Pancreas Flashcards

Question

Secretin stimulation test

Answer 1

-Evaluates pancreatic exocrine function -Normal values of pancreatic fluid: total volume 2 cc/kg/hr, bicarbonate: > 10 mmol/L in 1 hr, enzyme/amylase secretion: 6-18 U/kg Abnormalities -Chronic pancreatitis: decreased bicarb -End-stage pancreatitis: volume, bicarb, and amylase decreased -Pancreatic cancer: volume decreased -Malnutrition: amylase decreased Zollinger-Ellison - Increased volume

Answer 2

-Type 1 DM: pancreas does not produce insulin (loss of beta cells) -Type 2: body does not respond to insulin (insulin reisistance) -Type 3C: Pancreatic diabetes mellitus induced by exocrine disease due to chronic pancreatitis or resection -Impairment of beta cells & alpha cells -Decreased secretion of insulin, glucagon, & pancreatic polypeptide -Increased risk of hypoglycemia compared to type 1 DM given that alpha cells also affected -DKA/hyperglycemia rare

Answer 3

-Smoking= independent risk factor -Gallstones most common, alcohol 2nd most common -Post-ERCP risk increased with sphincter of Oddi dysfunction -Hyperlipidemia, hypercalcemia (colocalization & activation of trypsin) -Hereditary: autosomal dominant, mutation in PRSS1= premature activation of trypsinogen to trypsin + abnormalities of ductal secretion -Pancreatic or periampullary tumor: consider in idiopathic acute pancreatitis, esp if over 50 yo -Drugs: thiazide diuretics, furosemide, estrogen replacement therapy, steroid therapy in children

Answer 4

-Severe constant epeigastric pain that radiates through to mid back -N/v, fever Dx: >=2 -Acute, persistent severe epigastric pain -Elevation of serum amylase or lipase >=3x normal -Imaging only when above not met -Serum amylase increases immediately, peaks within several hours, remains elevated for 3 to 5 days -No correlation between amylase elevation & severity: severe disease pancreas may not have capacity to release enzyme & hemoconcentration from 3rd space fluid loss -Cullen's sign: umbilucus; Grey Turner's sign: flank discolration from bleeding into retroperitoneum

Answer 5

-Fluid therapy to restore/ maintain circulating blood volume= most important intervention in early management -Ballanced crystalloid, aim to restore normal blood volume, blood pressure, and urine output -LR suprerior to NS in reducing SIRS

Answer 6

-Early refeeding (<= 48 hours) if stable & tolerating diet -If not tolerating diet: give enteral nutrition through jejunal feeding tube

Answer 7

Avoid morphine= potential to cause sphincter of Oddi spasm

Answer 8

Ranson's Criteria with 3 or more points indicates severe pancreatitis, leading to ICU admission. Scored over 48 hours BISAP: BUN > 25, impaired mentation, SIRS >= 2, Age > 65, pleural effusion

Answer 9

-Inflammation & fibrosis leading to injury/loss of acinar & islet cells (exocrine and endocrine function decreased) -Alcohol most common cause (50%): induces sphincter of Oddi Spasm, increases secretion & permeability, decreases Blood Flow -Tobacco Sx: chronic pain, weight loss, pancreatic insufficiency

Answer 10

Dx: -Triad: pancreatic calcifications, steatorrhea, diabetes (seen in advanced disease) -Lipase/amylase normal/slightly elevated -CT: pancreas sunken & calcified with main duct beading & ectatic side branches ("chain of lakes"- alternating stenosis/ dilation) Work up: - CT if abnormality: EUS with biopsy to rule out cancer - If no mass on EUS, ERCP to look for strictures -ERCP most sensitive test to Dx chronic pancreatitis

Answer 11

-Pleural effusion or pancreatic ascites: from retroperitoneal fluid leak, may lead to fistula (Tx= thoracentesis/ paracentesis, NPO, octreotide; 50% resolve in 2-3 weeks) -Bile duct obstruction -Splenic vein thrombosis -Pseudoaneurysm Risk for pancreatic cancer with chronic pancreatitis

Answer 12

Initial treatment -Non-narcotic pain control -No alcohol or tobacco, small low-fat meals, consider pancreatic enzyme replacement -Specialized option if medical treatment fails: endoscopic decompression (less effective thanan surgery), celiac nerve block (limited success) -Frey, Puestow, whipple, beger, distal resection -If other surgeries fail: total pancreatectomy & islet cell autotransplantation -Surgical indications for chronic pancreatitis – only consider after all medical and endoscopic therapy have been maximized

Answer 13

If > 6 mm: Decompression Inflammatory Mass in Head: Frey Procedure -Fibrotic Parenchyma & Enlarged Head with Poor Drainage No Mass & Good Drainage: Puestow Procedure

