Juan Gurria

947 statements · 7 topics · summaries given as host listed separately

Islet Cell / TPIAT · guest expert Pancreatitis · guest expert Pediatric Robotic Surgery · guest expert Sarcoma (Ewing/Rhabdo) · guest expert

Featured statements

Please 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.

quote · Acute Pancreatitis

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.

quote · Acute Recurrent Pancreatitis

This 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.

quote · Acute Recurrent Pancreatitis

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

quote · Acute Pancreatitis

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.

quote · Chronic Pancreatitis

While 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.

quote · Chronic Pancreatitis

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Juan's statements about Acute Pancreatitis 128 statements

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Update Course 2023 - Updates in Pancreatitis

Quotation it is very important nowadays to feed the pancreas, even when there's pancreatitis Open

Statement Acute pancreatitis management has shifted from NPO and aggressive IV fluids causing pulmonary edema to early feeding and measured fluid resuscitation. Open

Quotation you cannot take care of a pancreas without a wonderful team Open

Statement For acute pancreatitis with tachycardia (HR 160) and hypotension in a 9-year-old, appropriate management is ICU admission with bolus ×2, maintenance IV fluids 1.5×, no antibiotics, and pain control. Open

Quotation Acute pancreatitis could be fatal Open

Statement Early fluid resuscitation is key to re-establish intravascular flow to the pancreas and prevent hypoxia, necrosis, and atrophic pancreatic insufficiency. Open

Quotation pancreatitis is a state of uh hypoxia. You need to re-establish the intravascular flow to the pancreas to prevent hypoxia, necrosis Open

Statement Excessive fluid resuscitation in pancreatitis leads to worse outcomes including fluid overload and multi-system organ failure. Open

Statement There is no indication for routine antibiotics in acute pancreatitis, even with necrosis or necrotizing pancreatitis, unless there are signs of sepsis or infected pancreatitis. Open

Quotation You cannot uh flow these lungs too much because the outcomes are worse Open

Statement Maintenance fluids should be 1.5 to 2 times normal maintenance, with reassessment at 12-24 hour mark to avoid fluid overload. Open

Statement Enteral nutrition as soon as the patient can tolerate PO is significantly better compared to TPN or NPO in acute pancreatitis. Open

Statement Some vomiting can be tolerated when feeding pancreatitis patients, similar to gastroschisis management, because feeding the gut produces dramatically better outcomes. Open

Quotation It's OK to tolerate some, some, some. Vomiting. If you can feed them, that's fine. Open

Statement No patient needs TPN in the first 7 days of acute illness. Open

Quotation nobody needs TPN the 1st 7 days of acute illness, right? Open

Statement The inflammatory head mass commonly seen in adult pancreatitis is rarely seen in children; pediatric patients typically have minimal duct change disease with small, usually non-dilated ducts. Open

Statement With every attack of pancreatitis, islet cells are lost, so repeated ERCPs that fail to prevent attacks result in progressive loss of beta-cell mass. Open

Statement ERCP does not change the islet yield available for transplantation, but pancreatitis attacks cause cell loss. Open

Quotation children get pancreatitis. We have a running list of 800 patients right now in Cin Children's. Open

Statement Genetic testing is key in pediatric pancreatitis and should be obtained for all patients with chronic or recurrent pancreatitis, and even considered after a first severe attack. Open

Statement Cincinnati Children's has a running list of 800 pancreatitis patients and receives over 100 TPIAT referrals per year, but only performs 20-25 procedures annually because not all patients are candidates. Open

Statement The most common cause of pancreatitis in children is medication-induced, but the most common risk factor is genetic factors. Open

Quotation The 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. Open

Quotation 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. Open

Statement PRSS1 (trypsinogen activator) is the most common genetic mutation in pediatric pancreatitis and the most aggressive, causing auto-attack by activating trypsin inside the pancreas. Open

Statement Cincinnati Children's genetic panel tests 10 different genetic markers for pancreatitis including PRSS1, CTRC, CFTR, and CPA1. Open

