In the acute post-op period, you have to manage their glucose for them. If you put them under stress. The cells die. Everybody's on insulin in the ICU. I want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive
Now, there's no reason to give antibiotics anymore at all for pancreatitis, even in the face of world of necrosis or necrotizing pancreatitis, unless there are signs of sepsis infected pancreatitis, which is a different beast
If you put them under stress, the cells die. Everybody's on insulin in the ICU. I want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive.
we're constantly checking the pressures in the portal vein to make sure we don't risk any thrombosis in the portal vein, which could cause a lot of morbidity to the patient.
Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center
▶Ep 3 · 0:48
quoteTPIAT is clearly one of the most complex abdominal surgical procedures we perform in children.↗
▶Ep 3 · 0:48
clinicalTPIAT is one of the most complex abdominal surgical procedures performed in children↗
▶Ep 3 · 0:54
clinicalSurgical indications for TPIAT are for patients with either chronic or acute recurrent pancreatitis↗
▶Ep 3 · 1:02
guidelinePatients are candidates for TPIAT when all medical and endoscopic therapy has failed↗
▶Ep 3 · 1:02
quoteThese patients are candidates for TPAT when all medical and endoscopic therapy has failed.↗
▶Ep 3 · 1:23
clinicalFull evaluation by the Pancreas Care Center team includes GI, social worker, endocrine, surgery, radiology, genetics, behavioral health, physical therapy, anesthesia and pain team↗
▶Ep 3 · 1:49
clinicalPatients are prepared with vaccinations for potential splenectomy before surgery↗
▶Ep 3 · 2:40
clinicalPain catheters are placed in the transversus abdominis muscle by pain specialists↗
▶Ep 3 · 3:14
clinicalThe pancreas has often been injured for years, which makes the dissection procedure quite challenging↗
▶Ep 3 · 3:14
quoteRemember, this, this pancreas has been injured for sometimes years, which makes this procedure quite challenging.↗
clinicalBlood supply to the pancreas is preserved until the very last moment because hypoxia of islet cells cannot be risked↗
▶Ep 3 · 7:15
clinicalIslet cells are infused into the portal vein with the goal of implanting in the liver and producing insulin↗
▶Ep 3 · 7:25
quotewe're constantly checking the pressures in the portal vein to make sure we don't risk any thrombosis in the portal vein, which could cause a lot of morbidity to the patient.↗
▶Ep 3 · 7:25
clinicalPortal vein pressures are constantly checked during islet infusion to prevent portal vein thrombosis↗
▶Ep 3 · 7:25
clinicalPortal vein thrombosis could cause significant morbidity to the patient↗
▶Ep 3 · 8:01
clinicalPatients are placed in intensive care unit to control hemodynamics and fluid shift balance↗
▶Ep 3 · 8:12
quoteWe want to make sure their eyelid cells are healing in a very homeostatic environment.↗
▶Ep 3 · 8:12
clinicalIslet cells need to heal in a homeostatic environment↗
▶Ep 3 · 8:18
clinicalGlucose and insulin are controlled via exogenous infusions post-operatively↗
▶Ep 3 · 8:22
clinicalNutrition is key in the healing of connections between the biliary tract and gastrointestinal tract↗
▶Ep 3 · 8:39
clinicalDischarge criteria include well-controlled pain, full feeds via tube or by mouth, and well-controlled glucose via continuous glucose monitoring↗
quoteit is very important nowadays to feed the pancreas, even when there's pancreatitis↗
▶Ep 13 · 0:44
quoteremember they, they used to tell you, put the patient NPO, throw him in the ICU and, and fluid his lungs, right? So we don't do that anymore.↗
▶Ep 13 · 3:55
clinicalAcute pancreatitis in children should be managed with early aggressive fluid resuscitation in the first 12–24 hours, then reassessed to avoid fluid overload.↗
