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Alimentary System > Surgery of pancreatic disorders > Flashcards

Surgery of pancreatic disorders Flashcards

1
Q

What are examples of pancreatic disorders?

A

Pancreatic cancer

Acute pancreatitis

Chronic pancreatitis

Intraductal papillary mucinous neoplasm (IPMN) and pancreatic cystic disease

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2
Q

What does IPMN stand for?

A

Intraductal papillary mucinous neoplasm

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3
Q

What is the incidence of pancreatic cancer in the UK?

A

10/100000

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4
Q

What age group is pancreatic cancer most common in?

A

60-80 years old

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5
Q

What is the male:female ratio of pancreatic cancer?

A

3:4

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6
Q

What is the 5 year survival rate of pancreatic cancer?

A

0.4%

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7
Q

What are risk factors for pancreatic cancer?

A

Smoking

Chronic pancreatitis

Adult onset of diabetes

Hereditary pancreatitis

Inherited predisposition

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8
Q

What is the presentation of pancreatic cancer?

A

Obstructive jaundice

Diabetes

Abdominal pain/back pain

Anorexia

Vomiting

Weight loss

Recurrent bouts pancreatitis

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9
Q

What investigations are done for pancreatic cancer?

A

Blood tests

Chest x-ray

Tumour markers (CA19-9)

Imaging/invasive investigations

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10
Q

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

A

CA19-9

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11
Q

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

A

CXR

USS

CT

MRCP

Laparoscopic USS

Peritoneal cytology

Percutaneous needle biopsy

PET scan

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12
Q

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

A

Basic history and examination

Chest x-ray and ECG

Respiratory function tests

Physiological scoring system

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13
Q

What types of surgery can be done for pancreatic cancer?

A

Kausch-Whipple

Pylorus-preserving pancreaticoduodenectomy (PPPD)

Palliative drainage

Metal stenting

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14
Q

What does PPPD stand for?

A

Pylorus-preserving pancreaticoduodenectomy

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15
Q

What is a pylorus-preserving pancreaticoduodenectomy

A

Similar to Whipples operation but none of the stomach is removed

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16
Q

What is Kausch-Whipple surgery?

A

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

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17
Q

What is Kausch-Whipple surgery also known as?

A

Pancreaticoduodectomy

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18
Q

What is acute pancreatitis?

A

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

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19
Q

What are the different classifications of acute pancreatitis?

A

Mild AP

Severe AP

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20
Q

What is mild acute pancreatitis associated with?

A

Minimal organ dysfunction and uneventful recovery

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21
Q

What is severe acute pancreatitis associated with?

A

Organ failure or local complication

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22
Q

What are some local complications of acute pancreatitis?

A

Acute fluid collection

Pseudocyst

Pancreatic abscess

Pancreatic necrosis

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23
Q

What is the aetiology of acute pancreatitis?

A

Gallstones

Alcohol

Viral infections (CMV, mumps)

Tumours

Anatomical abnormalities

ERCP

Lipid abnormalities

Hypercalcaemia

Postoperative trauma

Ischaemia

Drugs

Scorpion venom

Idiopathic

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24
Q

What viral infections can cause acute pancreatitis?

A

CMV

Mumps

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25
Q

What does CMV stand for?

A

Cytomegalovirus

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26
Q

What is the pathophysiology of acute pancreatitis caused by alcohol?

A

Direct injury

Increased sensitivity to stimulation

Oxidation products (acetaldehyde)

Non-oxidative metabolism (fatty acid ethyl esters)

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27
Q

What is the pathophysiology of pancreatitis caused by gallstones?

A

Passage of gallstone is essential

Raised pancreatic ductal pressure

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28
Q

What is the pathophysiology of acute pancreatitis caused by ERCP?

A

Increased pancreatic duct pressure

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29
Q

What are some symptoms of acute pancreatitis?

A

Abdominal pain

Nausea, vomiting

Collapse

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30
Q

What are some signs of acute pancreatitis?

A

Pyrexia

Dehydration

Abdominal tenderness

Circulatory failure

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31
Q

What does the management of acute pancreatitis involve?

A

General supportive care (analgesia, IV fluids, cardiovascular, respiratory and renal support)

Monitoring (pulse, BP, urine output, CVP, arterial line, HDU/ITU)

Investigations

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32
Q

What should be monitored when managing acute pancreatitis?

