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Update Course Rewind: Management of Chronic Pancreatitis 2023
With Dr. Juan Gurria · hosted by Dr. Cecilia Gigena
Chapter 1 of 5 · Case-Based Learning
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Case Presentation and Surgical Decision-Making
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Most of the pancreatic parenchyma is in the head and the uncinate process.
If a patient has a PRSS1 mutation and only the pancreatic head is removed, recurrent attacks will occur.
Up to 50% of patients with chronic pancreatitis will eventually require surgery.
TPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social worker, geneticists, psychiatry, and pain control.
Patients with chronic pancreatitis always have micro and macronutrient deficiencies.
Chronic pancreatitis patients sometimes need pancreatic enzyme replacement therapy.
In chronic pancreatitis, exocrine function is lost first, then endocrine function.
The primary goal of TPIAT is to restore the child's quality of life and return them to normal activities.
The secondary goal of TPIAT is to prevent brittle diabetes by preserving beta cell function.
All TPIAT patients require enzyme replacement therapy post-operatively.
With an islet cell count of 5000, there is a 50% chance of not requiring insulin post-TPIAT.
With an islet cell count of 5000, there is a 20% chance of requiring a small dose of insulin post-TPIAT.
With an islet cell count of 5000, 30% of patients remain diabetic post-TPIAT.
TPIAT potentially exchanges chronic pancreatitis for diabetes, and families must be counseled about this trade-off.
TPIAT surgery takes an average of 8 to 10 hours.
The pancreas is cemented in the retroperitoneum with neovascularization and collateralization, making removal the most problematic part of TPIAT.
Some chronic pancreatitis patients have thrombosis in the portal vein or splenic vein.
Pancreatectomy during TPIAT takes 3 to 4 hours.
During TPIAT, biliary and intestinal reconstruction is performed using a Roux-en-Y technique while islet isolation is occurring.
The spleen is removed along with the pancreas during TPIAT.
Islet cell isolation takes 4 to 4.5 hours.
Islet cells are injected into the portal vein inside the liver.
In the acute post-operative period, glucose must be managed externally to prevent stress on transplanted islet cells.
All TPIAT patients are on insulin in the ICU to allow islet cells to implant without stress.
Islet cells need to find new vessels from the liver to survive after transplantation.
Islet cells implant in the end branches of the portal vein inside the liver.
Extrahepatic islet cell reimplantation does not work as well as intrahepatic placement.
Extrahepatic islet cells produce a better glucagon response for hypoglycemia compared to intrahepatic cells.
The liver is the best site for islet cell transplantation.
The risk of portal vein thrombosis after intrahepatic islet injection is less than 1%.
Portal pressure is monitored during islet cell injection to prevent complications.
During TPIAT, the duodenum is removed at D1 post-pyloric level along with the pancreas.
The duodenum and pancreas share blood supply, making duodenal preservation difficult during TPIAT.