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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
What does CMV stand for?
Cytomegalovirus
26
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)
27
What is the pathophysiology of pancreatitis caused by gallstones?
Passage of gallstone is essential Raised pancreatic ductal pressure
28
What is the pathophysiology of acute pancreatitis caused by ERCP?
Increased pancreatic duct pressure
29
What are some symptoms of acute pancreatitis?
Abdominal pain Nausea, vomiting Collapse
30
What are some signs of acute pancreatitis?
Pyrexia Dehydration Abdominal tenderness Circulatory failure
31
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
32
What should be monitored when managing acute pancreatitis?
Pulse, BP Urine output Central venous pressure (CVP) Arterial line HDU/ITU
33
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
34
What critera does preducting severity of acute pancreatitis use?
Glasgow criteria
35
In the Glasgow criteria, what score inidcates severe acute pancreatitis?
3 or more
36
What does the Glasgow criteria check?
Glucose Serum calcium White cel count Albumin LDH Urea AST/ALT Arterial pO2
37
What glucose level gives a score of 1 on the Glasgow criteria?
>10mmol/L
38
What serum calcium level gives a score of 1 on the Glasgow criteria?
<2mmol/L
39
What white cell count gives a score of 1 on the Glasgow criteria?
>1500/mm3
40
What LDH level gives a score of 1 on the Glasgow criteria?
>700IU/L
41
What albumin level gives a score of 1 on the Glasgow criteria?
<32g/L
42
What urea level gives a score of 1 on the Glasgow criteria?
>16mmol/L
43
What AST/ALT level gives a score of 1 on the Glasgow criteria?
> 200 IU/L
44
What arterial pO2 level gives a score of 1 on the Glasgow criteria?
< 60mmHg
45
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
46
How is acute pancreatitis due to cholelithiasis managed?
ERCP & ES, cholecystectomy
47
How is acute pancreatitis due to alcohol managed?
Abstenence, counselling….
48
How is acute pancreatitis due to ischaemia managed?
Careful support, Correct cause
49
How is acute pancreatitis due to malignancy managed?
Resection or bypass
50
How is acute pancreatitis due to hyperlipidaemia managed?
Diet, lipid lowering drugs
51
How is acute pancreatitis due to anatomical abnormalities managed?
Correction if possible
52
How is acute pancreatitis due to cholelithiasis managed?
Stop or change
53
What are specific aspects of managing acute pancreatitis?
CT scanning Antibiotics Diagnosis of infection ERCP in gallstone pancreatitis Nutrition Manipulation of the inflammatory response
54
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
55
What is used to diagnose infection with acute pancreatitis?
CT guided FNA of pancreatic necrosis
56
What is CT guided FNA?
procedure performed by a radiologist to obtain a small tissue sample through a needle.
57
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
58
How is necrosis due to acute pancreatitis managed?
Sterile necrosis Infected necrosis: Necrosectomy Laparotomy Minimally invasive Abscess
59
What are examples of different kinds of necrosis due to acute pancreatitis?
sterile infected abscess
60
What are examples of different kinds of late complications due to acute pancreatitis?
Haemorrhage Portal hypertension Pancreatic duct stricture
61
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.
62
How does the incidence of males and females compare for chronic pancreatitis?
M > F
63
What are some causes of chronic pancreatitis?
Obstruction of MPD Autoimmune toxin idiopathic genetic environmental recurrent illness
64
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
65
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
66
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)
67
what is the environmental cause of Ch pancreatitis
Tropical chronic pancreatitis
68
what are recurrent injuries that lead to Ch pancreatitis
Biliary Hyperlipidemia Hypercalcemia
69
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.
70
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
71
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
72
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
73
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
74
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
75
What procedures can be done for pancreatic duct stenosis and obstruction?
Endoscopic PD sphincetortomy, dilation and lithotripsy
76
What are the different approaches for a caeliac plexus block?
The classic trans-crural approach Trans-aortic techniques Anterior Approaches
77
What surgery can be done for drainage during chronic pancreatitis?
Pancreatic duct sphincteroplasty Puestow (Rochelle modification)
78
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
79
What does DPPHR stand for?
Duodenum-preserving pancreatic head resection
80
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
81
What does MCN stand for?
Mucinous Cystic Neoplasia of the pancreas
82
What is another condition similar to MCN?
IPMN
83
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
84
What are different kinds of IPMN?
MD-IPMN BD-IPMN MCN
85
What are worrisome features of MD-IPMN?
MPD 5-9 mm, non-enhanced mural nodule, abrupt change in MPD LN’s.
86
When is IPMN considered high risk?
high risk stigmata: MPD > 10 mm Enhanced solid component
87
When is MCN considered high risk?
High risk stigmata: > 1cm with enhanced solid component MPD > 1cm
88
What are worrisome features of MCN?
>3 cm Enhanced cyst wall Non-enhanced nodules
89
What are indications for resection for MD-IPMN?
Indicated for MD-IPMN
90
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
91
What are indications for resection for MCN?
all MCN in fit patients indicated <4cm without mural nodules: lap. Spleen preservation
92
What are methods of IPMN and MCN resection?
Pancreatectomy + LN’s Focal and LN or spleen sparing: Laparoscopic Robotic Multifocal BD-IPMN: total pancreatectomy

Alimentary System (44 decks)

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