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Gastrointestinal > Surgery for Pancreatic Disorders > Flashcards

Surgery for Pancreatic Disorders Flashcards

1
Q

What are the aetiologies for pancreatic cancer?

A

Cigarette smoking

Chronic pancreatitis

Hereditary pancreatitis

Periampullary cancer is a feature of FAP

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2
Q

What is the presentation of pancreatic cancer?

A
  • Obstructive jaundice
  • Diabetes
  • Abdominal pain / Back pain
  • Anorexia
  • Vomiting
  • Weight loss
  • Recurrent bouts pancreatitis
  • Incidental finding
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3
Q

Who is most likely to be affected by pancreatic cancer?

A

Men:Women = 2:1

Most common in men over 70

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4
Q

What type of cancer are most of the pancreatic cancers?

A

90% of the pancreatic neoplasms are adenocarcinomas which arise from pancreatic ducts, they involve local structures and metastasis to lymph nodes at an early stage.

60% of the tumours arise from the head of the pancreas

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5
Q

What are general investigations for pancreatic cancer?

A

Blood tests

Chest X-Ray

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6
Q

What are the imaging / invasive investigations for pamcreatic cancer?

A

–USS

–?ERCP

–CT

–MR, MRCP

–Laparoscopy + Lap USS

–Peritoneal cytology

–EUS + FNA/ Bx

–Percutaneous needle biopsy

–PET

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7
Q

How do you assess a patient to make sure they are fit enough to consider major pancreatic resection?

A

•Patient assessment:

–Basic history and examination

–CXR, ECG

–Respiratory function tests

–Physiological “scoring system”:

  • –None established
  • –Performance status
  • –Lactate threshold

–Fully informed consent is vital

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8
Q

Why is there wight loss in pancreatic cancer?

A

As a result of anorexia

steatorrhoea

and metabolic effects of the tumour

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9
Q

How is tumour size determined?

A

Laparoscopy with laparascopic ultrasound

Also determines involvement of blood vessels and metastatic spread

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10
Q

What is the main role of ERCP in pancreatic cancer?

A

ERCP - to insert a stent into the comon bile duct to releive obstructive jaundice in inoperable patients

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11
Q

What are the two types of resection of the pancreas?

A

Two surgical procedures can lead to a cure: the classic Whipple operation, in which part of the pancreas, the gallbladder, the duodenum, the pylorus (outlet of the stomach), and the distal (lower) part of the stomach are removed

Pylorus-preserving pancreaticoduodenectomy (PPPD), or pylorus-preserving Whipple operation, in which the stomach and the pylorus are not removed.

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12
Q

What is 5 year survival for pancreatic cancer resection?

A

5 year survival in patients undergoing a complete resection is around 20%

(a mere 15% of tumours are amenable to curative resection since most neoplasms are locally advanced at the time of diagnosis)

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13
Q

What is therapy for pancreatic cacner int he majority of cases?

A

Pain and jaundice management

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14
Q

How do we manage pain and jaundice in patients with pancreatic cancer?

A

Pain - analgesic drugs, sometimes coeliac plexus neurolysis by percutaneous or endoscopic ultrasound guided alcohol injection

Jaundice: choledochojejunostomy in fit patients (Choledochojejunostomy is a procedure for creating an anastomosis of the common bile duct (CBD) to the jejunum, performed to relieve symptoms of biliary obstruction and restore continuity to the biliary tract)

In the elderly or those with very advanced disease: percutaneous or endoscopic stenting

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15
Q

What imaging techniques is ued to deliver a biliary stent?

A

ERCP or PTC (percutaneous transhepatic cholangiogram)

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16
Q

How do we treat duodenal obstruction?

A

Palliative bypass vs duodenal stent

17
Q

What is the presentation of acute pancreatitis?

A

Symptoms Abdominal pain

Nausea, vomiting

Collapse

Signs Pyrexia

Dehydration

Abdominal tenderness

Circulatory failure

18
Q

What is acute pancreatitis initial resuscitation and management?

General supportive care?

Monitoring?

Investigations?

