Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria

All right. Good morning. Good afternoon. Good evening. Uh, thank you for joining us, uh, whatever time zone you're in for an event that I've actually really been looking forward to. Uh, I'm Todd Ponsky. I'm a pediatric surgeon, uh, and helping with leading innovation here at Cincinnati Children's Hospital. But I really wanted to, to introduce our, our own rising star, uh, Doctor Juan Gurria, who, uh, is a Pediatric surgeon is the, has a million things that I'll tell you. But really, it's what he is as a person, and he is one of my favorite people. Um, and I think you'll see why. He's just an amazing guy and we, we begged him to talk about pancreas cause a lot of people really wanted to know about pancreas. Um, Doctor Gurria is, uh, currently has hold a lot of, uh, titles here. He's the surgical director of the Pancreas Care Center, which is an incredible center. He can explain, very robust on all elements of pancreas. It's an amazing team here that I've been following for years. Um, he's also the surgical director of, uh, uh, he's the director of surgical Critical. Care and the director of robotics. Um, he's really, uh, just an incredible, um, surgeon, clinician, and person. So, um, he also, uh, on Saturday, just got the award of the National Pancreas, uh, Center, uh, Foundation to be the, the rising star, the, the one person they Uh, a tribute to really being the right, the person of the year. So, uh, uh, incredibly exciting that I went to a pediatric surgeon. Um, and today he's gonna give us a lot of information about pancreatitis, um, uh, both, um, acute and chronic, and really focus on the surgical aspects of it. So, uh, Juan, thanks for doing this and, uh, take it away. Thank you. Thank you, Todd, and, uh, welcome, everybody. We're live streaming from Cincinnati, Ohio. Um, thank you to the entire global casting that they do a tremendous work in the background to make this happen. I appreciate, um, um, very humbly the invite to talk about, about pancreas, which is my huge passion. I'm gonna try to like sum up, sum up a lot of information, but feel free to, to reach out, put some questions in there. I'm gonna touch briefly on, on causes of pancreatitis in pediatrics, which is a different world, uh, uh, management of, of some of the acute pancreatitis, surgical options for that, and then Uh, uh, uh, uh, tied up with chronic pancreatitis management. So I hope you guys enjoy and, uh, please again ask any questions you might have. Uh, want to start with some of those pictures that you, this is the type of pancreas we deal with, uh, nowadays, and, you know, uh, a lot of my, my, my good mentors, uh, and, and surgical, um, uh, heroes and, and historic, uh, uh, uh, people out there. have always said do not mess with the pancreas and it's, that's, that's for a very good reason. Pancreas still, still provides or pretends a high, huge morbidity and mortality around the world, not only adults but also in pediatrics. I have no disclosures other than that. Um, talking about pancreas requires to understand what's happening in the pediatric world, right? Uh, these, these people, these, these, these patients are not alcoholics, they're not, uh, uh, uh, um, uh, usually not severely obese, full of stones, or smokers, right? So their disease, even though it presents as a similar pathologic problem in their bodies, it comes from a different reason. Um, now, to make the diagnosis, you need to make sure the symptoms are matching your lab work and your, and your imaging findings. You need the, uh, serum lipe at least 3 times the upper limit of normal, uh, but also you need to have the findings in imaging, either ultrasound, which is very popular in, in, in, in children, uh, but we're, uh, more and more performing, uh, um, MRIs for the detailed anatomy of those, uh, uh, dogs through an, uh, MRC. CP, uh, we use CT a lot to follow the progression of, of disease, but MRI is what gives you that, that, that key component of it. Now, what is causing pancreatitis in pediatrics? Massive amount of anatomic abnormalities, right? Um, pancreativism, uh, uh, uh, uh, anatomic difficulties from, from development in the biliary tree, right? It can cause strictures, long common channels between the pale duct and the pancreas, so forth. Now, They do a lot of, uh, the kids do a lot of activities, right? So trauma is a huge piece of that. Traumatic injuries cause pancreatitis. What about tumors? We do see tumors. We do not see PDA, a carcinoma. We do see solid pseudopapillary neoplasms a lot, um, endocrine, neuroendocrine tumors that can cause also pancreatitis. Now, but the huge black box in the history of the world, I remember like it used to be like. Trauma, alcohol, drugs, smoking, and then black box idiopathic pancreatitis. What, what, what is that? Uh, and we are, we now know it's genetic mutations and we have a running list of 1000 pediatric patients with pancreatitis in our center. I, I'm happy to say that we are the, the, the largest volume, uh, uh, center for pediatric pancreatitis care in the world, not just in the United States, um, um, and You know, over these 1000 patients, 85% have genetic mutations. So that big black box, we know that it is. We have a huge panel of 10 genetic mutations that we test for here came from Cincinnati Children's, and we're able to identify most of them. Now, there's a lot of them that we don't know what mutation it is, but We're sure it's a mutation. Now, you guys know this ones and you know the, the, the good old CFTR, uh, but I want to highlight the PRS as one mutation. Uh, I'll talk a little more about it, but this is very aggressive attacks very early in their years. We, we're seeing 123 year olds with acute pancreatitis, acute recurrent pancreatitis from a gene that affectstropsinogen. It autoactivates it. Uh, strips inside the pancreas, so it's degrading their pancreas inside themselves. Uh, we do have this pingo mutation, and very common, CTRC as well. Some other ones, very important ones that mess with the calcium metabolism, CASR, uh, can also play a role in this. So. When, when, we talk about pancreatitis in, in, in pediatrics, we need to make sure we're thinking genetics. Now, a big component of pediatric pancreas, uh, uh, uh, injury is also medications that we sometimes forget and we get all these consult, right, like a ALL patient from the oncology service on peasparaginase, belly pain, ileus, we think it's constipation, we think it's a gallbladder, check the pancreas. It always hits it, well, not always thankfully, but it hit it. Tends to heat the pancreas. Now we use very commonly steroids in the ICUs can cause pancreatitis, valproic acid, but also a very common medication is Lasix or diuretics can cause pancreatitis. So we need to be thinking about those things. All right. Here's some of the information I was talking to you about. That's our genetic panel on the, on the right lower, right lower uh screen there. Uh, the important thing from genetic, um, uh, or what we call hereditary pancreatitis is that Um, the, the, in pediatric patients, 80%% with acute pancreatitis, but some of them will transition straight into chronic pancreatitis. Now, the problem is that these genetic mutations, uh, um, can increase by a huge fall your risk of pancreatic cancer. Now, these kids are, you know, supposed to live. When you're diagnosed at 5 or 6 year old, they're, they still have hopefully 95 years of, of, of life, right? So the risk of pediatric uh uh of pancreatic cancer is just, it's just tremendous. So when we're dealing with genetic mutations, think about that and I, I counsel my patients' families when we're doing surgery with, with those things in mind. So, some of the complications that you guys see and, and uh hopefully you don't have to deal with this a lot because it can get very troublesome are, for example, this fluid collections, right? Most, remember kids heal a lot of things that an adult will never heal, right? This pancreatitis comes from the same, same pathophysiology, uh, um. It's, it's a, it's a matter of