861 timestamped statements
across 11 topics
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Summaries Juan gave as host are listed separately below.
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.
Now, there's no reason to give antibiotics anymore at all for pancreatitis, even in the face of world of necrosis or necrotizing pancreatitis, unless there are signs of sepsis infected pancreatitis, which is a different beast
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.
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.
PRSS one is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas. So, you get auto-attacked by pancreatitis. It's the most aggressive one.
Remember that pancreatitis is a state of, uh, hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis, atrophic pancreas insufficiency.
clinicalAcute pancreatitis management has shifted from NPO and aggressive IV fluids causing pulmonary edema to early feeding and measured fluid resuscitation.↗
▶Ep 9 · 0:35
quoteit is very important nowadays to feed the pancreas, even when there's pancreatitis↗
▶Ep 9 · 1:01
quoteyou cannot take care of a pancreas without a wonderful team↗
▶Ep 9 · 3:55
clinicalFor 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.↗
clinicalEarly fluid resuscitation is key to re-establish intravascular flow to the pancreas and prevent hypoxia, necrosis, and atrophic pancreatic insufficiency.↗
▶Ep 9 · 4:19
quotepancreatitis is a state of uh hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis↗
▶Ep 9 · 4:39
clinicalExcessive fluid resuscitation in pancreatitis leads to worse outcomes including fluid overload and multi-system organ failure.↗
▶Ep 9 · 4:42
guidelineThere is no indication for routine antibiotics in acute pancreatitis, even with necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis.↗
▶Ep 9 · 6:13
quoteYou cannot uh flow these lungs too much because the outcomes are worse↗
▶Ep 9 · 6:21
guidelineMaintenance fluids should be 1.5 to 2 times normal maintenance, with reassessment at 12-24 hour mark to avoid fluid overload.↗
▶Ep 9 · 9:24
clinicalEnteral nutrition as soon as the patient can tolerate PO is significantly better compared to TPN or NPO in acute pancreatitis.↗
▶Ep 9 · 10:19
clinicalSome vomiting can be tolerated when feeding pancreatitis patients, similar to gastroschisis management, because feeding the gut produces dramatically better outcomes.↗
▶Ep 9 · 10:21
quoteIt's OK to tolerate some, some, some. Vomiting. If you can feed them, that's fine.↗
▶Ep 9 · 11:02
clinicalNo patient needs TPN in the first 7 days of acute illness.↗
▶Ep 9 · 11:02
quotenobody needs TPN the 1st 7 days of acute illness, right?↗
▶Ep 9 · 12:13
clinicalThe 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.↗
▶Ep 9 · 14:38
clinicalWith every attack of pancreatitis, islet cells are lost, so repeated ERCPs that fail to prevent attacks result in progressive loss of beta-cell mass.↗
▶Ep 9 · 14:44
clinicalERCP does not change the islet yield available for transplantation, but pancreatitis attacks cause cell loss.↗
▶Ep 9 · 14:53
quotechildren get pancreatitis. We have a running list of 800 patients right now in Cin Children's.↗
▶Ep 9 · 14:59
epidemiologicalCincinnati 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.↗
▶Ep 9 · 14:59
guidelineGenetic 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.↗
▶Ep 9 · 15:23
quoteThe most common cause of pancreatitis in children is, is, is medicine induced. The most common risk factor for pancreatitis in children is, is genetic factors.↗
▶Ep 9 · 15:23
epidemiologicalThe most common cause of pancreatitis in children is medication-induced, but the most common risk factor is genetic factors.↗
▶Ep 9 · 15:32
quotePRSS one is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas. So, you get auto-attacked by pancreatitis. It's the most aggressive one.↗
▶Ep 9 · 15:32
clinicalPRSS1 (trypsinogen activator) is the most common genetic mutation in pediatric pancreatitis and the most aggressive, causing auto-attack by activating trypsin inside the pancreas.↗
▶Ep 9 · 15:48
clinicalCincinnati Children's genetic panel tests 10 different genetic markers for pancreatitis including PRSS1, CTRC, CFTR, and CPA1.↗
▶Ep 9 · 16:06
opinionGenetics have fundamentally changed the approach to pediatric chronic pancreatitis treatment.↗
▶Ep 9 · 16:33
clinicalIn 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.↗
▶Ep 9 · 16:33
quoteup to 50% of those children are gonna keep getting pancreatitis despite you opening the duct and draining it↗
▶Ep 9 · 16:49
quoteyou send half of your, the top of your pancreas to the trash↗
▶Ep 9 · 17:07
quoteunfortunately we don't have that just yet. That's why I still have a job.↗
▶Ep 9 · 18:24
quoteThis patient most likely is gonna keep getting pancreatitis despite you draining the duct. The, the parenchyma is gonna keep getting attacked by the mutation.↗
▶Ep 9 · 19:02
quoteTPIT, which is total pancreatectomy with eyelid autotransplantation. Uh, the main indication is, is for pain, chronic debilitating pain for children that are losing their lives.↗
▶Ep 9 · 19:08
clinicalThe 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.↗
clinicalThe secondary goal of TPIAT is to prevent brittle diabetes by returning beta cells to the patient.↗
▶Ep 9 · 19:56
quoteif you keep getting pancreatitis, you're losing time on that, right? The, the pancreas, we have 34 years old with like very atrophic pancreas↗
▶Ep 9 · 20:17
quoteWe don't offer. Uh, to take care of the pancreas unless you've maximize medical and endoscopic management.↗
▶Ep 9 · 20:59
clinicalMRCP is the best non-invasive imaging study for the pancreas, superior to ultrasound and CT.↗
▶Ep 9 · 21:07
clinicalERCP is more therapeutic than diagnostic in chronic pancreatitis.↗
▶Ep 9 · 21:12
clinicalPatients with chronic pancreatitis always have micronutrient and macronutrient deficiencies requiring nutritional support.↗
▶Ep 9 · 21:36
clinicalPatients with chronic pancreatitis lose exocrine function first, then endocrine function, requiring screening and often pancreatic enzyme replacement therapy.↗
▶Ep 9 · 21:48
clinicalWalled-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.↗
▶Ep 9 · 22:08
epidemiologicalChronic pancreatitis increases the risk of pancreatic cancer up to thirteenfold.↗
▶Ep 9 · 24:08
epidemiologicalUp to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 9 · 24:40
clinicalTPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social workers, geneticists, psychology, and pain management.↗
▶Ep 9 · 25:00
quotesome families ask us like, so you're gonna get rid of the pain, right? 100%, and you cannot say that, right?↗
▶Ep 9 · 25:07
clinicalPatients 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.↗
▶Ep 9 · 25:07
quotePeople that have chronic pain, their bodies, their brains learn how to be in pain, right? They can function in pain. That's called hyperalgesia and central sensitization.↗
▶Ep 9 · 25:18
quotewhen you take the, the, the organ part out, you maybe 90% of the pain is gone, but you cannot promise them that 10 that 10% is gonna linger for a little bit↗
▶Ep 9 · 26:32
clinicalIslet 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.↗
▶Ep 9 · 27:00
clinicalTPIAT outcomes: 50% of patients achieve insulin independence, 20% require small insulin doses, and 30% remain diabetic.↗
▶Ep 9 · 27:05
quoteI'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes.↗
▶Ep 9 · 27:05
clinicalTPIAT exchanges chronic pancreatitis for potential diabetes, which must be clearly communicated to families.↗
▶Ep 9 · 27:23
quoteMy day starts the, the night before as I start going through the case. It's a long day. It's a long day. I reviewed this case in my head, uh, 30 times before I go in.↗
▶Ep 9 · 27:32
clinicalTPIAT 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.↗
▶Ep 9 · 28:47
clinicalPylorus-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.↗
▶Ep 9 · 29:33
clinicalRoutine 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.↗
▶Ep 9 · 29:59
clinicalThere 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.↗
▶Ep 9 · 30:20
clinicalAll 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.↗
▶Ep 9 · 31:10
clinicalThe 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.↗
▶Ep 9 · 31:58
clinicalPortal vein thrombosis after islet injection occurs in less than 1% of cases; portal pressure is monitored during injection.↗
▶Ep 9 · 32:23
clinicalThe duodenum is resected at D1 post-pyloric during TPIAT because of shared blood supply with the pancreas; attempting to preserve it adds ischemia time.↗
Update Course Rewind: Management of Acute Pancreatitis 2023
clinicalBolus times 2 is adequate fluid resuscitation, with 1.5 times maintenance once past the early phase of acute resuscitation↗
▶Ep 10 · 2:06
quoteRemember that pancreatitis is a state of, uh, hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis, atrophic pancreas insufficiency.↗
▶Ep 10 · 2:06
clinicalPancreatitis is a state of hypoxia requiring re-establishment of intravascular flow to the pancreas to prevent hypoxia, necrosis, and atrophic pancreas insufficiency↗
▶Ep 10 · 2:22
clinicalEarly fluid resuscitation is key in pancreatitis management↗
▶Ep 10 · 2:26
clinicalExcessive fluid administration worsens outcomes in pancreatitis↗
▶Ep 10 · 2:29
quoteNow, there's no reason to give antibiotics anymore at all for pancreatitis, even in the face of world of necrosis or necrotizing pancreatitis, unless there are signs of sepsis infected pancreatitis, which is a different beast↗
▶Ep 10 · 2:29
guidelineThere is no reason to give antibiotics for pancreatitis, even in the face of necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis↗
▶Ep 10 · 2:57
guidelineThe North American Society of Pancreatitis, GI Pathology, and Nutrition published a position paper with guideline recommendations for pancreatitis management↗
▶Ep 10 · 3:07
clinicalEarly fluids lead to better outcomes in pancreatitis↗
▶Ep 10 · 3:11
guidelineRecommended fluid bolus is 10 to 20 mL per kg, up to 3L in the first 24 hours, with reassessment at the 12-hour mark using urine output and vital signs↗
▶Ep 10 · 3:25
clinicalExcessive fluid administration can flood the lungs and worsen outcomes↗
▶Ep 10 · 3:25
quoteYou cannot flow these lungs too much because the outcomes are worse.↗
▶Ep 10 · 3:45
quoteIt's been shown that LR. Decreases the incidence of inflammatory response and C, C-reactive protein at 24 hours compared to NS, right?↗
▶Ep 10 · 3:45
clinicalLactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis↗
▶Ep 10 · 3:54
clinicalIf albumin is low in pancreatitis patients, albumin should be given↗
▶Ep 10 · 3:58
clinicalEnrique de Madaria conducted a multi-center worldwide RCT called the Waterfall trial comparing moderate versus aggressive fluid resuscitation in pancreatitis↗
▶Ep 10 · 4:18
clinicalThe Waterfall trial was stopped early because patients receiving too much fluid were developing organ failure↗
▶Ep 10 · 4:27
clinicalA follow-up Waterland trial is underway to determine whether lactated Ringer's is better than normal saline, expected to be published in one to two years↗
▶Ep 10 · 4:47
clinicalPatients with pancreatitis should be fed as soon as they are able to tolerate oral intake↗
▶Ep 10 · 4:51
clinicalEnteral nutrition is significantly better compared to TPN or NPO in pancreatitis↗
▶Ep 10 · 4:57
clinicalGastric feeding is preferred over post-pyloric feeding in pancreatitis if the patient can tolerate it↗
▶Ep 10 · 5:19
opinionSome vomiting is tolerable during refeeding in pancreatitis, similar to gastroschisis management↗
▶Ep 10 · 5:19
quoteIf they cannot tolerate it, it's OK. I mean, but it's like gastroschisis, it's OK to tolerate some, some, some vomiting.↗
▶Ep 10 · 5:26
quoteIf you're losing nutrition and you're losing ground, the patient's gonna have a worse outcome. Their albumin is gonna drop, inflammatory reaction is gonna be worse.↗
▶Ep 10 · 5:26
clinicalIf nutrition is lost and the patient loses ground, outcomes will be worse, with dropping albumin and worse inflammatory reaction↗
▶Ep 10 · 5:34
clinicalOutcomes are dramatically better when the gut is fed in pancreatitis patients↗
Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria
▶Ep 11 · 5:44
guidelineDiagnosis of acute pancreatitis requires serum lipase at least 3 times the upper limit of normal, plus imaging findings (ultrasound, MRI/MRCP, or CT).↗
▶Ep 11 · 7:23
epidemiologicalIn the Cincinnati Children's cohort of 1000 pediatric pancreatitis patients, 85% have genetic mutations.↗
▶Ep 11 · 8:01
clinicalPRSS1 mutation causes very aggressive attacks very early in life (ages 1–3 years) because it autoactivates trypsinogen inside the pancreas.↗
▶Ep 11 · 8:37
clinicalMedications including L-asparaginase, steroids, valproic acid, and diuretics (Lasix) can cause pancreatitis in children.↗
▶Ep 11 · 9:32
clinicalHereditary pancreatitis increases the risk of pancreatic cancer by a huge fold, which is a major concern in children diagnosed at age 5–6 who may live 95 more years.↗
▶Ep 11 · 10:15
clinicalMost fluid collections in pediatric acute pancreatitis are self-limited and should not be touched unless absolutely necessary.↗
▶Ep 11 · 18:08
quotePlease do not touch these collections ever unless you absolutely have to.↗
▶Ep 11 · 18:40
clinicalEarly necrosectomies (before 4 weeks) usually increase mortality.↗
▶Ep 11 · 19:49
clinicalFollowing lipase levels tells you nothing about how the pancreas is behaving in acute pancreatitis; cross-sectional imaging is required.↗
▶Ep 11 · 21:36
clinicalAsymptomatic pseudocysts, regardless of size, do not require intervention.↗
▶Ep 11 · 23:29
clinicalPatients with acute pancreatitis should be fed as soon as possible (orally or via NG/NJ tube) because bacterial translocation from NPO status will complicate the disease.↗
▶Ep 11 · 23:29
quotePlease feed your patients as soon as you can, all right? If they're vomiting and they're gonna puke it, well, that doesn't make any sense. You, if you have to throw out an NG or an NG tube, feed the god because bacterial translocation from NPL will complicate acute pancreatitis.↗
▶Ep 11 · 25:13
epidemiologicalIn pediatric patients with hereditary pancreatitis or hereditary plus anatomic abnormalities, half will develop chronic pancreatitis.↗
▶Ep 11 · 25:38
clinicalCincinnati Children's evaluates over 100 patients per year for chronic pancreatitis but only operates on 25–30, because medical and endoscopic options should be exhausted first.↗
