Pancreas Flashcards
Beger
resection & drainage of dilated/normal duct, big HEAD
head resection; without splaying open PD
requires division of panc neck and two panc anastomoses
Frey and Puestow
lay open panc ducts
Frey cores without transection.
Frey
resection & drainage of dilated duct. big HEAD
Local resection of the pancreatic head with longitudinal pancreaticojejunostomy
Puestow
normal head, big ducts ONLY ONE WITH NORMAL HEAD
Longitudinal LATERAL pancreaticojejunostomy
indication: dilated pancreatic duct (> 6 mm) without pancreatic head enlargement
lateral pancreaticojejunostomy
modified Puestow; panc duct dil 2/2 stones/strictures >1-2cm away from the papilla
what procedure for distal panc stricture with side branch changes and normal head?
distal panc
what procedure for minimal change pancreatitis = small duct chronic pancreatitis?
- denervation (bilateral thoracoscopic splanchnicectomy or celiac ganglionectomy)
- total pancreatectomy with islet autotransplantation
contraindication to islet cell autotransplantation?
cancer or malignant potential neoplasm
grades panc leaks = 3x serum amylase POD3
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.
mucinous cyst neoplasm dx findings on CT scan
Solitary cyst surrouded by calcifications + INTERNAL septations (bad)
body/tail ?»»>
mucinous cyst neoplasm histology, hormone receptors?
mucin-rich cells, ovarian-like stroma, and are commonly estrogen receptor and progesterone receptor positive
mucinous cyst neoplasm risk factors for malignancy
septations, larger size (>6 cm), and mural nodularity
mucinous cyst neoplasm age group and presentation?
Mean age is fifth decade and 50% of patients have vague abdominal pain.
mucinous cystic neoplasm cyst studies
mucin-rich aspirate and high levels of carcinoembryonic antigen (> 192 ng/mL)
mgmt mucinous cystic neoplasm
resection w splenectomy
frequency of pancreatic cystic neoplasms
MCN – 10 to 45%
IPMN – 21 to 33%
***SCA – 32 to 39%
SPT (solid papillary tumor) – <10%
malignant potential of pancreatic cystic neoplasms
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.
ipmn presentation
pancreatitis-like, steatorrhea, weight loss
head»»»>
IPMN dx findings on CT scan
variable in size, multi-locular, can involve main- or branch-ducts
IPMN histo?
papillary projections of columnar-lined epithelium, varying degrees of dysplasia and abundant mucin
IPMN worrisome fatures vs
Fukuoka guidelines stigmata
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
ipmn mgmt
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
serous cystic neoplasm dx ct scan
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»_space;
can dx it off the CT scan alone
serous cystic neoplasm hsto
glycogen rich cuboidal epithelial lining without mitoses, nuclear polymorphism
Scant glycogen-rich cells, with positive periodic acid–Schiff stain
mgmt serous cn
resect if symptoms, lesions that demonstrate rapid growth, or lesions that are large and impose upon surrounding organs/physiology.
solitary papillary tumor ct dx
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.
solitary papillary tumor histo
solid sheets, appear similar to pancreatic neuroendocrine tumors
spt mgmt
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
sca vs spt presentation
SCA – females (75%) with peak incidence in the sixth decade.
SPT – females (>80%) with peak incidence in the third and fourth decades.
low cea fluid
pseudocyst and serous cn
high amylase fluid
pseudocyst and ipmn
low mucin
pseudocyst and serous cn
5 yr survival MCN, IPMN, SCA, SPT
MCN: 57% if malignant
IPMN: 40-60% If malignant
SCA: live forever
serous cystadeno: great px
SPT: 95% (resection is curatie)
pancreatic pseudocyst CA 19-9
HIGH. like IPMN with high risk
pancreatitis feeding
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
CA 19-9; where found?
biliary tree
correlates with tumor burden
used to monitor response to therapy (before imaging findings)
pancreatic adeno chemo
gemcitabine + cisplatin
FOLFIRINOX???
pancreatic divisum presentation
asx»_space;> pancreatitis
pancreatic divisum embryology
failed fusion of ducts at 8 WGA so pancreas drained Santorini (minor papilla)
pancreatic divisum dx
secretin enhanced MRCP (see long, dilated dorsal panc duct cross ant to CBD and drain superiorly into MINOR; and see separate SHORT ventral panc duct)
pancreatic divisum tx
ERCP with sphincteroplasty of the minor papilla
> 180 SMA involvement panc adeno
preop chemo; then restage and consider radiation vs surgery
abutment margin for cystG or cystD?
1cm; otherwise consider an operative cystJ Roux en Y
Appleby procedure
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
PVT and panc resection
contraindication
splenic VT is relative contraindication
collateralization makes it very high risk surgery
ampulla of vater adenoma
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
VIPoma irregularities
VIPoma = Verner-Morrison syndrome
hypoK
achlorhydria
metabolic acidosis, hypovolemia,
hyperCa
hyperglycemia
extra pancreatic VIPoma location:
adrenal, RP, mediastinum
communicating pseudocyst to panc duct mgmt
internal drainage (stent)
% OF PPL that lead to T1DM afer distal panc
10%
How to define acute and non-acute pancreatitis (thus acute collection vs pseudocyst and acute necrotic collections vs WOPN)
4 wks
timing VARD after nec panc perc drainage?
at least 4 weeks
Muir Torre syndrome
of Lynch syndrome MMR
sebaceous carcinoma with panc cancer
enucleation criteria
must be >3mm from main panc duct or portal vein
locally advanced panc ca
SMA abutment > 180
borderline panc ca
SMV and HA involvement
Protease serine 1 gene PRSS1 -
hereditary pancreatitis
Serine protease inhibitor Kazal type 1 gene SPINK1 - pancreatitis
cleaves activated trypsin, preventing premature activation of other zymogens within the pancreas and the pancreatic duct
defining resectability of pancreatic ca
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
staging for pancreatic ca
needs dx lap before definitive resection
dx lap strategy to assess for pancreatic ca extension?
