Surgery of Pancreatic Disorders Flashcards by Abby McCabe

What are examples of pancreatic disorders?

Pancreatic cancer

Acute pancreatitis

Chronic pancreatitis

Intraductal papillary mucinous neoplasm (IPMN) and pancreatic cystic disease

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What does IPMN stand for?

Intraductal papillary mucinous neoplasm

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What is the incidence of pancreatic cancer in the UK?

10/100000

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What age group is pancreatic cancer most common in?

60-80 years old

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What is the male:female ratio of pancreatic cancer?

3:4

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What is the 5 year survival rate of pancreatic cancer?

0.4%

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What are risk factors for pancreatic cancer?

Smoking

Chronic pancreatitis

Adult onset of diabetes

Hereditary pancreatitis

Inherited predisposition

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What is the presentation of pancreatic cancer?

Obstructive jaundice

Diabetes

Abdominal pain/back pain

Anorexia

Vomiting

Weight loss

Recurrent bouts pancreatitis

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What investigations are done for pancreatic cancer?

Blood tests

Chest x-ray

Tumour markers (CA19-9)

Imaging/invasive investigations

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What antigen is released by cancerous pancreatic cells that can be tested for?

CA19-9

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What imaging/invasive tests can be done to investigate pancreatic cancer?

CXR

USS

MRCP

Laparoscopic USS

Peritoneal cytology

Percutaneous needle biopsy

PET scan

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What is considered when considering if a patient with pancreatic cancer is fit for pancreatic resection?

Basic history and examination

Chest x-ray and ECG

Respiratory function tests

Physiological scoring system

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What types of surgery can be done for pancreatic cancer?

Kausch-Whipple

Pylorus-preserving pancreaticoduodenectomy (PPPD)

Palliative drainage

Metal stenting

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What does PPPD stand for?

Pylorus-preserving pancreaticoduodenectomy

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What is a pylorus-preserving pancreaticoduodenectomy

Similar to Whipples operation but none of the stomach is removed

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What is Kausch-Whipple surgery?

Removes head of pancreas, bile duct, gallbladder and the duodenum

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What is Kausch-Whipple surgery also known as?

Pancreaticoduodectomy

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What is acute pancreatitis?

An acute inflammatory process of the pancreas with involvement of other regional tissues or remote organ systems

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What are the different classifications of acute pancreatitis?

Mild AP

Severe AP

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What is mild acute pancreatitis associated with?

Minimal organ dysfunction and uneventful recovery

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What is severe acute pancreatitis associated with?

Organ failure or local complication

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What are some local complications of acute pancreatitis?

Acute fluid collection

Pseudocyst

Pancreatic abscess

Pancreatic necrosis

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What is the aetiology of acute pancreatitis?

Gallstones

Alcohol

Viral infections (CMV, mumps)

Tumours

Anatomical abnormalities

ERCP

Lipid abnormalities

Hypercalcaemia

Postoperative trauma

Ischaemia

Drugs

Scorpion venom

Idiopathic

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What viral infections can cause acute pancreatitis?

CMV

Mumps

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What does CMV stand for?

Cytomegalovirus

What is the pathophysiology of acute pancreatitis caused by alcohol?

Direct injury Increased sensitivity to stimulation Oxidation products (acetaldehyde) Non-oxidative metabolism (fatty acid ethyl esters)

What is the pathophysiology of pancreatitis caused by gallstones?

Passage of gallstone is essential Raised pancreatic ductal pressure

What is the pathophysiology of acute pancreatitis caused by ERCP?

Increased pancreatic duct pressure

What are some symptoms of acute pancreatitis?

Abdominal pain Nausea, vomiting Collapse

What are some signs of acute pancreatitis?

Pyrexia Dehydration Abdominal tenderness Circulatory failure

What does the management of acute pancreatitis involve?

General supportive care (analgesia, IV fluids, cardiovascular, respiratory and renal support) Monitoring (pulse, BP, urine output, CVP, arterial line, HDU/ITU) Investigations

What should be monitored when managing acute pancreatitis?

Pulse, BP Urine output Central venous pressure (CVP) Arterial line HDU/ITU

What investigations should be done for acute pancreatitis?

U/E, glucose Serum amylase FBC, clotting LFT ABG Chest x-ray, abdomen x-ray USS CT scan

What critera does preducting severity of acute pancreatitis use?

Glasgow criteria

In the Glasgow criteria, what score inidcates severe acute pancreatitis?

3 or more

What does the Glasgow criteria check?

Glucose Serum calcium White cel count Albumin LDH Urea AST/ALT Arterial pO₂

What glucose level gives a score of 1 on the Glasgow criteria?

\>10mmol/L

What serum calcium level gives a score of 1 on the Glasgow criteria?

\<2mmol/L

What white cell count gives a score of 1 on the Glasgow criteria?

\>1500/mm³

What albumin level gives a score of 1 on the Glasgow criteria?

\<32g/L

What LDH level gives a score of 1 on the Glasgow criteria?

\>700IU/L

What urea level gives a score of 1 on the Glasgow criteria?

\>16mmol/L

What AST/ALT level gives a score of 1 on the Glasgow criteria?

\>200IU/L

What arterial pO₂ level gives a score of 1 on the Glasgow criteria?

\<60mmHg

As well as the Glasgow criteria, what else can be used to predict the severity of acute pancreatitis?

Clinical assessment CT scanning Individual markers (CRP, IL-6)

How is acute pancreatitis due to cholelithiasis managed?

ERCP and ES, Cholecystectomy

How is acute pancreatitis due to alcohol managed?

Abstinence Counselling

How is acute pancreatitis due to ischaemia managed?

Careful support

How is acute pancreatitis due to malignancy managed?

