Pancreas

Question 1

Severe acute pancreatitis ddx?

Answer 1

• ddx-perf ulcer, boerhaaves sx, cholecystitis, cholangitis, MI, AAA dissection

Question 2

Severe acute pancreatitis hx?

Answer 2

• Hx- drinking, h/o pancreatitis,

Question 3

Severe acute pancreatitis PE?

Answer 3

• PE- jaundice, grey turner, cullen si, rectal exam, pulsatile mass

Question 4

Severe acute pancreatitis note?

Answer 4

• Note- arterial blood gas, 80% will resolve spontaneously

Question 5

Severe acute pancreatitis ranson score?

Answer 5

• Ranson score
  • admit-
    
    • GALAW >200, >55yrs, >350, AST>250, >16
  • 48hrs
    
    • CHHOBS Ca10%, PaO2 5, Base def >4, sequestration fluids >6L

Question 6

Severe acute pancreatitis mortality?

Answer 6

• 1-2 =1%, 3-4=15%, 5-6=40%mortality indicates the likelyhood of systemic complications and likelihood of necrosis

Question 7

Severe acute pancreatitis etiology?

Answer 7

• gallstone panc, ETOH, TG, divisum, trauma

Question 8

Severe acute pancreatitis management? MDOS? Ext ill?

Answer 8

• r/o other causes
  
  • Cardiac enzymes, CBC, Lipase, amylase, LFTs, CXR, US RUQ (check for stones)
  • Flat Upright XR (r/o perf ulcer)
  • CT Scan (will show inflammation around pancreas necrotic or ischemic)
• pain ctrl, fluids monitor o2 may need intubation,
• Admit patient +- ICU
• enteral feeding via nasojejunal tube (post pyloric) if ileum isn’t bad
• DVT and GI px
• Foley monitor UOP
• consider central line
• don’t start ABX cuz candida is associated with worse outcomes
• for patients with MODS and sepsis
  
  • then ct guided FNA of necrotic areas to determine bacterial contamination which needs intervention surgical or radiologic drainage.
• in ext ill patients then
  
  • perc drains placed at the time of FNA can sometimes stabilize patient prior to surgery to temporize and even treat definitively
• if possible wait 4 weeks for demarcation prior to necrosectomy minimize resection of viable pancreas and the accompany mortality

Question 9

Severe acute pancreatitis hemorrhagic?

Answer 9

• check hgb, transfuse, consider angiogram and embolization if doesn’t respond
• If fails then take to OR get proximal and distal control of aorta and open the the hematoma and find bleeder
• poor prognosis

Question 10

Severe acute pancreatitis patient deteriorates?

Answer 10

• if patient deteriorates after CT guided FNA then proceed with surgical debridement
  
  • access the lesser sac through the gastrocolic ligament or mesocolon
  • once pancreas is exposed the capsule is opened and all purulent material and necrotic tissue is removed from the pancreatic bed
  • you can do this with irrigation or ring forceps
  • inspect the transverse colon to make sure not compromised and if it is the right hemicolectomy
  • if you close then leave JP drains to maximize drainage debris or consider closed continuous lavage of retroperitoneum where undoing necrosis is anticipated
  • other option is leaving open and re-explore every 48 hrs until no further debridement is needed
  • if gallstone pancreatitis cholecystectomy should be deferred to a later date if the gallbladder is not easily accessible
  • post op comp -
    
    • MOF, hemorrhage, endocrine comp, fungal, fistula from duct or bowel, pseudocyst, abscess, vascular comp mesenteric or splenic venous thrombosis
    • follow with repeat imaging
    • consider feeding jejunostomy
  • manage pseudocyst with cystogastrostomy

Question 11

• Management of Gallstone pancreatitis? Mild, severe, infected fluid collections?

Answer 11

• Management of Gallstone pancreatitis
  
  • Mild
    
    • cont supportive care and serial exams
    • lap cholecystectomy with IOC w/in 4 days
  • Severe
    
    • may wait longer for inflammation to go down
    • may need ICU care
    • ERCP for evacuation of stones if no improvement in 24 hrs
    • If no gallstones, the repeat CT scan in 48hrs to look for necrosis, pseudocyst, abscess, phlegm, or fluid collections
• Infected fluid collections
  
  • need large perc drains and if fails with 24 to 48hrs then take to OR for surgical debridement and feed J-tube placement

Question 12

Cystic lesion hx?

