# Pancreatic Surgery & Critical Care — GCMD Library living collection

Updated: n/a · 3 episodes · 41 cited statements

## Episodes
### Pancreatic Inflammatory Disease
- [Update Course 2023 - Updates in Pancreatitis](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269) — video · 32:50 · [machine version](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269.md)

### Complex Pancreatic Procedures
- [Total Pancreatectomy with Islet Autotransplantation (TPIAT)](https://team.globalcastmd.com/watch/total-pancreatectomy-with-islet-autotransplantation-14986) — podcast · [machine version](https://team.globalcastmd.com/watch/total-pancreatectomy-with-islet-autotransplantation-14986.md)

### Multidisciplinary Pancreas Care
- [Pancreas Care Center | Cincinnati Children's](https://team.globalcastmd.com/watch/pancreas-care-center-cincinnati-children-s-14984) — video · [machine version](https://team.globalcastmd.com/watch/pancreas-care-center-cincinnati-children-s-14984.md)

## Chapters
- [0:04](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=4) Acute Pancreatitis Initial Management and Fluid Resuscitation (Ep 1)
- [5:39](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=339) Fluid Type Selection and Nutrition in Acute Pancreatitis (Ep 1)
- [10:42](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=642) Chronic Pancreatitis Diagnosis and Genetic Factors (Ep 1)
- [16:47](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1007) Surgical Decision-Making in Genetic Chronic Pancreatitis (Ep 1)
- [22:21](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1341) Total Pancreatectomy with Islet Autotransplantation Indications (Ep 1)
- [27:27](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1647) TPIAT Surgical Technique and Outcomes (Ep 1)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Acute pancreatitis management has shifted from NPO and aggressive IV fluids causing pulmonary edema to early feeding and measured fluid resuscitation. — Juan Gurria (clinical) [Ep 1 · 0:35](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=35)
- For acute pancreatitis with tachycardia (HR 160) and hypotension in a 9-year-old, appropriate management is ICU admission with bolus ×2, maintenance IV fluids 1.5×, no antibiotics, and pain control. — Juan Gurria (clinical) [Ep 1 · 3:55](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=235)
- Early fluid resuscitation is key to re-establish intravascular flow to the pancreas and prevent hypoxia, necrosis, and atrophic pancreatic insufficiency. — Juan Gurria (clinical) [Ep 1 · 4:19](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=259)
- Excessive fluid resuscitation in pancreatitis leads to worse outcomes including fluid overload and multi-system organ failure. — Juan Gurria (clinical) [Ep 1 · 4:39](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=279)
- There is no indication for routine antibiotics in acute pancreatitis, even with necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis. — Juan Gurria (guideline) [Ep 1 · 4:42](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=282)
- Maintenance fluids should be 1.5 to 2 times normal maintenance, with reassessment at 12-24 hour mark to avoid fluid overload. — Juan Gurria (guideline) [Ep 1 · 6:21](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=381)
- Enteral nutrition as soon as the patient can tolerate PO is significantly better compared to TPN or NPO in acute pancreatitis. — Juan Gurria (clinical) [Ep 1 · 9:24](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=564)
- Some vomiting can be tolerated when feeding pancreatitis patients, similar to gastroschisis management, because feeding the gut produces dramatically better outcomes. — Juan Gurria (clinical) [Ep 1 · 10:19](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=619)
- No patient needs TPN in the first 7 days of acute illness. — Juan Gurria (clinical) [Ep 1 · 11:02](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=662)
- The inflammatory head mass commonly seen in adult pancreatitis is rarely seen in children; pediatric patients typically have minimal duct change disease with small, usually non-dilated ducts. — Juan Gurria (clinical) [Ep 1 · 12:13](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=733)
- Genetic testing is key in pediatric pancreatitis and should be obtained for all patients with chronic or recurrent pancreatitis, and even considered after a first severe attack. — Juan Gurria (guideline) [Ep 1 · 14:59](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=899)
- The most common cause of pancreatitis in children is medication-induced, but the most common risk factor is genetic factors. — Juan Gurria (epidemiological) [Ep 1 · 15:23](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=923)
- PRSS1 (trypsinogen activator) is the most common genetic mutation in pediatric pancreatitis and the most aggressive, causing auto-attack by activating trypsin inside the pancreas. — Juan Gurria (clinical) [Ep 1 · 15:32](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=932)
- Cincinnati Children's genetic panel tests 10 different genetic markers for pancreatitis including PRSS1, CTRC, CFTR, and CPA1. — Juan Gurria (clinical) [Ep 1 · 15:48](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=948)
- Genetics have fundamentally changed the approach to pediatric chronic pancreatitis treatment. — Juan Gurria (opinion) [Ep 1 · 16:06](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=966)
- In children with genetic mutations causing pancreatitis, conventional drainage procedures (Frey, Puestow) fail in up to 50% because the parenchyma continues to be attacked by the mutation despite duct drainage. — Juan Gurria (clinical) [Ep 1 · 16:33](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=993)
- With every attack of pancreatitis, islet cells are lost, so repeated ERCPs that fail to prevent attacks result in progressive loss of beta-cell mass. — Juan Gurria (clinical) [Ep 1 · 14:38](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=878)
- ERCP does not change the islet yield available for transplantation, but pancreatitis attacks cause cell loss. — Juan Gurria (clinical) [Ep 1 · 14:44](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=884)
- Cincinnati Children's has a running list of 800 pancreatitis patients and receives over 100 TPIAT referrals per year, but only performs 20-25 procedures annually because not all patients are candidates. — Juan Gurria (epidemiological) [Ep 1 · 14:59](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=899)
- MRCP is the best non-invasive imaging study for the pancreas, superior to ultrasound and CT. — Juan Gurria (clinical) [Ep 1 · 20:59](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1259)
