Surgery of pancreatic disorders Flashcards
What are examples of pancreatic disorders?
Pancreatic cancer
Acute pancreatitis
Chronic pancreatitis
Intraductal papillary mucinous neoplasm (IPMN) and pancreatic cystic disease
What does IPMN stand for?
Intraductal papillary mucinous neoplasm
What is the incidence of pancreatic cancer in the UK?
10/100000
What age group is pancreatic cancer most common in?
60-80 years old
What is the male:female ratio of pancreatic cancer?
3:4
What is the 5 year survival rate of pancreatic cancer?
0.4%
What are risk factors for pancreatic cancer?
Smoking
Chronic pancreatitis
Adult onset of diabetes
Hereditary pancreatitis
Inherited predisposition
What is the presentation of pancreatic cancer?
Obstructive jaundice
Diabetes
Abdominal pain/back pain
Anorexia
Vomiting
Weight loss
Recurrent bouts pancreatitis
What investigations are done for pancreatic cancer?
Blood tests
Chest x-ray
Tumour markers (CA19-9)
Imaging/invasive investigations
What antigen is released by cancerous pancreatic cells that can be tested for?
CA19-9
What imaging/invasive tests can be done to investigate pancreatic cancer?
CXR
USS
CT
MRCP
Laparoscopic USS
Peritoneal cytology
Percutaneous needle biopsy
PET scan
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
What types of surgery can be done for pancreatic cancer?
Kausch-Whipple
Pylorus-preserving pancreaticoduodenectomy (PPPD)
Palliative drainage
Metal stenting
What does PPPD stand for?
Pylorus-preserving pancreaticoduodenectomy
What is a pylorus-preserving pancreaticoduodenectomy
Similar to Whipples operation but none of the stomach is removed
What is Kausch-Whipple surgery?
Removes head of pancreas, bile duct, gallbladder and the duodenum
What is Kausch-Whipple surgery also known as?
Pancreaticoduodectomy
What is acute pancreatitis?
An acute inflammatory process of the pancreas with involvement of other regional tissues or remote organ systems
What are the different classifications of acute pancreatitis?
Mild AP
Severe AP
What is mild acute pancreatitis associated with?
Minimal organ dysfunction and uneventful recovery
What is severe acute pancreatitis associated with?
Organ failure or local complication
What are some local complications of acute pancreatitis?
Acute fluid collection
Pseudocyst
Pancreatic abscess
Pancreatic necrosis
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
What viral infections can cause acute pancreatitis?
CMV
Mumps
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 LDH level gives a score of 1 on the Glasgow criteria?
> 700IU/L
What albumin level gives a score of 1 on the Glasgow criteria?
<32g/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?
> 200 IU/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
Modified Glasgow criteria
CT scanning
Individual markers CXR
CRP(>200, or persists >150)
IL 6
TAP
How is acute pancreatitis due to cholelithiasis managed?
ERCP & ES, cholecystectomy
How is acute pancreatitis due to alcohol managed?
Abstenence, counselling….
How is acute pancreatitis due to ischaemia managed?
Careful support, Correct cause
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 the inflammatory response
What kind of complications from acute pancreatitis can be picked up by CT scanning?
Days 4-10 to identify necrosis
Useful for complications
Acute fluid collections
Abscess
Necrosis
Monitoring progress of disease
What is used to diagnose infection with acute pancreatitis?
CT guided FNA of pancreatic necrosis
What is CT guided FNA?
procedure performed by a radiologist to obtain a small tissue sample through a needle.
What is the definitive management of acute pancreatitis summarised?
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
How is necrosis due to acute pancreatitis managed?
Sterile necrosis
Infected necrosis: Necrosectomy
Laparotomy
Minimally invasive
Abscess
What are examples of different kinds of necrosis due to acute pancreatitis?
sterile
infected
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, characterized 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?
M > F
What are some causes of chronic pancreatitis?
Obstruction of MPD
Autoimmune
toxin
idiopathic
genetic
environmental
recurrent illness
What are examples of things that can cause obstruction of the main pancreatic duct?
Tumour
Adenocarcinoma
IPMT
Sphincter of Oddi dysfunction
Pancreatic divisum
Inadequate accessory drainage
Duodenal obstruction
Tumour
Diverticulum
Trauma
Structure
Post necrotizing radiation
what are some examples of toxin causes of Ch pancreatitis
Ethanol (related to amount and length of consumption)
Smoking (odds ratio 8 to 17)
Drugs
what are some examples of genetic causes of Ch pancreatitis
Autosomal dominant (Condon 29 and 122)
Autosomal recessive/modifier genes
(CFTR, SPINK1, Codon A etc)
what is the environmental cause of Ch pancreatitis
Tropical chronic pancreatitis
what are recurrent injuries that lead to Ch pancreatitis
Biliary
Hyperlipidemia
Hypercalcemia
What is pancreatic divisum?
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.
What are clinical features of chronic pancreatitis?
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
What investigations are done for chronic pancreatitis?
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
What is the management of chronic pancreatitis?
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
What are some possible complications of chronic pancreatitis that requires surgery to fix?
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
What interventional procedures can be done for treatment of chronic pancreatitis?
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
What procedures can be done for pancreatic duct stenosis and obstruction?
Endoscopic PD sphincetortomy, dilation and lithotripsy
What are the different approaches for a caeliac plexus block?
The classic trans-crural approach
Trans-aortic techniques
Anterior Approaches
What surgery can be done for drainage during chronic pancreatitis?
Pancreatic duct sphincteroplasty
Puestow (Rochelle modification)
What surgery can be done for resection during chronic pancreatitis?
DPPHR (Beger)
PPPD
Whipple’s pancreatico-duodenectomy
Frey procedure
Spleen-preserving distal pancreatectomy
Central pancreatectomy
What does DPPHR stand for?
Duodenum-preserving pancreatic head resection
What is mucinous cystic neoplasia of the pancreas?
Mucinous cystic pancreatic neoplasms (MCPN) are rare tumors of the pancreas, which mostly occur in middle-aged females
What does MCN stand for?
Mucinous Cystic Neoplasia of the pancreas
What is another condition similar to MCN?
IPMN
What does IPMN stand for?
Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms of the pancreas that grow within the pancreatic ducts and produce mucin
What are different kinds of IPMN?
MD-IPMN
BD-IPMN
MCN
What are worrisome features of MD-IPMN?
MPD 5-9 mm,
non-enhanced mural nodule,
abrupt change in MPD
LN’s.
When is IPMN considered high risk?
high risk stigmata:
MPD > 10 mm
Enhanced solid component
When is MCN considered high risk?
High risk stigmata:
> 1cm with enhanced solid component
MPD > 1cm
What are worrisome features of MCN?
> 3 cm
Enhanced cyst wall
Non-enhanced nodules
What are indications for resection for MD-IPMN?
Indicated for MD-IPMN
What are indications for resection for BD-IPMN?
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
What are indications for resection for MCN?
all MCN in fit patients indicated
<4cm without mural nodules: lap. Spleen preservation
What are methods of IPMN and MCN resection?
Pancreatectomy + LN’s
Focal and LN or spleen sparing:
Laparoscopic
Robotic
Multifocal BD-IPMN: total pancreatectomy
