- Pancreas Basics
- Anatomy
- Head: arterial supply: ant/post sup/inf pancreaticoduodenal
- Uncinate process part of gland below left renal vein
- Taken during a whipple
- Junction of smv and splenic behind neck
- Exocrine: digestive enzymes and bicarb
- Trypsin
- Pepsin-pepsinogen (from stomach)
- Enzymes don’t act in acidic environment: neutralized by bicarb
- Secretin: specific for pancreas, most potent stimulator of bicarb secretion
- Cck: work on gb as well
- Endocrine: need 20% for full function
- Beta cells: Insulin
- Throughout pancreas: 10-25% of blood flow
- Delta Cells: Somatostatin:
- great inhibitor: block all endocrine and exocrine production
- Dec splanchnic pressure
- Alpha Cells: glucagon
- Beta cells: Insulin
- Anatomy
- Embryopathologies
- Annular Pancreas: incomplete fusion
- Assoc with downs: 20%
- Sx Obstruction
- Dx UGI contrast or endoscopy
- Smooth obstruction with dilation proximal
- Tx Duodenoduodenostomy or duodenojejunostomy
- No bx, no transection
- Pancreatic divisum: failure of fusion of dorsal to main pancreatic ducts
- Major (Wirsung) drains head of panc
- Lesser (Santorini) drains entire panc
- 10% of normal population
- 10% will develop pancreatitis
- Sx caused by stenosis/obstruction of the lesser papilla
- Assoc with pancreatitis, not ca
- Tx minor duct papillotomy
- Accessory Duct: vestigial dorsal panc with incomplete fusion
- Opens through minor/lesser papilla: duct of Santorini
- Most commonly remains in continuity with with panc duct thus occlusion at duodenum doesn’t create sx
- 3-14% pt with panc divisum may have obstructed accessory which causes pancreatitis
- Annular Pancreas: incomplete fusion
- Acute Pancreatitis
- Incidence 17/100,000, mortality 2-3%/yr
- Etiology: gallstone>etoh>idiopathic (blockage), vascular, infectious, neoplastic, divisum, cf
- Sx: Pain (95%), N/V (80%), Distention (75%), Guarding (50%)
- Biochemical: amylase, lipase, alanine aminotransferase (gallstone panc)
- Lipase = specific
- Amylase linked to pancreas, parotid, bowel (trauma) and increased in renal failure
- rises 2-12 hours: elevation degree doesn’t correlate with severity
- Imaging:
- u/s biliary duct
- 30-60% of pt with biliary etiology will suffer subsequent complications of biliary dz within 3 months if they don’t undergo chole
- Contrast ct (dynamic for non-perfused panc) best for m&m in first 24 hr
- A nml
- B mild edema
- C peripanc infiltrate
- D peripanc fluid collection
- E non enhanced or intrapanc fluid collection- m 57% & m 20%
- u/s biliary duct
- Prognostic Criteria
- Contrast enhanced
- Ransons 48 hr
- 24 hours: GALAW
- gluc 200, ast 250, ldh 350 (now lactate), age (55), wbc 16
- 48hrs
- fluid sequestration 6L, base deficit from acidification, diaphragm inc dec frc dec paO2 <60, bun >5, ca <8
- 4 = 30-40% mortality, 6 = 80-90% mortality
- 24 hours: GALAW
- Modified Glasgow
- Apache 2
- Basic Tx
- Hydration
- Analgesia: opioid
- NG suction: only beneficial in severe
- No benefit from somatostatin or h2 blocker
- Nutritional support: Tpn v Enteral feeds
- TPN not beneficial
- Enteral feeds via NJ not NG tube
- Reduce translocation of bact
- Promote gut immunity
- Enhance gut blood flow
- Dec incidence of infected necrosis
- Abx: imipenem
- Fever likely due to inflammatory response, not infection early on
- Pancreatic necrosis 30-50% get infected
- Ppx questionable: No benefit in mild pancreatitis
- Cochrane review 2005 10-14d use dec risk of superinfection
- GI suggests against it
- Surg exploration
- Identification of necrosis
- When in doubt of diagnosis or hemorrhagic with continuous bleed or abscess
