013A - Pancreas.pdf

PANCREAS KHRISTINE S. OLITA, MD OUTLINE ACUTE PANCREATITIS PANCREATIC EXOCRINE NEOPLASM CHRONIC PANCREATITIS Pancreatic cancer PANCREATIC ENDOCRINE NEOPLASM...

PANCREAS KHRISTINE S. OLITA, MD OUTLINE ACUTE PANCREATITIS PANCREATIC EXOCRINE NEOPLASM CHRONIC PANCREATITIS Pancreatic cancer PANCREATIC ENDOCRINE NEOPLASM Ampullary adenoma Insulinoma Lymphoma Noninsulinoma hyperinsulinemia hypoglycemia syndrome Cystic neoplasms Gastrinoma Vasoactive intestinal peptide secreting tumor (VIPoma) Glucagonoma Somatostinoma Nonfunctioning pancreatic endocrine tumors Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE ACUTE PANCREATITIS PANCREATIC EXOCRINE NEOPLASM CHRONIC PANCREATITIS Pancreatic cancer PANCREATIC ENDOCRINE NEOPLASM Ampullary adenoma Insulinoma Lymphoma Noninsulinoma hyperinsulinemia hypoglycemia syndrome Cystic neoplasms Gastrinoma Vasoactive intestinal peptide secreting tumor (VIPoma) Glucagonoma Somatostinoma Nonfunctioning pancreatic endocrine tumors ACUTE PANCREATITIS Most common inpatient principal gastrointestinal discharge diagnosis in the US (274,119 in 2009) 5-80 per 100,000 Incidence worldwide Crude mortality rate of 1/100,000 14th most common overall GI deaths 9th most common noncancer cause of GI deaths Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ACUTE PANCREATITIS Brunicardi, F., et.al. 2015. Schwartz’s Principles of Surgery, 10th edition. Mc-Graw Hill Education. New York. ACUTE PANCREATITIS Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ACUTE PANCREATITIS Epigastric pain radiating to the Diagnosis: back ü Elevated serum amylase and lipase (>3x upper normal) PE: o Epigastric tenderness ü Contrast-enhanced CT (If equivocal findings) o Cullen’s Sign - bruise-like discoloration around the umbilicus o Grey Turner’s Sign – bruise -like discoloration in the flanks Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ACUTE PANCREATITIS PREDICTING SEVERITY Prognostic or predictive markers that accurately stratify the risk Ranson’s Criteria BISAP APACHE II Modified Glasgow Criteria Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ACUTE PANCREATITIS PREDICTING SEVERITY ACUTE PANCREATITIS CLASSIFICATION OF SEVERITY Revised Atlanta Classification Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ACUTE PANCREATITIS MANAGEMENT Antibiotics – not recommended Pain management o Mild pain (NSAIDs) Fluid resuscitation o Severe pain (buprenorphine, pentazocine, procaine hydrochloride, o 5-10mL/kg for the 1st 24hours and meperidine) o Lactated Ringer’s solution o AVOID Morphine - causes spasm of Nutritional support the sphincter of Oddi o Enteral nutrition (mainstay) o NGT – if feeding is not tolerated within 3-5days o Parenteral nutrition* Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ACUTE PANCREATITIS MANAGEMENT Delayed surgical intervention is Indications for open surgery: better ü Step-up approach to percutaneous/ endoscopic Percutaneous drainage drainage Endoscopic drainage ü Abdominal compartment syndrome ü Acute abdomen (perforation or ischemia) Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE ACUTE PANCREATITIS PANCREATIC EXOCRINE NEOPLASM CHRONIC PANCREATITIS Pancreatic cancer PANCREATIC ENDOCRINE NEOPLASM Ampullary adenoma Insulinoma Lymphoma Noninsulinoma hyperinsulinemia hypoglycemia syndrome Cystic neoplasms Gastrinoma Vasoactive intestinal peptide secreting tumor (VIPoma) Glucagonoma Somatostinoma Nonfunctioning pancreatic endocrine tumors  Incurable, chronic inflammatory CHRONIC PANCREATITIS condition Multifactorial Highly variable presentation Challenging to treat Etiology: Alcohol (38-94%) Smoking (increase risk of cancer) Gallstones Obstruction Hereditary Hyperlipidemia Hypercalcemia Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc- Graw Hill Education. New York.  