Update Course Rewind: Management of Chronic Pancreatitis 2023

Global cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm Cecilia Hihona, 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 Dr. Juan Guria, a pediatric surgeon from Cincinnati Children's Hospital. And he started with a case. Okay, we have a five year old chronic pancreatitis, debilitating abdominal pain, multiple hospitals mission admissions in the last two years, fell behind on milestones, dialoted three times per week. MRCP, chronic changes, uh, minimal dog change disease, but has a PRS1 mutation, has had five years of these and a stent in the past with no improvement. So what should we do with this patient? Fry procedure, postop procedure, TPIAT or total pancreatectomy with islet auto transplantation, or whipple procedure. All right. 53% are doing TPIAT. Some people are doing whipple. Remember, there is some mutation, right? So if you most of the pancreatic parankima is in the head and the uncinate process. If you get rid of that head and there's a pancreatic PRS1 mutation, this kid is going to get recurring attacks. So, up to 50% of patients with chronic pancreatitis will eventually require surgery. Okay. TPIAT or total pancreatectomy with islet auto transplantation is a surgical procedure that some children with chronic pancreatitis may require, but it is not the only approach and they need a multi-disciplinary 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, right? surgery, massive GI, pantologist experts, social worker, geneticist, psych, pain control. So remember patients with chronic there are all are always having micro and macronutrient deficiencies. So we need to pay a lot of attention to. 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 having them support uh their nutrition with they these patients sometimes need pancreatic enzyme replacement therapy and they should be on, right? Um, you lose first your excrine, 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 drop 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 bril 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 this surgery? There's a lot of factors that play into insulin independence uh on the on the on the uh outcomes of this surgery. But right now, 50% chance, if you keep 5,000, 50% chance, you're not going to require insulin. 20% chance you'll require 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. Okay, so this is important. In kids with an island cell count of at least 5,000, they'll have 50% chance of not require insulin after the TPIAT, 20% chance of requiring small doses of insulin, and 30% will be fully dependent on insulin. Let's talk about the surgery itself. Want to explain what your day looks like when you do one of these operations? Where does it start and then what happens when you send off the the the pancreas and then you get it back, how you put it back in. It's taking about um average 8 to 10 hours. The 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 is cemented back there in the retroperitoneum with neovascularization, collaterallization. Some patients have thrombosis in the portal vein or in the splenic vein. So you deal with those collaterals as you go in. Um, pancreas comes out usually, you know, let's three three, four hours, right? And then we send, we have a um uh inhouse facility for the isolation in Children's. We have one of the experts, world experts from Pittsburgh working with us now, um doing the isolation. The pancreas goes out to the lab and as they're trying to get the islet cells back, I start the reconstruction. So the GI track and the patobiliry um, you know, it's a Ru why they goes up to the uh to the uh hepatic uh duct. And then you do the intestinal uh um reconstruction just like that. That's how we do it. We take the pancreas, the spleen comes with. Um, you see the bilug there in in green and we do a Ru why reconstruction. The cells isolation takes four hours, four hours and a half. Uh 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 islet isolation lab. Start the patobiliry and intestine reconstruction with the Ru white technique. Inject the cells into the portal vein. And how do we control them in the post up period? In the acute postop 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 in the branches of the portal vein inside the liver. Okay. Yeah, they live in the liver. Uh there's uh a lot of uh publications in extra hepatic uh re plantation of the islet cells. They don't work as well. Only they, you know, for for hypoglycemia, there's a good glucagon reaction when they're extra hepatic compared to intra hepatic. Um, however, the best site for them is the liver. This risk for portal vein thrombosis is very low, less than 1%, but it can happen. So we monitor the pressure as we're injecting. Do you take the duodenum when you take the pancreas? 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 sheer blood supply is hard. So you disconnect the the bile duct 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 islet transplantation or TPIAT. And for this, we need a multi-disciplinary 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 on a pancreatectomy with an extraction of the islet cells that will after be injected in the portal vein. 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. Global cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.