PPDUASOM
Upcoming SlideShare
Loading in...5
×
 

PPDUASOM

on

  • 3,235 views

 

Statistics

Views

Total Views
3,235
Views on SlideShare
3,230
Embed Views
5

Actions

Likes
3
Downloads
274
Comments
0

2 Embeds 5

http://www.uab.edu 4
http://www.slideshare.net 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

PPDUASOM PPDUASOM Presentation Transcript

  • Diseases of the Pancreas John Christein Section of Gastrointestinal Surgery Department of Surgery
  • Congenital Problems
  • Annular Pancreas
    • Developmental malrotation of the dorsal and ventral pancreas
    • Resulting in duodenal narrowing or obstruction
    • 50% identified in childhood
    • Treatment: duodenal bypass; do not divide pancreas - leak, pancreatitis
  • Annular Pancreas
  • Pancreas Divisum
    • Non-fusion of the ducts of Wirsung and Santorini
    • Maintain separate openings into duodenum
    • 3-10% population
    • Rediscovered with widespread use of ERCP/EUS
    • Rare cause of recurrent acute pancreatitis
    • Surgical therapy: sphincteroplasty of duct of Santorini plus/minus Wirsung
  • Pancreas Divisum
  • Pancreas Divisum
    • Recurrent acute pancreatitis
    • Endoscopic minor and major sphincteroplasty
    • Transduodenal minor sphincteroplasty
  • Pancreatitis
  • Marseilles Classification
    • Acute pancreatitis
    • Recurrent acute
    • Recurrent chronic
    • Chronic pancreatitis
  • Acute Pancreatitis
    • Moynihan 1925: “Acute pancreatitis is the most terrible of all calamities that occur in connection with the abdominal viscera. The suddenness of its onset, the illimitable agony which accompanies it and the morality attendant upon it render it the most formidable of catastrophes.”
  • Acute Pancreatitis
    • Pathologic classification
      • Edematous (mild) 80-90%
      • Hemorrhagic
      • Necrotizing
  • Acute Pancreatitis
    • Pathophysiology
      • Not clearly defined
      • Parenchymal or ductal disruption/obstruction
      • Reflux of bile/duodenal contents into the duct
      • Increased ductal permeability
      • Activation of pancreatic enzymes (trypsinogen)
      • Compliment activation
      • Ischemic injury
      • Reperfusion injury
  • Acute Pancreatitis
    • Morality
      • Overall < 2%
      • Severe pancreatitis 15%
      • (>3 Ranson’s criteria)
  • Acute Pancreatitis
    • Etiology
      • Biliary disease, ethanol > 80%
      • Other main causes
      • Hyperlipidemia (Types I, IV, V)
      • Pancreas divisum
      • Idiopathic
      • ERCP
      • Other causes: peptic ulcer, trauma, drugs (thiazides, steroids, imuran), hypercalcemia, hereditary, infectious agents (viral, bacterial), pancreatic carcinoma
  • Acute Pancreatitis
    • Diagnosis
      • Symptoms: progressive epigastric pain, nausea, vomiting
      • Signs: hypovolemia, tachycardia, orthostasis, abdominal tenderness/fullness
      • Laboratory studies: amylase, lipase, LFT
  • Acute Pancreatitis
      • Imaging
        • Plain films: segmental GI ileus
        • Ultrasound: pancreatic edema
        • CT scan: phlegmon, edema, fluid collections
        • Dynamic CT scan: bolus IV contrast. Defines areas of hypoperfusion/peripancreatic necrosis
  • Acute Pancreatitis
    • Differential diagnosis
        • Perforated peptic ulcer
        • Mesenteric ischemia (acute)
        • Strangulated small bowel
        • Biliary colic
        • Myocardial infarction
  • Acute Pancreatitis
    • Prognostic factors-Ranson’s criteria
      • On admission:
        • Age over 55 years
        • WBC count > 16,000
        • Blood glucose > 200
        • Serum LDG > 350
        • Serum SGOT > 250
  • Acute Pancreatitis
    • Prognostic factors-Ranson’s criteria
      • After 48 hours:
        • Hematocrit fall > 10%
        • BUN rise > 5
        • Calcium <8
        • pO2 < 60
        • Base deficit > 4
        • 6 liters or more fluid sequestration
        • No Risk Factors Mortality (%)
        • < 3 1
        • 3-4 15
        • 5-6 40
        • 7-8 100
  • Acute Pancreatitis
    • Supportive therapy
        • Volume resuscitation: CVP, Swan-Ganz
        • Analgesia
        • Antibiotics:
          • No role in mild pancreatitis
          • May decrease sepsis rate in severe NECROTIZING pancreatitis, but offers no survival advantage
  • Acute Pancreatitis
    • Therapy
      • Supportive therapy
          • Post duodenal enteral feeding
          • TPN: does not alter course of disease. Helps maintain nutrition
      • Endoscopic sphincterotomy if an impacted gallstone is suspected
  • Acute Pancreatitis
    • Operative Indications
      • Clinical deterioration
      • Infected Necrosis
    • Operative procedure
      • Drain & debride necrotic/infected tissue
  • Acute Pancreatitis
    • Complications
      • Pancreatic/peripancreatic Infected Necrosis
        • Translocation of gram negative organisms from the GI tract.
        • Diagnosis: septic clinical course and air on CT/ Percutaneous aspiration for culture.
        • Treatment:
          • Percutaneous drainage, well defined, loculated, liquefied abscesses
          • Surgical debridement/draining
