PANCREAS

Question 1

Gallstone pancreatitis

Answer 1

Usually passed down spontaneously

Cool them off

Same hospitalization cholecystectomy

Question 2

serous cystadenoma

Lab findings and management

Answer 2

CENTRAL SCAR
septations
Calcification (careful: also seen in mucinous)

Have central scar
Little calcium in the rim
Negative CEA

Just follow no more work up evident CT scan

Resect if symptomatic?

Question 3

Mucinous cystadenoma
Management
Lab findings

Answer 3

This needs to come out
Whipple

Increased CEA
CA 19 – nine

Question 4

IPMN
findings on path
work up
where in the panc are they found

Answer 4

Malignant potential

fish mouth / fish eye
mucin

Brusings @ ampula

HEAD of pancrease

NEED whipple if head of pancreas

Question 5

management of pancreatic pseudocyst

Answer 5

asymptomatic observe and follow

a laparoscopic surgical drainage method of choice

Cyst gastrostomy if: collection abuts gastric wall ( send this portion of tissue to path to rule out malignancy of gastric wall)

Roux-en-Y jejunum drainage if: - the cyst wall does not directly adherent to stomach

performed with 40-60 cm limb and anastomosed to the opening of the cyst.

The cyst duodenostomy if: - used if pseudocyst is in the head of the pancreas and adherent to the medial wall of the duodenum. Must safeguard sphincter of Odie and intrapancreatic portion of common bile duct

Distal pancreatectomy if: cysts is in the tail reserve for unusual settings-hemorrhage from pseudoaneurysm-preoperatively embolized

Question 6

Infected pseudocyst management

Answer 6

Traditionally all infected cysts were treated external drainage

This is the management of choice in this setting of sepsis

bacterial colonize cysts can be drained into the stomach with endoscopic or surgical approach!

Question 7

Workup for gastrinoma

Answer 7

Fasting serum gastrin greater than 750

Secretary and stimulation test confirms diagnosis of positive doubling fasting level or absolute increase of 200

octreotide scan

Hiding in the duodenum

Question 8

treatment of gastrinoma

Answer 8

Simple enucleation for many
May be multicentric

Bile duct, pancreatic duct, and vessels, and duodenum

His poor risk patient or bulky mass then cannulated with PPI

Question 9

gastrinoma usually found where

Answer 9

usually duodenum

Or

Head of the pancreas

Gastronomic triangle:

Con bile duct
Second portion of the duodenum
neck of the pancreas

Question 10

gastrinoma work up

Answer 10

Make sure Ca and PTH are not up!

Get neg H pylori.

Remember this is associated with MEN I

gastrin level

CT (or MRI)

consider

octreoscan - off PPI?

EUS

chromogranin A

–>ppi, consider octreotide (150-250mcg sq tid

or

LAR 20-30mg IM q4wks, titrate prn)

–>if occult –> observe vs exploratory surgery with duodenotomy/

IOU/local

Question 11

gastrinoma treatment

Answer 11

resection or enucleation

If duodenal:

duodenotomy
IOU
local resection 
or 
enucleation

If head of the pancreas and exophytic or peripheral:
enucleation

If head of the pancreas and deep or invasive and in proximity to pancreatic duct:
Whipple

 If distal (less common:
Distal panc

Question 12

gastrinoma prognosis of:

1. Gastrin independent
2. MEN I
3. Sporatic

Answer 12

1. Gastrin independent
   BEST
   can be large and in duodenum
2. MEN I
   Medium
3. Sporatic
   WORST!
   Mult and aggressive
   +/- consider nodes

Question 13

work up of pancreatic pseudocyst

Answer 13

CT scan

This is often enough with a history of multiple bouts of acute pancreatitis

If not a good history:

Endoscopic ultrasound (EUS)

excluding internal septations that are frequently found in cystic neoplasms.

EUS-guided fine needle aspiration of the cyst fluid can also help to discriminate these two diagnoses.

Cyst fluid high in amylase but low in mucin:
pseudocyst,

Cyst fluid has mucin and carcinoembryonic antigen :

suggestive of a mucinous cystic neoplasm.

