We really have to be cautious about, uh, um, what we are offering, the types of operations we're offering in patients, particularly with genetic risk factors, who tend to fail these conventional operations.
The number one prognostic factor for patients with pancreatoblastoma is complete surgical excision, whether that is at the initial presentation or following neoadjuvant chemotherapy.
We really have to consider degree of resection whenever we're considering removing a portion of the pancreas because we have to think about endocrine and exocrine needs long-term.
You really actually want to avoid enucleation or simply biopsy of these lesions. There tends to be a high recurrence rate if you're simply trying to enucleate these lesions.
We can really never confidently differentiate a benign versus a malignant lesion of the pancreas simply with cross-sectional imaging, whether it be CT scan or MRI.
quotewe're not force feeding the kids. Exactly. We're not pushing feeds in the face of ongoing emesis.↗
▶Ep 1 · 39:07
quoteyou really, you can very much be opening a can of worms if you're starting to stick things into the pancreas.↗
▶Ep 1 · 39:16
opinionSticking needles or drains into the pancreas risks introducing infection into sterile necrosis; intervention should be avoided unless there is true significant clinical deterioration.↗
clinicalThe day's sessions will cover surgical approaches, interventional endoscopic approaches, and medical management of acute, acute recurrent, and chronic pancreatitis↗
▶Ep 3 · 3:38
quoteAnything you wanted to know about the pancreas, uh, and we'll spend the next 4 hours talking about surgical approaches.↗
▶Ep 3 · 4:05
clinicalDr. Joe Palermo is a pediatric gastroenterologist and medical lead of the total pancreatectomy and islet auto transplantation program↗
▶Ep 3 · 4:23
clinicalKen Goldschneider is director of pain management at Cincinnati Children's, professor of clinical pediatrics and anesthesia, and plays a central role in pain management for patients with pancreatic diseases↗
▶Ep 3 · 4:40
clinicalDr. Maisam Abu El-Haija is a gastroenterologist, co-director of the course, and medical director of the Pancreas Care Center↗
▶Ep 3 · 4:54
clinicalTom Lynn is a gastroenterologist who manages the vast majority or all endoscopic needs for children with pancreatic disorders, director of endoscopy for the Pancreas Care Center, and co-director of endoscopy for the division of gastroenterology↗
▶Ep 3 · 5:17
clinicalAndrew Trout is the lead radiologist for the Pancreas Care Center, assistant professor of radiology, and dual certified in pediatric radiology and nuclear medicine↗
▶Ep 3 · 5:33
clinicalDr. Deb Elder is the endocrine director for the Pancreas Care Center and will join later in the event↗
▶Ep 3 · 5:47
clinicalDr. Milton Smith is medical director of therapeutic ERCP at University of Cincinnati and will join later in the event↗
▶Ep 3 · 5:53
quoteplease we'd like to keep this, uh, uh, highly interactive, so, um, bring us your questions, bring us your comments, and, uh, we hope to be able to answer them.↗
Pancreas Care Updates 2020 - FULL SHOW
▶Ep 7 · 39:40
quoteThe data, uh, you know, for CP is, is, uh, is not good. Uh, and, you know, first, you know, we've evolved from utilizing radiologic, uh, guidance, uh, to using EU US guidance, uh, from a safety perspective.↗
▶Ep 7 · 1:24:30
quoteThe last time, um, you know, I did a uh an open necrostectomy was during general surgery training about 2025 years ago.↗
▶Ep 7 · 1:27:30
epidemiologicalWell over 50% of patients with chronic pancreatitis eventually require some type of operation.↗
▶Ep 7 · 1:28:00
clinicalThe most common indication for surgery in chronic pancreatitis is debilitating pain that fails to respond to medical and endoscopic treatment options.↗
▶Ep 7 · 1:30:50
clinicalConventional operations for chronic pancreatitis result in initial pain relief in a number of patients, but pain recurs in approximately 50% of patients over the long term.↗
▶Ep 7 · 1:31:40
clinicalLarge dilated duct and inflammatory head masses are fairly uncommon in pediatric chronic pancreatitis patients, as opposed to the adult population where these anatomic findings are more common.↗
▶Ep 7 · 1:33:00
clinicalThe primary goal of total pancreatectomy with islet autotransplantation is to relieve pain and debilitation and impaired quality of life, not to preserve or save islets.↗
▶Ep 7 · 1:33:00
quoteThe primary goal is to relieve the pain and debilitation and impaired quality of life. That is the primary goal. It's not to preserve or save eyelets.↗
▶Ep 7 · 1:33:20
clinicalThe goal of the islet autotransplant component is to preserve beta cell mass and alpha cell mass to make glycemic control more straightforward than without the islet autotransplant.↗
▶Ep 7 · 1:35:20
clinicalChildren with genetic risk factors tend to fail conventional surgeries more often than those without genetic risk factors.↗
▶Ep 7 · 1:37:30