Statement Genetics have fundamentally changed the approach to pediatric chronic pancreatitis treatment. Open

Quotation up to 50% of those children are gonna keep getting pancreatitis despite you opening the duct and draining it Open

Statement In children with genetic mutations causing pancreatitis, conventional drainage procedures (Frey, Puestow) fail in up to 50% because the parenchyma continues to be attacked by the mutation despite duct drainage. Open

Quotation you send half of your, the top of your pancreas to the trash Open

Quotation unfortunately we don't have that just yet. That's why I still have a job. Open

Quotation This patient most likely is gonna keep getting pancreatitis despite you draining the duct. The, the parenchyma is gonna keep getting attacked by the mutation. Open

Quotation TPIT, 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. Open

Statement The main indication for TPIAT is chronic debilitating pain in children who have lost their quality of life—not attending school, withdrawn, unable to participate in activities. Open

Quotation There's no more ballerina dancers, right? Open

Statement The secondary goal of TPIAT is to prevent brittle diabetes by returning beta cells to the patient. Open

Quotation if you keep getting pancreatitis, you're losing time on that, right? The, the pancreas, we have 34 years old with like very atrophic pancreas Open

Quotation We don't offer. Uh, to take care of the pancreas unless you've maximize medical and endoscopic management. Open

Statement MRCP is the best non-invasive imaging study for the pancreas, superior to ultrasound and CT. Open

Statement ERCP is more therapeutic than diagnostic in chronic pancreatitis. Open

Statement Patients with chronic pancreatitis always have micronutrient and macronutrient deficiencies requiring nutritional support. Open

Statement Patients with chronic pancreatitis lose exocrine function first, then endocrine function, requiring screening and often pancreatic enzyme replacement therapy. Open

Statement Walled-off necrosis should be drained only if symptomatic (gastric outlet obstruction or pain) after the wall matures at 4-6 weeks; asymptomatic collections will self-resolve and do not require drainage or antibiotics. Open

Statement Chronic pancreatitis increases the risk of pancreatic cancer up to thirteenfold. Open

Statement Up to 50% of patients with chronic pancreatitis will eventually require surgery. Open

Statement TPIAT requires a multidisciplinary team including surgery, GI pancreatologists, social workers, geneticists, psychology, and pain management. Open

Quotation some families ask us like, so you're gonna get rid of the pain, right? 100%, and you cannot say that, right? Open

Quotation People 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. Open

Statement Patients with chronic pain develop hyperalgesia and central sensitization—their brains learn to function in pain—so removing the organ may eliminate 90% of pain but 10% may linger, requiring behavioral therapy. Open

Quotation when 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 Open

Statement Islet equivalent per kilogram of body weight is used as a prognostic marker; at approximately 5000 islet equivalents/kg there is a 50% chance of insulin independence. Open

Statement TPIAT outcomes: 50% of patients achieve insulin independence, 20% require small insulin doses, and 30% remain diabetic. Open

Statement TPIAT exchanges chronic pancreatitis for potential diabetes, which must be clearly communicated to families. Open

Quotation I'm exchanging potentially disease for a disease, right? Chronic pancreatitis for potential diabetes. Open

Quotation My 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. Open

Statement TPIAT surgery takes an average of 8-10 hours: 3-4 hours for pancreatectomy, 4-4.5 hours for islet isolation in the lab, and 2 hours for reconstruction. Open

Statement Pylorus-preserving resection with pyloric Botox injection is performed during TPIAT reconstruction to address gastroparesis that all pancreatitis patients have; Roux-en-Y reconstruction also helps with gastroparesis. Open

Statement Routine splenectomy is performed with TPIAT because the pancreas and spleen share blood supply via tiny branches from the splenic vessels; preserving the spleen adds ischemia time and causes islet cell loss. Open