Answer 12

• Hx-back pain, steatorrhea,weight loss (exocrine), new onset diabetes (endocrine)

Question 13

Cystic lesion rf?

Answer 13

• RF smoking, obesity, family

Question 14

Cystic lesion PE?

Answer 14

• PE - abdominal mass, lymhadenopathy, cachexia, jaundice

Question 15

Cystic lesion labs?

Answer 15

• CEA, AFP, LFTs, CA19-9

Question 16

Cystic lesion imaging diagnosics?

Answer 16

• CT pancreatic protocol
• MRCP- useful for cystic lesions detects small lesions 2/2 to the ductogram gadolinium and secretin injection; motifocalilty in absence h/o pancreatitis suggest IPMN
• EUS- if MRCP CI then use EUS with FNA of cystic fluid, nodules etc (cytopathology is gold std 2/2 to surgical bx most accurate and specific of malignancy, unfort is low sensitive 2/2 low cellularity

Question 17

Cystic lesion cyst vs bad?

Answer 17

• Pancreatic cyst CEA >192 predicts mucionous lesion but doesn’t determine malignancy, DNA KRAS
• Serum CA19-9adn HgbA1C do correlate with malignancy, serum amylase and lipase can also help determine if a cyst has malignant potential
• Alk phosp predicts biliary obstruction

Question 18

Cystic lesion ERCP, EUS?

Answer 18

• ERCP less common high risk profile but can use in combo c ductoscopy
• ERCP, EUS (stage and FNA LN), Bx and brushings
• no perc bx (seed)

Question 19

Cystic lesion ddx?

Answer 19

• inflammatory vs neoplastic;
• pseudocyst (inflam),
• IPMN,
  
  • papillary mucin producing neoplasm arising from main pancreatic duct
  • thick mucin exuding from ampulla during ERCP
  • mostly proximal and older pts
  • use Ca19-9 to distinguish
  • if involves main duct needs resection
• Cystadenoma,
• Cystadenocarcinoma,
• serous cystic neoplasm
  
  • usually evenly distributed throughout
  • usually only sx when enlarged
  • aspirate no mucin and have no malignant potential
  • usually nonoperative unless sx
• mucinous cystic neoplasm
  
  • usually body or tail
  • increase risk of cancer
  • elevated CEA aspirate
  • usually nonoperative unless sx

Question 20

Cystic lesion preop?

Answer 20

• Preop vaccinations

Question 21

Cystic lesion IPMN?

Answer 21

• Distal pancreatectomy, splenectomy
• IPMN -cause intermittent pancreatic duct obstruction with mucus (MC when main duct involved) exocrine affected (steatorrhea and weight loss) bloating (take oral pancreatic enzymes meds supp)
  
  • if side branch w/o sx and concerning imaging or cytopath then ok to do surveillance and an older patient. younger more chance to mutate
  • Main duct elevated rates of invasive cancer 50% Side branch 10%
  • imaging mural nodule near cyst higher risk
  • Tx segmental resection
  • multifocal disease need to weigh affects of leaving some behind and performing surveillance (just take the worst of it ie. distal pancreatectomy) vs doing a total pancreatectomy (endo & exocrine failure)

Question 22

Cystic lesion distal pancreatectomy?

Answer 22

• Surgery distal pancreatectomy
  
  • preop vaccinations splenectomy possible (try to preserve better )
  • explore liver and peritoneum for mets
  • take down gastrocolic ligament and enter lesser sac preserve gastroepiploic retract posterior wall of stomach cephlad
  • look for splenic artery superior border of pancreas
  • establish a plane on the inferior border of pancreas ID and preserve splenic vessels and dissect free from them
  • very tricky to preserve in cyst is near hilum
  • transect pancreatic parenchyma with a buttressed linear stapler with oversewing of main pancreatic duct
  • if you take the splenic vessels sometimes can salvage them based off the short gastrics
  • Intraoperative frozens of proximal margin
    
    • if “main duct” or “side branch- High grade” involved reresect, if side branch low grade back off if further resect meant total pancreatectomy.
    • Just remove the most threatening lesion and preserve gland
    • need negative margins
  • drains have no benefit but if placed if output is >50 ml/day check drain amylase to guide timing of removal
  • Annual surveillance of negative margins lesions H&P, MRI-MRCP, CT and serum studies
  • Semiannual for higher risk lesions and also include EUS-FNA c cytopath and molecular studies to monitor recurrence or progression

Question 23

Refractory Pain from Chronic Pancreatitis ddx?

