Pancreas

Question 1

How is pancreas divisum diagnosed and treated?

Answer 1

• diagnose with MRCP and secretin
• treat with ERCP and sphincteroplasty of the minor papilla

Question 2

When should you consider intervention for a pancreatic pseudocyst?

Answer 2

• most resolve spontaneously and can be managed expectantly
• can consider intervention if > 6cm or if symptomatic

Question 3

What is the difference between a pancreatic pseudocyst and walled-off necrosis?

Answer 3

pancreatic pseudocyst results from non-necrotizing pancreatitis

Question 4

When should necrotizing pancreatitis be treated with steroids? What is the agent of choice?

Answer 4

• only for signs of infectoin (gas in collection, fever, WBC)
• prefer to use imipenem

Question 5

Describe the step up approach to necrotizing pancreatitis.

Answer 5

• start with supportive care
• can add antibiotics and perc drainage if necessary
• can then upsize drain
• would then consider video-assisted RP debridement

Question 6

How do we define a post-operative pancreatic fistula?

Answer 6

when fluid has an amylase > 3 times serum

Question 7

How are pancreatic fistulas classified?

Answer 7

• defined as fluid amylase > 3x serum
• biochemical leak
• grade B: persistent drainage x3 weeks requiring non-operative intervention
• grade C: leak requiring reoperation or with development of sepsis, organ failure, or death

Question 8

What should you check to look for autoimmune pancreatitis?

Answer 8

IgG4

Question 9

What are the non-operative management principles of chronic pancreatitis?

Answer 9

• pain control
• nutritional optimization
• EtOH avoidance
• pancreatic enzyme replacement

Question 10

Describe a Puestow procedure. When should it be used?

Answer 10

• longitudinal pancreaticojejunostomy
• use for dilated pancreatic duct (>6mm) with normal pancreatic head

Question 11

Describe a Frey procedure. When should it be used?

Answer 11

• excavation of the pancreatic head with lateral longitudinal pancreaticojejunostomy
• use for those with disease primarily in pancreatic head with duct dilatation

Question 12

Describe the Beger procedure. When should it be used?

Answer 12

• resection of pancreatic head up to wall of duodenum with either end-to-end or side-to-side pancreaticojejunostomy
• use for those with disease primarily in the pancreatic head without duct dilatation

Question 13

What surgery should you offer those with chronic pancreatitis with the following features:
- primarily head disease without duct dilatation
- primarily head disease with duct dilatation
- diffuse disease with duct dilatation
- duct stricture with normal head

Answer 13

• primarily head disease without duct dilatation: Beger
• primarily head disease with duct dilatation: Frey
• diffuse disease with duct dilatation: Puestow
• duct stricture with normal head: distal pancreatectomy

Question 14

How should you managed minimal change chronic pancreatitis (small duct chronic pancreatitis)?

Answer 14

• resection and drainage procedures aren’t options
• denervation operation
• or total pancreatectomy with islet autotransplantation

Question 15

How should CEA be interpreted for those with a pancreatic cyst?

Answer 15

CEA > 192 indicates a mucinous cyst

Question 16

How should amylase be interpreted for those with a pancreatic cyst?

Answer 16

high amylase means its in communication with the pancreatic duct

Question 17

What are the CEA and amylase for a serous cystadenoma of the pancreas?

Answer 17

low for both

Question 18

What are the CEA and amylase for an IPMN?

Answer 18

both are elevated

Question 19

What are teh CEA and amylase for a mucinous cystic neoplasm of the pancreas?

Answer 19

• CEA is elevated
• amylase is low

Question 20

How should serous cystadenomas of the pancreas be managed?

Answer 20

resect if symptomatic, >4cm, or growing on surveillance

Question 21

How should mucinous cystic neoplasms of the pancreas be managed?

Answer 21

resect all given their malignant potential

Question 22

“patulous fish mouth with mucin secretions from the ampulla” is a pathognomonic endoscopic finding for those with what pancreatic disease?

Answer 22

a main duct IPMN

Question 23

How should IPMNs be managed?

