Surgery of Pancreatic Disorders Flashcards by Sophie Pitcairn

What are some pancreatic disorders?

Pancreatic cancer
Acute pancreatitis
Chronic pancreatitis
IPMN - Intraductal papillary mucinous neoplasm
Pancreatic cyst disease

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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

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What are the risk factors for cancer at head of pancreas?

Smoking
Chronic pancreatitis
Adult onset of DM
Hereditary pancreatitis

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What is the presentation of cancer of head of pancreas?

Obstructive jaundice
Diabetes
Abdominal pain/ back pain
Anorexia, vomiting, weight loss, recurrent bouts pancreatitis

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What are the general investigations of cancer in head of pancreas?

Blood tests and CXR

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What imaging is used for cancer of head of pancreas?

CT is gold standard
USS rules out gall stones
PET
ERCP

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What is the tumour marker for cancer of head of pancreas?

CA19-9 but is not diagnostic

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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

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What is used for patient assessment when considering major pancreatic resection?

CXR, ECG
Resp tests
Scoring - none established, performance status, lactate threshold

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What happens if pancreatic cancer is unresectable or patient unfit?

ERCP and stent to get rid of jaundice
Laparoscopic bypass
Open bypass

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What happens if pancreatic cancer is resectable?

USS then spiral CT/MRI
Laparotomy
Resection

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What is the types of surgery used for resection of pancreatic cancer?

Kausch-Whipple
PPPD - pylorus preserving pancreaticoduodenectomy

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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

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Explain PPPD surgery

Removes bile duct, head of pancreas and duodenum but leaves stomach intact
Better functional outcome

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What are the palliative options for obstructive jaundice?

Palliative bypass or ERCP/ PTC stenting

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What are the palliative options for duodenal obstruction?

Palliative bypass or duodenal stent

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What is the definition acute pancreatitis?

Acute inflammatory process of the pancreas with other regional tissues or remote organ system

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What are the classification of acute pancreatitis?

Mild and Severe AP

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What is mild AP?

Associated with minimal organ dysfunction and uneventful recovery - 70% is this

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What is severe AP?

Associated with organ failure or local complication

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What are some local complications of acute pancreatitis?

Acute fluid collections
Pseudocyst
Pancreatic abscess
Pancreatic necrosis

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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