- Serial ct is negative initially necrosis can take 3-10 d to manifest
- Serial debridement required: necrosectomy
- Open v closed drainage: experience open packing with drainage
- Mortality 25-30% for infected necrosectomy
- Peritoneal lavage no role
- Gallstone pancreatitis
- Ercp and Lap chole: procedure of choice
- Ercp reduces septic complication
- Tx pancreatitis then chole during same admission
- Labs don’t have to be normal just down trending
- Open chole and cbd exploration: more morbidity
- Pancreatitis with porcelain gb
- Tx pancreatitis then elective cholecystectomy
- Ercp and Lap chole: procedure of choice
- Complications
- Acute: Hemorrhage, abscess, fistula (biliary, pancreatic enteric, pseduocyst formation, mortality
- Chronic: Exocrine/endocrine insufficiency, strictures, hernia, pain
- Pseudocyst 8% (acute alcoholic panc)
- 30-50% of pt will develop acute fluid collections: most resolve
- 10% develop pseudocysts at 4 weeks
- Most common cause of cystic pancreatic lesion
- Most resolve spontaneously: <6cm <6wks
- Less likely to resolve if complicated: infection, rupture and hemorrhage
- Collection MC in lesser sac
- Sx obstruction, nausea, hyperamylasemia
- Dx: u/s best
- Tx:
- asym no treat
- sx and/or >6cmat >6wks
- Drain ext or int (ct and ercp)
- Percutaneous aspiration: high recurrence rate
- External drainage for poor operative risk: 20-30% will develop fistula
- Int: endoscopic cystogastrostomy, laparoscopy
- Avoid in cirrhotics: presence of perigastric varices
- Don’t have to biopsy wall unless open procedure; then, biopsy all
- No need for somatostatin analogue or tpn
- 30-50% of pt will develop acute fluid collections: most resolve
- Abscess 5%: necrotizing pancreatitis
- Necrotic material that gets infected
- Mortality 20%
- Fever white count stranding of surrounding fat
- Dx fna with g-stain and cx, radiologic gas
- Tx
- Abx: imipenem
- IR if stable
- Open debridement with planned return
- higher complication rate: fistulas
- Closed drainage: close fascia
- Complication diabetes
- Hemorrhage 5%
- Panc Ascites
- p/w ascites and wt loss
- Dx: paracentesis: elevated amylase/lipase
- ercp shows ductal disruption
- Tx: npo, hyperal, paracentesis if resp issues, somatostatin pos helpful, stenting duct open proximal duct
- surgery for major duct disruption
- Fistula: most will close within 4-6wks
- Somatostatin doesn’t hasten rate of closure
- ERCP and stent: close fistula in 85% of pt
- MCx death pulm insufficiency in first week
- MCx death >2wks sepsis
- Chronic Pancreatitis
- Basics
- MC alcoholic pancreatitis, 40-50y/o, steatorrhea, wt loss
- Not assoc with pancreatic adeno
- Autoimmune type dx with bx findings of lymphocytic invasion
- Assoc with other autoimmune conditions: sjogren’s and ibd
- Tx non surgical: corticosteroids very effective
- Sx: Pain continuous, type 2 dm
- Dx: axr calcified panc
- Ercp for pre-op
- Steatorrhea
- Dx with 24 hour fecal fat collection
- <20g: intestinal etiology
- >20g: pancreatic insufficiency
- Tx
- Stop PO etoh
- Etoh injection to celiac for pain
- Endoscopic sphincterotomy and duct evaluation
- Surgery Indications
- Intractable pain: unrelieved by avoidance behavior, medical tx, endoscopic tx
- Suspicion of underlying carcinoma
- Ppx against deteriorating panc endocrine and exocrine function
- Surgery Goals
- Relieve pain
- Preserve quality of life
- Nutritional status: exocrine/endocrine
- Avoid life long narcs: earlier than later <2 years
- Avoid chronic pain pathways from developing in the spinal cord and brain
- Surgical principles
- Decompression of the pancreatic duct