Answer 14

Small-Normal Ducts: Resection -Isolated head: Whipple or Beger procedure -Isolated tail: distal resection -Not isolated: total pancreatectomy & islet cell autotransplant

Answer 15

Dilated pancreatic duct ≥ 6 mm = These patients NEED a procedure to drain the bile duct * Peustow’s procedure: Roux en y Longitudinal pancreaticojejunostomy for diffusely dilated/strictured main pancreatic duct with no inflammation of pancreatic head o Requires a minimum of 6 cm length of anastomosis to pancreatic duct * Frey procedure (Peustow plus coring out head of pancreas), without transection of pancreatic neck): Duodenum preserving longitudinal Roux en y pancreaticojejunostomy with pancreatic head resection o For isolated pancreatic head involvement and main duct dilation o More commonly performed because technically easier to perform vs Beger Non dilated pancreatic duct = These patients NEED resection, not drainage * Beger procedure (duodenum preserving pancreatic head resection and Roux en y with two pancreaticojejunostomies using the same limb with pancreatic neck transection) o for isolated pancreatic head involvement without ductal dilation o Has more extensive vascular dissection of duodenum, can lead to duodenum necrosis * Whipple - normal ducts, isolated pancreatic head, or salvage after other failed procedures o Worse quality of life when compared to pancreas preserving surgeries above * Distal pancreatectomy - for normal ducts, but only distal gland affected * Diabetes  long term complication after these surgeries * Bilateral splanchnicectomy or celiac ganglionectomy  80% pain control Total pancreatectomy with auto islet transplantation for chronic pancreatitis, indicated for: - Last resort - Patients with small ducts and diffuse disease - Minimal change chronic pancreatitis

Answer 16

-Puestow Procedure= Longitudinal pancreaticojejunostomy -For dilated pancreatic duct (6mm or greater) would go with Peustow, so long as pancreatic head is normal -Beger Procedure= Resection of pancreatic head up to wall of duodenum with either end to end or side to side pancreaticojejunostomy (Duodenum preserving pancreatic head resection) -Frey Procedure= Lateral longitudinal pancreaticojejunostomy with an excavation of the pancreatic head (Core out head of pancreas but avoid pancreatic transection required of Beger procedure) -If pancreatic head dominant disease with or without duct dilation= Frey procedure -If distal pancreatic duct stricture with side branch changes and normal pancreatic head= distal pancreatectomy -Minimal change pancreatitis- resection/ drainage will not help- denervation operation (bilateral thoracoscopic splanchnicectomy)

Answer 17

CBD stricture 2/2 to chronic pancreatitis: Dx with MRCP. Do ERCP with brush biopsy if cannot rule out CA on MRCP. Tx: Choledocho-jejunostomy, NOT ERCP with stent

Answer 18

-Induces sphincter of Oddi spasm, increases secretion & permeabilit, decreases blood flow -Stellate cells: activated to myofibroblast phenotype= proinflammatory mediators & cytokines -Ethanol induces ductal permeability= prematurely activated enzymes to cause damage to pancreatic parenchyma -Forms protein plugs -Timing: males 18 years of drinking, females 11 years of drinking

Answer 19

Hereditary pancreatitis: -Autosomal Dominant -PRSS1 Mutation – Cationic Trypsinogen Gene Tropical pancreatitis: -Autosomal Recessive -SPINK1 Mutation – Serine Protease Inhibitor Kazal Type 1 -Associated with Eating Cassava Root Both: -Recurrent Acute Pancreatitis in Pediatrics & Chronic Pancreatitis in Adults -High Risk for Pancreatic CA -Dx: genetic testing -Treatment same as chronic pancreatitis

Answer 20

-Type 1: IgG4-related; extrapancreatic complications: biliary stricture, retroperitoneal fibrosis, interstitial nephritis -Type 2: not IgG4-related; limited to pancreas -CT: Diffuse hypoechoic enlargement & main duct narrowing -Biopsy: Plasma & lymphocytic infiltrate -Tx: Steroids

Answer 21

Infected pancreatic necrosis, walled off collections or infected pseudocyst with no main duct disruptions: -Optimal timing for pancreatic intervention is >4 weeks after onset of pancreatitis -Try to delay any intervention if possible unless: positive gram stain on FNA or patient is getting unstable -1st step after failed medical management/more septic is: ALMOST ALWAYS START WITH drainage: CT guided retroperitoneal drain placement. Wait 72 hours and can place more drains if more sick or collections are larger -Can be followed by video assisted retroperitoneal debridement or endoscopic debridement (step up approach) -Alternate first line therapy: endoscopic transmural drainage (needs to be 2 cm from stomach/duodenum) -Otherwise percutaneous drains have fallen out of favor and endoscopic drainage is first choice and now preferred over drains -Open debridement of the pancreas (last line) is only indicated for infected necrosis or abscess of pancreas, for which endoscopic measures have failed If you have a pancreatic pseudocyst and completely disrupted pancreatic duct: only real solution is surgery with lateral pancreatojejunostomy -Prophylactic antibiotics should not be started if no signs of infection. -If empiric antibiotics initiate: carbapenem; or cefepime + metronidazole