Answer 23

• DDx- PUD, hepatitis, biliary

Question 24

Refractory Pain from Chronic Pancreatitis hx?

Answer 24

acute pancreatitis, ETOH abuse, chronic Abdominal Pain, weight loss, steatorrhea, exocrine and endocrine insufficiency, malnutrition

Question 25

Refractory Pain from Chronic Pancreatitis note?

Answer 25

• Note- can have biliary complications

Question 26

Refractory Pain from Chronic Pancreatitis xray?

Answer 26

• a lot of calcifications and inflammation at the head (unique finding)

Question 27

Refractory Pain from Chronic Pancreatitis endocrine timing?

Answer 27

• endocrine d/o happens late

Question 28

Refractory Pain from Chronic Pancreatitis imaging?

Answer 28

• need good organ morphology, ductal anatomy, involvement of surrounding structures
• CT triphasic 2-3mm slices
• MRCP preferred noninvasive and avoids radiation-
  
  • ID dilated pancreatic duct with filling defects, stones etch
• EUS
  
  • useful for early dz and cystic lesions and tissue sampling neoplasia

Question 29

Refractory Pain from Chronic Pancreatitis goals of treatment?

Answer 29

• Goals of treatment
  
  • mainly palliative, r/o cancer, pain relief, preserve exo and endocrine function
  • enzyme replacement, insulin replacement

Question 30

Refractory Pain from Chronic Pancreatitis surgery success?

Answer 30

• Surgery provides relief 85%, celiac ganglion blocks and VATS splanchiectomy only temporary bridge lasts 3-6mo

Question 31

Refractory Pain from Chronic Pancreatitis goals of surgery?

Answer 31

• If dilated duct >10mm then Puestow

- Goal of operation is preserve as much as endo and exocrine fxn as possible

Question 32

Lateral RNY pancreaticojejunostomy? When a whipple? Postop?

Answer 32

• Lateral Roux en Y pancreaticojejunostomy
  
  • midline laparotomy
  • separate greater momentum from transverse mesocolon
  • remove adhesions b/w posterior wall of stomach chronically inflamed pancreas to expose anterior surface of pancreas
  • generous Kocher manuever to expose SMV elevaes and expose pancreatic head
  • palpate and aspirate 18 G needle
  • cautery parencyma to access lumen and use right angle and unroof towards the tail 2 cm from the end and towards ampula
  • suture control of pancreaticodoudenal arterial arcade
  • remove stones and get the proximal drainage going
  • in head of gland unroof dorsal and ventral duct
  • Roux en Y single layer continuous side to side PDS jejunal seromuscular and reach the duct of pancreas when possible o/w generous portions of fibrotic pancreatic capsule
• Whipple
  
  • If inflammation and calcifications concentrated at the head of pancreas with or without upstream dilation of main duct or a focal suspicious mass or biliary and or duodenal obstruction
• postop exhasherbation of exocrine insuff
  
  • give oral pancreatic enzyme pills and endocrine insuff sliding insulin initially
• avoid alcohol and tobacco and slow taper of narcotics

Question 33

Sx Pancreatic Pseudocyst H&P?

Answer 33

• early satiety, GOO, jaundice, abdominal pain, acute pancreatitis, pancreatic trauma, chronic sx
  
  • biliary sx, ETOH, medication list
  • recent ERCP, infection, weight loss, diabetes, fever

Question 34

Sx Pancreatic Pseudocyst PE?

Answer 34

• jaundice, abdominal mass, peritoneal signs

Question 35

Sx Pancreatic Pseudocyst Dx?