- Denervation
- Resection of abnormal a parenchyma
- Surgical decompression operations
- Puestow: lateral pancreaticojejunostomy: need dilated duct
- Early pain relief 80%
- 30% recurrent pain within 5 years: 2’ to persistent/recurrent dz in panc head with inadequate drainage
- Anastomosis should be >6cm and < 10cm (would involve the head)
- Whipple: pancreaticoduodenectomy
- Beger: duodenum preserving pancreatic head resection
- Frey: local resection of the pancreatic head, coring out, with longitudinal pancreaticojejunostomy
- Whipple/Beger/Frey
- Similar pain relief b/w 1-4 years in 80% of pt out to 8.5 years
- Total pancreatectomy
- Severe pain exocrine and endocrine failure
- Periop death 5%
- Complete pain relief 80%
- 20% disease related death
- Autoislet txp
- Can isolate from diseased pancreas
- Possible for off site pancreatectomy
- Portal vein/transhepatic pv delivery
- All pt undergoing pancreatectomy should be considered
- Cyst-enteric anastomosis: cyst gastrostomy, Roux en Y cyst jejunostomy
- Duct stenting w or w/o lithotripsy v surgical drainage
- Endoscopic tx less effective
- Pain relief in 32% at 2 years
- Puestow: lateral pancreaticojejunostomy: need dilated duct
- Outcome predictors
- Good outcome predictors
- >50 yo
- dz duration < 2 year: limited narc use
- isolated episodes of pain > constant
- hx of dm
- no previous peustow
- duct >6mm
- social support
- inflammatory dz in pancreatic head
- Poor predictors
- Dz duration >10 years
- No dz in panc head
- Poor results from previous peustow
- Good outcome predictors
- Sympathectomy
- Transthoracic v transhiatal
- Indicated prior to total pancreatectomy
- Selecting pt
- Small duct
- Drug seeking behavior, psychogenic dz
- Differential epidural anesthesia: placebo, splanchnic v somatic blocks: exclude pt who only benefit with placebo
- Basics
- Pancreatic Exocrine Neoplasm
- Cystic Neoplasm
- Incidental Cyst
- <2cm without suspicious findings: mri in 1 yr
- >4cm consider resection
- Pancreatic cyst: biopsy
- Mucinous=tumor=resect
- Serous=observe= 6 mo f/u
- Amylase, CEA, Viscosity
- Serous Cystic neoplasm: low, low, low
- Mucinous Cystic neoplasm: low, high, high
- Psuedocyst: High, High, Low
- Incidental Cyst
- Serous Cystadenoma
- Benign, glycogen-rich epithelial lining
- Don’t communicate with pancreatic ducts
- Cluster of grapes central scar appearance
- Cea <5
- VonHippel Landau: Found in tail, mostly benign
- Histo: bland cuboidal epithelium
- Tx
- Should be left alone
- Resection for symptoms or cannot r/o malignant
- Mucinous cystadenoma: malignant potential
- 30-50% harbor Ca
- Distal, female, middle aged, peripheral calcifications, pseudocyst
- No communication with ductal system
- Single or multiple septations
- Calcifications or papillary growths indicate ca
- Histo: ovarian like stroma pathognomonic
- Cea >250, tumor markers ca 19-9, 72-4, 125, 15.3, mostly malignant
- Tx Always resection
- complete resection with regional node dissection
- Rad role uncertain
- 5 yr survival 45%
- Solid Pseudopapillary
- Young women (80%)/children
- MC pancreatic tumor in pt under 21
- In body and tail
- Locally invasive, rarely metastatic
- Surgical resection usually curative: 90% cure if localized
- Young women (80%)/children
- IPMN
- Basics
- Main duct IPMN: MDIPMN: Diffuse or segmental
- 70% harbor malignancy
- 45% have invasive caricinoma in resection specimen
- Mixed type: behave like MDIPMN: tx the same
- Branch Duct: BDIPMN Usually in head or uncinate but can occur anywhere
- Variable risk for cancer
- Size dependent
- 1-3cm: reimage at 6 mo then CT cross sectional imaging q 1 year