microthrombosis inside the pancreatic tissue, which creates a massive inflammatory response. So you can have food collections. Most of them are self-limited. Now, pseudocysts, right, when we create a, a, a wall around it, you can have abscesses as well. But please, please, please try not to touch these things unless you absolutely have to. Now, We know you can have perpancretic fluid collections, right? A pseudocyst with a wall around it, acute necrosis around the pancreas, which is replacing the the pancreatic parenchyma. With necrotic tissue or after 4 weeks usually walls, walled off necrosis, which is the same concept, but now you're evolving to a chronic problem that has fully replaced the pancreatic parenchyma and has a buildup a wall around that. So when we talk about that, is there an, and, you know, time is, time is huge, right? Less than 4 weeks, you're gonna have acute problems. Over 4 weeks usually is when you develop the pseudocyst, which is uh either self-limited or, or amenable to, to, to drainage. But when you're dealing with wall of necrosis that there's an encapsular wall and you have necrotic tissue, those are, are gonna be problematic, and I highly encourage you to seek out help. Doesn't have to be, to be us in our center, but, but we're happy to help with this. We have experts thankfully, um, um, in our, our team, um, uh, that can help with this. Sometimes we have to like Put the patients in TPN for, for, for months, right? It's not the ideal by any means, but that's, that's the, that's the uh, the end of the spectrum. So when we're talking about chronic pancreatitis, I wanted to go back to acutely and say, but I wanted to talk about, about, about this chronic pancreatitis transition. Um, what, what, what happens there? You do start seeing calcifications, atrophy, doctor irregularities in the, in the pancreatic parenchyma and, and the duct that were not present with the acute events. That's when you start to get, get, uh, concerned about because the function of that pancreas is gonna start fading very soon. Um, remember that, usually the, um, Uh, exocrine function goes down first and then eventually, uh, the endocrine function of the eyelid cells. So you need to have evidence of, of abdominal pain consistent with pancreatic origin around the T10, uh, um, um, area. Evidence of exocrine, some, somewhat exocrine pancreatic insufficiency, at least that you can test that, uh, fecal elastic and a whole bunch of other, other labs that my, my medical colleagues take care of. But also, uh, can have endocrine pancreatic defici and they start, you start seeing some, some rise in your hemoglobin A1C, your, your glucose tolerant meal test, it starts, starts getting impaired. Uh, and we see that often even in early, early, uh, young, young patients. So, We need to monitor that and for that, I rely on my massive team, right? Um, we have experts, very smart people in the medical team that take care of this, thankfully, um, and hopefully, it will, you know, it's one day we will stop requiring surgery because of them because they're doing phenomenal work throughout the country, uh, uh, in, in the pancreas work, uh, especially in pediatrics. Now, When we have these patients that we follow for a long time, you need to keep monitoring for, for these deficiencies, diabetes, right? If you, if you forget that they're gonna develop diabetes and it's just seen, they start hitting their kidneys, they start hitting their arteries, uh, um, that can impair their, their overall, uh, uh, health. They have micro and micronnutrition, right, uh, deficiencies which will impair their Uh, milestone in brain development, right? So that's huge. We pay attention to that. All of them have some sort of gastroparesis, which is an important concept I'm gonna touch base on with the surgery team, uh, the surgery portion of it, but we see pseudoaneurysms on the splenic arteries, right? Celiac, SMAs, this could be a big problem. But remember, risk of pancreatic cancer is massive in these patients with hereditary pancreatitis. So talking about the team. You cannot take care of pancreatitis without a team. There's no way. You're only as good as your team is gonna be, and your outcomes are massively dependent on this. Uh, gastroenterologist, endocrine genetics, our pain experts are key for this. Uh, now we have expert radiologists, uh, taking, uh, care of, of our pancreas imaging every week. I meet with these people twice a week for this, for, for those reasons. If all your boxes are not checked. The management of pancreatic injury, especially in the acute setting, uh, um, uh, can be impaired. I have a, a great relation with a, with a PQ team that helped us with this. Uh, we ran together, you know, this is a thing you need to keep an eye on. Um. ID is massive, especially when you're dealing with acute pancreatitis and people are thinking, oh, it's infected. Let's start antibiotics, right? Let's get ID and let's start bombing with carbapenems or something that actually reaches the pancreas parenchyma. Uh, but be careful with that cause most times are, are not indicated. But for chronic pancreatitis, you need your IV team for sure, uh, especially if the spleen goes off, uh, um, uh, with like a splenic, um, uh, uh, thrombosis, for example, and your, your spleen starts failing. So, what are our objectives of treating this medical endoscopic and surgical, and hopefully, you never have to get to the surgery part of these things. You need to alleviate symptoms, try to slow the disease progression so you don't Uh, uh, uh, see that your patients fall off the, off the edge and treat their complications. You need to try to prevent these complications. There's massive opposition papers, um, out there from, from, from, from the, uh, uh, Society of, uh, North American Bankers and Castro, um, that have. Delineated very well how to treat for uh acute pancreatitis. But also, you know, the roles of endoscopic ultrasound and, or, or an ERCP it's huge. Uh, some some people out there think like, oh, pediatric patients don't, don't get pancreatitis. Uh, don't worry about that, and we don't need the ERCPs don't, don't, don't mess with the pancreas because if you put a wire, you're gonna get post ERCP pancreatitis, which happens around 10% of the times. It happens, but it's highly needed to, to diagnose and treat. And not in the acute setting though, remember, now EUS for the acute setting is huge, right? And you can, you can get a lot of information, rule out, rule out stones, especially in, in areas with a higher, uh, uh prevalence of, of, uh, obesity and, and, and, and, and, and, and, uh, uh, um, stone disease. Rule that out, please. Then rule out, uh, uh, anatomic abnormalities with your MRCP. Now, important tumors, make sure there's not a tumor there. So MRI EUS can give you all this information. Now, huge problem in, in, in pediatrics could be. Uh, um, blaming your acute pancreatitis on one of these factors without looking at autoimmune pancreatitis, right? Um, which can be treated with just steroids, so make sure you're not dealing with that. Um, so for ERCP, you know, I'm not a, a GI physician and I have experts for this, but I've seen them work very well for gallstones. You know, uh, doing the sphincterotomies for, for pancreatic division, um, stenting, uh, uh, strictures in the, in the, in, in either of the ducts, uh, if they have vision, um, but also the management of pancreas, right, like, you know, putting a, uh, a stent across injuries. Um, sometimes they're as small as 56 year olds riding a bike, and, and you, you have to deal with this, um. Thankfully, we have, we have, uh, uh, people that can help us here, here. We're definitely pampered and uh, uh, uh, from that, uh, uh, regard. Um, now, importantly for acute pancreatitis, talking about drainage of collections, right? So this is, this is key. You, you, everybody sees a collection of call IR during this thing or call surgery during this thing, put a, put a scope, put a drain something. Please do not touch these collections ever unless you absolutely have to. I'm gonna tell you when you