Answer 23

• resect main duct and mixed IPMNs
• less clear cut for branch duct IPMNs which can sometimes be watched

Question 24

What are high risk features of branch duct IPMNs? Moderate risk?

Answer 24

high risk
- enhancing mural nodule > 5mm
- MPD > 10mm
- obstructive jaundice

moderate risk
- cyst > 3cm
- thickened/enhancing wall
- nodule < 5mm
- lymphadenopathy
- abrupt change in MPD size with atrophy of distal
- cyst growth > 5mm over 2 years
- acute pancreatitis

Question 25

Are pancreatic neuroendocrine tumors usually function or not?

Answer 25

they are usually non-functional

Question 26

Where are the various PNETs usually found in the pancreatic parenchyma?

Answer 26

- head: insulinoma or somatostatinoma - body: insulinoma, VIPoma - tail: insulinoma, VIPoma, glucagonoma

Question 27

How should PNETs be managed?

Answer 27

those with locoregional disease should undergo resection given a significant portion are malignant

Question 28

What are the most common functional PNET?

Answer 28

insulinoma

Question 29

Describe the symptoms, workup, and management of insulinomas.

Answer 29

- present with fasting hypoglycemia, neuroglycopenic symptoms, and relief of symptoms with glucose - should have elevated insulin and c-peptide and at least 25mg/dL increase in glucose after administration of glucagon - localize with EUS/CT/MRI/selective intra-aterial calcium injection with hepatic venous sampling for insulin - manage with formal resection, can consider enucleation if <2cm and more than 2mm from duct

Question 30

Where is the gastrinoma triangle?

Answer 30

- junction of cystic duct and CBD - junction of neck and body of pancreas - junction of 2nd/3rd portions of duodenum

Question 31

Describe the symptoms, workup, localization, and management of gastrinomas.

Answer 31

- presents with abdominal pain, diarrhea, and weight loss with multifocal PUD - diagnose with fasting serum gastrin (>1000 diagnostic), can add secretin stim test if equivocal (>200 increase with secretin) - localize with CT/MRI/EUS/somatostatin receptor scintigraphy, selective inrta-arterial calcium injection management depends on location - duodenal mucosa: enucleation - noninvasive, <5cm in pancreatic head: enucleation - invasive or >5cm in pancreatic head: whipple - distal pancreas: distal pancreatectomy

Question 32

Describe the symptoms, workup, localization, and management of glucagonomas.

Answer 32

- presents with dermatitis (necrolytic migratory erythema), diabetes, depression, and DVT (factor X-like antigen secretion) - diagnose with fasting glucagon levels between 1000-5000 - localize with CT/MRI/somatostatin scintigraphy/selective aniogram/EUS - manage with resection and lymphadenectomy and cholecystectomy

Question 33

Describe the symptoms of a somatostatinoma.

Answer 33

cholecystitis, DM, malabsorption, and steatorrhea

Question 34

What are the symptoms of VIPoma?

Answer 34

WDHA syndrome - watery diarrhea - hypokalemia - achlorhydria

Question 35

What is the most common pancreatic tumor?

Answer 35

non-functional PNET

Question 36

Which pancreatic adenocarcinomas are borderline resectable?

Answer 36

<180 contact with SMA <180 contact with celiac contact of CHA without extension to bifurcation >180 contact with or wall irregularity of PV/SMV but amenable to resection and reconstruction

Question 37

Which pancreatic adenocarcinoma patients are candidates for neoadjuvant and adjuvant therapy?

Answer 37

- neoadjuvant: borderline resectable disease - adjuvant: consider for all patients

Question 38

Patient with history of multiple episodes of pancreatitis is now presenting with hematemesis what is the diagnosis and management?

Answer 38

gastric varices from splenic vein thrombosis, treat with splenectomy

Question 39

What is the medical management of functional neuroendocrine tumors of the pancreas while awaiting resection?

Answer 39

octreotide works for all but insulinoma

Question 40

What gene mutation is most common for those with hereditary pancreatitis?

Answer 40

PRSS1

Question 41

What somatic mutations are associated with pancreatic adenocarcinoma?

Answer 41

KRAS and TP53