PANCREAS Flashcards
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
Ranson’s criteria
GA LAW on admission Glucose 200 Age over 55 LDH 350 AST 250 WBC
C HOBBS 48 hour
Ca 8 Hematocrit 10% PaO2 60 Base deficit 4 B UN 5 Sequestration 6
0 – 2 2% mortality
3 – 4 15% mortality
5 – 6 40% mortality!
7 – 8 100% mortality!!!
Management of pancreatic crisis if you see air bubbles on the CT scan
Don’t need aspirate aspirate to start antibiotics
Management of infected pancreatic necrosis
To the operating room emergently
Gastrinoma prognosis by type
Familial best prognosis
MEN I medium prognosis
Spontaneous worse prognosis
open pancreatic necrosectomy
access via gastrocolic ligament
greater omentum separated from the middle of the transverse colon
–OR–
If collection extends into the mesocolon and the small bowel mesentery, a direct approach from below the transverse colon may be more appropriate.
Once the pancreas is exposed,
capsule is opened and all purulent material and necrotic tissue is removed from the pancreatic bed, being careful to preserve viable pancreatic tissue.
Sharp dissection is usually avoided; it is typically sufficient to remove tissue that comes easily with a ring forceps or irrigation.
The transverse colon should be inspected for viability;
if the colon is compromised, an extended right hemicolectomy should be performed.
Depending on the organization of the necrosis, the anticipated need for further debridement, and the degree of hemorrhage, it may be appropriate to pack the pancreatic bed and plan reoperation.
Jackson-Pratt (JP) drains
or
sump: Closed continuous lavage of the retroperitoneum may be appropriate in patients where ongoing necrosis is anticipated.
consider feeding J on takeback
interval chole also rec -
open sis gastrostomy
Upper Midland laparotomy
Cholecystectomy Plus minus cholangiogram
Anterior gastrotomy to expose the posterior wall
Aspiration assist to confirm location
Culture cyst fluid
Enter the posterior wall of the stomach and pseudocyst with electrocautery
* biopsy pseudocyst wall and submit for frozen and permanent (to exclude epithelial lined cyst)*
Explore pseudocyst cavity debridement necrosis
Performing anastomosis with locking vicryl suture
NJ tube
abx discontinued after operation!
DVT prof continued!
lateral pancreatico J
This drainage procedure is ideal to relieve pain associated with a pancreatic duct dilated ≥ 10 mm (Table 1).
midline laparotomy incision
lesser sac is entered by separating the greater omentum from the transverse mesocolon.
Adhesions between the posterior wall of
the stomach and the chronically inflamed pancreas are taken down to widely expose the anterior surface of the pancreas.
A generous Kocher maneuver to the level of the superior mesenteric vein (SMV) elevates and exposes the pancreatic head.
main pancreatic ductal system is usually readily identifiable by palpation and an 18G needle (location confirmed when clear fluid is aspirated), although occasionally intraoperative ultrasound is useful.
Cautery through the parenchyma overlying the needle widens initial access to the duct lumen,
right-angled clamp into the duct guides further unroofing, first toward the tail and then toward the ampulla.
Intraductal stones removed although occasionally they are deeply impacted within the head and uncinate process.
The duct should be opened to within 2 cm of the tip of the tail. In the head of the gland, both the dorsal and ventral duct systems are unroofed to within 1 to 2 cm of the duodenal wall.
This usually requires suture control of the anterior branches of the pancreaticoduodenal arterial arcade.
A Roux-en-Y conduit is used for drainage.
The jejunum is divided 20 cm distal to the ligament of Treitz using a 3.8-mm gastrointestinal (GIA) stapler.
The limb should be at least 50 cm, and a stapled or hand-sewn side-to-side enteroenterostomy is performed.
The Roux limb is advanced through the mesocolon to the right of the middle colic vessels and usually oriented with its proximal (stapled) end toward the pancreatic tail, although the reverse orientation may be used depending upon mesenteric flexibility.
An enterotomy slightly smaller than the length of the pancreatic duct is made on the antimesenteric aspect.
A single-layer, continuous, side-to-side anastomosis is then fashioned using double-armed absorbable monofilament suture.
