eMentorSurgery

Dear students, This is only for your revision and NOT A FULL TEXT.  

Pseudocyst of Pancreas

•        The term pseudocyst denotes absence of an epithelial liningin contrast to true cysts

•        Encapsulated collections of fluid with high enzyme concentrations thatarise from the pancreas.

•        They are usually located either within or adjacent to the pancreas inthe lesser sac.

•        The walls of a pseudocyst are formed by inflammatory fibrosis of theperitoneal, mesenteric and serosal membranes which limits spread of thepancreatic juice as the lesion develops.

Pseudocyst of Pancreas

•        Early or late presentation

•        Pain is the most common finding

•        Fever, weight loss, tenderness, palpable mass

•        Jaundice rarely

•        Elevated amylase and WBC in ~ 50%

•        CT scan is the investigation of choice

•        D/D Abscess, phlegmon, neoplastic cysts

Pseudocyst of Pancreas

Complications

•        Infection

–       > Abscess

•        Rupture

–       Severe chemical peritonitis

•        Haemorrhage

ChronicPancreatitis

•        Is an entity encompassing recurrent or persistent abdominal pain ofpancreatic origin combined with evidence of exocrine and endocrineinsufficiency and marked pathologically by irreversible parenchymaldestruction.

•        It is associated with alcohol abuse, Hyperparathyroidism, congenitalanomalies of the pancreatic duct and pancreatic trauma. It may also beidiopathic.

ChronicPancreatitis

•        Patients typically present in the fourth or fifth decade with a historyof alcohol abuse and with epigastric or back pain.

•        Anorexia and weight loss may be present.

•        1/3 of pts. Have insulin-dependent diabetes

•        1/4 of pts have steatorrhea.

•        Narcotic abuse is common

ChronicPancreatitis

•        PFA shows pancreatic calcifications in ~50%

•        CT scan can show pancreatic parenchymal nodularity, calcifications andpancreatic ductal dilatation.

•        Pancreatography (ERCP) is diagnostic

ChronicPancreatitis

Medical Treatment

•        Control of abdominal pain

•        Treatment of endocrine and exocrine insufficiency

ChronicPancreatitis

Surgical Treatment

•        Celiac plexus block (<30% long lasting benefit)

•        Thoracoscopic splachnicectomy

•        Ampullary procedures

–       Limited application

–       Pts with focal obstruction at the ampullary orifice

•        Ductal drainage procedures

–       Puestow procedure (side to side pancreatico-jejunostomy)

–       (pancreatic duct >1cm.)

•        Ablative procedures

–       Pancreatectomies

Neoplasmsof the pancreas

Exocrine tumours

Periampullary Carcinoma

•        Cancer of the head of pancreas 85%

•        Ampullary carcinoma 10%

•        Duodenal carcinomas <5%

•        Distal Common Bile Duct Ca <5%

PeriampullaryCarcinoma

•        Jaundice

•        Weight loss

•        Anorexia

•        Vague abdominal pain

•        Elevated bilirubin, Alk. Phosphatase, AST, ALT

•        Tumour markers CA 19-9 not sufficientlyaccurate

•        CT scan to determine the size and to detectmetastatic spread

•        Selective celiac and mesenteric angiogramcombined with portal venography  toassess resectability.

PeriampullaryCarcinoma

•        Palliation with Drainage of biliary tree withstents

•        Duodenal obstruction poorly palliatednon-operatively

•        Surgical treatment is feasible

•        Only 40% of pre-operatively resectable tumoursare resectable, and this rate is even lower for adeno-Ca of head of pancreas.

•        Whipple’s pancreaticoduodenectomy

PeriampullaryCarcinoma

•        Overall 5 year survival 25%

•        Head of pancreas Ca 5-year survival <20%

•        Other periampullary Ca 5 year survival ~60%

•        Chemotherapy alone not significant benefit

•        Combined Radio-chemotherapy and local radiationtherapy have shown some benefit at least in local tumour control.

Carcinomaof Body and Tail

•        30% of all cases of pancreatic Cancer

•        Weight loss and abdominal pain

•        CT scan and ERCP

•        Resectability rate <7%

•        Poor prognosis (mean survival 5 to 6 months)

Neoplasmsof the pancreas

Endocrine tumours

•        Pancreatic islet cell endocrine tumour are rare and are presumed tooriginate from neural crest cells.

•        Functional endocrine tumours are conventionally named according to themajor hormone produced by the hormone.

•        Malignancy is determined by the presence of local invasion, the spreadto regional lymph nodes, or the existence of hepatic or distant metastases.

Neoplasmsof the pancreas

Endocrine tumours

•        Up to 25% of pancreatic endocrine tumours are classified asnon-functional based on the absence of a clinical syndrome and the lack ofelevated serum hormone levels.

•        Non-functioning tumours frequently have clinical manifestations similarto the more common exocrine malignancies

•        Non-functioning tumours are associated with a higher malignancy ratethan are their functioning counterparts.

EndocrinePancreatic tumours

Principles of management

•        Recognition of the abnormal physiologic mechanism or characteristicsyndrome

•        Detection of hormone elevations in serum by radioimmunoassay

•        Localization and staging of the tumour in preparation for operativetherapy.

•        Goals of treatment:

–       control of symptoms due to hormone excess

–       Excision of maximal neoplastic tissue

–       Prevention of tumour recurrence.

EndocrinePancreatic tumours

•        Insulinoma

–       Most common endocrine tumour

–       90% benign solitary pancreatic adenomas

•        Gastrinoma

–       Second most common

–       Peptic ulcer disease.

–       Elevated serum gastrin

•        VIP-oma

–       Watery diarrhea, hypokalemia, achlorydria

•        Somatostatinoma