Pancreas

Anatomy

-retroperitoneal organ

-oblique position--slope upward -75-100 gm -15-20 cm Region 1.head -nest in c-loop -uncinate+head--wrap rt of PV 2.neck -L1,2

-directly over portal v 3.body+4.tail

-ant to splenic a/v Pancreatic duct

1.duct of wirsung

-main duct

-usually fuse 2 at pancreatic head -normal 4 mm

2.duct of santorini

-accessory duct -60%--minor papilla -30%--blind accessory duct -10%--not fuse2--as major drain :pancreatic divisum

:inadequate drain--pancreatitis :Tx--sphincterotomy minor papilla Vascular

-sup ant/post PDA <--GDA -inf ant/post PDA <--SMA -inf pancreatic a <--SMA Vein

-sup ant/post PDV--> PV -inf post PDV--> SMV

inf ant PDV + rt GEV + mCV-->SMV -SV--> PV

Lymphatic

-SMA & celiac node Nerve SympT5-9splancnic nceliac gg Parasympvagus n Physiology 1.Pancreatic enzyme Carbo -amylase : starchglucose Protein Endopeptidase -trypsinogen—ektrypsin -chymotrypsinogen—ekchymotrypsin -proelastase—ekelastase Exopeptidase -procarboxy peptidase—ekcarboxy p Fat -pancreatic lipase -phospholipase A2 -choles esterase 2.hormone 1.insulin b cell

2.glucagon alpha cell 3.somatostatin delta cell 4.pancrea polypeptide PP cell/F cell 5.amylin (IAPP) b cell 6.pancreastatin b cell 7.ghrelin epsilon cell 4--inh exocrine

5--counterregulate insulin

6--dec insulin/somato/exocrine, inc glucagon 7--dec insulin

*normal pancreas 20% = can survive

Heterotopic pancreas

-abnormal location of pancreatic tissue -exocrine+endocrine

-stomach/duodenum/meckel

-submucosal lesion, yellow, central umbilical -Sx in symptom/incidental finding

Annular pancreas

-congenital anomaly -band of ventral pancreas -duodenal obstruction - ½infant ½40yr

-1st _{choiceduodenoduodenostomy} -not reect bandpancreatic fistula

Acute pancreatitis -inflam.ds of pancreas -little/no fibrosis of gland Etiology

1.Biliary tract ds --stone -common channel hypothesis

-sphinc of oddi icompetent--duo reflux -colocalized--inactive-->active enz

2.alcohol --blockage mechanism -spasm sphincter of oddi

-elevate enz prot

3.tumor 4.iatrogenic

-ERCP

-pancreatic biopsy -bile duct exploration -distal gastrectomy -B.II gastrectomy 5.drugs 6.infection -mumps,m.pneumoniae,coxsackie 7.hyperlipidemia -hype TGA 8.miscellaneous -hyperparathyroid-->hypercal -ascaris, c.sinensis -hereditary pancreatitismutate PRSS1 -pancreatic divisum -azotemia -vasculitis -triniidadian scorpion S+S

-knife pain/boring through to back -relief by leaning forward

-pleural effusion--Lt side

-intravascu fluid loss into retroperi -bleeding from necrotize pancreatitis :cullen sign, grey turner sign :fox sign (inguinal echymosis) Serum amylase

-peak within hour -3-5 d

-no relate to severity

False +ve -gut obstr/perforate -DU/intraabdo inflam False -ve -hyperlipidemia Severity assess

1.early prognosis sign

A.Ranson criteria 1-2--mortality 0 3-5--mortaliy 10-20% >7--mortality >50% B.APACHE II ->7--severe pancreatitis 1.non GS Age>55 hct fall10 wBc>16000 BUN elevate >5 glC>200 ca<8 lDh>350 PaO2<60 AST>250 base deficit>4

fluid >6 l 2.GS Age>70 hct fall10 wBc>18000 BUN elevate >2 glC>220 ca<8 lDh>400 fluid >4 l AST>250 base deficit>5

2.biochemical marker

¤Assess severity--mild or severe -CRP

-uri trypsinogen activate peptide--TAP

3.CT

-gold std for assess severity CT severity index Barthaza point A=normal 0 B=pancreatic enlarge 1 C=pancreatic inflammation 2 D=1 collection 3 E=>=2 collection 4 Necrosis No 0 <30% 2 30-50% 4 >50% 6 CTSI c/p mortality 0-3 8% 3% 4-6 35% 6% 7-10 92% 27%

Acute pancreatitis Tx Mild pancreatitis ¤resting pancreas¤ -restrict oral food--3-7d