- ERCP is more therapeutic than diagnostic in chronic pancreatitis. — Juan Gurria (clinical) [Ep 1 · 21:07](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1267)
- Patients with chronic pancreatitis always have micronutrient and macronutrient deficiencies requiring nutritional support. — Juan Gurria (clinical) [Ep 1 · 21:12](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1272)
- Patients with chronic pancreatitis lose exocrine function first, then endocrine function, requiring screening and often pancreatic enzyme replacement therapy. — Juan Gurria (clinical) [Ep 1 · 21:36](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1296)
- Walled-off necrosis should be drained only if symptomatic (gastric outlet obstruction or pain) after the wall matures at 4-6 weeks; asymptomatic collections will self-resolve and do not require drainage or antibiotics. — Juan Gurria (clinical) [Ep 1 · 21:48](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1308)
- Chronic pancreatitis increases the risk of pancreatic cancer up to thirteenfold. — Juan Gurria (epidemiological) [Ep 1 · 22:08](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1328)
- Up to 50% of patients with chronic pancreatitis will eventually require surgery. — Juan Gurria (epidemiological) [Ep 1 · 24:08](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1448)
- The main indication for TPIAT is chronic debilitating pain in children who have lost their quality of life—not attending school, withdrawn, unable to participate in activities. — Juan Gurria (clinical) [Ep 1 · 19:08](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1148)
- The secondary goal of TPIAT is to prevent brittle diabetes by returning beta cells to the patient. — Juan Gurria (clinical) [Ep 1 · 19:22](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1162)
- TPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social workers, geneticists, psychology, and pain management. — Juan Gurria (clinical) [Ep 1 · 24:40](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1480)
- Patients with chronic pain develop hyperalgesia and central sensitization—their brains learn to function in pain—so removing the organ may eliminate 90% of pain but 10% may linger, requiring behavioral therapy. — Juan Gurria (clinical) [Ep 1 · 25:07](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1507)
- TPIAT exchanges chronic pancreatitis for potential diabetes, which must be clearly communicated to families. — Juan Gurria (clinical) [Ep 1 · 27:05](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1625)
- TPIAT surgery takes an average of 8-10 hours: 3-4 hours for pancreatectomy, 4-4.5 hours for islet isolation in the lab, and 2 hours for reconstruction. — Juan Gurria (clinical) [Ep 1 · 27:32](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1652)
- Routine splenectomy is performed with TPIAT because the pancreas and spleen share blood supply via tiny branches from the splenic vessels; preserving the spleen adds ischemia time and causes islet cell loss. — Juan Gurria (clinical) [Ep 1 · 29:33](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1773)
- There are four critical points where islet cells can be lost: (1) recurrent pancreatitis causing cell death, (2) ischemia during surgical dissection, (3) cell death during processing and injection, and (4) post-operative stress if glucose is not carefully managed. — Juan Gurria (clinical) [Ep 1 · 29:59](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1799)
- All TPIAT patients are kept on insulin in the ICU post-operatively to let the islet cells rest without working until they implant and establish new vascular supply from the liver. — Juan Gurria (clinical) [Ep 1 · 30:20](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1820)
- Islet equivalent per kilogram of body weight is used as a prognostic marker; at approximately 5000 islet equivalents/kg there is a 50% chance of insulin independence. — Juan Gurria (clinical) [Ep 1 · 26:32](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1592)
- TPIAT outcomes: 50% of patients achieve insulin independence, 20% require small insulin doses, and 30% remain diabetic. — Juan Gurria (clinical) [Ep 1 · 27:00](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1620)
- The liver is the best site for islet cell implantation via portal vein injection; extrahepatic sites (omentum, retroperitoneum, rectus muscle, gastric submucosa) have been tried but work less well. — Juan Gurria (clinical) [Ep 1 · 31:10](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1870)
- Portal vein thrombosis after islet injection occurs in less than 1% of cases; portal pressure is monitored during injection. — Juan Gurria (clinical) [Ep 1 · 31:58](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1918)
- The duodenum is resected at D1 post-pyloric during TPIAT because of shared blood supply with the pancreas; attempting to preserve it adds ischemia time. — Juan Gurria (clinical) [Ep 1 · 32:23](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1943)
- Pylorus-preserving resection with pyloric Botox injection is performed during TPIAT reconstruction to address gastroparesis that all pancreatitis patients have; Roux-en-Y reconstruction also helps with gastroparesis. — Juan Gurria (clinical) [Ep 1 · 28:47](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=1727)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The North American Society of Pancreatitis, GI Pathology and Nutrition recommends bolus 10-20 mL/kg up to 3 L in the first 24 hours, with reassessment at 12 hours preferred. — Juan Gurria summarizing a resource [Ep 1 · 5:45](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=345)
- Lactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis. — Juan Gurria summarizing a resource [Ep 1 · 6:32](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=392)
- The WATERFALL trial by Enrique de Madaria is a multi-center, multi-country RCT comparing lactated Ringer's versus normal saline in pancreatitis, with results expected in 1-2 years. — Juan Gurria summarizing a resource [Ep 1 · 8:33](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=513)
- Aggressive fluid resuscitation in the first 24 hours (better in first 12) is associated with shorter length of stay, less severe complications, and fewer ICU admissions. — Juan Gurria summarizing a resource [Ep 1 · 9:07](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=547)
- Gastric feeding is preferred over jejunal feeding in pancreatitis when the patient can tolerate it. — Juan Gurria summarizing a resource [Ep 1 · 9:47](https://team.globalcastmd.com/watch/update-course-2023-updates-in-pancreatitis-7269?t=587)

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