clinicalCriteria for consideration of TPIAT include objective diagnostic criteria for chronic pancreatitis or acute recurrent pancreatitis with pain and debilitation lasting at least 6 months, defined as chronic opioid dependence or impaired quality of life from frequent hospitalizations and school absences.↗
▶Ep 7 · 1:39:40
clinicalFor TPIAT, there is a minimum liver volume requirement of 400 cc in small children to accept the islet autotransplant; 3D reconstructions are used to assess liver volume in the smallest children.↗
▶Ep 7 · 1:40:50
clinicalThe islet isolation process takes about 3 to 4.5 hours and uses a combination of mechanical and enzymatic digestion (Ricordi method) to release a relatively pure islet solution in as small a tissue volume as possible.↗
▶Ep 7 · 1:42:00
clinicalDuring islet infusion, portal pressures are measured every 5 minutes; a pressure change greater than 25 centimeters of water is associated with a 10-fold increased risk of portal vein thrombosis.↗
▶Ep 7 · 1:42:30
clinicalIf portal vein pressures rise substantially during islet infusion, the infusion is paused to allow autoregulation; if pressures remain elevated, islets are placed in a secondary site such as the peritoneal cavity.↗
▶Ep 7 · 1:43:40
clinicalPostoperatively, blood glucoses are kept very tight in the ICU and early postoperative period over several weeks to months as islets engraft, because hyperglycemia is very detrimental to the islets.↗
▶Ep 7 · 1:44:40
clinicalBy the end of one week in the ICU after TPIAT, patients are at full feeds and transition out of the ICU to the endocrine floor where they are transitioned to an insulin pump.↗
▶Ep 7 · 1:52:00
clinicalIn an early Cincinnati Children's study of the first 20 TPIAT patients, there was a dramatic and significant decrease in opioid use even within the first 90 days after surgery.↗
▶Ep 7 · 1:53:00
clinicalBy 90 days post-TPIAT, there was dramatic improvement in getting patients off TPN who required it preoperatively, and a decrease in insulin requirements measured in units per kilogram per day.↗
▶Ep 7 · 1:53:50
clinicalQuality of life outcomes showed improvements in physical health scores and total SF-36 scores by 90 days after TPIAT in children.↗
▶Ep 7 · 1:54:40
clinicalReduction in opioid use after TPIAT occurs pretty quickly over the first 6 months and is sustained over time, though a percentage of patients continue on opioids.↗
▶Ep 7 · 1:55:20
clinicalPancreatitis pain shows dramatic improvement within the first 6 to 12 months after TPIAT and is sustained over time.↗
▶Ep 7 · 1:56:20
clinicalYounger children under 12 are more likely to achieve insulin independence after TPIAT, with rates approaching 50 to 60% at one year compared to 30 to 35% in children ages 13 to 19.↗
▶Ep 7 · 1:57:10
clinicalInsulin independence after TPIAT is largely predicted by the number of islet equivalents per kilogram body weight isolated from the pancreas; insulin independence rates at 3 years increase with greater islet equivalent yield.↗
▶Ep 7 · 1:58:10
clinicalIn children under 8 years old with high islet equivalent yield (median over 6000/kg), all patients had pain relief by 1 year and were free of opioids by a median of 68 days, with over 80% achieving at least a period of insulin independence.↗
▶Ep 7 · 1:58:50
clinicalAt most recent follow-up, 64% of children under 8 were insulin independent compared to 41% of children over 9 years old.↗
▶Ep 7 · 1:59:40
opinionYounger children may do better with insulin independence because they have a better metabolic milieu for engraftment, lower insulin demands, and beta cells from young children may have higher capacity to replicate.↗
▶Ep 7 · 2:00:40
clinicalMore substantial pancreatic atrophy, ductal dilation, and fibrosis on histopathology correlate with lower islet yield after TPIAT.↗
▶Ep 7 · 2:01:00
clinicalLonger duration of symptoms correlates with lower islet yield after TPIAT.↗
▶Ep 7 · 2:01:20
clinicalDuctal drainage procedures such as Puestow and distal pancreatectomy reduce islet yield and decrease the probability of insulin independence if a patient subsequently needs TPIAT or completion pancreatectomy.↗
▶Ep 7 · 2:01:40
quoteWe really have to be cautious about, uh, um, what we are offering, the types of operations we're offering in patients, particularly with genetic risk factors, who tend to fail these conventional operations.↗
▶Ep 7 · 2:01:50
quoteIt would, it would be disingenuous to try to predict that or to try to promise that, I should say.↗
▶Ep 7 · 2:02:10
clinicalIn adult TPIAT data at 10 years, insulin independence rates dropped from about low 30s percent early on to about low 20s percent, showing there is attrition over time.↗
Acute Pancreatitis
▶Ep 8 · 16:41
quotewe're not force feeding the kids. We're not pushing feeds in the face of ongoing emesis.↗
▶Ep 8 · 38:49
clinicalAspiration of pancreatic necrosis to rule out infection carries risk of introducing infection into a sterile collection; empiric antibiotics may be started if fever is present, but aspiration is rarely performed (Cincinnati has needed one necrosectomy in 10 years).↗
▶Ep 8 · 39:03
quoteyou really, you can very much be opening a can of worms if you're starting to stick things into the pancreas.↗
▶Ep 8 · 39:41