absolutely have to. There is No role, and this is not my opinion. This is, uh, position papers from the European Pancreas Club along with the American Pancreas Association, not only for adults, but, uh, uh, uh, mirror in Pediatrics. There is no role for early pancreatectomies of any kind. No role for early drainage, uh, uh, procedures. Um, this comes with a lot of morbidity, uh, unless the patient is not progressing, going into multi-organ failure. Early necrosectomies are usually necessary and increase mortality. Wait at least 4 weeks until it becomes a wall of necrosis. Now, people say like, oh it's infected. I, I, I can tell. You cannot tell. It's really hard. It's really hard. So if you see gas on the scan, sure, OK, I'll give you that. But go with clinical symptoms and your imaging as well. Can you do FNA? Yes, you can. Uh, some papers say you should. Some papers now, they say don't even test it. Clinical suspicion, um, uh, follow your patterns and your trends in your vital signs in the ICU to let you know, uh, when are you getting septic, not systemic inflammatory response which you will always get from pancreatitis, but septic. Now, if you have a strong clinical suspicion, start antibiotics, right? Carvenem, carpenem works great. Now, if you think you, you're not progressing, then drain the necrosis, then drain the collection, but I'm gonna tell you how. You always need cross-sectional imaging. Don't worry about the, the radiation at this point, scan this patient. We, we spare so many scans nowadays that sometimes we never want a scan. We have to, we have to specifically for diagnosis and progression of disease of, of, of, of pancreatitis. Remember, following the lipase tells you nothing of how this pancreas is behaving, OK? Um, so we all heard in the surgical world, I hope there's a lot of surgeons out there, but a step approach, absolutely, absolutely step means exactly that. Start with the least invasive thing you can do for this patient, right? Um, from, from, from, um, uh, some of our, our groups in the European Bankers Club, right, they're telling initiate, initiating with a transgres, trans-gastric endoscopic necrostectomy had a reduced risk of major complications and that it's, it's a huge difference, right? People say, no, I'm a surgeon, I, I'll Take care of this. No, no, no. Ask your GI colleagues put trans transgastric drainage, uh, aluminum opposing metal stent works great for these types of situations. Now, when you have to do surgery afterwards, chronic pancreatitis, you've had a stent, uh, good luck with that, but we can, we can manage, um, uh, usually you need one or two drains in there like the, the, the lamps plus a couple of pigtails to keep draining or keep going in there with your scope to drain this thing. Um, so when you have acute collections, right, but you're not. Suspicious for sepsis. When are you gonna drain this collection? Oh, it's too big. Well, it doesn't matter. We do not treat, I do not operate or treat CT scans or MRI's. How's the patient doing? Is the patient having no symptoms? Let him be. Hm. Most likely it will resolve. Big, big collections might not, but if you have chronic pain, gastric outlet obstruction symptoms, then go ahead and drain it. The patient is symptomatic, but after 4 weeks, and then you do a, a, a, a cyst gastrostomy. And they'll heal just fine with that, OK? Uh, so asymptomatic pseudosis regardless of the size do not require intervention. Now, in the step of approach, right? To a trans-gastric first, then try to do percutaneous retroperitoneal either with IR or through a vars, right? And necrosectomy like video assisted retro uh retroperative. To, uh, dissection of this necrosis in the pancreas can give you a huge advantage in the recovery. Once you start feeling, start seeing like renal failure or pulmonary problems from, from, uh, uh, fluid shifts, you're gonna be very, you know, uh, you're gonna be very happy that you did retroperoneal, uh, and it's not fully draining into the peritoneum. Laparoscopic and open ne necrostectomy, please reserve for, for extreme cases. You, you do not have, if you put a through a laparoscopic drain, you can do that. It's minimum invasive, it works, but you run the risk of having a, a, a, a, a pancreatico cutaneous fistula, and then you have to deal with that and then glue it or put a stent or something that comes with a whole bunch of different uh, uh, uh, potential problems. But laparotomies, necrostectomy. Only a few patients is not progressing, going into multi-organ failure, septic, and it's not getting better. Yes, mortality is gonna be huge, you know, Kim Davis did a massive review of literature and, and, and, and she keeps telling us, please go step up approach, the laparotomy for the, for the end, um, so. I hope acute pancreatitis, uh, uh, uh, um, problems and treatment, uh, it's makes sense, you know, nowadays, uh, we put a lot of effort in the, in the, in the management of it to try to prevent those complications, um. Key, a huge thing, right? People put all these patients NPO right away and do not feed the patients, uh, because they're thinking they're gonna affect the pancreas and get, and get worse. Please feed your patients as soon as you can, all right? If they're vomiting and they're gonna puke it, well, that doesn't make any sense. You, if you have to throw out an NG or an NG tube, feed the god because bacterial translocation from NPL will complicate acute pancreatitis. So feed the patients. We know that LR lactated Ringer solution at the initial uh recitation is better. That's from a paper, uh, that, that was published from our center by Doctor Farrell. Uh, it's better than, than normal saline. Um, uh, and, and we talked about the antibiotics. So nutrition, it's key, uh, to prevent complications that will make the patient have more chance of having exocrine endocrine occurring in sufficient future diabetes or requires surgery in the future. It, the, the level of atrophy in the pancreas after a massive, uh, um, um, uh, acute ne necrotizing, pancreatitis in pediatrics can be very detrimental very early in their lives. Um, so I hope that, that part is, is clears and, and, and it's helpful. Uh, we're happy to help with management of that at any point, of course. But now let's talk a little bit and shift gears. Any questions about AP there? No, OK, excellent. Let's talk a little bit about chronic pancreatitis cause this is, this is when it becomes a, a, a, a beast. And, and you cannot tackle this without a massive team, uh, helping and thinking, helping you think through this. And, I'm, I'm thankful that, that our team here, again, I meet with them, uh, uh, 3 times a week, and, and we talk about all our patients and we see scans and we see scans from other institutions and try to help navigate this because it's very challenging. As I said before, do not mess with it. Thank you because it can get really complicated. So Key thing here is that our pediatric patients with uh Especially if they have hereditary pancreatitis or hereditary plus anatomy like pancreatic disease. Half of those are gonna develop chronic pancreatitis. We still see some patients with genetic mutations that have a few events, necrosis results, and they're doing fine. Do not touch these patients. There's no need to do anything for them. We see referrals for that and, and we evaluate over 100 patients per, per year for chronic pancreatitis here. Um, and we only operate on 25, 30 of them. Because there's a reason, there's still medical things to do for them. There's still endoscopic, uh, uh, uh, exit, uh, uh, uh, uh, uh, and alternatives for, to care for the pancreas before you commit to, to, to something massive or a big operation. So, uh, if you're, if there's an excuse for malignancy or a tumor, of course, that's a different, different, uh, concept, OK? Now, the problem here is some of these patients, um, I thought they're like 345, hereditary pancreatitis. And all they've known in their life is pain. And you see these kids, and they're not achieving milestones. They're not developing. They're withdrawn from