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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
mgmt serous cn
resect if symptoms, lesions that demonstrate rapid growth, or lesions that are large and impose upon surrounding organs/physiology.
26
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.
27
solitary papillary tumor histo
solid sheets, appear similar to pancreatic neuroendocrine tumors
28
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
29
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.
30
low cea fluid
pseudocyst and serous cn
31
high amylase fluid
pseudocyst and ipmn
32
low mucin
pseudocyst and serous cn
33
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)
34
pancreatic pseudocyst CA 19-9
HIGH. like IPMN with high risk
35
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
36
CA 19-9; where found?
biliary tree correlates with tumor burden used to monitor response to therapy (before imaging findings)
37
pancreatic adeno chemo
gemcitabine + cisplatin FOLFIRINOX???
38
pancreatic divisum presentation
asx >>> pancreatitis
39
pancreatic divisum embryology
failed fusion of ducts at 8 WGA so pancreas drained Santorini (minor papilla)
40
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)
41
pancreatic divisum tx
ERCP with sphincteroplasty of the minor papilla
42
>180 SMA involvement panc adeno
preop chemo; then restage and consider radiation vs surgery
43
abutment margin for cystG or cystD?
1cm; otherwise consider an operative cystJ Roux en Y
44
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
45
PVT and panc resection
contraindication splenic VT is relative contraindication collateralization makes it very high risk surgery
46
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
47
VIPoma irregularities VIPoma = Verner-Morrison syndrome
hypoK achlorhydria metabolic acidosis, hypovolemia, hyperCa hyperglycemia
48
extra pancreatic VIPoma location:
adrenal, RP, mediastinum
49
communicating pseudocyst to panc duct mgmt
internal drainage (stent)
50
% OF PPL that lead to T1DM afer distal panc
10%
51
How to define acute and non-acute pancreatitis (thus acute collection vs pseudocyst and acute necrotic collections vs WOPN)
4 wks
52
timing VARD after nec panc perc drainage?
at least 4 weeks
53
Muir Torre syndrome
of Lynch syndrome MMR sebaceous carcinoma with panc cancer
54
enucleation criteria
must be >3mm from main panc duct or portal vein
55
locally advanced panc ca
SMA abutment > 180
56
borderline panc ca
SMV and HA involvement
57
Protease serine 1 gene PRSS1 -
hereditary pancreatitis
58
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
59
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
60
staging for pancreatic ca
needs dx lap before definitive resection
61
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
62
duct of santorini
ACCESSORY panc duct in dorsal panc bud
63
duct of Wirsung
MAJOR panc duct that merges with CBD before entering duo in ventrla pancreatic bud
64
annular pancreas
D2 trapped in panc band; XR: double bubble (duo obstruction) ass'd Down syndrome
65
pathophys of annular pancreas
failure of clockwise rotation of VENTRAL/main panc bud
66
mgmt of annular pancreas
don’t resect the pancreas; just DD or DJ or GJ
67
pancreas divisum
failure fusion of panc ducts; result in pancreatitis from SNATORINI/accessory stenosis Wirsung is gone.
68
dx pancreas divisum
ERCP with minor and major papilla
69
mgmt of pancreas divisum
ERCP with sphincteroplasty
70
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
71
pancreatitis bleeding
grey turner: flank ecchymosis cullens: periumbilican foxs: inguinal
72
pancreatitis avoid morphine
contracts sphincter of oddi; worsens pain
73
panc insufficiency dx
>90% panc function gone dx with fecal fat testing
74
mgmt panc insuff
creon, low fat diet, high carb/highprotein diet
75
MC genetic mutation in pancreatic ca
p16; 95% TSG binds cyclin complexes
76
HEAD NETs
gastrinoma, somatostatinoma
77
DISTAL NETs
glucagonoma, VIPoma
78
muchausen insulin
decreased C peptide and proinsulin
79
mgmt insulinoma
resection if > 2cm enucleat if <2cm 5Fu, streptozocin if metastatic diazoxide if symptomatic
80
panc fluid collections acute vs chronic
4 weeks WOPN pseudocyst vs acute necrotic acute peripanc
81
intervene pseudocyst
6 cm, sx after 6 wks Fiser says 3 mos
82
Infected necrotizing pancreatitis abx of choice
Imipenem
83
panc adenocarcinoma tx
Resect with adjuvant (FOLFIRINOX) Neoadj if borderline (need Bx first) Definitive chemorad if unresectable)
84
FOLFIRINOX
folinic acid luorouricil irinotecan oxaliplatin
85
Hx pancreatitis presents with hematemesis?
