Total pancreatectomy with islet autotransplantation (TPIAT) is most often performed to reduce pain in patients with disabling forms of recurrent acute and chronic pancreatitis. The IAT portion of the procedure achieves a secondary goal of mitigating postoperative diabetes. Over 80% of patients will have functioning (C-peptide–positive) transplanted islets. Overall, 20–30% of patients will stop insulin entirely, usually between several months to 1 year after TPIAT. Islet mass is the most important predictor of insulin independence, followed by age <2 years. Management of the TPIAT recipient starts with a careful preoperative assessment, screening for diabetes and islet function. Immediately after surgery, glucose is managed with an insulin drip, later transitioned to subcutaneous insulin by multiple daily injections or an insulin pump. Glucose should be strictly targeted to normoglycemia early after transplant to reduce islet loss during the period of islet engraftment. Long-term goals are to maintain HbA1c ≤6.5%. For individuals with islets that function well, insulin can be slowly weaned between 3 months and 1 year after TPIAT. Even patients who are insulin independent will require lifelong monitoring of glucose, as islet attrition occurs after IAT and patients will eventually need to resume insulin. A subset of patients also report hypoglycemia induced by carbohydrate-rich meals or exercise and may need close monitoring, dietary adjustments, and, rarely, pharmacologic management of hypoglycemia.