Pancreatic and biliary surgery Flashcards by Mathew Rogers

Any abnormalities?

Normal xray

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Any abnormalities?

pancreatic pseudocyst

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what abnormality is this?

pancreatic cancer

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pancreatic CT protocol?

Pancreatic protocol
5mm slices through pancreas
Sensitive and specific
Anyone can look at the films

Lot of radiation
Need to give contrast (nephrotoxic)

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MRI protocol?

No radiation
Don’t need contrast
Rendered diagnostic ERCP a thing of the past

Claustrophobic and noisy (open MRI)
 Metalwork problematic (Clips in brain)
 Takes longer than a CT

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What is this abnormality?

ERCP

An inoperable carcinoma of the pancreatic head is causing a distal, filliforme stenosis of the biliary duct.

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Pancreatic diseases?

Congenital abnormalities
Pancreatic injuries
Pancreatitis
Acute
Chronic
Pancreatic cancer
Pancreatic endocrine tumours

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Effects of cystic fibrosis on pancreas?

Cystic fibrosis
AR inherited disorder
Heterozygous carriers are at risk of pancreatitis
Generalised dysfunction of exocrine glands
Thick secretions block PD > duct ectasia and exocrine gland destruction
Pancreatic insufficiency > steatorrhoea > creon

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Pathology of pancreatic cancer?

Failure of complete rotation of the ventral pancreatic bud
Ring of pancreatic tissue surrounds 2nd or 3rd part of duodenum
Can present with vomiting
Treated with a bypass (resecting the band may result in a pancreatic fistula)
Cause of pancreatitis later in life

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Ectopic pancrease?

In submucosa of
Stomach
Duodenum
SB (incl Meckel’s)
Gallbladder
Hilum of the spleen
Liver
Can give symptoms and cause cysts (rare)

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causes of Congenital cystic disease of the pancrease?

Can accompany congenital cystic
Liver and kidney

Von Hippel-Lindau syndrome (AD condition)
Haemangioblastomas of brain, spinal cord & retina
Renal cysts and carcinomas
Phaeochromocytoma
Pancreatic cysts variable malignant potential

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Different types of pancreatic injury?

Blunt trauma e.g. RTA, Handlebar injuries
90% raised enzymes
CT
Centre portion transected > PD disruption
May need distal pancreatectomy

Iatrogenic injuries
Splenectomy
Pancreatic fistula

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Acute pancreatitis aetiology?

3% all cases of abdominal pain admitted
Mortality 10-15%
80% have mild attack – mortality 1%
Severe attack – mortality 20-50%

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Causes of pancreatitis?

I GET SMASHED

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune vasculitis, PAN
Scorpion venom
Hypercalaemia, hypothermia, hyperlipidaemia (TGs)
ERCP
Drugs (azathioprine, diuretics), duodenal obstruction (tumours, annular pancreas)

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Investigation for pancreatitis?

Amylase > 3x normal or > 1000
Other causes of raised amylase (usually less pronounced)
Cholecystitis
Mesenteric ishaemia
Perf PUD
Ectopic pregnancy
AXR
Sentinel loop
Loss of psoas shadow due to retroperitoneal fluid

USS ? Gallstones
? Biliary dilatation

CT Diagnostic
Complications

Scoring of pancreatitis?

PANCREAS

PaO2 < 8Kpa
Age > 55
Neutrophils (WCC >15)
Calcium < 2.0
Renal (urea > 16)
Enzymes (LDH > 600)
Albumin < 32
Sugar (glucose > 10)

Mild 0-1
Moderate 2-3
Severe 4 or more

Management of pancreatitis?

IVI and catheter
Analgesia
O2
No evidence for NBM unless ileus > N&V
Antibiotics, flimsy evidence, essentially if necrosis
CT – ideally day 5-7
ERCP if LFTs deranged and patient not settling

Local and Systemic complications of pancreatittis?

Local:

Acute fluid collection
Pseudocyst (>4 weeks)
Necrosis
Abscess
Ascites
Pseudoaneurysm (GDA or splenic)

Systemic:

Renal
Respiratory
Cardiovascular
Gut

Major cause of SIRS and MOF

Surgery for pancreatitis?

