Surgery Marrow Pg 291-300 (GIT)

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Questions and Answers

Which gene is associated with an increased risk of hereditary chronic pancreatitis?

SPINK1

CFTR

GLUT1

PRSS1 (correct)

Exocrine deficiency is less common than endocrine deficiency in benign pancreatic conditions.

False

What is the gold standard investigation for benign pancreatic conditions?

ERCP

The gene __________ is associated with tropical calcific pancreatitis and regulates premature activation of trypsinogen.

SPINK1 Signup and view all the answers

Match the clinical features with their respective deficiencies:

Malabsorption, Steatorrhea = Endocrine Deficiency Weight loss = Exocrine Deficiency Intractable pain = Exocrine Deficiency Blood glucose, HbA1c = Endocrine Deficiency Signup and view all the answers

Which of the following is the most common carcinoma of the pancreas?

Pancreatic Ductal Adenocarcinoma Signup and view all the answers

Smoking is not considered a risk factor for pancreatic cancer.

False Signup and view all the answers

What genetic mutation is associated with an increased risk of pancreatic cancer, prostate cancer, and male breast cancer?

BRCA-2 Signup and view all the answers

The hereditary condition that increases the risk of pancreatic cancer by 100 folds is known as ___ syndrome.

STK11 Peutz-Jeghers Signup and view all the answers

Match the following PanIN stages with their respective descriptors:

PanIN-1a = Mild dysplasia PanIN-1b = Moderate dysplasia PanIN-2 = Severe dysplasia PanIN-3 = Carcinoma in situ Signup and view all the answers

What is the first step in managing pain for patients undergoing gastroenterological and abdominal surgery?

Assess the patient's response to analgesics Signup and view all the answers

If a patient responds to analgesics, further intervention is necessary.

False Signup and view all the answers

What procedure is performed when the diameter of the main pancreatic duct is less than 5-6 mm?

ERCP + sphincterotomy Signup and view all the answers

A distal pancreatectomy involves removing the _______ and tail portion of the pancreas.

body Signup and view all the answers

Which procedure is indicated when stones are present throughout the pancreatic duct?

Puestow's procedure Signup and view all the answers

Match the surgical procedures with their indications:

Puestow's procedure = Stones present throughout the pancreatic duct Distal pancreatectomy = Removal of body & tail of pancreas End-to-end pancreatico-jejunostomy = Stones in distal pancreas ERCP + sphincterotomy = Biliary and pancreatic ductal disorders Signup and view all the answers

The Duval procedure is well-documented with detailed indications.

False Signup and view all the answers

What procedure combines Beger's and Puestow's procedures?

Frey's procedure Signup and view all the answers

Which of the following is a local complication of pancreatitis?

Pseudoaneurysm of splenic artery Signup and view all the answers

Systemic complications of pancreatitis are associated with mild severity according to the Atlanta Classification.

False Signup and view all the answers

What management option is indicated for significant abdominal distension due to pancreatic ascites?

Paracentesis Signup and view all the answers

The most common cause of early death in systemic complications of pancreatitis is __________.

MODS Signup and view all the answers

Match the following complications with their descriptions:

ARDS = Acute Respiratory Distress Syndrome SIRS = Systemic Inflammatory Response Syndrome Sepsis = Infection leading to systemic response Splenic vein thrombosis = Left sided portal hypertension Signup and view all the answers

Which of the following is the most common presentation of Periampullary Carcinoma?

Progressive obstructive jaundice Signup and view all the answers

Courvoisier's law refers to obstructive jaundice occurring without a palpable gallbladder.

False Signup and view all the answers

What is the significance of the waxing and waning of jaundice in Periampullary Carcinoma?

It is commonly seen in the ampullary variety. Signup and view all the answers

A __________ gallbladder is a possible finding in cases of inflammatory obstruction in Periampullary Carcinoma.

shriveled Signup and view all the answers

Match the specific presentations of Periampullary Carcinoma with their descriptions:

Waxing and waning of jaundice = Commonly seen in ampullary variety Jaundice associated with melena = Due to friable tumor growth Gastric outlet obstruction = Seen in duodenal adenocarcinoma Courvoisier's law = Obstructive jaundice plus a palpable gallbladder Signup and view all the answers

Which type of pancreatic condition involves abnormal duct anatomy without strictures?

Type 2 Signup and view all the answers

Which of the following is a condition associated with elevated levels of CA 19-9?

Pancreatic cancer Signup and view all the answers

Double duct sign indicates blockage of the ampullary opening.

True Signup and view all the answers

A pancreatic pseudocyst less than 6 cm in size typically requires intervention.

False Signup and view all the answers

What is the primary purpose of CA 19-9 in relation to pancreatic tumors?