quotepancreatitis is a state of uh hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis.↗
▶Ep 13 · 4:42
guidelineAntibiotics are not indicated in acute pancreatitis unless there are signs of sepsis or infected pancreatitis.↗
▶Ep 13 · 4:42
quotethere's no reason to give antibiotics anymore at all for pancreatitis, even in the face of world of necrosis or necrotizing pancreatitis, unless there are signs of sepsis infected pancreatitis↗
▶Ep 13 · 5:59
guidelineBolus 10–20 mL/kg up to 3 L in the first 24 hours, with maintenance fluids at 1.5–2× normal rate.↗
▶Ep 13 · 6:32
clinicalLactated Ringer's decreases inflammatory response and C-reactive protein at 24 hours compared to normal saline.↗
▶Ep 13 · 8:33
epidemiologicalThe WATERFALL trial (multi-center RCT by Enrique de Madaria) is comparing LR vs NS in acute pancreatitis, results expected in 1–2 years.↗
▶Ep 13 · 9:07
clinicalAggressive fluid resuscitation in acute pancreatitis is associated with shorter length of stay, fewer severe complications, and fewer ICU admissions.↗
▶Ep 13 · 9:24
clinicalEnteral nutrition (feeding the pancreas) is significantly better than TPN or NPO in acute pancreatitis.↗
▶Ep 13 · 9:47
guidelineNasogastric feeding is preferred over nasojejunal feeding if the patient can tolerate it.↗
▶Ep 13 · 10:35
quoteoutcomes are dramatically better when you feed the gut↗
▶Ep 13 · 15:02
epidemiologicalCincinnati Children's receives over 100 TPIAT referrals per year but performs only 20–25 procedures because not all patients are candidates.↗
▶Ep 13 · 15:11
guidelineGenetic testing should be obtained even after a first severe attack of pancreatitis in children.↗
▶Ep 13 · 15:23
epidemiologicalThe most common cause of pancreatitis in children is medication-induced; the most common risk factor is genetic.↗
▶Ep 13 · 15:23
quoteThe most common cause of pancreatitis in children is, is, is medicine induced. The most common risk factor for pancreatitis in children is, is genetic factors.↗
▶Ep 13 · 15:40
clinicalPRSS1 (trypsinogen activator) is the most common genetic mutation causing pancreatitis in children and is the most aggressive.↗
▶Ep 13 · 15:48
clinicalCincinnati Children's genetic panel tests 10 different markers for pancreatitis (PRSS1, CTRC, CFTR, CPA1, others).↗
▶Ep 13 · 16:33
clinicalUp to 50% of children with genetic pancreatitis continue to have attacks despite duct drainage procedures (Frey, Puestow).↗
▶Ep 13 · 16:40
quoteup to 50% of those children are gonna keep getting pancreatitis despite you opening the duct and draining it↗
▶Ep 13 · 18:30
opinionConventional drainage procedures (Frey, Puestow) are not recommended for children with genetic mutations because they do not address the underlying parenchymal disease.↗
▶Ep 13 · 19:08
guidelineThe primary indication for TPIAT is chronic debilitating pain that is unresponsive to medical and endoscopic management.↗
▶Ep 13 · 19:56
opinionThere is no set number of ERCPs before considering surgery, but early referral for TPIAT evaluation is better to preserve islet cell mass.↗
▶Ep 13 · 20:48
clinicalEndoscopic ultrasound can confirm the diagnosis of chronic pancreatitis in children.↗
▶Ep 13 · 20:59
clinicalMRCP with T2 sequences is the best non-invasive imaging study for the pancreas.↗
▶Ep 13 · 21:07
opinionERCP is more therapeutic than diagnostic in pediatric pancreatitis.↗
▶Ep 13 · 21:12
clinicalPatients with chronic pancreatitis have micro- and macronutrient deficiencies and often require pancreatic enzyme replacement therapy.↗
▶Ep 13 · 21:36
clinicalExocrine function is lost before endocrine function in chronic pancreatitis; screening for endocrine dysfunction is necessary.↗
▶Ep 13 · 21:48
guidelineWalled-off necrosis should be drained only if symptomatic (gastric outlet obstruction, pain); asymptomatic collections self-resolve.↗
▶Ep 13 · 22:08
epidemiologicalChronic pancreatitis increases the risk of pancreatic cancer up to thirteenfold.↗
