Surgery of the Endocrine Pancreas Flashcards
What is the endocrine function of the pancreas?
Secreting hormones into the circulation, which is primarily (though not exclusively) associated with the maintenance of normoglycaemia via the production of hormones insulin and glucagon.
What is the exocrine function of the pancreas?
Secreting pancreatic products into the gastrointestinal tract, primarily associated with the digestive process via the production of enzymes like trypsin, amylase and lipase which enter the duodenum via the pancreatic ducts and the duodenal papillae.
how to access the right lobe of the pancreas?
retracting the duodenum
Which way to retract the pancreas to access the dorsal aspect of R lobe?
Ventral + medial
Which way to retract the pancreas to access the ventral aspect of the R lobe?
Laterally
What is the blood supply to the pancreas? (1) where do these arise from? (2)
Pancreatic branches of the pancreaticoduodenal arteries
ARISE from: hepatic and cranial mesenteric arteries.
Where does the central body of the pancreas lie anatomically?
Next to pylorus and duodenum
Why is the central body of the pancreas the most difficult to access?
Pancreaticoduodenal arteries are embedded in the parenchyma.
How to access the left lobe of the pancreas?
stomach should be moved cranially and the transverse colon caudally within the deep leaf of the greater omentum.
What are the vessels which supply the left lobe of the pancreas?
- Mainly - splenic a, but also the common hepatic and gastroduodenal
In dogs, a duct carrying the pancreatic secretions travels along each lobe before meeting in a A) -shape, forming the B) duct which continues to the duodenum and the minor duodenal papilla.
A) Y
B) accessory pancreatic
There is also a pancreatic second duct which arises from the ducts in the left and right pancreatic lobes which enters the duodenum
With what and where does it enter?
With bile duct, at the major duodenal papilla
What are insulinomas tumours of?
Functional pancreatic tumour of B islet cells
What do insulinomas secrete? What does this lead to ?
insulin –> Hypoglycaemia
Other than insulin, what do insulinomas secrete? (2)
Glucagon
Gastrin
What type of tumours are 60% of insulinomas in dogs?
Malignant carcinoma
Where do insulinomas commonly met to? (3)
LN
Liver
Omentum
How many dogs with insulinomas have mets at time of diagnosis?
50%
What is a stage I insulinoma? (T1N0M0)
Invasion of the pancreas
What is a stage II insulinoma? (T1N1M0)
Invasion of pancreas and associated LN
What is a stage III insulinoma? (T1N0M1 or T1N1M1)
Distant mets
Other than carcinoma, what tumour type make up for the remaining insulinomas?
Adenomas
What breed do insulinomas commonly occur in?
Medium - Large
What tends to cause the clinical signs seen with insulinoma?
Hypoglycaemia
Clinical signs of insulinoma (5)
Seizure
Weakness
Ataxia
Exercise intolerance
Collapse
Some individuals with insulinomas will have a peripheral neuropathy which can lead to? (3)
Para/tetraparesis
Oesophageal motility disorders
Reduced anal tone
What is diagnostic of an insulinoma?
increased serum insulin levels should be documented during a period of hypoglycaemia with a high insulin level (>26µU/ml) at this point highly suggestive of insulinom
Imaging for insulinoma? (3)
- U/S; false negative common
- CT
- Dual phase CT angiogrpahy
What is it about insulinomas which makes surgical removal feasible?
Being encapsulated they are often well-defined
How common is it for surgical removal of insulinoma to be curative?
Rare
Dietary management is commonly used in the conservative management of insulinomas. What is the goal of this? How is this acheived?
Goal: Maintain appropriate blood glucose levels throughout the day and avoid foods that may incite a spike in insulin release.
Multiple small meals throughout the day and using foods that are high in protein, fat, and complex carbohydrates.
Why may glucocorticoids be used in medical stabilisation of insulinomas? (2)
stimulate the production of glucose whilst decreasing glucose uptake by cells
With insulinomas; why must great care be taken with IVFT with glucose?
Can stimulate further insulin
Feeding pre surgery with insulinomas?
A high sugar-based small meal is usually offered 2-3 hours before surgery.
What is associated with decreased hospital stays and shorter surgical times than more traditional suture techniques with pancreas surgery?
Vascular sealing device
At pancreatic surgeyr; what samples should be taken?
- Hepatic
- Regional LN
To stage the dx.
If an insulinoma cannot be identified at sugery. What can be done? How does this work?
dilute methylene blue has been historically described to be given intravenously to selectively stain islet cells.