▶Ep 11 · 26:50
clinicalChronic pain in pancreatitis involves brain plasticity, hypertrophic nerve reactions, and peripheral nerve hypersensitization, not just organic retroperitoneal pain.↗
▶Ep 11 · 27:43
clinicalAfter total pancreatectomy, 95% of pain is resolved, but 5% may persist due to central sensitization and requires behavioral medicine and psychiatric support.↗
▶Ep 11 · 27:43
quoteI'm gonna take your pancreas out if it's uh indicated, and I'm gonna take care of 95% of your pain. But that 5, 5% that is left. We need to work with psych, behavioral med, uh, and eventually reteach their brains how to live not in pain.↗
▶Ep 11 · 28:37
clinicalPediatric chronic pancreatitis usually presents with minimal ductal changes, not the dilated ducts seen in adults, so drainage procedures are often not applicable.↗
▶Ep 11 · 28:57
clinicalIn patients with genetic mutations, partial pancreatectomy (Whipple, distal pancreatectomy) discards islet mass and does not address the underlying defect, so the remaining pancreas continues to be affected.↗
▶Ep 11 · 28:57
quoteIf you have a genetic mutation and you chop off a piece of the pancreas, throw it in the trash. You can maybe relieve some of the pain. If you do whipple, have the pancreas drain better, do a piece so, I'm gonna touch base on that in a sec, drain the pancreatic duct better. But I put a piece of paper in the trash. And the genetic mutations will keep affecting the rest of the pancreas.↗
▶Ep 11 · 37:44
quoteWe're doing this for, for chronic pain and that should be the, the, the major thing in our head.↗
▶Ep 11 · 37:54
guidelineTPIAT is indicated when patients have chronic pancreatitis findings, at least 6 months of disease, exocrine or endocrine insufficiency, and impaired quality of life despite maximal medical and endoscopic therapy.↗
▶Ep 11 · 39:00
clinicalThe goal of islet autotransplantation is to replace beta cell mass and insulin secretory capacity, not to cure diabetes—pain control is the primary indication.↗
▶Ep 11 · 40:28
clinicalTPIAT used to be a 20-hour operation but is now down to an average of 8–9 hours at Cincinnati Children's.↗
▶Ep 11 · 43:15
clinicalSpleen-sparing TPIAT has equal glycemic outcomes to splenectomy TPIAT when islet equivalent per kilogram transplanted is matched.↗
▶Ep 11 · 43:42
clinicalSpleen-sparing TPIAT is now performed in 80% of cases (over the last 5 years), compared to none in the first 8 years of the program.↗
▶Ep 11 · 45:16
clinicalIntraoperative pyloric Botox injection reduces gastroparesis, decreases length of stay, and improves time to full oral intake and glycemic control after TPIAT.↗
▶Ep 11 · 46:27
clinicalIslet isolation takes about 3–3.5 hours, sometimes 4 hours depending on the degree of pancreatic injury.↗
▶Ep 11 · 47:39
clinicalTPIAT is performed under anticoagulation (heparin) to prevent portal vein thrombosis during islet infusion.↗
▶Ep 11 · 48:11
clinicalPortal vein thrombosis rate at Cincinnati Children's is less than 1% for TPIAT.↗
▶Ep 11 · 48:26
clinicalCincinnati Children's has performed close to 200 TPIAT cases with no anastomotic leaks.↗
▶Ep 11 · 50:07
clinicalPatients are extubated in the operating room after TPIAT.↗
▶Ep 11 · 51:32
clinicalYounger children are more likely to achieve insulin independence and opioid independence after TPIAT.↗
▶Ep 11 · 52:25
clinicalIslet yield (IEQ/kg) is inversely related to pancreatic calcification, ductal dilation, fibrosis, duration of symptoms, and prior resections or drainage procedures.↗
▶Ep 11 · 54:59
clinicalPredictors of insulin independence after TPIAT include younger age at surgery, smaller body surface area, no pre-existing insulin dependence, and higher IEQ/kg transplanted.↗
▶Ep 11 · 56:09
clinicalTPIAT dramatically improves quality of life in appropriately selected children, with families reporting they have 'never met this kid before'—new person, happy, playing, eating normally.↗
Juan's statements about Acute Recurrent Pancreatitis48 statements
Update Course Rewind: Management of Recurrent Pancreatitis
▶Ep 9 · 1:40
quoteEvery 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.↗
▶Ep 9 · 1:40
clinicalEvery ERCP carries a risk of post-ERCP pancreatitis, and with every pancreatitis attack, islet cells are lost.↗
▶Ep 9 · 1:57
clinicalPRSS1 is the most common genetic mutation in recurrent pancreatitis and is a trypsinogen activator that activates trypsin inside the pancreas.↗
▶Ep 9 · 1:57
quotePRSS1 is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas.↗
▶Ep 9 · 2:06
clinicalThe genetic panel at Cincinnati Children's tests 10 different genetic markers for pancreatitis (including PRSS1, CTRC, CFTR, CPA1).↗
▶Ep 9 · 2:17
quoteThat's how we're changing the approach to pediatric pancreatitis, chronic pan pancreatitis treatment because of the genetic factors.↗
▶Ep 9 · 2:17
opinionGenetic factors are changing the approach to pediatric chronic pancreatitis treatment.↗
▶Ep 9 · 2:48
quoteNo, 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.↗
▶Ep 9 · 2:48
clinicalThere is currently no medication to mitigate trypsin activation in genetic pancreatitis mutations.↗
▶Ep 9 · 3:09
clinicalIn a Frey procedure (partial head pancreatectomy with pancreaticojejunostomy), the top half of the pancreas is removed to open the duct, which results in loss of islet cells.↗
▶Ep 9 · 3:19
clinicalIn patients with PRSS1 mutation, draining the duct (e.g., via Frey) temporizes attacks but does not fix the problem, as the parenchyma continues to be attacked by the mutation and pancreatitis will likely recur.↗
▶Ep 9 · 3:19
quoteThis 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.↗
▶Ep 9 · 4:09
opinionThere is no set number of ERCPs that defines when to escalate care; the sooner the referral for evaluation, the better.↗
▶Ep 9 · 4:16
quoteWe don't offer, uh, to take care of the pancreas unless you've. Maximize medical and endoscopic management.↗
▶Ep 9 · 4:16
guidelineSurgical management of the pancreas is not offered unless medical and endoscopic management have been maximized.↗
▶Ep 9 · 4:23
clinicalIf the endoscopist has no further options (nothing to balloon dilate, open, or drain) and the patient continues to have pancreatitis despite stenting, there is no reason to continue ERCPs.↗
▶Ep 9 · 4:23
quoteIf 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.↗
▶Ep 9 · 4:58
clinicalMRCP is the best non-invasive imaging study for the pancreas, particularly with T2 sequences.↗
▶Ep 9 · 4:58
quoteMRCP is the best non-invasive study for pancreas by far, uh, with different uh uh T2 sequences.↗
▶Ep 9 · 5:07
clinicalERCP is more therapeutic than diagnostic.↗
▶Ep 9 · 5:22
quoteOnce 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.↗
▶Ep 9 · 5:22
clinicalPancreatic fluid collections should be drained once the wall is mature (4 to 6 weeks) only if the patient is symptomatic (e.g., gastric outlet obstruction or pain); asymptomatic collections will self-resolve and do not require drainage or antibiotics.↗
Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center
▶Ep 10 · 0:48
quoteTPIAT is clearly one of the most complex abdominal surgical procedures we perform in children.↗
▶Ep 10 · 0:48
opinionTPIAT is one of the most complex abdominal surgical procedures performed in children.↗
▶Ep 10 · 0:54
clinicalSurgical indications for TPIAT are for patients with either chronic or acute recurrent pancreatitis.↗
▶Ep 10 · 1:02
quoteThese patients are candidates for TPAT when all medical and endoscopic therapy has failed.↗
▶Ep 10 · 1:02
guidelinePatients are candidates for TPIAT when all medical and endoscopic therapy has failed.↗
▶Ep 10 · 1:23
clinicalThe Pancreas Care Center team includes GI, social worker, endocrine, surgery, radiology, genetics, behavioral health, physical therapy, anesthesia, and pain team.↗
▶Ep 10 · 1:45
clinicalThe entire team reviews and votes patients in for surgery to determine if they are candidates for TPIAT.↗
▶Ep 10 · 1:45
clinicalPatients are prepared with vaccinations for potential splenectomy before TPIAT surgery.↗
▶Ep 10 · 2:40
clinicalPain catheters are placed in the transversus abdominis muscle by pain specialists.↗
▶Ep 10 · 3:14
quoteRemember, this, this pancreas has been injured for sometimes years, which makes this procedure quite challenging.↗
▶Ep 10 · 3:14
clinicalThe pancreas in TPIAT patients has been injured for sometimes years, which makes the procedure quite challenging.↗
▶Ep 10 · 3:29
clinicalOn the right side, the small intestine (duodenum) and liver hilum are mobilized, with careful identification of bile ducts and blood supply to the liver.↗
▶Ep 10 · 4:06
clinicalBlood supply to the head and entire body of the pancreas is preserved very carefully until the very last moment to avoid hypoxia of islet cells.↗
▶Ep 10 · 4:06
quoteWe preserve very carefully the blood supply to the head and the entire body until the pancreas, until the very last moment because we cannot risk hypoxying these cells.↗
▶Ep 10 · 6:33
clinicalDuring islet processing, the surgical team performs reconstruction of the gastrointestinal tract by bringing a loop of duodenum up to the bile duct and reconnecting another loop of intestine to the duodenum past the pyloric muscle.↗
▶Ep 10 · 6:53
clinicalA feeding tube is placed to allow patients to be fed while important connections heal.↗
▶Ep 10 · 7:02
clinicalDrains are left where the spleen was removed and on top of the connection with the biliary tract.↗
▶Ep 10 · 7:15
clinicalIslet cells are transfused into the portal vein with the hope that they will implant in the liver and start producing insulin.↗
▶Ep 10 · 7:25
quoteWhile we infuse the eyelid itself, we're constantly checking the pressures in the portal vein to make sure we don't risk any thrombosis in the portal vein, which could cause a lot of morbidity to the patient.↗
▶Ep 10 · 7:25
clinicalPortal vein pressures are constantly checked during islet infusion to prevent portal vein thrombosis, which could cause significant morbidity.↗
▶Ep 10 · 8:01
clinicalPatients are placed in the intensive care unit post-operatively to control hemodynamics and fluid shift balance.↗
▶Ep 10 · 8:08
clinicalIslet cells need to heal in a very homeostatic environment, requiring close monitoring of vital signs.↗
▶Ep 10 · 8:18
clinicalGlucose and insulin are controlled via exogenous infusions post-operatively.↗
▶Ep 10 · 8:22
clinicalClose attention to nutrition is key in the healing of connections between the bile tract and gastrointestinal tract.↗
▶Ep 10 · 8:39
clinicalPatients are deemed ready for discharge when pain is well controlled, they are on full feeds (via tube or by mouth), glucose is well controlled via continuous glucose monitoring, and they have received full education.↗
▶Ep 10 · 8:47
clinicalAfter discharge, local GI physicians continue to follow patients along with the Cincinnati Children's team.↗
clinicalBolus times 2 is adequate fluid resuscitation, with 1.5 times maintenance once past the early phase of acute resuscitation↗
▶Ep 1 · 2:06
quoteRemember that pancreatitis is a state of, uh, hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis, atrophic pancreas insufficiency.↗
▶Ep 1 · 2:06
clinicalPancreatitis is a state of hypoxia requiring re-establishment of intravascular flow to the pancreas to prevent hypoxia, necrosis, and atrophic pancreas insufficiency↗
▶Ep 1 · 2:22
clinicalEarly fluid resuscitation is key in pancreatitis management↗
▶Ep 1 · 2:26
clinicalExcessive fluid administration worsens outcomes in pancreatitis↗
▶Ep 1 · 2:29
guidelineThere is no reason to give antibiotics for pancreatitis, even in the face of necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis↗
▶Ep 1 · 2:29
quoteNow, there's no reason to give antibiotics anymore at all for pancreatitis, even in the face of world of necrosis or necrotizing pancreatitis, unless there are signs of sepsis infected pancreatitis, which is a different beast↗
▶Ep 1 · 2:57
guidelineThe North American Society of Pancreatitis, GI Pathology, and Nutrition published a position paper with guideline recommendations for pancreatitis management↗
▶Ep 1 · 3:07
clinicalEarly fluids lead to better outcomes in pancreatitis↗
▶Ep 1 · 3:11
guidelineRecommended fluid bolus is 10 to 20 mL per kg, up to 3L in the first 24 hours, with reassessment at the 12-hour mark using urine output and vital signs↗
▶Ep 1 · 3:25
quoteYou cannot flow these lungs too much because the outcomes are worse.↗
▶Ep 1 · 3:25
clinicalExcessive fluid administration can flood the lungs and worsen outcomes↗
▶Ep 1 · 3:45
clinicalLactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis↗
▶Ep 1 · 3:45
quoteIt's been shown that LR. Decreases the incidence of inflammatory response and C, C-reactive protein at 24 hours compared to NS, right?↗
▶Ep 1 · 3:54
clinicalIf albumin is low in pancreatitis patients, albumin should be given↗
▶Ep 1 · 3:58
clinicalEnrique de Madaria conducted a multi-center worldwide RCT called the Waterfall trial comparing moderate versus aggressive fluid resuscitation in pancreatitis↗
▶Ep 1 · 4:18
clinicalThe Waterfall trial was stopped early because patients receiving too much fluid were developing organ failure↗
▶Ep 1 · 4:27
clinicalA follow-up Waterland trial is underway to determine whether lactated Ringer's is better than normal saline, expected to be published in one to two years↗
▶Ep 1 · 4:47
clinicalPatients with pancreatitis should be fed as soon as they are able to tolerate oral intake↗
▶Ep 1 · 4:51
clinicalEnteral nutrition is significantly better compared to TPN or NPO in pancreatitis↗
▶Ep 1 · 4:57
clinicalGastric feeding is preferred over post-pyloric feeding in pancreatitis if the patient can tolerate it↗
▶Ep 1 · 5:19
quoteIf they cannot tolerate it, it's OK. I mean, but it's like gastroschisis, it's OK to tolerate some, some, some vomiting.↗
▶Ep 1 · 5:19
opinionSome vomiting is tolerable during refeeding in pancreatitis, similar to gastroschisis management↗
▶Ep 1 · 5:26
clinicalIf nutrition is lost and the patient loses ground, outcomes will be worse, with dropping albumin and worse inflammatory reaction↗
▶Ep 1 · 5:26
quoteIf you're losing nutrition and you're losing ground, the patient's gonna have a worse outcome. Their albumin is gonna drop, inflammatory reaction is gonna be worse.↗
▶Ep 1 · 5:34
clinicalOutcomes are dramatically better when the gut is fed in pancreatitis patients↗
