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Section II General Surgery P203Surgical Recall Sixth > Pancreas, C55 P382-398 > Flashcards

Pancreas, C55 P382-398 Flashcards

1
Q

Identify the regions of the
pancreas:
P382 (picture)

A
  1. Head
  2. Neck (in front of the SMV)
  3. Uncinate process
  4. Body
  5. Tail
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2
Q

What structure is the tail of
the pancreas said to “tickle”?
P382

A

Spleen

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3
Q

Name the two pancreatic
ducts.
P382

A
  1. Wirsung duct

2. Santorini duct

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4
Q

Which duct is the main
duct?
P382

A

Duct of Wirsung is the major duct

Think: Santorini = Small duct

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5
Q

How is blood supplied to the
head of the pancreas?
P382

A 
1. Celiac trunk → gastroduodenal →
    Anterior superior pancreaticoduodenal
       artery
Posterior superior pancreaticoduodenal
       artery
2. Superior mesenteric artery →
    Anterior inferior pancreaticoduodenal
       artery
    Posterior inferior pancreaticoduodenal
       artery
3. Splenic artery →
    Dorsal pancreatic artery
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6
Q

Why must the duodenum be
removed if the head of the
pancreas is removed?
P382

A

They share the same blood supply

gastroduodenal artery

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7
Q 
What is the endocrine
function of the pancreas?
P383
A

Islets of Langerhans:
-cells: glucagon
-cells: insulin

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8
Q

What is the exocrine
function of the pancreas?
P383

A

Digestive enzymes: amylase, lipase,

trypsin, chymotrypsin, carboxypeptidase

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9
Q 
What maneuver is used to
mobilize the duodenum and
pancreas and evaluate the
entire pancreas?
P383
A

Kocher maneuver: Incise the lateral
attachments of the duodenum and then
lift the pancreas to examine the posterior
surface

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10
Q

PANCREATITIS
ACUTE PANCREATITIS
What is it?
P383

A

Inflammation of the pancreas

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11
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are the most common
etiologies in the United
States?
P383
A
  1. Alcohol abuse (50%)
  2. Gallstones (30%)
  3. Idiopathic (10%)
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12
Q 
PANCREATITIS
ACUTE PANCREATITIS
What is the acronym to
remember all of the causes
of pancreatitis?
P383
A

“I GET SMASHED”:
Idiopathic

Gallstones
Ethanol
Trauma
    Scorpion bite
    Mumps (viruses)
    Autoimmune
    Steroids
    Hyperlipidemia
    ERCP
    Drugs
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13
Q

PANCREATITIS
ACUTE PANCREATITIS
What are the symptoms?
P383

A 
Epigastric pain (frequently radiates to
back); nausea and vomiting
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14
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are the signs of
pancreatitis?
P383
A 
Epigastric tenderness
Diffuse abdominal tenderness
Decreased bowel sounds (adynamic ileus)
Fever
Dehydration/shock
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15
Q 
PANCREATITIS
ACUTE PANCREATITIS
What is the differential
diagnosis?
P384
A 
Gastritis/PUD
Perforated viscus
Acute cholecystitis
SBO
Mesenteric ischemia/infarction
Ruptured AAA
Biliary colic
Inferior MI/pneumonia
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16
Q 
PANCREATITIS
ACUTE PANCREATITIS
What lab tests should be
ordered?
P384
A 
CBC
LFT
Amylase/lipase
Type and cross
ABG
Calcium
Chemistry
Coags
Serum lipids
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17
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are the associated
diagnostic findings?
P384
A 
Lab—High amylase, high lipase, high
    WBC
AXR—Sentinel loop, colon cutoff,
    possibly gallstones (only 10% visible
    on x-ray)
U/S—Phlegmon, cholelithiasis
CT—Phlegmon, pancreatic necrosis
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18
Q 
PANCREATITIS
ACUTE PANCREATITIS
What is the most common
sign of pancreatitis on AXR?
P384
A

Sentinel loop(s)