Answer 22

-Collection of pancreatic fluid outside of the ducts (no epithelial lining) -Fibrotic capsule forms over 4-8 weeks, composed of collagen & granulation tissue -Most common cause: chronic pancreatitis -Resolve spontaneously; manage expectantly for at least 6 weeks (ideally 3mo). Also allows wall to mature. Consider intervention if >6cm or symptomatic. -Poor predictors: ≥ 6 weeks or ≥ 6 cm -Need ERCP or MRCP prior to intervention -FNA: no glycogen, no mucin, high amylase (>5000) -EUS with FNA is only done if diagnosis of pseudocyst is not clear -Patients who are symptomatic, have rapidly enlarging pseudocysts, or who have infected pseudocysts that do not improve with medical management: endoscopic drainage through stomach or duodenum (NEED TO BE AT LEAST 2 CM AWAY or less) Proffered route: -Endoscopic Cystogastrostomy or Cystoduodenostomy: requires mature cyst wall & pseudocyst wall must be adherent to stomach or duodenum -Roux en y cystojejunostomy: if away from stomach and duodenum -Use Full-Thickness Absorbable Sutures (Interrupted Closely Spaced or Running); always Send Bx -Consider Endoscopic Pancreatic Duct Stent if Pseudocyst Communicates to the Pancreatic Duct (Internal Pancreatic Fistula); Fistula May Present as Recurrent Pseudocyst After Prior Drainage -Absolute Contraindication: Pseudoaneurysm (Embolize First) -External Percutaneous Drain Have Higher Risk of Complications & Pancreaticocutaneous Fistula -The only indication to place a percutaneous drain in a pseudocyst, is in an infected pseudocyst in a pt who cannot tolerated endoscopic or surgical intervention (unstable) -Open cyst gastrostomy: anterior gastrostomy: drain pseudocyst from posterior wall of stomach using linear stapler-> close anterior wall -Cystduodenostomy: if near pancreatic head/duodenum If you see “septations” in pancreatic cyst, this is a solid component concerning for malignancy NOT pseudocyst

Answer 23

-Pancreatic Tissue Dies Due to Inflammation & Injury -Sterile Initially -Infected After 2-3 Weeks -Abscess After 5 Weeks – From Liquefication of Infected Necrosis -Most Common in Obese Complications -Portosplenomesenteric Venous Thrombosis (PSMVT) – 50% Risk -Diabetic Risk After Necrosectomy: 25%; risk Factors: Chronic Pancreatitis & Increased Size Resected Diagnosis -CT Atlanta Classification: acute necrotic collection vs walled-off pancreatic necrosis -CT showing gas within necrosis (highly specific but not sensitive) -Percutaneous needle aspiration consider in prolonged illness if CT is not specific -In necrotizing pancreatitis – enteral feeds decreased the rate of conversion to infected necrotizing pancreatitis -Antibiotics for necrotizing pancreatitis w signs of infection -Clinical signs: fever, elevated WBC -CT guided FNA with organisms -Imipenem is antibiotic of choice

Answer 24

Sterile: -Primary treatment: medical therapy (no antibiotics) -Surgical Debridement: Failure to Thrive, Persistent Abdominal Pain, Worsening Organ Failure, Should Be Delayed Until 30 Days After Diagnosis Infected: -Stable: “Step-Up Approach” -Unstable: Antibiotics & Open Necrosectomy (Blunt Finger Dissection – Best to Differentiate Live vs Necrotic Tissue) “Step-Up Approach” -Initial: Antibiotics & Drainage (Broad Spectrum; Imipenem – Excellent Pancreatic Penetration) -Drainage: Percutaneous or Endoscopic Approach -If Fails After 72 Hours: Second Drainage Procedure or “Upsize” the Drain -If Fails After 72 Hours Again: Video-Assisted Retroperitoneal Debridement (VARD) -If Still Fails: Laparoscopic/Open Debridement -Delayed Debridement Reduces Mortality & Severe Complications -Minimally Invasive Debridement Has Lower Risk of Widespread Contamination & Systemic Complications (Diabetes/Multisystem Organ Failure); Mortality Unchanged

Answer 25

Acute necrotic collection - <= 4 weeks, heterogenous, no defined wall Walled off necrosis – takes 4 weeks to mature, has capsule, all have necrotic debris in collection = heterogenous, can be intra or extrapancreatic Acute pancreatic fluid collection: <= 4 weeks, homogenous , no defined wall Pseudocyst – takes 4 weeks to mature. Fluid collection is homogenous, no internal septa, usually extra pancreatic

