Pancreatic and biliary surgery

Question 1

Any abnormalities?

Answer 1

Normal xray

Question 2

Any abnormalities?

Answer 2

pancreatic pseudocyst

Question 3

what abnormality is this?

Answer 3

pancreatic cancer

Question 4

pancreatic CT protocol?

Answer 4

Pancreatic protocol
5mm slices through pancreas
Sensitive and specific
Anyone can look at the films

Lot of radiation
Need to give contrast (nephrotoxic)

Question 5

MRI protocol?

Answer 5

No radiation
Don’t need contrast
Rendered diagnostic ERCP a thing of the past

Claustrophobic and noisy (open MRI)
 Metalwork problematic (Clips in brain)
 Takes longer than a CT

Question 6

What is this abnormality?

Answer 6

ERCP

An inoperable carcinoma of the pancreatic head is causing a distal, filliforme stenosis of the biliary duct.

Question 7

Pancreatic diseases?

Answer 7

Congenital abnormalities
Pancreatic injuries
Pancreatitis
Acute
Chronic
Pancreatic cancer
Pancreatic endocrine tumours

Question 8

Effects of cystic fibrosis on pancreas?

Answer 8

Cystic fibrosis
AR inherited disorder
Heterozygous carriers are at risk of pancreatitis
Generalised dysfunction of exocrine glands
Thick secretions block PD > duct ectasia and exocrine gland destruction
Pancreatic insufficiency > steatorrhoea > creon

Question 9

Pathology of pancreatic cancer?

Answer 9

Failure of complete rotation of the ventral pancreatic bud
Ring of pancreatic tissue surrounds 2nd or 3rd part of duodenum
Can present with vomiting
Treated with a bypass (resecting the band may result in a pancreatic fistula)
Cause of pancreatitis later in life

Question 10

Ectopic pancrease?

Answer 10

In submucosa of
Stomach
Duodenum
SB (incl Meckel’s)
Gallbladder
Hilum of the spleen
Liver
Can give symptoms and cause cysts (rare)

Question 11

causes of Congenital cystic disease of the pancrease?

Answer 11

Can accompany congenital cystic
Liver and kidney

Von Hippel-Lindau syndrome (AD condition)
Haemangioblastomas of brain, spinal cord & retina
Renal cysts and carcinomas
Phaeochromocytoma
Pancreatic cysts variable malignant potential

Question 13

Different types of pancreatic injury?

Answer 13

Blunt trauma e.g. RTA, Handlebar injuries
90% raised enzymes
CT
Centre portion transected > PD disruption
May need distal pancreatectomy

Iatrogenic injuries
Splenectomy
Pancreatic fistula

Question 14

Acute pancreatitis aetiology?

Answer 14

3% all cases of abdominal pain admitted
Mortality 10-15%
80% have mild attack – mortality 1%
Severe attack – mortality 20-50%

Question 15

Causes of pancreatitis?

Answer 15

I GET SMASHED

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune vasculitis, PAN
Scorpion venom
Hypercalaemia, hypothermia, hyperlipidaemia (TGs)
ERCP
Drugs (azathioprine, diuretics), duodenal obstruction (tumours, annular pancreas)

Question 16

Investigation for pancreatitis?

Answer 16

Amylase > 3x normal or > 1000
Other causes of raised amylase (usually less pronounced)
Cholecystitis
Mesenteric ishaemia
Perf PUD
Ectopic pregnancy
AXR
Sentinel loop
Loss of psoas shadow due to retroperitoneal fluid

USS ? Gallstones
? Biliary dilatation

CT Diagnostic
Complications

Question 17

Scoring of pancreatitis?

Answer 17

PANCREAS

PaO2 < 8Kpa
Age > 55
Neutrophils (WCC >15)
Calcium < 2.0
Renal (urea > 16)
Enzymes (LDH > 600)
Albumin < 32
Sugar (glucose > 10)

Mild 0-1
Moderate 2-3
Severe 4 or more

Question 18

Management of pancreatitis?

Answer 18

IVI and catheter
Analgesia
O2
No evidence for NBM unless ileus > N&V
Antibiotics, flimsy evidence, essentially if necrosis
CT – ideally day 5-7
ERCP if LFTs deranged and patient not settling

Question 19

Local and Systemic complications of pancreatittis?

Answer 19

Local:

Acute fluid collection
Pseudocyst (>4 weeks)
Necrosis
Abscess
Ascites
Pseudoaneurysm (GDA or splenic)

Systemic:

Renal
Respiratory
Cardiovascular
Gut

Major cause of SIRS and MOF

Question 20

Surgery for pancreatitis?

Answer 20

Necrosectomy for infected pancreatic necrosis
50% mortality
Drainage of pseudocyst
Endoscopic transgastric (bleeding)
Open

Question 21

Describe pancreatitis?

