1 00:00:00,000 --> 00:00:07,200 GlobalCast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child 2 00:00:07,200 --> 00:00:13,780 health around the globe. 3 00:00:13,780 --> 00:00:15,880 Hello pediatric surgery family. 4 00:00:15,880 --> 00:00:20,660 I'm Cecilia Gigena, a research fellow from Cincinnati Children's Hospital Medical Center. 5 00:00:20,660 --> 00:00:25,960 Our 11th annual update course in pediatric surgery was held this past August. 6 00:00:25,960 --> 00:00:30,960 In this video, we are going to talk about management of recurrent pancreatitis. 7 00:00:30,960 --> 00:00:37,240 And for that, we have Dr. Juan Gurria, a pediatric surgeon from Cincinnati Children's Hospital. 8 00:00:37,240 --> 00:00:39,600 So first, we started with a case. 9 00:00:39,600 --> 00:00:45,460 Seven-year-old with acute recurrent pancreatitis, abdominal pain, has a diagnosis of ARP, referred 10 00:00:45,460 --> 00:00:50,800 to you with an ERCP showing a stricture in the head of the pancreas and a dilated duct 11 00:00:50,800 --> 00:00:53,840 distal, we've seen this multiple times. 12 00:00:53,840 --> 00:00:57,640 Has had seven ERCPs and a stent in the past. 13 00:00:57,640 --> 00:01:00,200 So this is an ERCP. 14 00:01:00,200 --> 00:01:04,520 So we have a clear stricture in the area of the head of the pancreas and a dilated duct 15 00:01:04,520 --> 00:01:07,040 distal and you see clearly the branches. 16 00:01:07,040 --> 00:01:08,840 So what is your plan? 17 00:01:08,840 --> 00:01:15,840 MRCP to evaluate for chronic changes, repeat ERCP balloon dilation and stent placement, 18 00:01:15,840 --> 00:01:21,240 MRCP and obtain genetics, or admin implant for FRIE procedure. 19 00:01:21,240 --> 00:01:27,080 The FRIE procedure is a partial head pancreatectomy with duodenal preservation and a pancreatic 20 00:01:27,080 --> 00:01:28,080 jejunostomy. 21 00:01:28,080 --> 00:01:34,000 And it's interesting to see this very divided. 22 00:01:34,000 --> 00:01:36,440 So the main is repeat ERCP. 23 00:01:36,440 --> 00:01:37,440 So keep doing it. 24 00:01:37,440 --> 00:01:38,440 We're seven ERCPs in. 25 00:01:38,440 --> 00:01:40,560 The question is, when do you stop, right? 26 00:01:40,560 --> 00:01:43,960 Every time you get an ERCP, you have a risk of getting post ERCP pancreatitis. 27 00:01:43,960 --> 00:01:45,200 It's slow, right? 28 00:01:45,200 --> 00:01:48,580 But still a risk and you lose eyelid cells with every attack. 29 00:01:48,580 --> 00:01:50,540 So we're losing cells down the road. 30 00:01:50,540 --> 00:01:54,020 And as he said, genetic is key. 31 00:01:54,020 --> 00:01:57,360 So it is really important to get a genetic panel. 32 00:01:57,360 --> 00:02:03,120 PRS1 is the most common one, which is a trypsinogen activator. 33 00:02:03,120 --> 00:02:06,240 It activates trypsin inside the pancreas. 34 00:02:06,240 --> 00:02:10,280 There's CTRC, CFTR, you know, CPA1. 35 00:02:10,280 --> 00:02:12,720 There's a whole bunch of mutations that we now know. 36 00:02:12,720 --> 00:02:18,040 Our gene panel in Cincinnati runs 10 different genetic markers. 37 00:02:18,040 --> 00:02:23,760 So that's how we're changing the approach to pediatric pancreatitis, chronic pancreatitis 38 00:02:23,760 --> 00:02:25,880 treatment because of the genetic factors. 39 00:02:25,880 --> 00:02:26,880 Awesome. 40 00:02:26,880 --> 00:02:31,800 So if a patient has more than one episode of acute pancreatitis or a first really bad 41 00:02:31,800 --> 00:02:38,120 episode of it, we should perform an MRCP and a genetic panel to rule out genetic anomalies. 42 00:02:38,120 --> 00:02:44,040 Now, you have that patient that has the mutation that they're there, trypsin activated. 43 00:02:44,040 --> 00:02:45,040 How do you mediate that? 44 00:02:45,040 --> 00:02:48,020 Is there medication or is there another path that you can do to? 45 00:02:48,020 --> 00:02:49,020 Wonderful question. 46 00:02:49,020 --> 00:02:53,040 No, no, there's no, unfortunately, we don't have that just yet. 47 00:02:53,040 --> 00:02:54,760 That's why I still have a job. 48 00:02:54,760 --> 00:03:00,880 But I hope some one day we have, you know, I would do a PUSTO on this kid. 49 00:03:00,880 --> 00:03:02,300 What's the downside of that? 50 00:03:02,300 --> 00:03:06,080 So excellent question. 51 00:03:06,080 --> 00:03:09,600 If there's a generic mutation, say there's a PRS1 mutation, right? 52 00:03:09,600 --> 00:03:13,240 For a PUSTO, you have to like get the top of the top half of the pancreas out to open 53 00:03:13,240 --> 00:03:15,880 the duct, right? 54 00:03:15,880 --> 00:03:19,840 You throw some eyelid cells to the trash. 