▶Ep 13 · 24:08
epidemiologicalUp to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 13 · 24:17
quotegenetics have changed the world of how we approach uh uh pediatric uh uh chronic pancreatitis treatment↗
▶Ep 13 · 24:40
clinicalTPIAT requires a multidisciplinary team: surgery, GI pancreatologists, geneticists, social workers, psychologists, and pain specialists.↗
▶Ep 13 · 25:07
clinicalPatients with chronic pain develop hyperalgesia and central sensitization; removing the pancreas may not eliminate all pain, requiring behavioral therapy.↗
▶Ep 13 · 25:07
quotePeople that have chronic pain, their bodies, their brains learn how to be in pain, right? They can function in pain. That's called hyperalgesia and central sensitization.↗
▶Ep 13 · 25:23
quoteyou cannot promise them that 10 that 10% is gonna linger for a little bit. We need behavioral therapy for that.↗
▶Ep 13 · 25:52
quotethe goal is to bring this kid back to their life, right? There's a, a 5 year old should not be in the hospital every 6 weeks in ICU admissions and not being played, not being able to dance or play soccer↗
▶Ep 13 · 26:14
clinicalThe secondary goal of TPIAT is to preserve beta-cell function and prevent brittle diabetes.↗
▶Ep 13 · 26:40
clinicalIslet equivalent per kilogram of body weight around 5000 predicts a 50% chance of insulin independence after TPIAT.↗
▶Ep 13 · 27:00
epidemiological20% of TPIAT patients require a small dose of insulin, and 30% remain diabetic.↗
▶Ep 13 · 27:05
quoteI'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes.↗
▶Ep 13 · 27:05
opinionTPIAT exchanges chronic pancreatitis for potential diabetes; families must understand this trade-off.↗
▶Ep 13 · 27:36
clinicalTPIAT operative time averages 8–10 hours: 3–4 hours for pancreatectomy, 4–4.5 hours for islet isolation, 2 hours for reconstruction.↗
▶Ep 13 · 28:51
clinicalPyloric Botox injection during TPIAT has been shown to improve outcomes in gastroparesis, which all pancreatitis patients have.↗
▶Ep 13 · 28:59
clinicalRoux-en-Y reconstruction helps manage gastroparesis in TPIAT patients.↗
▶Ep 13 · 29:22
clinicalIslet cells are injected into the portal vein and implant in the end branches within the liver.↗
▶Ep 13 · 29:33
clinicalSplenectomy is routinely performed with TPIAT to minimize ischemia time and preserve islet cells, as the pancreas and spleen share blood supply.↗
▶Ep 13 · 29:56
quoteEvery time you start cutting these tiny vessels, you're having ischemia time. So you're losing eyelid cells.↗
▶Ep 13 · 30:01
clinicalIslet cells can be lost at four points: recurrent pancreatitis, ischemia during dissection, processing/injection, and acute post-op stress.↗
▶Ep 13 · 30:20
clinicalAll TPIAT patients are on insulin in the ICU post-operatively to minimize stress on newly transplanted islets and allow engraftment.↗
▶Ep 13 · 30:24
quoteI want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive.↗
▶Ep 13 · 31:26
clinicalExtrahepatic islet implantation sites (omentum, retroperitoneum, rectus muscle, gastric submucosa) have been tried but do not work as well as intrahepatic.↗
▶Ep 13 · 31:58
clinicalPortal vein thrombosis after islet injection occurs in less than 1% of cases; portal pressure is monitored during injection.↗
Update Course Rewind: Management of Acute Pancreatitis 2023
▶Ep 14 · 1:52
guidelineICU admission is indicated for patients who are not hemodynamically normal↗
guidelineBolus times 2 is adequate for initial fluid resuscitation, followed by 1.5x maintenance once past the early acute resuscitation phase↗
▶Ep 14 · 2:06
quoteRemember that pancreatitis is a state of, uh, hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis, atrophic pancreas insufficiency.↗
▶Ep 14 · 2:06
clinicalPancreatitis is a state of hypoxia requiring re-establishment of intravascular flow to the pancreas to prevent hypoxia, necrosis, and atrophic pancreas insufficiency↗