Splenectomy for SVT (gastric varices)
86
incidence of portosplenic venous thrombus in NECROTIZING acute pancreatitis
50% of patients but MC cause of splenic vein thrombus is CHRONIC PANCREATITIS
87
do patient need EGD to look for gastric/esophageal varix after diagnosed with post-pancreatitis splenic vein thrombus?
Ya..
88
arterial origins for pancreas
SMA - inf pancreaticoduodenal aa Celiac to GDA - sup pancreaticoduodenal aa splenic aa - pancreatic arteries (greater, inferior, dorsal)
89
rate of recurrent acute GSP within 3 mos if no same-admission CCY?
25%
90
autoimmune pancreatitis diagnostic/labs
increased IgG4, IgG4+ plasma cells appears like mass on CT scan in head
91
extrapancreatic manifestations of autoimmune pancreatitis?
bile ducts (jaundice) bowel (IBD-like sx) salivary/lacrimal glands (xerostomia and xerophthalmia) kidney (CKD) lungs (LAD)
92
93
when to drain biliary tree in pancreatic ca?
1. if resectable: only if very symptomatic 2. if neoadjv: only if jaundice use metal stent because easier to place, longer patency
94
somatic mutations associated with pan can
KRAS TP53 SMAD4 CDKN2A
95
ddx bleeding after VARD
splenic or GDA PSA!!! early: avulsion of peripanc aa/veins subacute >2 days: PSA
96
next step for suspected exocrine pancreas insufficiency?
fecal elastase-1 test
97
initial treatment for exocrine pancreas insufficiency
high carb high protein low fat creon
98
most potent stimulator for exocrine secretion?
1. secretin for BICARB & FLUID 2. cholecystokinin for ENZYME
99
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.
100
traumatic pancreatic hematoma?
explore all.
101
uncinate to SMV
uncinate is BEHIND SMV... rests ON AORTA
102
only pancreatic enzyme released in active form?
amylase
103
function of amylase
hydrolyzes alpha-1-4-linkages on glucose chains (CARBS)
104
exocrine function of pancreas (release of what things) 6
1. bicarb 2. amylase 3. lipase 4. trypsinogen 5. chymotrypsinogen 6. carboxypeptidase
105
blood flow from islet to alpha cells
islet to alpha (peripherally)
106
enterokinase release from
duo
107
how does duct of Wirsung fuse with dorsal duct?
posteriorly, to the right, and clockwise to fuse with the dorsal bud
108
Rx-induced pancreatitis
cimetidine azathioprine furosemide steorids
109
most important risk factor nec panc
obesity
110
ARDS and coagulopathy due to what in acute pancreatitis
ARDS: phospholipase coag: proteases
111
what imaging do you need before operative drainage of pseudocyst?
MRCP or ERCP to see if connects to a main duct
112
chronic pancreatitis cause
EtOH > idiopathic > stones unliek acute: Etoh and gallstones #1 tied
113
endocrine function in chronic pancreatitis (insufficiency)
is actually still intact while exocrine is not
114
chronic pancreatitis on CT scan
shrunked and calcified/fibrotic
115
chronic pancreatitis on ERCP
chain of lakes in advanced disease
116
MC cause of splenic vein thrombus
chronic pancreatitis
117
biggest risk factor for pancreatic adenocarcinoma
TOBACCO > EtOH, obesity `
118
MC complication after Whipple
DGE fistula leak marginal ulcer
119
120

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