Juan's statements about Choledochal Cyst21 statements
2025 Pediatric Surgery Update Course - Robotics in Pediatric Surgery: Which indications benefit the most?
▶Ep 5 · 0:24
epidemiologicalFour out of approximately 30 attendees perform robotic surgery; another 12 have robot access but do not use it↗
▶Ep 5 · 0:24
opinionCholedochal cyst is a perfect case for robotic surgery↗
▶Ep 5 · 0:24
clinicalRobotic instruments have seven degrees of freedom compared to six for the human hand↗
▶Ep 5 · 0:24
opinionAdrenalectomy for neuroblastoma confined to the adrenal is a perfect robotic case↗
▶Ep 5 · 0:24
quoteWho is a robotic surgery here in the audience? The ones who are not lifting up their hands, who has a robot available?↗
▶Ep 5 · 2:51
clinicalRoom turnover time for robotic cases can be reduced to 30 minutes with trained personnel↗
▶Ep 5 · 2:51
clinicalRobotic surgery shows lower conversion to open rates compared to laparoscopy in colorectal cases↗
▶Ep 5 · 2:51
clinicalLearning curve for basic proficiency is 20-30 cases for laparoscopy versus 10-15 cases for robotics↗
▶Ep 5 · 2:51
clinicalInitial cost premium for robotic surgery is approximately $4000 per case in most institutions↗
▶Ep 5 · 2:51
clinicalEach additional 15 minutes of operative time costs the same for robotic and laparoscopic surgery↗
▶Ep 5 · 2:51
epidemiologicalAll pediatric surgery fellowships are integrating robotic training↗
▶Ep 5 · 3:15
opinionMedian arcuate ligament release should not be performed laparoscopically or open anymore due to difficulty accessing the angle near the celiac trunk↗
▶Ep 5 · 3:38
guidelineThere is no FDA approval for robotic systems in pediatric surgery↗
▶Ep 5 · 3:38
quoteAre there FDA indications for the robot for pediatric surgery? Great question. Great question. No.↗
▶Ep 5 · 7:16
opinionRobotic surgery is not recommended for appendectomy↗
▶Ep 5 · 7:16
clinicalICG fluorescence allows visualization of adrenal arteries supplied by renal, diaphragmatic, and aortic vessels↗
▶Ep 5 · 12:55
opinionRobotic surgery is not a standard of care but a tool to aid efficiency and access to difficult angles↗
▶Ep 5 · 14:05
quoteThis is not about being cool. It's about efficiency and outcomes. Less cases to prove it now. Less cases to proficiency.↗
▶Ep 5 · 15:59
opinionSurgeons trained primarily in robotics cannot tie, sew, or work with 3mm instruments effectively↗
▶Ep 5 · 17:14
clinicalICG fluorescence in choledochal cyst surgery allows visualization far back to the head of the pancreas to achieve proper tapering, decreasing future cancer risk↗
▶Ep 5 · 17:14
clinicalNew robotic systems with tactile sensors reduce force application by 83%↗
Juan's statements about Chronic Pancreatitis193 statements
quoteit is very important nowadays to feed the pancreas, even when there's pancreatitis↗
▶Ep 5 · 0:35
clinicalAcute pancreatitis management has shifted from NPO and aggressive IV fluids causing pulmonary edema to early feeding and measured fluid resuscitation.↗
▶Ep 5 · 1:01
quoteyou cannot take care of a pancreas without a wonderful team↗
▶Ep 5 · 3:55
clinicalFor 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.↗
quotepancreatitis is a state of uh hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis↗
▶Ep 5 · 4:19
clinicalEarly fluid resuscitation is key to re-establish intravascular flow to the pancreas and prevent hypoxia, necrosis, and atrophic pancreatic insufficiency.↗
▶Ep 5 · 4:39
clinicalExcessive fluid resuscitation in pancreatitis leads to worse outcomes including fluid overload and multi-system organ failure.↗
▶Ep 5 · 4:42
guidelineThere is no indication for routine antibiotics in acute pancreatitis, even with necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis.↗
▶Ep 5 · 6:13
quoteYou cannot uh flow these lungs too much because the outcomes are worse↗
▶Ep 5 · 6:21
guidelineMaintenance fluids should be 1.5 to 2 times normal maintenance, with reassessment at 12-24 hour mark to avoid fluid overload.↗
▶Ep 5 · 9:24
clinicalEnteral nutrition as soon as the patient can tolerate PO is significantly better compared to TPN or NPO in acute pancreatitis.↗
▶Ep 5 · 10:19
clinicalSome vomiting can be tolerated when feeding pancreatitis patients, similar to gastroschisis management, because feeding the gut produces dramatically better outcomes.↗
▶Ep 5 · 10:21
quoteIt's OK to tolerate some, some, some. Vomiting. If you can feed them, that's fine.↗
▶Ep 5 · 11:02
quotenobody needs TPN the 1st 7 days of acute illness, right?↗
▶Ep 5 · 11:02
clinicalNo patient needs TPN in the first 7 days of acute illness.↗
▶Ep 5 · 12:13
clinicalThe 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.↗
▶Ep 5 · 14:38
clinicalWith every attack of pancreatitis, islet cells are lost, so repeated ERCPs that fail to prevent attacks result in progressive loss of beta-cell mass.↗
▶Ep 5 · 14:44
clinicalERCP does not change the islet yield available for transplantation, but pancreatitis attacks cause cell loss.↗
▶Ep 5 · 14:53
quotechildren get pancreatitis. We have a running list of 800 patients right now in Cin Children's.↗
▶Ep 5 · 14:59
guidelineGenetic 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.↗
▶Ep 5 · 14:59
epidemiologicalCincinnati 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.↗
▶Ep 5 · 15:23
epidemiologicalThe most common cause of pancreatitis in children is medication-induced, but the most common risk factor is genetic factors.↗
▶Ep 5 · 15:23
quoteThe most common cause of pancreatitis in children is, is, is medicine induced. The most common risk factor for pancreatitis in children is, is genetic factors.↗
▶Ep 5 · 15:32
quotePRSS one is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas. So, you get auto-attacked by pancreatitis. It's the most aggressive one.↗
▶Ep 5 · 15:32
clinicalPRSS1 (trypsinogen activator) is the most common genetic mutation in pediatric pancreatitis and the most aggressive, causing auto-attack by activating trypsin inside the pancreas.↗
▶Ep 5 · 15:48
clinicalCincinnati Children's genetic panel tests 10 different genetic markers for pancreatitis including PRSS1, CTRC, CFTR, and CPA1.↗
▶Ep 5 · 16:06
opinionGenetics have fundamentally changed the approach to pediatric chronic pancreatitis treatment.↗
▶Ep 5 · 16:33
clinicalIn 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.↗
▶Ep 5 · 16:33
quoteup to 50% of those children are gonna keep getting pancreatitis despite you opening the duct and draining it↗
▶Ep 5 · 16:49
quoteyou send half of your, the top of your pancreas to the trash↗
▶Ep 5 · 17:07
quoteunfortunately we don't have that just yet. That's why I still have a job.↗
▶Ep 5 · 18:24
quoteThis patient most likely is gonna keep getting pancreatitis despite you draining the duct. The, the parenchyma is gonna keep getting attacked by the mutation.↗
▶Ep 5 · 19:02
quoteTPIT, which is total pancreatectomy with eyelid autotransplantation. Uh, the main indication is, is for pain, chronic debilitating pain for children that are losing their lives.↗
▶Ep 5 · 19:08
clinicalThe 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.↗
clinicalThe secondary goal of TPIAT is to prevent brittle diabetes by returning beta cells to the patient.↗
▶Ep 5 · 19:56
quoteif you keep getting pancreatitis, you're losing time on that, right? The, the pancreas, we have 34 years old with like very atrophic pancreas↗
▶Ep 5 · 20:17
quoteWe don't offer. Uh, to take care of the pancreas unless you've maximize medical and endoscopic management.↗
▶Ep 5 · 20:59
clinicalMRCP is the best non-invasive imaging study for the pancreas, superior to ultrasound and CT.↗
▶Ep 5 · 21:07
clinicalERCP is more therapeutic than diagnostic in chronic pancreatitis.↗
▶Ep 5 · 21:12
clinicalPatients with chronic pancreatitis always have micronutrient and macronutrient deficiencies requiring nutritional support.↗
▶Ep 5 · 21:36
clinicalPatients with chronic pancreatitis lose exocrine function first, then endocrine function, requiring screening and often pancreatic enzyme replacement therapy.↗
▶Ep 5 · 21:48
clinicalWalled-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.↗
▶Ep 5 · 22:08
epidemiologicalChronic pancreatitis increases the risk of pancreatic cancer up to thirteenfold.↗
▶Ep 5 · 24:08
epidemiologicalUp to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 5 · 24:40
clinicalTPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social workers, geneticists, psychology, and pain management.↗
▶Ep 5 · 25:00
quotesome families ask us like, so you're gonna get rid of the pain, right? 100%, and you cannot say that, right?↗
▶Ep 5 · 25:07
clinicalPatients 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.↗
▶Ep 5 · 25:07
quotePeople that have chronic pain, their bodies, their brains learn how to be in pain, right? They can function in pain. That's called hyperalgesia and central sensitization.↗
▶Ep 5 · 25:18
quotewhen you take the, the, the organ part out, you maybe 90% of the pain is gone, but you cannot promise them that 10 that 10% is gonna linger for a little bit↗
▶Ep 5 · 26:32
clinicalIslet 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.↗
▶Ep 5 · 27:00
clinicalTPIAT outcomes: 50% of patients achieve insulin independence, 20% require small insulin doses, and 30% remain diabetic.↗
▶Ep 5 · 27:05
quoteI'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes.↗
▶Ep 5 · 27:05
clinicalTPIAT exchanges chronic pancreatitis for potential diabetes, which must be clearly communicated to families.↗
▶Ep 5 · 27:23
quoteMy day starts the, the night before as I start going through the case. It's a long day. It's a long day. I reviewed this case in my head, uh, 30 times before I go in.↗
▶Ep 5 · 27:32
clinicalTPIAT 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.↗
▶Ep 5 · 28:47
clinicalPylorus-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.↗
▶Ep 5 · 29:33
clinicalRoutine 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.↗
▶Ep 5 · 29:59
clinicalThere 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.↗
▶Ep 5 · 30:20
clinicalAll 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.↗
▶Ep 5 · 31:10
clinicalThe 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.↗
▶Ep 5 · 31:58
clinicalPortal vein thrombosis after islet injection occurs in less than 1% of cases; portal pressure is monitored during injection.↗
▶Ep 5 · 32:23
clinicalThe duodenum is resected at D1 post-pyloric during TPIAT because of shared blood supply with the pancreas; attempting to preserve it adds ischemia time.↗
Update Course Rewind: Management of Chronic Pancreatitis 2023
▶Ep 6 · 0:43
quoteOK, 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.↗
▶Ep 6 · 1:28
quoteSo, 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.↗
▶Ep 6 · 1:28
clinicalIf a patient has a PRSS1 mutation and only the pancreatic head is removed, recurrent attacks will occur.↗
▶Ep 6 · 1:28
clinicalMost of the pancreatic parenchyma is in the head and the uncinate process.↗
▶Ep 6 · 1:40
quoteSo, up to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 6 · 1:40
epidemiologicalUp to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 6 · 2:01
quoteNot everybody is, is a candidate for, they need support, they need social support, right?↗
▶Ep 6 · 2:10
guidelineTPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social worker, geneticists, psychiatry, and pain control.↗
▶Ep 6 · 2:18
quoteSo remember, patients with chronic pancreatitis are, are always having micro and macronutrient deficiencies, so we need to pay a lot of attention to this.↗
▶Ep 6 · 2:18
clinicalPatients with chronic pancreatitis always have micro and macronutrient deficiencies.↗
▶Ep 6 · 2:33
clinicalChronic pancreatitis patients sometimes need pancreatic enzyme replacement therapy.↗
▶Ep 6 · 2:40
quoteUm, you lose first your exocrine and then your endocrine function, so you need to keep screening for it.↗
▶Ep 6 · 2:40
clinicalIn chronic pancreatitis, exocrine function is lost first, then endocrine function.↗
▶Ep 6 · 2:49
quoteThe 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.↗
▶Ep 6 · 2:49
clinicalThe primary goal of TPIAT is to restore the child's quality of life and return them to normal activities.↗
▶Ep 6 · 2:59
clinicalThe secondary goal of TPIAT is to prevent brittle diabetes by preserving beta cell function.↗
▶Ep 6 · 2:59
quoteAnd as a secondary goal is to try to prevent the brittle diabetes that happens once your pancreas is out.↗
quoteThere'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.↗
▶Ep 6 · 3:23
clinicalWith an islet cell count of 5000, there is a 50% chance of not requiring insulin post-TPIAT.↗
▶Ep 6 · 3:36
clinicalWith an islet cell count of 5000, there is a 20% chance of requiring a small dose of insulin post-TPIAT.↗
▶Ep 6 · 3:40
clinicalWith an islet cell count of 5000, 30% of patients remain diabetic post-TPIAT.↗
▶Ep 6 · 3:42
clinicalTPIAT potentially exchanges chronic pancreatitis for diabetes, and families must be counseled about this trade-off.↗
▶Ep 6 · 3:42
quoteSo we need to tell the families they're, I'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes.↗
▶Ep 6 · 4:25
clinicalTPIAT surgery takes an average of 8 to 10 hours.↗
▶Ep 6 · 4:34
clinicalThe pancreas is cemented in the retroperitoneum with neovascularization and collateralization, making removal the most problematic part of TPIAT.↗
▶Ep 6 · 4:34
clinicalSome chronic pancreatitis patients have thrombosis in the portal vein or splenic vein.↗
▶Ep 6 · 4:51
clinicalPancreatectomy during TPIAT takes 3 to 4 hours.↗
▶Ep 6 · 5:09
clinicalDuring TPIAT, biliary and intestinal reconstruction is performed using a Roux-en-Y technique while islet isolation is occurring.↗
▶Ep 6 · 5:28
clinicalThe spleen is removed along with the pancreas during TPIAT.↗
▶Ep 6 · 5:35
clinicalIslet cell isolation takes 4 to 4.5 hours.↗
▶Ep 6 · 5:39
clinicalIslet cells are injected into the portal vein inside the liver.↗
▶Ep 6 · 6:05
clinicalIn the acute post-operative period, glucose must be managed externally to prevent stress on transplanted islet cells.↗
▶Ep 6 · 6:09
quoteIf you put them under stress, the cells die.↗
▶Ep 6 · 6:12