Answer 26

-Mild (no local/systemic complications): less than 1% -Moderate (transient organ failure < 48 hr): 10% -Severe (persistent organ failure): 20-40% -Critical: > 50% Elevated BUN/ creatinine &/or persistent SIRS after adequate fluid retention Most common causes of death: -Early (< 2 weeks): SIRS & organ failure -Later (> 2 weeks): sepsis

Answer 27

-25-30% risk of recurrence within 6-18 weeks -All should undergo elective cholecystectomy during same admission -Mild-moderate pancreatitis: early (< 48 hours) -Severe: wait until resolved -cholangitis or signs of clear obstruction: ERCP & sphincterotomy

Answer 28

Serous Cystic Neoplasm (Serous Cystadenomas) -Benign -MC in pancreatic head -MC middle-aged women -No connection with pancreatic duct -Usually have numerous loculations -High in glycogen, low CEA, low amylase, cytology= cuboidal cells -Present with abdominal pain, N/V, dyspepsia CT: -Classically will show a central scar (central calcification) -Honeycomb pattern Tx: Nothing, unless symptomatic or > 4 cm: resect

Answer 29

-Premalignant lesions -90% arise in body or tail -Female to male 9:1 (almost exclusively in elderly women) -Usually have single loculation -Classically CT will show “peripheral egg-shell” = calcifications in the wall = diagnostic!! -FNA: low amylase, high CEA, KRAS positive, + mucin, columnar cells, walls of the cyst contain “ovarian-type stroma” on path THESE DO NOT COMMUINCATE WITH MAIN PANCREATIC DUCT: contrast to IPMN ALL OF THESE Should be completely resected due to risk of CA If found in distal pancreas: MC operation is laparoscopic spleen preserving distal pancreatectomy

Answer 30

-MRI is the preferred imaging -Cyst FNA: High amylase, high CEA (> 200), KRAS positive, + Mucin, columnar cells Main duct IPMN – 60% risk of malignancy -Resection -On endoscopy the mucin will protrude through the ampulla and show a classic fish mouth appearance -If main duct involved: chronic obstructive pancreatitis, pancreatic insufficiency (steatorrhea, diabetes, weight loss) Mixed type - high risk of CA -Resection -Involves Main & Branch Ducts Branch duct IPMN – 25% malignancy -Surveillance vs. Resection (Fukuoka) WHO Dysplasia Grades -Low Grade: Adenoma -Moderate: Borderline -High Grade: Carcinoma in Situ -High Incidence of Extrapancreatic Malignancy (10-50%): Most Common: Colorectal Adenocarcinoma (#1 in US) & Gastric Adenocarcinoma Fukuoka Guidelines – Resection Indications for BD-IPMN -Further imaging/EUS FNA vs straight to resection -“High risk features” = straight to RESECTION: obstructive jaundice, mural nodules enhancing solid component, main pancreatic duct > 1.0 cm -“Worrisome features” (seen on MRI) = EUS WITH FNA; IPMN >= 3 cm in size, thickened or enhancing cyst wall, non-enhancing mural nodule, main pancreatic duct dilation 0.5 cm – 0.9 cm, abrupt caliber change in the main pancreatic duct, symptoms (abdominal pain, pancreatitis) -If any of these are found on EUS with FNA = RESECTION; mural nodules, thickened walls,+ Mucin, high CEA or + for KRAS If the branch duct IPMN does not meet any of the above criteria: Follow up MRI/CT in 1 year

Answer 31

-Leak: Pancreatic Fluid Leak Due to Duct Disruption -Fistula: Abnormal Connection from Pancreas to Other Structures/Spaces; internal or external -Low Output: < 200 cc/Day -High Output: > 200 cc/Day International Study Group of Pancreatic Fistula: -Postoperative Pancreatic Fistula: Drain Amylase 3x Upper Limit of Normal Serum Amylase on >= POD#3 Grade: -Biochemical Leak: No Clinical Implications= no change in vitals, no sepsis, no percutaneous/endoscopic drainage performed, < 3 weeks persistent drainage, no angiography performed for bleeding; previously Defined as Grade A Fistula – Now Considered as Part of the Natural Postoperative Course for Up to 3 Weeks After Surgery -Grade B Fistula: Clinical Implications -Grade C Fistula: Results in Reoperation, Organ Failure or Death Clinical Implications: -Requires a Change in Postoperative Management -Persistent Drainage > 3 Weeks -Drain Requires Repositioning Through Endoscopic or Percutaneous Procedures -Requires Angiographic Procedure for Bleeding -Signs of Infection without Organ Failure General Asymptomatic: Supportive (NPO, Nasojejunal Feeding & Octreotide); Repeat Imaging at 4-8 Weeks Symptomatic or Persistent on Repeat Imaging: ERCP & Stent If Fails: Surgery (Enteric Drainage, Pancreaticojejunostomy or Resection) Symptomatic Postoperative Fistula: Percutaneous Drain Diet Management: Low Output: Continue Oral Diet High Output: NPO & TPN Management: Any patient with abdominal fluid collection concerning for pancreatic leak and has symptoms requires a PC drain to be placed 1st start with if high output >400 cc then NPO and TPN. If low < 200 then okay to eat. Octreotide (lowers pancreatic fistula output) If it doesn’t resolve after 6-8 weeks: ERCP, sphincterotomy and stent placement Need to wait at least 2-3 months before thinking of operating