Predicting and assessing prognosis Signup and view all the answers

What type of drainage procedure is done using a pig-tail catheter for infected pseudocysts?

External drainage Signup and view all the answers

For chronic pancreatitis, abnormal anatomy of the duct with strictures is classified as Type ___ in the D'Egidio Classification.

3 Signup and view all the answers

The imaging technique used for visualizing the bile and pancreatic ducts is called ______.

ERCP Signup and view all the answers

Match the following pancreatic tumor diagnostic methods with their descriptions:

EUS = Endoscopic procedure using ultrasound for localized examination FNAC = Cytological technique for obtaining tissue samples MRCP = MRI technique used for visualizing ducts PET CT = Used in staging process Signup and view all the answers

Match the following interventions with their appropriate descriptions:

Cystojejunostomy = Internal drainage procedure Cystogastrostomy = Internal drainage procedure External drainage = Drainage with pig-tail catheter NOTES = Endoscopic approach Signup and view all the answers

What complication is associated with double stone impaction?

Biliary obstruction Signup and view all the answers

What imaging technique is now considered obsolete and involves examining the duodenum?

Duodenography Signup and view all the answers

Elevated CA 19-9 levels specifically indicate pancreatic cancer only.

False Signup and view all the answers

What is the most common complication associated with pseudocyst surgery?

Hemorrhage Signup and view all the answers

Thick-walled characteristics are associated with pseudocysts.

False Signup and view all the answers

Name one cause of chronic pancreatitis according to the TIGARO classification.

Toxins Signup and view all the answers

Chronic pancreatitis leads to irreversible damage to the pancreatic _______.

parenchyma Signup and view all the answers

Match the types of pancreatic conditions with their respective characteristics:

Mucinous Cystic Neoplasm = Increased CEA and thick-walled Pseudocyst = Normal CEA and thinner walls Chronic Pancreatitis = Provided by TIGARO classification Signup and view all the answers

Which intervention is indicated for symptomatic biliary or enteric obstruction in pancreatic necrosis?

Percutaneous drainage Signup and view all the answers

Fever, increased TLC, and CRP levels indicate the presence of infected pancreatic necrosis.

True Signup and view all the answers

What is the term for a pancreatic cyst that is lined by granulation tissue?

pseudocyst Signup and view all the answers

The __________ method for managing infected pancreatic necrosis includes continuous irrigation and drainage.

Beger’s Signup and view all the answers

Match the following characteristics with their respective pancreatic pathology:

Pseudocyst = Lined by granulation tissue Infected necrosis = Elevated CRP and TLC Acute pancreatitis = Epigastric lump Chronic pancreatitis = More common for pseudocysts Signup and view all the answers

What is the classification for a tumor with a diameter greater than 4 cm?

T₃ Signup and view all the answers

M₁ indicates no distant metastasis.

False Signup and view all the answers

List two criteria of unresectability in gastrointestinal surgery.

Peritoneal metastasis, malignant ascites Signup and view all the answers

If the superior mesenteric artery is involved in a tumor, it may be classified as __________ advanced.

locally Signup and view all the answers

Match the type of surgery with its indication:

Whipple surgery = Head of pancreas m/c site Distal pancreatectomy = Body/Tail of pancreas Signup and view all the answers

Study Notes

Decision Tree for Managing Pain

Analgesic response: If a patient responds to analgesics, no further intervention is needed.
No analgesic response: The next step depends on pancreatic duct diameter and drainage presence.
- Pancreatic duct diameter < 5-6 mm: ERCP + sphincterotomy is performed.
- Pancreatic duct diameter > 5-6 mm & Drainage: Puestow's procedure is performed.
- Resection:
 - Body & tail: Distal pancreatectomy is performed.
 - Head: Beger's, Duodenal preserving pancreatic head resection, or Duval procedure is performed.

Procedures & Indications

Puestow's procedure: Longitudinal pancreatico-jejunostomy for stones in the pancreatic duct.
Beger's procedure: Duodenum preservation procedure.
Duval procedure: Not further described in provided text.
End-to-end pancreatico-jejunostomy: Connecting pancreas directly to jejunum, used for stones in the distal pancreas.

Genes in Benign Pancreatic Conditions

PRSS1: Located on chromosome 7, increased risk of hereditary chronic pancreatitis.
SPINK1: Seen in tropical calcific pancreatitis.
- Secreted by acinar cells, associated with cassava ingestion.
- Regulates trypsinogen activation.
- Increased risk of cancer.
CFTR gene: Also plays a role in benign pancreatic conditions.

Clinical Features of Benign Pancreatic Conditions

Features are seen after 80-90% destruction of the pancreas.
Exocrine deficiency is more common than endocrine deficiency.