ERCP:
to see if communicates with duct

If communicates:
ECRP - transpapillary internal drainage

with stent of ampulla

Question 14

What is a pancreatic protocol CT scan

Answer 14

Find cuts 1 mm

− Arterial phase: At 20 seconds

− Pancreatic parenchymal phase: At 40 seconds

− Portal venous phase: At 70 seconds

Question 15

Options for drainage when cyst abuts the gastric wall

Answer 15

drained internally via ENDOSCOPIC cystogastrostomy.

puncturing the common wall with a needle knife sphincterotome,

serially dilating the orifice,

placing transgastric double-pigtail stents to prevent spontaneous closure.

Question 16

Options for drainage when pseudocyst in the head of the pancreas

Answer 16

ENDOSCOPIC transduodenal drainage!

Question 17

Relative contraindications for endoscopic drainage of pseudocysts

Answer 17

perigastric varices,
(splenic or portal vein thrombosis,)

transmural distances greater then 1 cm.

Question 18

open pseudocysts drainage

Answer 18

chole at same time if GS present

head of panc:
cystduo
- but often cyst-J can be easy

cyst abuts transverse colon:
cyst-J

Cyst -g

Question 19

Pancreaticoduodenectomy (PD) may be indicated in

Answer 19

patients in whom inflammation and calcification are concentrated within the head and uncinate process (with or without upstream dilation of the main pancreatic duct), when there is a focal mass suspicious for neoplasm, or when there is biliary and/ or duodenal obstruction.

Question 20

The presence of ductal connectivity of pancreatic lesion suggests

Answer 20

IPMN.

Question 21

Multifocality of panc lesion the absence of a history of pancreatitis such as in this case is virtually diagnostic of

Answer 21

IPMN.

Question 22

The presence of a central stellate scar in pancreatic lesion is classic for

Answer 22

microcystic SCN

but is unreliable for macrocystic serous lesions.

Question 23

panc lesion with Cystic dilation of the main pancreatic duct is typical of

Answer 23

IPMN

but may also be present in other cystic lesions (MCN, pNET)

and is associated with high rates of malignant transformation.

Question 24

Intracystic mural nodules are characteristic of

Answer 24

IPMNs

and

MCNs

and also serve as predictors of malignancy.

Question 25

Cyst fluid cytopathology

Answer 25

, second only to surgical pathology, remains the “gold standard” and most accurate and specific predictor of malignancy.

Unfortunately, it is not as sensitive, and this is most often due to low cellularity.

(carcinoembryonic antigen [CEA],
amylase)
molecular (DNA) analyses.

Pancreatic cyst fluid CEA > 192 ng/ mL predicts a mucinous lesion (MCN or IPMN)

but has no value in determination of malignant character.

Question 26

Elevated pancreatic cyst fluid amylase suggests

Answer 26

ductal connectivity (IPMN or pseudocyst),

but in ductal obstruction (e.g., mucin plug), it may be consistent with serum levels even in the presence of ductal connectivity.

Question 27

Molecular analyses may detect

Answer 27

KRAS mutations that predict a mucinous lesion (compliments CEA).

Quantity of DNA and number of DNA mutations may predict malignant potential.

Question 28

serum studies may be useful in the workup of the incidental pancreatic cyst

Answer 28

hemoglobin A1C (or fasting glucose)

cancer antigen 19-9 may predict malignant progression.

Alkaline phosphatase elevation, particularly in pancreatic head cysts, may indicate early biliary obstruction, which correlates with malignancy in pancreatic head cystic lesions.

serum amylase and lipase, even in the absence of clinical pancreatitis, may indicate a pancreatic cyst with greater malignant potential.

Question 29

management of patient with
side-branch IPMN
without symptoms,
No concerning radiographic features, or suspicious cytopathologic findings,

Answer 29

surveillance in lieu of surgery is an acceptable approach.

Surveillance may be less acceptable, however, in young patients due to the anticipated length of surveillance.

This is due both to the cumulative risk of malignant transformation over time as well as cost to the individual and society of prolonged surveillance.

Question 30

Main duct versus side branch versus mural nodule – involved IPMNs

Answer 30

reliably associated with elevated rates of invasive cancer, up to 50% to 60%,

side-branch IPMNs represent a risk of harboring invasive cancer of 10% to 20%.

mural nodule within the cystic lesion endoscopic finding associated with an increased rate of invasive cancer

The presence of a mural nodule within a branch-type IPMN has been validated as an independent predictor of invasive carcinoma.

