8. Surgery of Pancreas and Spleen Flashcards
1
Q
The spleen is located within what structure of the stomach?
A
within the leaf of the greater omentum
2
Q
How is the spleen attached to the stomach and what is the significance of this structure?
A
gastrosplenic ligament (def. contributes to disease)
3
Q
What are the branches that supply blood TO the spleen? and what drains blood out of the spleen?
A
- Blood in (Celiac a.—-> Splenic a.)
- Blood out (Splenic vein—>gastrosplenic vein—> portal vein)
4
Q
What is the difference between the white pulp and the red pulp in terms of the parenchyma of the spleen?
A
- White pulp (immune response)= nodular lymphoreticular tissue
- Red pulp = Venous sinuses where RBC and Antigens are stored
5
Q
What structures may resemble pathology in the spleen but are actually normal findings and their causes!!?? Which is most common
A
- Siderotic Plaques: (Calcium/iron deposits) MOST COMMON
- Ectopic splenic tissue
- Splenosis- usually from seeding of cells after sx or trauma
- Accessory spleen: congenital incidental
6
Q
What are some of the general functions of the spleen? (5 main)
A
- RBC storage (10-20% RBC and 30% platelets)
- RBC maturation (SUMMER CAMP FOR RBC)
- Senescent/sick RBC removal
- A. (RBC life-4 months, become non pliable and can’t squeeze through pores of splenic sinuses= rupture or they are phagocytized
- Hematopoiesis
- Immune Function (removal of bacteria better than the liver)
7
Q
What are the 2 main Morphological classifications of splenic pathology?
A
- Splenomegaly (symmetric enlargement)
- Mass (assymetric enlargement)
8
Q
What are some of the causes of Splenomegaly (symmetric enlargement)? (4)
A
- Drug induced
- Thiopental and Acepromazine (5-40% of blood can be sequestered during anesthesia)
- Propofol-minimal
- Congestion (TORSION) focus on this****
- Infiltrative diseases
- Immune mediated disease
9
Q
What are the main causes of splenic mass (asymmetric enlargement)?
A
- Neoplasia
- Hematoma***
- Nodular hyperplasia/EMH****
- Trauma—> Splenosis
- Abcess
10
Q
Splenic torsion may be an isolated event from_______ of the ______ ______(anatomical structure) during previous _____ or trauma or from absence of the ligament congenitally.
A
Splenic torsion may be an isolated event from STRETCHING** of the **GASTROSPLENIC LIGAMENT** (anatomical structure) during previous **GDV or trauma or from absence of the ligament congenitally.
11
Q
MOST COMMONLY, Splenic torsion is associated with this problem
A
GDV
12
Q
What breeds are associated with splenic torsion? (4)
A
Large & giant breeds
– Great Dane
– Greater Swiss Mountain dog
– German Shepherd
– English Bulldog (not asc with GDV)
Above breeds accont for 50% of cases
13
Q
Clinical signs of splenic torsion can either be _____ or _____
A
acute or chronic
14
Q
Describe the acute CS of splenic torsion? (6)
A
• Acute abdomen – Similar to GDV or BECAUSE of GDV
– Acute abdominal pain/shock
– Abdominal distention
– Cardiovascular collapse
– Dysrhythmias
– DIC
15
Q
Describe the chronic CS of splenic torsion? (6)
A
• Vague/Intermittent signs for up to 2 weeks
– Vomiting / diarrhea
– Weakness /depression
– Anemia
– Hematuria / Hemoglobinuria
– PU/PD
16
Q
What is the best imaging modality to differetiate from splenic torsion or from splenic mass, what are you looking for?
A
Ultrasonography (flow)
– Mottled/diffuse hypoechoic areas
– Intraluminal echogenic densities in veins
– No flow in splenic vessels in torsion
17
Q
Rads are okay for splenic torsion but not as good as U/S, why do we see gas bubbles often with torsions?
A
That portion of spleen dies off and attracts anaerobic bacteria and they often expire CO2 gas bubbles
18
Q
On radiographs, splenic masses are normally top ranked but many people will forget this problem that should be on their differentials because it often resembles a splenic mass on rads?
A
Splenic torsion
19
Q
Besides preop stabilization (fluids, transfusion, ab) what is the treatment of choice for Splenic torsion?
A
Exploratory Laparotomy to perform a splenectomy.
20
Q
What procedure will be often do upon exploratory laparotomy to treat splenic torsion to take out the spleen?