quotein the absence of true significant clinical deterioration, we, we really avoid, avoid sticking needles in the pancreas, sticking drains.↗
Jaimie's statements about Acute Recurrent Pancreatitis47 statements
clinicalThe day's sessions will cover surgical approaches, interventional endoscopic approaches, and medical management of acute, acute recurrent, and chronic pancreatitis↗
▶Ep 1 · 3:38
quoteAnything you wanted to know about the pancreas, uh, and we'll spend the next 4 hours talking about surgical approaches.↗
▶Ep 1 · 4:05
clinicalDr. Joe Palermo is a pediatric gastroenterologist and medical lead of the total pancreatectomy and islet auto transplantation program↗
▶Ep 1 · 4:23
clinicalKen Goldschneider is director of pain management at Cincinnati Children's, professor of clinical pediatrics and anesthesia, and plays a central role in pain management for patients with pancreatic diseases↗
▶Ep 1 · 4:40
clinicalDr. Maisam Abu El-Haija is a gastroenterologist, co-director of the course, and medical director of the Pancreas Care Center↗
▶Ep 1 · 4:54
clinicalTom Lynn is a gastroenterologist who manages the vast majority or all endoscopic needs for children with pancreatic disorders, director of endoscopy for the Pancreas Care Center, and co-director of endoscopy for the division of gastroenterology↗
▶Ep 1 · 5:17
clinicalAndrew Trout is the lead radiologist for the Pancreas Care Center, assistant professor of radiology, and dual certified in pediatric radiology and nuclear medicine↗
▶Ep 1 · 5:33
clinicalDr. Deb Elder is the endocrine director for the Pancreas Care Center and will join later in the event↗
▶Ep 1 · 5:47
clinicalDr. Milton Smith is medical director of therapeutic ERCP at University of Cincinnati and will join later in the event↗
▶Ep 1 · 5:53
quoteplease we'd like to keep this, uh, uh, highly interactive, so, um, bring us your questions, bring us your comments, and, uh, we hope to be able to answer them.↗
Pancreas Care Updates 2020 - FULL SHOW
▶Ep 7 · 39:40
quoteThe data, uh, you know, for CP is, is, uh, is not good. Uh, and, you know, first, you know, we've evolved from utilizing radiologic, uh, guidance, uh, to using EU US guidance, uh, from a safety perspective.↗
▶Ep 7 · 1:24:30
quoteThe last time, um, you know, I did a uh an open necrostectomy was during general surgery training about 2025 years ago.↗
▶Ep 7 · 1:27:30
epidemiologicalWell over 50% of patients with chronic pancreatitis eventually require some type of operation.↗
▶Ep 7 · 1:28:00
clinicalThe most common indication for surgery in chronic pancreatitis is debilitating pain that fails to respond to medical and endoscopic treatment options.↗
▶Ep 7 · 1:30:50
clinicalConventional operations for chronic pancreatitis result in initial pain relief in a number of patients, but pain recurs in approximately 50% of patients over the long term.↗
▶Ep 7 · 1:31:40
clinicalLarge dilated duct and inflammatory head masses are fairly uncommon in pediatric chronic pancreatitis patients, as opposed to the adult population where these anatomic findings are more common.↗
▶Ep 7 · 1:33:00
quoteThe primary goal is to relieve the pain and debilitation and impaired quality of life. That is the primary goal. It's not to preserve or save eyelets.↗
▶Ep 7 · 1:33:00
clinicalThe primary goal of total pancreatectomy with islet autotransplantation is to relieve pain and debilitation and impaired quality of life, not to preserve or save islets.↗
▶Ep 7 · 1:33:20
clinicalThe goal of the islet autotransplant component is to preserve beta cell mass and alpha cell mass to make glycemic control more straightforward than without the islet autotransplant.↗
▶Ep 7 · 1:35:20
clinicalChildren with genetic risk factors tend to fail conventional surgeries more often than those without genetic risk factors.↗
▶Ep 7 · 1:37:30
clinicalCriteria for consideration of TPIAT include objective diagnostic criteria for chronic pancreatitis or acute recurrent pancreatitis with pain and debilitation lasting at least 6 months, defined as chronic opioid dependence or impaired quality of life from frequent hospitalizations and school absences.↗
▶Ep 7 · 1:39:40
clinicalFor TPIAT, there is a minimum liver volume requirement of 400 cc in small children to accept the islet autotransplant; 3D reconstructions are used to assess liver volume in the smallest children.↗
▶Ep 7 · 1:40:50
clinicalThe islet isolation process takes about 3 to 4.5 hours and uses a combination of mechanical and enzymatic digestion (Ricordi method) to release a relatively pure islet solution in as small a tissue volume as possible.↗
▶Ep 7 · 1:42:00
clinicalDuring islet infusion, portal pressures are measured every 5 minutes; a pressure change greater than 25 centimeters of water is associated with a 10-fold increased risk of portal vein thrombosis.↗
▶Ep 7 · 1:42:30
clinicalIf portal vein pressures rise substantially during islet infusion, the infusion is paused to allow autoregulation; if pressures remain elevated, islets are placed in a secondary site such as the peritoneal cavity.↗
▶Ep 7 · 1:43:40
