Surgery of Pancreatic Disorders Flashcards
(66 cards)
1
Q
What is the epidemiology of head of pancreas carcinoma?
A
- 100/million per year UK
- Average age 60-80 yrs
- F>M
2
Q
What is the aetiology of pancreatic carcinoma?
A
Unknown
3
Q
What are the risk factors for pancreatic carcinoma?
A
- Smoking
- Chronic pancreatitis
- Adult onset diabetes
- Hereditary pancreatitis
- Inherited predisposition
- Periampullary cancer as a feature of FAP
4
Q
What is the hallmark feature of pancreatic carcinoma?
A
Painless obstructive jaundice
5
Q
How does pancreatic carcinoma present
A
- Diabetes
- Abdominal pain
- Back pain
- Anorexia
- Vomiting
- Weight loss
- Recurrent bouts of pancreatitis
- Incidental finding
6
Q
What general investigations should be carried out for pancreatic carcinoma?
A
- Blood tests
- CXR
7
Q
What tumour markers are there for pancreatic cancer?
A
CA19-9
8
Q
What imaging/invasive investigations should be carried out for pancreatic carcinoma?
A
- USS
- ERCP
- CT
- MR, MRCP
- Laparoscopy and Lap USS
- Peritoneal cytology
- EUS + FNA Bx
- Percutaneous needle biopsy
- PET
9
Q
How is a patient assessed for fitness for major pancreatic resection?
A
- Basic history and examination
- CXR, ECG
- Resp function tests
- Physiological scoring system (none established, performance status, lactate threshold)
- Fully informed consent
10
Q
What can be done for a patient with pancreatic cancer deemed to be unfir/unresectable?
A
ERCP+stent
11
Q
What investigations must be performed before a potentially resectable cancer is resected?
A
- USS
- ERCP + stent
- Spiral CT/MRI
- Laparoscopy/ Lap USS
- Laparotomy
- Resection
12
Q
What is the name of the surgery performed fro pancreatic cancer?
A
Kausch-Whipple
13
Q
How is palliative drainage achieved with obstructive jaundice?
A
- Palliative bypass
- ERCP
- PTC stenting
14
Q
How is palliative drainage achieved with duodenal obstruction?
A
- Palliative bypass
- Duodenal stent
15
Q
Acute pancreatitis
A
An acute inflammatory process of the pancreas with variable involvement of other regional tissue or remote organ systems
16
Q
Mild AP
A
Associated with minimal organ dysfunction and uneventful recovery
17
Q
Severe AP
A
Associated with organ failure or local complication
18
Q
What are the local complications of acute pancreatitis/
A
- Acute fluid collections
- Pseudocyst
- Pancreatic abscess
- Pancreatic necrosis
19
Q
What is the aetiology of acute pancreatitis?
A
- Gallstones
- Alcohol
- Viral infection: CMV, mumps
- Tumours
- Anatomical abnormalities
- ERCP
- Lipid abnormalities
- Hypercalcaemia
- Postoperative trauma
- Ischaemia
- Drugs
- Scorpion venom
- Idiopathic
20
Q
What is the pathophysiology of AP as a result of alcohol?
A
- Direct injury
- Increased sensitivity to stimulation
- Oxidation products (acetaldehyde)
- Non-oxidative metabolism
21
Q
What is the pathophysiology of AP as a result of gallstones?
A
- Passage of gallstones is essential
- Raised pancreatic ductal pressure
22
Q
What is the pathophysiology of AP as a result of ERCP?
A
-Increased pancreatic ductal pressure
23
Q
What are the symptoms of AP?
A
- Severe abdominal pain
- Nausea
- Vomiting
- Collapse
24
Q
What are the signs of AP?
A
- Pyrexia
- Dehydration
- Abdominal tenderness
- Circulatory failure
25
What general supportive care should be provided in AP initial resuscitation and management?
- Analgesia
- IV fluids
- CV support
- Resp support
- Renal support
26
What monitoring should be provided in AP initial resuscitation and management?
- Pulse
- BP
- Urine output
- CVP
- Arterial line
- HDU/ITU
27
What investigations should be carried out in AP initial resuscitation and management?
- U+Es
- Glucose
- Serum amylase
- FBC
- Clotting
- LFTs
- ABG
- CXR
- AXR
- USS
- CT
28
What are the criteria in the Glasgow criteria scoring system?
- Glucose >10mmol/L
- Serum Ca <2mmol
- WCC >1500/mm^3
- Albumin<32g/l
- LDH>700IU/L
- Urea>16mmol/L
- AST/ALT>200IU/L
- Arterial pO2 <60mmHg
29
When is AP predicted severe ?
If Glasgow criteria scoring is >3 at 48 hrs
30
How is a prediction of severity made for AP?