A
Gastropexy (especially with large breeds, small cohort study actually found GDV assoc. with splenic torsion potential)
21
Q
What do you never do to a splenic torson when performing a splenectomy?
A
DO NOT EVER DEROTATE THE SPLEEN PRIOR TO SPLENECTOMY
22
Q
When submitting a histopath assessment to ensure no underlying pathology to the lab it is IDEAL to send it how?
A
Send the whole spleen!!!
23
Q
What is the survival rate from splenic torsion?
A
93 of 102 so (91%) this is great!!!
24
Q
What is most definitely NEVER a cause of splenic torsion (DR. C did a study that proved this potential cause once considered is not found in ANY cause)??
A
Neoplasia
25
What is a rare cause of splenomegally where you find areas of infarct on abdominal u/s?
Splenic Infarction
26
Can we see splenic infarction on radiographs?
All we see is an enlarged spleen so rely on U/s to see infarct areas
27
Is Splenic infarction an emergency surgery potential?
DON"T RACE TO SURGERY!!! Figure out why first
28
What predisposes to splenic infarction?
prior splenic torsion caused from devascularized area that may turn into a mass effect such as a heatoma (POOR DR.C he said this happened to him!!!) Vasa ractus blood flow at the hilus must always be palpated
29
These hypercoaguaguable states can possibly cause splenic infarction? (5)
– Renal disease (PLN)
– Hyperadrenocorticism
– Neoplasia
– DIC
– Heart disease
30
Describe a very common entity with EMH and what is it often caused by?
**DIFFUSE or NODULAR HYPERPLASIA** from immune stimulation (Rickettsial infection) or splenic hyperactivity (IMHA – removing abnormal cells)
31
Nodular hyperplasia = sites of ______ \_\_\_\_\_\_
* \_\_\_\_\_\_\_\_\_\_\_\_
* \_\_\_\_\_\_\_\_\_\_\_\_
* \_\_\_\_\_\_\_\_\_\_\_\_
• Nodular hyperplasia = Sites of extramedullary hematopoiesis
– Single or multiple SUBCAPSULAR nodules
– \*Very Common entity\*
32
True or False
Diffuse or Nodular hyperplasia can often resemble cancer and FNA/cytology is a good dx madality to use
False- poor sensitivity
33
Nodular hyperplasia is often ______ but could _____ causing a \_\_\_\_\_\_\_\_
Nodular hyperplasia is often **asymptomatic** but could **rupture** causing a **hemoabdomen**
34
True or False:
Most nodular hyperplasias are malignant
False!!!!
70.5% (74/105) patients had benign splenic lesions
But of the 29.5% that we're malignant most were hamangiosarcoma :-(
35
What is the key point inf differentiating nodular hyperplasia from cancerous malignancies?
• **_Incidentally found_**, non-ruptured splenic masses or nodules w/o associated hemoperitoneum = Most commonly benign!
– Work w/ radiologist to help you rank ddx based on u/s characteristics
36
What are some causes of splenic trauma resulting in splenomegally?
• Blunt force (HBC/falls/dog attack) – Ruptures capsule & parenchyma
– Iatrogenic d/t laparotomy = Hemostatic agent & tamponade
37
What type of management is preferred for splenic trauma?
• Conservative management preferred & **successful**
**– Compression bandage = Controversial but this is the time to use it**
– Supportive care (careful PCV/TS tracking) & transfusion PRN
38
With splenic trauma treatment with splenectomy is partial considered for large breeds?
Splenectomy - Consider partial if possible but in at risk breeds for splenic disease **(labs/golden/GSD) please remove ALL**
39
What are our top 2 differentials for dogs with spenic neoplsia versus in cats?
**Dogs**
* Hemangiosarcoma
* Sarcoma (Fibrosarcoma, leiomyosarcoma, osteosarcoma)
**Cats**
* Mast cell tumor (MOST COMMON)
40
What is the rule of 2/3 with splenic neoplasia?
\*\*\*RULE OF 2/3rd’s\*\*\*
* 2/3rd’s of dogs w/ a splenic masses will have a malignancy
* 2/3rd’s of those malignancies will be hemangiosarcoma (HSA)
=66.6%
41
What is the difference in prognosis with small dogs versus large breeds, what is asc with malignancy in large breeds but not in small breeds?