Statement There are four critical points where islet cells can be lost: (1) recurrent pancreatitis causing cell death, (2) ischemia during surgical dissection, (3) cell death during processing and injection, and (4) post-operative stress if glucose is not carefully managed. Open

Statement All TPIAT patients are kept on insulin in the ICU post-operatively to let the islet cells rest without working until they implant and establish new vascular supply from the liver. Open

Statement The liver is the best site for islet cell implantation via portal vein injection; extrahepatic sites (omentum, retroperitoneum, rectus muscle, gastric submucosa) have been tried but work less well. Open

Statement Portal vein thrombosis after islet injection occurs in less than 1% of cases; portal pressure is monitored during injection. Open

Statement The duodenum is resected at D1 post-pyloric during TPIAT because of shared blood supply with the pancreas; attempting to preserve it adds ischemia time. Open

Update Course Rewind: Management of Acute Pancreatitis 2023

Statement Acute pancreatitis could be fatal Open

Quotation Acute pancreatitis could be fatal. Open

Statement Bolus times 2 is adequate fluid resuscitation, with 1.5 times maintenance once past the early phase of acute resuscitation Open

Quotation 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. Open

Statement Pancreatitis is a state of hypoxia requiring re-establishment of intravascular flow to the pancreas to prevent hypoxia, necrosis, and atrophic pancreas insufficiency Open

Statement Early fluid resuscitation is key in pancreatitis management Open

Statement Excessive fluid administration worsens outcomes in pancreatitis Open

Statement There 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 Open

Quotation 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 Open

Statement The North American Society of Pancreatitis, GI Pathology, and Nutrition published a position paper with guideline recommendations for pancreatitis management Open

Statement Early fluids lead to better outcomes in pancreatitis Open

Statement Recommended 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 Open

Statement Excessive fluid administration can flood the lungs and worsen outcomes Open

Quotation You cannot flow these lungs too much because the outcomes are worse. Open

Statement Lactated Ringer's decreases the incidence of inflammatory response and C-reactive protein at 24 hours compared to normal saline in pancreatitis Open

Quotation It's been shown that LR. Decreases the incidence of inflammatory response and C, C-reactive protein at 24 hours compared to NS, right? Open

Statement If albumin is low in pancreatitis patients, albumin should be given Open

Statement Enrique de Madaria conducted a multi-center worldwide RCT called the Waterfall trial comparing moderate versus aggressive fluid resuscitation in pancreatitis Open

Statement The Waterfall trial was stopped early because patients receiving too much fluid were developing organ failure Open

Statement A 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 Open

Statement Patients with pancreatitis should be fed as soon as they are able to tolerate oral intake Open

Statement Enteral nutrition is significantly better compared to TPN or NPO in pancreatitis Open

Statement Gastric feeding is preferred over post-pyloric feeding in pancreatitis if the patient can tolerate it Open

Statement Some vomiting is tolerable during refeeding in pancreatitis, similar to gastroschisis management Open

Quotation If they cannot tolerate it, it's OK. I mean, but it's like gastroschisis, it's OK to tolerate some, some, some vomiting. Open

Statement If nutrition is lost and the patient loses ground, outcomes will be worse, with dropping albumin and worse inflammatory reaction Open

Quotation If 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. Open

Statement Outcomes are dramatically better when the gut is fed in pancreatitis patients Open

Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria

Statement Diagnosis of acute pancreatitis requires serum lipase at least 3 times the upper limit of normal, plus imaging findings (ultrasound, MRI/MRCP, or CT). Open

Statement In the Cincinnati Children's cohort of 1000 pediatric pancreatitis patients, 85% have genetic mutations. Open

Statement PRSS1 mutation causes very aggressive attacks very early in life (ages 1–3 years) because it autoactivates trypsinogen inside the pancreas. Open

Statement Medications including L-asparaginase, steroids, valproic acid, and diuretics (Lasix) can cause pancreatitis in children. Open

Statement Hereditary 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. Open

Statement Most fluid collections in pediatric acute pancreatitis are self-limited and should not be touched unless absolutely necessary. Open

