Total Pancreatectomy with Islet Autotransplantation (TPIAT)

TPIAT is one of the most complex abdominal surgical procedures performed in children

Surgical indications for TPIAT are for patients with either chronic or acute recurrent pancreatitis

Patients are candidates for TPIAT when all medical and endoscopic therapy has failed

TPIAT preparation involves months of advance evaluation by the entire Pancreas Care Center team including GI, social worker, endocrine, surgery, radiology, genetics, behavioral health, physical therapy, anesthesia and pain team

Patients require vaccinations for potential splenectomy as part of TPIAT preparation

Pain catheters are placed in the transversus abdominis muscle by pain specialists during TPIAT

The pancreas in TPIAT patients has often been injured for years, making the procedure quite challenging

Blood supply to the pancreas must be preserved very carefully until the very last moment to avoid hypoxia of islet cells

Islet isolation involves injecting exocrine enzymes (collagenases and neutral proteases) into pancreatic ducts to break down extracellular matrix

Islet number correlates with good outcome in TPIAT

Islet cells are suspended in medium with albumin, heparin, and antibiotics for infusion

Islet cells are transfused into the portal vein with the goal of implanting in the liver to produce insulin

Portal vein pressures are constantly monitored during islet infusion to prevent portal vein thrombosis

Post-operative ICU care focuses on controlling hemodynamics, fluid balance, vital signs, and maintaining a homeostatic environment for islet cell healing

Glucose and insulin are controlled via exogenous infusions in the immediate post-operative period

Nutrition is key in the healing of connections between the biliary tract and gastrointestinal tract

Discharge criteria include well-controlled pain, full feeds via G-tube or by mouth, well-controlled glucose via continuous glucose monitoring, and completion of patient education