Surgery of Pancreatic Disorders Flashcards
What is the aeitology of pancreatic cancer
cigarette smoking
chronic pancreatitis
Diabetes Melitus (less than 2 yrs duration)
Hereditary pancreatitis
Inherited predisposition
What is the clinical presentation/signs of pancreatic cancer
Obstructive jaundice
Diabetes
Abdominal pain / Back pain
Anorexia
Vomiting
Weight loss
Recurrent bouts pancreatitis
What is the Invasive investigations for pancreatic cancer
USS ERCP CT MR, MRCP Laparoscopy + Lap USS Peritoneal cytology EUS + FNA/ Bx Percutaneous needle biopsy PET
What is the tumour marker for pancreatic cancer
CA19-9
What is the treatment options for pancreatic cancer
Surgery: resection
Palliative drainage
What is the name of the pancreatic resection surgery
Kaush whipple
{pancreaticoduodenectomy}
Describe the Kausch- Whipple
major surgical operation involving the removal of the head of the pancreas, the duodenum, the proximal jejunum, gallbladder, and part of the stomach
Why is the pylorus preserved in Kausch- whipple
Maintaining the pylorous of the stomach as is where the pacemaker is therefore gastric emptying isn’t delayed
What is palliative draining used to treat
Obstructive jaundice
Duodenal obstruction
What is the methods of palliative drainage used to treat obstructive jaundice in pancreatic cancer
Palliative bypass
ERCP
PTC stenting
What is the methods of palliative drainage used to treat duodenal obstruction in pancreatic cancer
Palliative bypass
Duodenal stent
Define the two classification of acute pancreatitis
Mild AP: Associated with minimal organ dysfunction and uneventful recovery
Severe AP: Associated with organ failure or local complication
What is the local complications caused by 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 (pancreas divisum)
ERCP
Lipid abnormalities
Hypercalcaemia
Postoperative Trauma
Ischaemia
Drugs
Idiopathic
What is the pathophysiology of how alcohol causes acute pancreatitis
direct injury
increased sensitivity to stimulation
oxidation products (acetaldehyde)
non-oxidative metabolism (fatty acid ethyl esters)
What is the pathophysiology of how ERCP causes acute pancreatitis
Increases pancreatic ductal pressure
What is the symptoms of acute pancreatitis
Abdominal pain
Nausea/vomiting
Collapse
What is the signs of acute pancreatitis
Pyrexia
Dehydration
Abdominal tenderness
Circulatory failure
What is the general supportive care given in acute pancreatitis
Analgesia Intravenous fluids Support to: Cardiovascular Respiratory Renal
What is monitored in acute pancreatitis
Pulse,
BP - arterial line
Urine output
Central Venous Pressure
Intensive unit care
What is the imagery investigations for acute pancreatitis
Chest and Abdomen X ray
Ultrasound
CT
ERCP
What further test are investigated in acute pancreatitis
U&E, glucose serum amylase FBC, LFT arterial blood gas
What are the results that predict the severity of acute pancreatitis in Modified Glasgow Criteria
Severe is >3
Glucose > 10 mmol/L
Serum [Ca2+] < 2.00 mmol
WCC > 15000/mm3
Albumin< 32 g//L
LDH > 700 IU/L
Urea > 16 mmol/L
AST/ALT > 200 IU/L
Arterial pO2 < 60mmHg
What is the treatment of acute pancreatitis if caused by gallstones
ERCP &ES
cholecystectomy
What is the management of acute pancreatitis
If due to Hyperlipideamia: Diet, lipid lowering drugs
Overall good nutrition
abstinence from alcohol or drugs
Correct anatomical abnormalities
If due to infection:
-antibiotics
Manipulate inflammatory response
Fluid collection
Why is CT scanning useful in the diagnosis and management of acute pancreatitis
Shows complications Acute fluid collections
Abscess
Necrosis
Monitors progress of disease
How is a Infection diagnosed in acute pancreatitis and what is the importance of this
CT guided fine needle aspiration
Make sure sepsis complications have not occurred
How is necrosis managed in acute pancreatitis
Necrosectomy
through Laparotomy
What are the later complications of acute pancreatitis due to necrosis
Abscess
Haemorrhage
Portal hypertension
Pancreatic duct stricture
What is the definition of 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
Aetiology chronic pancreatitis
O-A- TIGER
Obstruction of main pancreatic duct
Autoimmune
Toxic
(alcohol, smoking, drugs)
Idiopathic
Genetic
Environmental
(tropical chronic pancreatitis)
Recent injuries
What are the causes ob obstruction to main pancreatic duct
Spinchter of Oddi dysfunction
Pancreatic divisum (single pancreatic duct not formed)
Duodenal obstruction
- Tumour
- Diverticulum (blind tube)
Trauma
structure change due to radiation
What are the Hereditary genes of chronic pancreatitis
Autosomal dominant (Condon 29 and 122)
Autosomal recessive/modifier genes
CFTR, SPINK1, Codon A etc
What are the recurrent injuries that occur to causee chronic pancreatitis
Biliary
Hyperlipidemia
Hypercalcemia
What is the clinical features of chronic pancreatitis
Pain
Exocrine insufficiency
Diabetes
Jaundice
Duodenal obstruction
Upper GI haemorrhage
What is the imaging investigations for chronic pancreatitis
CT scan - shows local anatomy and complications
ERCP
MRCP
How is pancreatic exocrine function tested in the investigation of chronic pancreatitis
faecal / serum enzymes (elastase)
Pancreolauryl test (trypsin reponse to a stimulus)
Diagnostic Enzyme replacement
What is the management of chronic pancreatitis
abstinence from alcohol
analgesia
avoid high fat/protein diet
pancreatic supplementation for pain
anti-oxidant therapy
Insulin - for diabetes
When would surgery occur in chronic pancreatitis
Suspicion of malignancy
Intractable pain
Complications
What are the potential complications of chronic pancreatitis
Pancreatic duct stenosis
Cyst / pseudocysts
Biliary tract obstruction
Splenic/mesenteric vein thrombosis
Gastric varices
Portal vein compression
Duodenal stenosis
Colonic stricture
How do you manage pancreatic duct stenosis and obstruction
Endoscopic PD sphincetortomy, dilation
lithotripsy
How do you manage chronic pseuodocyts in chronic pancreatitis
Common biliary duct stenting or bypass
Define Caeliac plexus block and how you perform it
injections of pain medication that help relieve abdominal pain
Is either
- CT guided
- EUS guided
- Fluoroscopy guided
Define Splanchnectomy
surgical excision of a segment of one or more splanchnic nerves to relieve hypertension.
What are the two surgical procedures that are performed in chronic pancreatitis
Drainage
Resection
What are the types of drainage surgeries in Chronic pancreatitis
Pancreatic duct sphincteroplasty
Puestow (Rochelle modification)
What are the types of resection surgeries in Chronic pancreatitis
Duodenum preserving pancreatic head resection PPHR (Beger)
PPPD -pylorus preserving Pancreatoduodectomy
Whipple’s pancreatico-duodenectomy
Frey procedure (longitudinal pancreato-jejunostomy with local pancreatic resection)
Spleen-preserving distal pancreatectomy
Central pancreatectomy