Quotation Please do not touch these collections ever unless you absolutely have to. Open

Statement Early necrosectomies (before 4 weeks) usually increase mortality. Open

Statement Following lipase levels tells you nothing about how the pancreas is behaving in acute pancreatitis; cross-sectional imaging is required. Open

Statement Asymptomatic pseudocysts, regardless of size, do not require intervention. Open

Statement Patients 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. Open

Quotation Please 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. Open

Statement In pediatric patients with hereditary pancreatitis or hereditary plus anatomic abnormalities, half will develop chronic pancreatitis. Open

Statement Cincinnati 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. Open

Statement Chronic pain in pancreatitis involves brain plasticity, hypertrophic nerve reactions, and peripheral nerve hypersensitization, not just organic retroperitoneal pain. Open

Quotation I'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. Open

Statement After total pancreatectomy, 95% of pain is resolved, but 5% may persist due to central sensitization and requires behavioral medicine and psychiatric support. Open

Statement Pediatric chronic pancreatitis usually presents with minimal ductal changes, not the dilated ducts seen in adults, so drainage procedures are often not applicable. Open

Statement In 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. Open

Quotation If 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. Open

Quotation We're doing this for, for chronic pain and that should be the, the, the major thing in our head. Open

Statement TPIAT 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. Open

Statement The goal of islet autotransplantation is to replace beta cell mass and insulin secretory capacity, not to cure diabetes—pain control is the primary indication. Open

Statement TPIAT used to be a 20-hour operation but is now down to an average of 8–9 hours at Cincinnati Children's. Open

Statement Spleen-sparing TPIAT has equal glycemic outcomes to splenectomy TPIAT when islet equivalent per kilogram transplanted is matched. Open

Statement Spleen-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. Open

Statement Intraoperative pyloric Botox injection reduces gastroparesis, decreases length of stay, and improves time to full oral intake and glycemic control after TPIAT. Open

Statement Islet isolation takes about 3–3.5 hours, sometimes 4 hours depending on the degree of pancreatic injury. Open

Statement TPIAT is performed under anticoagulation (heparin) to prevent portal vein thrombosis during islet infusion. Open

Statement Portal vein thrombosis rate at Cincinnati Children's is less than 1% for TPIAT. Open

Statement Cincinnati Children's has performed close to 200 TPIAT cases with no anastomotic leaks. Open

Statement Patients are extubated in the operating room after TPIAT. Open

Statement Younger children are more likely to achieve insulin independence and opioid independence after TPIAT. Open

Statement Islet yield (IEQ/kg) is inversely related to pancreatic calcification, ductal dilation, fibrosis, duration of symptoms, and prior resections or drainage procedures. Open

Statement Predictors of insulin independence after TPIAT include younger age at surgery, smaller body surface area, no pre-existing insulin dependence, and higher IEQ/kg transplanted. Open

Statement TPIAT 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. Open

Juan's statements about Acute Recurrent Pancreatitis 96 statements

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Update Course Rewind: Management of Recurrent Pancreatitis

Quotation Every 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. Open

Statement Every ERCP carries a risk of post-ERCP pancreatitis, and with every pancreatitis attack, islet cells are lost. Open

Statement PRSS1 is the most common genetic mutation in recurrent pancreatitis and is a trypsinogen activator that activates trypsin inside the pancreas. Open

Quotation PRSS1 is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas. Open

Statement PRSS1 is the most common genetic mutation in recurrent pancreatitis and is a trypsinogen activator that activates trypsin inside the pancreas. Open

Quotation PRSS1 is the most common one, which is a trypsinogen activator. It activates trypsin inside the pancreas. Open

Statement The genetic panel at Cincinnati Children's tests 10 different genetic markers for pancreatitis (including PRSS1, CTRC, CFTR, CPA1). Open

Statement Genetic factors are changing the approach to pediatric chronic pancreatitis treatment. Open

