Complex Pancreas Surgery Offers Pain Relief for Children With Chronic Pancreatitis

In 2024, surgeons at Children's Hospital Los Angeles did something no other center in Southern California had done: they performed a total pancreatectomy with islet autotransplantation, known as TPIAT, on a pediatric patient. The hospital was one of only a few in the country to have done so in a child. Since then, the team has carried out the operation for four patients.

The procedure is as demanding as its name suggests. Surgeons remove the diseased pancreas, then transplant the patient's own islet cells, the clusters that produce insulin and other hormones, in an effort to preserve some endocrine function. It is meant for children whose lives have been taken over by acute recurrent pancreatitis or chronic pancreatitis, conditions that bring severe pain and repeated hospital stays.

The operation is only the beginning of the work. Recovery calls on a multidisciplinary team spanning critical care, pain management, gastroenterology, endocrinology, hematology, and infectious diseases. Kambiz Etesami, MD, FACS, Chief of Abdominal Organ Transplantation at CHLA, describes the aims in order: first, relieve the pain; second, preserve as many pancreatic islets as possible.

TPIAT sits within a broader CHLA Pancreas Program that cares for children and adolescents with these conditions long before surgery is on the table. Yuhua Zheng, MD, MS, the program's Medical Director, says the point of that early care is to catch damage while there is still tissue to protect. Her guidance on referral is specific: a child should be sent after two episodes of pancreatitis, or after a first episode in which chronic change is already visible. Every attack, she says, can do more harm, and the goal is to evaluate children before too much tissue and function is lost.

That evaluation can include advanced pancreatic endoscopy, among them ERCP (endoscopic retrograde cholangiopancreatography), endoscopic ultrasound, and endoscopic pancreatic function testing. It also includes comprehensive genetic testing. Zheng notes that genetic mutations are a common cause of these conditions in children, but standard testing panels can be too limited. CHLA looks at a much broader range of genes.

The specialists also push back on a common assumption: that severe pain should come with sharply elevated lipase. It does not always. Lipase reflects inflammation, Zheng says, but inflammation is only one source of pancreatic pain. Ischemia, hypersensitivity, and micro-obstruction can also cause significant pain. When lipase comes back lower, she says, some physicians question whether the child is truly hurting that much, yet in pancreatitis the lipase doesn't always match the pain.

Timing matters for surgery, too. A pancreas that is already severely scarred may yield fewer viable islets to transplant. The hospital points to a recent patient who had daily abdominal pain but still had largely intact islet cells at the time of TPIAT. The team isolated and transplanted a large number of islets, and the patient was off insulin two months after surgery. Zheng calls that the best outcome.

Not every patient will get there. Even when TPIAT does not eliminate the need for insulin, preserved islet function can still lower insulin requirements. But for children with debilitating pancreatitis, the primary goal remains relief from pain. The message from CHLA's specialists is that referral after a second episode, and attention to pain even when lipase is low, give those children the best chance of keeping more of their own islets.