Pancreas Flashcards by william hudson

Describe chronic panc procedures

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What does pancreatic mass bx with diffuse lymphocytic invasion indicate

Autoimmune panc

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How did the Halsted 1898 operation differ from WHipple in 1935

just the 2nd portion of the duo

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Original periop mortality? for periampullary ca
after tert centers
and now

20-40
5
2

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4 risk for pancreatic cancer

Smoking, obesity, DM2, and 1st degree relatives

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5 y survival for PDAC

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how many are surgical candidates for PDAC? how many of those make 5 years

20%; 20%

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2 risk factors for distal cholangio

liver flukes
PSC

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Only good thing about ampullary ACA

early obstruction

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Duodenal adeno is what % of SB CA; associated syndrome

56; FAP

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tumor marker for panc

cA 19-9

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What is the imaging modality of choice for PDAC? How does it appear?

CholangioCA?

Hypodensity surrounded by normal appearing tissue

OFten not seen —>CBD thickening seen

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What ‘sign’ can be seen radiologically for periampullary ca

double duct — PD and CBD

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T staging for periampullary CA

0-2
2-4
>4
local vessels

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Periampullary ca stage 2b - 3 diff

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What defines abuttment

loss of fat plane on imaging

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Whipple 6 big steps

1 - Met eval, full kocher to L renal v, expose Portal and SMV, LN harvest
2- Lesser sac,

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3 post operative tenets for whipple

Early feeding, early drain removal(3days), zero fluid balance

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3 major complications following whipple early post op

DGE, POPF, PPH

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Post op whipple hemorrhage causes eary v late

technical error

inflammation from panc leak —-> GDA PSA

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POPF grading scale

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5 year survival rate for all panc adenoca

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3 methods of non op biliary obstruction managmennt

endo stent> perc stent> perc drain

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difference in biliary stents

plastic temp

metal long term 12m, covered stents have better patency against overgrowth but can migrate

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non op options for GOO do to panc adenoca, what type of patient success rate?

stent if less than 6 months predicted 96%

3 operative palliative procedures for panc adenoca

roux choledocho GJJ Celiac neurolysis

Describe celiac neurolysis procedure

50% ethanol injection either side of aorta

Side effects folfirinox v gemcit

Why does all panc adeno get systemic therapy at some point

It is considered systemic disease at dg

Borderline cutoffs: artery, vein and extrapancreatic

Artery: <180 abuttment sma and celiac, short encasement CHA Vein:>180 SMV/PV; < 190 with contour irreg or thrombosis Extra: Suspicious mets(10-20% will have radiographically occult disease

2 arguments against the conko 001 adjuvant trial

Heavy bias only 50% received it

5 Neo adjuvant for PDAC pros and 3 cons

Pros: -all pts treated -aggressive tumors identified by response incs rads efficacy -dec fistula dec pos margins Cons: - Needs endo bx - possible endo stent - possible loss of "window" (2%)

how long is neo chemo for pdac

2 months

Schedule for resectable pdac including neo what is included in restaging

neo 2 m, RS, surgery, RS, adj 4 months CTDP CA19-9 ECOG

ECOG scale

Describe a serous cystadenoma Appearance on CT FNA results

benign, true epithelial lining with glyogen rich cuboidal cells starburst, honeycomb low cea, low mucin, atypia on FNA

Tx for serous cystadenoma

AS: obs Sympt/growing: resect

What radiologic characteristic of some serous cystad may cause dg confusion What additional test do we perform

multicystic FNA

describe rads findings for mucinous cystic neoplasm typical pt demographic Cell type found

singular, thick walled, large female 9:1 ovarian type stroma

ovarian type stroma is dg for what panc mass

mucinous cystic neo

what is often radiographically confused with mucinous cystadenoma What 2 labs can diff on fna

pseudocyst amy up in pseudo CEA above 200 is pathognomonic for mucinous cystic ne

Tx for mucinous cystic neo

resection

This panc pathology mimics PDAC radiographically and clinically

Autoimmune panc

IgG4 s serology used to dg what

autoimmune panc

Describe the histopathology findings for AIP

periductal lymphoplasmocytic infiltration with obliterative phlebitis Lymph infilt w/ storiform fibrosis and Igg4 cells

Tx for AIP What to monitor for after starting tx

steroids watch IgG4 and CA19-9 (occult malign monitoring)

how does acinar cell ca differ from pdac radiologically

hyperenhancing borders rather than discrete

What fna finding separates acinar cell ca tx?

lipaase resection

What is Schmid's triad

eosinophilia, polyarthralgia and eerythema nodosum found in acinar cell ca

Elevated LDH found on FNA with lobulated panc mass what is needed for treatment what is tx

lymphoma tissue CHOP

CHOP regimen and side effects

MC origin of met disease in panc, apearance on CT

RCC hypervasce

who revolutionized vascular transplant techniques and when

Alexs Carrell of France in 1300

4 selection criteria for panc transplant

under 55 not obese brittle diabetics with end stage dyfunction Failed medical tx

preferred procurement host preferred specimen on gross

bmi less than 30 under 50 soft pink

Ransons criteria

Atlanta Criteria

Main goal of initial resus in severe panc

hydrate till they piss 10-20 ml/kg/h of LAR for 24-48h plus goal directed

what is the initial insult starting acute panc then what 2 additional things happen

edema/microangiopathic change dec blood flow cell death and exocrine release

abx tenets for AP

hold unless obvious infection

decision algorithm for chol mild gs panc vs severe

chole same stay vs 6 weeks for severe

what is the mortality % for sev panc with more than 48h of SIRS

What percent of panc resections does IPMN account for

Cytology for IPMN

inc CEA and amylase

oncogenes for ipmn fam hx for ipmn

KRAS/GNAS Panc CA hx

3 high risk stigmata for ipmn

jaundice 10mm pd mural nodule>5mm

7 worrisome features for ipmn

mural nodule <5mm, PD 5-9mm, >3cm, thick wall, LN involv, inc CA19-9, grows >5mm in 2y, abrupt caliber change in PD

Observation of ipmn by size classification

<1cm: 6m then q2y 1-2cm: 6 6 1 1 2 2-3cm: EUS 3-6m, then MRI q1y >3cm : push surgery, EUS q 3-6m

How many people with IPMN resections are symptomatic what is a major associated comorbidity

50 DM

cancer and dyplasia rates for bd v md ipmns

BD: 15 and 9 MD 44 and 33

What CA19 9 level is concerning for IPMN, what is the ppv at this pointq

100 92%

What is the imaging modality and what might be even better for ipmn

MDCT panc protocol MRI/MRCP

epithelial types for BD and MD Ipmn

gastric intestinal

Post resection 5 y survival invasive v non for ipmn

47 93

margins for ipmn?

controversial

most common functional pnet s/s tx

insulinoma hypoglycemia enucleation

vipoma triad

diarrhea acholorydria hypokalemia

pnet for necroltyic migratory erythema management

glucagonoma lanreotide then surgery(aggressive)

What s/s show up for SSoma

cholelithiasis dm2 steatorrhea

what testing is done for insulinoma dg and what 3 criteria are met

72h fast gluc<45 insulin>5inc proinsuilin and c pep

imaging modality of choice for pnet what did it used to be

PET DOTATATE 68 GA DOTA peptide SS scan

2 metastatc pnet treatments and their receptor types when can mets be operated on

everolimus(mtor) sunitinib(rtki) iso liver

pnet size cutoff for aggressive surgical resection

2-3cm

Describe Appleby procedure