Surgery for pancreatic disorders Flashcards
What are some risk factors for cancer of the head of the pancreas?
smoking
FAP, chronic pancreatitis and adult onset diabetes
How may patients with pancreatic cancer present?
obstructive jaundice, abdominal pain, weight loss, diabetes, vomiting
What tumour marker would you look for?
CA19-9
What imaging/invasive investigations would be undertaken for cancer?
CT, ERCP, EUS, PET, USS, percutaneous needle biopsy, cytology, MRCP
What symptom is ERCP useful to treat?
jaundice - stenting
What are the steps and test which allow us to decide if a patient is fit for major pancreatic resection?
respiratory tests
exercise tests - lactate
CXR, ECG
If pancreatic cancer is unresectable what steps are taken?
ERCP and stent
laparascopic bypass - weight loss
open bypass
What are the steps for a resectable cancer?
USS, ERCP and stent, spiral CT/MRI, laparascopy, laparotomy, resect
At any stage can find out is unresectable and change treatment plan
What is the Kausch whipple surgery? basic principles.
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
How is obstructive jaundice treated with palliative draining?
ERCP and stent after a palliative bypass
How is duodenal obstruction treated with palliative draining?
palliative bypass and duodenal stent
What is the difference between mild and severe acute pancreatitis?
mild - minimal organ dysfunction, quick recovery
severe - organ failure association
What are local complications of acute pancreatitis?
fluid collection (acute) -> pseudocyst -> pancreatic abscess -> pancreatic necrosis
What are the most common causes of acute pancreatitis?
gallstones, alcohol, virus, drugs, tumours of head of pancreas, ERCP, idiopathic
Explain briefly how alcohol, gallstones and ERCP can cause acute pancreatitis?
alcohol - directly toxic, oxidation increased (acetylaldehyde)
other 2 both increase the pancreatic ductal pressure
Symptoms of acute pancreatitis?
abdominal pain, vomiting, nausea and collapse
Signs of acute pancreatitis?
pyrexia, tachycardia, dehydration, abdominal tenderness
General supportive care measures for acute pancreatitis
analgesia, IV fluids, support - CVS, resp, renal
Investigations for acute pancreatitis?
U+E, glucose, serum amylase, LFT, AXR, CXR, USS, CT, FBC and clotting
Monitoring acute pancreatitis…
arterial line
catheter - urine output
pulse, bp, CVP,
What are used to predict the severity of acute pancreatitis?
Modified Glasgow criteria - after 48 hours, score>3
CRP >200
CT, CXR
What is encompassed in the modified Glasgow criteria?
glucose, serum amylase, albumin, white cell count, serum calcium, AST/ALT, urea, arterial PO2
How is acute pancreatitis managed?
antibiotics for infection
alcohol abstinence
nutrition through NG tube
CT and ERCP
What does ERCP help treat in acute pancreatitis and what 2 conditions is it used to relieve?
gallstone obstruction
jaundice and cholangitis
How are recurring attacks of acute pancreatitis prevented?
gallstone removal
alcohol abstinence
identify the cause and treat
What are other definitive managements of acute pancreatitis?
fluid drainage, managing necrosis and late complications eg haemorrhage and portal hypertension
What is the mnemonic for chronic pancreatitis aetiology?
O-A-TIGER
Explain chronic pancreatitis mnemonic
O - obstructive MPD - tumour, stricture A - autoimmune T - toxin I - idiopathic G - genetic eg CFTR E - environmental R - recurrent injury
3 main clinical features of acute pancreatitis?
jaundice, pain, diabetes
Investigations of acute pancreatitis? imaging and blood
CT - local anatomy and complications
ERCP/MRCP
serum amylase/faecal amylase
Management of chronic pancreatitis? non surgical methods
analgesia alcohol abstinence pancreatic enzyme supplements avoid high fat diet - steathorrea diabetic control
Treatment for chronic pancreatitis?
caeliac plexus block (CT, FLUORSCOPY, EUS guided)
pancreatic duct sphincteroplasty - lithotripsy, dilation
CBD stent or bypass
What surgery is used to help drain in chronic pancreatitis?
pancreatic duct sphincterotomy
Peustow - join jejunum to stomach and pancreas to restore GIT
Resection surgery in chronic pancreatitis?
whipples
spleen preserving pancreatectomy
Prognosis for chronic pancreatitis?
high risk of death, 20-25yrs = 50% mortality