A

Pulse, BP

Urine output

Central venous pressure (CVP)

Arterial line

HDU/ITU

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33
Q

What investigations should be done for acute pancreatitis?

A

U/E, glucose

Serum amylase

FBC, clotting

LFT ABG

Chest x-ray, abdomen x-ray

USS

CT scan

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34
Q

What critera does preducting severity of acute pancreatitis use?

A

Glasgow criteria

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35
Q

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

A

3 or more

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36
Q

What does the Glasgow criteria check?

A

Glucose

Serum calcium

White cel count

Albumin

LDH

Urea

AST/ALT

Arterial pO2

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37
Q

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

A

> 10mmol/L

38
Q

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

A

<2mmol/L

39
Q

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

A

> 1500/mm3

40
Q

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

A

> 700IU/L

41
Q

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

A

<32g/L

42
Q

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

A

> 16mmol/L

43
Q

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

A

> 200 IU/L

44
Q

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

A

< 60mmHg

45
Q

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

A

Clinical Assessment

Modified Glasgow criteria

CT scanning

Individual markers CXR
CRP(>200, or persists >150)
IL 6
TAP

46
Q

How is acute pancreatitis due to cholelithiasis managed?

A

ERCP & ES, cholecystectomy

47
Q

How is acute pancreatitis due to alcohol managed?

A

Abstenence, counselling….

48
Q

How is acute pancreatitis due to ischaemia managed?

A

Careful support, Correct cause

49
Q

How is acute pancreatitis due to malignancy managed?

A

Resection or bypass

50
Q

How is acute pancreatitis due to hyperlipidaemia managed?

A

Diet, lipid lowering drugs

51
Q

How is acute pancreatitis due to anatomical abnormalities managed?

A

Correction if possible

52
Q

How is acute pancreatitis due to cholelithiasis managed?

A

Stop or change

53
Q

What are specific aspects of managing acute pancreatitis?

A

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

54
Q

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

A

Days 4-10 to identify necrosis

Useful for complications
Acute fluid collections
Abscess
Necrosis
Monitoring progress of disease

55
Q

What is used to diagnose infection with acute pancreatitis?

A

CT guided FNA of pancreatic necrosis

56
Q

What is CT guided FNA?

A

procedure performed by a radiologist to obtain a small tissue sample through a needle.

57
Q

What is the definitive management of acute pancreatitis summarised?

A

Prevention of recurrent attacks
Management of Gallstones
Investigations of non-gallstone pancreatitis
Alcohol abstinenece

Fluid collection:
Early collection
Pseudocyst
Pancreatic duct fistula

Management of Necrosis:
Sterile necrosis
Infected necrosis: Necrosectomy
Laparotomy
Minimally invasive
Abscess

58
Q

How is necrosis due to acute pancreatitis managed?

A

Sterile necrosis

Infected necrosis: Necrosectomy
Laparotomy
Minimally invasive

Abscess

59
Q

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

A

sterile
infected
abscess

60
Q

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

A

Haemorrhage
Portal hypertension
Pancreatic duct stricture

61
Q

What is chronic pancreatitis?

A

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

62
Q

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

A

M > F

63
Q

What are some causes of chronic pancreatitis?

A

Obstruction of MPD

Autoimmune

toxin

idiopathic

genetic

environmental

recurrent illness

64
Q

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

A

Tumour
Adenocarcinoma
IPMT

Sphincter of Oddi dysfunction

Pancreatic divisum
Inadequate accessory drainage

Duodenal obstruction
Tumour
Diverticulum

Trauma

Structure
Post necrotizing radiation

65
Q

what are some examples of toxin causes of Ch pancreatitis

A

Ethanol (related to amount and length of consumption)
Smoking (odds ratio 8 to 17)
Drugs

66
Q

what are some examples of genetic causes of Ch pancreatitis

A

Autosomal dominant (Condon 29 and 122)
Autosomal recessive/modifier genes
(CFTR, SPINK1, Codon A etc)

67
Q

what is the environmental cause of Ch pancreatitis

A

Tropical chronic pancreatitis

68
Q

what are recurrent injuries that lead to Ch pancreatitis

A

Biliary
Hyperlipidemia
Hypercalcemia

69
Q

What is pancreatic divisum?

A

Pancreas divisum is a congenital defect of the pancreas. It occurs when two parts of an embryo’s pancreas do not fuse together to form one main pancreatic duct, leaving the main pancreatic duct to drain through a smaller opening (minor papilla). The condition may rarely cause recurrent acute pancreatitis.