society, right? They don't wanna play soccer. They don't wanna go to school anymore. They're, they're, they're in instead of kids, they're, they're in in their house until 9, and, and families are exhausted. They're just losing control. They're on opioids when they're 5 or 6, right? Families are like getting divorced because they cannot handle this off-work ED visit after ED visit after the ED visit. Insurance is a problem, so. These kids are developing, uh, uh, also chronic pain, right? Chronic pain is not only like an organic part right here around T10 area in the retroperum. Chronic pain plays with brain plasticity, develops hypertrophic nerve reactions, uh, and I studied this part of my research and try to understand how they, they navigate this pain in my patients. Um, they have, uh, uh, uh, a hypersensitization of their peripheral nerves. And start, they, they start growing, they start misfiring even with a uh a gas on the nearby colon goes through the area and stimulates the celiac plexus, boom, massive pain and they, they end up in the, right, because the brain adapts and learn how to live their lives in pain. It's just like a wounded veteran, right? Um. Uh, uh, it happens very often and I see it in early in their lives. Uh, and I can tell them like you, I'm gonna take your pancreas out if it's uh indicated, and I'm gonna take care of 95% of your pain. But that 5, 5% that is left. We need to work with psych, behavioral med, uh, and eventually reteach their brains how to live not in pain. And that's a massive challenge. Now, these families come back and say, listen, I've never met this kid in my life. It's a new kid, happy playing. And so this is why when they're debilitated to the point of maximum medical endoscopic therapy, we need to do something for these kids. That's when we intervene. And I'm gonna talk to you a little bit more about that. There's a huge role of surgical management in Chronic pancreatitis in children, especially when they've reached this. If our medical colleagues, um, we cannot do anything else for them. Endoscopy says there's nothing I can, I can dilate or drain or something, um, um, and it's time for sure. Remember, pediatric patients usually present with minimal changes is, no, not, not, they don't present with a, a, a, a, a dilated dog that we can drain or offer a drainage procedure for them, um. So we need to think outside the box, think genetics, and offer a tailored approach to these patients. Now, conventional surgical approaches are out there and they're available, right? We can do those things, but If you, if you, if you have a genetic mutation and you chop off a piece of the pancreas, throw it in the trash. You can maybe relieve some of the pain. If you do whipple, have the pancreas drain better, do a piece so, I'm gonna touch base on that in a sec, drain the pancreatic duct better. But I put a piece of paper in the trash. And the genetic mutations will keep affecting the rest of the pancreas. So now, I, I did a disservice to that family, to that patient, to that pancreatic tissue, which is not fair. Um, and so, We talked about now, key component here, if you have an inflammatory head mass that usually is not the way pediatric ch chronic pancreatitis presents, is that's an adult, adult disease. If you have an inflammatory head mass, think autoimmune pancreatitis. Uh, we've got full, we've got some referrals like a, there's a tumor in the head of the pancreas referral for Whipple, and then we start evaluating and it happened to be an inflammatory head mass from autoimmune pancreatitis. So, Tailor surgical procedures to your patients, OK, uh, especially in pediatrics. So if you have large dog disease, which is very rare, this is adolescence calcified, uh, uh, uh, stones in the dog creating dilations. Um, this, this picture on the left, we rarely see this, OK, unless the pancreas is exhausted, there's strictures that have not been taken care of, uh, early in their disease by, by, uh, uh, a pediatric endoscopist, and they present like this, right? What I can tell that, you know, take the front, literally front of the pancreas, put a piece of small intestine to drain, uh, a suture to the duct and drain this duct into the intestine through a run-wide configuration, sure. You can do that, but oops, uh, did I look up? No. There you go. Uh, but if you have genetic mutation there, please do not do a Pto or try not to. Now, I was talking about the inflammatory head and pancreas, a whipple, beggar, burn, freight, um, now, they can work, right? If there's nothing else, the rest of the pancreas looks OK and there's no genetics involved, you have a, let's say, pancreatic division that was affecting the head, they cannot dilate this anymore, stricture, dilating the duct, and the only thing without genetic mutation, the only thing that affects the head. Sure, we can do this. Rarely in pediatrics, we've done it and people have done this a FRI procedures, which is a combined, you know, uh, uh, uh, uh, I'll show you in a second, the, the picture, but it's a combined res partial resection with drainage procedure. You resect part a piece of the head of the pancreas and, and look, do like a piece to piece of degenum, uh, uh, attached to the, to the duct. That, in my opinion, is the best, uh, uh, for that. Uh, to resolve that. Um. If you have a distal stricture that somehow you cannot deal with anymore. For example, like uh, this was a, a handlebar to the, to, to the, to the belly, injuring a 10 year old who was riding their bikes. They thought it was a transaction, but it wasn't through ERCP. It duct is intact, but eventually develops a stricture. We see this often, so mid-body to the tail, it's, it's dilated. They cannot do dilation or stents anymore. They cannot reach this area. Thistal pack, it's a very good, uh, uh, um. Uh, uh, cure for this, right? And we can do this minimal invasive robotic spleen sparing procedure, uh, um, uh, to, to, to, to, to, to cure this problem. But no single surgical procedure is recommended for all patients with chronic pancreatitis, especially in pediatrics. But think genetics, please think genetics, send a panel, send us the labels run the panel. For you if needed, but, um, uh, it's, it's very important because it will, it will help you make a, a, a, a, a, a path for, for these patients' care. This is just, uh, um, to, to, to clarify some of the concept I was talking about for standard whip for the patient, for the people that are not surgeons out there. The standard Whipple is literally you chop off the head of the pancreas, uh. The key thing is that you have to disconnect the the biliary system because it goes from behind and enters the, the pancreatic head. You have to disconnect that and then you have to bring a, a loop of jejunum up, hook it up to in pediatrics, uh, uh, 2 millimeters, sometimes 3 millimeters, uh, uh, uh diameter duct, pancreatic duct into the lumen of the, of the jejunum and then attached to the uh, uh, system, then attached back to the stomach. Uh, to reconstruct this. Complex procedure, complex operation, but when indicated, uh, can be very helpful for this patient. The Fry procedure I was talking about is the right upper, um, uh, it's a com combined drainage and partial resection. You clear some of the head of the pancreas, open the duct, and put a piece of works great for specific problems, um, and the classic piece on the beggar, which is a central. Um, so let's talk about. Uh, the role of, uh, total pan, this is, this is from our center as well. The role of total pancreatectomy with eyelid autotransplant. What is that? You know, these, these kids are presented with genetic mutations, chronic changes, they've, they've reached, uh, maximum medical, uh, therapy. They've reached maximal endoscopic therapy. There's nothing else I can do. They have recurrent admissions, chronic pain, opioid dependence, psych problem. We see a lot of, unfortunately, a lot of uh early teenagers with suicide attempts from, from chronic pain, which is, which is really, really sad. We can intervene earlier. Um, withdraw from society, don't go