Clinical presentation: CHRONIC PANCREATITIS o Pain (mid-epigastric) o Malabsorption o Weight loss o Diabetes Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2015. Schwartz’s Principles of Surgery, 10th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. CHRONIC PANCREATITIS DIAGNOSIS Amylase and lipase Imaging: o Ultrasound (Initial) o EUS o CT Scan o MRI o MRCP – screening for duct abnormalities o ERCP (Gold standard for diagnosing and staging CP) § 5% risk of pancreatitis Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. CHRONIC PANCREATITIS MANAGEMENT Medical Therapy o Pain medication o Somatostatin analogues (anti-secretory) o Enzyme therapy o Regional nerve block Endoscopic Surgical Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York.  Surgical CHRONIC PANCREATITIS o Sphincteroplasty MANAGEMENT o Drainage procedures § Pancreaticojejunostomy (Duval, Morbidity rate and operative time Puestow) o Frey < Beger < Whipple § Pancreatic resection (Whipple Procedure, Total Postoperative pain: same Pancreatectomy) Diabetes § Pancreatic head resection: v Duodenum-preserving o Slightly lower in Frey and Beger pancreatic head resection than Whipple (DPPHR) (Beger) v Local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR- LPJ) (Frey) Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. PANCREATICOJEJUNOSTOMY DUVAL AND PUESTOW Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. PANCREATICODUODENECTOMY WHIPPLE PROCEDURE Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. DUODENAL-PRESERVING PANCREATIC HEAD RESECTION BEGER Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. LOCAL RESECTION OF PANCREATIC HEAD WITH LONGITUDINAL PANCREATICOJEJUNOSTOMY FREY Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. CHRONIC PANCREATITIS COMPLICATIONS Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. CHRONIC PANCREATITIS COMPLICATIONS Pancreatic fluid Characteristic Management of Pseudocyst collection ü Conservative (first-line) Peripancreatic Lacks a well-organized wall fluid collection Early pancreatic >30% gland involvement ü Endoscopic drainage (sterile) necrosis Liquified and with debris o Transgastric or transduodenal Late pancreatic With well-defined margin/wall drainage with stent placement (sterile) necrosis Acute Occurs with preceding 3-4 weeks pseudocyst Resolve spontaneously (50%) ü Surgical drainage o Cystogastrostomy Chronic Persists for >6 weeks pseudocyst o Roux-en-Y cystojejunostomy Pancreatic Gross purulence present o Cystoduodenostomy abscess With documented bacterial/fungal organism Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ENDOLUMINAL CYSTOGASTROSTOMY Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. ROUX-EN-Y PANCREATICOJEJUNOSTOMY Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OUTLINE ACUTE PANCREATITIS PANCREATIC EXOCRINE NEOPLASM CHRONIC PANCREATITIS Pancreatic cancer PANCREATIC ENDOCRINE NEOPLASM Ampullary adenoma Insulinoma Lymphoma Noninsulinoma hyperinsulinemia hypoglycemia syndrome Cystic neoplasms Gastrinoma Vasoactive intestinal peptide secreting tumor (VIPoma) Glucagonoma Somatostinoma Nonfunctioning pancreatic endocrine tumors PANCREATIC ENDOCRINE NEOPLASMS INSULINOMA Most common Diagnostic test of choice: 90% Benign, 10% Malignant ü Low blood sugar Whipple’s Triad: ü Elevated Insulin and C-peptide ü Fasting hypoglycemia ü CT scan and EUS (localizes ü Serum glucose 2cm) Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. PANCREATIC ENDOCRINE NEOPLASMS NONINSULINOMA HYPERINSULINEMIA HYPOGLYCEMIA SYNDROME Beta-cell hypertrophy, islet hyperplasia and increased beta-cell mass Management: ü Conversion of the gastric bypass to a form of bariatric procedure that Nesideoblastosis: restores normal intestinal flow of o With ectopic islet tissue, multilobulated nutrients islets, and ductuloinsular complexes o Risk factors: § Roux-en-Y gastric bypass for obesity § Pancreatectomy o Prolonged hypersecretion of incretin hormones (GIP and GLP-1) after the gastric bypass Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York.  