▶Ep 14 · 2:22
clinicalEarly fluid resuscitation is the key to preventing pancreatic complications↗
▶Ep 14 · 2:22
quoteSo, early fluorociation. It's, it's the key. However, you cannot be too aggressive with fluids.↗
▶Ep 14 · 2:29
guidelineThere is no reason to give antibiotics for pancreatitis, even in the face of necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis↗
▶Ep 14 · 2:29
quoteNow, there's no reason to give antibiotics anymore at all for pancreatitis, even in the face of world of necrosis or necrotizing pancreatitis, unless there are signs of sepsis infected pancreatitis, which is a different beast↗
▶Ep 14 · 3:11
guidelineFluid bolus of 10 to 20 mL per kg, up to 3L in the first 24 hours, with reassessment at 12-hour mark using urine output and vital signs↗
▶Ep 14 · 3:25
quoteYou cannot flow these lungs too much because the outcomes are worse.↗
▶Ep 14 · 3:25
clinicalExcessive fluid administration leads to worse outcomes because it can overload the lungs↗
▶Ep 14 · 3:45
quoteIt's been shown that LR. Decreases the incidence of inflammatory response and C, C-reactive protein at 24 hours compared to NS, right?↗
▶Ep 14 · 3:45
clinicalLactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline↗
▶Ep 14 · 3:54
clinicalIf albumin is low, albumin should be given↗
▶Ep 14 · 4:10
clinicalThe Waterfall trial had to stop early because patients getting too much fluid were developing organ failure↗
▶Ep 14 · 4:27
clinicalThe Waterland trial is an upcoming multi-center, multi-country RCT that will compare lactated Ringer's to normal saline, expected in one to two years↗
▶Ep 14 · 4:47
clinicalEnteral nutrition is significantly better compared to TPN or NPO for pancreatitis patients↗
▶Ep 14 · 4:47
quoteFeed the pancreas as soon as the patient is able to tolerate PO. Just give in nutrition significantly better compared to TPN or NPO.↗
▶Ep 14 · 4:57
clinicalGastric feeding is preferred over other routes if the patient can tolerate it↗
▶Ep 14 · 5:19
opinionSome vomiting is tolerable when attempting enteral feeding, similar to gastroschisis management↗
▶Ep 14 · 5:21
quoteI mean, but it's like gastroschisis, it's OK to tolerate some, some, some vomiting.↗
▶Ep 14 · 5:26
clinicalIf nutrition is lost and the patient is losing ground, outcomes will be worse with dropping albumin and worse inflammatory reaction↗
▶Ep 14 · 5:34
clinicalOutcomes are dramatically better when feeding the gut compared to NPO or TPN↗
Update Course Rewind: Management of Chronic Pancreatitis 2023
▶Ep 15 · 1:28
quoteSo, if you, most of the pancreatic parenchyma is in the head and the uncinate process. If you get rid of that head and there's a pancreatic, uh, uh, PRS1 mutation, this kid is gonna get uh recurrent attacks.↗
▶Ep 15 · 1:28
clinicalMost of the pancreatic parenchyma is in the head and the uncinate process↗
▶Ep 15 · 1:33
clinicalPatients with PRSS1 mutation will get recurrent attacks if only the pancreatic head is removed↗
▶Ep 15 · 1:40
epidemiologicalUp to 50% of patients with chronic pancreatitis will eventually require surgery↗
▶Ep 15 · 2:18
clinicalPatients with chronic pancreatitis always have micro and macronutrient deficiencies↗
▶Ep 15 · 2:33
clinicalPatients with chronic pancreatitis sometimes need pancreatic enzyme replacement therapy↗
▶Ep 15 · 2:40
clinicalYou lose first your exocrine and then your endocrine function in chronic pancreatitis↗
▶Ep 15 · 2:49
quoteThe goals is to bring this kid back to their life, right? These kids are like totally withdrawn, they dropped their milestones dramatically, so it's important to bring, bring them back to their society.↗
▶Ep 15 · 3:06
clinicalAll TPIAT patients have enzyme replacement therapy↗
▶Ep 15 · 3:23
clinicalWith islet cell count of 5000, there is 50% chance of not requiring insulin↗
▶Ep 15 · 3:36
clinical20% chance of requiring a small dose of insulin after TPIAT↗