Exocrine vs Endocrine Deficiency

Exocrine Deficiency: Reduced pancreatic enzymes leading to malabsorption, steatorrhea, diarrhea, and weight loss.
Endocrine Deficiency: Reduced insulin, leading to elevated blood glucose and HbA1c, often with intractable pain.
Pain: Caused by fibrosis and ineffective drainage due to strictures, scars, and stones (CaCO3) in the pancreatic duct.

Investigations for Benign Pancreatic Conditions

MRCP with secretin stimulation: Shows ineffective drainage d/t stones and dilated main pancreatic duct.
ERCP: Gold standard investigation.
EUS: Diagnostic tool using Rosemont criteria.

Pancreatic Ductal Adenocarcinoma

Risk factors:
- Smoking
- Obesity
- African American ethnicity
- Genetic factors:
  - PRSS1 gene: Hereditary pancreatitis.
  - SPINK1 gene: Tropical calcific pancreatitis.
- Chronic pancreatitis
- Syndromes:
  - STK11 Peutz-Jeghers syndrome: Increased risk of pancreatic cancer 100-fold.
  - Familial atypical mole & multiple melanoma syndrome.
  - Cystic fibrosis.
  - BRCA-2 gene mutation.
  - Lynch-2 syndrome.
  - Familial adenomatous polyposis: Increased risk of periampullary cancer and pancreatic ductal adenocarcinoma.
BRCA-2 gene: Predisposes to pancreatic, prostate, and male breast cancer.
Lynch-1: Increased risk of colorectal cancer.
PanIN: Pancreatic intraepithelial neoplasia.

Pancreatic Tumour Investigation

CECT (Computed tomography): Used for localization.
Duodenography:
- Frostberg reverse 3 sign: Obsolete method.
- X-ray: Shows widening of duodenal loops.
MRCP & ERCP: Used for visualizing the bile and pancreatic ducts.
Double Duct Sign: Indicates ampullary opening blockage, widening of the pancreatic duct and CBD.

Transgastric EUS Guided FNAC

EUS (Endoscopic Ultrasound): Endoscopic procedure using ultrasound for localized examination.
FNAC (Fine needle aspiration cytology): A cytological technique for obtaining tissue samples.

CA 19-9

Predictive and prognostic marker: Helps predict and assess the prognosis of a disease.
Identifies patients for staging laparoscopy: Used to identify patients needing surgery staging.
Done prior to definitive surgery in GI tumors: To identify metastasis in GI malignancies.
Increased CA 19-9: Indicates staging laparoscopy is needed.
Normal CA 19-9 after neoadjuvant chemotherapy: Useful to see if chemotherapy was effective.
Important prognostic marker (Not specific): Important for prognosis, but might be elevated in other conditions.
Conditions with ↑ CA 19-9:
- Cholangiocarcinoma
- Gall bladder cancer
- Pancreatic cancer

Staging for Pancreatic Ductal Adenocarcinoma

PET CT (Positron Emission Tomography Computed Tomography): Used in the staging process.

Benign Pancreatic Conditions: Complications & Atlanta Classification

Local Complications: Pseudocyst, necrosis, pseudoaneurysm of splenic artery, splenic vein thrombosis, left pleural effusion.
Systemic Complications: ARDS, MODS (most common cause of early death), sepsis, SIRS (most common cause of death).
Pseudoaneurysm of splenic artery: Most common vessel involved; managed with ligation or embolization.
Splenic vein thrombosis: Leads to left-sided portal hypertension, clinical features include upper GI bleeding, managed by splenectomy.

Terminologies in Pancreatitis

Time since onset	Collection Type
4 weeks	Heterogeneous collection
	Pseudocyst

Management:
- Small collection on CECT: Conservative management.
- Symptomatic and large: Pigtail catheter and drainage.

Pancreatic Ascites

Caused by: Disruption of the pancreatic duct.
Features: Significant abdominal distention with intra-abdominal fluid (amylase and protein rich).
Management: Paracentesis (with pig-tail catheter), Octreotide/somatostatin (decreases secretions), stent placement.

Benign Pancreatic Conditions: D'Egidio Classification

	Type 1	Type 2	Type 3
Acute Pancreatitis	+	+	-
Chronic Pancreatitis	-	+	+
Ductal Anatomy	Normal	Abnormal without strictures	Abnormal with strictures
Ductal Communication	No	No	Yes
Appearance	-	-	Retention cyst

Management: Most cases resolve spontaneously..
Indications for intervention: Size > 6 cm, duration > 6 weeks, wall thickness > 6 mm.