Quotation That's how we're changing the approach to pediatric pancreatitis, chronic pan pancreatitis treatment because of the genetic factors. Open

Statement Genetic factors are changing the approach to pediatric chronic pancreatitis treatment. Open

Quotation That's how we're changing the approach to pediatric pancreatitis, chronic pan pancreatitis treatment because of the genetic factors. Open

Statement There is currently no medication to mitigate trypsin activation in genetic pancreatitis mutations. Open

Quotation No, 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. Open

Statement There is currently no medication to mitigate trypsin activation in genetic pancreatitis mutations. Open

Statement In 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. Open

Statement In 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. Open

Quotation This 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. Open

Statement There is no set number of ERCPs that defines when to escalate care; the sooner the referral for evaluation, the better. Open

Quotation We don't offer, uh, to take care of the pancreas unless you've. Maximize medical and endoscopic management. Open

Statement Surgical management of the pancreas is not offered unless medical and endoscopic management have been maximized. Open

Quotation We don't offer, uh, to take care of the pancreas unless you've. Maximize medical and endoscopic management. Open

Statement Surgical management of the pancreas is not offered unless medical and endoscopic management have been maximized. Open

Quotation 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. Open

Statement If 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. Open

Statement MRCP is the best non-invasive imaging study for the pancreas, particularly with T2 sequences. Open

Quotation MRCP is the best non-invasive study for pancreas by far, uh, with different uh uh T2 sequences. Open

Statement ERCP is more therapeutic than diagnostic. Open

Statement Pancreatic 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. Open

Quotation Once 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. Open

Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center

Quotation TPIAT is clearly one of the most complex abdominal surgical procedures we perform in children. Open

Statement TPIAT is one of the most complex abdominal surgical procedures performed in children. Open

Statement Surgical indications for TPIAT are for patients with either chronic or acute recurrent pancreatitis. Open

Statement Patients are candidates for TPIAT when all medical and endoscopic therapy has failed. Open

Quotation These patients are candidates for TPAT when all medical and endoscopic therapy has failed. Open

Statement Patients are candidates for TPIAT when all medical and endoscopic therapy has failed. Open

Statement The Pancreas Care Center team includes GI, social worker, endocrine, surgery, radiology, genetics, behavioral health, physical therapy, anesthesia, and pain team. Open

Statement Patients are prepared with vaccinations for potential splenectomy before TPIAT surgery. Open

Statement The entire team reviews and votes patients in for surgery to determine if they are candidates for TPIAT. Open

Statement Pain catheters are placed in the transversus abdominis muscle by pain specialists. Open

Statement The pancreas in TPIAT patients has been injured for sometimes years, which makes the procedure quite challenging. Open

Quotation Remember, this, this pancreas has been injured for sometimes years, which makes this procedure quite challenging. Open

Statement On the right side, the small intestine (duodenum) and liver hilum are mobilized, with careful identification of bile ducts and blood supply to the liver. Open

Statement Blood 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. Open

Quotation We 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. Open

Statement During 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. Open

Statement A feeding tube is placed to allow patients to be fed while important connections heal. Open

Statement Drains are left where the spleen was removed and on top of the connection with the biliary tract. Open

Statement Islet cells are transfused into the portal vein with the hope that they will implant in the liver and start producing insulin. Open

Quotation While 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. Open

Statement Portal vein pressures are constantly checked during islet infusion to prevent portal vein thrombosis, which could cause significant morbidity. Open

Statement Patients are placed in the intensive care unit post-operatively to control hemodynamics and fluid shift balance. Open

Statement Islet cells need to heal in a very homeostatic environment, requiring close monitoring of vital signs. Open

Statement Glucose and insulin are controlled via exogenous infusions post-operatively. Open

Statement Close attention to nutrition is key in the healing of connections between the bile tract and gastrointestinal tract. Open

Statement Patients 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. Open

Statement After discharge, local GI physicians continue to follow patients along with the Cincinnati Children's team. Open

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