Answer 35

• RUQ US r/o biliary cause and usually finds cyst
• CT scan will demonstrate number of cyst, size and location
  
  • look at relationship of the pseudocyst to stomach, duodenum, speen, tran colon, CBD, splenic,portal or MV thrombosis or visceral artery pseudoaneuysms and bleeding

Question 36

Sx Pancreatic Pseudocyst r/o cancer?

Answer 36

• distinguish from a cystic neoplasm is crucial esp in patients without h/o pancreatitis
• EUS can characterize a pseudocyst by excluding internal septations (cystic neoplasms) and also FNA cyst fluid (mucin, CEA, CA19-9 and amylase)
• pseudocyst = cyst fluid high in amylase and low in mucin and CEA

Question 37

Sx Pancreatic Pseudocyst cyst

Answer 37

• if cyst

Question 38

Sx Pancreatic Pseudocyst cyst >6 cm?

Answer 38

• If cyst is >6 cm repeat in 6 weeks
  
  • complications of observation
    
    • obstructive sx
    • portal HTN
    • hemosuccus pancreaticus, infection, fistula, rupture

Question 39

Sx Pancreatic Pseudocyst sx?

Answer 39

• Symptomatic
  
  • endoscopic interal drainage first
  • don’t perc drain it
  • if no communication then you can perf drain it and send fluid analysis
  • complications of aspiration include recurrence, fistula formation
  • if communication with duct then you can do surgical drainage procedure

Question 40

Sx Pancreatic Pseudocyst ERCP?

Answer 40

• ERCP can help determine pancreatic duct communication and place a transpapillary stent across ampulla into the cyst

Question 41

Sx Pancreatic Pseudocyst when surgery?

Answer 41

• if abuts stomach than endoscopic cystogastrostomy some times repeated endoscopic debridement
• Surgery if failed endoscopic
  
  • cholecystectomy if they have stones even if biliary pancreatitis isn’t established
  • Pseudocyst along the tail than maybe distal pancreaticomy esp if can’t decipher its a pseudocyst
  • Pseudocyst lie at the head or project through the transverse mesocolon -
    
    • then roux en y cystojejunostomy (easier than a cystodoudenostomy)

Question 42

Sx Pancreatic Pseudocyst cystgastrostomy?

Answer 42

• Cystogastrostomy if abuts and deforms the posterior gastric wall - biopsy wall
  
  • midline
  • cholecystectomy +-IOC
  • anterior gastrostomy (at least 5cm) to expose posterior gastric wall
  • aspirate pseudocyst to ensure location if bulge not present, culture fluid
  • electrocautery to open post gastric and anterior pseudocyst wall
  • biopsy wall frozens and permanent to exclude epithial lined cyst
  • explore pseudocyst cavity and deride necrosis
  • anastomsis locking PDS
  • enteral feed 24-48 hrs
  • dvt prophylaxis
  • complication anastomotic bleeding, ilieus, pseudoaneurysm
• Transpapillary and transgastric endoscopic tx are possible

Question 43

Pancreatic Divisum how common?

Answer 43

• 10% population

Question 44

Pancreatic Divisum w/u?

Answer 44

• RUQ US may be suggestive
• ERCP is diagnostic (be able to r/o cancer) and can’t see the ventral duct (which normally drains the head)
• CT scan can use r/o mass

Question 45

Pancreatic Divisum treatment? Chronic pancreatitis? Severely sx? ErCP? stenotic dorsal duct?

Answer 45

• Treatment
  
  • Chronic pancreatitis
    
    • r/o other causes
  • Severely sx- then surgery
    
    • if gallbladder present remove it and do an IOC
  • ERCP shows
    
    • dilated ducts do a Peustow
    • stenosis do a distal pancreatectomy
  • if stenotic dorsal duct
    
    • dorsal duct sphincterotomy
  • US the pancreas with simultaneous secretin injection and observe the dilation of the duct
    
    • this will cause pain
    • do an ecru and stent the duct and if relieved the pain then sphincterotomy will help
  • intraop
    
    • if duct is healthy do the sphincterotomy
    • if fibrosed and dilated then do a PJ
    • if stenotic then do a distal pancreatectomy
  • if gallbladder present remove it and do an IOC
  • surgical enlargement of minor papilla
  • transverse duodenotomy, cannulate orifice of minor papilla with probe incision along anterosuperior border of duct and pancreatic duct and duodenal mucosa are sutured together with fine absorable suture

Question 46

Pancreatic Ductal Disruption H&P?