clinicalPostoperatively, blood glucoses are kept very tight in the ICU and early postoperative period over several weeks to months as islets engraft, because hyperglycemia is very detrimental to the islets.↗
▶Ep 7 · 1:44:40
clinicalBy the end of one week in the ICU after TPIAT, patients are at full feeds and transition out of the ICU to the endocrine floor where they are transitioned to an insulin pump.↗
▶Ep 7 · 1:52:00
clinicalIn an early Cincinnati Children's study of the first 20 TPIAT patients, there was a dramatic and significant decrease in opioid use even within the first 90 days after surgery.↗
▶Ep 7 · 1:53:00
clinicalBy 90 days post-TPIAT, there was dramatic improvement in getting patients off TPN who required it preoperatively, and a decrease in insulin requirements measured in units per kilogram per day.↗
▶Ep 7 · 1:53:50
clinicalQuality of life outcomes showed improvements in physical health scores and total SF-36 scores by 90 days after TPIAT in children.↗
▶Ep 7 · 1:54:40
clinicalReduction in opioid use after TPIAT occurs pretty quickly over the first 6 months and is sustained over time, though a percentage of patients continue on opioids.↗
▶Ep 7 · 1:55:20
clinicalPancreatitis pain shows dramatic improvement within the first 6 to 12 months after TPIAT and is sustained over time.↗
▶Ep 7 · 1:56:20
clinicalYounger children under 12 are more likely to achieve insulin independence after TPIAT, with rates approaching 50 to 60% at one year compared to 30 to 35% in children ages 13 to 19.↗
▶Ep 7 · 1:57:10
clinicalInsulin independence after TPIAT is largely predicted by the number of islet equivalents per kilogram body weight isolated from the pancreas; insulin independence rates at 3 years increase with greater islet equivalent yield.↗
▶Ep 7 · 1:58:10
clinicalIn children under 8 years old with high islet equivalent yield (median over 6000/kg), all patients had pain relief by 1 year and were free of opioids by a median of 68 days, with over 80% achieving at least a period of insulin independence.↗
▶Ep 7 · 1:58:50
clinicalAt most recent follow-up, 64% of children under 8 were insulin independent compared to 41% of children over 9 years old.↗
▶Ep 7 · 1:59:40
opinionYounger children may do better with insulin independence because they have a better metabolic milieu for engraftment, lower insulin demands, and beta cells from young children may have higher capacity to replicate.↗
▶Ep 7 · 2:00:40
clinicalMore substantial pancreatic atrophy, ductal dilation, and fibrosis on histopathology correlate with lower islet yield after TPIAT.↗
▶Ep 7 · 2:01:00
clinicalLonger duration of symptoms correlates with lower islet yield after TPIAT.↗
▶Ep 7 · 2:01:20
clinicalDuctal drainage procedures such as Puestow and distal pancreatectomy reduce islet yield and decrease the probability of insulin independence if a patient subsequently needs TPIAT or completion pancreatectomy.↗
▶Ep 7 · 2:01:40
quoteWe really have to be cautious about, uh, um, what we are offering, the types of operations we're offering in patients, particularly with genetic risk factors, who tend to fail these conventional operations.↗
▶Ep 7 · 2:01:50
quoteIt would, it would be disingenuous to try to predict that or to try to promise that, I should say.↗
▶Ep 7 · 2:02:10
clinicalIn adult TPIAT data at 10 years, insulin independence rates dropped from about low 30s percent early on to about low 20s percent, showing there is attrition over time.↗
Acute Pancreatitis
▶Ep 8 · 16:41
quotewe're not force feeding the kids. We're not pushing feeds in the face of ongoing emesis.↗
▶Ep 8 · 38:49
clinicalAspiration of pancreatic necrosis to rule out infection carries risk of introducing infection into a sterile collection; empiric antibiotics may be started if fever is present, but aspiration is rarely performed (Cincinnati has needed one necrosectomy in 10 years).↗
▶Ep 8 · 39:03
quoteyou really, you can very much be opening a can of worms if you're starting to stick things into the pancreas.↗
▶Ep 8 · 39:41
quotein the absence of true significant clinical deterioration, we, we really avoid, avoid sticking needles in the pancreas, sticking drains.↗
Jaimie's statements about Hirschsprung disease4 statements
quotewe're not force feeding the kids. Exactly. We're not pushing feeds in the face of ongoing emesis.↗
▶Ep 12 · 39:07
quoteyou really, you can very much be opening a can of worms if you're starting to stick things into the pancreas.↗
▶Ep 12 · 39:16
opinionSticking needles or drains into the pancreas risks introducing infection into sterile necrosis; intervention should be avoided unless there is true significant clinical deterioration.↗
quoteAnything you wanted to know about the pancreas, uh, and we'll spend the next 4 hours talking about surgical approaches.↗
▶Ep 1 · 3:38
clinicalThe day's sessions will cover surgical approaches, interventional endoscopic approaches, and medical management of acute, acute recurrent, and chronic pancreatitis↗
▶Ep 1 · 4:05
clinicalDr. Joe Palermo is a pediatric gastroenterologist and medical lead of the total pancreatectomy and islet auto transplantation program↗
▶Ep 1 · 4:23