          • Mortality 50%
  • Pseudocyst
    • Walled off area of pancreatic necrosis and/or juice
    • 60-80% resolve spontaneously
    • Diagnosis: US, CT
    • Operation only if
      • Infection, hemorrhage
      • duodenal and/or
      • biliary obstruction
      • PAIN
  • Pseudocyst
      • Percutaneous aspiration: high recurrence rate or persistent pancreaticocutaneous fistula
      • Internal Drainage
        • Cystgastrostomy, Cystenterostomy
  • Gallstone Pancreatitis
    • Common – channel pathogenesis of biliary pancreatitis first proposed by Opie in 1901
    • Transient blockage of the ampulla of Vater by migratory stone
    • 90% mild attacks (<3 Ranson’s criteria)
    • 10% severe attacks (>3 Ranson’s criteria)
  • Gallstone Pancreatitis
        • A gallstone initiates pancreatitis
        • Early removal of an impacted stone
        • Surgery should be performed during the initial hospitalization after the pancreatitis has subsided.
        • ERCP/sphincterotomy may be of benefit
  • Chronic Pancreatitis
    • Indication for operation
        • Intractable pain
        • Biliary obstruction
        • Duodenal obstruction
        • Suspected carcinoma
        • Preoperative evaluation
        • ETOH/Narcotic
        • Malnutrition or Jaundice
        • Radiographic studies: ERCP/EUS/CT
  • Chronic Pancreatitis
        • Large Duct (>8 mm)
        • Lateral pancreaticojejunostomy (Peustow): 80% effective
        • Small Duct
        • Resective procedures
          • Whipple
          • Total with Auto Islet Transplantation
  • Pancreatic Neoplasms
  • Periampullary Tumors
    • Head of the pancreas (80%)
    • Ampullary (10-15%)
    • Duodenual (4%)
    • Distal Cholangiocarcinoma (3%)
    • Mean age: 62 years
    • Men 65%
  • Periampullary Tumors
    • Pancreatic Carcinoma
      • 20% increase in the last 20 years
      • 4 TH Leading cause of cancer death in women
      • 3 rd Leading cause of cancer death in men
      • Resectability rate 5-15%
        • Regionally unresectable (mesenteric vasculature)
        • Distant metastases
      • Resectability of other periampullary lesions 60-70%
  • Periampullary Tumors
    • Diagnosis
      • Symptoms: weight loss, pain, pruritis
      • Signs: jaundice
      • Laboratory studies: Hyperbilirubinemia, CA 19-9
      • Pancreas Protocol CT
      • EUS
      • ERCP
  • Periampullary Tumors
    • Surgery
      • Curative procedures
        • Pancreaticoduodenectomy (Whipple)
        • Standard vs. pylorus sparing
      • Local excision
        • Small, localized ampullary lesions in high risk patients
  • Periampullary Tumors
    • Palliative procedures
        • Biliary and/or enteric bypass
    • Five Year Survival
        • Pancreas 0-14%
        • Ampulla 40%
        • Duodenum 30%
        • Distal Bile duct 40%
    • Non-operative therapy
        • Stents: endoscopic, percutaneous
        • Radiation
        • Chemotherapy
  • Cystic Neoplasms
    • Histological Types
    • IPMN – main duct or side branch
    • Serous cystadenoma
    • Mucinous cystadenoma: malignant potential
    • Cystic Neuroendocrine tumor
    • Always rule out pseudocyst
  • Cystic Neoplasms
    • Malignant lesions usually symptomatic
      • Pain, jaundice, mass
    • Survival
      • Serous tumors: excellent
      • Cystadenocarcinoma
        • Resectable : 76% survival
        • Unresectable: mean survival 4 months
  • Neuroendocrine Tumors (islet cell)
    • MEN I: pancreas (80%), pituitary (40%), parathyroid (50%), adrenal cortex (35%)
    • Insulinoma
    • Gastrinoma
    • Glucagonoma
    • VIPoma
    • Somatostatinoma
    • Non-Functioning
  • Neuroendocrine Tumors (islet cell)
    • Insulinoma
      • Most common islet cell tumor
      • 90% benign, solitary
      • Symptoms from neuroglycopenia
        • Diagnosis
          • Whipple’s Triad
            • Fasting blood sugar <50mg.%
            • Symptoms after fasting
            • Relief of symptoms with glucose administration
  • Gastrinoma (Zollinger-Ellison syndrome)
    • First described in 1954
    • Severe ulcer diathesis
    • Diarrhea caused by a non-beta islet cell tumor of the pancreas. At least 50% are both malignant and multiple.
  • VIPoma (Verner-Morrison, WDHA)
      • Watery diarrhea, hypochloremia, achlorhydria
      • Elevated vasoactive intestinal peptide (VIP)
      • 60% malignant
      • Therapy: surgical excision, streptozotocin, somatostatin/Sandostatin
  • Glucagonoma
      • Extremely rare
      • Clinical syndrome: weight loss, mild diabetes, stomatitis, anemia, migratory necrolytic erythema , diarrhea
      • Elevated serum glucagon
      • 60-70% malignant
      • Treatment: surgical excision, somatostatin/Sandostatin analog
  • Non-functioning Islet Cell Tumors
    • Rare: 1:100,000 population
      • Do not produce detectable hormones
      • Most are solitary lesions
    • Clinical presentation
        • Pain, weight loss
    • Diagnosis: EUS, CT
    • Management
      • Surgery: resection; even metastatic disease
      • Chemotherapy: streptozocin
    • Survival: 58% at 5 years (overall)