- >3cm, mural nodules, positive cytology or symptomatic
- Size dependent
- Variable risk for cancer
- Sx
- N/V/Abd pain/ back pain/wt loss/ anorexia
- Pancreatitis
- Sx of exocrine and endocrine panc insufficiency
- DM, high hba1c
- Grading
- Low grade dysplasia-adenoma
- Moderate: Borderline
- High: invasive
- Surgical Indication
- Symptoms
- Recurrent pancreatitis
- Communication with main duct
- Cancer/risk for developing
- IPMN are thought to follow an orderly progression from a benign neoplasm to ca
- Size dictates plan
- 1cm 17% (probably lower) Ca risk
- <1cm: mri/ct at 1 year
- <2 cm with mural nodule 25% Ca risk
- >2 cm regardless of nodule 27% Ca risk
- 1-3cm: eus plus mrcp/ercp
- high risk: resect
- Low risk: early repeat of mr/ct
- 1-3cm: eus plus mrcp/ercp
- <3cm: inc factors
- older age
- presence of sx
- dm
- Specific radiographic features:
- solid component
- main panc ductal dilation >5mm
- lymphadenopathy
- presence of mural nodules
- presence of synchronous lesions
- an inc in cyst size during follow up
- Without mural nodules risk of malignancy <40%
- Cytology
- HGA: high grade atypia: most sensitive predictor of Ca in all cysts and in small <30mm bd ipmn
- Cytology detected 30% more cancers in small cysts than dilated MDIPMN or mural nodules
- Progression to malignancy 5-6 years, varies with subtype
- Colloid carcinoma 30-50% pt with intestinal type ipmn
- Ductal adenoca develops in >50% pancreaticobiliary type ipmn, 10-30% gastric branch ipmn
- >3 cm = resection
- 1cm 17% (probably lower) Ca risk
- Recurrence after resection 17%
- 28% at 2 years
- Adeno (95%)
- Basics
- 33,000 new cases 32,000 deaths/yr
- Risk: tobacco x2, meat x2.5, endogenous cck, genetic 3-5% (85% k-ras mutation)
- Age, M>F, Blacks
- Assoc: dm, chronic panc, smoking, etoh
- 92% adeno, 5% cystadeno, 3% acinar cell
- Sx jaundice back pain, migratory thrombophlebitis
- Dx double duct sign in contrast ercp/mrcp of terminal bile and panc duct
- Poor yield: CT, fna, duct cytology
- 85% Ca 19-9, ca 50%, ca 125 (peritoneal carcinomatosis)
- Adeno Location 75% in head 20 % body 5% tail
- 65% distant mets
- 15% locally advanced:
- chemorad: med survival 17 mo
- no chemorad 7 mo
- 20% resectable
- CT staging: Contrast enhanced CT with 1mm cuts: pancreas protocol
- High predictive value for unresectability: 90-100%
- Obvious vascular invasion
- Distant metastases
- Low predictive value for resectability: May miss subtle vasc invasion
- High predictive value for unresectability: 90-100%
- EUS: when to perform
- Suspected panc mass and negative ct
- Staging: particularly with ct showing resectable lesion
- Tissue Dx
- Unresectable dz: tissue is the issue: neoadjuvant/palliative chemo
- Poor surgical candidates
- Median survival
- Resectable: 24-30mo
- Local advanced 10-18mo
- Metastatic 6-10mo
- Systemic therapy not very effective
- Median survival
- Pre-Op
- coagulopathy (vit k)
- No role for pre-op hyperal: no imp survival
- Pre-op biliary drainage: no role, elevated infectious complication
- Major controversy: if surgery planned soon, don’t 2’ infectious issues
- Stent or not
- Plastic metal
- Covered uncovered
- Factors affecting survival: tumor left at resection, tumor diameter, dna content, LN status
- Not Operable:
- LN: celiac, base of mesentery, sma, LN portal mesentery
- Options
- Locally invasive without liver mets:
- Biliary bypass and chemorad (gemcitabine and external beam rad): inc median survival 6 to 22 mo
- Bypass to cbd or gb
- Biliary bypass and chemorad (gemcitabine and external beam rad): inc median survival 6 to 22 mo
