Surgery of Pancreatic Disorders Flashcards
What is the epidemiology of head of pancreas carcinoma?
- 100/million per year UK
- Average age 60-80 yrs
- F>M
What is the aetiology of pancreatic carcinoma?
Unknown
What are the risk factors for pancreatic carcinoma?
- Smoking
- Chronic pancreatitis
- Adult onset diabetes
- Hereditary pancreatitis
- Inherited predisposition
- Periampullary cancer as a feature of FAP
What is the hallmark feature of pancreatic carcinoma?
Painless obstructive jaundice
How does pancreatic carcinoma present
- Diabetes
- Abdominal pain
- Back pain
- Anorexia
- Vomiting
- Weight loss
- Recurrent bouts of pancreatitis
- Incidental finding
What general investigations should be carried out for pancreatic carcinoma?
- Blood tests
- CXR
What tumour markers are there for pancreatic cancer?
CA19-9
What imaging/invasive investigations should be carried out for pancreatic carcinoma?
- USS
- ERCP
- CT
- MR, MRCP
- Laparoscopy and Lap USS
- Peritoneal cytology
- EUS + FNA Bx
- Percutaneous needle biopsy
- PET
How is a patient assessed for fitness for major pancreatic resection?
- Basic history and examination
- CXR, ECG
- Resp function tests
- Physiological scoring system (none established, performance status, lactate threshold)
- Fully informed consent
What can be done for a patient with pancreatic cancer deemed to be unfir/unresectable?
ERCP+stent
What investigations must be performed before a potentially resectable cancer is resected?
- USS
- ERCP + stent
- Spiral CT/MRI
- Laparoscopy/ Lap USS
- Laparotomy
- Resection
What is the name of the surgery performed fro pancreatic cancer?
Kausch-Whipple
How is palliative drainage achieved with obstructive jaundice?
- Palliative bypass
- ERCP
- PTC stenting
How is palliative drainage achieved with duodenal obstruction?
- Palliative bypass
- Duodenal stent
Acute pancreatitis
An acute inflammatory process of the pancreas with variable involvement of other regional tissue or remote organ systems
Mild AP
Associated with minimal organ dysfunction and uneventful recovery
Severe AP
Associated with organ failure or local complication
What are the local complications of acute pancreatitis/
- Acute fluid collections
- Pseudocyst
- Pancreatic abscess
- Pancreatic necrosis
What is the aetiology of acute pancreatitis?
- Gallstones
- Alcohol
- Viral infection: CMV, mumps
- Tumours
- Anatomical abnormalities
- ERCP
- Lipid abnormalities
- Hypercalcaemia
- Postoperative trauma
- Ischaemia
- Drugs
- Scorpion venom
- Idiopathic
What is the pathophysiology of AP as a result of alcohol?
- Direct injury
- Increased sensitivity to stimulation
- Oxidation products (acetaldehyde)
- Non-oxidative metabolism
What is the pathophysiology of AP as a result of gallstones?
- Passage of gallstones is essential
- Raised pancreatic ductal pressure
What is the pathophysiology of AP as a result of ERCP?
-Increased pancreatic ductal pressure
What are the symptoms of AP?
- Severe abdominal pain
- Nausea
- Vomiting
- Collapse
What are the signs of AP?
- Pyrexia
- Dehydration
- Abdominal tenderness
- Circulatory failure
What general supportive care should be provided in AP initial resuscitation and management?
- Analgesia
- IV fluids
- CV support
- Resp support
- Renal support
What monitoring should be provided in AP initial resuscitation and management?
- Pulse
- BP
- Urine output
- CVP
- Arterial line
- HDU/ITU
What investigations should be carried out in AP initial resuscitation and management?
- U+Es
- Glucose
- Serum amylase
- FBC
- Clotting
- LFTs
- ABG
- CXR
- AXR
- USS
- CT
What are the criteria in the Glasgow criteria scoring system?
- Glucose >10mmol/L
- Serum Ca <2mmol
- WCC >1500/mm^3
- Albumin<32g/l
- LDH>700IU/L
- Urea>16mmol/L
- AST/ALT>200IU/L
- Arterial pO2 <60mmHg
When is AP predicted severe ?
If Glasgow criteria scoring is >3 at 48 hrs
How is a prediction of severity made for AP?
- Clinical assessment
- Modified Glasgow criteria
- CT scan
- CXR
- CRP>200 or persistent >150
- IL6
- TAP
AP Identification and Management of Precipitating Factors: Cholelithaiasis
ERCP and ES, cholescystectomy
AP Identification and Management of Precipitating Factors: alcohol
- Abstinence
- Counselling
AP Identification and Management of Precipitating Factors: Ischaemia
- Careful support
- Correct cause
AP Identification and Management of Precipitating Factors: Malignancy
- Resection
- Bypass
AP Identification and Management of Precipitating Factors: Hyperlipidaemia
- Diet
- Lipid lowering drugs
AP Identification and Management of Precipitating Factors: Anatomical abnormalities
Correction if possible
AP Identification and Management of Precipitating Factors: Drugs
- Stop
- Change
What are the specific aspects of management for AP?