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19
Q

PANCREATITIS
ACUTE PANCREATITIS
What is the treatment?
P384

A 
NPO
IVF
NGT if vomiting
\+/– TPN vs. postpyloric tube feeds
H(2) blocker/PPI
Analgesia (Demerol®, not morphine—
less sphincter of Oddi spasm)
Correction of coags/electrolytes
\+/– Alcohol withdrawal prophylaxis
“Tincture of time”
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20
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are the possible
complications?
P385
A 
Pseudocyst
Abscess/infection
Pancreatic necrosis
Splenic/mesenteric/portal vessel rupture
     or thrombosis
Pancreatic ascites/pancreatic pleural
    effusion
Diabetes
ARDS/sepsis/MOF
Coagulopathy/DIC
Encephalopathy
Severe hypocalcemia
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21
Q

PANCREATITIS
ACUTE PANCREATITIS
What is the prognosis?
P385

A

Based on Ranson’s criteria

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22
Q 
PANCREATITIS
ACUTE PANCREATITIS
Are postpyloric tube feeds
safe in acute pancreatitis?
P385
A

YES

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23
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are Ranson’s criteria for the following stages:
At presentation?
P385
A
  1. Age >55
  2. WBC >16,000
  3. Glc >200
  4. AST >250
  5. LDH >350
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24
Q 
PANCREATITIS
ACUTE PANCREATITIS
What are Ranson’s criteria for the following stages:
During the initial
48 hours?
P385
A
  1. Base deficit > 4
  2. BUN increase > 5 mg/dL
  3. Fluid sequestration > 6 L
  4. Serum Ca⁺ < 8
  5. Hct decrease > 10%
  6. PO(2) (ABG) < 60 mm Hg
    (Amylase value is NOT one of
    Ranson’s criteria!)
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25
``` PANCREATITIS ACUTE PANCREATITIS What is the mortality per positive criteria: 0 to 2? 3 to 4? 5 to 6? 7 to 8? P385 ```
0 to 2? < 5% 3 to 4?  ≈ 15% 5 to 6?  ≈ 40% 7 to 8? ≈ 100%
26
``` PANCREATITIS ACUTE PANCREATITIS How can the admission Ranson criteria be remembered? P386 ```
“GA LAW (Georgia law)”: Glucose >200 Age >55 ``` LDH >350 AST >250 WBC >16,000 (“Don’t mess with the pancreas and don’t mess with the Georgia law”) ```
27
``` PANCREATITIS ACUTE PANCREATITIS How can Ranson’s criteria at less than 48 hours be remembered? P386 ```
``` “C HOBBS (Calvin and Hobbes)”: Calcium 10% O(2) 4 Bun >5 increase Sequestration >6 L ```
28
``` PANCREATITIS ACUTE PANCREATITIS How can the AST versus LDH values in Ranson’s criteria be remembered? P386 ```
Alphabetically and numerically: A before L and 250 before 350 Therefore, AST >250 and LDH >350
29
``` PANCREATITIS ACUTE PANCREATITIS What is the etiology of hypocalcemia with pancreatitis? P386 ```
Fat saponification: fat necrosis binds to | calcium
30
``` PANCREATITIS ACUTE PANCREATITIS What complication is associated with splenic vein thrombosis? P386 ```
``` Gastric varices (treatment with splenectomy) ```
31
``` PANCREATITIS ACUTE PANCREATITIS Can TPN with lipids be given to a patient with pancreatitis? P386 ```
Yes, if the patient does not suffer from | hyperlipidemia (triglycerides <300)
32
``` PANCREATITIS ACUTE PANCREATITIS What is the least common cause of acute pancreatitis (and possibly the most commonly asked cause on rounds!) P386 ```
``` Scorpion bite (found on the island of Trinidad) ```
33
PANCREATITIS CHRONIC PANCREATITIS What is it? P387
``` Chronic inflammation of the pancreas region causing destruction of the parenchyma, fibrosis, and calcification, resulting in loss of endocrine and exocrine tissue ```
34
PANCREATITIS CHRONIC PANCREATITIS What are the subtypes? P387
1. Chronic calcific pancreatitis | 2. Chronic obstructive pancreatitis (5%)
35
PANCREATITIS CHRONIC PANCREATITIS What are the causes? P387
``` Alcohol abuse (most common; 70% of cases) Idiopathic (15%) Hypercalcemia (hyperparathyroidism) Hyperlipidemia Familial (found in families without any other risk factors) Trauma Iatrogenic Gallstones ```
36
PANCREATITIS CHRONIC PANCREATITIS What are the symptoms? P387