- Gastric bypass for actual (pre-mortal) or pending obstruction
- Duodenal stent v gastrojej: duodenal stent faster for enteral feeds to start but less long term durability
- Biliary stent placement: Covered metal better: endoscopic better
- Celiac plexus neurolysis: moderately effective
- Palliative resection more morbid than bypass without significant change in survival
- 8.2mo palliative 6.4 mo. Bypass
- Locally invasive without liver mets:
- Operable
- Stage 1&2 with 2b: locally advanced borderline resectable
- Stage 3 unresectable for cure
- 2cm, LN to spleen, peripancreatic, LN prepyloric, LN colon mesentery, part of smvsma
- Peripanc nodes still ok
- Celiac lymph nodes not ok
- Portal vein resection has equivalent survival as those without pv involvement so long as rest of stage is no different
- No benefit in resecting artery
- No benefit to extended lymphadenectomy
- Op mortality whipple should be <3%
- Age isnt a c/i though morbidity higher and survival less
- Complications inc with age and bmi
- Neoadjuvant tx appears to offer benefit to 20% of pt
- Gemcitabine based: Improves progression free survival but greater toxicity
- Rarely converts unresectable to resectable
- Adjuvant tx is standard for >stage 2 but additional survival still limited
- Up to 30% never get it d/t complications
- Dx Laparoscopy
- Detects carcinomatosis in most pt (ct as sensitive)
- Reduces morbitdity and avoids needless laparotomy in most pt with carcinomatosis
- Reduces costs if yield is 10%
- Improves staging for subsequent tx
- Eliminates expensive, useless tx
- Predictor for pt, clinical trials
- Laparoscopic whipple:
- Benefit from distal, subtotal, medial,
- Reduced los complications
- Improved QOL
- Median survival <2years
- Pancreaticoduodenectomy 10% 5 yr survival
- Pylorus sparing no better than distal gastrectomy
- Pyloric preserving done 2’ to dumping symptom risk
- Mucosal anastomosis of panc duct commonly thought to make less fistula, not true
- No advantage for total pancreatectomy
- Expect an intense desmoplastic reaction by tumor
- Complications
- Leak 15-25% of cases: most heal with conservative mgmt
- Octreotide
- Fistula: 10-40%
- RF: small duct, soft pancreas, bmi, poor nutrition
- Octreotide
- Decreases fistula output
- Doesn’t affect periop pancreatitis, postop mortality, reoperation rates, icu stay
- Leak 15-25% of cases: most heal with conservative mgmt
- Mets: gemcitabine
- Basics
- Cystic Neoplasm
- PNET: Pancreatic neuroendocrine tumors, pancreatic islet cell tumors, pancreatic endocrine tumors
- Basics
- Ddx
- Adeno: much more common
- Carcinoid
- Most spontaneous, 10% assoc with MEN1, vonHippel landau, tuberous sclerosis, neurofibromatosis
- Most nonfunctional and not assoc with hormone hypersecretion
- Prolonged silent progression
- Incidental find
- CT will find 70% of 3cm and 50% of 1cm
- 50% will have liver mets
- Serum marker CGA chromogranin A
- Tx
- Without mets: parenchymal sparing resection
- With mets: possible surgical debulking
- Localized liver: resect
- Diffuse: chemo
- Chemo: survival benefit
- Streptozocin and doxorubicin and 5fu: 37mo survival rate
- Temozolomide single agent or with capecitabine
- Bevacizumab, sunitinib, sorafenib
- Ddx
- Insulinoma
- MC functional neuroendocrine tumor
- Basics
- From beta cells though out panc
- Females, b/w 40-50
- most <1.5 cm
- multiple in familial type
- children dysidoblastosis
- majority benign: 20% malig
- P/w hypoglycemia on fasting or after exercise: resuscitate
- npo with iv saline
- check blood gluc q 6, if doesn’t drop <50 in 72 hr done
