event will be recorded and available after 48 hours
clinicalTodd Ponsky1:22 β
A new video portal will allow users to search by keyword and watch specific segments rather than entire events
clinicalTodd Ponsky1:27 β
The Center of Telehealth at Cincinnati Children's is used daily by experts to help physicians and patients around the world
clinicalTodd Ponsky2:00 β
Cincinnati Children's Pancreas Care Center is staffed by a large multidisciplinary group rather than one or two specialists
clinicalTodd Ponsky2:38 β
Dr. Jamie Nathan is assistant professor of surgery and pediatrics, a pediatric and transplant surgeon, and surgical director of the Pancreas Care Center at Cincinnati Children's
host_summaryTodd Ponsky3:06 β
The day's sessions will cover surgical approaches, interventional endoscopic approaches, and medical management of acute, acute recurrent, and chronic pancreatitis
clinicalJamie Nathan3:38 β
Dr. Joe Palermo is a pediatric gastroenterologist and medical lead of the total pancreatectomy and islet auto transplantation program
clinicalJamie Nathan4:05 β
Ken Goldschneider is director of pain management at Cincinnati Children's, professor of clinical pediatrics and anesthesia, and plays a central role in pain management for patients with pancreatic diseases
clinicalJamie Nathan4:23 β
Dr. Maisam Abu El-Haija is a gastroenterologist, co-director of the course, and medical director of the Pancreas Care Center
clinicalJamie Nathan4:40 β
Tom Lynn is a gastroenterologist who manages the vast majority or all endoscopic needs for children with pancreatic disorders, director of endoscopy for the Pancreas Care Center, and co-director of endoscopy for the division of gastroenterology
clinicalJamie Nathan4:54 β
Andrew Trout is the lead radiologist for the Pancreas Care Center, assistant professor of radiology, and dual certified in pediatric radiology and nuclear medicine
clinicalJamie Nathan5:17 β
Dr. Deb Elder is the endocrine director for the Pancreas Care Center and will join later in the event
clinicalJamie Nathan5:33 β
Dr. Milton Smith is medical director of therapeutic ERCP at University of Cincinnati and will join later in the event
clinicalJamie Nathan5:47 β
Total Pancreatectomy with Islet Autotransplantation: Pancreatic Disease
TPIAT is indicated for chronic pain unresponsive to optimal medical and endoscopic approaches or surgical approaches and significantly impaired quality of life with repeated acute pancreatitis episodes, repeated admissions, missed school or work.
guidelineJoe Palermo5:28 β
The main indication for TPIAT is chronic pain, not the transplant outcome; the primary goal is pain relief and full function, with insulin independence being secondary.
opinionJamie20:31 β
TPIAT criteria include diagnosis of acute recurrent pancreatitis or chronic pancreatitis, chronic pain of greater than 6 months duration with either daily opioid use or severely impaired quality of life, absence of reversible cause, failure of medical or endoscopic intervention, and adequate beta cell function.
guidelineJamie23:20 β
Contraindications to islet autotransplantation include pre-existing insulin dependent diabetes mellitus, liver disease with portal hypertension or portal vein thrombosis.
guidelineJamie23:59 β
Patients with central sensitization of pain, functional pain disorders, drug seeking behavior, or severe psychosocial maladaptation do not do as well after TPIAT.
clinicalJamie24:35 β
Prior ductal drainage procedures and distal pancreatectomy compromise islet yield.
clinicalJamie29:41 β
Surgical drainage procedures are avoided in patients anticipated to require future TPIAT, particularly those with genetic etiologies.
guidelineJamie29:50 β
Portal vein pressures exceeding 25 centimeters of water pressure are associated with higher risk of portal vein thrombosis post TPIAT.
clinicalJamie31:45 β
Tight glucose control between 80 and 120 is critical postoperatively to protect from toxic hyperglycemia, as islets do not resume function immediately and rely on diffusion of nutrients and oxygen until neovascularization occurs over weeks to months.
clinicalJamie32:43 β
Up to 85-90% of TPIAT patients can achieve opioid independence, with most improvement occurring over the first several months.
epidemiologicalJamie36:56 β
In children, 40% of TPIAT patients achieve insulin independence (typically over the first 12 months), 30% have partial graft function requiring basal insulin only, and 30% require basal-bolus insulin.
epidemiologicalJamie37:37 β
Data from Minnesota shows the best outcomes in patients under 12 years old, with up to 55% insulin independence rate.
epidemiologicalJamie37:57 β
Higher replicatory capacity of islets in younger children and possible islet neogenesis of ductal origin may explain better outcomes in younger patients.
clinicalJamie38:14 β
Islet function has been shown to be durable in children for as long as 10 years post TPIAT and is especially good for patients under 21 or with a short history of pancreatic disease.
epidemiologicalJamie38:26 β
All TPIAT patients have delayed gastric emptying that resolves in several weeks, typically by 3-5 weeks.
clinicalJamie30:41 β
Complications occur in 15-20% of TPIAT cases, including bleeding (5-7%), abscesses, wound infections, bowel obstructions, portal vein thrombosis, and anastomotic leaks.
epidemiologicalJamie36:16 β
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