Downsides of using methylene blue for pancreas locating? (3)
- Maximum effect after 30 mins
- Often alot of the pancreas turns blue
- Fatal heinz body aenamia
A quick way to identify if area of pancreas has insulinoma?
resect portion(s) of the pancreas and check for changes in blood glucose, as this should occur vert rapidly (provide the animal is moderately hypoglycemic) very rapidly following resection.
Monitor blood glucose after pancreatectomy, rebound hyperglycaemia can occur; why?
suppression of normal insulin producing β cells.
Common post op complications after pancreatectomy (3)
Pancreatitis
Hyper glycaemia
Hypoglycaemia
Survival time of insulinoma with medical tx?
6.5mo
Survival time of insulinoma with partial pancreatectomy?
2-3yr
Common adjunctive therapy in dogs after insulinoma?
Prednisolone
Why are glucocorticoids not commonly used with insulinomas?
decrease insulin sensitivity and increase endogenous (hepatic) glucose production
Other drugs such as octreotide, streptozotocin or diazoxide are not commonly used in insulinomas; why is this?
Side effects
What adjunctive therapy is used in humans for insulinoma and may have some use in dogs?
Tyrosine kinase inhibitors, such as toceranib phosphate
T or F
One of the goals of dietary management is to avoid foods that may incite a spike in insulin release.
True
T or F
Canine insulinomas have been noted to be poorly vascular.
False
T or F
An insulinoma is classified as stage I when there is distance metastasis.
False
T or F
Glucagonoma causes hypoglycaemia
False
What do patients with glucagonoma commonly present with?
Necrolytic dermatitis like syndrome similar to hepatocutaneous syndrome seen in liver disease.
Diagnosing glucagonoma? (2)
- Identify mass
- Serum glucagon conc
How likely are glucagonomas to met and the prognosis?
Common - poor prognosis
T or F
Gastrinomas can arise from pancreatic cells (non-β cells), as well as from elsewhere in the gastrointestinal tract
True
When gastrinomas arise in the pancreas, what syndrome describes the collection of a non-β cell, gastrin secreting, pancreatic neoplasia
Zollinger-Ellis
Zollinger-Ellis syndrome describes the collection of a non-β cell, gastrin secreting, pancreatic neoplasia leading to (2)
Gastric acid hypersecretion and gastrointestinal ulceration
Where do gastrinomas met to?
Liver
Regional LN
How to diagnose gastrinoma?
They are often too small to be diagnosed via imaging and serum gastrin levels (> 1000 pg/ml) are used after a period of 12 hours without food (and without antacid medication such as H2 blockers).
In cases without metastasis; gastrinoma tx?
Surgical removal - partial pancreaectomy
Prognosis of gastrinoma?
Poor
What must NOT be given when assessing bloods for gastrinoma?
Antacid e.g. H2 blocker
Tx of gastrinoma to aid efficacy of medical?
Even in patients with metastasis, resection or debulking of the primary tumour and any identifiable metastasis
The distal part of the right limb of the pancreas is often used for biopsy - why? (2)
furthest from the pancreatic ducts
furthest from any blood supply whose damage might affect other organs.
How to biopsy pancreas? what is involved in this technique?
A suture fracture technique, where a loop of suture is tightened crushing the parenchyma and any anatomy internal to this section
What technique is used where the mass is located at a level where a suture fracture technique is not feasible (e.g., body of the pancreas)?
Blunt dissect
What % of the pancreas can be resected without impact on either endocrine or exocrine function.
75-90
Does the pancreas regenerate?
dogs have significant capacity to regenerate pancreatic tissue following partial resection.
If a vessel sealing device has not been used, what vessels should be ligated with partial pancreaectomy?
pancreatico-duodenal vessels
It is challenging to remove the right limb of the pancreas without damaging
Vascular supply of duodenum
IF a patient survives total pancreatomy. (RARE). What is inevitable? (2)
Diabetes mellitus
EPI
Are you able to identify whether statement below is true or false?
Up to 75-90% of the pancreas can be resected without impact on either endocrine or exocrine function.
True
Post op feeding following pancreas sx?
feeding tube placement considered
early return to feeding, starting per os or via tube feeding with small quantities of low-fat bland food. If this approach causes a deterioration, then feeding should be withdrawn and a further attempt made in due course.
Following panc Sx, what may need to be supplemented in patients that have been or are anorexic/hyporexic and preserving normotension is important to maintain pancreatic perfusion and allow healing.
Potassium
Suggested post panc analgesia?
Opiod
Ketamine
Lidocaine
Tx options for nasuea post panc sx?
Maropitant
Metoclopramide CRI
