surgery of pancreatic disorders Flashcards by oli crawford

whos more likely to get cancer to the head of pancreas

60-80 yr and women

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what is the 6th killer cancer in uk

cancer of head of pancreas

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risk factors of cancer head of pancreas

Unknown
Risk factors:
cigarette smoking: 25–30%
chronic pancreatitis: 5–15 fold
Adult onset DM of less than two years’ duration
Hereditary pancreatitis
Inherited predisposition:
Periampullary cancer is a feature of FAP

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presentation of cancer head of pancreas

Obstructive jaundice

Diabetes
Abdominal pain / Back pain
Anorexia
Vomiting
Weight loss
Recurrent bouts pancreatitis

Incidental finding

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investigations of cnacer head of pancreas

General investigations
Blood tests
CXR
Tumour markers
CA19-9

Imaging / Invasive Investigations
USS
?ERCP
CT
MR, MRCP
Laparoscopy + Lap USS
Peritoneal cytology
EUS + FNA/ Bx
Percutaneous needle biopsy
PET

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patient assessment for head of pancreas cancer

Basic history and examination
CXR, ECG
Respiratory function tests
Physiological “scoring system”
None established
Performance status
Lactate threshold
Fully informed consent is vital

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when would you do palliative bypass for pancreatic cancer?

for obstructive jaundice and duodenal obstruction

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what is the definition of acute pancreatitis?

An acute inflammatory process of the pancreas, with variable

involvement of other regional tissues or remote organ systems

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when is acute pancreatitis mild and when is it severe

mild: Associated with minimal organ dysfunction and uneventful recovery
severe: Associated with organ failure or local complication

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what are local complications of acute pancreatitis?

Acute fluid collections

Pseudocyst

Pancreatic abscess

Pancreatic necrosis

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aetiology of acute pancreatitis

Gallstones 
Alcohol 
Viral Infection: CMV, mumps 
Tumours 
Anatomical abnormalities (P.D.)
ERCP
Lipid abnormalities
Hypercalcaemia 
Postoperative Trauma 
Ischaemia 
Drugs	
Scorpion venom
“Idiopathic”

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pathophysiology of acute pancreatitis

Alcohol
direct injury increased
sensitivity to stimulation

oxidation products (acetaldehyde)

non-oxidative metabolism (fatty acid ethyl esters)

Gallstones
passage of gallstone is essential

raised pancreatic ductal pressure

ERCP
increased pancreatic ductal pressure

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symptoms of acute pancreatitis

Abdominal pain
Nausea, vomiting
Collapse

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signs of pancreatitis

Pyrexia
Dehydration
Abdominal tenderness
Circulatory failure

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monitoring acute pancreatitis

Pulse, BP
Urine output
CVP
Arterial line
HDU / ITU

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general supportive care of acute pancreatitis

Analgesia
Intravenous fluids
Cardiovascular	}
Respiratory	}  support
Renal		}

investigations of acute pancreatitis

U/E, glucose
serum amylase
FBC, clotting
LFT	ABG
CXR	AXR
USS
CT scanning

prediction of severity of disease for acute pancreatitis

Glucose > 10 mmol/L
Serum [Ca2+] < 2.00 mmol
WCC > 15000/mm3			Predicted severe ≥ 3
Albumin< 32 g//L
LDH > 700 IU/L
Urea > 16 mmol/L
AST/ALT > 200 IU/L
Arterial pO2 < 60mmHg

modified glasgow criteria >3

how do you manage cholelithaisasis?

ERCP & ES, cholecystectomy

how do you manage alcohol?

abstenence, counselling

how do you manage ischaemia?

careful support, correct cause

how do you manage malignancy?

Resection or bypass

how do you manage hyperlipidaemia?

Diet, lipid lowering drugs

how do you manage drugs

stop or change

specific aspects of management for acute pancreatitis

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

what is CT good for when investigating acute pancreatitis?

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

definitive management of acute pancreatitis

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 Late complications: Haemorrhage Portal hypertension Pancreatic duct stricture ```

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.

whos more likely to get chronic pancreatitis?

males

causes of chronic pancreatitis

``` O- A -Tiger Obstruction of MPD Tumour Adenocarcinoma IPMT Sphincter of Oddi dysfunction Pancreatic divisum Inadequate accessory drainage Duodenal obstruction Tumour Diverticulum Trauma Structure Post necrotizing radiation ``` Autoimmune Toxin Ethanol (related to amount and length of consumption) Smoking (odds ratio 8 to 17) Drugs Idiopathic Genetic Autosomal dominant (Condon 29 and 122) Autosomal recessive/modifier genes (CFTR, SPINK1, Codon A etc) Environmental Tropical chronic pancreatitis Recurrent injuries Biliary Hyperlipidemia Hypercalcemia

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

investigations of chronic pancreatitis

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

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 ```

surgery for chronic pancreatitis

``` 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 ```

prognosis of chronic pancreatitis

Mortality 50% over 20-25y 20% die of complications Rest die as a result of associated conditions Morbidity is still a major cause for concern

indication for resection

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

methods of resection

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