Surgery Pancreas

Question 1

main pancreatic duct and accessory pancreatic duct

Answer 1

main: duct of wirsung
accessory: duct of santorini

pancreatic sphincter of oddi

Question 2

blood supply of pancreas

Answer 2

splenic artery, gastroduodenal a, sma, hepatic a

spenic v!! + smv –> hepatic portal vein

Question 3

innervation of pancreas

Answer 3

extrinsic: vagus nerve, abdominopelvic splanchnic nerve
intrinsic: pns is vagus, sympathetic fibers

Question 4

t/f pancreatic ca has good prognosis

Answer 4

false, 5 year survival is 6%, worst prognosis of all malignancies

Question 5

risk factors for pancreatic ca

Answer 5

• > 60 yo, african american, men
• fhx = 2-3x
• cigarette smoking
• diet: high fat, low fiber, fruits and vegetables
• diabetes

Question 6

early manifestation of occult pancreatic ca

Answer 6

• new onset diabetes

- sudden increase in insulin req in an elderly patient with preexisting diabetes

Question 7

genetics of pancreatic ca

Answer 7

kras oncogene !!
her-2/neu oncogene
tumor suppressor genes deleted or mutated (p53, p16, dpc4, brca2

Question 8

pathology of pancreatic ca

Answer 8

• most common: ductal pancreatic adenoca
• adenosquamous ca
• acinar cell ca

Question 9

common locations for pancreatic ca

Answer 9

head or uncinate !!

body, tail

Question 10

staging for pancreatic ca

Answer 10

t1 < 2 cm
t2 > 2cm
t3 extension into duodenum or bile duct
t4 extension into portal vein, smv, sma, stomach, spleen, colon

n0 none
n1 regional

m0 none
m1 distant

Question 11

s/sx in pancreatic ca

Answer 11

• pain, jaundice, weight loss, distended gallbladder

- curvoisier gallbladder (painless jaundice + distended gallbladder)

Question 12

lab results in pancreatic ca

Answer 12

• increased direct bilirubin
• inc alp
• prolonged pt due to depleted vit k
• ca 19-9

Question 13

t/f uts is one of the most common modalities but pancreas is obscured by surrounding tissues

Answer 13

true, pancreatic abnormalities manifest as derangement in the surrounding structures (portal and splenic vein)

Question 14

ercp is commonly employed for evaluation of ___

Answer 14

pancreatitis

Question 15

diagnosis of pancreatic neoplasms

Answer 15

initial evaluation: abdominal uts

• with stone + dilated bile duct = ercp
• no stone + dilated bile duct = ct scan (dynamic contrast enhanced spiral ct)

Question 16

unresectable neoplasm if with:

Answer 16

• hepatic or sma invasion
• enlarged ln outside boundaries of resection
• ascites
• distant metastasis
• distant organ invasion

Question 17

other diagnostics

Answer 17

pet scan: differentiates pancreatitis vs pancreatic ca
eus: detects small masses missed by ct
diagnostic laparoscopy with uts: can predict resectability

Question 18

palliative measures for pancreatic ca

Answer 18

• palliative surgery and endoscopy to control or relieve pain, jaundice causing pruritus, and duodenal obstruction
• palliative chemo and radiation (gemcitabine)

Question 19

what is whipple procedure

Answer 19

• no need for tissue biopsy, confirmed with ca 19-9

- pacreaticoduodenectomy

Question 20

contraindications for resection

Answer 20

• liver metastasis (any size)
• celiac ln involvement
• peritoneal implants
• transverse mesocolon invasion
• hepatic hilar ln involvement

Question 21

findings not contraindicating

Answer 21

• duodenal or distal stomach invasion
• peripancreatic ln involvement
• porta hepatis ln involvement that is resectable

Question 22

structures involved in pancreatic resection and anastomosis

Answer 22

jejunum and pancreatic body

Question 23

special cases

Answer 23

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