Total Pancreatectomy with Autologous Islet Transplantation

Total pancreatectomy with autologous islet transplantation (TPIAT) is a complex pancreas-preserving surgical strategy for selected patients with severe debilitating chronic pancreatitis refractory to conservative and endoscopic therapy. The pancreas is completely removed, the islets of Langerhans are isolated using collagenase-Liberase digestion in a specialized laboratory, and the islet preparation is infused into the portal vein for engraftment in the liver.

Indications include intractable pain from chronic pancreatitis (idiopathic, hereditary CFTR/PRSS1/SPINK1 mutations, post-traumatic, autoimmune), recurrent acute pancreatitis with daily pain, narcotic dependence, and quality-of-life impairment. Pre-operative evaluation includes endocrine function (HbA1c, mixed-meal tolerance test, C-peptide), exocrine function, psychosocial assessment, and exclusion of malignancy.

The procedure involves total pancreatectomy with splenectomy and Roux-en-Y reconstruction. Islet yield (target > 5,000 IEQ per kg body weight) determines insulin independence at 1 year (30-50%) versus partial graft function reducing exogenous insulin needs. Long-term outcomes include pain relief in 60-80%, opioid weaning, weight gain, and improved quality of life. Lifelong exocrine enzyme replacement is required. Complications include portal vein thrombosis, hepatic bleeding, surgical site infection, and brittle diabetes.