:if improve--low prot/low fat diet -NG suction ,H2 blocker

-fluid balance

-avoid morphine--Oddi spasm -no document infect--no ATB Severe pancreatitis

-may develop ARDS :PLP-A2

:ICAM-1,PMN,sub-P,chemokine -peritoneal lavage--unclear Infection

-most common of death

I/C of infection

-retroperi air

-CT,u/s guide FNA +ve Sterile necrosis

3 degree aggressive

1.no systemic c/p

-as mild pancreatitis

2.systemic c/p, suspect infection

-FNA confirm

3.very ill, hi APACHE/Ranson

-aggressive debridement Pancreatic abscess -2-6 wk -external drainage Biliary pancreatitis 1.Urgent intervention -48-72hr 2.Delayed intervention ->72hr, but in hospitalization ¤favor 1 as 2 ¤cholecystectomy + CBD clearance (in obstructive pancreatitis) ¤hi risk--ERCP

3.obstruction persist>24hr

-emer ERCP+EST+remove stone ¤routine ERCP--not use

Chronic pancreatitis ¤risk ca 10x Etiology -alcohol 70% -idiopathic 20% -other--hereditary,hyperparathyroid hyperTGA,autoimmune,divisum Classification

1.chronic calcify (lithogenic) P -alcoholic,hereditary,hyperlipid, hypercal,drug induce,idiopathic 2.chronic obstructive P -pancreatic tumor -stricture -pancreatic divisum -GS related 3.chronic inflam P -unknown

(diffuse fibrosis and loss of acinar c mononuclear infiltrate the gland) 4.chronic autoimmune P

-asso PSC,PBC,sjogren synd 5.asymp pancreatic fibrosis -alcoholic,Tropical (nutrition) P (diffuse perilobar fibrosis) Tropical (nutrition) pancreatitis -indonesia,india,africa

-toxic product--cassava root :+HCL-->hydrocyanide

-asso mutate PSTI or SPINK1 gene Hereditary pancreatitis

-AD

-chronic nonalcoholic pancreatitis -childhood/adolescence

-calcify pancreas, pancreatic d obstr -PRSS1, SPINK1, CFTR gene

Idiopathic pancreatitis -no obvious cause -young adult, no fam.hx -spon.gene mutation

Histology

-nodular scarring

-perilobular fibrosis--panc stellate cell -loss of acinar cell

-dilate ductular structure -stone formation--caco3 :lithostathine are inhibited

(lithostathine--inh caco3 formation)

Imaging for 1.dx 2.assess severity 3.c/p 4.Tx option u/s -screening methods EUS

-can small lesion <1cm -can cytology,chemical sample ERCP

-Dx + can Tx maneuver -invasive procedure

-gold std for chronic pancreatitis CT

-earliest change--dilate 2°duct and heterogenous paren change MRCP -hi risk pt S+S 1.pain -steady,constant pain -penetrate to back -exacerbate by eating/alc

(alc-->tempo relief-->more severe) -typical flex abdo,sit with hip flexd -n/v, anorexia

Pain etiology

1.ductal HT--stricture,stone 2.retro.inflam--chronic pain

3.acute inc duct P--acute exacerbate Strategy to relief pain

1.decompress secretory compartment 2.resect focus of inflam change 3.neural ablative procedure Burned out pancreatitis

-dec/absent pain over period of year -appear symp of exo/endo.def -correlate with mild-->severe form 2.malabsorp+wt loss

-<10%exocrine fxndiarrhea/steatorrhea -lipase def earlier > trypsin def

3.apancreatic diabetes--DM type3

-<20%endocrine fxnimpair glc metabo -hypoglycemia > hypergly

-brittle diabetes--difficult to control -global def 3 H--insulin+gluca+PP

Chronic pancreatitis (cont) Lab 1.blood -lipase/amylase--endo.fxn -PP (test meal)--exo.fxn 2.secretion Direct -enz,bicarbonate Indirect 1.bentiromide test -urine PABA

-proteolytic metabol p-aminobenzoic 2.schilling test

-urine cobalamine

-absorb b12 by panc exocrine 3.fecal fat/chymotrypsin/elastase 4.14CO2-olein absorption -triolein breath test

Chronic pancreatitis c/p

1.pseudocyst

-most common c/p

-acute = 3-4wk chronic = >6wk -non-epi wall of granu/fibrosis -50%--can spon resolve ->6cm--less resolve -compress adjacent organ :SMV/PV thrombosis :pseudoaneurysm of GDA -perforate--peritonitis/bleeding Tx 1.asymp--expectant Tx 2.suspect infect--FNA -if infect--sx/percu drain 3.fail1,symp