Necrosectomy for infected pancreatic necrosis
50% mortality
Drainage of pseudocyst
Endoscopic transgastric (bleeding)
Open

Describe pancreatitis?

Chronic inflammatory disease with progressive and irreversible destruction of pancreatic tissue
Fibrosis of the pancreas
Ducts become strictured and ectatic
Ductal stones
Alcohol most common cause (although any cause of ductal obstruction)

Features of chronic pancreatitis?

Pain
Loss of exocrine function
Steatorrhoea
Need to take creon
Loss of endocrine function
Diabetes

Investgations of chronic pancreatitis?

Amylase – Often normal
AXR – calcification
CT
MRI – Good for looking at PD
ERCP
Faecal elastase

Treatment for chronic pancreatittis?

Analgesia is the mainstay
Coeliac plexus blocks
Creon
Insulin
STOP DRINKING
Surgery last resort as major surgery

Pancreatic tumours?

Many benign and malignant tumours Armed forces Institute of Pathology Classification of Exocrine Primary Pancreatic Neoplasia Carcinoma (adeno) commonest and important 10 per 100 000 population Disease of ageing M=F 85% adenocarcinomas Aetiology Smoking Chronic pancreatitis 1% of all pancreatic tumours thus very rare Insulin secreting tumour Treated by removing tumour (enucleation) Gastrin secreting tumour Zollinger-Ellison syndrome PPI or resection Other rarer types

Investigations of chronic pancreatitis?

Epigastric / back pain (confers poor prognosis) Weight loss Anorexia Vomiting (GOO) Painless jaundice

What is Courvoisiers law?

Painless jaundice and a palpable gallbladder is unlikely to be due to stones

Investigations for courvoisiers law?

LFTs CA19-9 USS (biliary dilatation) CT (pancreatic protocol) Primary tumour Relationship to vessels (SMA, SMV, portal v) Nodes Mets

Treatment for courvoisiers law?

Most cases inoperable Palliative treatment Chemotherapy &/or best supportive care Biliary stent Duodenal stent Double bypass ## Footnote Operable cases Whipples / PPPD (pylorus preserving pancreatico-duodenectomy)

Whipples prognosis?

Less than 5% 5 year survival Up to 40% for peri-ampullary tumours

Describe Cholangiosarcoma?

Adenocarcinoma of the bile duct Extrahepatic Intrahepatic Rare 1:100 000 Rarely resectable

Describe gallbladder cancer?

Rare 1:100 000 Often found incidentally Poor prognosis May need extended cholecystectomy

Describe gall stones?

Pigment stones and cholesterol stones ALL ARE MIXED ## Footnote Cause (imbalance of 3 bile constituents) Bile salts Lecithin Cholesterol Fat female fair fertile 40

Problems galltones causes?

None Biliary colic (pain-severe) - Murphy’s sign Cholecystitis (raised temp & WCC) Pancreatitis Obstructive jaundice (Alp raised \> ALT) Cholangitis:- Charcot’s triad – pain, jaundice, fever/rigors Mirizzi syndrome:- Type I (stone/oedema pressing on ducts (CHD) Type II (stone fistulating into bile ducts) Gallstone ileus:- AXR – SBO, Calcified stone RIF, air in biliary tree (GB cancer – very rare)

Causes of gallstones?

Pigment stones and cholesterol stones ALL ARE MIXED ## Footnote Cause (imbalance of 3 bile constituents) Bile salts Lecithin Cholesterol Fat female fair fertile 40

How to diagnose a gallstone?

USS Acoustic shadow Diameter of CBD 7-8 normal Increases with age Up to 1 cm post cholecystectomy Correlate with clinical findings

treatment for a gallstone?

Incidental finding – leave alone Biliary colic – lap chole (acute vs elective) Cholecystitis – Abs \> lap chole Pancreatitis – as above Obstructive jaundice – lap CBD expl / ERCP Cholangitis – ERCP Mirizzi syndrome - complex Gallstone ileus - Take stone out. Leave RUQ

Lap Chole?

Lap chole 5% conversion to open No access (adhesions) Bleeding Anatomy not typical/difficult Calot’s triangle 1 in 300 risk bile duct injury Bile leak