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ABSITE > pancreas > Flashcards

pancreas Flashcards

1
Q

Beger

A

resection & drainage of dilated/normal duct, big HEAD
head resection; without splaying open PD

requires division of panc neck and two panc anastomoses

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2
Q

Frey and Puestow

A

lay open panc ducts
Frey cores without transection.

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3
Q

Frey

A

resection & drainage of dilated duct. big HEAD

Local resection of the pancreatic head with longitudinal pancreaticojejunostomy

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4
Q

Puestow

A

normal head, big ducts ONLY ONE WITH NORMAL HEAD

Longitudinal LATERAL pancreaticojejunostomy

indication: dilated pancreatic duct (> 6 mm) without pancreatic head enlargement

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5
Q

lateral pancreaticojejunostomy

A

modified Puestow; panc duct dil 2/2 stones/strictures >1-2cm away from the papilla

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6
Q

what procedure for distal panc stricture with side branch changes and normal head?

A

distal panc

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7
Q

what procedure for minimal change pancreatitis = small duct chronic pancreatitis?

A
  1. denervation (bilateral thoracoscopic splanchnicectomy or celiac ganglionectomy)
  2. total pancreatectomy with islet autotransplantation
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8
Q

contraindication to islet cell autotransplantation?

A

cancer or malignant potential neoplasm

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9
Q

grades panc leaks = 3x serum amylase POD3

A

former grade A postoperative pancreatic fistula is now redefined and called a biochemical leak, because it has no clinical importance and is no longer referred to as a true pancreatic fistula

grade B fistula requires a change in postoperative management. Drains are either left in place for more than 3 weeks or repositioned through endoscopic or percutaneous procedures, but without evidence of end-organ failure or need for reoperation.

grade C postoperative pancreatic fistula refers to a postoperative pancreatic fistula that requires reoperation or leads to single or multiple organ failure and/or mortality attributable to the fistula.

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10
Q

mucinous cyst neoplasm dx findings on CT scan

A

Solitary cyst surrouded by calcifications + INTERNAL septations (bad)

body/tail ?»»>

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11
Q

mucinous cyst neoplasm histology, hormone receptors?

A

mucin-rich cells, ovarian-like stroma, and are commonly estrogen receptor and progesterone receptor positive

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12
Q

mucinous cyst neoplasm risk factors for malignancy

A

septations, larger size (>6 cm), and mural nodularity

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13
Q

mucinous cyst neoplasm age group and presentation?

A

Mean age is fifth decade and 50% of patients have vague abdominal pain.

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14
Q

mucinous cystic neoplasm cyst studies

A

mucin-rich aspirate and high levels of carcinoembryonic antigen (> 192 ng/mL)

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15
Q

mgmt mucinous cystic neoplasm

A

resection w splenectomy

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16
Q

frequency of pancreatic cystic neoplasms

A

MCN – 10 to 45%
IPMN – 21 to 33%
***SCA – 32 to 39%
SPT (solid papillary tumor) – <10%

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17
Q

malignant potential of pancreatic cystic neoplasms

A

MCN
Benign (adenomatous) – 72%
Low-grade malignant (borderline) – 11%
Malignant (CIS or invasive ca) - 17%

IPMN
Main-duct type (MD-IPMN)
Carcinoma in situ – 19%
Invasive carcinoma – 43%

Branched-duct type (BD-IPMN)
Carcinoma in situ – 7%
Invasive carcinoma – 18%

Mixed-duct type – risk of malignancy intermediate between MD-IPMN and BD-IPMN.

SCA – Not expected to have malignant potential.

SPT – 10–15% of patients demonstrate metastatic disease.

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18
Q

ipmn presentation

A

pancreatitis-like, steatorrhea, weight loss
head»»»>

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19
Q

IPMN dx findings on CT scan

A

variable in size, multi-locular, can involve main- or branch-ducts

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20
Q

IPMN histo?

