Surgery of pancreatic disorders Flashcards
epidemiology of pancreatic cancer
F>M
5 year survival 0.4%
6th killer cancer in uk
risk factors for pancreatic cancer (5)
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
presentation of pancreatic cancer (7)
obstructive jaundice diabetes abdominal pain radiating to the back anorexia vomiting weight loss recurrent bouts pancreatitis
investigations carried out for pancreatic head cancer
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
what is a double duct seen in imaging and what does it indicate
simultaneous dilatation of common bile and pancreatic ducts
indicates carcinoma of the head of the pancreas and ampullary tumours
what is the ‘whipple’ otherwise known as a pancreaticoduodenectomy?
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
Palliative drainage can be carried out in which cases?
used to treat symptoms but not cure
sometimes used if patient has obstructive jaundice or duodenal obstruction
Definition of acute pancreatitis
An acute inflammatory process of the pancreas, with variable
involvement of other regional tissues or remote organ systems
severe Acute pancreatitis
associated with organ failure or local complication
local complications of acute pancreatitis
acute fluid collections
pseudocyst
pancreatic abscess
pancreatic necrosis
Aetiologies of acute pancreatitis (11)
Gallstones Alcohol Viral Infection: CMV, mumps Tumours ERCP Lipid abnormalities Hypercalcaemia Postoperative Trauma Ischaemia Drugs “Idiopathic”
Alcohol as a cause of acute pancreatitis
direct injury
increased sensitivity to stimulation
oxidation products
non-oxidative metabolism
Gallstones as a cause of acute pancreatitis
blockage causes raised pancreatic ductal pressure
signs of acute pancreatitis
pyrexia
dehydration
abdominal tenderness
circulatory failure
symptoms of acute pancreatitis
abdominal pain
nausea
vomiting
collapse
general management of acute pancreatitis
analgesia
IV fluids
cardio, resp and renal support
How is acute pancreatitis monitored in high dependency or intensive care unit?
pulse, BP
urine output
CVP
arterial line
investigations carried out for acute pancreatitis (8)
Urea + electrolytes glucose FBC clotting LFT CXR USS CT scan
Management options if there is malignancy present
resection (removing cancerous tissue)
bypass
specific aspects of acute pancreatitis management (6)
CT scanning Antibiotics Diagnosis of infection ERCP in gallstone pancreatitis Nutrition Manipulation of the inflammatory response
why is CT used for acute pancreatitis? (4)
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
What is a CT-guided FNAC?
CT guided Fine Needle Aspiration Cytology
a safe, rapid, and reliable procedure to look for pancreatic necrosis
takes a sample from pancreas
How can nutritional support be given to patients?
nasogastric feeding - tolerable in most cases
enteral feeding (through GI tract) is better than IV feeding
acute pancreatitis management
prevention of recurrent attacks
management of gallstones
investigations of non-gallstone pancreatitis
alcohol abstinence
Manage fluid collection
types of fluid collection you could get with acute pancreatitis?
early collection
pseudocyst
pancreatic duct fistula
Management of necrosis
necrosectomy - laparotomy or minimally invasive
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
genetic causes of chronic pancreatitis: examples of autosomal dominant and recessive genes
dominant = Condon 29 and 122
recessive = CFTR, SPINK1, Codon A
clinical features of chronic pancreatitis (6)
pain pancreatic exocrine insufficiency - late on diabetes jaundice duodenal obstruction - rare upper GI heamorrhage
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
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
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
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
mortality rate for chronic pancreatitis?
mortality 50% over 20-25 years
20% die of complications
Methods of resection surgery
Pancreatectomy + Lymp nodes
Focal and LN or spleen sparing:
Laparoscopic
Robotic
What are the types of drainage surgery of the pancreas?
Pancreatic duct sphincteroplasty
Puestow (Rochelle modification)