Answer 32

Caused by retroperitoneal leakage of pancreatic duct disruption or ruptured pseudocyst Can occur after trauma This is not a pancreatic pleural fistula Majority close on their own Dx: aspiration  high amylase and protein > 25 Tx: thoracentesis/paracentesis Then treat like fistula NPO, TPN, octreotide. ERCP with stent placement if that fails

Answer 33

Pancreatic ductal adenocarcinoma - #1 MC periampullary tumor - 5YS 7% Distal cholangiocarcinoma – 2nd MC periampullary tumor (10%) - Cystic duct to ampulla, basically all of CBD - 5YS 35% Ampullary adenocarcinoma – 3rd MC periampullary tumor (8%) - Ampulla of Vater - 5YS 65% Duodenal adenocarcinoma – 4th MC periampullary tumor 4% - 5YS 50% Tx: For resection, generally use pancreatic CA guidelines for contraindication etc

Answer 34

-Most Common Exocrine Pancreatic Neoplasia (85-90%) -Most Common Location: Main Duct & Head -Spreads Through Lymphatics Lymphatic spread 1st RF: # smoking, AGE (older), obesity, diabetes, family history of pancreatic CA, chronic pancreatitis, FAP, BRCA2, Peutz- Jegers, Prognosis based on vascular and nodal invasion, and ability of R0 resection KRAS2 – involved in 95% of pancreatic cancer. MC gene mutation. BRCA2: associated with increased risk of pancreatic CA CA 19-9: correlates with tumor burden. Higher level, higher tumor stage. If > 1000 then 95% chance it is unresectable. - Used as marker to monitor response to therapy Diagnosis: - CT has 85% sensitivity to diagnose (best initial test), - ERCP has 90% sensitivity (however should not be used routinely. Only for high suspicion and no mass on CT) - PET is not recommended for staging Chemo – - Gemcitabine + Capecitabine 1st line - FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) ONLY for highly functional patients. Actually has better survival when compared to gemcitabine Adjuvant Chemotherapy: for ALL If after obtained CT, vascular involvement is still not clear  Next step is EUS to check for resectability Preoperative ERCP and stent placement for a patient with obstructive jaundice before a whipple increases risk of wound infection and pancreatic fistula. Should only be used in cholangitis or severe pruritus. Also dilated duct helps intra-op If the patient presents with resectable tumor and has obstructive jaundice  next step is whipple not stent placement

Answer 35

- Metal stents for biliary obstruction = longer patency rates. - Plastic stents for biliary obstruction need to be exchanged q2-3 months, increased occlusion rates - For GOO or duodenal obstruction – duodenal stent just as good as gastrojejunostomy. Endoscopic stents better if < 6 months life expectancy. > 6 months = gastroJ

Answer 36

2nd MC pancreatic tumor 20% associated with familial syndromes. Mostly sporadic Most are non-functional Biochemical workup must be done when found. Workup: - Obtain Chromogranin A level: elevated in 60% of functional and nonfunctional and Pancreatic polypeptide - All need CT/MRI - If initial imaging fails to localize: then somatostatin (octreotide) receptor scintigraphy or Functional PET Scan (Ga-68 DOTATATE) (higher sensitivity) -CT can miss small tumors, especially duodenal gastrinoma -If above can’t find it, and especially for DUODENAL gastrinoma: EUS -Selective Arterial Stimulation with Hepatic Venous Sampling: Insulinoma (Calcium Stimulation) or Gastrinoma (Secretin Stimulation) - Can’t use somatostatin study for insulinomaomaostain receptor expression - low s - Best imaging to localize: 68Ga somatostatin receptor positron emission tomography PET/PET-CT (DODATATE scan) - However most hospitals don’t have it so use: octreotide scan - All need EUS with FNA: Gives you information about whether its malignant AND if lymph nodes are involved - For Gastrinoma, Consider Surgical Exploration with Palpation or Intraoperative Ultrasound if High Suspicion but All Imaging Negative

Answer 37

70% of PNET are non-functional 90% of non-functional tumors are malignant, and they are very aggressive. Most cases have metastatic disease when found More indolent compared to adenocarcinoma Tx: - If < 2 cm, low grade, asymptomatic: you can observe vs enucleation - If > 2 cm, invasive, OR NODE POSITIVE: whipple or distal pancreatectomy with splenectomy. All need lymphadenectomy. - Tumors that are small, not near pancreatic duct, and benign: Can enucleate - OK to resect liver metastatic disease for cure