clinicalKen Goldschneider is director of pain management at Cincinnati Children's, professor of clinical pediatrics and anesthesia, and plays a central role in pain management for patients with pancreatic diseases↗
▶Ep 1 · 4:40
clinicalDr. Maisam Abu El-Haija is a gastroenterologist, co-director of the course, and medical director of the Pancreas Care Center↗
▶Ep 1 · 4:54
clinicalTom Lynn is a gastroenterologist who manages the vast majority or all endoscopic needs for children with pancreatic disorders, director of endoscopy for the Pancreas Care Center, and co-director of endoscopy for the division of gastroenterology↗
▶Ep 1 · 5:17
clinicalAndrew Trout is the lead radiologist for the Pancreas Care Center, assistant professor of radiology, and dual certified in pediatric radiology and nuclear medicine↗
▶Ep 1 · 5:33
clinicalDr. Deb Elder is the endocrine director for the Pancreas Care Center and will join later in the event↗
▶Ep 1 · 5:47
clinicalDr. Milton Smith is medical director of therapeutic ERCP at University of Cincinnati and will join later in the event↗
▶Ep 1 · 5:53
quoteplease we'd like to keep this, uh, uh, highly interactive, so, um, bring us your questions, bring us your comments, and, uh, we hope to be able to answer them.↗
Jaimie's statements about Pancreatic Tumors46 statements
clinicalElevated lipase and elevated bilirubin suggest obstruction in the pancreatic head, which can be caused by neoplasms or more commonly in pediatrics by non-neoplastic findings such as autoimmune pancreatitis or complications of pancreatitis.↗
▶Ep 1 · 5:14
epidemiologicalPancreatoblastoma is the most common malignant pancreatic tumor in children, typically presenting in patients less than 10 years of age.↗
▶Ep 1 · 5:40
clinicalIn pancreatoblastoma, alpha-fetoprotein is elevated in up to 80% of cases.↗
▶Ep 1 · 5:50
epidemiologicalUp to 45-50% of pancreatoblastoma cases present with metastases.↗
▶Ep 1 · 6:00
clinicalPancreatoblastomas respond well to chemotherapy with a cisplatin and doxorubicin-based regimen.↗
▶Ep 1 · 6:10
clinicalThe number one prognostic factor for pancreatoblastoma is complete surgical excision, whether at initial presentation or following neoadjuvant chemotherapy.↗
▶Ep 1 · 6:10
quoteThe number one prognostic factor for patients with pancreatoblastoma is complete surgical excision, whether that is at the initial presentation or following neoadjuvant chemotherapy.↗
▶Ep 1 · 6:25
epidemiologicalSolid pseudopapillary neoplasms are more common in young female patients, typically in their second or third decade of life.↗
▶Ep 1 · 6:40
clinicalSolid pseudopapillary tumors are indolent and slow-growing, often presenting with very large masses in the body and tail of the pancreas.↗
▶Ep 1 · 6:50
quoteYou really actually want to avoid enucleation or simply biopsy of these lesions. There tends to be a high recurrence rate if you're simply trying to enucleate these lesions.↗
▶Ep 1 · 6:55
clinicalEnucleation or simple biopsy of solid pseudopapillary neoplasms should be avoided due to high recurrence rates; complete surgical resection is required.↗
▶Ep 1 · 7:04
epidemiologicalSolid pseudopapillary neoplasms have a recurrence rate of up to 10% but excellent long-term survival with 95% 10-year survival.↗
▶Ep 1 · 9:30
epidemiologicalNeuroendocrine tumors make up about 1-2% of all pancreatic tumors and can be either benign adenomas or malignant carcinomas.↗
▶Ep 1 · 9:45
epidemiologicalNeuroendocrine tumors tend to present in children over 10 years of age, though they are more common in middle-aged patients.↗
▶Ep 1 · 9:55
clinicalIn 10% of patients, neuroendocrine tumors may present in the setting of multiple endocrine neoplasia type 1, von Hippel-Lindau, or tuberous sclerosis.↗
▶Ep 1 · 10:10
epidemiologicalInsulinoma is the most common neuroendocrine tumor, accounting for almost 50% of pancreatic neuroendocrine tumors, followed by gastrinomas at 30%.↗
▶Ep 1 · 10:25
epidemiologicalInsulinomas are typically benign; 6% can be malignant. 90% are solitary, 10% are associated with MEN1.↗
▶Ep 1 · 10:40
clinicalInsulinomas present with Whipple's triad: symptoms of hypoglycemia, low fasting blood glucose, and symptom resolution with glucose administration.↗
▶Ep 1 · 12:00
clinicalOn imaging, a solid lesion in the pancreas is more worrisome than a cystic lesion when found incidentally.↗
▶Ep 1 · 13:40
clinicalUltrasound is low cost and easily accessible but the pancreas is often suboptimally visualized and characterization of pancreatic masses is poor.↗
▶Ep 1 · 14:00
clinicalCT scan is rapidly acquired with good resolution but has downsides of radiation and need for contrast; it is often used for solid tumor staging.↗
▶Ep 1 · 14:20
clinicalMRI provides better differentiation between solid and cystic or fluid components and can better characterize components of a pancreatic mass.↗
▶Ep 1 · 15:03
clinicalCross-sectional imaging (CT or MRI) cannot confidently differentiate a benign versus malignant pancreatic lesion.↗
▶Ep 1 · 15:03
quoteWe can really never confidently differentiate a benign versus a malignant lesion of the pancreas simply with cross-sectional imaging, whether it be CT scan or MRI.↗