clinicalAll TPIAT patients are on insulin in the ICU to allow islet cells to implant without stress.↗
▶Ep 6 · 6:14
clinicalIslet cells need to find new vessels from the liver to survive after transplantation.↗
▶Ep 6 · 6:14
quoteI want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive.↗
▶Ep 6 · 6:27
clinicalIslet cells implant in the end branches of the portal vein inside the liver.↗
▶Ep 6 · 6:34
clinicalExtrahepatic islet cell reimplantation does not work as well as intrahepatic placement.↗
▶Ep 6 · 6:43
clinicalExtrahepatic islet cells produce a better glucagon response for hypoglycemia compared to intrahepatic cells.↗
▶Ep 6 · 6:51
clinicalThe liver is the best site for islet cell transplantation.↗
▶Ep 6 · 6:54
clinicalThe risk of portal vein thrombosis after intrahepatic islet injection is less than 1%.↗
▶Ep 6 · 6:54
clinicalPortal pressure is monitored during islet cell injection to prevent complications.↗
▶Ep 6 · 7:05
clinicalDuring TPIAT, the duodenum is removed at D1 post-pyloric level along with the pancreas.↗
▶Ep 6 · 7:10
clinicalThe duodenum and pancreas share blood supply, making duodenal preservation difficult during TPIAT.↗
Update Course Rewind: Management of Recurrent Pancreatitis
▶Ep 7 · 1:40
quoteEvery 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.↗
▶Ep 7 · 1:40
clinicalEvery ERCP carries a risk of post-ERCP pancreatitis, and with every pancreatitis attack, islet cells are lost.↗
▶Ep 7 · 1:57
quotePRSS1 is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas.↗
▶Ep 7 · 1:57
clinicalPRSS1 is the most common genetic mutation in recurrent pancreatitis and is a trypsinogen activator that activates trypsin inside the pancreas.↗
▶Ep 7 · 2:06
clinicalThe genetic panel at Cincinnati Children's tests 10 different genetic markers for pancreatitis (including PRSS1, CTRC, CFTR, CPA1).↗
▶Ep 7 · 2:17
quoteThat's how we're changing the approach to pediatric pancreatitis, chronic pan pancreatitis treatment because of the genetic factors.↗
▶Ep 7 · 2:17
opinionGenetic factors are changing the approach to pediatric chronic pancreatitis treatment.↗
▶Ep 7 · 2:48
quoteNo, 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.↗
▶Ep 7 · 2:48
clinicalThere is currently no medication to mitigate trypsin activation in genetic pancreatitis mutations.↗
▶Ep 7 · 3:09
clinicalIn a Frey procedure (partial head pancreatectomy with pancreaticojejunostomy), the top half of the pancreas is removed to open the duct, which results in loss of islet cells.↗
▶Ep 7 · 3:19
quoteThis 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.↗
▶Ep 7 · 3:19
clinicalIn patients with PRSS1 mutation, draining the duct (e.g., via Frey) temporizes attacks but does not fix the problem, as the parenchyma continues to be attacked by the mutation and pancreatitis will likely recur.↗
▶Ep 7 · 4:09
opinionThere is no set number of ERCPs that defines when to escalate care; the sooner the referral for evaluation, the better.↗
▶Ep 7 · 4:16
guidelineSurgical management of the pancreas is not offered unless medical and endoscopic management have been maximized.↗
▶Ep 7 · 4:16
quoteWe don't offer, uh, to take care of the pancreas unless you've. Maximize medical and endoscopic management.↗
▶Ep 7 · 4:23
quoteIf 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.↗
▶Ep 7 · 4:23
clinicalIf the endoscopist has no further options (nothing to balloon dilate, open, or drain) and the patient continues to have pancreatitis despite stenting, there is no reason to continue ERCPs.↗
▶Ep 7 · 4:58
quoteMRCP is the best non-invasive study for pancreas by far, uh, with different uh uh T2 sequences.↗
▶Ep 7 · 4:58
clinicalMRCP is the best non-invasive imaging study for the pancreas, particularly with T2 sequences.↗
▶Ep 7 · 5:07
clinicalERCP is more therapeutic than diagnostic.↗
▶Ep 7 · 5:22
quoteOnce 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.↗
▶Ep 7 · 5:22
clinicalPancreatic fluid collections should be drained once the wall is mature (4 to 6 weeks) only if the patient is symptomatic (e.g., gastric outlet obstruction or pain); asymptomatic collections will self-resolve and do not require drainage or antibiotics.↗
Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center
▶Ep 9 · 0:48
opinionTPIAT is one of the most complex abdominal surgical procedures performed in children.↗
▶Ep 9 · 0:48
quoteTPIAT is clearly one of the most complex abdominal surgical procedures we perform in children.↗
▶Ep 9 · 0:54
clinicalSurgical indications for TPIAT are for patients with either chronic or acute recurrent pancreatitis.↗
▶Ep 9 · 1:02
guidelinePatients are candidates for TPIAT when all medical and endoscopic therapy has failed.↗
▶Ep 9 · 1:02
quoteThese patients are candidates for TPAT when all medical and endoscopic therapy has failed.↗
▶Ep 9 · 1:23
clinicalThe Pancreas Care Center team includes GI, social worker, endocrine, surgery, radiology, genetics, behavioral health, physical therapy, anesthesia, and pain team.↗
▶Ep 9 · 1:45
clinicalThe entire team reviews and votes patients in for surgery to determine if they are candidates for TPIAT.↗
▶Ep 9 · 1:45
clinicalPatients are prepared with vaccinations for potential splenectomy before TPIAT surgery.↗
▶Ep 9 · 2:40
clinicalPain catheters are placed in the transversus abdominis muscle by pain specialists.↗
▶Ep 9 · 3:14
clinicalThe pancreas in TPIAT patients has been injured for sometimes years, which makes the procedure quite challenging.↗
▶Ep 9 · 3:14
quoteRemember, this, this pancreas has been injured for sometimes years, which makes this procedure quite challenging.↗
▶Ep 9 · 3:29
clinicalOn the right side, the small intestine (duodenum) and liver hilum are mobilized, with careful identification of bile ducts and blood supply to the liver.↗
▶Ep 9 · 4:06
clinicalBlood supply to the head and entire body of the pancreas is preserved very carefully until the very last moment to avoid hypoxia of islet cells.↗
▶Ep 9 · 4:06
quoteWe preserve very carefully the blood supply to the head and the entire body until the pancreas, until the very last moment because we cannot risk hypoxying these cells.↗
▶Ep 9 · 6:33
clinicalDuring islet processing, the surgical team performs reconstruction of the gastrointestinal tract by bringing a loop of duodenum up to the bile duct and reconnecting another loop of intestine to the duodenum past the pyloric muscle.↗
▶Ep 9 · 6:53
clinicalA feeding tube is placed to allow patients to be fed while important connections heal.↗
▶Ep 9 · 7:02
clinicalDrains are left where the spleen was removed and on top of the connection with the biliary tract.↗
▶Ep 9 · 7:15
clinicalIslet cells are transfused into the portal vein with the hope that they will implant in the liver and start producing insulin.↗
▶Ep 9 · 7:25
clinicalPortal vein pressures are constantly checked during islet infusion to prevent portal vein thrombosis, which could cause significant morbidity.↗
▶Ep 9 · 7:25
quoteWhile we infuse the eyelid itself, we're constantly checking the pressures in the portal vein to make sure we don't risk any thrombosis in the portal vein, which could cause a lot of morbidity to the patient.↗
▶Ep 9 · 8:01
clinicalPatients are placed in the intensive care unit post-operatively to control hemodynamics and fluid shift balance.↗
▶Ep 9 · 8:08
clinicalIslet cells need to heal in a very homeostatic environment, requiring close monitoring of vital signs.↗
▶Ep 9 · 8:18
clinicalGlucose and insulin are controlled via exogenous infusions post-operatively.↗
▶Ep 9 · 8:22
clinicalClose attention to nutrition is key in the healing of connections between the bile tract and gastrointestinal tract.↗
▶Ep 9 · 8:39
clinicalPatients are deemed ready for discharge when pain is well controlled, they are on full feeds (via tube or by mouth), glucose is well controlled via continuous glucose monitoring, and they have received full education.↗
▶Ep 9 · 8:47
clinicalAfter discharge, local GI physicians continue to follow patients along with the Cincinnati Children's team.↗
Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria
▶Ep 11 · 5:44
guidelineDiagnosis of acute pancreatitis requires serum lipase at least 3 times the upper limit of normal, plus imaging findings (ultrasound, MRI/MRCP, or CT).↗
▶Ep 11 · 7:23
epidemiologicalIn the Cincinnati Children's cohort of 1000 pediatric pancreatitis patients, 85% have genetic mutations.↗
▶Ep 11 · 8:01
clinicalPRSS1 mutation causes very aggressive attacks very early in life (ages 1–3 years) because it autoactivates trypsinogen inside the pancreas.↗
▶Ep 11 · 8:37
clinicalMedications including L-asparaginase, steroids, valproic acid, and diuretics (Lasix) can cause pancreatitis in children.↗
▶Ep 11 · 9:32
clinicalHereditary pancreatitis increases the risk of pancreatic cancer by a huge fold, which is a major concern in children diagnosed at age 5–6 who may live 95 more years.↗
▶Ep 11 · 10:15
clinicalMost fluid collections in pediatric acute pancreatitis are self-limited and should not be touched unless absolutely necessary.↗
▶Ep 11 · 18:08
quotePlease do not touch these collections ever unless you absolutely have to.↗
▶Ep 11 · 18:40
clinicalEarly necrosectomies (before 4 weeks) usually increase mortality.↗
▶Ep 11 · 19:49
clinicalFollowing lipase levels tells you nothing about how the pancreas is behaving in acute pancreatitis; cross-sectional imaging is required.↗
▶Ep 11 · 21:36
clinicalAsymptomatic pseudocysts, regardless of size, do not require intervention.↗
▶Ep 11 · 23:29
clinicalPatients with acute pancreatitis should be fed as soon as possible (orally or via NG/NJ tube) because bacterial translocation from NPO status will complicate the disease.↗
▶Ep 11 · 23:29
quotePlease feed your patients as soon as you can, all right? If they're vomiting and they're gonna puke it, well, that doesn't make any sense. You, if you have to throw out an NG or an NG tube, feed the god because bacterial translocation from NPL will complicate acute pancreatitis.↗
▶Ep 11 · 25:13
epidemiologicalIn pediatric patients with hereditary pancreatitis or hereditary plus anatomic abnormalities, half will develop chronic pancreatitis.↗
▶Ep 11 · 25:38
clinicalCincinnati Children's evaluates over 100 patients per year for chronic pancreatitis but only operates on 25–30, because medical and endoscopic options should be exhausted first.↗
▶Ep 11 · 26:50
clinicalChronic pain in pancreatitis involves brain plasticity, hypertrophic nerve reactions, and peripheral nerve hypersensitization, not just organic retroperitoneal pain.↗
▶Ep 11 · 27:43
clinicalAfter total pancreatectomy, 95% of pain is resolved, but 5% may persist due to central sensitization and requires behavioral medicine and psychiatric support.↗
▶Ep 11 · 27:43
quoteI'm gonna take your pancreas out if it's uh indicated, and I'm gonna take care of 95% of your pain. But that 5, 5% that is left. We need to work with psych, behavioral med, uh, and eventually reteach their brains how to live not in pain.↗
▶Ep 11 · 28:37
clinicalPediatric chronic pancreatitis usually presents with minimal ductal changes, not the dilated ducts seen in adults, so drainage procedures are often not applicable.↗
▶Ep 11 · 28:57
clinicalIn patients with genetic mutations, partial pancreatectomy (Whipple, distal pancreatectomy) discards islet mass and does not address the underlying defect, so the remaining pancreas continues to be affected.↗
▶Ep 11 · 28:57
quoteIf you have a genetic mutation and you chop off a piece of the pancreas, throw it in the trash. You can maybe relieve some of the pain. If you do whipple, have the pancreas drain better, do a piece so, I'm gonna touch base on that in a sec, drain the pancreatic duct better. But I put a piece of paper in the trash. And the genetic mutations will keep affecting the rest of the pancreas.↗
▶Ep 11 · 37:44
quoteWe're doing this for, for chronic pain and that should be the, the, the major thing in our head.↗
▶Ep 11 · 37:54
guidelineTPIAT is indicated when patients have chronic pancreatitis findings, at least 6 months of disease, exocrine or endocrine insufficiency, and impaired quality of life despite maximal medical and endoscopic therapy.↗
▶Ep 11 · 39:00
clinicalThe goal of islet autotransplantation is to replace beta cell mass and insulin secretory capacity, not to cure diabetes—pain control is the primary indication.↗
▶Ep 11 · 40:28
clinicalTPIAT used to be a 20-hour operation but is now down to an average of 8–9 hours at Cincinnati Children's.↗
▶Ep 11 · 43:15
clinicalSpleen-sparing TPIAT has equal glycemic outcomes to splenectomy TPIAT when islet equivalent per kilogram transplanted is matched.↗
▶Ep 11 · 43:42
clinicalSpleen-sparing TPIAT is now performed in 80% of cases (over the last 5 years), compared to none in the first 8 years of the program.↗
▶Ep 11 · 45:16
clinicalIntraoperative pyloric Botox injection reduces gastroparesis, decreases length of stay, and improves time to full oral intake and glycemic control after TPIAT.↗
▶Ep 11 · 46:27
clinicalIslet isolation takes about 3–3.5 hours, sometimes 4 hours depending on the degree of pancreatic injury.↗
▶Ep 11 · 47:39
clinicalTPIAT is performed under anticoagulation (heparin) to prevent portal vein thrombosis during islet infusion.↗
▶Ep 11 · 48:11
clinicalPortal vein thrombosis rate at Cincinnati Children's is less than 1% for TPIAT.↗
▶Ep 11 · 48:26
clinicalCincinnati Children's has performed close to 200 TPIAT cases with no anastomotic leaks.↗
▶Ep 11 · 50:07
clinicalPatients are extubated in the operating room after TPIAT.↗
▶Ep 11 · 51:32
clinicalYounger children are more likely to achieve insulin independence and opioid independence after TPIAT.↗
▶Ep 11 · 52:25
clinicalIslet yield (IEQ/kg) is inversely related to pancreatic calcification, ductal dilation, fibrosis, duration of symptoms, and prior resections or drainage procedures.↗
▶Ep 11 · 54:59
clinicalPredictors of insulin independence after TPIAT include younger age at surgery, smaller body surface area, no pre-existing insulin dependence, and higher IEQ/kg transplanted.↗
▶Ep 11 · 56:09