Answer 38

Functional pancreatic neuroendocrine tumors 30% These are usually multifocal especially in MEN1 Octreotide for symptom palliation effective for all except somatostatinoma MC in pancreatic head - gastrinoma and somatostatinoma Non-functional > 2 cm, somatostatinoma, gastrinoma, VIPoma  all need formal resection with lymphadenectomy +/- splenectomy

Answer 39

Insulinoma – 90% benign. 99% found in pancreas. Evenly distributed in pancreas. MC to be solitary & small (<3 cm) MC NET in pancreas Sx: “Whipple Triad”= fasting hypoglycemia, neuroglycopenic sx (confusion, combativeness, seizures, visual changes, loss of consciousness), relief with glucose administration Dx: - Insulin to glucose ration > 0.3 after fasting - High C peptide and insulin - Fasting hypoglycemia <50 and fasting insulin > 24 - These are diagnostic - Insulin to C-peptide ratio should be < 1.0 if it is more, than this is factitious - Additionally screen with sulfonylurea & meglitinide levels -CT is the initial localization study -If above doesn’t localize then: MRI with DOTATE or endoscopic US -Octreotide scan does not work here for localization -Selective pancreatic arterial calcium stimulation with hepatic venous insulin sampling  BEST TEST to localize if can’t see on CT - VERY INVASIVE, most likely you won’t use this Treatment: - <2 cm enucleate: additional requirements- single lesion, ≥ 2-3 mm From the Main Pancreatic Duct (Reduce Leak Risk), Well-Encapsulated, no Local Invasion - > 2 cm formal resection (whipple or distal pancreatectomy): Head/Neck: Pancreaticoduodenectomy, Body/Tail: Distal Pancreatectomy (Concurrent Splenectomy if Malignancy is Suspected), Entire Pancreas: Total Pancreatectomy Diazoxide – Inhibits Insulin Release, used preop to control hypoglycemia symptoms Octreotide – also used preop to control symtpoms Chemo: 5FU and streptazosin and debulking for recurrence or mets. Liver-Directed Therapy: Resection of Metastases if Able Radiofrequency Ablation (RFA) or Cryoablation 35 Hepatic Artery Embolization

Answer 40

Zollinger-Ellison Syndrome 70% found in the duodenum (MC 1st portion), 25% in pancreas 60% most are malignant and most commonly found in head of pancreas Most are multifocal 75% sporadic, 25% MENI -In pancreas usually >= 3 cm (duodenal <1 cm) -In pancreas liver mets commun (duodenal uncommon) Gastrinoma triangle (Passaro Triangle) – junction between cystic duct and CBD, Junction of neck and body of pancreas , 2nd and 3rd portion of duo -Triad= abdominal pain, diarrhea, weight loss in the presence of PUD -PUD Often Severe and Refractory to Initial Management with Proton Pump Inhibitors -Ulcers (MC proximal duodenum, can be found distally though) and DIARRHEA (even with fasting) Will see prominent gastric folds with Gastric Enterochromaffin-Like (ECL) Cell Hyperplasia MC mets to liver (Strongest prognostic indicator) All patients with suspected gastrinoma should be screened for MEN1 Work up: Genetic testing, gastrinoma level, CT abd, EUS, octreotide/DOTA scan Dx (need both): - 1st DC any PPI, H2 blocker - Screening: 1st get fasting serum gastrin >100. If negative, excludes gastrinoma - If positive, this is not diagnostic - Confirming test: 24-hour stomach basal acid output > 15. - Confirming test (MC used): Gastric pH <2 is consistent with gastrinoma. >3 excludes it - Performed if above tests are unclear: Fasting Secretin test – Check gastrin before, at 5, 10, 15 minutes after secretin given - Increase in gastrin > 120 above baseline = diagnostic. Tx: Medical: 1st give PPI Surgical: - If has MEN1, - Surgery usually not performed due to multifocality and metastatic disease spread - Surgery only indicated here if gastrinoma is identifiable and > 2 cm - Must do surgery for hyperparathyroidism 1st - For sporadic cases – Perform surgery, if no evidence of metastatic disease - Duodenal gastrinoma: resection with margins and lymphadenectomy - 2nd portion: whipple - Pancreatic gastrinoma: Mobilize pancreas, intra-op US, and palpation - Neck/Body/tail distal pancreatectomy +/- splenectomy. Take peripancreatic nodes - Head: enucleation if <2 cm. > 2 cm: whipple. Both need periportal, peri-duodenal, perihepatic lymph node dissection - Patients with liver mets can undergo surgery only if all of the tumor can be removed Chemo: 5FU and streptazosin for malignant disease. Palliation is octreotide and PPI. Mets disease and severe symptoms despite maximum medical tx: total gastrectomy. NO VAGOTOMY