-internal drain > ext drain (fistula) Methods 1.Percu.cath based -transgastric puncture -stent placement--cysto-gastros 2.Endoscopic -transgastric/duo puncture -stent placement 3.Sx -cystogastros -Roux en Y cystojejunos -cystoduodenos

4.ERCP--in commu c duct system Transpapillary stent

1.direct into pseudocyst or 2.left across duct leakage 5.resection

-tail pancreas --distal pancreatectomy

2.pancreatic ascitis

-subacute progress abdo.swelling paracenthesis

-fluid hi prot >25g/dl -hi amylase

pancreatic pleural effusion -fluid track into chest -internal pancreatic fistula Non-sx Tx

-antisecretory--octreotide -bowel rest,PPN

-pancreatic plural effusion--ICD Sx Tx

-ERCP--locate leak site +/- stent -Roux en Y pancreaticojejunostomy -distal pancreatectomy

3.pancreatic enteric fistula

Transverse/splenic flexure colon -most common

-colonic bleeding/sepsis -require sx

Stomach/duodenum -close spontaneous -persist as internal fistula

4.pancreatic head mass

-30% of advance CP -inflammatn process -severe pain

-stenosis of distal CBD/duo/PD/PV -can transform to dysplasia Tx -DPPHR 5.PV/SV thrombosis -consequence of 4 -varices formation -SV thrombosis + GV

-->lt side or sinsitral portal HT Tx

Chronic pancreatitis Tx 1.analgesia -narcotic -gabapentin -stop alcohol 2.enzyme Tx

Non enteric coat (conventional) -bind CCK releasing peptide -downregulate release CCK Enteric coat

-protect acid degradation

3.antisecretory Tx

-somatostatin--inh exocrine + CCK :200 mcg sc q 8 hr

4.neurolytic Tx

-celiac plexus neurolysis -alcohol injection -EUS guide -short life (6mo)

5.endoscopic Tx

Pancreatic duct stent -prox P duct stenosis -decomp P duct leak -drain P pseudocyst Pancreatic divisum

-minor papilla sphincterotomy Chronic pancreatitis Sx 1.sphincteroplasty

-sclerosing papillitis :pancreatitis

:passage of gall stone -endoscopic or transduodenal 2.drainage procedures

Peustow procedure

-side to side Roux en Y PJ

-in ductal HT--max.diameter 6mm

3.resection procedure

Distal pancreatectomy

-40-80%

-focal change to body,tail -no signi.duct dilatation -hi recurrece

95%Distal pancreatectomy

-sclerotic dz--small duct -preserve in PD groove

Proximal pancreatectomy

-whipple--std or PPPD

Total pancreatectomy

-no pain relief than PD -hyper/hypoglycemia

Hybrid procedure

1.DPPHR

-Duodenum Preserving Pancreatic HR -Beger procedure

-resect neck,subtotal head -preserve duodenum,CBD -roux limb of jejunum 2.LR-LPJ

-Local Resection pancreatic head c longitudinal PJ

-Frey procedure

-side to side Roux en Y PJ

-complete decompress entire duct :excavation head

:distal pancreatic dochotomy -preserve pancreatic neck -preserve post capsule -not touch PV/SMV 3.OPPHR

-Organ preserving PHR -excavation pancreatic head -without LPJ

4.denervation procedure -symptomatic relies

-poor candidate for resect/drainage -Neurolytic tx--neural ablation -Direct infiltraton of celiac GG -Operative celiac gangliectomy -Transhiatal splanchniectomy -Transthorasic splanchniectomy -Videoscopic transthorasic- splanchniectomy

Cystic neoplasm 1.pseudocyst

-most common cystic lesion -fuid--hi amylase 2.serous cystadenoma -benign lesion -50% asymptom -older women -1/2--head, 1/2--neck/body/tail -spong appearance -microcystic

-fluid--low CEA(<200) ,amylase -asso VHL 17%

Imaging

-well circum,small septate central scar,calcification

Sx

-symptomatic ->= 4 cm -can not r/o ca

3.mucinous cystadenoma/ca -benign/malignant

-2/3 body/tail

-fluid--hi CEA suggest ca

Imaging

-thick wall, not commu PD -may nodule,calcify in wall -viscous mucin

Patho

-submu--highly cellular stroma of spindle cell w elongate nuclei -->similar--ovarian stroma (key pathology) Tx -resection = Tx of choice -distal pancreatectomy 4.IPMN -head pancreas -arise in PD -recurrent pancreatitis Classification