A

papillary projections of columnar-lined epithelium, varying degrees of dysplasia and abundant mucin

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21
Q

IPMN worrisome fatures vs
Fukuoka guidelines stigmata

A

symptomatic, biliary obstruction, large >3 cm, mural nodules <5 mm, MAIN DUCT dilation 5-9m, abrupt change in duct size
Lymphadenopathy
pancreatitis

**High-risk stigmata:
Obstructive jaundice secondary to pancreatic head cystic lesion
Enhanced solid component
MPD size > 10 mm

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22
Q

ipmn mgmt

A

resect if stigmata then follow q6 MRI if not fully resected
stigmata: main duct (30-50% malignant potential), >3cm, cyst wall thick, main duct 5+mm

if R0, CT at 2 and 5 years

if invasive, may need adjuvant chemo

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23
Q

serous cystic neoplasm dx ct scan

A

septations and thick fibrous walls with innumerable small cysts (microcystic) with thin, clear fluid, which results in a honeycomb appearance with a central calcified scar (10–20% of the time), variable in size (mean 6 cm)

HEAD&raquo_space;

can dx it off the CT scan alone

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24
Q

serous cystic neoplasm hsto

A

glycogen rich cuboidal epithelial lining without mitoses, nuclear polymorphism

Scant glycogen-rich cells, with positive periodic acid–Schiff stain

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25
Q

mgmt serous cn

A

resect if symptoms, lesions that demonstrate rapid growth, or lesions that are large and impose upon surrounding organs/physiology.

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26
Q

solitary papillary tumor ct dx

A

irregular cystic cavities with hemorrhage

solid mass with slight contrast enhancement in the arterial phase, but enhances significantly in the venous phase,
while cystic portions of the lesion do not enhance. Central calcification may be seen.

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27
Q

solitary papillary tumor histo

A

solid sheets, appear similar to pancreatic neuroendocrine tumors

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28
Q

spt mgmt

A

though indolent, SPT are malignant and should be resected in surgically fit patients. Due to its well-encapsulated state, enucleation may be considered, as opposed to segmental pancreatic resection.

recurs in 4 years so CT annually til 5 years

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29
Q

sca vs spt presentation

A

SCA – females (75%) with peak incidence in the sixth decade.
SPT – females (>80%) with peak incidence in the third and fourth decades.

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30
Q

low cea fluid

A

pseudocyst and serous cn

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31
Q

high amylase fluid

A

pseudocyst and ipmn

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32
Q

low mucin

A

pseudocyst and serous cn

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33
Q

5 yr survival MCN, IPMN, SCA, SPT

A

MCN: 57% if malignant
IPMN: 40-60% If malignant
SCA: live forever
serous cystadeno: great px
SPT: 95% (resection is curatie)

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34
Q

pancreatic pseudocyst CA 19-9

A

HIGH. like IPMN with high risk

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35
Q

pancreatitis feeding

A

regular diet through the mouth??? (score) as soon as resuscitated.
if can’t tolerate, feed distally
if can’t tolerate, wait 7 days NPO until initiating TPN

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36
Q

CA 19-9; where found?

A

biliary tree

correlates with tumor burden

used to monitor response to therapy (before imaging findings)

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37
Q

pancreatic adeno chemo

A

gemcitabine + cisplatin

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38
Q

pancreatic divisum presentation

A

asx&raquo_space;> pancreatitis

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39
Q

pancreatic divisum embryology

A

failed fusion of ducts at 8 WGA so pancreas drained Santorini (minor papilla)

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40
Q

pancreatic divisum dx

A

secretin enhanced MRCP (see dorsal panc duct cross ant to CBD and drain superiorly into MINOR; and see separate ventral panc duct)

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41
Q

pancreatic divisum tx

A

ERCP with sphincteroplasty of the minor papilla

42
Q

> 180 SMA involvement panc adeno

A

preop chemo; then restage and consider radiation vs surgery

43
Q

abutment margin for cystG or cystD?