A

General supportive care

Analgesia

Intravenous fluids

Cardiovascular support

Respiratory support

Renal support

Monitoring:

Pulse, BP

Urine output

CVP

Arterial line

HDU / ITU

Investigations:

Investigations

U/E, glucose

serum amylase

FBC, clotting

LFT ABG

CXR AXR

USS

CT scanning

19
Q

What is the modified glasgow criteria a measure of?

A

Acute panreatitis severity

High severity involves:

High white cell count

High blood glucose

High blood urea

High AST

Low serum albumin

Low serum calcium

Low arterial partial pressure oxygen

High CRP

20
Q

How do we manage acute pancreatitis precipitating factors?

A
  • Cholelithaiasis - ERCP and ES, cholecystectomy
  • Alcohol - abstenence, counselling
  • Ischaemia - careful support, correct cause
  • Malignancy - Resection or bypass
  • Hyperlipidaemia - Diet, lipid lowering drugs
  • Anat. Abnormalities, correction if possible
  • Drugs - stop or change
21
Q

What is the point of CT scanning in acute pancreatitis?

A

Helpful in diagnosis

Can identify necrosis in 4-10 days

Useful for complications:

Abscess

Necrosis

Acute fluid collections

Monitoring progress of disease

22
Q

Why is ERCP and edoscopic sphincterotomy controversial?

A

Reduces complications in severe gallstone acute pancreatitis

Associated with higher mortality

Indicated in those with jaundice and cholangitis

23
Q

How do we provide nutrition to patients with AP?

A

Nutrition is vitally important - no need to ‘rest the gland’

Enteral feeding is superior to parenteral feeding

Nasogastric feeding is tolerable in most cases and not associated with any increase in complications

Enteral involves putting a tube into the abdomen, into the stomach

Parenteral is putting the tube directly into the vein via catheter

24
Q

How do you prevent further attacks of acute pancreatitis?

A

Management of gallstones

Investigations of non-gallstone pancreatitis

Alcohol abstinence

25
Q

What are the causes of chronic pancreatitis?

A

O A TIGER

•Obstruction of MPD

–Tumour

  • Adenocarcinoma
  • IPMT

–Sphincter of Oddi dysfunction

–Pancreatic divisum - most pancreatic drainage occurs through a smaller accessory ampulla rather than through the major ampulla

  • Inadequate accessory drainage

–Duodenal obstruction

  • Tumour
  • Diverticulum

–Trauma

–Structure

  • Post necrotizing radiation

•Autoimmune

•Toxin

–Ethanol (related to amount and length of consumption)

–Smoking (odds ratio 8 to 17)

–Drugs

•Idiopathic

•Genetic

–Autosomal dominant (Condon 29 and 122)

–Autosomal recessive/modifier genes

  • (CFTR, SPINK1, Codon A etc)
  • Environmental

–Tropical chronic pancreatitis

•Recurrent injuries

–Biliary

–Hyperlipidemia

–Hypercalcemia

26
Q

What are causes of pancreatic duct obstruction?

A

Tumour

Trauma

Pancreas divisum

Fibrosis

Cycstic fibrosis

Hyperlipidaemia

Hereditary pancreatitis

Tropical pancreatitis

Hyperthyroidism

27
Q

What are the surgical treatments availabe for pancreatic duct stenosis?

A

•Endoscopic PD sphincetortomy, dilation and lithotripsy

28
Q

What are other surgical treatments for chronic pancreatitis?

A

Management of chronic pseudocyst

Common bile duct stenting or bypass

Thoracoscopic Splanchnectomy (surgical excision of a segment of one or more splanchnic nerves to relieve hypertension)

Caeliac plexus block (Celiac plexus blocks are injections of pain medication that help relieve abdominal pain, commonly due to cancer or chronic pancreatitis. The celiac plexus is a bundle of nerves that surrounds the aorta, the main artery into your abdomen)

29
Q

What are the types of drainage surgery of the pancreas?

A

–Pancreatic duct sphincteroplasty

  • Puestow (Rochelle modification)
30
Q

What is the prognosis for chronic pancreatitis?

A
  • 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

Gastrointestinal (38 decks)

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