Epigastric and/or back pain, weight loss, | steatorrhea
37
``` PANCREATITIS CHRONIC PANCREATITIS What are the associated signs? P387 ```
Type 1 diabetes mellitus (up to one third) | Steatorrhea (up to one fourth), weight loss
38
``` PANCREATITIS CHRONIC PANCREATITIS What are the signs of pancreatic exocrine insufficiency? P387 ```
Steatorrhea (fat malabsorption from lipase insufficiency—stools float in water) Malnutrition
39
``` PANCREATITIS CHRONIC PANCREATITIS What are the signs of pancreatic endocrine insufficiency? P387 ```
Diabetes (glucose intolerance)
40
``` PANCREATITIS CHRONIC PANCREATITIS What are the common pain patterns? P387 ```
Unrelenting pain | Recurrent pain
41
``` PANCREATITIS CHRONIC PANCREATITIS What is the differential diagnosis? P387 ```
PUD, biliary tract disease, AAA, | pancreatic cancer, angina
42
``` PANCREATITIS CHRONIC PANCREATITIS What percentage of patients with chronic pancreatitis have or will develop pancreatic cancer? P387 ```
≈2%
43
``` PANCREATITIS CHRONIC PANCREATITIS What are the appropriate lab tests? P388 ```
Amylase/lipase 72-hour fecal fat analysis Glc tolerance test (IDDM)
44
``` PANCREATITIS CHRONIC PANCREATITIS Why may amylase/lipase be normal in a patient with chronic pancreatitis? P388 ```
Because of extensive pancreatic tissue | loss (“burned-out pancreas”)
45
``` PANCREATITIS CHRONIC PANCREATITIS What radiographic tests should be performed? P388 ```
``` CT—Has greatest sensitivity for gland enlargement/atrophy, calcifications, masses, pseudocysts KUB—Calcification in the pancreas ERCP—Ductal irregularities with dilation and stenosis (Chain of Lakes), pseudocysts ```
46
``` PANCREATITIS CHRONIC PANCREATITIS What is the medical treatment? P388 ```
``` Discontinuation of alcohol use—can reduce attacks, though parenchymal damage continues secondary to ductal obstruction and fibrosis Insulin for type 1 diabetes mellitus Pancreatic enzyme replacement Narcotics for pain ```
47
``` PANCREATITIS CHRONIC PANCREATITIS What is the surgical treatment? P388 ```
Puestow—longitudinal pancreaticojejunostomy (pancreatic duct must be dilated) Duval—distal pancreaticojejunostomy Near-total pancreatectomy
48
PANCREATITIS CHRONIC PANCREATITIS What is the Frey procedure? P388
Longitudinal pancreaticojejunostomy with | core resection of the pancreatic head
49
``` PANCREATITIS CHRONIC PANCREATITIS What is the indication for surgical treatment of chronic pancreatitis? P388 ```
Severe, prolonged/refractory pain
50
``` PANCREATITIS CHRONIC PANCREATITIS What are the possible complications of chronic pancreatitis? P388 ```
``` Insulin dependent diabetes mellitus Steatorrhea Malnutrition Biliary obstruction Splenic vein thrombosis Gastric varices Pancreatic pseudocyst/abscess Narcotic addiction Pancreatic ascites/pleural effusion Splenic artery aneurysm ```
51
PANCREATITIS GALLSTONE PANCREATITIS What is it? P389
Acute pancreatitis from a gallstone in or passing through the ampulla of Vater (the exact mechanism is unknown)
52
PANCREATITIS GALLSTONE PANCREATITIS How is the diagnosis made? P389
Acute pancreatitis and cholelithiasis and/or choledocholithiasis and no other cause of pancreatitis (e.g., no history of alcohol abuse)
53
``` PANCREATITIS GALLSTONE PANCREATITIS What radiologic tests should be performed? P389 ```
U/S to look for gallstones CT to look at the pancreas, if symptoms are severe
54
PANCREATITIS GALLSTONE PANCREATITIS What is the treatment? P389
Conservative measures and early interval cholecystectomy (laparoscopic cholecystectomy or open cholecystectomy) and intraoperative cholangiogram (IOC) 3 to 5 days (after pancreatic inflammation resolves)
55
``` PANCREATITIS GALLSTONE PANCREATITIS Why should early interval cholecystectomy be performed on patients with gallstone pancreatitis? P389 ```
``` Pancreatitis will recur in ≈33% of patients within 8 weeks (so always perform early interval cholecystectomy and IOC in 3 to 5 days when pancreatitis resolves) ```
56
PANCREATITIS GALLSTONE PANCREATITIS What is the role of ERCP? P389