to school, not playing soccer anymore. We, we don't have a ballerie, ballerina dancer in the house, piano player anymore. When all this is, is happening, we need to attack this through a commitment which is called total pancreatectomy. Now, You say, well, I'll just chop off the pancreas, right? Dealing with a healthy pancreas is challenging. Now, imagine putting cement, throwing cement on top of the pancreas and try to peel it off of that. It's challenging, can be dangerous. Um, uh, you need, you need expert hands in it, um, and, and a, and a team to, to help you with this. I've worked, uh, with this, uh, uh, um, uh, for this surgery with my transplant surgeons as well. Um. The, the, the, the spleen is, you know, the pancreatic, the splenic vessels are embedded in the back of the pancreas, so peeling it off of the spleen is not easy. We're trying very hard to, to do splenic, uh, uh, sparing approach, and I'll show you some of those numbers, but, um, that's gonna be another webinar probably. But, um, uh, when they've reached this, this, this, this state, right? You take the pancreas out now what they become automatically exocrine in sufficient, of course, which is easy fixed through a pill, right? But also they become automatic diabetics. But what do we do for that? Our colleagues in Minnesota said, well, let's put these eyelids, let's take them out from the pancreatic tissue, infuse them back into the portal system. Massive, huge. They started doing some of that in PS as well. We took over. We're, we're doing the, the entire pediatric population along with a couple of centers out there in the country, um. But it's a, it's a huge, huge thing, right? Um. And, and, and I'm gonna talk about who does better with this either on transplantation in a sec, but remember, the key, uh, or the, or the highlight of this, the, the, the why we do this operation is to control their chronic pain, and chronic debilitation, right? Not the diabetes thing. We're thinking about I need to get this kid back to their house with a smile, back to society, school, and soccer, right? We'll deal with diabetes. We might be exchanging a disease for a disease. Most likely we'll be. All right. I'll show you the numbers while. We're getting better on that. But we need to be OK with that. Family needs to be OK with that. Patients to be OK with that. Now, diabetes doesn't come just chronic pain. So, most people are OK with this. Um, we're paying more and more and more attention to how to keep eyelet cells alive. And the key for that is Less pancreatitis attacks, right? before an operation. The more pancreatitis attacks, the more cells are gonna lose. We used to think, oh, more ERCPs are gonna kill mo islet cells. No, not necessarily. Studies show that ERCPs do not, however, you're requiring 20 ERCPs there's something wrong, you do something for that. Um, um, higher BMIs, obesity, right? Can, can, can have, uh, problems early with that. Now. Uh, uh, um, uh, segmental pancreatic resections, you, you're throwing tissue to the trash, so you're losing cells. Um, so all those things playing, playing a role, how many eyelid cells you're losing. So we're trying to, to, to, to grow eyelid cells now, right? So hopefully, one day you come back and I'll, I'll give you your vaccine and we'll get more eyelid cells because you're starting to become diabetic. But remember, we're doing this for, for chronic pain and that should be the, the, the major thing in our head. Um, so when this happens, we have criteria for this, but every patient is different. There's no, oh, if you reach 5 years old, that's it. No, there's no, every patient is gonna tell us when they're ready for this, OK? And uh, uh, we have listed this. This is published out there from our center as well. You have findings of CD of course, you need to have at least 6 months of disease. You need to have at least a criteria, positive criteria for chronic pancreatitis, via EUS MRI or, or MRCP or CT scan, some sort of insufficiency, either exocrine or endocrine, but definitely, definitely impaired quality of life. That's why it will make me go and take a pancreas out of, of, of, of a, of a pediatric patient, OK? So, Now, obviously we'll never propose this if there's a massive contraindication to either psycho, psychosocial, right? There's no family support, um, uh, uh, uh, of this patient is not stable, uh, uh, uh, from their mental health that will not withstand a massive, uh, uh, post-surgical, uh, um, um, uh, uh, problem like this, right? So sometimes we have to say no to those, to, to those patients, as we talked about willing to accept the risk of lifelong diabetes. So. Uh, we talk about this quality of life. So, but the goal of the eyelid, eyelid autotransplant, and you know we do it just like the, the, the picture is showing it, and I'm gonna touch base a little bit more details of this, is to replace this beta cell mass and insulin insulin secretory capacity, right? Now, all patients become a little bit Uh, uh, uh, uh, uh, insulin dependent at the beginning, we put them all in insulin drips to try to give the cells a vacation. I want them to engraft. I want them to live happy, find oxygen, and engrafting the liver, uh, before we commit to, to stopping the insulin. So. How do we do this? And, and, you know, there's an awesome webinar uh from Globalcast that shows my day in the operating room about, about a full TPIT. I encourage you guys to look it up and it's, it's, it's, it's, it's pretty cool. They did a wonderful job with, with this. Um, but it's a, it's a big ordeal, like we're preparing for this patient months in advance. The entire team, we're meeting, we're voting who's gonna be a candidate, Lily, thankfully, it's not my decision. Right, I am just a part of a wonderful team, and we need to vote, we say, raise hands and say yes, no, defer, because some of my colleagues will say, oh, there's, I still can do something here. I can put in another stent, I can do, patient's doing well, or, or behavioral medicine tells me uh uh um they're not ready. They cannot, this family cannot withstand this. Perfect. So I need the input from everybody. We, we work as a team and we make a decision together. No, the night before. It's a big operation. It used to be a 20-hour operation. We have it down to an average of around 8 or 9 hours, but it's a big operation. Um, the patient rolls in at 7:30 in the morning. We line up, we put pain catheters. My, my pain team is, is wonderful and I have all these, uh, uh, uh, um, uh, um, errospinal catheters that control very well the pain. Um. Of course, it would centralized and all that. The goal is to get the entire pancreas out, OK? And sometimes it's really hard. You can imagine peeling it off of the celiac of the, of the splenic vessels of the portal vein even though it sits on top of the superior mesenteric artery. So we do this, uh, obviously the duodenum comes with, so we need to disconnect the, the delivery system right there depicted in, in green, um, and it used to be an automatic pancreas duodenum, spleen comes out, right? But What we noticed now, and, and I started, you know, getting calls from the families out there like, hey, I need to run to the ED for a fever for IV antibiotics because I don't have a splint. I said, you know, and call after call after call, I said, you know, is there a way to spread the spleen, right? There's a, there's a group out there. They started doing that in adults and like, OK, yes, it can be done and, and outcomes might not be, uh, might not be, uh, uh, um, very different because people think, well, You know, you, the majority of your eyelid cell mass lives in the body and the tail, distal side of your, of your pancreas. So you get tributaries from the splenic artery into the pancreatic curriculum, right? It takes a while to peel this pancreas out. If you start trying to get all these tributaries off. You increase your warm ischemia time with these pains to delight itself, for sure. So people say, well, your, your glycemic outcomes are going to be worse. So, but I was in this predicament like, OK, these families are