**Small breed dogs (\<16 kg)**
* 50:50 split = Benign vs. malignant
* Wheaten Terriers predisposed
**• Hemoperitoneum NOT associated w/ malignancy**
**NOT A POOR PROGNOSIS IN SMALL BREED**, poor prognosis in large breeds
42
What are some of the risk factors for hemangiosarcoma with splenic neoplasia?
* Age – Older
* Size of dog - \> 21kg
* Breed – GSD, labs, Goldens, poodles
**_• Presence of hemoperitoneum = \> chance of malignancy =\>80%!!! (HOLY SHIT)_**
43
What is an interesting discovery in terms of splenic mass size and prognostics?
* SIZE MATTER
* Bigger the mass the better the prognosis
* Smaller the mass the worse the prognosis :-(
44
WE must know the numbers for HSA prognosis
* Outcome is \_\_\_\_\_
* If surgery how long do we get?
* Surgery + Chemo (Dox + Palladia) MST?
* Surgery + chemo + Immunotherpay MST? STAGES AND NUMBERS
* What is the major issue?
WE must know the numbers for HSA prognosis
* Outcome is **POOR**
* If surgery how long do we get?
* **1-3 MONTHS (JUST SAY 3 MONTHS)**
* Surgery + Chemo (Dox + Palladia) MST?
* **6-7 MONTHS (SLIDE SAID 5-6) 1 YEAR SURVIVAL ONLY HAPPENS IN 10% OF PATIENTS**
* Surgery + chemo + Immunotherpay MST?
* STAGE 1: (non ruptured spleen -425 days
* Stage 2: NO BENEFIT to do this
* _**\*\*Issue is that in nearly ALL cases microscopic metastasis is present at the time of diagnosis\*\***_
45
MOST vets when hemangiosarcoma will opt to not take it out because the prognosis of poor but what does Dr. C want to encourage us todo? When should we not indicate surgery?
State the survival stats we have to commit to memory but he does feel it is worth it often to give them more time and months alive!!!
## Footnote
**I DO feel comfortable doing surgery for this disease, even in at risk breeds w/ hemoperitoneum**
• I do NOT feel good about surgery when:
– Obvious grossly visible metastasis present pre-op
– Very sick dogs (coagulopathic/those needing high volume transfusion)
– Owner is not informed
46
What is an alternative therapy that increased MST 112 or 30-308 days? What does it contain and do?
C versicolor mushroom (Turkey tail) used an an adjunctive therpay
• Contains polysaccharopeptide (PSP), which causes cell-cycle arrest at the G1/S checkpoint w/ alterations in apoptogenic & extracellular signaling proteins
– Net result = Reduction in proliferation & in apoptosis in cancer cells
47
There is now a future prospective vaccine that holds promise with HSA cancer cells because of this vaccines ability to target those stem cells secreted by HSA......what are those cells secreted and how does this vaccine work?
* HSA cancer stem cells shown to express EGFR & Urokinase plasminogen activator receptor (uPAR)
* **eBAT** (blocks EGFR)= Bispecific urokinase angiotoxin designed to target (inhibit) EGFR
– Mutation in EGFR = Triggers cancer cell to continue to grow/divide
* **6-month survival = 70% (historical control \< 40%)**
– 6 dogs w/ ST’s **\> 450 days**
48
What are the 2 techniques considered when performing a complete splenectomy? Which is most common
* Ligation of individual hilar vessels (most common)
* Ligation of the splenic and short gastric aa.
49
What are the pro/con of ligation of indiv. hilar vesselv with a complete splenectomy?
* Predicable perseveration of vascular branches to pancreas and stomach
* Time consuming to do by hand
**• Less risk of PO hemorrhage**
50
What are the pro/con of ligation of the splenic and shortgastric aa. with a complete splenectomy?
– w/out compromising blood flow to greater curvature of stomach it can:
* decrease surgical time
* More challenging if large mass or omental adhesions distort anatomy
* Increased risk of major hemorrhage w/ technique failure :-(
51
What is the COMPLETE splenectomy referred technique if anatomic distortion of vasculature d/t adhesions or size of mass? Describe the 2 basic details?
Hilar Dissection
* Make sure to Isolate and double ligate vessels at hilus
* Preserves branches to pancreas & stomach
52
When doing the splenic artery ligation technique for complte splenectomy we open this structure and indentify the splenic artery and vein. We carefully preserve the branch that travels to this stucture? What method do we use to ligate?
