Pancreas Surgical Management
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Surgical Management In Pancreatic Disorders https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/
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Pancreas Surgical Management
- 1. SURGICAL MANAGEMENT IN PANCREATIC DISORDERS Dr. Dhaval O. Mangukiya MS(Mumbai),DMAS(France) Fellow HPB & GI Surgery(IHPBA) Consultant Surgical Gastroenterologist SIDS Hospital
- 2. SPECTRUM ď‚„ Inflammation ď‚„ Acute Pancreatitis ď‚„ Chronic Pancreatitis ď‚„ Trauma ď‚„ Tumor ď‚„ Benign (Cystic Neoplasms) ď‚„ Malignant ď‚„ Other (NETs)
- 3. REVISED ATLANTA CLASS. Mild acute pancreatiisâ–¸ No organ failure ď‚„ No organa failure ď‚„ No local or systemic complications Moderately severe acute pancreatitis ď‚„ Organ failure that resolves within 48 h (transient organ failure) and/or ď‚„ Local or systemic complications without persistent organ failure Severe acute pancreatitis ď‚„ Persistent organ failure (>48 hrs) ď‚„ Single organ failure ď‚„ Multiple organ failure
- 5. Revised Atlanta classification of fluid collections in acute pancreatitis (4). ANC = acute necrotic collection, APFC = acute peripancreatic fluid collection, WON = walled-off necrosis. ACUTE PANCREATITIS
- 6. BISAP SCORE ď‚„ BUN >25mg/dL ď‚„ Impaired mental status ď‚„ SIRS ď‚„ Age >60 year ď‚„ Pleural effusion ď‚„ Other predictors: CRP, Procalcitonin
- 7. MASTERLY INACTIVITY…….  Acute pancreatitis  Necrotising pancreatitis  Acute fluid collection  Infective pancreatic necrosis (early stage)
- 8. INTERVENTION Delayed necrosectomy ď‚„ Early vs late necrosectomy in severe necrotising pancreatitis ď‚„ Juan Mier et al ď‚„ The American Journal of Surgery, Feb 1997, Vol 173, Issue 2 ď‚„ Reduction of mortalaity 56% to 27% (72 hrs vs 12 days) ď‚„ Reduction in mortality with delayed surgical therapy of severe pancreatitis ď‚„ Werner Hartwig et al ď‚„ Journal of Gastrointestinal Surgery, 2002, Vol 6, Issue 3 ď‚„ Reduction of mortality from 39% to 12%
- 9. NECROSECTOMY ď‚„ A Step-up Approach or Open Necrosectomy for Necrotizing Pancreatitis ď‚„ Hjalmar C. van Santvoort, Marc G. Besselink, Olaf J. Bakker, et al. ď‚„ Dutch pancreatitis study group ď‚„ The new engl j med 362;16 nejm.org april 22, 2010 ď‚„ Percutaneus drainage followed by minimal invasive retroperitoneal necrosectomy ď‚„ Significant reduction in complications and mortality
- 10. ď‚„ Open necrosectomy ď‚„ Laparoscopic necrosectomy ď‚„ Endoscopic necrosectomy
- 11. CHRONIC PANREATITIS ď‚„ Drainage procedures ď‚„ WON drainage ď‚„ Pseudocyst ď‚„ Duct ď‚„ Others ď‚„ Aneurysm ď‚„ Bile duct stricture ď‚„ PHT ď‚„ Inflammatory mass/Resection
- 12. 20 yr old female with repeated episodes of haematemesis and black colored stool associated with chronic upper abdominal pain. Upper GI scopy was normal. On CT scan reported as GDA aneurysm with chronic pancreatitis. But on looking into with detail my diagnosis was haemosuccus pancreaticus. Which was very much true as intraop findings. Pancreatic side branch pseudoaneurysm ligation with head coring and roux en Y pancreaticojejunostmy done. Excellent post op recovery.
