Our surgical technique that has evolved continuously over our study interval has been described elsewhere.10 (link),11 (link) TP is performed in such a way that the blood supply to the pancreas is preserved until just before its removal, thus minimizing warm ischemia time and maximizing islet preservation. In the early part of our TP-IAT series, we restored gastrointestinal continuity by anastomosing the first portion of the duodenum to the fourth portion of the duodenum and then performing a choledochoduodenostomy to the first part of duodenum. Because of a significant number of patients with bile reflux gastritis and ascending cholangitis, we modified the typical resection to preserve the pylorus, to resect most of the duodenum with the pancreas, and to create a Roux-en-Y biliary drainage entering the enteric stream 40 cm distal to a duodenojejunostomy. We routinely placed a gastrojejunostomy feeding tube in the stomach, using the Stamm technique, with the tip of the jejunal limb placed in the jejunum. In addition, in all patients, we performed a cholecystectomy and, if not previously done, an appendectomy.