PANCREAS Flashcards
Gallstone pancreatitis
Usually passed down spontaneously
Cool them off
Same hospitalization cholecystectomy
serous cystadenoma
Lab findings and management
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?
Mucinous cystadenoma
Management
Lab findings
This needs to come out
Whipple
Increased CEA
CA 19 – nine
IPMN
findings on path
work up
where in the panc are they found
Malignant potential
fish mouth / fish eye
mucin
Brusings @ ampula
HEAD of pancrease
NEED whipple if head of pancreas
management of pancreatic pseudocyst
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
Infected pseudocyst management
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!
Workup for gastrinoma
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
treatment of gastrinoma
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
gastrinoma usually found where
usually duodenum
Or
Head of the pancreas
Gastronomic triangle:
Con bile duct
Second portion of the duodenum
neck of the pancreas
gastrinoma work up
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
gastrinoma treatment
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
gastrinoma prognosis of:
- Gastrin independent
- MEN I
- Sporatic
- Gastrin independent
BEST
can be large and in duodenum - MEN I
Medium - Sporatic
WORST!
Mult and aggressive
+/- consider nodes
work up of pancreatic pseudocyst
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
What is a pancreatic protocol CT scan
Find cuts 1 mm
− Arterial phase: At 20 seconds
− Pancreatic parenchymal phase: At 40 seconds
− Portal venous phase: At 70 seconds
Options for drainage when cyst abuts the gastric wall
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.
Options for drainage when pseudocyst in the head of the pancreas
ENDOSCOPIC transduodenal drainage!
Relative contraindications for endoscopic drainage of pseudocysts
perigastric varices,
(splenic or portal vein thrombosis,)
transmural distances greater then 1 cm.
open pseudocysts drainage
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
Pancreaticoduodenectomy (PD) may be indicated in
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.
The presence of ductal connectivity of pancreatic lesion suggests
IPMN.
Multifocality of panc lesion the absence of a history of pancreatitis such as in this case is virtually diagnostic of
IPMN.
The presence of a central stellate scar in pancreatic lesion is classic for
microcystic SCN
but is unreliable for macrocystic serous lesions.
panc lesion with Cystic dilation of the main pancreatic duct is typical of
IPMN
but may also be present in other cystic lesions (MCN, pNET)
and is associated with high rates of malignant transformation.
Intracystic mural nodules are characteristic of
IPMNs
and
MCNs
and also serve as predictors of malignancy.
Cyst fluid cytopathology
, 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.
Elevated pancreatic cyst fluid amylase suggests
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.
Molecular analyses may detect
KRAS mutations that predict a mucinous lesion (compliments CEA).
Quantity of DNA and number of DNA mutations may predict malignant potential.
serum studies may be useful in the workup of the incidental pancreatic cyst
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.
management of patient with
side-branch IPMN
without symptoms,
No concerning radiographic features, or suspicious cytopathologic findings,
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.
Main duct versus side branch versus mural nodule – involved IPMNs
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.
The surgical treatment of IPMN
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).
threshold for biliary decompression
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.
Preoperative biliary decompression has been associated with:
increased risk of postoperative infection
avoided if not indicated.
When biliary decompression is warranted, or in cases where the etiology of biliary obstruction is not clear by noninvasive means - what’s next
“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
When a tissue diagnosis is needed and cannot be established by endobiliary means what is next
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,
n cases where a malignant diagnosis is established, staging for metastatic disease should include
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.
contraindication to surgical resection
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.
Pancreatic fistula after whipple
Pancreatic fistula,
Enteral nutrition may be maintained
low-output fistulae (typically defined as
Pseudoaneurysm formation at the GDA stump
angiographic intervention with occlusion or exclusion of the GDA pseudoaneurysm.
PNETs associated inherited disorders
MEN-1,
von Hippel– Lindau syndrome,
neurofibromatosis 1,
Tuberous sclerosis
MEN-1, the majority of patients develop what kind of pancreatic tumor
nonfunctional PNETs,
while gastrinoma is the most common functional PNET,
followed by in order of decreasing frequency:
insulinoma,
glucagonoma,
VIPoma,
somatostatinoma.
WDHA syndrome
(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.
Octreotide scintigraphy performs well for
gastrinoma,
VIPoma,
glucagonoma,
NOT insulinomas.
localize PNET
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.
Whipple’s triad:
symptoms of hypoglycemia,
documented serum glucose of
work up of gastrinoma
*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
first step in treating ZE in MEN I
address sx with PPI
Then address parathyroid hyperplasia - 3.5 gland
resectable ZE gastrinoma
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.
Chemotherapy for her pancreas
5-FU because everyone gets..
gemcitabine
“the pancreas is golden put on the gem”