Answer 46

• fistula, ascites, pleural effusions
• acute or chronic pancreatitis
• PE- fluid wave, ascites

Question 47

Pancreatic Ductal Disruption Dx?

Answer 47

• Na, HCO3, pre-albumin
• CT scan- show fluid and inflammation
• if suspect ductal disruption then perform paracentesis and find a high amylase level
• send fluid for cultures
• ERCP to ID site of disruption
  
  • place a transpapillary stent to decrease pressure and assist with spontaneous closure of duct

Question 48

Pancreatic Ductal Disruption Tx?

Answer 48

• pancreatic ascites
  
  • central line, TPN, NPO
  • Octreotide, perc drain and or chest tube for external drainage
  • dilate pancreatic duct (>7mm) - PJ
  • if dilated duct and cyst involved then do a PJ c cyst incorporation
  • if not dilated and tail disruption - distal pancreatectomy
  • body disruption- distal pancreatectomy
  • neck involved- extended distal pancreatectomy
  • Head involvement - operative debridement and ERCP stenting
  • ECF
    
    • wait at least 6 weeks give chance to heal unless there is dilate duct
    • if persist > 2-3 mo consider surgical resection
  • Pleural effusions
    
    • chest tubes, TPN, octreotide,
    • ERCP and stent and consider surgery based on results

Question 49

Preambulary Cancer/Pancreatic cancer hx?

Answer 49

• Hx- painless obstructive jaundice

- biliary colic, abdominal pain, weight loss, ETOH and tobacco, blood per rectum

Question 50

Preambulary Cancer/Pancreatic cancer PE?

Answer 50

• abdomen, palpable GB, ascites, umbilical nodes, supraclavicular adenopathy

Question 51

Preambulary Cancer/Pancreatic cancer dx?

Answer 51

• w/u for obstructive jaundice but want to r/o cancer
• LFT, amylas, lipase, CEA and CA 19-9
• US r/o stones
• CT scan r/o masses, staging (liver mets, peritoneal mets, invasion into PV, common hepatic/SMV/SMA/celiac, ascites)
• ERCP stent relief check cytology, brushings or bx
• EUS (FNA) assess mesenteric vascular invasion, nodal involvement , bx for dx

Question 52

Preambulary Cancer/Pancreatic cancer tx? resectable? palliation?

Answer 52

• • Contraindications
    
    • if no vascular or mets then treat or LN outside of resection area
    • imaging showing encasement of SMA/SMV/PV/H/C (suggestive signs- loss of fat plane b.w pancreas and PV or smb and tumor around PV >50% circumference)
    • Periaortic or celiac nodes
• maximize nutrition and cardiopulmonary status
• staging laparoscopy r/o peritoneal mets and liver mets
• if unresectable
  
  • palliate c gastric or biliary bypass
• resectable
  
  • whipple
• If vascular invasion or mets
  
  • do EUS c FNA or CT guided bx to confirm dx of cancer
  • neoadjuvant chemo radiation and reassess in 3 months
• Palliation
  
  • may include
    
    • gastro-j bypass or duodenal sparing
    • hepatico-j and chemical splanchniectomy with 50% ETOH to celiac plexus
  • Chemo
    
    • 5-FU, gemcitabine, external xrt may increase median survival to 12 mo for unresectable cancer