Answer 41

-Most common in body & tail -Most are malignant & sporadic -Weight loss (MC presenting sx) -Diabetes, DVT, Depression, Dermatitis stomatitis (oral mucosa, tongue, lips), Diarrhea -Necrolytic migratory rash: plaques, central clearing, pruitic & painful -Dx: fasting glucagon level (>500 pm/mL) Tx: whipple (head/neck) or distal pancreatectomy with splenectomy (body/tail); removal of the body and tail of the pancrease to the left of the SMA and SMV. Do lymphadenectomy. Octreotide for symptoms, and zinc, amino acids and fatty acids for skin rash. Chemo same

Answer 42

75-90% in pancreas; other sites: lung, colon, liver, pediatric pateients- adrenal gland or sympathetic ganglion -Most malignant & metastasized at time of dx, solitary, large (> 3 cm) -Body or tail of pancreas VIPoma (Verner-Morrison Syndrome)/ Watery diarrhea with hypokalemia and achlorhydria (WDHA) Syndrome Triad: watery diarrhea, hypokalemia, achlorhydria Dx: exclude other causes of diarrhea and high VIP level (>= 200) Tx: fluid resuscitation, electrolyte replacement, Octreotide for symptoms, resection -Head/Neck: Pancreaticoduodenectomy -Body/Tail: Distal Pancreatectomy (Concurrent Splenectomy if Malignancy is Suspected) -Entire Pancreas: Total Pancreatectomy

Answer 43

-Pancreas (MC), duodenum -Most common in head (MC specific site in ampulla and periampullary area) -Solitary, large (5-6 cm in pancreas, 2-5 cm in duodenum), malignant, metastases at dx -Somatostatinoma – worst prognosis of all -35-45% MEN-1 -50% duodenal somatostatinomas associated with neurofibromatosis type 1 -Triad: diabetes, cholelithiasis, diarrhea/ steatorrhea -Ohter sx: abdominal pain, weight loss, hypochlorydria Dx: fasting somatostatin level Tx: cholecystectomy with resection. Chemo for malignant same

Answer 44

-Resection of pancreatic head & duodenum -Classic pancreaticoduodenectomy: pancreatic Head & Duodenum, gallbladder & Common Bile Duct, gastric Antrum & Pylorus, proximal Jejunum (15 cm) Performed for: - Periampullary carcinoid - Adenocarcinoma in 1st or 2nd portion of duodenum - Neuroendocrine (gastrinoma, carcinoid, somatostatinoma), in 2nd portion of duodenum - Distal cholangiocarcinoma (distal to cystic duct) - Gastrinoma (sporadic) in 2nd portion of duodenum or > 2 cm in pancreatic head - Pancreatic endocrine neoplasm (insulinoma) in head of pancreas > 2 cm - Neuroendocrine (gastrinoma, carcinoid, somatostatinoma) > 2 cm in 2nd portion of duodenum Whipple NOT performed for: - Lymphoma in 1st or 2nd portion of duochemo-XRT - Symptomatic duodenal diverticulitis in 2nd portion: if biliopancreatic sx: ERCP, stent placement - Crohn’s affecting duodenum: if stricture in 1st or if in 2nd portion: gastroJ with vagotomy Whipple steps: Abdominal exploration: -Staging laparoscopy: evaluate for tumor metastases (examine visceral & peritoneal surfaces, omentum, bowel; hepatic lesions- intraoperative US or bx with frozen section). -Metastases= abort case Desection -Kocher maneuver: mobilize duodenum & head of pancreas; incise lateral peritoneal attachments to the 2nd & 3rd portions of the duodenum; allos duodenum & head of pancreas to be moved to patient's left side -Enter lesser sac through gastrocolic ligament -Isolate portal structures: Common Hepatic/Bile Duct, Common Hepatic Artery, & Portal Vein), monitor for & Preserve a Replaced Right Hepatic Artery Resection -Cholecystectomy -Common Hepatic Duct (CHD) Transection: Divide the CHD Just Proximal to the Cystic Duct -Divide the Gastroduodenal Artery (GDA): divide as it Originates Off the Common Hepatic Artery (CHA) -Transect the Stomach: transect 2 cm Proximal to the Pylorus -Transect the Proximal Jejunum: mobilize & Transect 15-20 cm Distal to the Ligament of Treitz -Transect the Neck of the Pancreas: Developing a Tunnel Anterior to the SMV (Posterior to the Pancreatic Neck) -Retract Specimen Medially Off the SMV-Portal Vein Confluence: exposes Inferior Pancreaticoduodenal Arteries – Carefully Ligate Branches to Avoid Avulsion -Lymphadenectomy: regional Lymph Nodes Along the CBD, CHA, Portal Vein, & Pancreaticoduodenal Arteries, minimum 12 Lymph Nodes Reconstruction -Pancreaticojejunostomy -Hepaticojejunostomy -Gastrojejunostomy -Leave 1-2 Closed-Suction Drains Anterior/Posterior to the HJ & PJ to Monitor for Leak/Fistula: Amylase Checked on Postoperative Day #1 & #3 (Remove if < 5000 U/L) Complications: -Delayed gastric emptying (MC): treatment: metoclopramide (reglan) or erythromycin, NGT for decompression or NJ tube for enteral nutrition -Pospoerative pancreatic fistula -Postpancreatectomy hemorrhage: GDA stump most common -Bilioenteric stricture -Biliary leak: from hepaticojejunostomy; tx= percutaneous drainage until resolution