1. Cholangitis | 2. Refractory choledocholithiasis
57
PANCREATITIS HEMORRHAGIC PANCREATITIS What is it? P389
Bleeding into the parenchyma and retroperitoneal structures with extensive pancreatic necrosis
58
PANCREATITIS HEMORRHAGIC PANCREATITIS What are the signs? P389
Abdominal pain, shock/ARDS, Cullen’s | sign, Grey Turner’s sign, Fox’s sign
59
``` PANCREATITIS HEMORRHAGIC PANCREATITIS Define the following terms: Cullen’s sign P389 ```
``` Bluish discoloration of the periumbilical area from retroperitoneal hemorrhage tracking around to the anterior abdominal wall through fascial planes ```
60
``` PANCREATITIS HEMORRHAGIC PANCREATITIS Define the following terms: Grey Turner’s sign P390 ```
``` Ecchymosis or discoloration of the flank in patients with retroperitoneal hemorrhage from dissecting blood from the retroperitoneum (Think: Grey TURNer = TURN side to side = flank [side] hematoma) ```
61
PANCREATITIS HEMORRHAGIC PANCREATITIS Fox’s sign P390
Ecchymosis of the inguinal ligament from blood tracking from the retroperitoneum and collecting at the inguinal ligament
62
``` PANCREATITIS HEMORRHAGIC PANCREATITIS What are the significant lab values? P390 ```
Increased amylase/lipase Decreased Hct Decreased calcium levels
63
``` PANCREATITIS HEMORRHAGIC PANCREATITIS What radiologic test should be performed? P390 ```
CT scan with IV contrast
64
PANCREATIC ABSCESS What is it? P390
Infected peripancreatic purulent fluid | collection
65
PANCREATIC ABSCESS What are the signs/ symptoms? P390
Fever, unresolving pancreatitis, epigastric | mass
66
PANCREATIC ABSCESS What radiographic tests should be performed? P390
Abdominal CT with needle aspiration → | send for Gram stain/culture
67
PANCREATIC ABSCESS What are the associated lab findings? P390
Positive Gram stain and culture of | bacteria
68
PANCREATIC ABSCESS Which organisms are found in pancreatic abscesses? P390
``` Gram negative (most common): Escherichia coli, Pseudomonas, Klebsiella Gram positive: Staphylococcus aureus, Candida ```
69
PANCREATIC ABSCESS What is the treatment? P390
Antibiotics and percutaneous drain placement or operative débridement and placement of drains
70
PANCREATIC NECROSIS What is it? P391
Dead pancreatic tissue, usually following | acute pancreatitis
71
PANCREATIC NECROSIS How is the diagnosis made? P391
Abdominal CT with IV contrast; dead pancreatic tissue does not take up IV contrast and is not enhanced on CT scan (i.e., doesn’t “light up”)
72
PANCREATIC NECROSIS What is the treatment: Sterile? P391
Medical management
73
PANCREATIC NECROSIS What is the treatment: Suspicious of infection? P391
CT-guided FNA
74
PANCREATIC NECROSIS What is the treatment: Toxic, hypotensive? P391
Operative débridement
75
PANCREATIC PSEUDOCYST What is it? P391 (picture)
Encapsulated collection of pancreatic | fluid
76
PANCREATIC PSEUDOCYST What makes it a “pseudo” cyst? P391
Wall is formed by inflammatory fibrosis, | NOT epithelial cell lining
77
PANCREATIC PSEUDOCYST What is the incidence? P391
≈1 in 10 after alcoholic pancreatitis
78
PANCREATIC PSEUDOCYST What are the associated risk factors? P391
Acute pancreatitis < chronic | pancreatitis from alcohol
79
``` PANCREATIC PSEUDOCYST What is the most common cause of pancreatic pseudocyst in the United States? P391 ```
Chronic alcoholic pancreatitis
80
PANCREATIC PSEUDOCYST What are the symptoms? P392
``` Epigastric pain/mass Emesis Mild fever Weight loss Note: Should be suspected when a patient with acute pancreatitis fails to resolve pain ```
81
PANCREATIC PSEUDOCYST What are the signs? P392
Palpable epigastric mass, tender | epigastrium, ileus
82
PANCREATIC PSEUDOCYST What lab tests should be performed? P392
Amylase/lipase Bilirubin CBC
83
PANCREATIC PSEUDOCYST What are the diagnostic findings? P392
``` Lab—High amylase, leukocytosis, high bilirubin (if there is obstruction) U/S—Fluid-filled mass CT—Fluid-filled mass, good for showing multiple cysts ERCP—Radiopaque contrast material fills cyst if there is a communicating pseudocyst (i.e., pancreatic duct communicates with pseudocyst) ```