A

1cm; otherwise consider an operative cystJ Roux en Y

44
Q

Appleby procedure

A

distal pancreatectomy with en bloc splenectomy and pancan resection and relies on the presence of collateral arterial circulation via an intact pancreaticoduodenal arcade and the gastroduodenal artery to maintain prograde hepatic arterial perfusion

45
Q

PVT and panc resection

A

contraindication
splenic VT is relative contraindication
collateralization makes it very high risk surgery

46
Q

ampulla of vater adenoma

A

endoscopic resection if <1cm into bil/panc duct; <2-3 cm
transduodenal ampullectomy (exise tumor and BP ductal junction, reconstruct and reimplant new channel back into duodenal wall) otherwise

47
Q

VIPoma irregularities

A

hypoK
achlorhydria
metabolic acidosis, hypovolemia,
hyperCa
hyperglycemia

48
Q

extra pancreatic VIPoma location:

A

adrenal, RP, mediastinum

49
Q

communicating pseudocyst to panc duct mgmt

A

internal drainage (stent)

50
Q

% OF PPL that lead to T1DM afer distal panc

A

10%

51
Q

How to define acute and non-acute pancreatitis (thus acute collection vs pseudocyst and acute necrotic collections vs WOPN)

A

4 wks

52
Q

timing VARD after nec panc perc drainage?

A

at least 4 weeks

53
Q

Muir Torre syndrome

A

of Lynch syndrome MMR
sebaceous carcinoma with panc cancer

54
Q

enucleation criteria

A

must be >3mm from main panc duct or portal vein

55
Q

locally advanced panc ca

A

SMA abutment > 180

56
Q

borderline panc ca

A

SMV and HA involvement

57
Q

Protease serine 1 gene PRSS1 -

A

hereditary pancreatitis

58
Q

Serine protease inhibitor Kazal type 1 gene SPINK1 - pancreatitis

A

cleaves activated trypsin, preventing premature activation of other zymogens within the pancreas and the pancreatic duct

59
Q

defining resectability of pancreatic ca

A

unresectable: CT evidence of distant metastatic spread to the liver, peritoneum, or lung

locally advanced (unresectable): which is defined by CT evidence of arterial encroachment of the celiac axis or superior mesenteric artery, or venous involvement or occlusion of the superior mesenteric or portal veins

potentially resectable:no CT evidence of extrapancreatic disease, a patent superior mesenteric vein (SMV)-portal vein confluence, and no evidence of direct tumor extension to the celiac axis or superior mesenteric artery

60
Q

staging for pancreatic ca

A

needs dx lap before definitive resection

61
Q

dx lap strategy to assess for pancreatic ca extension?

A

-direct inspection of the pancreas and the peripancreatic lymph node burden
-evaluate adjacent organs etc
-pelvic washings
-washings in the lesser sac can be performed to allow for cytologic evaluation
-laparoscopic ultrasound can be used as an adjunct to assess patency of nearby vessels, stenosis of the pancreatic duct, and to guide lymph node biops

62
Q

duct of santorini

A

ACCESSORY panc duct in dorsal panc bud

63
Q

duct of Wirsung

A

MAJOR panc duct that merges with CBD before entering duo in ventrla pancreatic bud

64
Q

annular pancreas

A

D2 trapped in panc band;

XR: double bubble (duo obstruction)

ass’d Down syndrome

65
Q

pathophys of annular pancreas

A

failure of clockwise rotation of VENTRAL/main panc bud

66
Q

mgmt of annular pancreas

A

don’t resect the pancreas; just DD or DJ or GJ

67
Q

pancreas divisum

A

failure fusion of panc ducts; result in pancreatitis from SNATORINI/accessory stenosis
Wirsung is gone.

