Surgery of Pancreatic Disorders Flashcards
Describe who is more likely to get pancreatic cancer.
60-80yo
Pretty even male : female
What is the cause of pancreatic cancer?
Unknown
What are some of the risk factors for pancreatic cancer?
Smoking
Chronic pancreatitis
Adult onset of diabetes
Genetics
How does pancreatic cancer prsent?
Obstructive jaundice
Weight loss
Anorexia
Recurrent pancreatitis
Vomiting
Abdominal/back pain
What are the general investigations carried out for diagnosis of pancreatic cancer?
CXR
Bloods
List some imaging investigations which can be useful for staging of the pancreatic cancer.
Ultrasound
CT
MRI
PET
ERCP
Which investigation is the gold standard for diagnosing pancreatic cancer?
CT scan
What happens during ERCP (endoscopic retrograde cholangio pancreatography)?
Camera goes down stomach -> duodenum
Catheter is inserted in the bile duct and ampulla to inject contrast which would show a dilated bile duct
How would it be determined whether a patient is fit for major pancreatic resection or not?
Basic history and examination
CXR, ECG
Resp. function tests
Physiosocial scoring
In terms of staging, which two investigations would be carried out first?
Ultrasound, then CT
Name two procedures that can be done for pancreatic resection.
Whipple’s
PPD (pylorus pancreaticoduodenectomy)
In terms of palliative care, how can obstructive jaundice be resolved?
ERCP and stenting
If during a surgery, removal of the pancreatic cancer is not doable, what can be done instead?
Biliary bypass
In terms of palliative care, how can duodenal obstruction be resolved?
Duodenal stent
What is acute pancreatitis?
Acute inflammatory process of pancreas with variable involvement of other regional tissues/organs
What is meant by mild acute pancreatitis?
Associated w minimal organ dysfunction and uneventful recovery
What is meant by severe acute pancreatitis?
Associated w organ failure or local complication
What are some of the local complications those with severe acute pancreatitis may face?
Acute fluid collections
Pseudocyst
Pancreatic abscess
Pancreatic necrosis
What causes acute pancreatitis?
Gallstones
Alcohol
Viral infection
Tumours
Anatomical abnormalities
Drugs
Hypercalcaemia
Ischaemia
Scorpion venom!!!
Just read through, next card is gonna ask which are more common!
What are the most likely causes of acute pancreatitis?
Gallstones
Alcohol
Describe how alcohol can cause acute pancreatitis.
Causes direct injury as produces oxidation products like acetaldehyde.
How does acute pancreatitis present?
Abdominal pain
Nausea, vomiting
Collapse
What are some of the clinical signs suggesting acute pancreatitis?
Pyrexia
Dehydration
Abdominal tenderness
Circulatory failure
In acute pancreatitis, what would be raised in the bloods?
Amylase
What can be done to help rank the severity of acute pancreatitis?
Clinical assessment
Use of modified Glasgow criteria
CT scanning
Individual markers e.g. CXR
How is acute pancreatitis managed?
Treat the underlying condition first e.g. if the cause is cholelithiasis, presenting with jaundice, we would give an ERCP
What would you do if the acute pancreatitis was brought about by alcohol?
Refer the patient to alcohol cessation
What would be the management if the acute pancreatitis was due to hyperlipidaemia?
Lipid lowering drugs or diet
What would be the management if the acute pancreatitis was due to malignancy?
Resection or bypass
What would be the management if the acute pancreatitis was due to anatomical abnormalities?
Correction of abnormalities if possible
What would be the management if the acute pancreatitis was due to drugs?
Change or correct the drugs being taken
How many days does it take to identify necrosis on CT after acute pancreatitis?
4-10
Why are antibiotics not given at the start of a mild acute attack of pancreatitis?
No sepsis and body would develop resistant microorganisms
When would a patient w acute pancreatitis be given antibiotics?
If there were signs of sepsis
How can we determine if something is sepsis or SIRS (systemic inflammatory response syndrome)?
CT guided FNA of pancreas
fine needle aspiration
When would a patient w acute pancreatitis be given ERCP?
If the patient has jaundice or associated cholangitis
In terms of nutrition, what is done for those with acute pancreatitis?
