Surgery of the Endocrine Pancreas

Question 1

What is the endocrine function of the pancreas?

Answer 1

Secreting hormones into the circulation, which is primarily (though not exclusively) associated with the maintenance of normoglycaemia via the production of hormones insulin and glucagon.

Question 2

What is the exocrine function of the pancreas?

Answer 2

Secreting pancreatic products into the gastrointestinal tract, primarily associated with the digestive process via the production of enzymes like trypsin, amylase and lipase which enter the duodenum via the pancreatic ducts and the duodenal papillae.

Question 3

how to access the right lobe of the pancreas?

Answer 3

retracting the duodenum

Question 4

Which way to retract the pancreas to access the dorsal aspect of R lobe?

Answer 4

Ventral + medial

Question 5

Which way to retract the pancreas to access the ventral aspect of the R lobe?

Answer 5

Laterally

Question 6

What is the blood supply to the pancreas? (1) where do these arise from? (2)

Answer 6

Pancreatic branches of the pancreaticoduodenal arteries
ARISE from: hepatic and cranial mesenteric arteries.

Question 7

Where does the central body of the pancreas lie anatomically?

Answer 7

Next to pylorus and duodenum

Question 8

Why is the central body of the pancreas the most difficult to access?

Answer 8

Pancreaticoduodenal arteries are embedded in the parenchyma.

Question 9

How to access the left lobe of the pancreas?

Answer 9

stomach should be moved cranially and the transverse colon caudally within the deep leaf of the greater omentum.

Question 10

What are the vessels which supply the left lobe of the pancreas?

Answer 10

• Mainly - splenic a, but also the common hepatic and gastroduodenal

Question 11

In dogs, a duct carrying the pancreatic secretions travels along each lobe before meeting in a A) -shape, forming the B) duct which continues to the duodenum and the minor duodenal papilla.

Answer 11

A) Y
B) accessory pancreatic

Question 12

There is also a pancreatic second duct which arises from the ducts in the left and right pancreatic lobes which enters the duodenum

With what and where does it enter?

Answer 12

With bile duct, at the major duodenal papilla

Question 13

What are insulinomas tumours of?

Answer 13

Functional pancreatic tumour of B islet cells

Question 14

What do insulinomas secrete? What does this lead to ?

Answer 14

insulin –> Hypoglycaemia

Question 15

Other than insulin, what do insulinomas secrete? (2)

Answer 15

Glucagon
Gastrin

Question 16

What type of tumours are 60% of insulinomas in dogs?

Answer 16

Malignant carcinoma

Question 17

Where do insulinomas commonly met to? (3)

Answer 17

LN
Liver
Omentum

Question 18

How many dogs with insulinomas have mets at time of diagnosis?

Answer 18

50%

Question 19

What is a stage I insulinoma? (T1N0M0)

Answer 19

Invasion of the pancreas

Question 20

What is a stage II insulinoma? (T1N1M0)

Answer 20

Invasion of pancreas and associated LN

Question 21

What is a stage III insulinoma? (T1N0M1 or T1N1M1)

Answer 21

Distant mets

Question 22

Other than carcinoma, what tumour type make up for the remaining insulinomas?

Answer 22

Adenomas

Question 23

What breed do insulinomas commonly occur in?

Answer 23

Medium - Large

Question 24

What tends to cause the clinical signs seen with insulinoma?

Answer 24

Hypoglycaemia

Question 25

Clinical signs of insulinoma (5)

Answer 25

Seizure Weakness Ataxia Exercise intolerance Collapse

Question 26

Some individuals with insulinomas will have a peripheral neuropathy which can lead to? (3)

Answer 26

Para/tetraparesis Oesophageal motility disorders Reduced anal tone

Question 27

What is diagnostic of an insulinoma?

Answer 27

increased serum insulin levels should be documented during a period of hypoglycaemia with a high insulin level (>26µU/ml) at this point highly suggestive of insulinom

Question 28

Imaging for insulinoma? (3)

Answer 28

- U/S; false negative common - CT - Dual phase CT angiogrpahy

Question 29

What is it about insulinomas which makes surgical removal feasible?

Answer 29

Being encapsulated they are often well-defined

Question 30

How common is it for surgical removal of insulinoma to be curative?

Answer 30

Rare

Question 31

Dietary management is commonly used in the conservative management of insulinomas. What is the goal of this? How is this acheived?

Answer 31

Goal: Maintain appropriate blood glucose levels throughout the day and avoid foods that may incite a spike in insulin release. Multiple small meals throughout the day and using foods that are high in protein, fat, and complex carbohydrates.

Question 32

Why may glucocorticoids be used in medical stabilisation of insulinomas? (2)

Answer 32

stimulate the production of glucose whilst decreasing glucose uptake by cells

Question 33

With insulinomas; why must great care be taken with IVFT with glucose?

Answer 33

Can stimulate further insulin

Question 34

Feeding pre surgery with insulinomas?

Answer 34

A high sugar-based small meal is usually offered 2-3 hours before surgery.

Question 35

What is associated with decreased hospital stays and shorter surgical times than more traditional suture techniques with pancreas surgery?

Answer 35

Vascular sealing device

Question 36

At pancreatic surgeyr; what samples should be taken?

Answer 36

- Hepatic - Regional LN To stage the dx.

Question 37

If an insulinoma cannot be identified at sugery. What can be done? How does this work?

Answer 37

dilute methylene blue has been historically described to be given intravenously to selectively stain islet cells.