Question 31

The surgical treatment of IPMN

Answer 31

segmental resection of the affected pancreatic segment.

This is often complicated by the fact that IPMN presents as multifocal lesions affecting more than one region of the pancreatic gland (as demonstrated in this case by the synchronous 5-mm cyst within the head of the pancreas).

Question 32

threshold for biliary decompression

Answer 32

Malnourished or debilitated patients,
and patients with marked hyperbilirubinemia (total bilirubin > 12 mg/ dL),

optimization of nutritional and functional status prior to consideration of surgical therapy.

Question 33

Preoperative biliary decompression has been associated with:

Answer 33

increased risk of postoperative infection

avoided if not indicated.

Question 34

When biliary decompression is warranted, or in cases where the etiology of biliary obstruction is not clear by noninvasive means - what’s next

Answer 34

“direct cholangiography”

most common initial:
endoscopic retrograde cholangiography (ERC),

Second choice:
percutaneous transhepatic cholangiography (PTC) r

eserved for patients in whom endobiliary access is either not possible (e.g., following gastric bypass) or unsuccessful.

ERCP allows placement of an endobiliary stent
with brushing

Question 35

When a tissue diagnosis is needed and cannot be established by endobiliary means what is next

Answer 35

endoscopic ultrasound (EUS),

fine needle aspiration of any identified periampullary mass,

allows assessment of the pancreatic parenchyma for endosonographic evidence of chronic pancreatitis

may allow evaluation of the relationship of periampullary tumors to the mesenteric and hepatic vessels,

Question 36

n cases where a malignant diagnosis is established, staging for metastatic disease should include

Answer 36

a CT scan of the chest.

PET reserved for patients with extrapancreatic CT findings that may be suggestive of metastases, especially when not amenable to percutaneous biopsy.

A serum CA 19-9 should ideally be drawn after the patient’s jaundice is palliated,

may be falsely elevated in cases of biliary obstruction or cholangitis.

Question 37

contraindication to surgical resection

Answer 37

Direct arterial involvement
(is most often considered a contraindication to surgical resection)

mesenteric venous
the degree of mesenteric venous involvement and options for venous reconstruction must be considered carefully as well.

“borderline” resectable due to either long segment venous involvement or questionable arterial involvement, neoadjuvant chemoradiation may be given in order to improve the likelihood of a margin-negative resection.

A multidisciplinary approach to pancreatic malignancy, combining surgical therapy with systemic chemotherapy and RADIATION therapy, has been shown to provide the optimal patient outcomes for this complicated disease.

performance status should be considered for adjuvant chemotherapy ± radiation. Ideally, adjuvant therapy should be started within 6 to 10 weeks of the date of surgical resection.

(Clinical Scenarios in Surgery Series) (Kindle Locations 4897-4907). Lippincot (Wolters Kluwer Health). Kindle Edition.

Question 38

Pancreatic fistula after whipple

Answer 38

Pancreatic fistula,

Enteral nutrition may be maintained

low-output fistulae (typically defined as

Question 39

Pseudoaneurysm formation at the GDA stump

Answer 39

angiographic intervention with occlusion or exclusion of the GDA pseudoaneurysm.

Question 40

PNETs associated inherited disorders

Answer 40

MEN-1,

von Hippel– Lindau syndrome,

neurofibromatosis 1,

Tuberous sclerosis

Question 41

MEN-1, the majority of patients develop what kind of pancreatic tumor

Answer 41

nonfunctional PNETs,

while gastrinoma is the most common functional PNET,

followed by in order of decreasing frequency:

insulinoma,

glucagonoma,

VIPoma,

somatostatinoma.

Question 42

WDHA syndrome

Answer 42

(watery diarrhea, hypokalemia, achlorhydria),

may have diarrhea up to 20 times per day, as

well as significant dehydration and muscle weakness from water and electrolyte losses.

