Update Course Rewind: Management of Chronic Pancreatitis 2023

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm Cecilia Jigena, 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 talking about management of chronic pancreatitis with Doctor Juan Gurria, a pediatric surgeon from Cincinnati Children's Hospital, and he started with a case. OK, we have a 5-year-old, chronic pancreatitis, debilitating abdominal pain, multiple hospital admission admissions in the last 2 years, fell behind on milestones, Dilaudid 3 times per week. MRCP chronic changes, minimal duct change disease, but has appeared as one mutation, has had 5 ERCPs and a stent in the past with no improvement. So what should we do with these patients? Fray procedure, post-op procedure? TPIAT or total pancreatectomy with eyelid autotransplantation or Whipple procedure. All right. 53% are doing TPIT. Some people are doing the Whipple. Remember, there is a mutation, right? So, 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. So, up to 50% of patients with chronic pancreatitis will eventually require surgery. OK. TPIAT or total pancreatectomy with eyelet autotransplantation, is a surgical procedure that some children with chronic pancreatitis may require, but it is not the only approach. And they need a multidisciplinary team. Not everybody is, is a candidate for, they need support, they need social support, right? We, our team requires, I'm just a part of it, uh, right? Surgery, massive GI pancreatologists, experts, social worker, geneticists, psych, pain control. So remember, patients with chronic pancreatitis are, are always having micro and macronutrient deficiencies, so we need to pay a lot of attention to this. That's why uh we, our GI colleagues are, are, you know, they are the experts on this, and, and they work really hard on, on, on having them support. Uh, their nutrition with the, these patients sometimes need pancreatic enzyme replacement therapy and they should be on, right? Um, you lose first your exocrine and then your endocrine function, so you need to keep screening for it. So let's talk about the goals of TPIAT. The 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. And as a secondary goal is to try to prevent the brittle diabetes that happens once your pancreas is out. All patients have enzyme replacement therapy, of course, you cannot, we cannot provide that service, um, just yet, but if you don't give the beta cells back, You know, they're going to become diabetic. And what is the percentage of diabetes after the surgery? There's a lot of factors that play into insulin independence uh on the, on the, on the, on the outcomes of this surgery, but right now, 50% chance if you hit 5000, 50% chance you're not going to require insulin. 20% chance you will require a, a, a small dose of insulin. The other 30% are still diabetics. So we need to tell the families they're, I'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes. OK, so this is important. In kids with an islet cell count of at least 5000, they'll have 50% chance of not requiring insulin. After the TPIT, 20% chance of requiring small doses of insulin, and 30% will be fully dependent on insulin. Let's talk about the surgery itself. Well, explain what your day looks like when you do one of these operations. When does it start and then what happens when you send off the, the, the pancreas, and then when you get it back, how do you put it back in? It's taking about, um, average. 8 to 10 hours. They, uh, you start at 7:30, we, you know, put all the necessary lines, central line, arterial line. Um, taking out the pancreas is the, the most problematic part, as you can imagine, it's cemented back there in the retroperitoneum with neovascularization, collateralization, some patients have thrombosis in the portal vein or in the splenic vein, so you deal with those collaterals as you go in, um. The pancreas comes out, usually, you know, it's 334 hours, right? And then we send, we have a, um, uh, in-house facility for the eyelid isolation in Cincinnati Children's. We have one of the experts, world experts, uh, from Pittsburgh working with us now, um, doing the eyelid isolation. The pancreas goes out to the lab, and as they're trying to get the eyelid cells back, I started the reconstruction. So the GI tract and the patobiliary, um, you know, it's, it's a run wide that goes up to the, to the, um, hepatic, uh, duct, and then you do the intestinal con uh, um, a reconstruction just like that. That's how we do it. We take the pancreas, the spleen comes with, um, you see the bile duct there and. In green, and we do a ring-wide reconstruction. The cells isolation takes 4 hours, 4.5 hours. Um, they come back and we inject them right there in the portal vein, um, inside the liver. Great. So the steps are pancreatectomy and a splenectomy. Send the pancreas to the eyelid isolation lab. Start the patobiliary and intestine reconstruction with the room-wide technique. Inject the cells into the portal vein, and how do we control them in the post-op period? 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. So where do the cells eventually implant? In the In the end, uh, end branches of the portal vein inside the liver. Yeah, they live in the liver. Uh, there's a, a lot of, uh, publications in extrahepatic, uh, reimplantation of the eyelid cells. They don't work as well. Only they, you know, for, for hypoglycemia, there's a good glucagon reaction when they're extrahepatic compared to intrahepatic. Um, however, the best site for them is the liver. There's risk for portal vein thrombosis is very low, less than 1%, but it can happen, so we monitor the portal pressure as we're, as we're injecting. Do you take the duodenum when you take the pancreas, or you just shave it off the duodenum? No, no, we take the duodenum right at D1 post pyloric. We take for the same. Reason, you could spare duodenum, but the shared blood supply is hard, so you disconnect the, the bile ducts and the duodenum. Perfect. So let's summarize. Chronic pancreatitis is an affection of the pancreas that leads to pancreatic insufficiency and damage of the islet cells. One of the treatments is a total pancreatectomy with eyelid transplantation or TPIAT, and for this we need a multidisciplinary team. Our goals in the surgery are to treat the chronic pain these patients have and to avoid diabetes. 50% of the patients will not require any insulin at all. 20% will require small doses, and 30% will be fully dependent on insulin. The surgery consists of a pancreatectomy with an extraction of the islet cells that will after be injected in the portal vein. Hope you enjoyed 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. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.