Surgery of pancreatic disorders Flashcards

1
Q

epidemiology of pancreatic cancer

A

F>M
5 year survival 0.4%

6th killer cancer in uk

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2
Q

risk factors for pancreatic cancer (5)

A

cigarette smoking: 25–30%

chronic pancreatitis: 5–15 fold

Adult onset DM of less than two years’ duration

Hereditary pancreatitis

Inherited predisposition ie
Periampullary cancer is a feature of FAP

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3
Q

presentation of pancreatic cancer (7)

A
obstructive jaundice
diabetes
abdominal pain radiating to the back
anorexia
vomiting 
weight loss
recurrent bouts pancreatitis
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4
Q

investigations carried out for pancreatic head cancer

A
blood tests
CXR
tumour markers - CA19-9
ERCP - examines pancreatic and bile ducts
USS
CT
MRI
MRCP
Laparoscopy + Lap USS
peritoneal cytology
percutaneous needle biopsy 
PET scan
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5
Q

what is a double duct seen in imaging and what does it indicate

A

simultaneous dilatation of common bile and pancreatic ducts

indicates carcinoma of the head of the pancreas and ampullary tumours

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6
Q

what is the ‘whipple’ otherwise known as a pancreaticoduodenectomy?

A

generally the removal of the gallbladder, common bile duct, part of the duodenum, and the head of the pancreas

most common type of surgery to remove pancreatic tumours

only carried out usually if cancer hasn’t spread past the head

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7
Q

Palliative drainage can be carried out in which cases?

A

used to treat symptoms but not cure

sometimes used if patient has obstructive jaundice or duodenal obstruction

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8
Q

Definition of acute pancreatitis

A

An acute inflammatory process of the pancreas, with variable

involvement of other regional tissues or remote organ systems

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9
Q

severe Acute pancreatitis

A

associated with organ failure or local complication

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10
Q

local complications of acute pancreatitis

A

acute fluid collections
pseudocyst
pancreatic abscess
pancreatic necrosis

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11
Q

Aetiologies of acute pancreatitis (11)

A
Gallstones 
Alcohol 
Viral Infection: CMV, mumps 
Tumours 
ERCP
Lipid abnormalities
Hypercalcaemia 
Postoperative Trauma 
Ischaemia 
Drugs	
“Idiopathic”
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12
Q

Alcohol as a cause of acute pancreatitis

A

direct injury
increased sensitivity to stimulation
oxidation products
non-oxidative metabolism

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13
Q

Gallstones as a cause of acute pancreatitis

A

blockage causes raised pancreatic ductal pressure

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14
Q

signs of acute pancreatitis

A

pyrexia
dehydration
abdominal tenderness
circulatory failure

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15
Q

symptoms of acute pancreatitis

A

abdominal pain
nausea
vomiting
collapse

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16
Q

general management of acute pancreatitis

A

analgesia
IV fluids
cardio, resp and renal support

17
Q

How is acute pancreatitis monitored in high dependency or intensive care unit?

A

pulse, BP
urine output
CVP
arterial line

18
Q

investigations carried out for acute pancreatitis (8)

A
Urea + electrolytes
glucose
FBC
clotting
LFT
CXR
USS
CT scan
19
Q

Management options if there is malignancy present

A

resection (removing cancerous tissue)

bypass

20
Q

specific aspects of acute pancreatitis management (6)

A
CT scanning
Antibiotics 
Diagnosis of infection
ERCP in gallstone pancreatitis
Nutrition
Manipulation of the inflammatory response
21
Q

why is CT used for acute pancreatitis? (4)

A

occasionally helpful in diagnosis

useful in severe disease

days 4-10 to identify necrosis

useful for complications like acute fluid collections, abscess, necrosis, monitoring progress of disease

22
Q

What is a CT-guided FNAC?

A

CT guided Fine Needle Aspiration Cytology

a safe, rapid, and reliable procedure to look for pancreatic necrosis

takes a sample from pancreas

23
Q

How can nutritional support be given to patients?

A

nasogastric feeding - tolerable in most cases

enteral feeding (through GI tract) is better than IV feeding

24
Q

acute pancreatitis management

A

prevention of recurrent attacks
management of gallstones

investigations of non-gallstone pancreatitis
alcohol abstinence

Manage fluid collection

25
types of fluid collection you could get with acute pancreatitis?
early collection pseudocyst pancreatic duct fistula
26
Management of necrosis
necrosectomy - laparotomy or minimally invasive
27
Causes of chronic pancreatitis. Remember O-A-TIGER
Obstruction of MPD Autoimmune Toxin - ethanol, smoking, drugs Idiopathic Genetic - Aut. dominant, Aut. recessive Environmental - tropical ch. pancreatitis Recurrent injuries - biliary, hyperlipidaemia/hypercalcemia
28
genetic causes of chronic pancreatitis: examples of autosomal dominant and recessive genes
dominant = Condon 29 and 122 recessive = CFTR, SPINK1, Codon A
29
clinical features of chronic pancreatitis (6)
``` pain pancreatic exocrine insufficiency - late on diabetes jaundice duodenal obstruction - rare upper GI heamorrhage ```
30
Investigations for chronic pancreatitis (5)
CT scan: local anatomy and complications ERCP / MRCP Pancreatic exocrine function (used infrequently): faecal / serum enzymes (elastase) Pancreolauryl test (enzyme response to a stimulus) Diagnostic Enzyme replacement
31
Management of chronic pancreatitis (9)
Counselling Abstinence from alcohol Management of acute attacks Analgesia Avoid high fat, high protein diet Pancreatic supplementation controversial for pain Anti-oxidant therapy Steatorrhoea: Reduce fat intake Pancreatic supplementation Diabetes
32
Is surgery offered to patients with chronic pancreatitis?
only after full evaluation suspicion of malignancy? intractable pain have to evaluate the risks/complications like pancreatic duct stenosis, cysts, biliary tract obstruction, duodenal stenosis etc
33
Interventional procedures for chronic pancreatitis
For pancreatic Duct Stenosis and obstruction: Endoscopic PD sphincterotomy, dilation and lithotripsy - shock waves Management of chronic pseudocyst CBD stenting or bypass Thoracoscopic Splanchniectomy - splanchnic nerve removal Caeliac plexus block to alleviate pain - CT guided - EUS guided - Fluoroscopy guided
34
mortality rate for chronic pancreatitis?
mortality 50% over 20-25 years 20% die of complications
35
Methods of resection surgery
Pancreatectomy + Lymp nodes Focal and LN or spleen sparing: Laparoscopic Robotic
36
What are the types of drainage surgery of the pancreas?
Pancreatic duct sphincteroplasty Puestow (Rochelle modification)