* Omental bursa
* Preserve branch (pancreatic artery) to left limb of pancreas (primary blood supply)
* Ligate with the triple clamp technique bc of the high potential for hemorrhage
53
When doing splenectomies we can either use clips because it's often faster and easier than hand sewn but what are the disadvantages and who can't we use this with?
Disadvantages = Clip instability, use limited to vessels **\< 4 mm diamete**r & implantation of non-absorbable materials (large breed dogs we can't use these because they have LARGE vessels)
54
Where can we not use clips for sure in large breed dogs?
**\*\*\*\*Most medium to larg breed dogs will have hilar vessels over 4 mm especially in the center where the splenic artery and vein are directly feeding so don't use clips here!!!**
55
This ligation device was replaced by electrocautery but is still used? can't be used in?
LDS (Ligate Divide Stapler)
Can't be used in large breeds
56
What is the benefit and vessel size increase we can use when he have the **ELECTROTHERMAL BIPOLAR SYSTEM - \*\*Ligasure\*\*??** Downfall it's $60,000 for the generator it needs
* Handles vessels up to **7mm** w/ minimal thermal damage to surrounding tissue (up to 2 mm)
* Minimal complications
* Musch faster and **NOOOO foreign material (clips/suture) left behind**
57
ELECTROTHERMAL BIPOLAR SYSTEM - \*\*Ligasure\*\* achieves local hemostasis by vessel compression and obliteration through emission of ______ energy. It denatures _______ in vessels
* Bipolar energy
* Denatures collagen/elastin in vessels
58
What type of splenic surgery is Dr. C not a hige fan, what are the only indications where he might conider insitituting it (3) what's it better todo normally for at risk breeds for splenic disease?
_Partial Splenectomy_
– Trauma
– Focal abscess
– Partial infarction
* **\*\*Please remove the whole spleen in at risk breeds for splenic disease\*\***
59
What is the most common post op complication with partialsplenectomy? State some others that are iatrogenic, infection, etc.? (6)
* **Hemorrhage (most common)**
* Pancreatitis / necrosis **(iatrogenic) OVERLIGATION**
* Gastric wall compromise **(iatrogenic) OVERLIGATION**
* Subclinical hemoparasite infections
– Increased Bartonella infection risk
• Portal vein thrombosis
* **_Arrythmias have an increased death rate 2 times the normal when they are present from post opp hemorrhage so cardiac assessment is crucial_**
60
Is the perioperative mortality rate good or bad with partial splenectomy?
7.6% which is not that bad!!! pretty good
61
What is the cause of of the arrythmias with spectomies? ARE THEY ATRIAL OR VENTRICULAR? How should we monitor? What patients do we really monitor? (4)
* Compromised venous return to the heart caused by intraabdominal mehorroahe and compression of the caudal vena cava
* **Typically Ventricular (LIKE GDV's)**
* **Post op Closely Monitor through telemetry**
* **Especially monitor with splenic rupture patients**
62
The pancreas consists of right and left limbs with a central body, the left limb is supplied by this artery and the body/right limb are supplied by this branch?
* – Left limb - Branch of splenic a.
* – Body/Right limb – Caudal pancreaticoduodenal a.---\> Branch of cranial mesenteric a.
63
The _____ \_\_\_\_\_ drains the right lobe and then enters the ______ at this location....?
The **PANCREATIC DUCT** drains the right lobe and enters the **DUODENUM at the major duodenal papilla with bile duct**
64
Do cats have a accessory pancreatic duct?
No!!! They primarily **_ONLY_** have the **_PANCREATIC DUCT_**
**_"Cat's can't accessorize that!"_**
65
The _____ \_\_\_\_\_\_ drains the left lobe and into the duodenum at the minor _____ in \_\_\_\_\_
The **Accessory Pancreatic duct (LARGER ONE)** drains the left lobe and into the duodenum at the minor Duodenal papilla in dogs
66
Which is larger the pancreatic duct or accessory pancreatic duct?
Accessory Pancreatic Duct
67
What are the main physiological functions of the pancreas?
Exocrine and Endocrine
68
Describe the exocrine functions of the pancreas? (2)
– Digestive secretions via duct system
– Major and minor duodenal papilla
69
What are the endocrine functions of the pancreas? What cells do they contain?
Endocrine has the **islets of Langerhans!!!**
* **A: make glucagon**
* **_B: insulin (60-75% of islet cells)_**
* **D: Somatostatin**
* **F or (P): pancreatic polypeptide**
70
What is a very common pancreatic disease but it's not surgical?