- if drops: insulin, c-peptide draw then give gluc
- visual disturbance mc sx
- dx: whipple’s triad (within 3 d fast)
- serum insulin high (c-peptide)
- fasting <45mg/dl
- hypogly sx
- 72 hour fast under monitored conditions: glucose <45 with serum insulin higher than 5 and high c-peptide >0.7 and proinsulin
- r/o factitious hypoglecmia with c-peptide and proinsulin levels
- ct scan, fractionated portal blood,
- octreotide not helpful
- somatostatin receptor scintigraphy don’t work to image
- Tx: surgical exploration
- Intraop u/s: resection location based
- Distal pancreatectomy
- Enucleation in body and head
- Resect metastatic lesion
- Chemo
- Diazoxide
- Dilantin
- Ocreotide
- Streptazosin
- Gastrinoma
- Basics
- Incidence: .5-3/100,000
- Second MC functional neuroendocrine tumor
- 30% familial (men1), 70% sporadic
- 60% malignant
- Usually multicentric
- 2M>F
- Gastrinoma triangle: duodenum wall mc
- Cystic to cbd, portion 2-3 duodenum, panc head and neck
- Sx Acid secretion: pain & diarrhea
- Dx basal acid o/p >15 meq/hr
- post antrectomy >5 meq/hr
- basal/max >0.6 (close to 1)
- fasting serum gastin level (>500)
- gastrin assay high gastrin, high acid (ph 2.5)
- no acid: pernicious anemia
- stimulation study
- Ca infusion: gastrin must go up by 400
- Secretin infusion: must go up 100 over baseline (over 200)
- must be off PPI for 1 wk, bridge with h2 blockers
- ppI increase serum gastrin 5x
- hold h2 blockers 24hrs prior to test
- Localize lesion
- Ct scan: 60%, U/s: 60%, Angio: 60%
-
- EUS better for pancreatic than duodenal tumors (can ID only 50%)
- Intraopduodenotomy for localization
- Somatostatin receptor scintigraphy with single photon emission computed tomography
- Most sensitive tests: 80-85% Tx of choice
- Fractionated portal venous blood: 95% (hemobilia, intraperitoneal hemorrhage)
-
- Manage
- Familial: not for operation
- Medical management: check hypercalcemia men-1, ctrl this
- Ctrl acid with ppi
- Med management fails, Highly selective vagotomy (worsens diarrhea)
- Simvastatin
- Med management fails: last resort total gastrectomy
- Sporadic
- Enucleation, excision
- Metastatic:
- Can enucleate
- Total gastrectomy
- Simvastatin
- Chemo
- Streptazosin: most effective
- Diabetic after 1 dose
- Streptazosin: most effective
- Familial: not for operation
- ZES: Zollinger-Ellison Syndrome
- Sx: Refractory Ulcers, Diarrhea
- Distal cluster of H pylori neg ulcers
- VIPoma
- 50y/o, Solitary >3cm
- 50% malignant: can include somatostatin, glucagon, insulin
- Sx watery dia, achlorhydria, hypoK
- Dx: Localize with octreotide scan
- Tx
- Correct elyte, fluid and dia
- Excise lesion
- If in liver excise liver lesion
- Glucagonoma
- Basics: 60-80% malignant found 80% in the tail and body
- Sx: 4D’s: diabetes, dermatitis, DVT, and depression
- Dermatitis 90%: migratory dermatitis: pathogmnomonic
- Necrolytic migratory erythema: predates other systemic symptoms
- Dm 90%
- Wt loss 90%
- Anemia, abd pain, diarrhea, dvt, pe (10%)
- Anemia: kupfer metabolism imp in hemoglobin metabolism
- Hypocholesterolemia
- Dx: ct scan
- Octreotide scan
- Tx: resection/ablation
- Octreotide: worsen dm, improve skin
- Somatostatinoma
- Basics
- 1: 40mill
- Assoc with NF
- Present very large, commonly with gallstones from cholestasis
- 90% Malig
- 75% panc, 25% sb and periampulary/duodenal wall
- Sx diabetes, cholelithiasis, steatorrhea, jaundiced and level >10
- Hyperchlohydria
- Dx/ Octreotide scan
- Tx/ Resection
- Basics
- Basics
Pancreas: eat when you can, sleep when you can, don’t touch the pancreas
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