68
Q

dx pancreas divisum

A

ERCP with minor and major papilla

69
Q

mgmt of pancreas divisum

A

ERCP with sphincteroplasty

70
Q

ranson’s criteria

A

on admit: 55 YO, WBC 16K, BG 200+, AST 250, LDH 350

after 48 hours: Hct 10%, BUN 5, Ca < 8, PaO2 < 60, base def > 4, fluid sequestration 6L

8 things = 100% mortality

71
Q

pancreatitis bleeding

A

grey turner: flank ecchymosis
cullens: periumbilican
foxs: inguinal

72
Q

pancreatitis avoid morphine

A

contracts sphincter of oddi; worsens pain

73
Q

panc insufficiency dx

A

> 90% panc function gone

dx with fecal fat testing

74
Q

mgmt panc insuff

A

creon, low fat diet, high carb/highprotein diet

75
Q

MC genetic mutation in pancreatic ca

A

p16; 95%

TSG binds cyclin complexes

76
Q

HEAD NETs

A

gastrinoma, somatostatinoma

77
Q

DISTAL NETs

A

glucagonoma, VIPoma

78
Q

muchausen insulin

A

decreased C peptide and proinsulin

79
Q

mgmt insulinoma

A

resection if > 2cm
enucleat if <2cm
5Fu, streptozocin if metastatic
diazodie if symptomatic

80
Q

panc fluid collections acute vs chronic

A

4 weeks
WOPN pseudocyst vs acute necrotic acute peripanc

81
Q

intervene pseudocyst

A

6 cm, sx after 6 wks

82
Q

Infected necrotizing pancreatitis abx of choice

A

Imipenem

83
Q

panc adenocarcinoma tx

A

Resect with adjuvant (FOLFIRINOX)

Neoadj if borderline (need Bx first)

Definitive chemorad if unresectable)

84
Q

FOLFIRINOX

A

folinic acid
luorouricil
irinotecan
oxaliplatin

85
Q

Hx pancreatitis presents with hematemesis?

A

Splenectomy for SVT (gastric varices)

86
Q

incidence of portosplenic venous thrombus in NECROTIZING acute pancreatitis

A

50% of patients

87
Q

do patient need EGD to look for gastric/esophageal varix after diagnosed with post-pancreatitis splenic vein thrombus?

A

Ya..

88
Q

arterial origins for pancreas

A

SMA - inf pancreaticoduodenal aa
Celiac to GDA - sup pancreaticoduodenal aa
splenic aa - pancreatic arteries (greater, inferior, dorsal)

89
Q

rate of recurrent acute GSP within 3 mos if no same-admission CCY?

A

25%

90
Q

autoimmune pancreatitis diagnostic/labs

A

increased IgG4, IgG4+ plasma cells

appears like mass on CT scan in head

91
Q

extrapancreatic manifestations of autoimmune pancreatitis?

A

bile ducts (jaundice)
bowel (IBD-like sx)
salivary/lacrimal glands (xerostomia and xerophthalmia)
kidney (CKD)
lungs (LAD)

92
Q
A
93
Q

when to drain biliary tree in pancreatic ca?

A
  1. if resectable: only if very symptomatic
  2. if neoadjv: only if jaundice

use metal stent because easier to place, longer patency

94
Q

somatic mutations associated with pan can

A

KRAS
TP53
SMAD4
CDKN2A

95
Q

ddx bleeding after VARD

A

splenic or GDA PSA!!!

early: avulsion of peripanc aa/veins
subacute >2 days: PSA

96
Q

next step for suspected exocrine pancreas insufficiency?

A

fecal elastase-1 test

97
Q

initial treatment for exocrine pancreas insufficiency

A

high carb
high protein
low fat
creon

98
Q

most potent stimulator for exocrine secretion?

A
  1. secretin for BICARB & FLUID
  2. cholecystokinin for ENZYME
99
Q

zollinger ellison dx

A

gastrin > 1000 pg/mL

if more equivocal range but still suspect, can do secretin stimulation test to make sure it increases by 200.

100
Q
A

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