• Pancreatitis – Very common BUT NOT a surgical disease
– Cross-over in clinical signs that may prompt exp. Lap but could EXACERBATE the condition d/t manipulation & hypoperfusion/tension during anesthesia
71
This pancreatic disease is Usually a result of excess or deficiency in production of one of the hormones? Which is most common
Endocrine pancreatic neoplasia (insulin based insulinoma is most common)
72
This pancreatic sx technique is when you need to Obtain from edge of organ (careful of deep vessels) What's different about cats?
Laparoscopic biopsy
– Cats may not have grossly abnormal tissue = Procure multiple samples
73
What pancreatic sx technique is indicated with focal lesions in body, how do we obtain it?
Surgical Biopsy - Guillotine technique (Description to follow)
* shave biopsy or Trucut- Watch for surrounding adjacent vessels or ducts
74
What pancreatic sx technique do you do if the lesion is near the CAUDAL aspect of the limb?
Do partial pancreatectomy if lesion near caudal aspect of limb(s)
75
Why do we rarely do a total pancreatectomy and why would we even do them if we had to?
High morbidity and mortality: **Usually in conjunction w/ resection and anastomosis of proximal duodenum, ligation of common bile duct and cholecystojejunostomy (Billroth II)**
– If NOT done w/ Billroth II then caudal pancreaticoduodenal aa./vv. must be spared =VERY difficult… (AKA unless you a badass like Dr. C ya aint doin it)
• Indications
**– Acute trauma**
**– Severe, chronic fibrosis**
**– Extensive neoplasia**
76
What do we do is _diffuse_ disease is present in the pancreas for sx? Where to sample?
**Suture Fracture (Guillotine) Technique**
– Sample distal aspect of right limb = easiest to access
• Procure multiple bx‘s
77
What is the indication for a partial pancreatectomy and what do we incise (\_\_\_\_\_\_ and \_\_\_\_\_\_\_) and dissect between? State what instruments work best for ligation.
• Indications
**– Tumor removal**
* Incise omentum & capsule
* Dissect between lobules to isolate vessels & ducts in portion of gland to be removed
**• Hemoclips or bipolar cautery work BEST for ligations**
78
WIth partial pancreatectomies, if the remaining ducts are patent **(yes jennnn that means open)** what percentage of pancreas can be removed??? \_\_\_\_%
80%
79
**Pancreatitis is the most common** surgical complication with this sx procedure of the pancreas? What does that mean you have todo with owners
Partial Pancreatectomy
* BE NICE TO THE OWNERS JENNNNN, even if you want to punch them in the face for letting their dog eat 5 sticks of butter.
* Real note: Warn them!!! Very unpredictable for who gets PO problems
80
What can takeplace with partial pancreatectomy is the pancreatic drainaige is COMPLETELY OBSTRUCTED. FUCKKK now tell me how to treat it?
**EXOCRINE pancreatic insuffiency can result!!!**
**(**if you mistakenly said endocrine I'm gonna punch you in your fucking twat Pierce)
**Treat by giving pancreatic enzyme supplementation and feeding a low fat/high digestible food**
81
What can result when performing partial pancreatectomy if 80-90% of the pancreatic tissue can be removed and how do we treat it?
(which I mentioned like 5 cards ago but lemme guess YA ALREADY FORGOT....anyways I guess I'll say it again......**.remember we said we take that much if the remaining ducts are patent \<3**
**Endocrine pancreatic insufficiency (i.e. diabetes mellitus) and treat it with insulin supplementation**
yea Jenn it's okay to say ENDOcrine now your twat is safe from punches bc you're gonna get this question right on that exammmm beeeetch \<3 yewww
82
What is a rare but relevant surgical complication that can happen from partial pancreatectomy and explain what happens?
* **Devitalization of duodenum**
The caudal pancreaticoduodenal a. arises from the cranial mesenteric a. and then the Vessel also supplies branches of the duodenum. Both closely associated w/ proximal portion of the right lobe of pancreas and If damaged then duodenum can be compromised
83
What do you not do to the area the arrow is pointing to?
You cut that branch and I cut you!!!!!
**Do not ligate it**
84
What is Dr. C preferred dissection / resection tool for pancreatic surgery and why does he like it?