Answer 45

-Resection of the Pancreatic Body & Tail to the Left of the SMA/SMV Procedure -Enter Lesser Sac: divide Gastrocolic Ligament & Mobilize Omentum -Mobilize Stomach – Ligate Gastrosplenic Ligament & Retract Cranially -Mobilize Pancreatic Body/Tail – Spare Splenic Artery/Vein -Transect Pancreas Spleen -Always Vaccinate Preoperatively -Concurrent Splenectomy if Concern for Malignancy -Ligate: Splenic Artery (First), Then IMV & Finally Splenic Vein -May Preserve IMV if it is Proximal to Lesion or Enters SMV

Answer 46

* Occurs exclusively in young females * Has some malignant potential * Resect all of these (<35)

Answer 47

Pancreatic lymphoma Will have B type symptoms, fevers, chills night sweats. CT will show bulky lymphadenopathy!!! Will not have weight loss, back pain, obstructive jaundice Treatment: chemotherapy alone, cyclophosphamide, vincristine, Doxorubicin (Adriamycin), prednisone

Answer 48

-Rare -Most common primary: melanoma, RCC

Answer 49

-MRCP better characterize duct anatomy (than abdominal CT) -EUS allows for aspiration for cyst fluid analysis (CEA and Amylase) -CEA >192 c/w mucinous cyst -High amylase indicates ductal communication (pseudocyst or IPMN)

Answer 50

simultaneous dilation of common bile duct/ billiard tree and pancreatic duct that suggests biliary obstruction; commonly associated with pancreatic head tumors, particularly periampullary tumors Next step: ERCP for visualization of biliary tree & pancreatic ducts and bx/ brushings; can also place biliary stent -Presents with...chronic alcohol use, abdominal pain, jaundice, unintentional weight loss, hepatomegaly, RUQ tenderness

Answer 51

Any metastases, extension into the hepatoduodenal ligament, involvement of major arterial structures, inolvement of nodal or neural structures around the celiac or superior mesenteric artereries Isolated involvement of the ssuperior mesenteric vein or portal vein can be resected in select patients

Answer 52

-Mobilize Duodenum, Pancreas & Spleen -Ligate GDA -Cholecystectomy & Transect CBD -Proximal Transection – Prepyloric or Postpyloric -Distal Transection – Distal to Ligament of Treitz -Ligate Splenic Artery (First) Then Splenic Vein -Preserve Left Gastric Artery (Only Remaining Supply to the Stomach) -Dissect Pancreas Off Portal Vein & SMA Reconstruction: Hepaticojejunostomy (HJ) & Gastrojejunostomy (GJ) Islet Cell Autotransplantation: -Contraindications: Diabetic or Pancreatic Malignancy -Procedure: Islet Cells Isolated in Lab, Infused into Portal Vein & Lodge in Liver -No Immunosuppression Required

Answer 53

Lateral Pancreaticojejunostomy -Opening of Lateral Main Pancreatic Duct with Anastomosis to Roux-en-Y Jejunal Limb -Enlarged Ducts (> 6 mm) & No Head Mass -Indications: Chronic Pancreatitis -Open duct anteriorly, clear intraductal stones, -Anastomose Duct to Roux-en-Y Jejunal Limb

Answer 54

-Lateral Pancreaticojejunostomy with “Core Out” of Fibrotic Head -Enlarged Ducts (> 6 mm) & Inflammatory Head Mass -Chronic pancreatitis -Spares More Pancreas Than Beger -Open Duct Anteriorly Along Its Entire Length -“Core Out” Fibrotic Pancreatic Head Without Transecting Neck -Anastomose Duct to Roux-en-Y Jejunal Limb

Answer 55

-Duodenal Preserving Pancreatic Head Resection & Pancreaticojejunostomy -Small-Normal Ducts & Isolated to Head -Chronic Pancreatitis -Transect Pancreatic Neck at Portal Vein -Subtotal Head Resection: Preserve Peripheral Parenchyma Along Duodenum; Spares Duodenum & CBD -Anastomose Duct to Roux-en-Y Jejunal Limb

Pancreas Flashcards

(80 cards)