Surgery for pancreatic disorders

Question 1

What are some risk factors for cancer of the head of the pancreas?

Answer 1

smoking

FAP, chronic pancreatitis and adult onset diabetes

Question 2

How may patients with pancreatic cancer present?

Answer 2

obstructive jaundice, abdominal pain, weight loss, diabetes, vomiting

Question 3

What tumour marker would you look for?

Answer 3

CA19-9

Question 4

What imaging/invasive investigations would be undertaken for cancer?

Answer 4

CT, ERCP, EUS, PET, USS, percutaneous needle biopsy, cytology, MRCP

Question 5

What symptom is ERCP useful to treat?

Answer 5

jaundice - stenting

Question 6

What are the steps and test which allow us to decide if a patient is fit for major pancreatic resection?

Answer 6

respiratory tests
exercise tests - lactate
CXR, ECG

Question 7

If pancreatic cancer is unresectable what steps are taken?

Answer 7

ERCP and stent
laparascopic bypass - weight loss
open bypass

Question 8

What are the steps for a resectable cancer?

Answer 8

USS, ERCP and stent, spiral CT/MRI, laparascopy, laparotomy, resect
At any stage can find out is unresectable and change treatment plan

Question 9

What is the Kausch whipple surgery? basic principles.

Answer 9

Remove the head of pancreas (tumour), duodenum, gallbladder, proximal jejunum and part of stomach and join the stomach, pancreas and common hepatic duct to the jejunum

Question 10

How is obstructive jaundice treated with palliative draining?

Answer 10

ERCP and stent after a palliative bypass

Question 11

How is duodenal obstruction treated with palliative draining?

Answer 11

palliative bypass and duodenal stent

Question 12

What is the difference between mild and severe acute pancreatitis?

Answer 12

mild - minimal organ dysfunction, quick recovery

severe - organ failure association

Question 13

What are local complications of acute pancreatitis?

Answer 13

fluid collection (acute) -> pseudocyst -> pancreatic abscess -> pancreatic necrosis

Question 14

What are the most common causes of acute pancreatitis?

Answer 14

gallstones, alcohol, virus, drugs, tumours of head of pancreas, ERCP, idiopathic

Question 15

Explain briefly how alcohol, gallstones and ERCP can cause acute pancreatitis?

Answer 15

alcohol - directly toxic, oxidation increased (acetylaldehyde)
other 2 both increase the pancreatic ductal pressure

Question 16

Symptoms of acute pancreatitis?

Answer 16

abdominal pain, vomiting, nausea and collapse

Question 17

Signs of acute pancreatitis?

Answer 17

pyrexia, tachycardia, dehydration, abdominal tenderness

Question 18

General supportive care measures for acute pancreatitis

Answer 18

analgesia, IV fluids, support - CVS, resp, renal

Question 19

Investigations for acute pancreatitis?

Answer 19

U+E, glucose, serum amylase, LFT, AXR, CXR, USS, CT, FBC and clotting

Question 20

Monitoring acute pancreatitis…

Answer 20

arterial line
catheter - urine output
pulse, bp, CVP,

Question 21

What are used to predict the severity of acute pancreatitis?

Answer 21

Modified Glasgow criteria - after 48 hours, score>3
CRP >200
CT, CXR

Question 22

What is encompassed in the modified Glasgow criteria?

Answer 22

glucose, serum amylase, albumin, white cell count, serum calcium, AST/ALT, urea, arterial PO2

Question 23

How is acute pancreatitis managed?

Answer 23

antibiotics for infection
alcohol abstinence
nutrition through NG tube
CT and ERCP

Question 24

What does ERCP help treat in acute pancreatitis and what 2 conditions is it used to relieve?

Answer 24

gallstone obstruction

jaundice and cholangitis

Question 25

How are recurring attacks of acute pancreatitis prevented?

Answer 25

gallstone removal alcohol abstinence identify the cause and treat

Question 26

What are other definitive managements of acute pancreatitis?

Answer 26

fluid drainage, managing necrosis and late complications eg haemorrhage and portal hypertension

Question 27

What is the mnemonic for chronic pancreatitis aetiology?

Answer 27

O-A-TIGER

Question 28

Explain chronic pancreatitis mnemonic

Answer 28

``` O - obstructive MPD - tumour, stricture A - autoimmune T - toxin I - idiopathic G - genetic eg CFTR E - environmental R - recurrent injury ```

Question 29

3 main clinical features of acute pancreatitis?

Answer 29

jaundice, pain, diabetes

Question 30

Investigations of acute pancreatitis? imaging and blood

Answer 30

CT - local anatomy and complications ERCP/MRCP serum amylase/faecal amylase

Question 31

Management of chronic pancreatitis? non surgical methods

Answer 31

``` analgesia alcohol abstinence pancreatic enzyme supplements avoid high fat diet - steathorrea diabetic control ```

Question 32

Treatment for chronic pancreatitis?

Answer 32

caeliac plexus block (CT, FLUORSCOPY, EUS guided) pancreatic duct sphincteroplasty - lithotripsy, dilation CBD stent or bypass

Question 33

What surgery is used to help drain in chronic pancreatitis?

Answer 33

pancreatic duct sphincterotomy | Peustow - join jejunum to stomach and pancreas to restore GIT

Question 34

Resection surgery in chronic pancreatitis?

Answer 34

whipples | spleen preserving pancreatectomy

Question 35

Prognosis for chronic pancreatitis?

Answer 35

high risk of death, 20-25yrs = 50% mortality