84
PANCREATIC PSEUDOCYST What is the differential diagnosis of a pseudocyst? P392
Cystadenocarcinoma, cystadenoma
85
``` PANCREATIC PSEUDOCYST What are the possible complications of a pancreatic pseudocyst? P392 ```
Infection, bleeding into the cyst, fistula, pancreatic ascites, gastric outlet obstruction, SBO, biliary obstruction
86
PANCREATIC PSEUDOCYST What is the treatment? P392
Drainage of the cyst or observation
87
``` PANCREATIC PSEUDOCYST What is the waiting period before a pseudocyst should be drained? P392 ```
It takes 6 weeks for pseudocyst walls to “mature” or become firm enough to hold sutures and most will resolve in this period of time if they are going to
88
``` PANCREATIC PSEUDOCYST What percentage of pseudocysts resolve spontaneously? P392 ```
≈50%
89
``` PANCREATIC PSEUDOCYST What is the treatment for pseudocyst with bleeding into cyst? P392 ```
Angiogram amd embolization
90
PANCREATIC PSEUDOCYST What is the treatment for pseudocyst with infection? P393
Percutaneous external drainage/ | IV antibiotics
91
PANCREATIC PSEUDOCYST What size pseudocyst should be drained? P393
``` Most experts say: Pseudocysts larger than 5 cm have a small chance of resolving and have a higher chance of complications Calcified cyst wall Thick cyst wall ```
92
``` PANCREATIC PSEUDOCYST What are three treatment options for pancreatic pseudocyst? P393 ```
1. Percutaneous aspiration/drain 2. Operative drainage 3. Transpapillary stent via ERCP (pseudocyst must communicate with pancreatic duct)
93
``` PANCREATIC PSEUDOCYST What are the surgical options for the following conditions: Pseudocyst adherent to the stomach? P393 ```
Cystogastrostomy (drain into the | stomach)
94
``` PANCREATIC PSEUDOCYST What are the surgical options for the following conditions: Pseudocyst adherent to the duodenum? P393 ```
Cystoduodenostomy (drain into the | duodenum)
95
``` PANCREATIC PSEUDOCYST What are the surgical options for the following conditions: Pseudocyst not adherent to the stomach or duodenum? P393 ```
Roux-en-Y cystojejunostomy (drain into | the Roux limb of the jejunum)
96
``` PANCREATIC PSEUDOCYST What are the surgical options for the following conditions: Pseudocyst in the tail of the pancreas? P393 ```
Resection of the pancreatic tail with the | pseudocyst
97
``` PANCREATIC PSEUDOCYST What is an endoscopic option for drainage of a pseudocyst? P393 ```
Endoscopic cystogastrostomy
98
``` PANCREATIC PSEUDOCYST What must be done during a surgical drainage procedure for a pancreatic pseudocyst? P393 ```
Biopsy of the cyst wall to rule out a cystic | carcinoma (e.g., cystadenocarcinoma)
99
``` PANCREATIC PSEUDOCYST What is the most common cause of death due to pancreatic pseudocyst? P393 ```
Massive hemorrhage into the pseudocyst
100
PANCREATIC CARCINOMA What is it? P394
Adenocarcinoma of the pancreas arising | from duct cells
101
PANCREATIC CARCINOMA What are the associated risk factors? P394
Smoking 3X risk, diabetes mellitus, heavy alcohol use, chronic pancreatitis, diet high in fried meats, previous gastrectomy
102
PANCREATIC CARCINOMA What is the male to female ratio? P394
3:2
103
PANCREATIC CARCINOMA What is the African American to white ratio? P394
2:1
104
PANCREATIC CARCINOMA What is the average age? P394
>60 years
105
PANCREATIC CARCINOMA What are the different types? P394
>80% are duct cell adenocarcinomas; other types include cystadenocarcinoma and acinar cell carcinoma
106
PANCREATIC CARCINOMA What percentage arise in the pancreatic head? P394
66% arise in the pancreatic head; 33% | arise in the body and tail
107
``` PANCREATIC CARCINOMA Why are most pancreatic cancers in the tail nonresectable? P394 ```
These tumors grow without symptoms until it is too late and they have already spread— head of the pancreas tumors draw attention earlier because of biliary obstruction
108
``` PANCREATIC CARCINOMA What are the signs/ symptoms of tumors based on location: Head of the pancreas? P394 ```