clinicalTPIAT dramatically improves quality of life in appropriately selected children, with families reporting they have 'never met this kid before'—new person, happy, playing, eating normally.↗
Juan's statements about Islet Cell / TPIAT26 statements
Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center
▶Ep 3 · 0:48
quoteTPIAT is clearly one of the most complex abdominal surgical procedures we perform in children.↗
▶Ep 3 · 0:48
opinionTPIAT is one of the most complex abdominal surgical procedures performed in children.↗
▶Ep 3 · 0:54
clinicalSurgical indications for TPIAT are for patients with either chronic or acute recurrent pancreatitis.↗
▶Ep 3 · 1:02
guidelinePatients are candidates for TPIAT when all medical and endoscopic therapy has failed.↗
▶Ep 3 · 1:02
quoteThese patients are candidates for TPAT when all medical and endoscopic therapy has failed.↗
▶Ep 3 · 1:23
clinicalThe Pancreas Care Center team includes GI, social worker, endocrine, surgery, radiology, genetics, behavioral health, physical therapy, anesthesia, and pain team.↗
▶Ep 3 · 1:45
clinicalPatients are prepared with vaccinations for potential splenectomy before TPIAT surgery.↗
▶Ep 3 · 1:45
clinicalThe entire team reviews and votes patients in for surgery to determine if they are candidates for TPIAT.↗
▶Ep 3 · 2:40
clinicalPain catheters are placed in the transversus abdominis muscle by pain specialists.↗
▶Ep 3 · 3:14
clinicalThe pancreas in TPIAT patients has been injured for sometimes years, which makes the procedure quite challenging.↗
▶Ep 3 · 3:14
quoteRemember, this, this pancreas has been injured for sometimes years, which makes this procedure quite challenging.↗
▶Ep 3 · 3:29
clinicalOn the right side, the small intestine (duodenum) and liver hilum are mobilized, with careful identification of bile ducts and blood supply to the liver.↗
▶Ep 3 · 4:06
clinicalBlood supply to the head and entire body of the pancreas is preserved very carefully until the very last moment to avoid hypoxia of islet cells.↗
▶Ep 3 · 4:06
quoteWe preserve very carefully the blood supply to the head and the entire body until the pancreas, until the very last moment because we cannot risk hypoxying these cells.↗
▶Ep 3 · 6:33
clinicalDuring islet processing, the surgical team performs reconstruction of the gastrointestinal tract by bringing a loop of duodenum up to the bile duct and reconnecting another loop of intestine to the duodenum past the pyloric muscle.↗
▶Ep 3 · 6:53
clinicalA feeding tube is placed to allow patients to be fed while important connections heal.↗
▶Ep 3 · 7:02
clinicalDrains are left where the spleen was removed and on top of the connection with the biliary tract.↗
▶Ep 3 · 7:15
clinicalIslet cells are transfused into the portal vein with the hope that they will implant in the liver and start producing insulin.↗
▶Ep 3 · 7:25
clinicalPortal vein pressures are constantly checked during islet infusion to prevent portal vein thrombosis, which could cause significant morbidity.↗
▶Ep 3 · 7:25
quoteWhile we infuse the eyelid itself, we're constantly checking the pressures in the portal vein to make sure we don't risk any thrombosis in the portal vein, which could cause a lot of morbidity to the patient.↗
▶Ep 3 · 8:01
clinicalPatients are placed in the intensive care unit post-operatively to control hemodynamics and fluid shift balance.↗
▶Ep 3 · 8:08
clinicalIslet cells need to heal in a very homeostatic environment, requiring close monitoring of vital signs.↗
▶Ep 3 · 8:18
clinicalGlucose and insulin are controlled via exogenous infusions post-operatively.↗
▶Ep 3 · 8:22
clinicalClose attention to nutrition is key in the healing of connections between the bile tract and gastrointestinal tract.↗
▶Ep 3 · 8:39
clinicalPatients are deemed ready for discharge when pain is well controlled, they are on full feeds (via tube or by mouth), glucose is well controlled via continuous glucose monitoring, and they have received full education.↗
▶Ep 3 · 8:47
clinicalAfter discharge, local GI physicians continue to follow patients along with the Cincinnati Children's team.↗
Juan's statements about Pancreatic Surgery & Critical Care64 statements
clinicalAcute pancreatitis management has shifted from NPO and aggressive IV fluids causing pulmonary edema to early feeding and measured fluid resuscitation.↗
▶Ep 1 · 0:35
quoteit is very important nowadays to feed the pancreas, even when there's pancreatitis↗
▶Ep 1 · 1:01
quoteyou cannot take care of a pancreas without a wonderful team↗
▶Ep 1 · 3:55
clinicalFor 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.↗
quotepancreatitis is a state of uh hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis↗
▶Ep 1 · 4:19
clinicalEarly fluid resuscitation is key to re-establish intravascular flow to the pancreas and prevent hypoxia, necrosis, and atrophic pancreatic insufficiency.↗
▶Ep 1 · 4:39
clinicalExcessive fluid resuscitation in pancreatitis leads to worse outcomes including fluid overload and multi-system organ failure.↗
▶Ep 1 · 4:42
guidelineThere is no indication for routine antibiotics in acute pancreatitis, even with necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis.↗
▶Ep 1 · 6:13
quoteYou cannot uh flow these lungs too much because the outcomes are worse↗
▶Ep 1 · 6:21
guidelineMaintenance fluids should be 1.5 to 2 times normal maintenance, with reassessment at 12-24 hour mark to avoid fluid overload.↗
▶Ep 1 · 9:24
clinicalEnteral nutrition as soon as the patient can tolerate PO is significantly better compared to TPN or NPO in acute pancreatitis.↗
▶Ep 1 · 10:19
clinicalSome vomiting can be tolerated when feeding pancreatitis patients, similar to gastroschisis management, because feeding the gut produces dramatically better outcomes.↗
▶Ep 1 · 10:21
quoteIt's OK to tolerate some, some, some. Vomiting. If you can feed them, that's fine.↗
▶Ep 1 · 11:02
quotenobody needs TPN the 1st 7 days of acute illness, right?↗
▶Ep 1 · 11:02
clinicalNo patient needs TPN in the first 7 days of acute illness.↗
▶Ep 1 · 12:13
clinicalThe 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.↗
▶Ep 1 · 14:38
clinicalWith every attack of pancreatitis, islet cells are lost, so repeated ERCPs that fail to prevent attacks result in progressive loss of beta-cell mass.↗
▶Ep 1 · 14:44
clinicalERCP does not change the islet yield available for transplantation, but pancreatitis attacks cause cell loss.↗
▶Ep 1 · 14:53
quotechildren get pancreatitis. We have a running list of 800 patients right now in Cin Children's.↗
▶Ep 1 · 14:59
guidelineGenetic 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.↗
▶Ep 1 · 14:59
epidemiologicalCincinnati 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.↗
▶Ep 1 · 15:23
epidemiologicalThe most common cause of pancreatitis in children is medication-induced, but the most common risk factor is genetic factors.↗
▶Ep 1 · 15:23
quoteThe most common cause of pancreatitis in children is, is, is medicine induced. The most common risk factor for pancreatitis in children is, is genetic factors.↗
▶Ep 1 · 15:32
quotePRSS one is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas. So, you get auto-attacked by pancreatitis. It's the most aggressive one.↗
▶Ep 1 · 15:32
clinicalPRSS1 (trypsinogen activator) is the most common genetic mutation in pediatric pancreatitis and the most aggressive, causing auto-attack by activating trypsin inside the pancreas.↗
▶Ep 1 · 15:48
clinicalCincinnati Children's genetic panel tests 10 different genetic markers for pancreatitis including PRSS1, CTRC, CFTR, and CPA1.↗
▶Ep 1 · 16:06
opinionGenetics have fundamentally changed the approach to pediatric chronic pancreatitis treatment.↗
▶Ep 1 · 16:33
quoteup to 50% of those children are gonna keep getting pancreatitis despite you opening the duct and draining it↗
▶Ep 1 · 16:33
clinicalIn 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.↗
▶Ep 1 · 16:49
quoteyou send half of your, the top of your pancreas to the trash↗
▶Ep 1 · 17:07
quoteunfortunately we don't have that just yet. That's why I still have a job.↗
▶Ep 1 · 18:24
quoteThis patient most likely is gonna keep getting pancreatitis despite you draining the duct. The, the parenchyma is gonna keep getting attacked by the mutation.↗
▶Ep 1 · 19:02
quoteTPIT, which is total pancreatectomy with eyelid autotransplantation. Uh, the main indication is, is for pain, chronic debilitating pain for children that are losing their lives.↗
▶Ep 1 · 19:08
clinicalThe 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.↗
clinicalThe secondary goal of TPIAT is to prevent brittle diabetes by returning beta cells to the patient.↗
▶Ep 1 · 19:56
quoteif you keep getting pancreatitis, you're losing time on that, right? The, the pancreas, we have 34 years old with like very atrophic pancreas↗
▶Ep 1 · 20:17
quoteWe don't offer. Uh, to take care of the pancreas unless you've maximize medical and endoscopic management.↗
▶Ep 1 · 20:59
clinicalMRCP is the best non-invasive imaging study for the pancreas, superior to ultrasound and CT.↗
▶Ep 1 · 21:07
clinicalERCP is more therapeutic than diagnostic in chronic pancreatitis.↗
▶Ep 1 · 21:12
clinicalPatients with chronic pancreatitis always have micronutrient and macronutrient deficiencies requiring nutritional support.↗
▶Ep 1 · 21:36
clinicalPatients with chronic pancreatitis lose exocrine function first, then endocrine function, requiring screening and often pancreatic enzyme replacement therapy.↗
▶Ep 1 · 21:48
clinicalWalled-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.↗
▶Ep 1 · 22:08
epidemiologicalChronic pancreatitis increases the risk of pancreatic cancer up to thirteenfold.↗
▶Ep 1 · 24:08
epidemiologicalUp to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 1 · 24:40
clinicalTPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social workers, geneticists, psychology, and pain management.↗
▶Ep 1 · 25:00
quotesome families ask us like, so you're gonna get rid of the pain, right? 100%, and you cannot say that, right?↗
▶Ep 1 · 25:07
clinicalPatients 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.↗
▶Ep 1 · 25:07
quotePeople that have chronic pain, their bodies, their brains learn how to be in pain, right? They can function in pain. That's called hyperalgesia and central sensitization.↗
▶Ep 1 · 25:18
quotewhen you take the, the, the organ part out, you maybe 90% of the pain is gone, but you cannot promise them that 10 that 10% is gonna linger for a little bit↗
▶Ep 1 · 26:32
clinicalIslet 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.↗
▶Ep 1 · 27:00
clinicalTPIAT outcomes: 50% of patients achieve insulin independence, 20% require small insulin doses, and 30% remain diabetic.↗
▶Ep 1 · 27:05
quoteI'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes.↗
▶Ep 1 · 27:05
clinicalTPIAT exchanges chronic pancreatitis for potential diabetes, which must be clearly communicated to families.↗
▶Ep 1 · 27:23
quoteMy day starts the, the night before as I start going through the case. It's a long day. It's a long day. I reviewed this case in my head, uh, 30 times before I go in.↗
▶Ep 1 · 27:32
clinicalTPIAT 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.↗
▶Ep 1 · 28:47
clinicalPylorus-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.↗
▶Ep 1 · 29:33
clinicalRoutine 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.↗
▶Ep 1 · 29:59
clinicalThere 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.↗
▶Ep 1 · 30:20
clinicalAll 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.↗
▶Ep 1 · 31:10
clinicalThe 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.↗
▶Ep 1 · 31:58
clinicalPortal vein thrombosis after islet injection occurs in less than 1% of cases; portal pressure is monitored during injection.↗
▶Ep 1 · 32:23
clinicalThe 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's statements about Pancreatitis266 statements
quoteit is very important nowadays to feed the pancreas, even when there's pancreatitis↗
▶Ep 13 · 0:35
clinicalAcute pancreatitis management has shifted from NPO and aggressive IV fluids causing pulmonary edema to early feeding and measured fluid resuscitation.↗
▶Ep 13 · 1:01
quoteyou cannot take care of a pancreas without a wonderful team↗
▶Ep 13 · 3:55
clinicalFor 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.↗
clinicalEarly fluid resuscitation is key to re-establish intravascular flow to the pancreas and prevent hypoxia, necrosis, and atrophic pancreatic insufficiency.↗
▶Ep 13 · 4:19
quotepancreatitis is a state of uh hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis↗
▶Ep 13 · 4:39
clinicalExcessive fluid resuscitation in pancreatitis leads to worse outcomes including fluid overload and multi-system organ failure.↗
▶Ep 13 · 4:42
guidelineThere is no indication for routine antibiotics in acute pancreatitis, even with necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis.↗
▶Ep 13 · 6:13
quoteYou cannot uh flow these lungs too much because the outcomes are worse↗
▶Ep 13 · 6:21
guidelineMaintenance fluids should be 1.5 to 2 times normal maintenance, with reassessment at 12-24 hour mark to avoid fluid overload.↗
▶Ep 13 · 9:24
clinicalEnteral nutrition as soon as the patient can tolerate PO is significantly better compared to TPN or NPO in acute pancreatitis.↗
▶Ep 13 · 10:19
clinicalSome vomiting can be tolerated when feeding pancreatitis patients, similar to gastroschisis management, because feeding the gut produces dramatically better outcomes.↗
▶Ep 13 · 10:21
quoteIt's OK to tolerate some, some, some. Vomiting. If you can feed them, that's fine.↗
▶Ep 13 · 11:02
clinicalNo patient needs TPN in the first 7 days of acute illness.↗
▶Ep 13 · 11:02
quotenobody needs TPN the 1st 7 days of acute illness, right?↗
▶Ep 13 · 12:13
clinicalThe 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.↗
▶Ep 13 · 14:38
clinicalWith every attack of pancreatitis, islet cells are lost, so repeated ERCPs that fail to prevent attacks result in progressive loss of beta-cell mass.↗
▶Ep 13 · 14:44
clinicalERCP does not change the islet yield available for transplantation, but pancreatitis attacks cause cell loss.↗
▶Ep 13 · 14:53