Question 53

Whipple description

Answer 53

• Whipple
  
  • I. Diagnostic laparoscopy-looking for metastatic disease and biopsy any suspicious nodes with frozen. Also ifpossible biopsy the lesion to get a tissue diagnosisifpossible. Alsolookatrootofmesentery to detennine if tethered by tumor indicating vessel involvement. Ifall negative proceed.
  • 2. Chevron incision
  • 3. Mobilize hepatic flexure and duodenum widely with Kocher maneuver.
  • 4. Reflect duodenum and pancreatic head medially to expose rvCIAorta and palpate the tumor noting size and consistency. Inspect for lymph nodes and ensure that tumor is not adherent to IV elAorta- if involved surgery contraindicated.
  • 5. Continue duodenal mobilization to 3’d/4Ib portion on the left until a defect in the peritoneum is created posterior to duodenum and anterior to aorta and LOT can be palpated. - Signals end of duodenal mobilization.
  • 6. Dissect avascular plane between pancreas and mesocolon medially until SMV is encountered at preventing further dissection.
  • 7. Divide venous tributaries from head ofpancreas preserving the middle colic vein. May divide the gastroepiploic vein from greater curvature of stomach as it enters SMV. Once SMV is dissected free can start dissection ofstomach and duodenum.
  • 8. Incise gastrocolic ligament entering lesser sac attempting to preserve gastroepiploic arcades on lesser curve.
  • 9. Adhesions between posterior stomach and pancreas are divided. Continue dissection laterally to the pylorus and complete division of transvel1ie mesocolon to gastrocolic omentum attatchmenK Divide gastoepiploic artery and vein.
  • 10. Continue dissection of duodenum 1-2 em past gastroduodenal artery which can be seen and felt on the pancreas. (now dissection should have reached same level and plane as earlier dissection of SMV and neck o f pancreas)
  • 11. Incise along inferior margin ofpancreas for 4 em along body of gland allowing deeper dissection to the leftofthe neck ofthe gland reaching the level ofthe future pancreaticojejunostomy.
  • 12. At this point it should be clear that the mass can be completely ressected and is free o f the portal vein and the SMV.
  • 13. Divide the stomach at the antrum using a TA stapler. Oversew the staple line starting at lesser curve to -5 em from greater curvature.
  • 14. Retract stomach to left upper quadrant to expose the hepatoduodenalligament.
  • 15. Incise hepatoduodenalligament and dissect the hepatic artery of all adjacent tissue which will be removed.
  • 16. Divide and ligate the gastroduodenal artery and R gastric artery near origin.
  • 17. Dissection is continued caudally to superior borderofpancreasandalladjacentnodesare swept toward specimen.
  • 18. Anterior portal vein is now dissected cmnially along the Rand L hepatic arteries to the point at which the CBD will be divided.
  • 19. Cholecystectomy
  • 20. Transect CBD or hepatic duct
  • 21 . Carefully dissect behind neck of pancreas and anterior to portal vein and pass umbellical tape behind neck of pancreas.
  • 22. Expose ligament ofTreitz and proximal jejunum. Divide the ligament ofTreitz. 23. Expose and divide proximal jejunal arcades starting 15 cm away from ligament oftreitz and divide the jejunum with GIA stapler.
  • 24. Divide the accessible mesenleric arcades to the proximal jejunum/duodenum oflhe specimen side close 10 the bowel wall until retroperitoneal duodenum reached.
  • 25 Pass stump through to right side and also pass distal end through mesenteric window posterior to the SMAlSMV .
  • 26. Elevate tile pancreatic neck with the umbelliclIl tape and hemostatic sutures are placed at the inferior and superior aspects of tbe pancreas on either side. 27. Divide pancreatic neck with TA stapler or knife. 28. Remaining attatchments to SMV and portal vein are divided and specimen is sent for frozen. If margins negative cant ifnot reresect margins.
  • Reconstruction
    
    29. End to side pancrealicojejunoslomy- probe pancreatic duct to ensure patency. Insert 5fpediatric feeding tube and leave as sten!.
  • 30. 21ayer duct to mucosal anastomosis: JSI place postcrior row of sutures 3-0 silk from parenchyma to jejunum. Open jejunum and place 4-0 PDS sutures x2 at posterosuperior margin of anastomosis and cut short end. lSI suture is continued as posterior row inner suture line from bowel to pancreas to duct and use 2nd suture as continued anterior suture line and tie two suture. Complete anterior second layer with 3-0 silk sutures.
  • 30. End 10 side hepaticojcjunoslomy: Single layer of 4-0 PDS interrupted for anastomosis.
  • 31. Gastrojejunostomy: 2 layer sutured anastomosis with 3-0 PDS and 3-0 silk.
  • 32 . Put JP drains: I near the pancreaticojejunostomy and 1 behind