▶Ep 15 · 3:40
clinical30% of TPIAT patients are still diabetics↗
▶Ep 15 · 3:42
quoteSo we need to tell the families they're, I'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes.↗
▶Ep 15 · 4:25
clinicalTPIAT surgery takes on average 8 to 10 hours↗
clinicalIslet cell isolation takes 4 to 4.5 hours↗
▶Ep 15 · 5:39
clinicalIslet cells are injected into the portal vein inside the liver↗
▶Ep 15 · 6:09
quoteIf you put them under stress, the cells die. Everybody's on insulin in the ICU. I want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive.↗
▶Ep 15 · 6:12
clinicalAll patients are on insulin in the ICU post-TPIAT to avoid stressing the cells↗
▶Ep 15 · 6:27
clinicalIslet cells implant in the end branches of the portal vein inside the liver↗
▶Ep 15 · 6:34
clinicalExtrahepatic reimplantation of islet cells does not work as well as intrahepatic↗
▶Ep 15 · 6:43
clinicalExtrahepatic islet cells have good glucagon reaction for hypoglycemia compared to intrahepatic↗
▶Ep 15 · 6:51
clinicalThe best site for islet cell reimplantation is the liver↗
▶Ep 15 · 6:54
clinicalRisk for portal vein thrombosis after islet injection is very low, less than 1%↗
▶Ep 15 · 7:05
clinicalThe duodenum is taken right at D1 post pyloric during TPIAT↗
▶Ep 15 · 7:10
clinicalDuodenum-sparing is difficult due to shared blood supply with pancreas↗
Update Course Rewind: Management of Recurrent Pancreatitis
▶Ep 17 · 1:40
clinicalEvery ERCP carries a risk of post-ERCP pancreatitis, and islet cells are lost with every pancreatitis attack↗
▶Ep 17 · 1:40
quoteEvery time you get an, an ERCP you have a risk of getting post-E ERCP pancreatitis. It's low, right? But it's still a risk, and you lose eyelet cells with every attack.↗
▶Ep 17 · 1:57
clinicalPRSS1 is the most common genetic mutation in pediatric pancreatitis and is a trypsinogen activator that activates trypsin inside the pancreas↗
▶Ep 17 · 2:12
clinicalCincinnati Children's genetic panel tests 10 different genetic markers for pancreatitis↗
▶Ep 17 · 2:17
opinionGenetic factors are changing the approach to pediatric chronic pancreatitis treatment↗
▶Ep 17 · 2:48
quoteNo, no, there's no, unfortunately we don't have that just yet. That's why I still have a job, but, uh, I hope, I hope some Monday we have, you know.↗
▶Ep 17 · 2:48
clinicalThere is currently no medication to mediate trypsin activation in genetic pancreatitis↗
▶Ep 17 · 3:09
clinicalFrey procedure requires removing the top half of the pancreas to open the duct, resulting in loss of islet cells↗
▶Ep 17 · 3:19
quoteThis patient most likely is gonna keep getting pancreatitis despite you draining the duct. The, the parenchyma is gonna keep getting attacked by the mutation.↗
▶Ep 17 · 3:19
clinicalIn patients with PRSS1 mutation, drainage procedures only temporize attacks by draining the duct but do not fix the underlying problem, as the parenchyma continues to be attacked by the mutation↗
▶Ep 17 · 4:09
guidelineThere is no set number of ERCPs that defines when to consider chronic pancreatitis; sooner referral is better for evaluation↗
▶Ep 17 · 4:16
quoteWe don't offer, uh, to take care of the pancreas unless you've. Maximize medical and endoscopic management.↗
▶Ep 17 · 4:16
guidelineSurgical pancreatic intervention is not offered unless medical and endoscopic management have been maximized↗
▶Ep 17 · 4:31
clinicalIf a stent is placed and the patient continues to have pancreatitis, there is no reason to continue with ERCPs↗
▶Ep 17 · 4:58
clinicalMRCP is the best non-invasive study for the pancreas, particularly with T2 sequences↗
guidelinePancreatic fluid collections should be drained only if symptomatic once the wall is mature at 4 to 6 weeks↗
▶Ep 17 · 5:28
quoteIf there's no symptoms, don't drain it. If the patient's not having gastric outlet obstruction or pain, there's no need to drain this.↗
▶Ep 17 · 5:29
