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Lower Gastrointestinal Surgery, Liver, Spleen and Pancreas > Surgery of the Endocrine Pancreas > Flashcards

Surgery of the Endocrine Pancreas Flashcards

1
Q

What is the endocrine function of the pancreas?

A

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.

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2
Q

What is the exocrine function of the pancreas?

A

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.

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3
Q

how to access the right lobe of the pancreas?

A

retracting the duodenum

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4
Q

Which way to retract the pancreas to access the dorsal aspect of R lobe?

A

Ventral + medial

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5
Q

Which way to retract the pancreas to access the ventral aspect of the R lobe?

A

Laterally

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6
Q

What is the blood supply to the pancreas? (1) where do these arise from? (2)

A

Pancreatic branches of the pancreaticoduodenal arteries
ARISE from: hepatic and cranial mesenteric arteries.

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7
Q

Where does the central body of the pancreas lie anatomically?

A

Next to pylorus and duodenum

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8
Q

Why is the central body of the pancreas the most difficult to access?

A

Pancreaticoduodenal arteries are embedded in the parenchyma.

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9
Q

How to access the left lobe of the pancreas?

A

stomach should be moved cranially and the transverse colon caudally within the deep leaf of the greater omentum.

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10
Q

What are the vessels which supply the left lobe of the pancreas?

A
  • Mainly - splenic a, but also the common hepatic and gastroduodenal
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11
Q

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

A) Y
B) accessory pancreatic

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12
Q

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?

A

With bile duct, at the major duodenal papilla

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13
Q

What are insulinomas tumours of?

A

Functional pancreatic tumour of B islet cells

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14
Q

What do insulinomas secrete? What does this lead to ?

A

insulin –> Hypoglycaemia

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15
Q

Other than insulin, what do insulinomas secrete? (2)

A

Glucagon
Gastrin

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16
Q

What type of tumours are 60% of insulinomas in dogs?

A

Malignant carcinoma

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17
Q

Where do insulinomas commonly met to? (3)

A

LN
Liver
Omentum

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18
Q

How many dogs with insulinomas have mets at time of diagnosis?

A

50%

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19
Q

What is a stage I insulinoma? (T1N0M0)

A

Invasion of the pancreas

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20
Q

What is a stage II insulinoma? (T1N1M0)

A

Invasion of pancreas and associated LN

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21
Q

What is a stage III insulinoma? (T1N0M1 or T1N1M1)

A

Distant mets

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22
Q

Other than carcinoma, what tumour type make up for the remaining insulinomas?

A

Adenomas

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23
Q

What breed do insulinomas commonly occur in?

A

Medium - Large

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24
Q

What tends to cause the clinical signs seen with insulinoma?

A

Hypoglycaemia

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25
Q

Clinical signs of insulinoma (5)

A

Seizure
Weakness
Ataxia
Exercise intolerance
Collapse

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26
Q

Some individuals with insulinomas will have a peripheral neuropathy which can lead to? (3)

A

Para/tetraparesis
Oesophageal motility disorders
Reduced anal tone

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27
Q

What is diagnostic of an insulinoma?

A

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

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28
Q

Imaging for insulinoma? (3)

A
  • U/S; false negative common
  • CT
  • Dual phase CT angiogrpahy
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29
Q

What is it about insulinomas which makes surgical removal feasible?

A

Being encapsulated they are often well-defined

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30
Q

How common is it for surgical removal of insulinoma to be curative?

A

Rare

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31
Q

Dietary management is commonly used in the conservative management of insulinomas. What is the goal of this? How is this acheived?

A

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.

32
Q

Why may glucocorticoids be used in medical stabilisation of insulinomas? (2)

A

stimulate the production of glucose whilst decreasing glucose uptake by cells

33
Q

With insulinomas; why must great care be taken with IVFT with glucose?

A

Can stimulate further insulin

34
Q

Feeding pre surgery with insulinomas?

A

A high sugar-based small meal is usually offered 2-3 hours before surgery.

35
Q

What is associated with decreased hospital stays and shorter surgical times than more traditional suture techniques with pancreas surgery?

A

Vascular sealing device

36
Q

At pancreatic surgeyr; what samples should be taken?

A
  • Hepatic
  • Regional LN
    To stage the dx.
37
Q

If an insulinoma cannot be identified at sugery. What can be done? How does this work?

A

dilute methylene blue has been historically described to be given intravenously to selectively stain islet cells.