1.main duct typeca 75% 2.branch duct typeca 20% -uncinate/less malignancy 3.combined type

Pre-op

-EUS,MRCP,ERCP

ERCP

-mucin extrude from ampulla -->fish eye lesion

Sx

Main duct typeSx

-extent resection based on intraop -can intraop P.ductoscope / frozen

Branch duct typeca f/u if - no symp

-<3 cm

-no mural nodule/thick septum 5.solid pseudopapillary tumor -solid cystic tumor

-young women -not true epi lining

-histo similar NE tumor, but not stain 6.NE tumor

Ca pancreas

-worst prognosis of all malignant -80% of pt asso DM

-new onset DM--can early manifest -2/3--head/uncinate

Patho

-ductal adenoca--75% -adenosquamous ca -acinar cell ca--large tumor Risk

-fam hx -smoking 2x

-chro pancreatitis 20x--esp fam.CP Genetic

-K-ras oncogene--most common -HER2/neu oncogene

-p53,p16,DPC4,BRCA2 Precursor lesion

-Pancreatic intraepi neoplasia -PanIN 1A,1B,2,3

Staging T1 <=2cm T2 >2cm

T3 beyond pancreas, no celiac involve T4 celiac/sma involve

N1 LN metas

Diagnostic study

CT scan

-dx/staging of choice

-accuracy for unresect - hi--90-95% accuracy for resect - low--80% Unresect

-distant metas

-SMA/hepatic a involved -LN enlarge outside pancreas -ascites

-¤¤PV/SMV not C/I

PET scan

-distinguish CP vs ca

EUS

-detect small lesion, miss by CT -no mass but hi suspicion -can transluminal bx

-sens for PV/smv invasion , not sma

Accuracy for resecectable 80%

-but intra-op 20% = unresectable

Dx lap+u/s -inc resectable to 98% Use in -tumor>4cm -body/tail -equivocal of metas/ascites in CT -ca19-9>1000 Periampullary adenoma Excised locally 1.endoscopic 2.longtitu.duodenotomy -2-3 mm margin I/C -<2cm -no malignant on bx

-no invasion duo.wall--EUS can help FAP asso

-hi incidence of ca

Whipple sx

Finding C/I resection

-liver metas, any size -celiac LN involves -peritoneal implant -hepatic hilar LN involves

Finding not C/I resection

-invade duo/stomach -invade pancreatic LN

-invade porta LN, that can remove Procedure

-incision

:midline incision--xiphoid-umbilicus :bilat subcostal incision

-assess resectability

-open gastrohepatic lig--celiac LN -assess base of T.mesocolon,MC a. -mobilize off asc/hep flexure colon -kocher maneuver

-SMV is identify

-dissect up toward inf of neck of P -ligate GE vv--prevent traction injury -assess aberrant RHA

:from sma--post of P--parallel PV :palpate HD lig

-assess porta hepatis -identify GDA--ligate -HA is retracted medially CBD is retracted laterally -dissect ant surface of PV -mobilize GB,ligate cystic a/d -remove GB

-dissect CHD circumferentially -PPPD--divide duo 2cm distal to pylo classic--antrum

-divide jejunum beyond lig of Treitz -divide CHD just above cystic d and dissect down to sup duodenum -divide P neck ant to PV

-ligate fragile v br to PV/smv Reconstruction step 1st--pancreas 2nd--bile duct 3rd--duo/stomach 1.pancreaticojejunostomy :duct to mucosa vs invagination :end to side vs end to end 2.choledochojejunostomy

:10 cm jejunal limb from panc anas 3.duodenojejunostomy

:10-15 cm from biliary anas Whipple c/p

Cause of death

-sepsis -hemorrhage -cardiovas event

1.delay gastric emptying time -conservative tx

-erythromycin 2.pancreatic fistula

Prevention

-end to side vs end to end -duct to mucosa--large duct -invaginated--small duct -jejunum vs stomach -pancreatic duct stent -octreotide

:in hi risk--duct<3mm :unclear

3.hemorrhage -dissect portal v

Zollinger Ellison Synd (ZES)

-uncontrol secrete of abnormal gastrin by duodenal or pancreatic NE tumor -80%=sporadic--solitary-->90% cure

20%=inherited--MEN1--multiple -80% in gastrinoma triangle

:cystic d--jxn 2/3 duo--jxn neck/body -50%=malignant

2clinical syndrome by

epi hyperplasia & giant gastric fold 1.ZES 2.Menetrier disease Symptom -epigastric pain -GERD -diarrhea -PU (90% of pt)