- CT
- Antibiotics
- Diagnosis of infection
- ERCP in gallstone pancreatitis
- Nutrition
- Manipulation of the inflammatory response
When can necrosis by AP be detected on CT?
Days 4-10
What complications of AP is CT useful for identifying?
- Acute fluid collections
- Abscess
- Necrosis
- Monitoring progress of disease
What infections are associated with AP?
- Sepsis
- SIRS
When is ERCP and ES definitely indicated in AP?
In those with jaundice and cholangitis
Why is ERCP and ES still controversial in the treatment of AP?
- Reduces complications in severe gallstones
- Associated with higher mortality
What role does nutrition play in the treatment of AP?
- Nutrition vitally important
- Enteral feeding is superior to parenteral feeding
- NG feeding is tolerable in most cases and is not associated with any increase in complications
What is the definitive management for AP in the prevention of recurrent attacks?
- Management of gallstones
- Investigations of non-gallstone pancreatitis
- Alcohol abstinence
What is the definitive management for fluid collect in AP?
- Early collection: sit it out
- Pseudocyst: doesn’t have a capsule
- Pancreatic duct fistula: manage pancreas accordingly
What is the definitive management of necrosis in AP?
- Sterile and infected necrosis
- Necrosectomy by laparotomy or minimally invasive
What are late complications of AP?
- Haemorrhage
- Portal hypertension
- Pancreatic duct stricture
Chronic pancreatitis
Continuing chronic inflammatory process of the pancreas characterised by irreversible morphological changes leading to chronic pain and/or impairment of endocrine and exocrine function of the pancreas
What is the epidemiology of chronic pancreatitis?
- M>F
- Increasing in the Western World
What are the causes of chronic pancreatitis?
- Obstruction of MPD
- Autoimmune
- Toxin
- Idiopathic
- Genetic
- Environmental
- Recurrent injuries
What can cause obstruction of the MPD?
- Tumour
- Sphincter of Oddi dysfunction
- Pancreatic divisum
- Duodenal obstruction
- Trauma
- Stricture
What toxins can cause CP?
- Ethanol
- Smoking
- Drugs
What genes can cause CP?
- Autosomal dominant (Condon 29 and 122)
- Autosomal recessive (CFTR, SPINK1,)
What environmental factor can cause CP?
Tropical chronic pancreatitis
What recurrent injuries can cause CP?
- Biliary
- Hyperlipidaemia
- Hypercalcemia
What are the clinical features of CP?
- Pain
- Pancreatic exocrine insufficiency
- Diabetes
- Jaundice
- Duodenal obstruction
- Upper GI haemorrhage
Describe the pain linked to CP.
- Most significant factor affecting quality of life
- Linked to binges
- Become more frequent and less treatable by abstinence
- Pathogenesis unknown
What investigations should be carried out for CP?
- CT
- ERCP/MRCP
- Pancreatic exocrine function
- Faecal/serum enzymes
- Pancreolauryl test
- Diagnostic enzyme replacement
What conservative management is there for CP?
- Counselling
- Alcohol abstinence
- Management of acute attacks
- Analgesia
- Avoid high fat, high protein diet
- Pancreatic supplementation
- Anti-oxidant therapy
When should surgery be considered for CP?
-Suspicion of malignancy
-Intractable pain
-Complications that require surgical intervention
ONLY AFTER FULL EVALUATION
What complications of CP require surgical intervention?
- Pancreatic duct stenosis
- Cyst, pseudocysts
- Biliary tract obstruction
- Splenic vein thrombosis/ gastric varicies
- Portal vein compression/ mesenteric vein thrombosis
- Duodenal stenosis
- Colonic stricture
What interventional procedures are there for CP?
- PD stenosis and obstruction: endoscopic PS sphincetortomy, dilation and lithotripsy
- Management of chronic pseudocyst
- Thoracoscopic
- Spanchnectomy
- Celiac plexus block
What surgery is available for drainage in CP?
- Pancreatic duct sphincteroplasty
- Puestow
What surgery is available for resection in CP?
- DPPHR
- PPPD
- Whipple
- Frey procedure
- Spleen preserving distal pancreatectomy
- Central pancreatectomy
What is the prognosis for CP?
- Mortality 50% over 20-25yr
- 20% die of complications
- Rest die as a result of associated conditions
- Morbidity is still a major cause for concern
