Update Course Rewind: Management of Acute Pancreatitis 2023

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm Cecilia Gijena, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held this past August. In this video, we are going to talk about management of recurrent pancreatitis. And for that, we have Dr. Juan Currea, a pediatric surgeon from Cincinnati Children's Hospital. So first, we started with a case. Seven-year-old with acute recurrent pancreatitis, abdominal pain. This has a diagnosis of ARP, referred to you with an ERCP showing a stricture in the head of the pancreas and a dilated duct distally. We've seen this multiple times. Um has had seven ERCPs and a stent in the past. So, this is the ERCP. So, we have a clear stricture in the area of the head of the pancreas and a dilated duct distally, and you see clearly the branches. So, what is your plan? MRCP to evaluate for chronic changes. Repeat ERCP balloon dilatation and stent placement. MRCP and obtain genetics, or admit and plan for fry procedure. The fry procedure is a partial head pancreatectomy with duodeno preservation and a pancreaticojejunostomy. And it's interesting to see this uh very divided. Um MRC so the main is repeat ERCP. So keep doing. We're seven ERCPs in. The question is when do you stop, right? Every time you get a new ERCP, you have a risk of getting post-ERCP pancreatitis. It is low, right? But still a risk and you lose islet cells with every attack. So we're losing cells down the road. And as he said, genetic is key. So it is really important to get a genetic panel. PRS is one. Is the most common one of uh which is a trypsinogen activator. It activates trips inside the pancreas. There's CTRC, CFTR, um, you know, CPA1. There's a whole bunch of mutations that we now know. We our gene gene panel in Cincinnati runs 10 different genetic markers. So that's how we're changing the approach to pediatric pancreatitis, chronic chronic pancreatitis treatment because of the genetic factors. Awesome. So if a patient has more than one episode of acute pancreatitis, or a first really bad episode of it, we should perform an MRCP and a genetic panel to rule out genetic anomalies. Now, we have that patient that has the mutation that they're their trips and activated. What's how do you mediate that? Is there medication? Is there another path that you can do to Wonderful question. No, there's no unfortunately we don't have that just yet. That's why I still have a job. episode. But uh I hope I hope someday we have, you know, I want to do a few go on this kid. What's the downside of that? So, excellent excellent uh question. If there's a genetic mutation, let's say there's a PRSS1 mutation, right? For a pistol you have to like get the top of the top half of the pancreas out to open the duct, right? Um you you throws uh some islet cells to the trash. Um this patient most likely is going to keep getting pancreatitis despite you draining the duct. They the parenchyma is going to keep getting attacked by the mutation. So, you're temporizing um the attack by draining the duct. Uh, but you're not fixing the problem. Great. So genetics are very important before any resection procedure. To avoid losing pancreatic cells in pathologies that will not benefit from a resection and drainage, that instead, from an islet cells transplant. So, I know the scenario really much points towards, okay, maybe recurrent or chronic pancreatitis, but after how many do you feel like okay, this is all we're dealing with? Two ERCPs, three, when do you start thinking, considering that this might be a problem? That's a great question. We don't have a set number of ERCPs. So, uh there's no set limit on that. The sooner the referral the better for evaluation. We don't offer uh to take out the pancreas unless you've maximized medical and endoscopic management. If there's no other options and your endoscopic guy tells you, you know what, there's nothing for me to balloon dilate, open, drain or anything, there's been a stent. Even with the stent, the patient keeps getting pancreatitis. There's no reason to keep going with ERCPs. So, do endoscopic treatment at first. But if it fails, transfer to a specialized center that does TPIAT, or total pancreatectomy with islet autotransplantation. Now, what about imaging for these patients? So, we use endoscopic ultrasound and ultrasound, CT scan is imaging of choice once they come. MRCP is the best non-invasive study for pancreas by far. Uh, with different uh uh T2 sequences, um, um, they're great. An ERCP, of course, is more therapeutic than diagnostic. Awesome. Start with ultrasound, then CT. And for better see the pancreatic anatomy, MRCP with T2 sequences. Now, what about fluid collections? Once the the wall is mature in four to six weeks, uh, if there's symptoms, drain it. If there's no symptoms, don't drain it. If the patient is not having gastric outlet obstruction or pain, there's no need to drain this. Um, it will it will self-resolve. Uh, and of course, there's no need for antibiotics. Awesome. Time to summarize. Recurrent pancreatitis is a rare pathology that can lead to chronic pancreatitis and it is associated with genetic mutations. If genetic mutations are confirmed, we should avoid partially resecting pancreatic tissue as in a fry procedure to avoid losing pancreatic cells. The treatment should start with endoscopic approach, keeping in mind that if it fails, a TPIAT should be considered sooner rather than later. For liquid collections, surgical treatment should be only done if the patient is symptomatic. I hope you enjoy the video, and thank you for watching. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.