Surgery of Pancreatic Disorders Flashcards
What are some pancreatic disorders?
Pancreatic cancer
Acute pancreatitis
Chronic pancreatitis
IPMN - Intraductal papillary mucinous neoplasm
Pancreatic cyst disease
Explain epidemiology of cancer of head of pancreas?
Commonest 60-80 years
Equal ratio of men to women
5 year survival is 7%
5th killer of cancer in UK
What are the risk factors for cancer at head of pancreas?
Smoking
Chronic pancreatitis
Adult onset of DM
Hereditary pancreatitis
What is the presentation of cancer of head of pancreas?
Obstructive jaundice
Diabetes
Abdominal pain/ back pain
Anorexia, vomiting, weight loss, recurrent bouts pancreatitis
What are the general investigations of cancer in head of pancreas?
Blood tests and CXR
What imaging is used for cancer of head of pancreas?
CT is gold standard
USS rules out gall stones
PET
ERCP
What is the tumour marker for cancer of head of pancreas?
CA19-9 but is not diagnostic
What is a diagnostic feature of pancreatic cancer on ERCP?
Double duct
In bile duct and ampulla - injecting contrast
Shows dilation and obstruction of pancreatic duct
What is used for patient assessment when considering major pancreatic resection?
CXR, ECG
Resp tests
Scoring - none established, performance status, lactate threshold
What happens if pancreatic cancer is unresectable or patient unfit?
ERCP and stent to get rid of jaundice
Laparoscopic bypass
Open bypass
What happens if pancreatic cancer is resectable?
USS then spiral CT/MRI
Laparotomy
Resection
What is the types of surgery used for resection of pancreatic cancer?
Kausch-Whipple
PPPD - pylorus preserving pancreaticoduodenectomy
Explain Kausch-Whipple surgery
Half/quarter of stomach removed with head of pancreas, duodenum and lower end of bile duct
Replacing open ends by anastomosing
Explain PPPD surgery
Removes bile duct, head of pancreas and duodenum but leaves stomach intact
Better functional outcome
What are the palliative options for obstructive jaundice?
Palliative bypass or ERCP/ PTC stenting
What are the palliative options for duodenal obstruction?
Palliative bypass or duodenal stent
What is the definition acute pancreatitis?
Acute inflammatory process of the pancreas with other regional tissues or remote organ system
What are the classification of acute pancreatitis?
Mild and Severe AP
What is mild AP?
Associated with minimal organ dysfunction and uneventful recovery - 70% is this
What is severe AP?
Associated with organ failure or local complication
What are some local complications of acute pancreatitis?
Acute fluid collections
Pseudocyst
Pancreatic abscess
Pancreatic necrosis
What are the main causes of acute pancreatitis?
Gall stones
Alcohol
Viral infection
Tumours
How does alcohol cause acute pancreatitis?
Direct injury
Increased sensitivity to simulation
Oxidation products
Non-oxidative metabolism
How does gall stones cause acute pancreatitis?
Passage of gall stones is essential so raised pancreatic ductal pressure
How does ERCP (endoscopic retrograde cholangiopancreatography) cause acute pancreatitis?
Increased pancreatic ductal pressure
What are the symptoms for acute pancreatitis?
Abdominal pain
Nausea, vomiting
Collapse
What are the signs for acute pancreatitis?
Pyrexia, dehydration, abdominal tenderness and circulatory failure
What investigations are used for acute pancreatitis?
U/E, glucose, FBC, clotting, LFT, ABG< CXR, USS and CT if doubtful
What are some general supporting care for acute pancreatitis?
Analgesia, IV fluids
Cardio, Resp and renal support
What is used for prediction of severity of disease?
Clinical assessment
CT scanning
Individual markers - CXR, CRP, TAP
What are some precipitating factors for acute pancreatitis?
Cholelithiasis
Alcohol
Ischaemia
Malignancy
Hyperlipidaemia
Drugs
What is the management for acute pancreatitis?
CT scanning, antibiotics, diagnosis of infection, ERCP if gall stones, nutrition and manipulation of inflammatory response
Why is CT scans used for acute pancreatitis?
Acute fluid collections
Abscess
Necrosis - shows 4-10 days
Monitoring progress of disease
Why are antibiotics controversial in acute pancreatitis?
Not recommended in acute attack as sepsis is not there yet
Patient could then become resistant to microorganisms
How is infection diagnosed in acute pancreatitis?
Sepsis or SIRS systemic inflammatory response syndrome)
CT guided FNA of pancreatic necrosis
Describe ERCP in acute pancreatitis
Reduces complication in severe gallstones AP
Associated with higher mortality
Indicated in those with jaundice and cholangitis
How do we prevent recurrent attacks in acute pancreatitis?
Management of gallstones
Investigations of non- gallstone pancreatitis
Alcohol abstinence
When is fluid collection done in acute pancreatitis?
Early collection
Pseudocyst
Pancreatic duct fistula
How is necrosis managed in acute pancreatitis?
If infected then necroscopy - laproscopy,
Abscess drained through skin
What are some late complications of acute pancreatitis?
Haemorrhage
Portal hypertension
Pancreatic duct stricture
What is the definition of chronic pancreatitis?
Continuing chronic inflammatory process of pancreas characterised by irreversible morphological change leading to pain or impairment of endocrine function
What are the causes for chronic pancreatitis?
Obstruction of main pancreatic duct
Autoimmune
Toxin
Idiopathic
Genetic
Environmental
Recurrent injuries (O-A-TIGER)
What is the main issue affecting the body and tail of pancreas?
Alcohol
What are some clinical features of chronic pancreatitis?
Pain and erythema
Pancreatic exocrine insufficiency
Diabetes
Jaundice
Duodenal obstruction
Upper GI haemorrhage
What investigations are used for chronic pancreatitis?
CT scan
ERCP/ MRCP
Pancreatic exocrine function - serum enzymes, pancreolauryl test and diagnostic enzyme replacement
When is surgery used for chronic pancreatitis?
Suspicion of malignancy
Intractable pain
Complications
What are some interventional procedures used for chronic pancreatitis?
Endoscopic PD sphincterotomy
CBD stenting or bypass
Thoracoscopic
Splanchnectomy
Coeliac plexus block
What resection surgery can used in chronic pancreatitis?
DPPHR, PPPD, Whipple’s, Frey, Spleen preserving and central pancreatectomy
What drainage techniques can be used in chronic pancreatitis?
Pancreatic duct sphincteroplasty
Puestow
What are the types if mucinous cystic neoplasia of the pancreas?
IPMN - intraductal papillary mucinous neoplasia
Can get main duct or bile duct
MCN - mucinous cystic neoplasia
When is MD-IPMN high risk stigmata?
If MPD is more than 1cm
Enhanced solid component
When is MCN high risk stigmata?
More than 1cm with enhanced solid component
MPD is more than 1cm
When IPMN and MCN indicated for resection?
MD-IPMN and MCN indicated
BD-IPMN - if more than 3cm in elderly without moral nodules then can be observed
But if younger and over 2cm then considered
What are the methods of resection for IPMN and MCN?
Pancreatectomy and LN
Focal and LN or spleen sparing - laparoscopic, robotic
Total pancreatectomy