- Clinical assessment
- Modified Glasgow criteria
- CT scan
- CXR
- CRP>200 or persistent >150
- IL6
- TAP
31
AP Identification and Management of Precipitating Factors: Cholelithaiasis
ERCP and ES, cholescystectomy
32
AP Identification and Management of Precipitating Factors: alcohol
- Abstinence
| - Counselling
33
AP Identification and Management of Precipitating Factors: Ischaemia
- Careful support
| - Correct cause
34
AP Identification and Management of Precipitating Factors: Malignancy
- Resection
| - Bypass
35
AP Identification and Management of Precipitating Factors: Hyperlipidaemia
- Diet
| - Lipid lowering drugs
36
AP Identification and Management of Precipitating Factors: Anatomical abnormalities
Correction if possible
37
AP Identification and Management of Precipitating Factors: Drugs
- Stop
| - Change
38
What are the specific aspects of management for AP?
- CT
- Antibiotics
- Diagnosis of infection
- ERCP in gallstone pancreatitis
- Nutrition
- Manipulation of the inflammatory response
39
When can necrosis by AP be detected on CT?
Days 4-10
40
What complications of AP is CT useful for identifying?
- Acute fluid collections
- Abscess
- Necrosis
- Monitoring progress of disease
41
What infections are associated with AP?
- Sepsis
| - SIRS
42
When is ERCP and ES definitely indicated in AP?
In those with jaundice and cholangitis
43
Why is ERCP and ES still controversial in the treatment of AP?
- Reduces complications in severe gallstones
| - Associated with higher mortality
44
What role does nutrition play in the treatment of AP?
- Nutrition vitally important
- Enteral feeding is superior to parenteral feeding
- NG feeding is tolerable in most cases and is not associated with any increase in complications
45
What is the definitive management for AP in the prevention of recurrent attacks?
- Management of gallstones
- Investigations of non-gallstone pancreatitis
- Alcohol abstinence
46
What is the definitive management for fluid collect in AP?
- Early collection: sit it out
- Pseudocyst: doesn't have a capsule
- Pancreatic duct fistula: manage pancreas accordingly
47
What is the definitive management of necrosis in AP?
- Sterile and infected necrosis
| - Necrosectomy by laparotomy or minimally invasive
48
What are late complications of AP?
- Haemorrhage
- Portal hypertension
- Pancreatic duct stricture
49
Chronic pancreatitis
Continuing chronic inflammatory process of the pancreas characterised by irreversible morphological changes leading to chronic pain and/or impairment of endocrine and exocrine function of the pancreas
50
What is the epidemiology of chronic pancreatitis?
- M>F
| - Increasing in the Western World
51
What are the causes of chronic pancreatitis?
- Obstruction of MPD
- Autoimmune
- Toxin
- Idiopathic
- Genetic
- Environmental
- Recurrent injuries
52
What can cause obstruction of the MPD?
- Tumour
- Sphincter of Oddi dysfunction
- Pancreatic divisum
- Duodenal obstruction
- Trauma
- Stricture
53
What toxins can cause CP?
- Ethanol
- Smoking
- Drugs
54
What genes can cause CP?
- Autosomal dominant (Condon 29 and 122)
| - Autosomal recessive (CFTR, SPINK1,)
55
What environmental factor can cause CP?
Tropical chronic pancreatitis
56
What recurrent injuries can cause CP?
- Biliary
- Hyperlipidaemia
- Hypercalcemia
57
What are the clinical features of CP?
- Pain
- Pancreatic exocrine insufficiency
- Diabetes
- Jaundice
- Duodenal obstruction
- Upper GI haemorrhage
58
Describe the pain linked to CP.
- Most significant factor affecting quality of life
- Linked to binges
- Become more frequent and less treatable by abstinence
- Pathogenesis unknown
59
What investigations should be carried out for CP?
- CT
- ERCP/MRCP
- Pancreatic exocrine function
- Faecal/serum enzymes
- Pancreolauryl test
- Diagnostic enzyme replacement
60
What conservative management is there for CP?
- Counselling
- Alcohol abstinence
- Management of acute attacks
- Analgesia
- Avoid high fat, high protein diet
- Pancreatic supplementation
- Anti-oxidant therapy
61
When should surgery be considered for CP?
-Suspicion of malignancy
-Intractable pain
-Complications that require surgical intervention
ONLY AFTER FULL EVALUATION
62
What complications of CP require surgical intervention?
- Pancreatic duct stenosis
- Cyst, pseudocysts
- Biliary tract obstruction
- Splenic vein thrombosis/ gastric varicies
- Portal vein compression/ mesenteric vein thrombosis
- Duodenal stenosis
- Colonic stricture
63
What interventional procedures are there for CP?
- PD stenosis and obstruction: endoscopic PS sphincetortomy, dilation and lithotripsy
- Management of chronic pseudocyst
- Thoracoscopic
- Spanchnectomy
- Celiac plexus block
64
What surgery is available for drainage in CP?
- Pancreatic duct sphincteroplasty
| - Puestow
65
What surgery is available for resection in CP?
- DPPHR
- PPPD
- Whipple
- Frey procedure
- Spleen preserving distal pancreatectomy
- Central pancreatectomy
66
What is the prognosis for CP?
- Mortality 50% over 20-25yr
- 20% die of complications
- Rest die as a result of associated conditions
- Morbidity is still a major cause for concern