**LIGASURE FOR PANCREATIC SURGERY**
* Faster sx & shorter hospitalization w/ ligasure
* **NO Pancreatitis**
85
Collections of pancreatic secretions and cellular debris w/in fibrous sac or wall of ______ \_\_\_\_\_\_(his most fav fucking tissue to talk about)
**Pancreatic pseudocyst**
* granulation tissue
86
Are pancreatic pseudocysts technically a cyst?
**Lacks epithelial wall = Not true cysts**
– Fluid is NOT secreted from lining rather is thought to leak from damaged pancreatic ducts and vessels
87
Pancreatic pseudocyst is often a ASYMPTOMATIC _______ finding and may be assocaitaed with recurrent bouts of _____ or \_\_\_\_\_
incidental; pancreatitis; trauma
88
What is the common signalment associated with Pancreatic Pseudocyst? Describe the symptoms?
**– Middle aged to older, dogs mostly**
– Cats affected too (rare)
Most asyptomatic but can have Vague signs of abdominal discomfort, anorexia, +/- vomiting
89
What is the imaging dx of choice for PP (pancreatic pseudocyst)
U/S = Test of choice and most sensitive for dx
90
Can you differentiate a pseudocyst from an abcess on ultrasound?
FUCK NOOOOO!
91
What is the 1st line of Tx with PP if diagnostic / therpeutic? DOes it cure it?
Percutaneous aspiration (especially if aclinical)
NOT A CURATIVE TREATMENT im bout to ask ya that in the next card so quit being impatient
92
What is the Treatment of choice of PP is the animal is ill from the dz? Describe the prognosis
**• Surgical Resection (curative treatment\*\*\*\*\*\*)**
**– If possible (location dependent)**
**– Treatment of choice for ”cure”**
* Debride & drain – Omentalize (this does not surgically treat for cure)
* \>75% successfully treated and survived
93
\_\_\_\_\_\_ \_\_\_\_\_\_\_
* Usually secondary to acute bouts of pancreatitis
* Most are sterile - i.e. No bacteria yielded on culture
Pancreatic abcess
94
What causes significant inflammation with pancreatic abscess's?
Enzymes escape into surrounding tissue causing significant inflammation and fibrous tissue formation
95
Describe some of the variable CS seen with pancreatic abcess?
## Footnote
– Anorexia, depression, V/D, prior treatment for gastroenteritis
– Abdominal pain, palpable mass, icterus, pyrexia
96
What do we often see with radiographs with pancreatic abscess's?
– Increased soft tissue density in right cranial or central cranial abdomen
## Footnote
**• Ascites/peritonitis**
97
We often see variable lab data with pancreatic abscess's like Leukocytosis, neutrophilia, Electrolyte abnormalities if vomiting, Amylase / lipase – Insensitive and nonspecific and of Little value but what is pretty unique see on lab data?
**– Hyperbilirubinemia/elevated LEZ d/t EHBO**
**• Inflammation of pancreas causing duodenal papilla of CBD to swell shut**
98
Can we easily RESECT pancreatic abscess from the pancreas?
• Resection is Often very challenging as disease is NOT localized
99
When debriding and draining pancreatic abcess what can we do to have a better outcome compared to open drainage?
\*\*Omentalize\*\*
100
Post operatively what is really important to have after debriding and draining a pancreatic abscess?
**PO enteral nutrition plan – HAVE ONE = Need post-gastric feeding!**
101
Describe the prognosis of pancreatic abcess?
_**• Guarded in dogs\*\***_
• High perioperative mortality (40% in dogs & 25% in cats)
– they often become Septic
– Generalized peritonitis
• Long & involved ICU care PO
**• Potential recurrence if non-resectable**
102
What are our top to ddx for ENDOcrine pancreatic neoplasia?
* Insulinoma
* Gastrinoma
103
Which ENDOcrine pancreatic neoplasia is Adenocarcinoma of non-β islet cells and APUD cell tumors??
• Gastrinoma
104
Which ENDOcrine pancreatic neoplasia is Adenocarcinoma of β-cell pancreatic islets?
• Insulinoma
105
Describe invasion (or not) malignancy (or benign) potential of apncreatic neoplasia (EXOcrine adenocarcinoma)?
Malignant & invade locally
– Metastasis = 50 -78% at time of Dx
– UNCOMMON (Fortunately)
106
Describe invasion (or not) malignancy (or benign) potential of ncreatic neoplasia (EXOcrine adenocarcinoma)?