▶Ep 1 · 15:25
clinicalA completely cystic pancreatic lesion is less concerning for malignancy, but if the mass has solid components, it becomes more concerning for neoplasm.↗
▶Ep 1 · 17:20
clinicalPediatric EUS is not practical in many institutions because there are not many practitioners in the pediatric GI community comfortable with pediatric EUS.↗
▶Ep 1 · 18:24
epidemiologicalIn the pediatric realm, autoimmune pancreatitis is more common than pancreatic neoplasm.↗
▶Ep 1 · 18:35
clinicalWith negative biliary cytology and after biliary and pancreatic duct stenting, a four-week steroid trial with taper can be initiated for presumed autoimmune pancreatitis, even if IgG4 findings are normal.↗
▶Ep 1 · 19:05
clinicalType 1 autoimmune pancreatitis is IgG4-mediated; type 2 autoimmune pancreatitis is IgG4-negative.↗
▶Ep 1 · 20:03
clinicalAutoimmune pancreatitis with a pancreatic head mass is typically very steroid responsive, with rapid resolution of the mass in most cases.↗
▶Ep 1 · 22:40
clinicalFor malignant pancreatic head lesions, a radical resection (Whipple pancreaticoduodenectomy) is required; for benign or borderline benign lesions, duodenum-preserving pancreatic head resections (Beger or Berne procedures) may be considered.↗
▶Ep 1 · 23:00
quoteWe really have to consider degree of resection whenever we're considering removing a portion of the pancreas because we have to think about endocrine and exocrine needs long-term.↗
▶Ep 1 · 23:20
epidemiologicalStudies report up to about a 10% risk of diabetes (endocrine impairment) after just a distal pancreatectomy in the setting of otherwise normal pancreas.↗
▶Ep 1 · 24:50
clinicalEnucleation may be appropriate for pancreatic neuroendocrine tumors but should be used sparingly; it is not recommended for solid pseudopapillary neoplasms due to higher recurrence risk.↗
▶Ep 1 · 27:20
quoteThe literature is actually replete with cases of these masquerades and mimicking.↗
▶Ep 1 · 28:53
clinicalType 1 autoimmune pancreatitis is IgG4-related systemic disease involving multiple organs (sialoadenitis, sclerosing cholangitis, retroperitoneal fibrosis) and responds quickly to steroids; IgG4 levels are elevated in 90% of patients.↗
▶Ep 1 · 29:40
clinicalType 2 autoimmune pancreatitis is pancreas-specific with normal IgG4 levels; 30% of patients also have IBD. Histology shows idiopathic duct-centric pancreatitis.↗
▶Ep 1 · 30:10
epidemiologicalOver 90% of children with autoimmune pancreatitis present with abdominal pain; about 40% present with obstructive jaundice.↗
▶Ep 1 · 30:30
epidemiologicalPositive serologies for IgG4 are described in only 22% of children with autoimmune pancreatitis in one study.↗
▶Ep 1 · 30:45
epidemiologicalIn pediatric autoimmune pancreatitis, focal enlargement in the pancreatic head occurs in about 50% of patients; global pancreatic enlargement in 30%; main pancreatic duct irregularity in two-thirds; common bile duct strictures in 55%; and the capsule-like rim sign in only 16%.↗
▶Ep 1 · 31:30
epidemiological93% of pediatric patients with autoimmune pancreatitis respond to steroids, indicating very steroid-responsive disease.↗
▶Ep 1 · 32:30
epidemiologicalAutoimmune pancreatitis in children more commonly follows a type 2 presentation rather than type 1 or IgG4-related presentation, based on data from the INSPIRE consortium and European pancreatic consortium.↗
▶Ep 1 · 33:20
clinicalIdeally, a tissue diagnosis should be obtained before initiating therapy for autoimmune pancreatitis, but barriers in pediatrics (limited EUS-skilled endoscopists and pathologists, inadequate biopsies) often cannot be overcome.↗
▶Ep 1 · 33:50
guidelineThe diagnosis of autoimmune pancreatitis in children can be made with a combination of clinical and imaging findings because the risk of pediatric neoplasm is lower than autoimmune pancreatitis.↗
▶Ep 1 · 34:30
clinicalClinical response to corticosteroid therapy for autoimmune pancreatitis should be seen within a few weeks; imaging response should be anticipated after about three months.↗
▶Ep 1 · 34:45
quoteYou don't want to keep treating something that ends up being a pancreatic neoplasm with steroids.↗
Jaimie's statements about Pancreatitis18 statements
quotewe're not force feeding the kids. Exactly. We're not pushing feeds in the face of ongoing emesis.↗
▶Ep 2 · 39:07
quoteyou really, you can very much be opening a can of worms if you're starting to stick things into the pancreas.↗
▶Ep 2 · 39:16
opinionSticking needles or drains into the pancreas risks introducing infection into sterile necrosis; intervention should be avoided unless there is true significant clinical deterioration.↗
quoteAnything you wanted to know about the pancreas, uh, and we'll spend the next 4 hours talking about surgical approaches.↗
▶Ep 8 · 3:38
clinicalThe day's sessions will cover surgical approaches, interventional endoscopic approaches, and medical management of acute, acute recurrent, and chronic pancreatitis↗
▶Ep 8 · 4:05