suffering, glycemic, but I'm, I'm doing this more for pain, but also let's pay attention to themselves. What should we do? I said, OK, let's, let's, let's try as planning, sparing approach. And it's a game-time decision. I cannot tell you what I'm gonna do from an MRCP and the CT scan. I go in there, put my hands in there like, OK. There's significant atrophy, it's not a stuck, or there's just a small segment. I'm gonna give it a shot, right? There's still, it still takes a little more time and risk. If I'm gonna put the patient at risk, absolutely, spleen comes out, period, or we start losing some blood or something. Um, but I started doing that, I started experiencing splets and I said, OK, let me make sure I'm doing the right thing, right? So I got the 1st 20, the 1st 36. I said, let's compare. Historical controls random uh uh uh uh uh uh and our new, our, our new patients spur that we spur the spleen, OK. And we, uh, we accounted for eyelid, and this is about to be published, so you cannot repeat this just yet, but about to be published in next month, hopefully. Um, uh, uh, we accounted for the same eyelid equivalent per kilogram transplanted, so there's no confounders there. All right, we said, how are the outcomes? Am I spending too much time on killing cells? Outcomes are equal. So my, right now, my approach is I'm gonna spray the spleen on every patient unless I cannot. Right there, it's gonna take me too long. I'm gonna put the patient at risk. Or just sim like simply not what's the percentage right now. So right now, so we we did none in the first like 8 years of the program. Uh, we did one in, in the following year. Right now we're 80% we explained in the last 5 years. So we're getting better at it and uh obviously I'm gonna keep observing this and, and redo this, this, this study when I have more, more, more patients on the docket there. I wanna make sure we're not doing something that we're not supposed to. So I hope that's clears. Um, the, the, obviously the gallbladder comes out. Uh, I take out the appendix take out the appendix because with all this dissection, I don't, I don't want these patients, they're young, right? They can get appendicitis very often. I don't wanna go back into those benefits I take the appendix out. Um, if I cannot put this, the entire cell pellet volume in the portal vein, I, I usually do, a mental patch, and I'll, you know, uh, those outcomes are for, for another talk, but, uh, uh, they're not as, as, as, as, as great, but there's only a, uh, uh, a certain amount we can put in the portal vein, especially in children, because you can risk portal vein thrombosis. By the way, I do this operation under anticoagulation, which could, uh, bleeding risk, uh, uh, uh, out there, right? Um. So, obviously they, I do a GJ tube to try to feed them. I'm gonna show you how the reconstruction happens. It's just like this. We have a gastric, uh, I do post-pyloric, uh, uh, uh, duodenal resection and, uh, since they all have gastroparesis, I started injecting Botox in the pyloric muscle muscle to keep the gate open, so less gastroparesis after his reconstruction. I studied that as well, and they have led decreased length of stay and and, and, and faster. Um, uh, return to full PO intake, uh, and when we do this, to better glycemic control as well. So we have a gastroadodenogenostomy, varicodenostomy, and junonostomy. The GJ tube goes through the first two, right there, OK? Um, so, oh, this is the, the paper I was talking about, and the outcomes were better, so I put pyloric Botox on all the patients intraoperatively. Um, so we have a lab in our center that we do here the installation, uh, uh, in-house. We have, we're lucky to have one of the, well, the world expert isolator, uh, that has trained several people, not only the United States but also in Europe, um, and how to do this. Um, it's both that enzymatic and mechanical digestion that we, we Or they've perfected, um, we've added certain different things to try to make them as pure as we can. The eyelid cells do not travel alone and you're like, oh, let me just grab a few eyelids. They travel in clumps, so you need to degrade some of the tissue around them. Um, you, they come with exocrine, uh, uh, cells as well. Um, so this is a very detailed process. It takes about 3 hours, 3.5 hours, uh, sometimes 4 depending on the, on the, on the, on the degree of injury in the pancreas, OK. That's for a different talk, and I'm not the expert on that. We have thankfully experts that can explain this, this better. But the key for this, let's say, you know, when I take the things out and it's in the, in the lab, they're working on extracting the cells, and I'm, I'm working on the, on the, well, uh, I'm with the team working. Working the reconstruction, doing all these uh new connections, uh, while they prepare the cells. Um, usually, uh, uh, uh, we're ready to, to go when the, when the cells come back, they bring it back just like you see that, like, like in a, in a, just looks like a plated, platelet back transfusion, um, uh, and I injected the, the, the splenic vein into the portal vein, um, um, just like you see in the picture with an angioca. Now. You're putting milkshake in a, in a, in a low flow vein, right? You can clog this up really, really easily. So what we do is do this case under anticoagulation, we boseparin right for doing this, um, and we have several different factors to, to, to work with in, in, with diuretics and pressures and to balance the perfect uh uh uh uh central venous pressure to, to inject this. Um. There's only a certain amount. We cannot go over the threshold to injecting pediatric patients cause we run the risk of clotting this. And we, we have more than that. We, we do the mental therapy. Um, so one of the complications, this is, oh sorry, these are, these are not our numbers, this is national, national stuff, um, uh, but you can have bleeding, of courses, you're, you're playing with a time bomb there, a ticking bomb, um, um, but thankfully, you know, bleeding, you can, you can stop right there. Thrombosis is a big problem in our center is less than 1%, uh, but that could be very detrimental if you increase it, you know. Uh, uh, your, suddenly your small intestine cannot drain anymore, um, uh, and your liver starts, uh, starts suffering. So that's a, that's a big problem. One infection obstruction, we thankfully don't have any leaks, uh, in our center. We're over, um, closer to 200 cases now, and, and we haven't had that problem. Um, but they all get gastric empty, uh, problems, of course, so we're trying to work on that. We have pathways, very well-defined pathways from pre-op to the OR to the post-op care and the PICU to the floor that we know exactly what's gonna happen when for these patients unless they're out of, of the pathway for some, some reason, some complication. But we take very good care of, or we try our best to care for these cells. Like I have them in the, in the operating room on, on drips from D10. LR system is a two-pack system with an insulin drip. I'm controlling glucose and insulin for them, so these cells. Stay alive for as long as possible or we don't kill. So, so I keep, I keep trying to keep the, the glucose between 80 to 120 throughout the entire, the, the case, the post-op care and the floor, uh, uh, some, some, sometimes, sometimes it's really hard, especially in the older adolescents who have had a lot of problems and a lot of atrophy and you don't have enough cells to give. I'm gonna talk about that in a sec, but I'm managing hour by hour, minute by minute, these cells and this insulin. Uh, in the ICU, um, um, along with the PQ team. You know, we have an entire protocol for this and, you know, for another, for another talk, but they're all always in, in pancreatic replacement therapy when we start feeds. Um, uh, we started, we, we start decompressing the GI tract, then we start feeds through the GJA tube, um, and, and we transition them out of the ICU once they're at goal feeds, when the insulin and the glucose is gonna be more stable. They don't need to be in the