Answer 21

Chronic inflammatory disease with progressive and irreversible destruction of pancreatic tissue
Fibrosis of the pancreas
Ducts become strictured and ectatic
Ductal stones
Alcohol most common cause (although any cause of ductal obstruction)

Question 22

Features of chronic pancreatitis?

Answer 22

Pain
Loss of exocrine function
Steatorrhoea
Need to take creon
Loss of endocrine function
Diabetes

Question 23

Investgations of chronic pancreatitis?

Answer 23

Amylase – Often normal
AXR – calcification
CT
MRI – Good for looking at PD
ERCP
Faecal elastase

Question 24

Treatment for chronic pancreatittis?

Answer 24

Analgesia is the mainstay
Coeliac plexus blocks
Creon
Insulin
STOP DRINKING
Surgery last resort as major surgery

Question 25

Pancreatic tumours?

Answer 25

Many benign and malignant tumours

Armed forces Institute of Pathology Classification of Exocrine Primary Pancreatic Neoplasia

Carcinoma (adeno) commonest and important

10 per 100 000 population
Disease of ageing
M=F
85% adenocarcinomas
Aetiology
Smoking
Chronic pancreatitis

1% of all pancreatic tumours thus very rare
Insulin secreting tumour
Treated by removing tumour (enucleation)
Gastrin secreting tumour
Zollinger-Ellison syndrome
PPI or resection
Other rarer types

Question 26

Investigations of chronic pancreatitis?

Answer 26

Epigastric / back pain (confers poor prognosis)
Weight loss
Anorexia
Vomiting (GOO)
Painless jaundice

Question 27

What is Courvoisiers law?

Answer 27

Painless jaundice and a palpable gallbladder is unlikely to be due to stones

Question 28

Investigations for courvoisiers law?

Answer 28

LFTs
CA19-9
USS (biliary dilatation)
CT (pancreatic protocol)
Primary tumour
Relationship to vessels (SMA, SMV, portal v)
Nodes
Mets

Question 29

Treatment for courvoisiers law?

Answer 29

Most cases inoperable
Palliative treatment
Chemotherapy &/or best supportive care
Biliary stent
Duodenal stent
Double bypass

Operable cases
Whipples / PPPD (pylorus preserving pancreatico-duodenectomy)

Question 30

Whipples prognosis?

Answer 30

Less than 5% 5 year survival
Up to 40% for peri-ampullary tumours

Question 31

Describe Cholangiosarcoma?

Answer 31

Adenocarcinoma of the bile duct
Extrahepatic
Intrahepatic
Rare 1:100 000
Rarely resectable

Question 32

Describe gallbladder cancer?

Answer 32

Rare 1:100 000
Often found incidentally
Poor prognosis
May need extended cholecystectomy

Question 33

Describe gall stones?

Answer 33

Pigment stones and cholesterol stones
ALL ARE MIXED

Cause (imbalance of 3 bile constituents)
Bile salts
Lecithin
Cholesterol

Fat female fair fertile 40

Question 34

Problems galltones causes?

Answer 34

None
Biliary colic (pain-severe) - Murphy’s sign
Cholecystitis (raised temp & WCC)
Pancreatitis
Obstructive jaundice (Alp raised > ALT)
Cholangitis:-
Charcot’s triad – pain, jaundice, fever/rigors

Mirizzi syndrome:-
Type I (stone/oedema pressing on ducts (CHD)
Type II (stone fistulating into bile ducts)
Gallstone ileus:-
AXR – SBO, Calcified stone RIF, air in biliary tree
(GB cancer – very rare)

Question 35

Causes of gallstones?

Answer 35

Pigment stones and cholesterol stones
ALL ARE MIXED

Cause (imbalance of 3 bile constituents)
Bile salts
Lecithin
Cholesterol

Fat female fair fertile 40

Question 36

How to diagnose a gallstone?

Answer 36

USS
Acoustic shadow
Diameter of CBD
7-8 normal
Increases with age
Up to 1 cm post cholecystectomy
Correlate with clinical findings

Question 37

treatment for a gallstone?

Answer 37

Incidental finding – leave alone
Biliary colic – lap chole (acute vs elective)
Cholecystitis – Abs > lap chole
Pancreatitis – as above
Obstructive jaundice – lap CBD expl / ERCP
Cholangitis – ERCP
Mirizzi syndrome - complex
Gallstone ileus - Take stone out. Leave RUQ

Question 38

Lap Chole?

Answer 38

Lap chole
5% conversion to open
No access (adhesions)
Bleeding
Anatomy not typical/difficult Calot’s triangle
1 in 300 risk bile duct injury
Bile leak