clinicalDr. Joe Palermo is a pediatric gastroenterologist and medical lead of the total pancreatectomy and islet auto transplantation program↗
▶Ep 8 · 4:23
clinicalKen Goldschneider is director of pain management at Cincinnati Children's, professor of clinical pediatrics and anesthesia, and plays a central role in pain management for patients with pancreatic diseases↗
▶Ep 8 · 4:40
clinicalDr. Maisam Abu El-Haija is a gastroenterologist, co-director of the course, and medical director of the Pancreas Care Center↗
▶Ep 8 · 4:54
clinicalTom Lynn is a gastroenterologist who manages the vast majority or all endoscopic needs for children with pancreatic disorders, director of endoscopy for the Pancreas Care Center, and co-director of endoscopy for the division of gastroenterology↗
▶Ep 8 · 5:17
clinicalAndrew Trout is the lead radiologist for the Pancreas Care Center, assistant professor of radiology, and dual certified in pediatric radiology and nuclear medicine↗
▶Ep 8 · 5:33
clinicalDr. Deb Elder is the endocrine director for the Pancreas Care Center and will join later in the event↗
▶Ep 8 · 5:47
clinicalDr. Milton Smith is medical director of therapeutic ERCP at University of Cincinnati and will join later in the event↗
▶Ep 8 · 5:53
quoteplease we'd like to keep this, uh, uh, highly interactive, so, um, bring us your questions, bring us your comments, and, uh, we hope to be able to answer them.↗
Acute Pancreatitis
▶Ep 12 · 16:41
quotewe're not force feeding the kids. We're not pushing feeds in the face of ongoing emesis.↗
▶Ep 12 · 38:49
clinicalAspiration of pancreatic necrosis to rule out infection carries risk of introducing infection into a sterile collection; empiric antibiotics may be started if fever is present, but aspiration is rarely performed (Cincinnati has needed one necrosectomy in 10 years).↗
▶Ep 12 · 39:03
quoteyou really, you can very much be opening a can of worms if you're starting to stick things into the pancreas.↗
▶Ep 12 · 39:41
quotein the absence of true significant clinical deterioration, we, we really avoid, avoid sticking needles in the pancreas, sticking drains.↗
Jaimie's statements about Pediatric Oncology46 statements
clinicalElevated lipase and elevated bilirubin suggest obstruction in the pancreatic head, which can be caused by neoplasms or more commonly in pediatrics by non-neoplastic findings such as autoimmune pancreatitis or complications of pancreatitis.↗
▶Ep 249 · 5:14
epidemiologicalPancreatoblastoma is the most common malignant pancreatic tumor in children, typically presenting in patients less than 10 years of age.↗
▶Ep 249 · 5:40
clinicalIn pancreatoblastoma, alpha-fetoprotein is elevated in up to 80% of cases.↗
▶Ep 249 · 5:50
epidemiologicalUp to 45-50% of pancreatoblastoma cases present with metastases.↗
▶Ep 249 · 6:00
clinicalPancreatoblastomas respond well to chemotherapy with a cisplatin and doxorubicin-based regimen.↗
▶Ep 249 · 6:10
clinicalThe number one prognostic factor for pancreatoblastoma is complete surgical excision, whether at initial presentation or following neoadjuvant chemotherapy.↗
▶Ep 249 · 6:10
quoteThe number one prognostic factor for patients with pancreatoblastoma is complete surgical excision, whether that is at the initial presentation or following neoadjuvant chemotherapy.↗
▶Ep 249 · 6:25
epidemiologicalSolid pseudopapillary neoplasms are more common in young female patients, typically in their second or third decade of life.↗
▶Ep 249 · 6:40
clinicalSolid pseudopapillary tumors are indolent and slow-growing, often presenting with very large masses in the body and tail of the pancreas.↗
▶Ep 249 · 6:50
quoteYou really actually want to avoid enucleation or simply biopsy of these lesions. There tends to be a high recurrence rate if you're simply trying to enucleate these lesions.↗
▶Ep 249 · 6:55
clinicalEnucleation or simple biopsy of solid pseudopapillary neoplasms should be avoided due to high recurrence rates; complete surgical resection is required.↗
▶Ep 249 · 7:04
epidemiologicalSolid pseudopapillary neoplasms have a recurrence rate of up to 10% but excellent long-term survival with 95% 10-year survival.↗
▶Ep 249 · 9:30
epidemiologicalNeuroendocrine tumors make up about 1-2% of all pancreatic tumors and can be either benign adenomas or malignant carcinomas.↗
▶Ep 249 · 9:45
epidemiologicalNeuroendocrine tumors tend to present in children over 10 years of age, though they are more common in middle-aged patients.↗
▶Ep 249 · 9:55
clinicalIn 10% of patients, neuroendocrine tumors may present in the setting of multiple endocrine neoplasia type 1, von Hippel-Lindau, or tuberous sclerosis.↗
▶Ep 249 · 10:10
epidemiologicalInsulinoma is the most common neuroendocrine tumor, accounting for almost 50% of pancreatic neuroendocrine tumors, followed by gastrinomas at 30%.↗
▶Ep 249 · 10:25
epidemiologicalInsulinomas are typically benign; 6% can be malignant. 90% are solitary, 10% are associated with MEN1.↗
▶Ep 249 · 10:40
clinicalInsulinomas present with Whipple's triad: symptoms of hypoglycemia, low fasting blood glucose, and symptom resolution with glucose administration.↗
▶Ep 249 · 12:00