70
Q

What are clinical features of chronic pancreatitis?

A

Pain
most significant factor wrt quality of life
linked to binges
become more frequent and less treatable by abstinence
pathogenesis unknown

Pancreatic exocrine insufficiency
Late manifestation

Diabetes

Jaundice

Duodenal obstruction
Uncommon

Upper GI haemorrhage

71
Q

What investigations are done for chronic pancreatitis?

A

Careful detailed history

Appropriate imaging:
CT scan: local anatomy and complications
ERCP / MRCP

Pancreatic exocrine function (used infrequently):

faecal / serum enzymes (elastase)

Pancreolauryl test (enzyme reponse to a stimulus)

Diagnostic Enzyme replacement

72
Q

What is the management of chronic pancreatitis?

A

Conservative management
Counselling
Abstinence from alcohol
Management of acute attacks
Analgesia
? Interventional methods of analgesia
Avoid high fat, high protein diet
Pancreatic supplementation controversial for pain
Anti-oxidant therapy
Steatorrhoea:
Reduce fat intake
Pancreatic supplementation
Diabetes

73
Q

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

A

Suspicion of malignancy
Intractable pain
Complications
Pancreatic duct stenosis
Cyst / pseudocysts
Biliary tract obstruction
Splenic vein thrombosis / gastric varices
Portal vein compression / mesenteric vein thrombosis
Duodenal stenosis
Colonic stricture

74
Q

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

A

PD Stenosis and obstruction: Endoscopic PD sphincetortomy, dilation and lithotripsy

Management of chronic pseudocyst

CBD stenting or bypass

Thoracoscopic
Splanchnectomy

Caeliac plexus block
CT guided
EUS guided
Fluoroscopy guided

75
Q

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

A

Endoscopic PD sphincetortomy, dilation and lithotripsy

76
Q

What are the different approaches for a caeliac plexus block?

A

The classic trans-crural approach

Trans-aortic techniques

Anterior Approaches

77
Q

What surgery can be done for drainage during chronic pancreatitis?

A

Pancreatic duct sphincteroplasty
Puestow (Rochelle modification)

78
Q

What surgery can be done for resection during chronic pancreatitis?

A

DPPHR (Beger)
PPPD
Whipple’s pancreatico-duodenectomy
Frey procedure
Spleen-preserving distal pancreatectomy
Central pancreatectomy

79
Q

What does DPPHR stand for?

A

Duodenum-preserving pancreatic head resection

80
Q

What is mucinous cystic neoplasia of the pancreas?

A

Mucinous cystic pancreatic neoplasms (MCPN) are rare tumors of the pancreas, which mostly occur in middle-aged females

81
Q

What does MCN stand for?

A

Mucinous Cystic Neoplasia of the pancreas

82
Q

What is another condition similar to MCN?

A

IPMN

83
Q

What does IPMN stand for?

A

Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms of the pancreas that grow within the pancreatic ducts and produce mucin

84
Q

What are different kinds of IPMN?

A

MD-IPMN
BD-IPMN
MCN

85
Q

What are worrisome features of MD-IPMN?

A

MPD 5-9 mm,
non-enhanced mural nodule,
abrupt change in MPD
LN’s.

86
Q

When is IPMN considered high risk?

A

high risk stigmata:
MPD > 10 mm
Enhanced solid component

87
Q

When is MCN considered high risk?

A

High risk stigmata:
> 1cm with enhanced solid component
MPD > 1cm

88
Q

What are worrisome features of MCN?

A

> 3 cm
Enhanced cyst wall
Non-enhanced nodules

89
Q

What are indications for resection for MD-IPMN?

A

Indicated for MD-IPMN

90
Q

What are indications for resection for BD-IPMN?

A

In elderly >3 cm without high risk stigmata (mural nodules, positive cytology): can be observed

In younger patients: >2 cm may be considered depending on location

91
Q

What are indications for resection for MCN?

A

all MCN in fit patients indicated
<4cm without mural nodules: lap. Spleen preservation

92
Q

What are methods of IPMN and MCN resection?

A

Pancreatectomy + LN’s
Focal and LN or spleen sparing:
Laparoscopic
Robotic
Multifocal BD-IPMN: total pancreatectomy

Alimentary System (44 decks)

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