If you cannot establish nutrition orally, an MG tube will be used via enteric route
How can recurrent attacks of acute pancreatitis be prevented?
Treat gallstones
Alcohol abstinence
What should be done if there is sterile necrosis as a result of acute pancreatitis?
Nothing
What should be done if there is infected necrosis as a result of acute pancreatitis?
Drainage or necrosectomy
What should be done if there is abscess formation as a result of acute pancreatitis?
Drainage through the skin
What are some of the late complications of acute pancreatitis?
Haemorrhage
Portal hypertension
Pancreatic duct stricture
What is chronic pancreatitis?
Continuing inflammation of pancreas which impairs the exocrine and endocrine functions of the pancreas
What are the causes of chronic pancreatitis?
O A TIGER!!!
Obstruction
Autoimmune
Toxin
Idiopathic
Genetic
Environmental
Recurrent injuries
What are some of the obstructions which can cause chronic pancreatitis?
Tumours
Sphincter of Oddi dysfunction
Duodenal obstruction
Trauma
What are some of the toxins which can cause chronic pancreatitis?
Drugs
Smoking
Alcohol
What are some of the genetic conditions which can cause chronic pancreatitis?
Condon 29 and 122
CFTR
SPINK1
Condon A
What are some of the recurrent injuries which can cause chronic pancreatitis?
Biliary
Hyperlipidaemia
Hypercalcinaemia
What are the clinical presentations of chronic pancreatitis?
Pain
Jaundice
Pancreatic hormone insufficiency
Diabetes
Upper GI haemorrhage
Which investigations are carried out for chronic pancreatitis?
CT
ERCP/MRCP
Test of pancreatic exocrine function
Diagnostic enzyme replacement
Why is MRCP useful in the diagnosis of chronic pancreatitis?
Monitors progression
Why is ERCP useful in the diagnosis of chronic pancreatitis?
Shows biliary or pancreatic duct obstruction
When would surgery be carried out in cases of chronic pancreatitis?
Suspicion of malignancy
Intractable pain
Complications arise
List the complications of chronic pancreatitis which require surgery.
-Pancreatic duct stenosis
-Cyst/ pseudocysts
-Biliary tract obstruction
-Splenic vein thrombosis
-Portal vein compression
-Duodenal stenosis
-Colonic stricture
How would pancreatic duct stenosis be treated surgically?
Via endoscopy
How would cysts be treated surgically?
Drainage
How would splenic vein thrombosis be treated surgically?
Laparoscopic splenectomy
How would portal vein compression be treated surgically?
Anticoagulation
How would duodenal stenosis be treated surgically?
Laparoscopic bypass
How would colonic stricture be treated surgically?
Surgical disconnection/excision of part of bowel
Which nerve plexus could be blocked to reduce pain from chronic pancreatitis?
Caeliac plexus
How can a caeliac plexus block be carried out?
CT guided
Which types of surgery may be required for chronic pancreatitis if the medical management surgeries fail?
Drainage
Resection
Name two types of drainage surgery for chronic pancreatitis.
Pancreatic duct sphincteroplasty
Puestow
Name two types of resection surgery for chronic pancreatitis.
Whipple’s pancreatico-duodectomy
Spleen-preserving distal pancreatectomy
What is mucinous cystic neoplasia of the pancreas (MCN)?
Rare tumours found in the pancreas
What are the different types of MCN of the pancreas?
MD-IPMN (main duct intraductal papillary mucinous neoplasia)
BD-IPMN (branch duct intraductal papillary mucinous neoplasia)
MCN (mucinous cystic neoplasia)
Describe MD-IPMN (main duct IPMN)
Arises from whole of pancreatic duct and pancreatic duct is dilated due to mucus
Describe BD-IPMN (branch duct IPMN)
Side branch of pancreatic duct leading to a cyst
Describe MCN
Single cyst
Why are these MCN’s and subtypes important?
High chance they develop into cancer
When would a MD-IPMN be at a high risk of developing into cancer?
When main pancreatic duct >10mm
Enhanced solid component
When would a MCN be at a high risk of developing into cancer?
Enhanced solid component >1cm
List some of the different methods of resection.
Pancreatectomy
Focal
Spleen sparing
Laparoscopic
Robotic
Multifocal