Painless jaundice from obstruction of common bile duct; weight loss; abdominal pain; back pain; weakness; pruritus from bile salts in skin; anorexia; Courvoisier’s sign; acholic stools; dark urine; diabetes
109
``` PANCREATIC CARCINOMA What are the signs/ symptoms of tumors based on location: Body or tail? P394 ```
Weight loss and pain (90%); migratory thrombophlebitis (10%); jaundice (<10%); nausea and vomiting; fatigue
110
``` PANCREATIC CARCINOMA What are the most common symptoms of cancer of the pancreatic HEAD? P394 ```
1. Weight loss (90%) 2. Pain (75%) 3. Jaundice (70%)
111
PANCREATIC CARCINOMA What is “Courvoisier’s sign”? P395
Palpable, nontender, distended gallbladder
112
``` PANCREATIC CARCINOMA What percentage of patients with cancers of the pancreatic HEAD have Courvoisier’s sign? P395 ```
33%
113
``` PANCREATIC CARCINOMA What is the classic presentation of pancreatic cancer in the head of the pancreas? P395 ```
Painless jaundice
114
``` PANCREATIC CARCINOMA What metastatic lymph nodes described classically for gastric cancer can be found with metastatic pancreatic cancer? P395 ```
Virchow’s node; Sister Mary Joseph’s | nodule
115
PANCREATIC CARCINOMA What are the associated lab findings? P395
``` Increased direct bilirubin and alkaline phosphatase (as a result of biliary obstruction) Increased LFTs Elevated pancreatic tumor markers ```
116
``` PANCREATIC CARCINOMA Which tumor markers are associated with pancreatic cancer? P395 ```
CA-19-9
117
PANCREATIC CARCINOMA What does CA-19-9 stand for? P395
Carbohydrate Antigen 19-9
118
PANCREATIC CARCINOMA What diagnostic studies are performed? P395
Abdominal CT, U/S, cholangiography (ERCP to rule out choledocholithiasis and cell brushings), endoscopic U/S with biopsy
119
PANCREATIC CARCINOMA What are the pancreatic cancer STAGES: Stage I? P395
Tumor is limited to pancreas, with no | nodes or metastases
120
PANCREATIC CARCINOMA What are the pancreatic cancer STAGES: Stage II? P395
Tumor extends into bile duct, peripancreatic tissues, or duodenum; there are no nodes or metastases
121
PANCREATIC CARCINOMA What are the pancreatic cancer STAGES: Stage III? P395
Same findings as stage II plus positive | nodes or celiac or SMA involvement
122
PANCREATIC CARCINOMA What are the pancreatic cancer STAGES: Stage IV? P396
Tumor extends to stomach, colon, spleen, or major vessels, with any nodal status and no distant metastases
123
PANCREATIC CARCINOMA What are the pancreatic cancer STAGES: Stage IVB? P396
``` Distant metastases (any nodal status, any tumor size) are found ```
124
PANCREATIC CARCINOMA What is the treatment based on location: Head of the pancreas? P396
Whipple procedure | pancreaticoduodenectomy
125
PANCREATIC CARCINOMA What is the treatment based on location: Body or tail? P396
Distal resection
126
PANCREATIC CARCINOMA What factors signify inoperability? P396
``` Vascular encasement (SMA, hepatic artery) Liver metastasis Peritoneal implants Distant lymph node metastasis (periaortic/celiac nodes) Distant metastasis Malignant ascites ```
127
``` PANCREATIC CARCINOMA Is portal vein or SMV involvement an absolute contraindication for resection? P396 ```
No—can be resected and reconstructed with vein interposition graft at some centers
128
``` PANCREATIC CARCINOMA Should patients undergo preoperative biliary drainage (e.g., ERCP)? P396 ```
No (exceptions for symptoms/ | preoperative XRT, trials, etc.)
129
PANCREATIC CARCINOMA Define the Whipple procedure (pancreaticoduodenectomy). P396
``` Cholecystectomy Truncal vagotomy Antrectomy Pancreaticoduodenectomy—removal of head of pancreas and duodenum Choledochojejunostomy—anastomosis of common bile duct to jejunum Pancreaticojejunostomy—anastomosis of distal pancreas remnant to jejunum Gastrojejunostomy—anastomosis of stomach to jejunum ```
130
PANCREATIC CARCINOMA What is the complication rate after a Whipple procedure? P396
≈25%
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``` PANCREATIC CARCINOMA What mortality rate is associated with a Whipple procedure? P397 ```
<5% at busy centers
