Surgery for pancreatic disorders Flashcards
Acute pancreatits definition and classification?
An acute inflammatory process of the pancreas, with variable
involvement of other regional tissues or remote organ systems”
Classification:
Mild AP: Associated with minimal organ dysfunction and uneventful recovery
Severe AP: Associated with organ failure or local complication
Acute pancreatitis –Local Complications
Acute fluid collections
Pseudocyst
Pancreatic abscess
Pancreatic necrosis
Acute pancreatitis- Aetiology
Gallstones Alcohol Viral Infection: CMV, mumps Tumours Anatomical abnormalities (P.D.) ERCP Lipid abnormalities Hypercalcaemia Postoperative Trauma Ischaemia Drugs Scorpion venom “Idiopathic”
Acute pancreatitis - Pathophysiology
Alcohol direct injury
increased sensitivity to stimulation
oxidation products (acetaldehyde)
non-oxidative metabolism (fatty acid ethyl esters)
Gallstones passage of gallstone is essential
raised pancreatic ductal pressure
ERCP increased pancreatic ductal pressure
Acute pancreatitis-presentation
Gradual or sudden pain in the upper abdomen that gets worse after eating
(may
radiate to back)
Collapse
Tachycardia and hypovolemic shock
Oliguria, acute renal failure
Nausea and vomiting
Pyrexia
Addominal distension
Abdominal guarding
Paralytic ileus
–
hypoactive bowel sounds
Hypocalcaemia (tetany
–muscle spasms
-rare)
Hypoxia (escalating to respiratory failure)
Hyperglycaemia (occasionally diabetic coma)
Effusions (ascetic and pleural; high amylase)
In severe disease: peritoneal sig
ns. Ascites, jaundice, palpable abdominal mass,
Cullen’s sign, Turner’s sign and signs of hypovolemic shock
Acute pancreatitisInitial resuscitation and management
General supportive care Analgesia Intravenous fluids Cardiovascular } Respiratory } support Renal } Monitoring Pulse, BP Urine output CVP Arterial line HDU / ITU Investigations U/E, glucose serum amylase FBC, clotting LFT ABG CXR AXR USS CT scanning
Acute pancreatitis - Prediction of severity of disease
Modified Glasgow criteria At 48 hours
Glucose > 10 mmol/L Serum [Ca2+] < 2.00 mmol WCC > 15000/mm3 Predicted severe ≥ 3 Albumin< 32 g//L LDH > 700 IU/L Urea > 16 mmol/L AST/ALT > 200 IU/L Arterial pO2 < 60mmHg Predicted severe ≥ 3
Clinical Assessment
Modified Glasgow criteria
CT scanning
Individual markers CXR
CRP(>200, or persists >150)
IL 6
TAP
Acute pancreatitis Identification & management of precipitating factors
Cholelithiasis = ERCP & ES, cholecystectomy
Alcohol = Abstinence, counselling
Ischaemia = Careful support, Correct cause
Malignancy = Resection or bypass
Hyperlipidaemia = Diet, lipid lowering drugs
Anat. Abnormalities = Correction if possible
Drugs = Stop or change
Acute pancreatitis Specific aspects of management
CT scanning Antibiotics Diagnosis of infection ERCP in gallstone pancreatitis Nutrition Manipulation of the inflammatory response
Acute pancreatitis - CT scanning use
Occasionally helpful in diagnosis Useful in severe disease Days 4-10 to identify necrosis Useful for complications Acute fluid collections Abscess Necrosis Monitoring progress of disease
Acute pancreatitis - Antibiotics
controversial
Acute pancreatitis - Diagnosis of infection
? Sepsis or SIRS ? = CT guided FNA of pancreatic necrosis
Acute pancreatitis - ERCP & ES
Still controversial
Reduces complications in severe gallstone AP
Associated with a higher mortality
Definitely indicated in those with jaundice and cholangitis
Acute pancreatitis - Nutrition
Nutrition vitally important, despite previous theories
about “resting the gland”
Enteral feeding is superior to parenteral feeding
Nasogastric feeding is tolerable in most cases, and
not associated with any increase in complications
Acute pancreatitis – Definitive Management
Prevention of recurrent attacks:
Management of Gallstones
Investigations of non-gallstone pancreatitis
Alcohol abstinenece
Fluid collection:
Early collection
Pseudocyst
Pancreatic duct fistula
Management of Necrosis: Sterile necrosis Infected necrosis: Necrosectomy Laparotomy Minimally invasive Abscess Late complications: Haemorrhage Portal hypertension Pancreatic duct stricture
Chronic Pancreatitis Definition
Continuing chronic inflammatory process of the pancreas, characterized by irreversible morphological changes leading to chronic pain and / or impairment of endocrine and exocrine function of the pancreas.