ICU, uh, for a week. They're actually, actually, uh, we extubate them. In the operating room after the case. But we want those glucose and insulin, uh, levels to be as perfect as possible. Uh, most patients come from out of state, so we discharge you locally a room at the old house, um, cause we wanna give them clothes. Uh, we bring them back almost every day for a couple of weeks. We check everything from, from, um, Platelet levels if they don't have a spleen to anticoagulation, to glucose monitoring, to, to, uh, medication, antibiotics, uh, uh, uh, uh, motility, uh, uh, uh, uh, uh, medications, and, and we follow that very closely. Most of that follow-up is, is done by my GI colleagues, of course, thanks to them. We have care masks for, for the entire family, so they're not alone. So, Talk about some of the, of the alcohol, and this is, this is the magic of it, right? And, and honestly, I don't keep, I don't want to keep doing this, this crazy operation for, for a long time. I hope my, my medical colleagues can find a, a, a, um, uh, um, a solution for this, but Uh, you, we've seen this, and this is a little all I wanted to show this cause it's initial from, from, uh, Minnesota, but now our center has the exact same graph, over 80% drop in opioid use. At the first month or two with a sustained effect for years wow. So the opiate use just drops and stays dropped, and it's a sustained effect, which is a massive thing. Now, the earlier the better, the easier it is to get him, the less exposure to opiates, of course, the easier it is to get him off, but we know that younger children are more likely to achieve insulin dependence and opioid independence. Uh, uh, post CTAT, uh, uh, uh, the younger they are, the better the outcome, of course. You don't wanna pull the trigger too early if it's not indicated, but that's the key, when to do this. And the family ask me, when should we do this? Well, I don't know. Yeah, your, your son or your daughter's gonna let me know or let us know. But we know the earlier the better. Eyelid yield is like the amount of eyelid equivalent per kilogram of body weight that we're gonna transfuse back to the patient, and there's a mathematical equation that we can come up with, uh, not, not we, uh, uh, uh, Minnesota, uh, uh, uh, uh, um, uh, to see how much the, the, the, the, the, the mass of the volume of the eyelet cells we're gonna, uh, um, infuse back to them. Uh, and we know there's a relation with how much we're giving to like, of course, the degree of atrophy from pancreas calcification, ductal elation, how much fibrosis when they cut the cells in the, in the, in the lab, and the duration of symptoms. OK, so that's when it tells, uh, should we wait too long or should we just start getting these patients earlier. Obviously, any resection or ductal drainage procedures will impair your, your yield. So, uh, this is not just my, my, my, uh, opinion. So we know, and I told you from this magic number of IED equivalent uh per kilo, which is an eyelid mass standardized to the size of a medium eyelet cells volume which is 150 microns. We know that the closer we get to 5000 eyelet equivalents of kilogram or higher of auto-transplanted eyelet cells into a coral vein, the, the better the outcome is gonna be recorded at 36 months. This is from Minnesota as well, size 92% insulin independence. We're hitting right now. Uh, uh, 70% because we started doing like very older, uh, adolescents that had almost no pancreas, so we're, our data is a little lagging, but now we're like started to to give you an example like 8 years ago at 40%, 50%, 60% or 70% that we're rising really fast in insulin dependence, uh, because we're having a better product of uh eyelet equivalent, uh, uh, uh, isolation, and, and, and, uh, uh, at the center, the center is just having more experience. So from our center, oops, sorry, the sort of predictors of glycemicia cause my, my, my endocrine team is just phenomenal and I can tell you that I, I can show you here like uh uh 72% at that time, this is 5 years ago, uh uh 70% were uh testing positive for genetic mutations. Right now we're almost at 80%. So we know that. The younger they are, the better, uh, um, um, the better, the more eyelet cells transplanted, the better, right? Of insulin, like within a mean of 9000 eyelid uh equivalents per kilogram transplanted of insulin. A tiny dose of insulin, less than 0.5 total daily dose of insulin. When you reach close to those 5000. Under 5000 or 1000, you will be a diabetic. So I tell them this. Now, again, this is a few years, new outcomes are coming up. Hopefully, new webinar, I'm gonna show you new outcomes of over 160 patients that are, that, uh, uh, uh, we have, we have uh accounted for. So more outcomes to come here. Uh, optimal like of insulin, or I'm talking about graft function status, optimal or good. All right. We're closer to 60%. We're now up to 70% of, of insulin independence, and patients fully diabetic are about still 30, 35%, which is, which is the older adolescents usually. All right. So, uh younger time of surgery, smaller body surface area, no history of, if they're, if they come with insulin, they're gonna become diabetic cause there's, those cells are, are wasted and they're, they're exhausted they cannot function anymore. And the higher the IAQ per kilo, the better insulin dependence, OK? Now I was talking to you about the spleen preserving, um, more to come on this. I don't even wanna, uh, show you this just yet, but we had no difference in median transplanted is equivalence per kilogram, no difference C peptide levels and or hemoglobin A1C at 12 months, or outcomes are equal. I'm trying to spread this clean, um. Really quick here, opiate, opiate use, it's, it's dramatic, dramatic, uh, sustained effect, nutrition, they're all eating by mouth or through GJA2 for a month and then after that, full PO. They're not in TPN. They're not parental, uh, uh, nutrition anymore. Uh, but here it's huge and I'm almost done, but quality of life is what, what matters. Uh, dramatic change in their lives. Like you, you know, I was just there at the National Factor Foundation, uh, uh, uh, meeting and And, and these families. Literally 5 of my kids were like, I've never met this kid anymore. Like I've never met this kid in, in my, in, in, in the, in the, in my life, new person. Uh, I cannot give him uh uh control now. They're running around eating pizza, cheeseburgers. So, Uh, this one of our patients who, who was a ballerina dancer, stopped for five years and now is back on that, um, to appropriately selected children. TBAT achieves durable pain relief and dramatically, dramatically, I cannot like, uh, stress this enough, improves quality of life. All right, so you need a team, a huge team to do this. We're doing more and more research to make this better, provide better pain control, provide better survival for islet cells, um, um, uh, to, to, to give you better outcomes, but Um, the key is selecting your patients as well. Again, we see over 100 per year of, of, of, of these patients in, in, in terms of evaluations, and we only do, uh, 25 to 30 a year. But because there's still more room to work with these patients sometimes, and you need to be careful with this. Um, let's just, uh, we have questions. So first of all, that was a lot in a, a short, so for those of you asking, yes, this is recorded, and we will release pieces of this throughout, uh, all the different social media channels, YouTube, whatever, and we'll have it available, uh, for those who, uh, have joined, we can send you the recording, um, but, uh, and this will all be on the state current app. So whatever you use. Um, we have a few questions. We have about 4 or 5 questions in the audience, but I, I wanna make sure I got this right. So, main issue, pain. Absolutely. Basically, life can be life destroying if you really don't manage it well. You go as long as you can without Removing the pancreas to the point where um you, you wanna make sure you preserve the pancreas, but at some point, it's just not, the pain's getting intolerable. It's not gonna get