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PANCREATIC CARCINOMA What is the “pyloruspreserving Whipple”? P397
No antrectomy; anastomose duodenum | to jejunum
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PANCREATIC CARCINOMA What are the possible post-Whipple complications? P397
Delayed gastric emptying (if antrectomy is performed); anastomotic leak (from the bile duct or pancreatic anastomosis), causing pancreatic/biliary fistula; wound infection; postgastrectomy syndromes; sepsis; pancreatitis
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``` PANCREATIC CARCINOMA Why must the duodenum be removed if the head of the pancreas is resected? P397 ```
They share the same blood supply
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PANCREATIC CARCINOMA What is the postoperative adjuvant therapy? P397
Chemotherapy +/– XRT
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``` PANCREATIC CARCINOMA What is the palliative treatment if the tumor is inoperable and biliary obstruction is present? P397 ```
PTC or ERCP and placement of stent | across obstruction
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PANCREATIC CARCINOMA What is the prognosis at 1 year after diagnosis? P397
Dismal; 90% of patients die within 1 year | of diagnosis
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PANCREATIC CARCINOMA What is the survival rate at 5 years after resection? P397
20%
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MISCELLANEOUS What is an annular pancreas? P397
Pancreas encircling the duodenum; if obstruction is present, bypass, do not resect
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MISCELLANEOUS What is pancreatic divisum? P397
``` Failure of the two pancreatic ducts to fuse; the normally small duct (Small  Santorini) of Santorini acts as the main duct in pancreatic divisum (Think: the two pancreatic ducts are Divided  Divisum) ```
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MISCELLANEOUS What is heterotopic pancreatic tissue? P398
Heterotopic pancreatic tissue usually found in the stomach, intestine, duodenum
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MISCELLANEOUS What is a Puestow procedure? P398
Longitudinal filleting of the pancreas/ pancreatic duct with a side-to-side anastomosis with the small bowel
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``` MISCELLANEOUS What medication decreases output from a pancreatic fistula? P398 ```
Somatostatin (GI-inhibitory hormone)
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MISCELLANEOUS Which has a longer half-life: amylase or lipase? P398
Lipase; therefore, amylase may be normal | and lipase will remain elevated longer
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MISCELLANEOUS What is the WDHA syndrome? P398
``` Pancreatic VIPoma (Vasoactive Intestinal Polypeptide tumor) Also known as Verner-Morrison syndrome Tumor secretes VIP, which causes: Watery Diarrhea Hypokalemia Achlorhydria (inhibits gastric acid secretion) ```
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MISCELLANEOUS What is the Whipple triad of pancreatic insulinoma? P398
1. Hypoglycemia (Glc <50) 2. Symptoms of hypoglycemia: mental status changes/vasomotor instability 3. Relief of symptoms with administration of glucose
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MISCELLANEOUS What is the most common islet cell tumor? P398
Insulinoma
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``` MISCELLANEOUS What pancreatic tumor is associated with gallstone formation? P398 ```
Somatostatinoma (inhibits gallbladder | contraction)
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``` MISCELLANEOUS What is the triad found with pancreatic somatostatinoma tumor? P398 ```
1. Gallstones 2. Diabetes 3. Steatorrhea
150
``` MISCELLANEOUS What are the two classic findings with pancreatic glucagonoma tumors? P398 ```
1. Diabetes 2. Dermatitis/rash (necrotizing migratory erythema)

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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