clinicalOn imaging, a solid lesion in the pancreas is more worrisome than a cystic lesion when found incidentally.↗
▶Ep 249 · 13:40
clinicalUltrasound is low cost and easily accessible but the pancreas is often suboptimally visualized and characterization of pancreatic masses is poor.↗
▶Ep 249 · 14:00
clinicalCT scan is rapidly acquired with good resolution but has downsides of radiation and need for contrast; it is often used for solid tumor staging.↗
▶Ep 249 · 14:20
clinicalMRI provides better differentiation between solid and cystic or fluid components and can better characterize components of a pancreatic mass.↗
▶Ep 249 · 15:03
clinicalCross-sectional imaging (CT or MRI) cannot confidently differentiate a benign versus malignant pancreatic lesion.↗
▶Ep 249 · 15:03
quoteWe can really never confidently differentiate a benign versus a malignant lesion of the pancreas simply with cross-sectional imaging, whether it be CT scan or MRI.↗
▶Ep 249 · 15:25
clinicalA completely cystic pancreatic lesion is less concerning for malignancy, but if the mass has solid components, it becomes more concerning for neoplasm.↗
▶Ep 249 · 17:20
clinicalPediatric EUS is not practical in many institutions because there are not many practitioners in the pediatric GI community comfortable with pediatric EUS.↗
▶Ep 249 · 18:24
epidemiologicalIn the pediatric realm, autoimmune pancreatitis is more common than pancreatic neoplasm.↗
▶Ep 249 · 18:35
clinicalWith negative biliary cytology and after biliary and pancreatic duct stenting, a four-week steroid trial with taper can be initiated for presumed autoimmune pancreatitis, even if IgG4 findings are normal.↗
▶Ep 249 · 19:05
clinicalType 1 autoimmune pancreatitis is IgG4-mediated; type 2 autoimmune pancreatitis is IgG4-negative.↗
▶Ep 249 · 20:03
clinicalAutoimmune pancreatitis with a pancreatic head mass is typically very steroid responsive, with rapid resolution of the mass in most cases.↗
▶Ep 249 · 22:40
clinicalFor malignant pancreatic head lesions, a radical resection (Whipple pancreaticoduodenectomy) is required; for benign or borderline benign lesions, duodenum-preserving pancreatic head resections (Beger or Berne procedures) may be considered.↗
▶Ep 249 · 23:00
quoteWe really have to consider degree of resection whenever we're considering removing a portion of the pancreas because we have to think about endocrine and exocrine needs long-term.↗
▶Ep 249 · 23:20
epidemiologicalStudies report up to about a 10% risk of diabetes (endocrine impairment) after just a distal pancreatectomy in the setting of otherwise normal pancreas.↗
▶Ep 249 · 24:50
clinicalEnucleation may be appropriate for pancreatic neuroendocrine tumors but should be used sparingly; it is not recommended for solid pseudopapillary neoplasms due to higher recurrence risk.↗
▶Ep 249 · 27:20
quoteThe literature is actually replete with cases of these masquerades and mimicking.↗
▶Ep 249 · 28:53
clinicalType 1 autoimmune pancreatitis is IgG4-related systemic disease involving multiple organs (sialoadenitis, sclerosing cholangitis, retroperitoneal fibrosis) and responds quickly to steroids; IgG4 levels are elevated in 90% of patients.↗
▶Ep 249 · 29:40
clinicalType 2 autoimmune pancreatitis is pancreas-specific with normal IgG4 levels; 30% of patients also have IBD. Histology shows idiopathic duct-centric pancreatitis.↗
▶Ep 249 · 30:10
epidemiologicalOver 90% of children with autoimmune pancreatitis present with abdominal pain; about 40% present with obstructive jaundice.↗
▶Ep 249 · 30:30
epidemiologicalPositive serologies for IgG4 are described in only 22% of children with autoimmune pancreatitis in one study.↗
▶Ep 249 · 30:45
epidemiologicalIn pediatric autoimmune pancreatitis, focal enlargement in the pancreatic head occurs in about 50% of patients; global pancreatic enlargement in 30%; main pancreatic duct irregularity in two-thirds; common bile duct strictures in 55%; and the capsule-like rim sign in only 16%.↗
▶Ep 249 · 31:30
epidemiological93% of pediatric patients with autoimmune pancreatitis respond to steroids, indicating very steroid-responsive disease.↗
▶Ep 249 · 32:30
epidemiologicalAutoimmune pancreatitis in children more commonly follows a type 2 presentation rather than type 1 or IgG4-related presentation, based on data from the INSPIRE consortium and European pancreatic consortium.↗
▶Ep 249 · 33:20
clinicalIdeally, a tissue diagnosis should be obtained before initiating therapy for autoimmune pancreatitis, but barriers in pediatrics (limited EUS-skilled endoscopists and pathologists, inadequate biopsies) often cannot be overcome.↗
▶Ep 249 · 33:50
guidelineThe diagnosis of autoimmune pancreatitis in children can be made with a combination of clinical and imaging findings because the risk of pediatric neoplasm is lower than autoimmune pancreatitis.↗
▶Ep 249 · 34:30
clinicalClinical response to corticosteroid therapy for autoimmune pancreatitis should be seen within a few weeks; imaging response should be anticipated after about three months.↗
▶Ep 249 · 34:45
quoteYou don't want to keep treating something that ends up being a pancreatic neoplasm with steroids.↗