Intervention for Benign Pancreatic Conditions

External drainage:*
Indications: Infected pseudocyst, hemorrhage inside cyst
Principles:
- Drainage with pigtail catheter
- Rule out communication with duct (to avoid pancreatic fistula)
- Management: Stent in duct followed by external drainage
Internal drainage:*
Cystojejunostomy
Cystogastrostomy
Surgical approaches:*
Open surgery
Laparoscopic
Endoscopy/Natural orifice transluminal endoscopic SX (NOTES)

Periampullary Carcinoma

Periampullary carcinoma is a group of four cancers located within 2 cm of the ampullary opening:
1. Carcinoma head of pancreas
2. Ampullary variety
3. Cholangiocarcinoma of distal CBD
4. Duodenal adenocarcinoma
Clinical Presentation:
- Progressive obstructive jaundice: Most common presentation.
- Weight loss
- Pain: High intensity in the tail and body.
Specific presentations:
- Waxing and waning of jaundice: Commonly seen in ampullary variety.
- Jaundice associated with melena: Due to friable (easily broken) tumor growth.
- Gastric outlet obstruction: Seen in duodenal adenocarcinoma.
- Courvoisier's law: Obstructive jaundice plus a palpable gallbladder, rarely caused by gallstones.
Further Obstruction Details:
- Tumor blocking CBD (Common Bile Duct) leading to a common obstruction.
- Obstruction leading to Dilated Biliary Tree and Distended Gall Bladder: Possible findings.
- Palpable gall bladder: Possible, and pyriform (pear-shaped).
- Gallstones causing CBD obstruction: Uncommon cause of combined jaundice and palpable gallbladder.
- No gallstone obstruction: Could suggest an inflammatory fibrosis of gallbladder causing the conditions.
- Shriveled gall bladder: Possible in cases of inflammatory obstruction

Chronic Pancreatitis

**TIGARO classification of causes: **
- Toxins: Alcohol (most common), cigarette smoking, hypercalcemia, chronic renal failure.
- Idiopathic: Unknown cause.
- Genetic: PRSSI, CFTR, SPINK 1 mutation.
- Autoimmune: IgG4 mediated.
- Recurrent: Post necrotic (severe acute pancreatitis), recurrent acute pancreatitis, vascular diseases.
- Obstructive: Gall stones, pancreatic divisum, pancreatic duct scars.
Note: Fibrosis and chronic inflammation lead to irreversible damage to the pancreatic parenchyma.

PANCREATIC NECROSIS

Indications for intervention:
- Persistent pain.
- Failure to improve clinically with conservative management.
- Symptomatic biliary/enteric obstruction.
Management:
- No intervention: Possible outcomes are either improvement or high mortality.
- Step-up approach:
  - Percutaneous drainage with pigtail catheter.
  - Minimally invasive retroperitoneal debridement (option if percutaneous drainage fails, but results in high mortality).
Diagnosis:
- CT: Gas bubbles.
Infected Necrosis:
- Fever (+)
- Increased TLC
- Increased CRP
Beger's method for infected necrosis:
- High mortality.
- Continuous irrigation and drainage of saline through both tubes.

PSEUDOCYST:

Definition: Lined by granulation tissue.
Location: Lesser sac (most common), Abdomen.
Clinical features:
- Epigastric lump
- Nausea and vomiting
- History of acute pancreatitis/recurrent attacks in the past.
More common in: Chronic pancreatitis.

Additional Notes

Active space: Mentioned in the graphic.
Gas bubbles (+): Mentioned in the graphic.
Heterogeneous: Mentioned in the graphic.

AJCC Classification (7th & 8th) - Tumour Staging

Stage	Diameter (cm)
T₁	≤4
T₂	2-4
T₃	>4
T₄	Adjacent structure involvement

AJCC Classification (7th & 8th) - Metastasis Staging

Stage	Description
M₀	No distant metastasis
M₁	Distant metastasis, most common site: liver

Management of Resectable Tumor: Varadhachary - Katz Criteria

Clinical Stage of Disease	AJCC	Involvement of Superior Mesenteric A.	Involvement of Celiac Axis	Involvement of Common Hepatic A.	Involvement of Superior Mesenteric V.- Portal V.Junction	Mx
Resectable (All 4 resectables)	I/II	No involvement	-	-	Patent	Surgery
Borderline		No involvement	-	-	Short segment occlusion	Chemotherapy → Sx
Locally Advanced (Only if required)	III				Long segment of occlusion	Unresectable → Palliative

Peritoneal Mets:

Diagnostic laparoscopy: 10C.
Procedure abandoned.
Criteria of unresectability:
- Peritoneal mets
- Malignant ascites
- Liver mets

Surgical Management

	Resectable	Unresectable
Head (m/c site), Periampullary	Whipple surgery
Body/Tail	Distal pancreatectomy

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Description

This quiz covers decision trees and procedures for pain management in patients with pancreatic conditions. It includes responses to analgesics and further interventions based on pancreatic duct characteristics. Test your knowledge of procedures like Puestow's, Beger's, and the implications of pancreatic duct diameter.