Total pancreatectomy with islet autotransplantation (TPIAT) can ease the severe pain caused by acute and chronic pancreatitis. But while solving one problem, TPIAT can lead to another: fully insulin-dependent post-pancreatectomy diabetes. Pediatric endocrinologists at Cincinnati Children’s are developing new strategies to reduce the risk, including early initiation of insulin pump therapy.  

TPIAT involves removing the entire pancreas and reconstructing the gastrointestinal tract. After the pancreas is removed, it is taken to a laboratory, where skilled technicians remove islet cells, which are responsible for producing insulin and other hormones. The islets are infused into the patient’s liver via the portal vein. These cells need time to develop blood supply in the liver in the first seven to 10 days following transplant. This is known as the critical engraftment period, when islet cells are at the highest risk for metabolic failure and necrosis.  

A glucotoxic environment can further escalate that risk, which is why the TPIAT team prioritizes tight glycemic control beginning in the intensive care unit. There, patients receive intravenous insulin with the goal of achieving a blood glycemic range of 80-120 mg/dL. Before 2017, patients at Cincinnati Children’s transitioned to multiple daily injections (MDI) when they were transferred from the intensive care unit (ICU) to the surgical floor. They began insulin pump therapy several days later, prior to hospital discharge.  

“As our program developed, we hypothesized that transitioning to an insulin pump earlier in the process, and bypassing the use of MDI completely, would lead to better glycemic control in the critical engraftment period,” says Deborah Elder, MD, endocrine director at the Pancreas Care Center. “Now, instead of transferring from the ICU to the surgical floor, patients go from the ICU to the endocrine unit to ensure optimal insulin pump therapy management. Nurses on the endocrine unit have completed additional training in post-op surgical management for TPIAT patients.” 

During the first 10 post-op days, early insulin pump therapy initiation has led to less blood glucose variability, more time in range and fewer incidences of hyper- and hypoglycemia. Encouraged by these short-term outcomes, published in the Journal of Clinical Medicine, Elder and her colleagues wanted to see whether the strategy impacts long-term outcomes. So they did a retrospective analysis of 40 pediatric patients who underwent TPIAT at Cincinnati Children’s. Fourteen of the patients had been managed with IV insulin followed by MDI and pump therapy, and 26 had received IV insulin followed by early pump therapy. Siobhan Tellez, MSN, an endocrine nurse practitioner with the Pancreas Care Center, shared the team’s findings in an oral presentation at the American Diabetes Association’s 82nd Scientific Sessions in June 2022. Among the team’s findings: 

• The early pump group had a higher proportion of individuals off insulin at one-year post-TPIAT: 43% of early pump users vs. 14% of MDI users. 

• Of those individuals off insulin, 100% of the early pump users weaned off insulin by six months post-TPIAT, compared with 30% in the MDI group. 

• The early pump users had lower fasting glucose and greater c-peptide production, suggestive of improved islet graft function.

Families play a critical role in managing their child’s glucose levels after hospital discharge. Certified diabetes educators at Cincinnati Children’s provide extensive outpatient diabetes management education before and after the hospital stay. This helps families better understand diabetes, glucose management technologies and the importance of tight glycemic control.  

Elder is passionate about caring for this unique patient population and loves being part of a team that guides kids and families through the long healing process. “We develop close relationships with them, and it’s exciting to witness their recovery,” she says. “Before you know it, they are back to school, sports and all the normal childhood activities that make life fun.”  

In April 2022, the Pancreas Care Center team at Cincinnati Children’s performed its 100th TPIAT. The team performs 20 to 25 TPIAT procedures per year on patients as young as 3. To learn more about the center or to refer a patient, contact Deborah.Elder@cchmc.org.