Pancreas

Question 1

35F w/ pancreatic cyst w/ low amylase, CEA 0.35, not communicating with main pancreatic duct duct and CT showing central calcification adjacent to multiple cysts… most likely diagnosis?

Answer 1

serous cystadenoma

Question 2

Pseudocyst: Location? Cytology? Viscosity? Amylase? CEA? KRAS mutation?

Answer 2

Location: evenly distributed in pancreas Cytology: pigmented histocytes Viscosity: low Amylase: high CEA: < 200 ng/mL KRAS mutation: negative

Question 3

Serous cystadenomas (SCN) Location? Cytology? Viscosity? Amylase? CEA? KRAS mutation?

Answer 3

Location: evenly distributed in pancreas Cytology: Bland periodic acid Schiff+ Viscosity: low Amylase: low CEA: < 0.5 ng/mL KRAS mutation: negative

Question 4

Mucinous Cystic Neoplasm (MCN): Location? Cytology? Viscosity? Amylase? CEA? KRAS mutation?

Answer 4

Location: Tail Cytology: Mucinous Viscosity: Increased Amylase: low CEA: > 200 ng/mL KRAS mutation: positive

Question 5

IPMN Location? Cytology? Viscosity? Amylase? CEA? KRAS mutation?

Answer 5

Location: Head Cytology: mucinous Viscosity: high Amylase: high CEA: > 200ng/mL KRAS mutation: positive

Question 6

35F. multiple cystic lesions not communicating with pancreatic duct.

CEA 0.35. Amylase low.

What is the CT scan showing?

Diagnosis?

Answer 6

CT scan: central calcificaiton surrounded by multiple cysts

pathognomonic for Serous cyst adenoma

Question 7

What is the Beger procedure?

What are the indications?

What are the steps?

Answer 7

The Beger procedure is a DUODENEM-preserving pancreatic head resection.

Indication = large inflammatory mass in the head of the pancreas with NO evidence of distal ductal dilation

1) Dissect pancreatic head to the level of the portal vein
2) Transect the pancreatic head leaving a thin rim of pancreatic tissue abutting duodenem
3) Reconstruct with Roux-en-Y jejunal loop to pancreatic tail remnant (end to side) and to the excavated pancreatic head (side to side)

Question 8

What is the Puestow procedure?

Indication?

Answer 8

The Puestow procedure is a logintudinal pancreaticojejunostomy

Indication: chronic pancreatitis with dilation of pancreatic duct (>= 7mm)

Question 9

What is the Frey procedure?

Indications?

Answer 9

The Frey procedure involves coring out the head of the pancreas with a longitudinal dissection of the pancreatic duct toward the tail (usually performed WITH a roux-en-y pancreaticojejunostomy)

Indication: smaller inflammatory masses of the pancreatic head with dilated pancreatic ducts

Question 10

What is the Whipple procedure?

Indication?

Answer 10

The whipple procedure (pancreaticoduodenectomy) involves resection of the pancreatic head, duodenem, and distal one third of the stomach. Reconstruction involves a gastrojejunostomy (G-J), pancreaticojejunostomy (P-J), and hepaticojejunostomy (H-J).

Indications: neoplasms isolated to the head of the pancreas

Question 11

What is the Bern procedure?

Indication?

Answer 11

The Bern procedure is a modification of the Beger procedure that invovles RESECTION of the pancreatic head. Different than the Berger procedure in that the pancreas is NOT resected at the level of the portal vein. Reconstruction only requires singla anstamosis with a roux-en-y jejunal loop to the pancreas.

Indication: inflammation of pancreatic head with no ductal dilation

Question 12

What is the 5 year survival rate after resection for IPMN vs. pancreatic ductal adenocarcinoma?

why is there a difference?

Answer 12

IPMN 5 year survival rate 43-60%

Pancreatic ductal adenocarcinoma 15%

This is due to advanced T stage and increased likelihood of mets when pancreatic adenocarcinoma is found.

Question 13

What are the Fukouka Guidelines?

Pros? Cons?

Answer 13

Fukouka Guidelines for pancreatic cysts

“Worrisome Features”

1) dilateded pancreatic duct w/o solid cyst
2) Solid cystic component without ductal dilation
3) cyst > 3cm
4) history of pancreatitis
5) thick/enhancing wall cysts

Pro: good positive predictive value for the diagnosis of advanced neoplasm

Con: miss cases of invasive cancer and high grade dysplasia

Question 14

What are the components of Ranson’s criteria for an alcoholic?

Answer 14

At Admission:

• Glucose > 200
• Age > 55 y/o
• LDH > 350
• AST > 250
• WBC > 16,000

In 48 hours:

• Calcium < 8mg/dl
• Hematocrit decrease > 10%
• PO2 < 60mmHg
• BUN inc > 5 mg/dl
• Base deficit > 4 mEq/L
• Fluid Sequestration/loss > 6L

Question 15

What are the components of Ranson’s criteria for biliary-related diseases?

Answer 15

At Admission:

• Glucose > 220
• Age > 70 y/o
• LDH > 250
• AST > 250
• WBC > 18,000

In 48 hours:

• Calcium < 8mg/dl
• Hematocrit decrease > 10%
• PO2 < 60mmHg
• BUN inc > 2 mg/dl
• Base deficit > 5 mEq/L
• Fluid Sequestration/loss > 4L