-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
duct of santorini
ACCESSORY panc duct in dorsal panc bud
duct of Wirsung
MAJOR panc duct that merges with CBD before entering duo in ventrla pancreatic bud
annular pancreas
D2 trapped in panc band;
XR: double bubble (duo obstruction)
ass’d Down syndrome
pathophys of annular pancreas
failure of clockwise rotation of VENTRAL/main panc bud
mgmt of annular pancreas
don’t resect the pancreas; just DD or DJ or GJ
pancreas divisum
failure fusion of panc ducts; result in pancreatitis from SNATORINI/accessory stenosis
Wirsung is gone.
dx pancreas divisum
ERCP with minor and major papilla
mgmt of pancreas divisum
ERCP with sphincteroplasty
ranson’s criteria
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
pancreatitis bleeding
grey turner: flank ecchymosis
cullens: periumbilican
foxs: inguinal
pancreatitis avoid morphine
contracts sphincter of oddi; worsens pain
panc insufficiency dx
> 90% panc function gone
dx with fecal fat testing
mgmt panc insuff
creon, low fat diet, high carb/highprotein diet
MC genetic mutation in pancreatic ca
p16; 95%
TSG binds cyclin complexes
HEAD NETs
gastrinoma, somatostatinoma
DISTAL NETs
glucagonoma, VIPoma
muchausen insulin
decreased C peptide and proinsulin
mgmt insulinoma
resection if > 2cm
enucleat if <2cm
5Fu, streptozocin if metastatic
diazoxide if symptomatic
panc fluid collections acute vs chronic
4 weeks
WOPN pseudocyst vs acute necrotic acute peripanc
intervene pseudocyst
6 cm, sx after 6 wks
Fiser says 3 mos
Infected necrotizing pancreatitis abx of choice
Imipenem
panc adenocarcinoma tx
Resect with adjuvant (FOLFIRINOX)
Neoadj if borderline (need Bx first)
Definitive chemorad if unresectable)
FOLFIRINOX
folinic acid
luorouricil
irinotecan
oxaliplatin
Hx pancreatitis presents with hematemesis?
Splenectomy for SVT (gastric varices)
incidence of portosplenic venous thrombus in NECROTIZING acute pancreatitis
50% of patients
but MC cause of splenic vein thrombus is CHRONIC PANCREATITIS
do patient need EGD to look for gastric/esophageal varix after diagnosed with post-pancreatitis splenic vein thrombus?
Ya..
arterial origins for pancreas
SMA - inf pancreaticoduodenal aa
Celiac to GDA - sup pancreaticoduodenal aa
splenic aa - pancreatic arteries (greater, inferior, dorsal)
rate of recurrent acute GSP within 3 mos if no same-admission CCY?
25%
autoimmune pancreatitis diagnostic/labs
increased IgG4, IgG4+ plasma cells
appears like mass on CT scan in head
extrapancreatic manifestations of autoimmune pancreatitis?
bile ducts (jaundice)
bowel (IBD-like sx)
salivary/lacrimal glands (xerostomia and xerophthalmia)
kidney (CKD)
lungs (LAD)
when to drain biliary tree in pancreatic ca?
- if resectable: only if very symptomatic
- if neoadjv: only if jaundice
use metal stent because easier to place, longer patency
somatic mutations associated with pan can
KRAS
TP53
SMAD4
CDKN2A
ddx bleeding after VARD
splenic or GDA PSA!!!
early: avulsion of peripanc aa/veins
subacute >2 days: PSA
next step for suspected exocrine pancreas insufficiency?
fecal elastase-1 test
initial treatment for exocrine pancreas insufficiency
high carb
high protein
low fat
creon
most potent stimulator for exocrine secretion?
- secretin for BICARB & FLUID
- cholecystokinin for ENZYME
zollinger ellison dx
gastrin > 1000 pg/mL
if more equivocal range but still suspect, can do secretin stimulation test to make sure it increases by 200.
traumatic pancreatic hematoma?
explore all.
uncinate to SMV
uncinate is BEHIND SMV… rests ON AORTA
only pancreatic enzyme released in active form?
amylase
function of amylase
hydrolyzes alpha-1-4-linkages on glucose chains (CARBS)
exocrine function of pancreas (release of what things) 6
- bicarb
- amylase
- lipase
- trypsinogen
- chymotrypsinogen
- carboxypeptidase
blood flow from islet to alpha cells
islet to alpha (peripherally)
enterokinase release from
duo
how does duct of Wirsung fuse with dorsal duct?
posteriorly, to the right, and clockwise to fuse with the dorsal bud
Rx-induced pancreatitis
cimetidine
azathioprine
furosemide
steorids
most important risk factor nec panc
obesity
ARDS and coagulopathy due to what in acute pancreatitis
ARDS: phospholipase
coag: proteases
what imaging do you need before operative drainage of pseudocyst?
MRCP or ERCP to see if connects to a main duct
chronic pancreatitis cause
EtOH > idiopathic > stones
unliek acute: Etoh and gallstones #1 tied
endocrine function in chronic pancreatitis (insufficiency)
is actually still intact while exocrine is not
chronic pancreatitis on CT scan
shrunked and calcified/fibrotic
chronic pancreatitis on ERCP
chain of lakes in advanced disease
MC cause of splenic vein thrombus
chronic pancreatitis
biggest risk factor for pancreatic adenocarcinoma
TOBACCO > EtOH, obesity `
MC complication after Whipple
DGE
fistula
leak
marginal ulcer