Question 38

Downsides of using methylene blue for pancreas locating? (3)

Answer 38

- Maximum effect after 30 mins - Often alot of the pancreas turns blue - Fatal heinz body aenamia

Question 39

A quick way to identify if area of pancreas has insulinoma?

Answer 39

resect portion(s) of the pancreas and check for changes in blood glucose, as this should occur vert rapidly (provide the animal is moderately hypoglycemic) very rapidly following resection.

Question 40

Monitor blood glucose after pancreatectomy, rebound hyperglycaemia can occur; why?

Answer 40

suppression of normal insulin producing β cells.

Question 41

Common post op complications after pancreatectomy (3)

Answer 41

Pancreatitis Hyper glycaemia Hypoglycaemia

Question 42

Survival time of insulinoma with medical tx?

Answer 42

6.5mo

Question 43

Survival time of insulinoma with partial pancreatectomy?

Answer 43

2-3yr

Question 44

Common adjunctive therapy in dogs after insulinoma?

Answer 44

Prednisolone

Question 45

Why are glucocorticoids not commonly used with insulinomas?

Answer 45

decrease insulin sensitivity and increase endogenous (hepatic) glucose production

Question 46

Other drugs such as octreotide, streptozotocin or diazoxide are not commonly used in insulinomas; why is this?

Answer 46

Side effects

Question 47

What adjunctive therapy is used in humans for insulinoma and may have some use in dogs?

Answer 47

Tyrosine kinase inhibitors, such as toceranib phosphate

Question 48

T or F One of the goals of dietary management is to avoid foods that may incite a spike in insulin release.

Answer 48

True

Question 49

T or F Canine insulinomas have been noted to be poorly vascular.

Answer 49

False

Question 50

T or F An insulinoma is classified as stage I when there is distance metastasis.

Answer 50

False

Question 51

T or F Glucagonoma causes hypoglycaemia

Answer 51

False

Question 52

What do patients with glucagonoma commonly present with?

Answer 52

Necrolytic dermatitis like syndrome similar to hepatocutaneous syndrome seen in liver disease.

Question 53

Diagnosing glucagonoma? (2)

Answer 53

- Identify mass - Serum glucagon conc

Question 54

How likely are glucagonomas to met and the prognosis?

Answer 54

Common - poor prognosis

Question 55

T or F Gastrinomas can arise from pancreatic cells (non-β cells), as well as from elsewhere in the gastrointestinal tract

Answer 55

True

Question 56

When gastrinomas arise in the pancreas, what syndrome describes the collection of a non-β cell, gastrin secreting, pancreatic neoplasia

Answer 56

Zollinger-Ellis

Question 57

Zollinger-Ellis syndrome describes the collection of a non-β cell, gastrin secreting, pancreatic neoplasia leading to (2)

Answer 57

Gastric acid hypersecretion and gastrointestinal ulceration

Question 58

Where do gastrinomas met to?

Answer 58

Liver Regional LN

Question 59

How to diagnose gastrinoma?

Answer 59

They are often too small to be diagnosed via imaging and serum gastrin levels (> 1000 pg/ml) are used after a period of 12 hours without food (and without antacid medication such as H2 blockers).

Question 60

In cases without metastasis; gastrinoma tx?

Answer 60

Surgical removal - partial pancreaectomy

Question 61

Prognosis of gastrinoma?

Answer 61

Poor

Question 62

What must NOT be given when assessing bloods for gastrinoma?

Answer 62

Antacid e.g. H2 blocker

Question 63

Tx of gastrinoma to aid efficacy of medical?

Answer 63

Even in patients with metastasis, resection or debulking of the primary tumour and any identifiable metastasis

Question 64

The distal part of the right limb of the pancreas is often used for biopsy - why? (2)

Answer 64

furthest from the pancreatic ducts furthest from any blood supply whose damage might affect other organs.

Question 65

How to biopsy pancreas? what is involved in this technique?

Answer 65

A suture fracture technique, where a loop of suture is tightened crushing the parenchyma and any anatomy internal to this section

Question 66

What technique is used where the mass is located at a level where a suture fracture technique is not feasible (e.g., body of the pancreas)?

Answer 66

Blunt dissect

Question 67

What % of the pancreas can be resected without impact on either endocrine or exocrine function.

Answer 67

75-90

Question 68

Does the pancreas regenerate?

Answer 68

dogs have significant capacity to regenerate pancreatic tissue following partial resection.

Question 69

If a vessel sealing device has not been used, what vessels should be ligated with partial pancreaectomy?

Answer 69

pancreatico-duodenal vessels

Question 70

It is challenging to remove the right limb of the pancreas without damaging

Answer 70

Vascular supply of duodenum

Question 71

IF a patient survives total pancreatomy. (RARE). What is inevitable? (2)

Answer 71

Diabetes mellitus EPI

Question 72

Are you able to identify whether statement below is true or false? Up to 75-90% of the pancreas can be resected without impact on either endocrine or exocrine function.

Answer 72

True

Question 73

Post op feeding following pancreas sx?

Answer 73

feeding tube placement considered early return to feeding, starting per os or via tube feeding with small quantities of low-fat bland food. If this approach causes a deterioration, then feeding should be withdrawn and a further attempt made in due course.

Question 74

Following panc Sx, what may need to be supplemented in patients that have been or are anorexic/hyporexic and preserving normotension is important to maintain pancreatic perfusion and allow healing.

Answer 74

Potassium

Question 75

Suggested post panc analgesia?

Answer 75

Opiod Ketamine Lidocaine

Question 76

Tx options for nasuea post panc sx?

Answer 76

Maropitant Metoclopramide CRI