quotechildren get pancreatitis. We have a running list of 800 patients right now in Cin Children's.↗
▶Ep 13 · 14:59
guidelineGenetic 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.↗
▶Ep 13 · 14:59
epidemiologicalCincinnati 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.↗
▶Ep 13 · 15:23
epidemiologicalThe most common cause of pancreatitis in children is medication-induced, but the most common risk factor is genetic factors.↗
▶Ep 13 · 15:23
quoteThe most common cause of pancreatitis in children is, is, is medicine induced. The most common risk factor for pancreatitis in children is, is genetic factors.↗
▶Ep 13 · 15:32
quotePRSS one is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas. So, you get auto-attacked by pancreatitis. It's the most aggressive one.↗
▶Ep 13 · 15:32
clinicalPRSS1 (trypsinogen activator) is the most common genetic mutation in pediatric pancreatitis and the most aggressive, causing auto-attack by activating trypsin inside the pancreas.↗
▶Ep 13 · 15:48
clinicalCincinnati Children's genetic panel tests 10 different genetic markers for pancreatitis including PRSS1, CTRC, CFTR, and CPA1.↗
▶Ep 13 · 16:06
opinionGenetics have fundamentally changed the approach to pediatric chronic pancreatitis treatment.↗
▶Ep 13 · 16:33
quoteup to 50% of those children are gonna keep getting pancreatitis despite you opening the duct and draining it↗
▶Ep 13 · 16:33
clinicalIn 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.↗
▶Ep 13 · 16:49
quoteyou send half of your, the top of your pancreas to the trash↗
▶Ep 13 · 17:07
quoteunfortunately we don't have that just yet. That's why I still have a job.↗
▶Ep 13 · 18:24
quoteThis patient most likely is gonna keep getting pancreatitis despite you draining the duct. The, the parenchyma is gonna keep getting attacked by the mutation.↗
▶Ep 13 · 19:02
quoteTPIT, which is total pancreatectomy with eyelid autotransplantation. Uh, the main indication is, is for pain, chronic debilitating pain for children that are losing their lives.↗
▶Ep 13 · 19:08
clinicalThe 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.↗
clinicalThe secondary goal of TPIAT is to prevent brittle diabetes by returning beta cells to the patient.↗
▶Ep 13 · 19:56
quoteif you keep getting pancreatitis, you're losing time on that, right? The, the pancreas, we have 34 years old with like very atrophic pancreas↗
▶Ep 13 · 20:17
quoteWe don't offer. Uh, to take care of the pancreas unless you've maximize medical and endoscopic management.↗
▶Ep 13 · 20:59
clinicalMRCP is the best non-invasive imaging study for the pancreas, superior to ultrasound and CT.↗
▶Ep 13 · 21:07
clinicalERCP is more therapeutic than diagnostic in chronic pancreatitis.↗
▶Ep 13 · 21:12
clinicalPatients with chronic pancreatitis always have micronutrient and macronutrient deficiencies requiring nutritional support.↗
▶Ep 13 · 21:36
clinicalPatients with chronic pancreatitis lose exocrine function first, then endocrine function, requiring screening and often pancreatic enzyme replacement therapy.↗
▶Ep 13 · 21:48
clinicalWalled-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.↗
▶Ep 13 · 22:08
epidemiologicalChronic pancreatitis increases the risk of pancreatic cancer up to thirteenfold.↗
▶Ep 13 · 24:08
epidemiologicalUp to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 13 · 24:40
clinicalTPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social workers, geneticists, psychology, and pain management.↗
▶Ep 13 · 25:00
quotesome families ask us like, so you're gonna get rid of the pain, right? 100%, and you cannot say that, right?↗
▶Ep 13 · 25:07
quotePeople that have chronic pain, their bodies, their brains learn how to be in pain, right? They can function in pain. That's called hyperalgesia and central sensitization.↗
▶Ep 13 · 25:07
clinicalPatients 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.↗
▶Ep 13 · 25:18
quotewhen you take the, the, the organ part out, you maybe 90% of the pain is gone, but you cannot promise them that 10 that 10% is gonna linger for a little bit↗
▶Ep 13 · 26:32
clinicalIslet 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.↗
▶Ep 13 · 27:00
clinicalTPIAT outcomes: 50% of patients achieve insulin independence, 20% require small insulin doses, and 30% remain diabetic.↗
▶Ep 13 · 27:05
quoteI'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes.↗
▶Ep 13 · 27:05
clinicalTPIAT exchanges chronic pancreatitis for potential diabetes, which must be clearly communicated to families.↗
▶Ep 13 · 27:23
quoteMy day starts the, the night before as I start going through the case. It's a long day. It's a long day. I reviewed this case in my head, uh, 30 times before I go in.↗
▶Ep 13 · 27:32
clinicalTPIAT 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.↗
▶Ep 13 · 28:47
clinicalPylorus-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.↗
▶Ep 13 · 29:33
clinicalRoutine 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.↗
▶Ep 13 · 29:59
clinicalThere 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.↗
▶Ep 13 · 30:20
clinicalAll 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.↗
▶Ep 13 · 31:10
clinicalThe 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.↗
▶Ep 13 · 31:58
clinicalPortal vein thrombosis after islet injection occurs in less than 1% of cases; portal pressure is monitored during injection.↗
▶Ep 13 · 32:23
clinicalThe duodenum is resected at D1 post-pyloric during TPIAT because of shared blood supply with the pancreas; attempting to preserve it adds ischemia time.↗
Update Course Rewind: Management of Acute Pancreatitis 2023
clinicalBolus times 2 is adequate fluid resuscitation, with 1.5 times maintenance once past the early phase of acute resuscitation↗
▶Ep 14 · 2:06
clinicalPancreatitis is a state of hypoxia requiring re-establishment of intravascular flow to the pancreas to prevent hypoxia, necrosis, and atrophic pancreas insufficiency↗
▶Ep 14 · 2:06
quoteRemember that pancreatitis is a state of, uh, hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis, atrophic pancreas insufficiency.↗
▶Ep 14 · 2:22
clinicalEarly fluid resuscitation is key in pancreatitis management↗
▶Ep 14 · 2:26
clinicalExcessive fluid administration worsens outcomes in pancreatitis↗
▶Ep 14 · 2:29
guidelineThere is no reason to give antibiotics for pancreatitis, even in the face of necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis↗
▶Ep 14 · 2:29
quoteNow, there's no reason to give antibiotics anymore at all for pancreatitis, even in the face of world of necrosis or necrotizing pancreatitis, unless there are signs of sepsis infected pancreatitis, which is a different beast↗
▶Ep 14 · 2:57
guidelineThe North American Society of Pancreatitis, GI Pathology, and Nutrition published a position paper with guideline recommendations for pancreatitis management↗
▶Ep 14 · 3:07
clinicalEarly fluids lead to better outcomes in pancreatitis↗
▶Ep 14 · 3:11
guidelineRecommended fluid bolus is 10 to 20 mL per kg, up to 3L in the first 24 hours, with reassessment at the 12-hour mark using urine output and vital signs↗
▶Ep 14 · 3:25
clinicalExcessive fluid administration can flood the lungs and worsen outcomes↗
▶Ep 14 · 3:25
quoteYou cannot flow these lungs too much because the outcomes are worse.↗
▶Ep 14 · 3:45
quoteIt's been shown that LR. Decreases the incidence of inflammatory response and C, C-reactive protein at 24 hours compared to NS, right?↗
▶Ep 14 · 3:45
clinicalLactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis↗
▶Ep 14 · 3:54
clinicalIf albumin is low in pancreatitis patients, albumin should be given↗
▶Ep 14 · 3:58
clinicalEnrique de Madaria conducted a multi-center worldwide RCT called the Waterfall trial comparing moderate versus aggressive fluid resuscitation in pancreatitis↗
▶Ep 14 · 4:18
clinicalThe Waterfall trial was stopped early because patients receiving too much fluid were developing organ failure↗
▶Ep 14 · 4:27
clinicalA follow-up Waterland trial is underway to determine whether lactated Ringer's is better than normal saline, expected to be published in one to two years↗
▶Ep 14 · 4:47
clinicalPatients with pancreatitis should be fed as soon as they are able to tolerate oral intake↗
▶Ep 14 · 4:51
clinicalEnteral nutrition is significantly better compared to TPN or NPO in pancreatitis↗
▶Ep 14 · 4:57
clinicalGastric feeding is preferred over post-pyloric feeding in pancreatitis if the patient can tolerate it↗
▶Ep 14 · 5:19
opinionSome vomiting is tolerable during refeeding in pancreatitis, similar to gastroschisis management↗
▶Ep 14 · 5:19
quoteIf they cannot tolerate it, it's OK. I mean, but it's like gastroschisis, it's OK to tolerate some, some, some vomiting.↗
▶Ep 14 · 5:26
quoteIf you're losing nutrition and you're losing ground, the patient's gonna have a worse outcome. Their albumin is gonna drop, inflammatory reaction is gonna be worse.↗
▶Ep 14 · 5:26
clinicalIf nutrition is lost and the patient loses ground, outcomes will be worse, with dropping albumin and worse inflammatory reaction↗
▶Ep 14 · 5:34
clinicalOutcomes are dramatically better when the gut is fed in pancreatitis patients↗
Update Course Rewind: Management of Chronic Pancreatitis 2023
▶Ep 15 · 0:43
quoteOK, 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.↗
▶Ep 15 · 0:43
quoteOK, 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.↗
▶Ep 15 · 1:28
quoteSo, 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.↗
▶Ep 15 · 1:28
quoteSo, 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.↗
▶Ep 15 · 1:28
clinicalIf a patient has a PRSS1 mutation and only the pancreatic head is removed, recurrent attacks will occur.↗
▶Ep 15 · 1:28
clinicalMost of the pancreatic parenchyma is in the head and the uncinate process.↗
▶Ep 15 · 1:28
clinicalMost of the pancreatic parenchyma is in the head and the uncinate process.↗
▶Ep 15 · 1:28
clinicalIf a patient has a PRSS1 mutation and only the pancreatic head is removed, recurrent attacks will occur.↗
▶Ep 15 · 1:40
epidemiologicalUp to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 15 · 1:40
epidemiologicalUp to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 15 · 1:40
quoteSo, up to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 15 · 1:40
quoteSo, up to 50% of patients with chronic pancreatitis will eventually require surgery.↗
▶Ep 15 · 2:01
quoteNot everybody is, is a candidate for, they need support, they need social support, right?↗
▶Ep 15 · 2:01
quoteNot everybody is, is a candidate for, they need support, they need social support, right?↗
▶Ep 15 · 2:10
guidelineTPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social worker, geneticists, psychiatry, and pain control.↗
▶Ep 15 · 2:10
guidelineTPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social worker, geneticists, psychiatry, and pain control.↗
▶Ep 15 · 2:18
clinicalPatients with chronic pancreatitis always have micro and macronutrient deficiencies.↗
▶Ep 15 · 2:18
clinicalPatients with chronic pancreatitis always have micro and macronutrient deficiencies.↗
▶Ep 15 · 2:18
quoteSo remember, patients with chronic pancreatitis are, are always having micro and macronutrient deficiencies, so we need to pay a lot of attention to this.↗
▶Ep 15 · 2:18
quoteSo remember, patients with chronic pancreatitis are, are always having micro and macronutrient deficiencies, so we need to pay a lot of attention to this.↗
▶Ep 15 · 2:33
clinicalChronic pancreatitis patients sometimes need pancreatic enzyme replacement therapy.↗
▶Ep 15 · 2:33
clinicalChronic pancreatitis patients sometimes need pancreatic enzyme replacement therapy.↗
▶Ep 15 · 2:40
quoteUm, you lose first your exocrine and then your endocrine function, so you need to keep screening for it.↗
▶Ep 15 · 2:40
clinicalIn chronic pancreatitis, exocrine function is lost first, then endocrine function.↗
▶Ep 15 · 2:40
clinicalIn chronic pancreatitis, exocrine function is lost first, then endocrine function.↗
▶Ep 15 · 2:40
quoteUm, you lose first your exocrine and then your endocrine function, so you need to keep screening for it.↗
▶Ep 15 · 2:49
quoteThe 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.↗
▶Ep 15 · 2:49
quoteThe 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.↗
▶Ep 15 · 2:49
clinicalThe primary goal of TPIAT is to restore the child's quality of life and return them to normal activities.↗
▶Ep 15 · 2:49
clinicalThe primary goal of TPIAT is to restore the child's quality of life and return them to normal activities.↗
▶Ep 15 · 2:59
clinicalThe secondary goal of TPIAT is to prevent brittle diabetes by preserving beta cell function.↗
▶Ep 15 · 2:59
clinicalThe secondary goal of TPIAT is to prevent brittle diabetes by preserving beta cell function.↗
▶Ep 15 · 2:59
quoteAnd as a secondary goal is to try to prevent the brittle diabetes that happens once your pancreas is out.↗
▶Ep 15 · 2:59
quoteAnd as a secondary goal is to try to prevent the brittle diabetes that happens once your pancreas is out.↗
clinicalWith an islet cell count of 5000, there is a 50% chance of not requiring insulin post-TPIAT.↗
▶Ep 15 · 3:23
quoteThere'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.↗
▶Ep 15 · 3:23
clinicalWith an islet cell count of 5000, there is a 50% chance of not requiring insulin post-TPIAT.↗
▶Ep 15 · 3:23
quoteThere'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.↗
▶Ep 15 · 3:36
clinicalWith an islet cell count of 5000, there is a 20% chance of requiring a small dose of insulin post-TPIAT.↗
▶Ep 15 · 3:36
clinicalWith an islet cell count of 5000, there is a 20% chance of requiring a small dose of insulin post-TPIAT.↗
▶Ep 15 · 3:40
clinicalWith an islet cell count of 5000, 30% of patients remain diabetic post-TPIAT.↗
▶Ep 15 · 3:40
clinicalWith an islet cell count of 5000, 30% of patients remain diabetic post-TPIAT.↗
▶Ep 15 · 3:42
clinicalTPIAT potentially exchanges chronic pancreatitis for diabetes, and families must be counseled about this trade-off.↗
▶Ep 15 · 3:42
quoteSo we need to tell the families they're, I'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes.↗
▶Ep 15 · 3:42
