Update Course Rewind: Management of Recurrent Pancreatitis

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 Gena, 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 Doctor Juan Gurria, a pediatric surgeon from Cincinnati Children's Hospital. So first we started with a case. 7 year old with acute recurrent pancreatitis, abdominal pain. It 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 7 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 distal and you see clearly the branches. So, what is your plan? MRCP to evaluate for chronic changes, repeat ERCP balloon dilation and stent placement, MRCP and obtain genetics, or admin and plan for FRI procedure? The FR procedure is a partial head pancreatectomy with duodenal preservation and a pancreaticajeinostomy. And it's interesting to see this uh very divided um. MRC so the main is repeat ERCP. So keep doing it. We're 7 ERCPs in. The question is, when do you stop, right? Every 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. 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. PRSS1 is the most common one, which is a trypsinogen activator. It activates trypsin 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, um, uh, markers. So, that's how we're changing the approach to pediatric pancreatitis, chronic pan pancreatitis treatment because of the genetic factors. Awesome. So if a patient has more than 1 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 you have that patient that has the mutation that they're, they're trypsin activated. What's, how do you mediate that? Is there medication or is there another path that you can do to wonderful question. No, 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. I would do a pow on this kid. What's the downside of that? So, excellent excellent question. If there's a generic 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 throw, uh, some eyelet cells to the trash. Um, this patient most likely is gonna keep getting pancreatitis despite you draining the duct. The, the parenchyma is gonna 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, but instead from an islet cells transplant. So I know the scenario. Pretty much points towards, OK, maybe recurrent or chronic pancreatitis, but after how many do you feel like, OK, this is what we're dealing with? 2, ERCPs, 3, 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 an evaluation. We don't offer, uh, to take care of the pancreas unless you've. Maximize 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 eyelid autotransplantation. Now, what about imaging for these patients? So we use endoscopic ultrasound. An ultrasound and 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 that. 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 4 to 6 weeks, uh, if there's symptoms, drain it. If 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. Um, it will, it will self resolve, uh, and, of course, there's no need for antibiotics. Also, 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 fright procedure to avoid losing pancreatic cells. The treatment should start with endoscopic approach, keeping in mind that if it fails, a TPI-AT should be considered sooner rather than later. For liquid collection, surgical treatment should be only done if the patient is symptomatic. I 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.