Resection or bypass

How is acute pancreatitis due to hyperlipidaemia managed?

Diet Lipid lowering drugs

How is acute pancreatitis due to anatomical abnormalities managed?

Correction if possible

How is acute pancreatitis due to cholelithiasis managed?

Stop or change

What are specific aspects of managing acute pancreatitis?

CT scanning Antibiotics Diagnosis of infection ERCP in gallstone pancreatitis Nutrition Manipulation of inflammatory response

What kind of complications from acute pancreatitis can be picked up by CT scanning?

Acute fluid collections Abscess Necrosis Monitoring progress of disease

What is used to diagnose infection with acute pancreatitis?

CT guided FNA or pancreatic necrosis

What is CT guided FNA?

CT guided fine needle aspiration

What is the definitive management of acute pancreatitis summarised?

Prevention of recurrent attacks Fluid collection Management of necrosis Managment of complications

What management is used to prevent further attacks of acute pancreatitis?

Management of gallstones Investigations of non-gallstones pancreatitis Alcohol abstinence

How is necrosis due to acute pancreatitis managed?

Laparotomy

What are examples of different kinds of necrosis due to acute pancreatitis?

Sterile necrosis Infected necrosis Abscess

What are examples of different kinds of late complications due to acute pancreatitis?

Haemorrhage Portal hypertension Pancreatic duct stricture

What is chronic pancreatitis?

Continuing chronic inflammatory process of the pancreas characterised by irreversible morphological changes leading to chronic pain and/or impairment of endocrine and exocrine function of the pancreas

How does the incidence of males and females compare for chronic pancreatitis?

Males greater than females

What are some causes of chronic pancreatitis?

Obstruction of the main pancreatic duct Autoimmune Toxin Idiopathic Genetic Environmental Recurrent injuries

What are examples of things that can cause obstruction of the main pancreatic duct?

Tumour (adenocarcinoma, IPMT) Sphincter of Oddi dysfunction Pancreatic divisum Duodenal obstruction (tumour, diverticulum) Trauma Stricture

What is pancreatic divisum?

Congenital abnormality where a single pancreatic duct is not formed but remains as a ventral and dorsal duct

What are examples of toxins that can cause chronic pancreatitis?

Ethanol Smoking Drugs

What are examples of genetic causes of chronic pancreatitis?

Autosomal dominant (codon 29 and 122) Autosomal ressesive (CFTR, SPINK1, codon A)

What are examples of recurrent injuries that can cause chronic pancreatitis?

Biliary Hyperlipidaemia Hypercalcaemia

What are clinical features of chronic pancreatitis?

Pain Pancreatic exocrine insufficiency Diabetes Jaundice Duodenal obstruction (uncommon) Upper GI haemorrhage

What investigations are done for chronic pancreatitis?

Appropriate imaging (CT scan, ERCP/MRCP) Pancreatic exocrine function (used infrequently)

What is done to look at pancreatic exocrine function?

Faecal/serum enzymes (elastase) Pancreolauryl test (enzyme response to stimulus)

What is the management of chronic pancreatitis?

Counselling Abstinence from alcohol Management of acute attacks Analgesia Avoid high fat, high protein diet Surgery

What are some possible complications of chronic pancreatitis that requires surgery to fix?

Pancreatic duct stenosis Cyst/pseudocysts Biliary tract obstruction Splenic vein thrombosis/gastric varices Portal vein compression/mesenteric vein thrombosis Duodenal stenosis Colonic stricture

What interventional procedures can be done for treatment of chronic pancreatitis?

CBD stenting or bypass Thoracoscopic splanchnectomy Caeliac plexus block

What procedures can be done for pancreatic duct stenosis and obstruction?

Endoscopic PD sphincterotomy, dilation and lithotripsy

What are the different approaches for a caeliac plexus block?

Classic trans-crural Trans-aortic Anterior approach

What are different ways of guiding a caeliac plexus block?

CT guided EUS guided Fluoroscopy guided

What surgery can be done for drainage during chronic pancreatitis?

Pancreatic duct sphincteroplasty Rochelle modification

What surgery can be done for resection during chronic pancreatitis?

DPPHR PPPD Whipple's pancreaticoduodectomy Frey procedure Spleen-preserving distal pancreatectomy Central pancreatectomy

What does DPPHR stand for?

Duodenal preserving pancreatic head resection

What is mucinous cystic neoplasia of the pancreas?

Mucin producing and septated cyst forming epithelial neoplasia of the pancreas with distincive ovarian type stroma

What is stroma?

Part of an organ or tissue with a structural or connective role

What does MCN stand for?

Mucinous cystic neoplasia of the pancreas

What is another condition similar to MCN?

Intraductal papillary mucinous neoplasm (IPMN)

What does IPMN stand for?

Intraductal papillary mucinous neoplasm

What are different kinds of IPMN?

MD-IPMN (main duct) BD-IPMN (biliary duct)

What are worrisome features of MD-IPMN?

Main pancreatic duct 5-9mm Non-enhanced mural nodule Abrupt change in main pancreatic duct Lymph nodes involvement

When is IPMN considered high risk?

MPD \> 10mm Enhanced solid component

When is MCN considered high risk?

\>1cm with enhanced solid component Main pancreatic duct \>1cm

What are worrisome features of MCN?

\>3cm Enhanced cyst wall Non-enhanced nodules

What are indications for resection for MD-IPMN?

Always indicated

What are indications for resection for BD-IPMN?

In elderly \>3cm without high risk In younger patients \>2cm may be considered

What are indications for resection for MCN?

All MCN in fit patients are indicated

What are methods of IPMN and MCN resection?

Pancreatectomy Focal and LN or spleen sparing (laparoscopic, robotic, multifocal BD-IPMN)