clinicalAsymptomatic fluid collections without gastric outlet obstruction or pain will self-resolve and do not require drainage↗
▶Ep 17 · 5:35
guidelineAntibiotics are not needed for pancreatic fluid collections↗
Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center
▶Ep 21 · 0:48
quoteTPIAT is clearly one of the most complex abdominal surgical procedures we perform in children.↗
▶Ep 21 · 0:48
clinicalTPIAT is one of the most complex abdominal surgical procedures performed in children↗
▶Ep 21 · 0:54
clinicalSurgical indications for TPIAT are for patients with either chronic or acute recurrent pancreatitis↗
▶Ep 21 · 1:02
guidelinePatients are candidates for TPIAT when all medical and endoscopic therapy has failed↗
▶Ep 21 · 1:02
quoteThese patients are candidates for TPAT when all medical and endoscopic therapy has failed.↗
▶Ep 21 · 1:23
clinicalFull evaluation by the Pancreas Care Center team includes GI, social worker, endocrine, surgery, radiology, genetics, behavioral health, physical therapy, anesthesia and pain team↗
▶Ep 21 · 1:49
clinicalPatients are prepared with vaccinations for potential splenectomy before surgery↗
▶Ep 21 · 2:40
clinicalPain catheters are placed in the transversus abdominis muscle by pain specialists↗
▶Ep 21 · 3:14
quoteRemember, this, this pancreas has been injured for sometimes years, which makes this procedure quite challenging.↗
▶Ep 21 · 3:14
clinicalThe pancreas has often been injured for years, which makes the dissection procedure quite challenging↗
clinicalBlood supply to the pancreas is preserved until the very last moment because hypoxia of islet cells cannot be risked↗
▶Ep 21 · 7:15
clinicalIslet cells are infused into the portal vein with the goal of implanting in the liver and producing insulin↗
▶Ep 21 · 7:25
clinicalPortal vein thrombosis could cause significant morbidity to the patient↗
▶Ep 21 · 7:25
clinicalPortal vein pressures are constantly checked during islet infusion to prevent portal vein thrombosis↗
▶Ep 21 · 7:25
quotewe're constantly checking the pressures in the portal vein to make sure we don't risk any thrombosis in the portal vein, which could cause a lot of morbidity to the patient.↗
▶Ep 21 · 8:01
clinicalPatients are placed in intensive care unit to control hemodynamics and fluid shift balance↗
▶Ep 21 · 8:12
clinicalIslet cells need to heal in a homeostatic environment↗
▶Ep 21 · 8:12
quoteWe want to make sure their eyelid cells are healing in a very homeostatic environment.↗
▶Ep 21 · 8:18
clinicalGlucose and insulin are controlled via exogenous infusions post-operatively↗
▶Ep 21 · 8:22
clinicalNutrition is key in the healing of connections between the biliary tract and gastrointestinal tract↗
▶Ep 21 · 8:39
clinicalDischarge criteria include well-controlled pain, full feeds via tube or by mouth, and well-controlled glucose via continuous glucose monitoring↗
Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria
guidelineDiagnosis of acute pancreatitis requires serum lipase ≥3× upper limit of normal plus imaging findings (ultrasound, MRCP, or CT)↗
▶Ep 26 · 7:23
epidemiological85% of 1000+ pediatric pancreatitis patients at Cincinnati Children's have genetic mutations↗
▶Ep 26 · 8:01
clinicalPRSS1 mutation causes autoactivation of trypsinogen, leading to aggressive early-onset pancreatitis in children as young as 1–3 years↗
▶Ep 26 · 8:55
clinicalMedications causing pediatric pancreatitis include L-asparaginase, steroids, valproic acid, and furosemide↗
▶Ep 26 · 9:32
clinicalHereditary pancreatitis markedly increases lifetime risk of pancreatic cancer↗
▶Ep 26 · 10:15
clinicalMost pediatric pancreatitis fluid collections are self-limited and do not require intervention↗
▶Ep 26 · 16:10
clinicalERCP is essential for diagnosis and treatment of pediatric pancreatitis but carries ~10% risk of post-ERCP pancreatitis↗
▶Ep 26 · 17:00
