Modification of Whipple All stomach is intact and pylorus is preserved

Lecture 21 Surgery of Pancreatic Disorders Flashcards by Jessica Eze

What are the presentation of pancreatic cancer

Obstructive jaundice
Diabetes
Abdominal pain / Back pain
Anorexia
Vomiting
Weight loss
Recurrent bouts pancreatitis
Incidental finding

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Aetiology of Pancreatic cancer

Uknown
Smoking
Chronic pancreatitis
Hereditary
Periampullary cancer is a feature of FAP

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Investigation of pancreatic cancer

Blood test
CXR
Tumour markers

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What is the name of the tumour marker for pancreatic cancer

CA19-9

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Imagine and Invasive investigations used for pancreatic cancer

USS
ERCP
CT
MRCP
Laparoscopy
Peritoneal cytology
EUS + FNA
PET
Percutaneous need biopsy

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What type of surgeries can be performed for pancreatic cancer

Kausch-Whipple

PPPD

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Describe the Kausch Whipple

Half of pancreas and stomach removed

* Whole duodenum resected

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Describe PPPD

Modification of Whipple

* All stomach is intact and pylorus is preserved

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What are the classifications of acute pancreatitis

Mild AP

Severe AP

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Describe mild AP

Associated with minimal organ dysfunction and uneventful recovery

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Describe Severe AP

Associated with organ failure or local complication (lung, kidneys etc.)

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What are local complications of severe AP

Acute fluid collections

Pseudocyst
Pancreatic abscess
Pancreatic necrosis

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Aetiology of acute pancreatitis

Gallstones
Alcohol
Drugs
Virus
Trauma
Tumours
ErCP
Lipid abnormalities
Ischaemia 
Idiopathic

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symptoms of acute pancreatitis

Abdominal pain
Nausea
Vomiting
Collapse

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Signs of acute pancreatitis

Pyrexia
Dehydration
Abdominal tenderness
Circulatory failure

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What is the modified Glasgow/PANCREAS score

PaO2
Age
Neutrophils
Calcium
Renal function
Enzymes
Albumin
Sugar (glucose)

How is Cholelithiasis manages

ERCP & ES, cholecystectomy

How is the factor of alcohol managed

Abstinence and counselling

How is ischaemia managed

Careful support and correcting cause

How is malignancy managed

Resection or bypass

How is hyperlipidaemia managed

Diet, lipid lowering drugs

Aetiology of chronic pancreatitis

Obstruction of main pancreatic duct
Autoimmune-IgG4
Toxin
Idiopathic
Genetic 
Environmental
Recurrent injuries

Name the genes responsible for chronic pancreatic cancer

– Autosomal dominant (Condon 29 and 122)
– Autosomal recessive/modifier genes
• (CFTR, SPINK1, Codon A

Clinical Features of chronic pancreatitis

Pain
Pancreatic exocrine insufficiency
Diabetes 
Jaundice
Duodenal obstruction
Upper GI haemorrhage

Investigations for chronic pancreatitis

``` History CT scan/X-ray (calcification) ERCP/MRCP Faecal/serum enzymes (elastase) Pancreolauryl test ```

Management of Chronic Pancreatitis

``` Counselling • Abstinence from alcohol • Management of acute attacks • Analgesia • ? Interventional methods of analgesia • Avoid high fat, high protein diet • Pancreatic supplementation controversial for pain • Anti-oxidant therapy Steatorrhoea: • Reduce fat intake • Pancreatic supplementation ```

When is surgery an intervention for chronic pancreatitis

When there is a suspicion of a malignancy

Complications of surgery

* Pancreatic duct stenosis * Cyst / pseudocysts- Drainage * Biliary tract obstruction * Splenic vein thrombosis / gastric varices * Portal vein compression / mesenteric vein thrombosis * Duodenal stenosis-ERCP * Colonic stricture

Treatment for chronic pancreatitis

``` Endoscopic PD sphincetortomy, dilation and lithotripsy Management of chronic pseudocyst • CBD stenting or bypass • Thoracoscopic • Splanchnectomy • Caeliac plexus block- Caeliac plexus block- to minimize pain by CT/EUS/Fluoroscopy using alcohol – CT guided – EUS guided – Fluoroscopy guided • Classical trans-crual approach • Trans-aortic techniques ```

Surgery techniques for chronic pancreatitis

``` • Drainage: – Pancreatic duct sphincteroplasty – Puestow (Rochelle modification) • Resection: – DPPHR (Beger) – PPPD (Duodenum preserving pancreatic head resection) – Whipple’s pancreatico-duodenectomy – Frey procedure – Spleen-preserving distal pancreatectomy – Central pancreatectomy ```

What does MCN stand for

Mucinous Neoplasia

What are the 2 types of IPMN

Main duct | Branch Duct

Describe MD-IPMN High risk stigmata

MPD>10mm | Enhanced solid component

Describe worrisome features of MD-IPMN

5-9mm Non-enhanced mural nodule Abrupt change in MPD LNs

Describe MCN High risk stigmata

>1cm with enhanced solid component | MPD>1cm

Describe worrisome features of McN

>3cm Enhanced cyst wall Non-enhanced nodules

Methods of resection for MCN

* Pancreatectomy + LN’s * Focal and LN or spleen sparing: * Laparoscopic * Robotic * Multifocal BD-IPMN: total pancreatectomy