better, and you have to make that decision. And there's a stepwise process you can do. From what I saw, this is me seeing if I got this right. You do the different operations you could do for chronic pancreatitis, but the ultimate is a total pancreatectomy, but then auto-transplant the eyelid cells, correct? And you know, it's, it's, it depends on the patient. Like, I would never offer a segmental resection on a patient that has a, a PS as one mutation ever, right? It depends on the patient. Because, yeah, because I'm gonna throw a piece of the, to the pancreas to the trash, and then when the patient needs a TDIT, then I have less cells. So we have, uh, uh, people, like, it's always interesting. I wish we had more, um, information about who the audience was, but we have people from very different, uh, specialties, different locations. Um, it seems like 70% are surgeons, so we'll, we'll hit on that. The first, uh, question was. Um, regarding necrotizing pancreatitis, uh, it's not something you talked about in this talk. We could do another talk, but big talk if there's just a question of, um, do you usually manage if you get called for a suspected pancreatic leak conservatively, and then if there's a biliary leak, how do you know there's a biliary leak, and, and what is your approach to those? So we can either Hit on it briefly or we could um email it. You can email us and then we could talk that yeah, I know, in, in brief, yeah, I, I always, I always get involved, uh, uh, when the, when the GI team gets a consult for this or the PQ, uh, I always get involved because it's, it's time. Uh, of intervention is key, and the, the, the, the, the, the selection of intervention is key, right? If, for example, trauma, if the trauma comes in, I have my earsCPs go in and do an ERCP right away to see if it's leaking. If it's leaking and we can do surgery on it, we'll do surgery. If he can stent it, that's it. Now, if we have a necroti. Seeing pancreatitis that you're suspecting a leak, right? You let the necrosis settle down. You don't want to intervene right there at all. Now, if you have to retroperoneal drain or most likely and more often and less invasive and with better outcomes, transgastric, once the timing is, is appropriate, my GI colleague, uh, David Vitale or Gary Brat, which are interventional endoscopists, uh, they go in transgastric. Uh, luminos or metal stent, pigtail catheter, drainage. And even if there's a leak, have it drain into the stomach. Quiet down that necrosis and let's see what the patient's gonna do. We re-image it too. It's 4 weeks, 6 weeks. If they're still leaking, then necrosis control, then the patient is out of multireal failure or something, recovered, not septic, but we're leaking. We can put a drain. What I would ask is, let us know what specific parts of pancreas you guys want us to do more on. One is very eager and willing to do whatever everyone wants. And I also wanna say is, you know, we, we love sharing knowledge around the world. We love putting it into places where people can talk about it, share it. Um, but also, if there's an interest beyond that where you, some of the things that were talked about, you wanna know more details about, let us know, uh, uh, regarding that as well. Um, question, random question, do you prefer NJ or NG? I told you this was gonna be a question of what I learned from the other, um, for chronic or acute pancreatitis. Uh, so it, it depends on the patient. If the patient has been like there's a lot of high vomiters, they cook a lot, and there's a lot that don't. If you can feed normal, feed normal by mouth mouth. Oh, mouth is not doing well. NG, oh, I'm puking throwing in. It's like the patient's gonna tell you, but wasn't there something. Like you don't have to feed the bowel, feed the, the gut nutrition prevents bacterial translocation, prevents sepsis, prevents that was a big thing I learned. That's huge. I was taught, you know, don't feed, but now we feed, yeah, feed the feed, feed, feed, OK, yeah, um, and, um, OK, um, what else is there? da da da da da. OK. Uh, what is the best time for drainage of a pseudocyst for post-acute pancreatitis? Wonderful question. No earlier than 4 weeks. You don't have a mature wall before that. And then you just like poke it and start spilling the perineum or the retroperoneum, and then you create a massive partholic gutter's retroperineal fluid collection that if you just poke it and you infected, you run the risk of infecting the collection, then. You're in a big trouble. Then it becomes necrosis. It starts eating the tissues surrounding the retroperineum, and then you have another systemic inflammatory response, multi-organ failure problem. Wait until the, the wall is mature, scan him again, look at the wall, how much is pushing on that back of the stomach. 6 weeks is optimal. Again, I'm not an expert on that because I have the, the experts on that, but they tell me no earlier than 4 weeks. We, we've done one earlier than 4 weeks because he was fully mature, but 4 to 6 weeks is perfect. So I just put my email in there. Um, if you have any questions, I can send them over to Juan, uh, please, please do, and, uh, you know, we, we really wanna figure out how we can best share information around the world, and I know that what we talked about today, the TPIAT, the, the total pancreatectomy with eyelet autotransplantation, that is a very, um, you know, um, specific, highly technical thing that not every place can do so. Uh, you know, uh all of the stages of what, what was talked about today, we'd be happy to go into depth on. If, if your center is, uh, one that just manages early, uh, treatment, great. Let's do it. If it's maybe about how to do those, uh, primary operations, we could go into that. If it's some interested in TPIAT, let us know. I mean, all of those things. It's, it's hard to, to satisfy everyone for what they're looking for, but let us know, and we will push out information every day, um, on everything. So, question, um, and then we'll have to wrap up, but I'd like to hear your opinion on non-operative management of pseudocysts. Yeah, don't touch them. The patient is asymptomatic. Do not touch it. Don't touch it. That was the thing in the beginning where you said, yeah, yeah, yeah. They're, they're not vomiting. They're tolerating. Yeah, there's no pain. They can eat. Don't touch it. Reimage it 4 weeks or 6 weeks and see where they are, uh, uh, um, just to make sure that it is resolved. If it's not resolving, then, then you can do something about it. I'll go, well, not me, but my colleagues trans gastro, uh, and, and real quick, um, you know, we're always available to, to help, uh, or assist or, or, or, or. Work around a case with you guys. You know when we do TPITs, uh, we work with the primary GIs in their home, in their homeland, and, and we take the patient, we do whatever we have to do and send them back to them. Those are the, they're doctors, so we work with them, and, and, and, and we never just take the, the, the patient and, and keep the patient. We'll send them back to their primary GI doc or physician, and we work with them pre and post. OK, this is great. Uh, you have our information. Uh, let us know what you wanna hear about. Um, like I said, we'll push this stuff out throughout the week, different clips of this, the key points made, um, on all the social channels and the state current app, and we'll send, uh, emails to those who registered, uh, which should be all of you, and, uh, let us know, communicate with us. We are an email, a phone call away, and we love sharing this kind of information, man, you are awesome. Um, we're so excited. I've been chasing after one, saying we, we love to, every time he talks, he's got. So much stuff to teach us and uh we wanna do one on robotics. We wanna do, we had a request again for acute pancreatitis, chronic, all the different things. We'll do it. We'll get it out there. And uh to everyone all over the world, thank you for joining us. Uh and again, good morning, good afternoon, and good evening. And we will see you next time. Thank you.