clinicalAutoimmune pancreatitis can mimic chronic pancreatitis and should be ruled out before surgery; it responds to steroids↗
▶Ep 26 · 18:08
quotePlease do not touch these collections ever unless you absolutely have to.↗
▶Ep 26 · 18:40
guidelineEarly necrosectomy (before 4 weeks) increases mortality; wait for walled-off necrosis to mature↗
▶Ep 26 · 20:11
clinicalTransgastric endoscopic necrosectomy reduces major complications compared to open surgery↗
▶Ep 26 · 21:08
quoteI do not operate or treat CT scans or MRIs. How's the patient doing?↗
▶Ep 26 · 21:36
guidelineAsymptomatic pseudocysts, regardless of size, do not require intervention↗
▶Ep 26 · 23:29
clinicalEarly enteral nutrition (as soon as tolerated) prevents bacterial translocation and reduces complications in acute pancreatitis↗
▶Ep 26 · 23:48
clinicalLactated Ringer's solution is superior to normal saline for initial resuscitation in acute pancreatitis↗
▶Ep 26 · 25:18
epidemiological~50% of pediatric patients with hereditary or anatomic pancreatitis develop chronic pancreatitis↗
▶Ep 26 · 26:54
clinicalChronic pain in pediatric pancreatitis involves central sensitization and brain plasticity, requiring multidisciplinary pain management↗
▶Ep 26 · 28:57
opinionSegmental pancreatic resections in genetic pancreatitis discard islet-cell mass and leave remaining pancreas vulnerable to ongoing disease↗
▶Ep 26 · 31:52
clinicalPancreatic trauma in children (e.g., handlebar injury) can cause ductal strictures requiring distal pancreatectomy if endoscopic therapy fails↗
▶Ep 26 · 34:11
guidelineTPIAT is indicated for patients with refractory chronic pain, failed maximal medical/endoscopic therapy, and severe quality-of-life impairment↗
▶Ep 26 · 36:03
opinionThe primary goal of TPIAT is pain control and quality-of-life restoration, not diabetes prevention↗
▶Ep 26 · 36:55
clinicalIslet-cell yield is reduced by frequent pancreatitis attacks, obesity, and prior segmental resections↗
▶Ep 26 · 37:44
quoteWe're doing this for chronic pain and that should be the major thing in our head.↗
▶Ep 26 · 43:36
clinicalSpleen-sparing TPIAT is now performed in 80% of cases without compromising islet yield or glycemic outcomes↗
▶Ep 26 · 44:47
clinicalPortal vein thrombosis is a major complication of TPIAT; anticoagulation during surgery is mandatory↗
▶Ep 26 · 45:00
clinicalPyloric botulinum toxin injection during TPIAT reduces gastroparesis and shortens length of stay↗
▶Ep 26 · 50:04
clinicalTPIAT patients are extubated in the operating room and maintained on insulin drip to rest islet cells during engraftment↗
▶Ep 26 · 50:58
clinicalOver 80% of TPIAT patients achieve sustained reduction in opioid use within 1–2 months↗
▶Ep 26 · 51:45
clinicalYounger age at TPIAT, higher islet yield, and absence of pre-op insulin use predict better glycemic outcomes↗
▶Ep 26 · 53:03
clinicalInsulin independence after TPIAT is ~70% overall and approaches 92% when ≥5000 islet equivalents/kg are transplanted↗
▶Ep 26 · 56:09
clinicalFamilies report dramatic quality-of-life improvements after TPIAT: children return to school, sports, and normal social activities↗
▶Ep 26 · 56:22
quoteI've never met this kid in my life. It's a new kid, happy playing.↗
▶Ep 26 · 57:09
epidemiologicalCincinnati Children's evaluates >100 chronic pancreatitis patients per year but performs TPIAT in only 25–30, reflecting careful patient selection↗
▶Ep 26 · 1:02:22
guidelinePseudocyst drainage should not be performed before 4 weeks; wall maturation is required to avoid spillage and infection↗
clinicalAfter TPIAT, all patients are on insulin in the ICU to allow islet cells to engraft without metabolic stress↗
▶Ep 25 · 13:27
quoteIn the acute post-op period, you have to manage their glucose for them. If you put them under stress. The cells die. Everybody's on insulin in the ICU. I want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive↗