• May have vomiting, abdominal pain, weight loss and signs of EHBO
107
What is the prognosis of EXOcrine adenocarcinoma pancreatic neoplasia?
• Poor prognosis
– 3 month survival in dogs
– \< 7 days in cats
108
Are insulinoma's mostly benign or malignant?
90% malignant
109
What age and breeds often get insulinoma?
* Uncommon in dogs/Rare in cats
* Older dogs/Breed predispositions
GSD, Poodle, Boxer, Goldens
110
What is the pathophys for Insulinoma's?? State some CS?
• β-cells of the islets of Langerhans =
Secrete insulin despite hypoglycemia
• Weakness, seizure
– Polyneuopathy – Chronic hypoglycemia can damage nerves
111
This is a tentative dx of Insulinoma and also has CS associated with hypoglycemia?
**WHIPPLE’S TRIAD**
112
What is the conc. of fasted glucose for whipple's triad?
• Fasting blood glucose conc. of 40mg/dL or lower
113
With whipples triad you get neuro signs such as seizures, what can you do relieve them?
Relief of neurologic signs (i.e. seizures) w/ feeding or glucose administration
114
What is diagnostic for Whipple's Triad?
**• \*\*Fasting insulin-glucose ratio diagnostic for condition\*\***
– Insulin HIGH despite HYPOGLYCEMIA
**Normal fasting serum immunoreactive insulin concentrations range from 5 to 26 μIU/ml, whereas insulin levels in affected animals often exceed 70 μIU/ml**
115
What kinds of meals can you do for medical management for Insulinoma?
• Small, frequent meals (3-6/day)
– High protein, complex carbohydrates
116
With Insulinoma, what does glucocorticoid therapy do in terms of medical management ?
• \*Glucocorticoid therapy
– Increases hepatic glucose production & decreases cellular glucose uptake
117
With Insulinoma, what does oral hyperglycemic agents therapy do in terms of medical management ?
• \*Oral hyperglycemic agents
– Diazoxide = Inhibits pancreatic insulin secretion and glucose uptake by tissue
118
With Insulinoma, what does streptozotocin do in terms of medical management ?
Streptozotocin – Naturally occurring alkylating antineoplastic agent that is particularly toxic to the insulin-producing beta cells
– HIGH SE profile – Not commonly used
119
If severe insulinoma what do you do for medical management?
If severe = ICU and dextrose supplementation in fluids BUT don’t’ overdo it! Remember these dogs are used to living hypoglycemic
120
What is the gold standard treatment for insulinoma?
• \*Partial pancreatectomy = Gold standard treatment\*
– Applicable when solitary nodules present. Fortunately = Most common scenario
121
What is the best chance to ID the insulinoma tumor when no nodules were seen at surgery or Preop scanning?
Contrast CT scan = Best chance to ID tumor
122
What are the other options for treatment of the insulinoma when no nodules were seen?
## Footnote
* IV Methylene blue = May stain neoplastic islet cells to ID tumor
* Intraoperative ultrasound
* Do not do indiscriminate surgical excision. Used to be recommendation
123
Describe the in incidence of metastasis at surgery?
• 50% incidence of metastasis at surgery
– Resect any enlarged regional LN’sc
124
Do insulinomas's have a high rate of recurrence?
Recurrence of **hypoglycemia** d/t metastasis = Common
125
Describe the prognosis of insulinoma with MST when surgery and medical therapy on relapse?
• MST w/ sx then medical therapy on relapse = 1316 d (3.6 y)
– Prednisone was main source
– No benefit from Diazoxide in this study but small numbers
126
What are the stages of insulinoma and corresponding MST?
– I (Confined to panc.) = MST - 785 d
– I (Regional LN invol.) = MST – 547 d
– III (Systemic mets) = MST – 217 d
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Are gastrinoma's malignant or benign, where do they derive from?
* Rare tumors in dogs & cats – Highly malignant
* Derived from ectopic amine precursor uptake decarboxylase (APUD) cells in the pancreas & produce an excess of the hormone gastrin = Causes multiple duodenal ulcerations
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WHat is Zollinger Ellison syndrom in terms of Gastrinoma?
**_Zollinger-Ellison syndrome_** - Describes syndrome of gastric acid
hypersecretion, gastrointestinal ulceration & non–β-cell pancreatic tumors
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Gastrinoma's often have _____ prognosis, what is diagnostic for it?
poor; High serum gastrin levels = Diagnostic