55 00:03:19,840 --> 00:03:23,720 This patient most likely is going to keep getting pancreatitis despite you draining 56 00:03:23,720 --> 00:03:25,400 the duct. 57 00:03:25,400 --> 00:03:28,580 The parenchyma is going to keep getting attacked by the mutation. 58 00:03:28,580 --> 00:03:37,440 So you're temporizing the attack by draining the duct, but you're not fixing the problem. 59 00:03:37,440 --> 00:03:38,440 Great. 60 00:03:38,440 --> 00:03:44,820 So genetics are very important before any resection procedure to avoid losing pancreatic 61 00:03:44,820 --> 00:03:50,800 cells in pathologies that will not benefit from a resection and drainage, but instead 62 00:03:50,800 --> 00:03:53,120 from an eyelid cells transplant. 63 00:03:53,120 --> 00:03:58,280 So I know the scenario pretty much points towards, okay, maybe recurrent or chronic 64 00:03:58,280 --> 00:04:02,600 pancreatitis, but after how many do you feel like, okay, this is what we're dealing with? 65 00:04:02,600 --> 00:04:08,760 Two, ERCPs, three, when do you start thinking considering that this might be a problem? 66 00:04:08,760 --> 00:04:09,760 That's a great question. 67 00:04:09,760 --> 00:04:11,280 We don't have a set number of ERCPs. 68 00:04:11,280 --> 00:04:16,680 So there's no set limit on that, the sooner the referral, the better for an evaluation. 69 00:04:16,680 --> 00:04:23,480 We don't offer to take out the pancreas unless you've maximized medical and endoscopic management. 70 00:04:23,480 --> 00:04:27,800 If there's no other options and your endoscopic guy tells you, you know what, there's nothing 71 00:04:27,800 --> 00:04:31,800 for me to balloon dilate, open drain or anything. 72 00:04:31,800 --> 00:04:35,320 There's been a stent, even with the stent, the patient keeps getting pancreatitis. 73 00:04:35,320 --> 00:04:37,660 There's no reason to keep going with ERCPs. 74 00:04:37,660 --> 00:04:43,000 So do endoscopic treatment at first, but if it fails, transfer to a specialized center 75 00:04:43,000 --> 00:04:49,960 that does TPIAT or total pancreatectomy with eyelid auto transplantation. 76 00:04:49,960 --> 00:04:53,040 Now what about imaging for this patient? 77 00:04:53,040 --> 00:04:58,840 So we use endoscopic ultrasound and ultrasound CT scan is imaging of choice once they come. 78 00:04:58,840 --> 00:05:06,360 MRCP is the best non-invasive study for pancreas by far with different T2 sequences. 79 00:05:06,360 --> 00:05:10,920 They're great and ERCP of course is more therapeutic than diagnostic. 80 00:05:10,920 --> 00:05:11,920 Awesome. 81 00:05:11,920 --> 00:05:19,760 Start with ultrasound, then CT and for better see the pancreatic anatomy, MRCP with T2 sequences. 82 00:05:19,760 --> 00:05:22,840 Now what about fluid collections? 83 00:05:22,840 --> 00:05:28,120 Once the wall is mature in four to six weeks, if there's symptoms, drain it. 84 00:05:28,120 --> 00:05:29,760 If there's no symptoms, don't drain it. 85 00:05:29,760 --> 00:05:34,440 If the patient is not having gastric alveolar obstruction or pain, there's no need to drain 86 00:05:34,440 --> 00:05:35,960 this. 87 00:05:35,960 --> 00:05:40,360 They will self-resolve and of course there's no need for antibiotics. 88 00:05:40,360 --> 00:05:41,360 Awesome. 89 00:05:41,360 --> 00:05:43,080 Time to summarize. 90 00:05:43,080 --> 00:05:47,360 Recurrent pancreatitis is a rare pathology that can lead to chronic pancreatitis and it 91 00:05:47,360 --> 00:05:50,720 is associated with genetic mutations. 92 00:05:50,720 --> 00:05:55,920 If genetic mutations are confirmed, we should avoid partially resecting pancreatic tissue 93 00:05:55,920 --> 00:06:01,120 as in a fry procedure to avoid losing pancreatic cells. 94 00:06:01,120 --> 00:06:05,400 The treatment should start with endoscopic approach, keeping in mind that if it fails, 95 00:06:05,400 --> 00:06:10,080 a TPIAT should be considered sooner rather than later. 96 00:06:10,080 --> 00:06:15,280 For liquid collection, surgical treatment should be only done if the patient is symptomatic. 97 00:06:15,280 --> 00:06:18,960 I hope you enjoyed the video and thank you for watching. 98 00:06:18,960 --> 00:06:22,240 Don't forget to subscribe to the Stay Current MD YouTube channel. 99 00:06:22,240 --> 00:06:26,880 Follow our social media channels and download the Stay Current MD app for tons of content 100 00:06:26,880 --> 00:06:30,480 in pediatric surgery. 101 00:06:30,480 --> 00:06:36,120 Global Cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child 102 00:06:36,120 --> 00:07:01,120 health around the globe.