Acid hypersecretion, peptic ulceration, PANCREATIC ENDOCRINE NEOPLASMS esophagitis GASTRINOMA Associated with Zollinger-Ellison Syndrome Passaro’s Triangle (most common location) Diagnostic test of choice: ü Serum gastrin >1000 pg/mL ü Octreotide Scintigraphy + CT Management: ü Enucleation/ Resection (w/o liver metastasis ü Streptozocin, Doxorubicin, 5-FU (Unresectable) 80% 5-year survival (if w/o liver metastasis) 20-50% 5 year survival (if with liver metastasis) Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. PANCREATIC ENDOCRINE NEOPLASMS VASOACTIVE INTESTINAL PEPTIDE SECRETING TUMOR VIPoma Diagnostic test of choice: WDHA syndrome ü VIP measurement o Watery Diarrhea ü CT scan (localizes tumor) o Hypokalemia ü EUS (most sensitive) o Achlorhydria Management: Distal pancreas (location) ü Fluid and electrolyte replacement ü Somatostatin analogues ü Palliative debulking ü Hepatic artery embolization* Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. PANCREATIC ENDOCRINE NEOPLASMS GLUCAGONOMA Diabetes + dermatitis Diagnostic test of choice: Necrolytic migratory erythema ü Serum glucagon >500 pg/mL o Cyclic migrations of lesions with ü CT scan (localizes tumor) spreading margins and healing centers Management: o lower abdomen, perineum, perioral area, and feet ü Control of diabetes ü Parenteral nutrition Malnutrition ü Octreotide/ Somatostatin analogues Location: Body and tail of the pancreas ü Debulking Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. PANCREATIC ENDOCRINE NEOPLASMS SOMATOSTINOMA Gallstones (bile stasis) Diagnostic test of choice: Diabetes (inhibition of insulin secretion) ü Serum somatostatin >10 ng/mL Steatorrhea (inhibition of pancreatic ü CT scan (localizes tumor) exocrine secretion and bile secretion) Management: Abdominal pain, jaundice, cholelithiasis ü Complete tumor excision + cholecystectomy Location: Proximal pancreas/ pancreatoduodenal groove o Ampulla/ periampullary area (60%) Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. PANCREATIC ENDOCRINE NEOPLASMS NONFUNCTIONING PANCREATIC ENDOCRINE TUMORS Pancreatic Endocrine Tumors (PET) Management: Pancreatic Neuroendocrine Tumors ü Surgical resection (if no (pNET) metastasis) ü Tumors of the body and tail (include splenectomy) No clinical syndrome ü Observation: o Small (80 years old) Nonspecific and variable symptoms 1/10,000 is malignant 2-10% Mortality Diagnosis 30-40% Morbidity ü MRI with MRCP (preferred imaging modality) Goal: ü EUS (For high-risk cyst) o Identify the minority of cysts that pose ü CT Scan a significant risk o Provide individual patients with an accurate assessment of their unique risk-benefit ratio of resection vs. surveillance Brunicardi, F., et.al. 2019. Schwartz’s Principles of Surgery, 11th edition. Mc-Graw Hill Education. New York. OTHER PANCREATION EXOCRINE NEOPLASMS CYSTIC NEOPLASMS University Hospital of Leicester. 2014. Cystic neoplasms. Aslan, A, Inan, I., Orman, S., Aslan, M., Acar, M. 2017. Radiological and endoscopic imaging methods in the management of cystic pancreatic neoplasms. Acta gastro-enterological belgica. Tanaka M, Fernández-Del Castillo C, Kamisawa T, Jang JY, Levy P, Ohtsuka T, Salvia R, Shimizu Y, Tada M, Wolfgang CL. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology. 2017 Sep-Oct;17(5):738-753. doi: 10.1016/j.pan.2017.07.007. Epub 2017 Jul 13. PMID: 28735806. Tanaka M, Fernández-Del Castillo C, Kamisawa T, Jang JY, Levy P, Ohtsuka T, Salvia R, Shimizu Y, Tada M, Wolfgang CL. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology. 2017 Sep-Oct;17(5):738-753. doi: 10.1016/j.pan.2017.07.007. Epub 2017 Jul 13. PMID: 28735806. Aslan, A, Inan, I., Orman, S., Aslan, M., Acar, M. 2017. Radiological and endoscopic imaging methods in the management of cystic pancreatic neoplasms. Acta gastro-enterological belgica. THANK YOU