- 13. PANCREATIC TRAUMA ď‚„ Injury severity scoring Grade Description 1 Haematoma Minor contusion without duct injury Laceration Superficial laceration without duct injury 2 Haematoma Major contusion without duct injury Laceration Major laceration without duct injury 3 Laceration Distal transection of parachyma/duct 4 Laceration Proximal transection or injury inv. papilla 5 Laceration Massive disruption of head Advance one grade for multiple injuries upto 3
- 14. MANAGEMENT
- 15. TUMOR Cystic Neoplasm of Pancreas ď‚„ Increasingly incidentally detected ď‚„ Imaging important for determining prognosis and management ď‚„ CT>MR generally preferred for characterization except for IPMN ď‚„ Role of Endoscopic US : increasing
- 16. Hutchins GF, Draganov PV, Cystic neoplasms of the pancreas: A diagnostic challenge World J Gastroenterol 2009 January 7; 15(1): 48-54
- 17. CLASSIFICATION OF CYSTIC PANCREATIC LESIONS ď‚„Pseudocyst ď‚„Common cystic pancreatic neoplasms ď‚„ Serous cystadenoma ď‚„ Mucinous cystic neoplasm ď‚„ IPMN ď‚„Rare cystic pancreatic neoplasms ď‚„ Solid pseudopapillary tumor ď‚„ Acinar cell cystadenocarcinoma ď‚„ Lymphangioma ď‚„ Hemangioma ď‚„ Paraganglioma
- 18. CLASSIFICATION OF CYSTIC PANCREATIC LESIONS (CONT) Solid pancreatic lesions with cystic degeneration  Pancreatic adenocarcinoma  Cystic islet cell tumor (insulinoma, glucagonoma, gastrinoma)  Metastasis  Cystic teratoma  Sarcoma True epithelial cysts* *Associated with von Hippel–Lindau disease, autosomal - dominant polycystic kidney disease, and cystic fibrosis)
- 19. MANAGEMENT
- 20. PANCREATIC NET
- 21. THE GUT AND PANCREATIC NEUROENDOCRINE CELL SYSTEM Gut ECL-cells (Histamine, CgA, gastrocalcin?) G-cells (Gastrin) S-cells (Somatostatin) P-cells (unknown secretory product) EC-cells (Serotonin, Tachykinins, CgA) “Other neuroendocrine cells” and peptidergic neurons Common “stem-cell” in the pancreatic ducts β-cell (Insulin) α-cell (Glucagon) D-cell (Somatostatin) PP-cell (Pancreatic polypeptide) D1 (unknown secretory product) Pancreas
- 22. CLINICAL SYDROME Carcinoid syndrome Zollinger Ellison syndrome Hypoglycemic (Insulinoma) Verner-Morrison (WDHA) syndrome Glucagonoma syndrome Somatostatinoma syndrome “Non-functioning” Tumours Serotonin, Histamine, Tachykinins, Bradykinin Serotonin, Tachykinins Bradykinin Gastrin Insulin, proinsulin IGF-I/II VIP, PHM Glucagon, (Glicentin) Somatostatin CgA, HCG-α/β, PP, PYY (no endocrine related symptoms) Lung, Stomach and Pancreas = Foregut Ileum and Jejunum = Midgut Pancreas Duodenum Pancreas (Sareomas) Pancreas, Ganglioneuro- mas, Paraganglioma, Lung Pancreas Pacreas, Duodenum Pancreas, Colon Secretory Products Causing the Syndrome Tumour Location
- 23. ď‚„ 27 year old female with severe burning epigastric pain and severe diarrhea. USG finding was left renal tumor. On CT scan 3 vascular tumors in body, tail pancreas and splenic hilum. Provisional dignosis was NET most likely gastrinoma. S. Gastrin >1000. She underwent laparoscopic distalpancreato splenectomy and discharged on 4th postopday without any complication. HP with IHC confirms gastrinoma.
- 24. ď‚„ 60 year old male diabetic hypertensive case of obstructive jaundice diagnosed to have periampullary adenoca. Operated for whipple's pancreatoduodenectomy. Soft pancreas duct size 5 mm. ICU stay 1 day for observartion. Discahrged without any adverse events on 7th post op day.