Chronic pancreatitis- Epidemiology
Unclear due to difficulty in early diagnosis
Increasing in the Western World
Copenhagen: 13/100,000
M > F
Close correlation with alcohol consumption per head pop
Causes of Ch pancreatitis
(O-A-TIGER)
Obstruction of MPD from :
Tumour
-Adenocarcinoma
-IPMT
Sphincter of Oddi dysfunction
Pancreatic divisum
-Inadequate accessory drainage
Duodenal obstruction
-Tumour
-Diverticulum
Trauma
Structure
-Post necrotizing radiation
Autoimmune
Toxin
-Ethanol (70% cause) (related to amount and length of consumption)
-Smoking (odds ratio 8 to 17)
-Drugs
Idiopathic (20% cases)
Genetic
-Autosomal dominant (Condon 29 and 122)
-Autosomal recessive/modifier genes
(CFTR, SPINK1, Codon A etc)
Environmental
-Tropical chronic pancreatitis
Recurrent injuries
-Biliary
-Hyperlipidemia
-HypercalcemiaChronic pancreatitis-Clinical Features
Pain most significant factor wrt quality of life linked to binges become more frequent and less treatable by abstinence pathogenesis unknown Pancreatic exocrine insufficiency Late manifestation Diabetes Jaundice Duodenal obstruction Uncommon Upper GI haemorrhage
Chronic pancreatitis - Investigations
Try to ensure correct diagnosis
Careful detailed history
Appropriate imaging:
CT scan: local anatomy and complications
ERCP / MRCP
Pancreatic exocrine function (used infrequently):
faecal / serum enzymes (elastase)
Pancreolauryl test (enzyme reponse to a stimulus)
Diagnostic Enzyme replacement
Chronic pancreatitis- Management
Conservative management Counselling Abstinence from alcohol Management of acute attacks Analgesia ? Interventional methods of analgesia Avoid high fat, high protein diet Pancreatic supplementation controversial for pain Anti-oxidant therapy Steatorrhoea: Reduce fat intake Pancreatic supplementation Diabetes
Chronic pancreatitis - Surgery indications and complications
Suspicion of malignancy Intractable pain Complications Pancreatic duct stenosis Cyst / pseudocysts Biliary tract obstruction Splenic vein thrombosis / gastric varices Portal vein compression / mesenteric vein thrombosis Duodenal stenosis Colonic stricture
Only after full evaluation
reatment: interventional procedures
PD Stenosis and obstruction: Endoscopic PD sphincetortomy, dilation and lithotripsy Management of chronic pseudocyst CBD stenting or bypass Thoracoscopic Splanchnectomy Caeliac plexus block CT guided EUS guided Fluoroscopy guided classic trans-crural approach Anterior Approaches
Surgery procedures in cp
Drainage: Pancreatic duct sphincteroplasty Puestow (Rochelle modification) Resection: DPPHR (Beger) PPPD Whipple’s pancreatico-duodenectomy Frey procedure Spleen-preserving distal pancreatectomy Central pancreatectomy
Chronic pancreatitis - Prognosis
Mortality 50% over 20-25y
20% die of complications
Rest die as a result of associated conditions
Morbidity is still a major cause for concern
Mucinous Cystic Neoplasia of the pancreas
Autopsy: small cystic lesions were found in nearly half of 300 patients Atypia 3.4% Increasing use of imaging (1-2%) Increase in recognition Understanding of natural history: malignancy potential Progression and recurrence
IPMN & MCN1
Autopsy: small cystic lesions were found in nearly half of 300 patients Atypia 3.4% Increasing use of imaging (1-2%) Increase in recognition Understanding of natural history: malignancy potential Progression and recurrence
Classification of MD-IPMN and
MCN
MD-IPMN: high risk stigmata: MPD > 10 mm Enhanced solid component worrisome features: MPD 5-9 mm, non-enhanced mural nodule, abrupt change in MPD LN’s.
MCN: High risk stigmata: > 1cm with enhanced solid component MPD > 1cm Worrisome features: >3 cm Enhanced cyst wall Non-enhanced nodules
Indication for resection for MD-IPMN and
MCN
Indicated for MD-IPMN
BD-IPMN
In elderly >3 cm without high risk stigmata (mural nodules, positive cytology): can be observed
In younger patients: >2 cm may be considered depending on location
MCN: all MCN in fit patients indicated
<4cm without mural nodules: lap. Spleen preservation
Methods of resection for MD-IPMN and
MCN
Pancreatectomy + LN’s Focal and LN or spleen sparing: Laparoscopic Robotic Multifocal BD-IPMN: total pancreatectomy