clinicalTPIAT potentially exchanges chronic pancreatitis for diabetes, and families must be counseled about this trade-off.↗
▶Ep 15 · 3:42
quoteSo we need to tell the families they're, I'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes.↗
▶Ep 15 · 4:25
clinicalTPIAT surgery takes an average of 8 to 10 hours.↗
▶Ep 15 · 4:25
clinicalTPIAT surgery takes an average of 8 to 10 hours.↗
▶Ep 15 · 4:34
clinicalSome chronic pancreatitis patients have thrombosis in the portal vein or splenic vein.↗
▶Ep 15 · 4:34
clinicalThe pancreas is cemented in the retroperitoneum with neovascularization and collateralization, making removal the most problematic part of TPIAT.↗
▶Ep 15 · 4:34
clinicalSome chronic pancreatitis patients have thrombosis in the portal vein or splenic vein.↗
▶Ep 15 · 4:34
clinicalThe pancreas is cemented in the retroperitoneum with neovascularization and collateralization, making removal the most problematic part of TPIAT.↗
▶Ep 15 · 4:51
clinicalPancreatectomy during TPIAT takes 3 to 4 hours.↗
▶Ep 15 · 4:51
clinicalPancreatectomy during TPIAT takes 3 to 4 hours.↗
▶Ep 15 · 5:09
clinicalDuring TPIAT, biliary and intestinal reconstruction is performed using a Roux-en-Y technique while islet isolation is occurring.↗
▶Ep 15 · 5:09
clinicalDuring TPIAT, biliary and intestinal reconstruction is performed using a Roux-en-Y technique while islet isolation is occurring.↗
▶Ep 15 · 5:28
clinicalThe spleen is removed along with the pancreas during TPIAT.↗
▶Ep 15 · 5:28
clinicalThe spleen is removed along with the pancreas during TPIAT.↗
▶Ep 15 · 5:35
clinicalIslet cell isolation takes 4 to 4.5 hours.↗
▶Ep 15 · 5:35
clinicalIslet cell isolation takes 4 to 4.5 hours.↗
▶Ep 15 · 5:39
clinicalIslet cells are injected into the portal vein inside the liver.↗
▶Ep 15 · 5:39
clinicalIslet cells are injected into the portal vein inside the liver.↗
▶Ep 15 · 6:05
clinicalIn the acute post-operative period, glucose must be managed externally to prevent stress on transplanted islet cells.↗
▶Ep 15 · 6:05
clinicalIn the acute post-operative period, glucose must be managed externally to prevent stress on transplanted islet cells.↗
▶Ep 15 · 6:09
quoteIf you put them under stress, the cells die.↗
▶Ep 15 · 6:09
quoteIf you put them under stress, the cells die.↗
▶Ep 15 · 6:12
clinicalAll TPIAT patients are on insulin in the ICU to allow islet cells to implant without stress.↗
▶Ep 15 · 6:12
clinicalAll TPIAT patients are on insulin in the ICU to allow islet cells to implant without stress.↗
▶Ep 15 · 6:14
quoteI want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive.↗
▶Ep 15 · 6:14
clinicalIslet cells need to find new vessels from the liver to survive after transplantation.↗
▶Ep 15 · 6:14
clinicalIslet cells need to find new vessels from the liver to survive after transplantation.↗
▶Ep 15 · 6:14
quoteI want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive.↗
▶Ep 15 · 6:27
clinicalIslet cells implant in the end branches of the portal vein inside the liver.↗
▶Ep 15 · 6:27
clinicalIslet cells implant in the end branches of the portal vein inside the liver.↗
▶Ep 15 · 6:34
clinicalExtrahepatic islet cell reimplantation does not work as well as intrahepatic placement.↗
▶Ep 15 · 6:34
clinicalExtrahepatic islet cell reimplantation does not work as well as intrahepatic placement.↗
▶Ep 15 · 6:43
clinicalExtrahepatic islet cells produce a better glucagon response for hypoglycemia compared to intrahepatic cells.↗
▶Ep 15 · 6:43
clinicalExtrahepatic islet cells produce a better glucagon response for hypoglycemia compared to intrahepatic cells.↗
▶Ep 15 · 6:51
clinicalThe liver is the best site for islet cell transplantation.↗
▶Ep 15 · 6:51
clinicalThe liver is the best site for islet cell transplantation.↗
▶Ep 15 · 6:54
clinicalPortal pressure is monitored during islet cell injection to prevent complications.↗
▶Ep 15 · 6:54
clinicalThe risk of portal vein thrombosis after intrahepatic islet injection is less than 1%.↗
▶Ep 15 · 6:54
clinicalPortal pressure is monitored during islet cell injection to prevent complications.↗
▶Ep 15 · 6:54
clinicalThe risk of portal vein thrombosis after intrahepatic islet injection is less than 1%.↗
▶Ep 15 · 7:05
clinicalDuring TPIAT, the duodenum is removed at D1 post-pyloric level along with the pancreas.↗
▶Ep 15 · 7:05
clinicalDuring TPIAT, the duodenum is removed at D1 post-pyloric level along with the pancreas.↗
▶Ep 15 · 7:10
clinicalThe duodenum and pancreas share blood supply, making duodenal preservation difficult during TPIAT.↗
▶Ep 15 · 7:10
clinicalThe duodenum and pancreas share blood supply, making duodenal preservation difficult during TPIAT.↗
Update Course Rewind: Management of Recurrent Pancreatitis
▶Ep 17 · 1:40
clinicalEvery ERCP carries a risk of post-ERCP pancreatitis, and with every pancreatitis attack, islet cells are lost.↗
▶Ep 17 · 1:40
quoteEvery 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.↗
▶Ep 17 · 1:57
quotePRSS1 is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas.↗
▶Ep 17 · 1:57
clinicalPRSS1 is the most common genetic mutation in recurrent pancreatitis and is a trypsinogen activator that activates trypsin inside the pancreas.↗
▶Ep 17 · 2:06
clinicalThe genetic panel at Cincinnati Children's tests 10 different genetic markers for pancreatitis (including PRSS1, CTRC, CFTR, CPA1).↗
▶Ep 17 · 2:17
opinionGenetic factors are changing the approach to pediatric chronic pancreatitis treatment.↗
▶Ep 17 · 2:17
quoteThat's how we're changing the approach to pediatric pancreatitis, chronic pan pancreatitis treatment because of the genetic factors.↗
▶Ep 17 · 2:48
quoteNo, 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.↗
▶Ep 17 · 2:48
clinicalThere is currently no medication to mitigate trypsin activation in genetic pancreatitis mutations.↗
▶Ep 17 · 3:09
clinicalIn a Frey procedure (partial head pancreatectomy with pancreaticojejunostomy), the top half of the pancreas is removed to open the duct, which results in loss of islet cells.↗
▶Ep 17 · 3:19
quoteThis 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.↗
▶Ep 17 · 3:19
clinicalIn patients with PRSS1 mutation, draining the duct (e.g., via Frey) temporizes attacks but does not fix the problem, as the parenchyma continues to be attacked by the mutation and pancreatitis will likely recur.↗
▶Ep 17 · 4:09
opinionThere is no set number of ERCPs that defines when to escalate care; the sooner the referral for evaluation, the better.↗
▶Ep 17 · 4:16
guidelineSurgical management of the pancreas is not offered unless medical and endoscopic management have been maximized.↗
▶Ep 17 · 4:16
quoteWe don't offer, uh, to take care of the pancreas unless you've. Maximize medical and endoscopic management.↗
▶Ep 17 · 4:23
clinicalIf the endoscopist has no further options (nothing to balloon dilate, open, or drain) and the patient continues to have pancreatitis despite stenting, there is no reason to continue ERCPs.↗
▶Ep 17 · 4:23
quoteIf 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.↗
▶Ep 17 · 4:58
quoteMRCP is the best non-invasive study for pancreas by far, uh, with different uh uh T2 sequences.↗
▶Ep 17 · 4:58
clinicalMRCP is the best non-invasive imaging study for the pancreas, particularly with T2 sequences.↗
▶Ep 17 · 5:07
clinicalERCP is more therapeutic than diagnostic.↗
▶Ep 17 · 5:22
quoteOnce 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.↗
▶Ep 17 · 5:22
clinicalPancreatic fluid collections should be drained once the wall is mature (4 to 6 weeks) only if the patient is symptomatic (e.g., gastric outlet obstruction or pain); asymptomatic collections will self-resolve and do not require drainage or antibiotics.↗
Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center
▶Ep 21 · 0:48
opinionTPIAT is one of the most complex abdominal surgical procedures performed in children.↗
▶Ep 21 · 0:48
quoteTPIAT is clearly one of the most complex abdominal surgical procedures we perform in children.↗
▶Ep 21 · 0:54
clinicalSurgical indications for TPIAT are for patients with either chronic or acute recurrent pancreatitis.↗
▶Ep 21 · 1:02
guidelinePatients are candidates for TPIAT when all medical and endoscopic therapy has failed.↗
▶Ep 21 · 1:02
quoteThese patients are candidates for TPAT when all medical and endoscopic therapy has failed.↗
▶Ep 21 · 1:23
clinicalThe Pancreas Care Center team includes GI, social worker, endocrine, surgery, radiology, genetics, behavioral health, physical therapy, anesthesia, and pain team.↗
▶Ep 21 · 1:45
clinicalThe entire team reviews and votes patients in for surgery to determine if they are candidates for TPIAT.↗
▶Ep 21 · 1:45
clinicalPatients are prepared with vaccinations for potential splenectomy before TPIAT surgery.↗
▶Ep 21 · 2:40
clinicalPain catheters are placed in the transversus abdominis muscle by pain specialists.↗
▶Ep 21 · 3:14
clinicalThe pancreas in TPIAT patients has been injured for sometimes years, which makes the procedure quite challenging.↗
▶Ep 21 · 3:14
quoteRemember, this, this pancreas has been injured for sometimes years, which makes this procedure quite challenging.↗
▶Ep 21 · 3:29
clinicalOn the right side, the small intestine (duodenum) and liver hilum are mobilized, with careful identification of bile ducts and blood supply to the liver.↗
▶Ep 21 · 4:06
clinicalBlood supply to the head and entire body of the pancreas is preserved very carefully until the very last moment to avoid hypoxia of islet cells.↗
▶Ep 21 · 4:06
quoteWe preserve very carefully the blood supply to the head and the entire body until the pancreas, until the very last moment because we cannot risk hypoxying these cells.↗
▶Ep 21 · 6:33
clinicalDuring islet processing, the surgical team performs reconstruction of the gastrointestinal tract by bringing a loop of duodenum up to the bile duct and reconnecting another loop of intestine to the duodenum past the pyloric muscle.↗
▶Ep 21 · 6:53
clinicalA feeding tube is placed to allow patients to be fed while important connections heal.↗
▶Ep 21 · 7:02
clinicalDrains are left where the spleen was removed and on top of the connection with the biliary tract.↗
▶Ep 21 · 7:15
clinicalIslet cells are transfused into the portal vein with the hope that they will implant in the liver and start producing insulin.↗
▶Ep 21 · 7:25
clinicalPortal vein pressures are constantly checked during islet infusion to prevent portal vein thrombosis, which could cause significant morbidity.↗
▶Ep 21 · 7:25
quoteWhile we infuse the eyelid itself, we're constantly checking the pressures in the portal vein to make sure we don't risk any thrombosis in the portal vein, which could cause a lot of morbidity to the patient.↗
▶Ep 21 · 8:01
clinicalPatients are placed in the intensive care unit post-operatively to control hemodynamics and fluid shift balance.↗
▶Ep 21 · 8:08
clinicalIslet cells need to heal in a very homeostatic environment, requiring close monitoring of vital signs.↗
▶Ep 21 · 8:18
clinicalGlucose and insulin are controlled via exogenous infusions post-operatively.↗
▶Ep 21 · 8:22
clinicalClose attention to nutrition is key in the healing of connections between the bile tract and gastrointestinal tract.↗
▶Ep 21 · 8:39
clinicalPatients are deemed ready for discharge when pain is well controlled, they are on full feeds (via tube or by mouth), glucose is well controlled via continuous glucose monitoring, and they have received full education.↗
▶Ep 21 · 8:47
clinicalAfter discharge, local GI physicians continue to follow patients along with the Cincinnati Children's team.↗
Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria
▶Ep 26 · 5:44
guidelineDiagnosis of acute pancreatitis requires serum lipase at least 3 times the upper limit of normal, plus imaging findings (ultrasound, MRI/MRCP, or CT).↗
▶Ep 26 · 7:23
epidemiologicalIn the Cincinnati Children's cohort of 1000 pediatric pancreatitis patients, 85% have genetic mutations.↗
▶Ep 26 · 8:01
clinicalPRSS1 mutation causes very aggressive attacks very early in life (ages 1–3 years) because it autoactivates trypsinogen inside the pancreas.↗
▶Ep 26 · 8:37
clinicalMedications including L-asparaginase, steroids, valproic acid, and diuretics (Lasix) can cause pancreatitis in children.↗
▶Ep 26 · 9:32
clinicalHereditary pancreatitis increases the risk of pancreatic cancer by a huge fold, which is a major concern in children diagnosed at age 5–6 who may live 95 more years.↗
▶Ep 26 · 10:15
clinicalMost fluid collections in pediatric acute pancreatitis are self-limited and should not be touched unless absolutely necessary.↗
▶Ep 26 · 18:08
quotePlease do not touch these collections ever unless you absolutely have to.↗
▶Ep 26 · 18:40
clinicalEarly necrosectomies (before 4 weeks) usually increase mortality.↗
▶Ep 26 · 19:49
clinicalFollowing lipase levels tells you nothing about how the pancreas is behaving in acute pancreatitis; cross-sectional imaging is required.↗
▶Ep 26 · 21:36
clinicalAsymptomatic pseudocysts, regardless of size, do not require intervention.↗
▶Ep 26 · 23:29
clinicalPatients with acute pancreatitis should be fed as soon as possible (orally or via NG/NJ tube) because bacterial translocation from NPO status will complicate the disease.↗
▶Ep 26 · 23:29
quotePlease feed your patients as soon as you can, all right? If they're vomiting and they're gonna puke it, well, that doesn't make any sense. You, if you have to throw out an NG or an NG tube, feed the god because bacterial translocation from NPL will complicate acute pancreatitis.↗
▶Ep 26 · 25:13
epidemiologicalIn pediatric patients with hereditary pancreatitis or hereditary plus anatomic abnormalities, half will develop chronic pancreatitis.↗
▶Ep 26 · 25:38
clinicalCincinnati Children's evaluates over 100 patients per year for chronic pancreatitis but only operates on 25–30, because medical and endoscopic options should be exhausted first.↗
▶Ep 26 · 26:50
clinicalChronic pain in pancreatitis involves brain plasticity, hypertrophic nerve reactions, and peripheral nerve hypersensitization, not just organic retroperitoneal pain.↗
▶Ep 26 · 27:43
