Table 1. Recommendations from Pancreasfest in regard to indications, contraindications, evaluation, and timing for TP-IAT ⁹ .

Guidance statement	Evidence level a	Grade of recommendation
The primary indication for TP-IAT is to treat intractable pain in patients with impaired quality of life due to CP or RAP in whom medical, endoscopic, or prior surgical therapy have failed	2a	B
TP-IAT should not be performed in patients with active alcoholism, active illicit substance abuse, or untreated/uncontrolled psychiatric illness that could be expected to impair the patient's ability to adhere to a complicated medical management plan…Patients with poor support networks have a relative contraindication due to the cost and complexity of managing diabetes and pancreatic enzyme replacement therapies	5	D
TP-IAT should not be performed in patients with specific medical conditions, including: c-peptide negative diabetes, type 1 diabetes, portal vein thrombosis, portal hypertension, significant liver disease, high-risk cardio-pulmonary disease, or known pancreatic cancer	5	D
There are no studies that specifically evaluate contraindications to this procedure. However, TP and TP-IAT are major surgical procedures, with potential operative complications, a prolonged surgical recovery, and an intensive post-operative regimen that includes management of diabetes mellitus and lifelong enzyme therapy for pancreatic enzyme insufficiency	5	D
The severity, frequency, and duration of pain symptoms, narcotic requirements, disability/impaired quality of life, residual islet function, rate of disease progression, and age of the patient should be considered in timing of the procedure	5	D
Patients who meet the inclusion criteria (see above) and who are not excluded should be evaluated by a multi-disciplinary team who will review alternative interventions, assess the likelihood of success in reducing pain and preventing or minimizing diabetes, follow the patient through the procedure and provide guidance for long-term care	5	D
Evaluation should include confirming that pancreatitis is the primary diagnosis, determining that the pain is of pancreatic origin, monitoring the presence of diabetes, assessing beta-cell mass, and assessing the patency of the portal venous system, evaluating for liver disease, and determining immunization status	5	D

CP, chronic pancreatitis; RAP, recurrent acute pancreatitis; TP-IAT, Total Pancreatectomy with Islet Autologous Transplant.

^aMethods of developing consensus based on the Grading of Recommendations, Assessment, Development, and Evaluation Grid.¹⁰