Neuroendocrine Neoplasms
Most common (functional) PNET overall?
Insulinoma
High levels of amylase indicates what feature of a cystic neoplasm?
Ductal communication :
Seen with Pseudocyst or IPMN
Most common presentation of pancreatic cancer ?
Painless jaundice
Name a method of draining a pancreatic pseudocyst?
transpapillary endoscopic stenting, endoscopic transluminal drainage , open/lap cystgastrostomy,
cystjejunostomy
What are the criteria (2) that define a pancreatic fistula ?
drain output w/ amylase > 3 times serum + a clinically relevant condition related directly to the post op panc fistula ie :
persistent drainage for 3 wks, needing perc / endoscopic drainage, needing angiographic procedures for bleeding, signs of infection
Describe the gastrinoma triangle ?
Cystic duct and CBD junction, junction of 2nd/3rd pt of duodenom, junction of neck and body of pancreas
Name at least one indication to intervene on a pancreatic pseudocyst ?
(leave along for ideally 3 mo but at least 6 wks) : intervene if > 6 cm or symptomatic
BEFORE SURGERY ALWAYS GET MRC VS ERCP as often associated w/ some duct abnormality
What is Couvoisier's sign ?
obstructive jaundice w/ palpable gallbladder
Describe the step up approach to infected necrotizing pancreatitis?
ICU fluid resus + abx, then perc drain, then upsize drain then video assisted RP drainage to complete debridement
Antibiotic of choice for infected necrotizing pancreatitis?
Imipenem
Describe the treatment for an insulinoma based on location?
head : enucleate (if benign, <2 cm), sus for malig or > 2 cm (whipple)
Distal - distal pancreatectomy
High CEA levels are seen in what (2) types of cystic neoplasms?
mucinous cyst or IPMN
When would you recommend preoperative biliary drainage in pancreatic cancer patients?
drain if getting neoadjuvant trt and jaundiced / pruritis / cholangitis (stent w/ self expanding metal stents )
*no effect on survival and assoc w/ increased wound infection rates
What is a common cause of isolated gastric varices and what is the treatment?
splenic vein thrombosis 2/2 pancreatitis : trt w/ splenectomy
Patients with IPMN have a higher risk for extrapancreatic malignancies. What is the most common one ?
Colon adenocarcinoma
What are the features of WDHA syndrome ? This is seen with what type of neoplasm?
(watery diarrhea (5L/d), hypokal, achlorhydria, met acidosis) , may also have hyperglycemia, hypercalcemia
VIPoma
*stim secretion of fluid and electrolytes into lumen and inhibits gastric acid secretion),
Pathognomic finding for IPMN
endoscopic observation of muscin secreting from a patoulous fish mouth papilla pathognomic
Describe criteria for borderline resectable pancreatic Cancer vs unresectable disease?
Borderline resectable : < 180 deg contact w/ SMA or celiac, reconstructable involvement of SMV or PV
- un-resectable : > 180 deg contact w/ SMA / celiac , mets , un-reconstructable involvement of SMV or PV
What is resected in a Whipple ?
panc head, duodenum, first 15 cm of jejunum, CBD, gall bladder and pt of the stomach
However, a common variation called the pylorus-preserving Whipple leaves the entire stomach intact, which can preserve normal stomach function and is often preferred when possible
Gene associated with chronic pancreatitis
PRSS1 (and R122H)
Presentation of a glucagonoma (2) ?
dermatitis(necrolytic migratory erythema)
DM
depression
DVT (2/2 to factor 10 like antigen sec by tumor),
weight loss
glossitis
List (2) high risk features of IPMN warranting need for resection.
obstructive jaundice, enhancing solid component, main duct >1 cm
*Worrying features you may watch in unfit surgical candidates : IPMN > 3 cm (> 2 cm in young pt) , thick cyst wall, main duct 5-9mm, non-enhancing mural nodules, abrupt caliber change of duct, LDN, pancreatitis
Presentation and management of pancreatic lymphoma
typ large B cell, mc in the head , in men in 5/6th decade, large homogenous poorly enhancing mass with peripancreatic LDN, ductal dilation is uncommon / as is vascular invasion
chemo , CHOP / R-CHOP (add rituximab) : cyclophosphamise, doxorubicin, vincristine sulfate, prednisone
Name the surgical treatment for Annular pancreas ?
sugical bypass to relived dudenal or gastric outlet obstruction : duodenoduodenostomy, GJ, DJ
- resection of the panc/ annulus should be avoided as it is associated with pancreatitis , fistula, incomplete relief of obstruction
*no trt for patients that are asymptomatic
What is a Puestow procedure and in what circumstance is it used?
chronic pancreatitis to decompress the ductal system :
longitudinal pancreaticoJejunostomy: trt duct > 7 mm w/ normal pancreatic head.
creation of retrocolic roux limb , 1-2 layer side to side pancreaticoJejenostomy, duct is opened from head to tail