***The jejunal sutures are full thickness or seromuscular;
the pancreatic sutures should reach the duct lumen where possible but otherwise should ***include generous portions of fibrotic pancreatic capsule
Pancreaticoduodenectomy
(Whipple Procedure) (clinical scenarios)
midline incision is used
(first eval if cancer if this is a cancer operation)
generous Kocher extended to mobilize the hepatic flexure.
A cholecystectomy is performed, and the common bile duct is isolated at its insertion to the cystic duct.
gastroduodenal artery (GDA) is isolated and its identity confirmed by a persistent pulsation in the common hepatic artery after compression.
An accessory or replaced right hepatic artery, if present, is usually palpable at the posterior aspect of the gastrohepatic ligament at the foramen of Winslow and should be preserved.
The GDA is divided
underlying portal vein (PV) identified.
A tunnel posterior to the neck of the pancreas is started.
lesser sac is entered via the gastrocolic ligament in an avascular plane,
the right gastroepiploic vein is divided,
infrapancreatic SMV exposed.
tunnel behind the neck of the pancreas is completed,
a Penrose drain or umbilical tape is passed through it for traction.
Once resectability has been assured, the bile duct is divided
just proximal to the cystic duct insertion (if there is extrahepatic biliary dilation)
or
just distal to it (if there is not).
stomach is divided between two firings of a 4.8-mm GIA 60 stapler, starting from the greater curve near the junction of the right and left gastroepiploic arcades and ending at the lesser curve just proximal to the incisura angularis.
lesser omentum is divided, including the right gastric artery.
ligament of Treitz is taken down,
jejunum divided with a 3.8-mm GIA 60 stapler 20 cm distally,
proximal mesojejunum and mesoduodenum are divided.
The proximal jejunum is then advanced into the supracolic compartment by passing it POSTERIOR to the superior mesenteric vessels.
dividethe pancreatic neck with cautery between stay sutures.
carefully dividing small tributaries of the PV from the uncinate process and retroperitoneal tissues posteriorly - pancreas is now free
The jejunum at the distal staple line is advanced through the transverse mesocolon (retrocolic) to the right of the middle colic vessels.
pancreaticojejunostomy
pancreatic duct-to-mucosa anastomosis with transanastomotic 5 fr stenting.
Hepatico- J end-to-side single layer interrupted or continuous anastomosis.
Gastrojejunostomy
hand-sewn in two-layer
afferent limb oriented toward the lesser curve.
Duodenumsparing pancreatic head resection (DSPHR)
may be a safe and effective alternative for some patients and is indeed the preferred approach in many European centers.
The Beger procedure
has been advocated for patients with an inflammatory pancreatic head mass. In this form of DSPHR, after a generous Kocher, a tunnel between the neck of the pancreas and the PV is developed as in a standard PD. However, the GDA and supraduodenal bile duct are spared. The neck is transected, the head retracted laterally, and tributaries to the PV controlled. The pancreatic head is resected 5 mm off the duodenal wall down to but sparing the intrapancreatic common bile duct. A Roux-en-Y pancreaticojejunostomy is fashioned to the left side of the pancreas (body and tail) and then tacked over the right-sided pancreatic head excavation. A modification of this approach (Berne variant) involves coring out the pancreatic head without formal transection
Pancreatic tail resction
lesser sac
dorsal panc
splenic artery superior boarder of panc
inferiro border panc - watch the splenic VEIN
retract vein posterior
encircle splenic artery at neck where it comes from ciliac trunc
try to perserve splenic vessels
pancreatic neck is transected once vessels are controlled
pancreatic duct is sutured close
frozen section for margin
if positive - re-resection = TOTAL pancreatectomy!!! controvertial
management of low grade side brach IPMN with positive margin
does not need re-resection
you can just remove the most concerning lesion
high grade you need to take the whole 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, direct cholangiography is necessary.
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.
ERC allows placement of an endobiliary stent
with brushing
Patients with clearly resectable disease and good overall health status, who have a periampullary mass with obstructive jaundice and no evidence of metastases, may appropriately be taken to the operating room for resection without a tissue diagnosis in many cases.
Biliary decompression and tissue sampling from biliary strictures may also be accomplished by PTC. When a tissue diagnosis is needed and cannot be established by endobiliary means
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,