Typical ulcer=proximal duodenum Atyp ulcer=distal duo,jejunum,multi

DDx

-recurrent PU -secrete diarrhea

-gastric rugal hypertrophy -esophagitis c stricture -bleeding or perforate ulcer -familial ulcer

-ulcer w hyperca -gastric carcinoid

Dx

-gastrin level (false+ve=antisecrete) :>1000 pg/mL

:if equivocal case--secretin stimu test -BAO>15mEq/h, >5mEq/h (PU sx) -secretin stimulation test

:confirm test

:iv bolus of secretin (2u/kg) :gastrin level before/after injection :inc serum gastrin of 200 pg/ml -serum ca,parathyroid level r/o men1

Imaging

1.u/s--not very sensitive 2.CT--detect lesion>2cm 3.MRI

4.EUS

-more sensitive

-may miss smaller lesion -confuse normal LN

5.Somatostatin R.Scintigraphy--SRS -octreotide scan

-imaging of choice

-gastrinoma cell--type2 somato R 6.Dx angiography and transhepatic selective venous sampling of portal s. -a.catheter--gastroduodenal,splenic -v.catheter--hepatic v

-inject secretin--gastrin in hepatic v -signi elevate in hepatic v gastrin indicate tumor is supplied by inject a. *most important locate tumor is intraop EL

Rx

1.sporadic (nonfamilial) gastrinoma -usually solitary

-intra op u/s

-should sx resection--possible cure -explor gastrinoma triangle+pancreas -other site

:liver,stomach,SMB,mesen,pelvis -if can't locate, should consider :longitudinal duodenotomy Operable dz

Solitary tumor in pancreas -->pancreatic resection

Involved pancreas not main duct -->enucleation

Submu of duodenum

-->full thickness excision duo wall

¤exised all LN in passaro triangle

Inoperable dz or can't localization -highly selective vagotomy -5FU, doxorubicin

Liver metas

-if can resect 1°tumor-->metastec 2.MEN1

-rarely cure by operation -multiple lesion

Insulinoma

-90% = benign/solitary/sporadic 10% = malignant/MEN1/multifoci -most common panc endocrine T whipple triads

1.BS<50

2.relief symptom by glc 3.symp fasting hypoglycemia Symptom

1.autonomic nervous overactivity -fatigue,weak,hunger,tremor,sweating 2.CNS disturbance

-anxiety,agitate,coma,delirium Pathognomonic finding -serum insulin > 5mcU/mL (during sym hypoglycemic) -elevated c-peptide level

:r/o admin of insulin or oral drug (proinsulin-->insulin+c-peptide) Dx ratio -Bl insulin:glc > 0.4 Localization -CT,MRI--locate 50-60% -selective angiogram

Portovenous sampling insulin level -intra a.injection of ca (0.025meq/kg) (ca release insulin)

-into GDa,SMa,RHa or Spa -obtain insulin from rt hepatic v Tx

-typical cure by enucleation -close to panc duct and >2cm

may require a distal pancreatectomy or pancreaticoduodenectomy Glucagonoma -DM asso dermatitis -malnutrition -body/tail Dermatitis

-classic necrolytic migratory erythema -cyclic migration

-lower abdo, perieum, perioral,feet -spreading margin, healing center Dx -serum glucagon >500 pg/ml Tx -control DM, PPN, octreotide -distal pancreatectomy+/-splenectomy Somatostatinoma -GS -DM--inh insulin -steatorrhea--inh exo Clinical -abdo.pain--25% -jx--25% -cholelithesis--19% Location -peiampullar area--60% -prox.pancreas / PD groove Dx

-serum somatostatin level >10 ng/ml Tx

-complete excision tumor -cholecystectomy VIPoma WDHA synd -watery diarrhea -hypokalemia -achlorhydria

-most com--distal pancreas -most--outside pancreas Clinical

-massive(5L/d), intermittent diarrhea Dx

-serum VIP level

:multiple time-->episodic dz -EUS--most sens -CT Tx -somatostatin--control diarrhea Outside pancreas -palliative debulking -HA embolization

Nonfxn islet cell tumor -usually malignant

-clinical silent until size produce symp -large tumor, metas when dx

-marker of lesion = elevate PP -grow slowly

Summary

Location Benign:malignant Lab Sporadic:MEN1

Gastrinoma Pazzaro 50:50 gastrin>1000 pg/ml 80:20

Insulinoma 1/3+1/3+1/3 90:10 insulin/glc>0.4 90:10

Glucagonama body/tail 30:70 glucagon>500 pg/ml

Somatostatinoma head 10:90 somato>10 ng/ml