Total Pancreatectomy with Islet Autotransplantation (TPIAT)
The Pancreas Care Center (PCC) at Cincinnati Children’s Hospital Medical Center is one of only a few institutions in the United States offering total pancreatectomy with islet autotransplantation (TPIAT) for patients as young as three years old.
If your child suffers from severe, debilitating pain due to chronic or acute recurrent pancreatitis, TPIAT may help. The procedure, part of which involves removal of the pancreas and reconstruction of the gastrointestinal tract, has made it possible for many children to return to their normal activities without pain.
Surgically removing the pancreas is a dramatic step, and the recovery process can take several months. Our team will give you the information and support you need to make the best decision for your child.
Treatment Approach
Our pediatric specialists have years of experience in managing pancreatic disease in children. They work together to address each child’s unique physiological, nutritional, and psychosocial needs before, during and after TPIAT.
The multidisciplinary team includes pediatric gastroenterologists, surgeons, pain management specialists and endocrinologists. They see the patient and family in the outpatient clinic and meet frequently with one another to discuss the care plan. Their individual perspectives help establish a balanced picture of how the patient is doing and how to proceed. Patients receive additional support throughout their course of treatment from nurse practitioners, nurses, social workers, genetic counselors, and diabetes educators.
In addition, our team works closely with colleagues at the University of Cincinnati Medical Center, who were among the first in the country to perform TPIAT in adolescents and adults.
What is TPIAT?
TPIAT is discussed when treatment options such as medical management and endoscopic treatments do not relieve the symptoms of pancreatitis. It is an option only when other treatments have failed to relieve the pain and suffering related to the disease. The goal of the TPIAT is to provide pain relief and improve quality of life. TPIAT involves two steps in one operation:
- Total Pancreatectomy (“TP”) - This involves removing the entire pancreas and reconstructing the gastrointestinal tract. To prevent postsurgical complications, the appendix and gallbladder are removed. The spleen is removed because of shared blood vessels with the pancreas.
- Islet AutoTransplantation (“IAT”) - After the pancreas has been removed, an “islet isolation team” takes the pancreas to a laboratory where the islets are isolated and recovered. The islets have beta cells inside them. The beta cells are responsible for producing insulin. The team returns the islets to the operating room. The surgeon transplants them into your child’s liver. The hope is that these cells will continue to produce insulin as they did in the pancreas. We want the islet cells to make insulin and provide good blood glucose control. We will not know for several months if this will happen. Cincinnati Children’s islet lab allows for on-site extraction of islet cells. This offers patients the benefits of higher quality islet cell production, reduced operating time and a faster recovery. Research also shows that patients who receive TPIAT with on-site islet cell preparation show less dependence on insulin after surgery.
Patients with severe, debilitating pain caused by chronic or acute recurrent pancreatitis may benefit from TPIAT. Your child’s doctor may recommend it if other treatments have failed.
Patients who undergo TPIAT typically have been experiencing this type of abdominal pain for more than six months. They are unable to go to school or be active, and have been hospitalized one or more times for the pain.
Who is a Candidate for TPIAT?
Patients with severe, debilitating pain caused by chronic or acute recurrent pancreatitis may benefit from TPIAT. Your child’s doctor may recommend it if other treatments have failed.
Patients who undergo TPIAT typically have been experiencing this type of abdominal pain for more than six months. They are unable to go to school or be active, and have been hospitalized one or more times for the pain.
TPIAT Evaluation
Our care team will provide a full evaluation to decide whether TPIAT is the best way to treat your child’s pancreatic problems. We first want to give an overview about what the pancreas is supposed to do. We want to explain how TPIAT may help people who are suffering from acute recurrent pancreatitis or chronic pancreatitis.
The evaluation visit can be time consuming. It usually takes multiple days to complete. It can include appointments with:
- Gastroenterology (GI)
- Surgery
- Endocrinology
- Pain Management
- Behavioral Medicine and Clinical Psychology (BMCP)
- Physical Therapy
- Social Work
- Infectious Disease
During the evaluation, our care team will collect all the information we need about your child’s condition. It is a chance for our care team to get to know you and your family, and for you, to learn more about us. Our goals for this visit are:
- Get to know you and your child
- Evaluate your child’s cause for pancreatic disease and assess the severity of the disease
- Test the function of the pancreas
- Understand what you and your child can expect from our team
- Share our thoughts about your child’s pancreatic disease stage
- Give you and your child a chance to ask questions and share concerns
- Decide if further testing is needed
- Determine whether TPIAT is a good option for your child
We will also want to make sure that you, your child and family know:
- Details of your child’s illness
- What TPIAT involves
- Risks, benefits, and both expected and unexpected outcomes of TPIAT
Your child will most likely need testing as part of the evaluation visit. These tests might include:
- Blood tests
- Genetic testing
- Mixed meal test (MMT)
- Imaging tests, such as magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Endoscopic ultrasound (EUS)
You will meet with the surgeon to talk about what the operation involves, what the surgeon expects the outcome to be, and what your child’s recovery will look like. You and your child will also meet with an infectious disease doctor. This is because the TPIAT operation involves removing your child’s spleen. It is important that your child has certain immunizations before the TPIAT to reduce the risk of getting a serious infection called sepsis. The infectious disease provider will discuss this with you.
After the evaluation is complete and all of your child’s test results are available, the PCC team will meet to decide what course of treatment is best for your child. The team will answer these questions before making a decision:
- What caused your child’s pancreatic disease?
- How severe is the disease?
- Will TPIAT improve your child’s quality of life?
- Are there any medical issues that may prevent a successful surgery?
- Are there any other treatment options besides a TPIAT that could benefit your child?
- Does your family have the support needed to get through the TPIAT process, including the hospital stay?
- Does your family have the resources needed to meet your child’s needs during this challenging time?
After the team finalizes the recommended treatment plan for your child, the gastroenterology nurse will contact you. The recommendation will be one of these options:
- Approved: Your child is a candidate for TPIAT. We can proceed with the scheduling process.
- Deferred: Your child is not a candidate for TPIAT at this time. The team will work with you and your child’s primary gastroenterologist (GI doctor) to create a treatment plan that does not include TPIAT for now.
- Decision Pending: Your child needs further testing or evaluation before the team can make the decision.
- Not a Candidate: The child is not a candidate for TPIAT.
The team will talk with you about other treatment options for your child. You will be able to talk with the doctor or nurse about the treatment recommendation and next steps.
During Surgery
TPIAT can last the majority of the day. Our surgery nurse practitioners play an important role during this long day. They will provide your family with updates from the operating room and spend time with you and your child in the pediatric intensive care unit after surgery.