clinicalAfter total pancreatectomy, 95% of pain is resolved, but 5% may persist due to central sensitization and requires behavioral medicine and psychiatric support.↗
▶Ep 26 · 27:43
quoteI'm gonna take your pancreas out if it's uh indicated, and I'm gonna take care of 95% of your pain. But that 5, 5% that is left. We need to work with psych, behavioral med, uh, and eventually reteach their brains how to live not in pain.↗
▶Ep 26 · 28:37
clinicalPediatric chronic pancreatitis usually presents with minimal ductal changes, not the dilated ducts seen in adults, so drainage procedures are often not applicable.↗
▶Ep 26 · 28:57
quoteIf you have a genetic mutation and you chop off a piece of the pancreas, throw it in the trash. You can maybe relieve some of the pain. If you do whipple, have the pancreas drain better, do a piece so, I'm gonna touch base on that in a sec, drain the pancreatic duct better. But I put a piece of paper in the trash. And the genetic mutations will keep affecting the rest of the pancreas.↗
▶Ep 26 · 28:57
clinicalIn patients with genetic mutations, partial pancreatectomy (Whipple, distal pancreatectomy) discards islet mass and does not address the underlying defect, so the remaining pancreas continues to be affected.↗
▶Ep 26 · 37:44
quoteWe're doing this for, for chronic pain and that should be the, the, the major thing in our head.↗
▶Ep 26 · 37:54
guidelineTPIAT is indicated when patients have chronic pancreatitis findings, at least 6 months of disease, exocrine or endocrine insufficiency, and impaired quality of life despite maximal medical and endoscopic therapy.↗
▶Ep 26 · 39:00
clinicalThe goal of islet autotransplantation is to replace beta cell mass and insulin secretory capacity, not to cure diabetes—pain control is the primary indication.↗
▶Ep 26 · 40:28
clinicalTPIAT used to be a 20-hour operation but is now down to an average of 8–9 hours at Cincinnati Children's.↗
▶Ep 26 · 43:15
clinicalSpleen-sparing TPIAT has equal glycemic outcomes to splenectomy TPIAT when islet equivalent per kilogram transplanted is matched.↗
▶Ep 26 · 43:42
clinicalSpleen-sparing TPIAT is now performed in 80% of cases (over the last 5 years), compared to none in the first 8 years of the program.↗
▶Ep 26 · 45:16
clinicalIntraoperative pyloric Botox injection reduces gastroparesis, decreases length of stay, and improves time to full oral intake and glycemic control after TPIAT.↗
▶Ep 26 · 46:27
clinicalIslet isolation takes about 3–3.5 hours, sometimes 4 hours depending on the degree of pancreatic injury.↗
▶Ep 26 · 47:39
clinicalTPIAT is performed under anticoagulation (heparin) to prevent portal vein thrombosis during islet infusion.↗
▶Ep 26 · 48:11
clinicalPortal vein thrombosis rate at Cincinnati Children's is less than 1% for TPIAT.↗
▶Ep 26 · 48:26
clinicalCincinnati Children's has performed close to 200 TPIAT cases with no anastomotic leaks.↗
▶Ep 26 · 50:07
clinicalPatients are extubated in the operating room after TPIAT.↗
▶Ep 26 · 51:32
clinicalYounger children are more likely to achieve insulin independence and opioid independence after TPIAT.↗
▶Ep 26 · 52:25
clinicalIslet yield (IEQ/kg) is inversely related to pancreatic calcification, ductal dilation, fibrosis, duration of symptoms, and prior resections or drainage procedures.↗
▶Ep 26 · 54:59
clinicalPredictors of insulin independence after TPIAT include younger age at surgery, smaller body surface area, no pre-existing insulin dependence, and higher IEQ/kg transplanted.↗
▶Ep 26 · 56:09
clinicalTPIAT dramatically improves quality of life in appropriately selected children, with families reporting they have 'never met this kid before'—new person, happy, playing, eating normally.↗
Juan's statements about Pediatric Oncology21 statements
2025 Pediatric Surgery Update Course - Robotics in Pediatric Surgery: Which indications benefit the most?
▶Ep 591 · 0:24
quoteWho is a robotic surgery here in the audience? The ones who are not lifting up their hands, who has a robot available?↗
▶Ep 591 · 0:24
opinionCholedochal cyst is a perfect case for robotic surgery↗
▶Ep 591 · 0:24
clinicalRobotic instruments have seven degrees of freedom compared to six for the human hand↗
▶Ep 591 · 0:24
opinionAdrenalectomy for neuroblastoma confined to the adrenal is a perfect robotic case↗
▶Ep 591 · 0:24
epidemiologicalFour out of approximately 30 attendees perform robotic surgery; another 12 have robot access but do not use it↗
▶Ep 591 · 2:51
epidemiologicalAll pediatric surgery fellowships are integrating robotic training↗
▶Ep 591 · 2:51
clinicalRoom turnover time for robotic cases can be reduced to 30 minutes with trained personnel↗
▶Ep 591 · 2:51
clinicalEach additional 15 minutes of operative time costs the same for robotic and laparoscopic surgery↗
▶Ep 591 · 2:51
clinicalInitial cost premium for robotic surgery is approximately $4000 per case in most institutions↗
▶Ep 591 · 2:51
clinicalLearning curve for basic proficiency is 20-30 cases for laparoscopy versus 10-15 cases for robotics↗
▶Ep 591 · 2:51
clinicalRobotic surgery shows lower conversion to open rates compared to laparoscopy in colorectal cases↗
▶Ep 591 · 3:15
opinionMedian arcuate ligament release should not be performed laparoscopically or open anymore due to difficulty accessing the angle near the celiac trunk↗
▶Ep 591 · 3:38
guidelineThere is no FDA approval for robotic systems in pediatric surgery↗
▶Ep 591 · 3:38
quoteAre there FDA indications for the robot for pediatric surgery? Great question. Great question. No.↗
▶Ep 591 · 7:16
clinicalICG fluorescence allows visualization of adrenal arteries supplied by renal, diaphragmatic, and aortic vessels↗
▶Ep 591 · 7:16
opinionRobotic surgery is not recommended for appendectomy↗
▶Ep 591 · 12:55
opinionRobotic surgery is not a standard of care but a tool to aid efficiency and access to difficult angles↗
▶Ep 591 · 14:05
quoteThis is not about being cool. It's about efficiency and outcomes. Less cases to prove it now. Less cases to proficiency.↗
▶Ep 591 · 15:59
opinionSurgeons trained primarily in robotics cannot tie, sew, or work with 3mm instruments effectively↗
▶Ep 591 · 17:14
clinicalNew robotic systems with tactile sensors reduce force application by 83%↗
▶Ep 591 · 17:14
clinicalICG fluorescence in choledochal cyst surgery allows visualization far back to the head of the pancreas to achieve proper tapering, decreasing future cancer risk↗
Juan's statements about Pediatric Robotic Surgery22 statements
host summaryJuan Gurria summarizing a resource: remember they, they used to tell you, put the patient NPO, throw him in the ICU and, and fluid his lungs, right? So we don't do that anymore.↗
▶Ep 9 · 5:45
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 9 · 6:32
host summaryJuan Gurria summarizing a resource: Lactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis.↗
▶Ep 9 · 8:33
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 9 · 9:07
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 9 · 9:47
host summaryJuan Gurria summarizing a resource: Gastric feeding is preferred over jejunal feeding in pancreatitis when the patient can tolerate it.↗
▶Ep 9 · 13:13
host summaryJuan Gurria summarizing a resource: Children don't get pancreatitis↗
Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria
▶Ep 11 · 5:03
host summaryJuan Gurria summarizing a resource: do not mess with the pancreas↗
▶Ep 11 · 18:17
host summaryJuan Gurria summarizing a resource: Position papers from the European Pancreas Club and American Pancreas Association state there is no role for early pancreatectomies or early drainage procedures in acute pancreatitis.↗
▶Ep 11 · 20:06
host summaryJuan Gurria summarizing a resource: The step-up approach for necrotizing pancreatitis—starting with transgastric endoscopic necrosectomy—reduces major complications compared to open surgery.↗
▶Ep 11 · 23:48
host summaryJuan Gurria summarizing a resource: Lactated Ringer solution for initial resuscitation in acute pancreatitis is better than normal saline, per a paper from Cincinnati Children's by Dr. Farrell.↗
▶Ep 11 · 28:01
host summaryJuan Gurria summarizing a resource: These families come back and say, listen, I've never met this kid in my life. It's a new kid, happy playing.↗
▶Ep 11 · 50:58
host summaryJuan Gurria summarizing a resource: TPIAT results in over 80% reduction in opioid use at 1–2 months, with sustained effect for years.↗
▶Ep 11 · 53:03
host summaryJuan Gurria summarizing a resource: Transplanting ≥5000 islet equivalents per kilogram into the portal vein predicts 92% insulin independence at 36 months (Minnesota data); Cincinnati Children's currently achieves 70% insulin independence.↗
Summaries Juan gave as host · Chronic Pancreatitis14 summaries
host summaryJuan Gurria summarizing a resource: remember they, they used to tell you, put the patient NPO, throw him in the ICU and, and fluid his lungs, right? So we don't do that anymore.↗
▶Ep 5 · 5:45
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 5 · 6:32
host summaryJuan Gurria summarizing a resource: Lactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis.↗
▶Ep 5 · 8:33
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 5 · 9:07
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 5 · 9:47
host summaryJuan Gurria summarizing a resource: Gastric feeding is preferred over jejunal feeding in pancreatitis when the patient can tolerate it.↗
▶Ep 5 · 13:13
host summaryJuan Gurria summarizing a resource: Children don't get pancreatitis↗
Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria
▶Ep 11 · 5:03
host summaryJuan Gurria summarizing a resource: do not mess with the pancreas↗
▶Ep 11 · 18:17
host summaryJuan Gurria summarizing a resource: Position papers from the European Pancreas Club and American Pancreas Association state there is no role for early pancreatectomies or early drainage procedures in acute pancreatitis.↗
▶Ep 11 · 20:06
host summaryJuan Gurria summarizing a resource: The step-up approach for necrotizing pancreatitis—starting with transgastric endoscopic necrosectomy—reduces major complications compared to open surgery.↗
▶Ep 11 · 23:48
host summaryJuan Gurria summarizing a resource: Lactated Ringer solution for initial resuscitation in acute pancreatitis is better than normal saline, per a paper from Cincinnati Children's by Dr. Farrell.↗
▶Ep 11 · 28:01
host summaryJuan Gurria summarizing a resource: These families come back and say, listen, I've never met this kid in my life. It's a new kid, happy playing.↗
▶Ep 11 · 50:58
host summaryJuan Gurria summarizing a resource: TPIAT results in over 80% reduction in opioid use at 1–2 months, with sustained effect for years.↗
▶Ep 11 · 53:03
host summaryJuan Gurria summarizing a resource: Transplanting ≥5000 islet equivalents per kilogram into the portal vein predicts 92% insulin independence at 36 months (Minnesota data); Cincinnati Children's currently achieves 70% insulin independence.↗
Summaries Juan gave as host · Pancreatic Surgery & Critical Care7 summaries
host summaryJuan Gurria summarizing a resource: remember they, they used to tell you, put the patient NPO, throw him in the ICU and, and fluid his lungs, right? So we don't do that anymore.↗
▶Ep 1 · 5:45
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 1 · 6:32
host summaryJuan Gurria summarizing a resource: Lactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis.↗
▶Ep 1 · 8:33
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 1 · 9:07
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 1 · 9:47
host summaryJuan Gurria summarizing a resource: Gastric feeding is preferred over jejunal feeding in pancreatitis when the patient can tolerate it.↗
▶Ep 1 · 13:13
host summaryJuan Gurria summarizing a resource: Children don't get pancreatitis↗
Summaries Juan gave as host · Pancreatitis14 summaries
host summaryJuan Gurria summarizing a resource: remember they, they used to tell you, put the patient NPO, throw him in the ICU and, and fluid his lungs, right? So we don't do that anymore.↗
▶Ep 13 · 5:45
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 13 · 6:32
host summaryJuan Gurria summarizing a resource: Lactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis.↗
▶Ep 13 · 8:33
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 13 · 9:07
host summaryJuan Gurria summarizing a resource: 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.↗
▶Ep 13 · 9:47
host summaryJuan Gurria summarizing a resource: Gastric feeding is preferred over jejunal feeding in pancreatitis when the patient can tolerate it.↗
▶Ep 13 · 13:13
host summaryJuan Gurria summarizing a resource: Children don't get pancreatitis↗
Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria
▶Ep 26 · 5:03
host summaryJuan Gurria summarizing a resource: do not mess with the pancreas↗
▶Ep 26 · 18:17
host summaryJuan Gurria summarizing a resource: Position papers from the European Pancreas Club and American Pancreas Association state there is no role for early pancreatectomies or early drainage procedures in acute pancreatitis.↗
▶Ep 26 · 20:06
host summaryJuan Gurria summarizing a resource: The step-up approach for necrotizing pancreatitis—starting with transgastric endoscopic necrosectomy—reduces major complications compared to open surgery.↗
▶Ep 26 · 23:48
host summaryJuan Gurria summarizing a resource: Lactated Ringer solution for initial resuscitation in acute pancreatitis is better than normal saline, per a paper from Cincinnati Children's by Dr. Farrell.↗
▶Ep 26 · 28:01
host summaryJuan Gurria summarizing a resource: These families come back and say, listen, I've never met this kid in my life. It's a new kid, happy playing.↗
▶Ep 26 · 50:58
host summaryJuan Gurria summarizing a resource: TPIAT results in over 80% reduction in opioid use at 1–2 months, with sustained effect for years.↗
▶Ep 26 · 53:03
host summaryJuan Gurria summarizing a resource: Transplanting ≥5000 islet equivalents per kilogram into the portal vein predicts 92% insulin independence at 36 months (Minnesota data); Cincinnati Children's currently achieves 70% insulin independence.↗