38
Q

Downsides of using methylene blue for pancreas locating? (3)

A
  • Maximum effect after 30 mins
  • Often alot of the pancreas turns blue
  • Fatal heinz body aenamia
39
Q

A quick way to identify if area of pancreas has insulinoma?

A

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.

40
Q

Monitor blood glucose after pancreatectomy, rebound hyperglycaemia can occur; why?

A

suppression of normal insulin producing β cells.

41
Q

Common post op complications after pancreatectomy (3)

A

Pancreatitis
Hyper glycaemia
Hypoglycaemia

42
Q

Survival time of insulinoma with medical tx?

A

6.5mo

43
Q

Survival time of insulinoma with partial pancreatectomy?

A

2-3yr

44
Q

Common adjunctive therapy in dogs after insulinoma?

A

Prednisolone

45
Q

Why are glucocorticoids not commonly used with insulinomas?

A

decrease insulin sensitivity and increase endogenous (hepatic) glucose production

46
Q

Other drugs such as octreotide, streptozotocin or diazoxide are not commonly used in insulinomas; why is this?

A

Side effects

47
Q

What adjunctive therapy is used in humans for insulinoma and may have some use in dogs?

A

Tyrosine kinase inhibitors, such as toceranib phosphate

48
Q

T or F
One of the goals of dietary management is to avoid foods that may incite a spike in insulin release.

A

True

49
Q

T or F
Canine insulinomas have been noted to be poorly vascular.

A

False

50
Q

T or F
An insulinoma is classified as stage I when there is distance metastasis.

A

False

51
Q

T or F
Glucagonoma causes hypoglycaemia

A

False

52
Q

What do patients with glucagonoma commonly present with?

A

Necrolytic dermatitis like syndrome similar to hepatocutaneous syndrome seen in liver disease.

53
Q

Diagnosing glucagonoma? (2)

A
  • Identify mass
  • Serum glucagon conc
54
Q

How likely are glucagonomas to met and the prognosis?

A

Common - poor prognosis

55
Q

T or F

Gastrinomas can arise from pancreatic cells (non-β cells), as well as from elsewhere in the gastrointestinal tract

A

True

56
Q

When gastrinomas arise in the pancreas, what syndrome describes the collection of a non-β cell, gastrin secreting, pancreatic neoplasia

A

Zollinger-Ellis

57
Q

Zollinger-Ellis syndrome describes the collection of a non-β cell, gastrin secreting, pancreatic neoplasia leading to (2)

A

Gastric acid hypersecretion and gastrointestinal ulceration

58
Q

Where do gastrinomas met to?

A

Liver
Regional LN

59
Q

How to diagnose gastrinoma?

A

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).

60
Q

In cases without metastasis; gastrinoma tx?

A

Surgical removal - partial pancreaectomy

61
Q

Prognosis of gastrinoma?

A

Poor

62
Q

What must NOT be given when assessing bloods for gastrinoma?

A

Antacid e.g. H2 blocker

63
Q

Tx of gastrinoma to aid efficacy of medical?

A

Even in patients with metastasis, resection or debulking of the primary tumour and any identifiable metastasis

64
Q

The distal part of the right limb of the pancreas is often used for biopsy - why? (2)

A

furthest from the pancreatic ducts
furthest from any blood supply whose damage might affect other organs.

65
Q

How to biopsy pancreas? what is involved in this technique?

A

A suture fracture technique, where a loop of suture is tightened crushing the parenchyma and any anatomy internal to this section

66
Q

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)?

A

Blunt dissect

67
Q

What % of the pancreas can be resected without impact on either endocrine or exocrine function.

A

75-90

68
Q

Does the pancreas regenerate?

A

dogs have significant capacity to regenerate pancreatic tissue following partial resection.

69
Q

If a vessel sealing device has not been used, what vessels should be ligated with partial pancreaectomy?

A

pancreatico-duodenal vessels

70
Q

It is challenging to remove the right limb of the pancreas without damaging

A

Vascular supply of duodenum

71
Q

IF a patient survives total pancreatomy. (RARE). What is inevitable? (2)

A

Diabetes mellitus
EPI

72
Q

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.

A

True

73
Q

Post op feeding following pancreas sx?

A

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.

74
Q

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.

A

Potassium

75
Q

Suggested post panc analgesia?

A

Opiod
Ketamine
Lidocaine

76
Q

Tx options for nasuea post panc sx?

A

Maropitant
Metoclopramide CRI

Lower Gastrointestinal Surgery, Liver, Spleen and Pancreas (10 decks)

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