In working up patients with suspected functional tumors, the abnormal physiology or characteristic syndrome must be recognized. Well-described clinical syndromes exist for gastrinoma (not discussed in this chapter), insulinoma, glucagonoma, VIPoma, and somatostatinoma. Hormone elevation should be detected in the serum, and commercial assays are available for measuring insulin, VIP, somatostatin, and glucagon. The next step involves tumor localization and staging in preparation for operative intervention. The initial imaging study used by most to identify and stage a PNET is a high-quality contrast-enhanced computed tomography (CT) scan. Pancreatic neuroendocrine tumors are typically hyperdense (i.e., enhance with contrast) and spherical on the arterial phase of imaging (Figure 2). CT is useful in assessing the size and location of the pancreatic tumor, peripancreatic lymph node involvement, and the presence or absence of liver metastases for staging and surgical planning. Although dependent on the size of the tumor, the sensitivity and accuracy of CT approximate 94% and 82%, respectively.

Dimick, Justin B.; Upchurch, Gilbert R.; Sonnenday, Christopher J. (2012-06-18). Clinical Scenarios in Surgery: Decision Making and Operative Technique: 1 (Clinical Scenarios in Surgery Series) (Kindle Locations 10023-10032). Lippincot (Wolters Kluwer Health). Kindle Edition.

Question 43

Octreotide scintigraphy performs well for

Answer 43

gastrinoma,
VIPoma,
glucagonoma,

NOT insulinomas.

Question 44

localize PNET

Answer 44

CT

octreotide (not insulinoma)

EUS - good

PTPVS - percutaneous transhepatic portal venous sampling

venous catheter percutaneously through the liver into the portal vein and sequentially sampling for hormone levels in the

splenic vein,
superior mesenteric vein,
portal vein,

regionalizing the location of hormone production.

The second technique (referred to by some as the Imamura test) is a doubly invasive test that involves selective visceral arterial injection of calcium with concurrent hepatic venous sampling for insulin.

Calcium is serially injected at low doses through an arterial catheter into the splenic, gastroduodenal, and inferior pancreaticoduodenal arteries and samples are drawn from a hepatic vein catheter before and immediately after each injection, thereby allowing regionalization of the blood supply to the occult tumor.

Question 45

Whipple’s triad:

Answer 45

symptoms of hypoglycemia,

documented serum glucose of

Question 46

work up of gastrinoma

Answer 46

*FIRST step is to r/o MEN 1

do this with Ca and PTH (becasue high penetrance of hyperplasia in MEN 1)

The diagnosis of ZES is achieved by measuring fasting
gastrin,
basal acid output,
postsecretin challenge testing.

Dimick, Justin B.; Upchurch, Gilbert R.; Sonnenday, Christopher J. (2012-06-18). Clinical Scenarios in Surgery: Decision Making and Operative Technique: 1 (Clinical Scenarios in Surgery Series) (Kindle Locations 10300-10301). Lippincot (Wolters Kluwer Health). Kindle Edition.

fasting serum concentration of gastrin.

serum gastrin concentration > 100 pg/ mL.

Because PPI therapy can induce hypergastrinemia, we checked the patient’s PPI for 1 week prior to the test.

However, many patients with ZES have gastric acid hypersecretion and minimally increased fasting serum gastrin concentrations (100 to 1,000 pg/ mL). For these patients, the secretin stimulation test is the provocative test of choice to establish the diagnosis of ZES.

CT - gastrinoma trinagle
poor sens for finding hepatic lesions

Octrotide scan - fails to find 50% of duo tumors because often sub 1 cm

Question 47

first step in treating ZE in MEN I

Answer 47

address sx with PPI

Then address parathyroid hyperplasia - 3.5 gland

Question 48

resectable ZE gastrinoma

Answer 48

only if tumor is larger than 2 cm in MEN I..

goal of surgery is to avoid liver mets from forming

enuculation

or distal panc if tail

go to whipple if cant avoid

for patients with ZES not undergoing a pancreaticoduodenectomy,

routinely perform a duodenotomy for direct inspection and exploration of the duodenal mucosa

Duodenotomy was particularly important in the detection of small duodenal tumors, allowing localization of 90% of subcentimeter tumors versus only 50% discovered on preoperative imaging. A recent prospective study of patients with sporadic ZES who underwent surgical exploration revealed a significantly higher cure rate following duodenotomy, both immediately and long term.

Question 49

Chemotherapy for her pancreas

Answer 49

5-FU because everyone gets..

gemcitabine

“the pancreas is golden put on the gem”