Main duct IPMN (MD-IPMN) has a high risk of malignancy, especially invasive carcinoma, at around 43-61%. Resection is strongly recommended for MD-IPMN with obstructive jaundice, MPD size over 10mm, or enhancing solid components. Branch duct IPMN (BD-IPMN) has a lower risk of around 18-31% but certain features like size over 3cm or worrisome features increase risk. Follow up is important after resection or non-resection of IPMN to monitor for recurrence, progression, or development of pancreatic ductal adenocarcinoma.
Benign Billiary Stricture By Dr Dhaval Mangukiya
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Benign Billiary Stricture By Dr Dhaval Mangukiya
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
review of literature for transjugular intrahepatic portosystemic shunt placement and balloon occluded retrograde transvenous obliteration in management of patients with varices hemorrhage
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
review of literature for transjugular intrahepatic portosystemic shunt placement and balloon occluded retrograde transvenous obliteration in management of patients with varices hemorrhage
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
2. Introduction
Intraductal papillary mucinous neoplasm (IPMN) > pancreatic cyst
Male : Female (MD-IPMN and BD-IPMN in Asia) >> 3 : 1.8
Asymptomatic present with abdominal discomfort
Malignancy in MD-IPMN and mixed-type IPMN 60%
(Invasive cancer 45%)
Malignancy in BD-IPMN 25% (Invasive cancer < 20%)
Tanaka M, et al. Pancreatology 2017;17:738-53
3. Morphologic classification
Main duct IPMN (MD-IPMN)
Mean frequency of Inv-IPMN and HGD = 61.6% (Inv-IPMN 43.1%)
Branch duct IPMN (BD-IPMN)
Mean frequency of Inv-IPMN and HGD = 31.1% (Inv-IPMN 18.5%)
Mixed type IPMN
Minimal MPD involvement
Extensive MPD involvement
Tanaka M, et al. Pancreatology 2017;17:738-53
5. Histologic subtypes
Gastric
most common in BD-IPMN
Papilla lining
MUC5AC - positive
MUC1 and MUC2 – negative
If carcinoma develop tubular
type
Intestinal
most common in MD-IPMN
33% - invasive carcinoma
Colloid type
MUC2 and CDX2 - positive
Tanaka M, et al. Pancreatology 2017;17:745
6. Histologic subtypes
Pancreatobiliary
Rare
Tubular type and aggressive
Oncocytic
Complex multilocular cyst
Ductal dilatation
Mucin extrusion (Ampulla)
MUC6 – positive
Good prognosis
Tanaka M, et al. Pancreatology 2017;17:745
10. Once detection of the Cyst..
Pancreatic cyst < 5 mm, no symptom and no invasive carcinoma
characteristic F/U imaging
Pancreatic cyst > 5 mm MRCP
“procedure of choice” for evaluating pancreatic cyst
Tanaka M, et al. Pancreatology 2017;17:738-53
11. EUS-FNA
For cyst fluid and tissue cytology
Limitation: Operator dependent
For diagnosis (HGD&Inv-IPMN)
in mucinous cyst
Sensitivity 72%
Positive predictive value 80%
Tanaka M, et al. Pancreatology 2017;17:738-53
SEEDING…????
12. Ngamruengphon S, et al. Endoscopy 2013;45:619-26
EUS-FNA >> not associated with a risk of needle track seeding
13. ERCP with brushing and washing
cytology
Mural nodule size > 5 mm
CEA level in pancreatic juice > 30 ng/ml
Useful for diagnosis HGD and Inv-IPMN in BD-IPMN
Positive predictive value 100%
Negative predictive value 96.3%
Hirono S, et al. Ann Surg 2012;255:517-22
14. High risk stigmata of malignancy
Obstructive jaundice with pancreatic head cyst
Enhancing solid component within cyst (≥ 5 mm)
MPD size ≥ 10 mm
Tanaka M, et al. Pancreatology 2017;17:738-53
15. Worrisome features
Clinical pancreatitis
Cyst size ≥ 3 cm
Enhancing mural nodule < 5 mm
Thickened enhanced cyst walls
MPD size 5-9 mm
Abrupt change of MPD caliber with
distal pancreatic atrophy
Lymphadenopathy
Rising serum CA19-9
Rapid growth rate ≥ 5mm/2years
Tanaka M, et al. Pancreatology 2017;17:738-53
17. Main duct IPMN (MD-IPMN)
Features suspected MD-IPMN
Diffuse dilatation of MPD
Thickened wall of MPD
Intraductal mucin or mural nodule
Incidence of Inv-IPMN and HGD in MD-
IPMN is 61.6%
Incidence of Inv-IPMN alone ~ 43.1%)
5 year survival rates 31-54%
Tanaka M, et al. Pancreatology 2017;17:738-53
18. Indications for resection in MD-IPMN
Strongly recommend for all surgically fit patients with
MPD > 10 mm
Jaundice
Mural nodules
In MPD 5-9 mm (WF): no immediate resection
There is no cut-off size of mural nodule to predict Inv-IPMN or HGD
in MD-IPMN
Tanaka M, et al. Pancreatology 2017;17:738-53
19. Resection of MD-IPMN
Diffuse MPD dilation & no focal lesion >> ERCP
Mucin extrusion or mural nodule MD-IPMN
Aim of resection >> complete removal of tumor
with negative margin
MD-IPMN at middle segment or pancreatic body
>> right sided pancreatectomy or
pancreaticoduodenetomy
Frozen section for adequate margin
Tally NJ, Practical Gastroenterology&Hepatology; 2010
20. Intraoperative frozen section
HGD or invasive carcinoma is present at the margin
Further resection until negative margin
LGD - not require any further therapy
Low-grade pancreatic intraepithelial neoplasia (PanIN)
As LGD - no further resection
Negative margin in frozen but Inv-IPMN at margin ***
Closed follow-up
Tanaka M, et al. Pancreatology 2017;17:738-53
21. Total pancreatectomy in MD-IPMN
Consider in patient
Definitive diagnosis
Size of MPD dilation
Present of symptom or mural nodules
Young patient who can handle the exocrine
and endocrine insufficiency
Intraductal ultrasonography and
intraoperative pancreatoscopy have been
used to obtain additional information
Michael J, et al. Intraoperative pancreatoscopy. Journal of gastrointestinal surgery 2014;18:1100-07
23. Branch duct IPMN (BD-IPMN)
Incidence of Inv-IPMN and HGD in BD-IPMN is 31%
Incidence of Inv-IPMN only ~18.5%
Rate of progression to HGD or invasive cancer 1.4-6.9% per year
Tanaka M, et al. Pancreatology 2017;17:738-53
29. Method of resection
Standard pancreatectomy
>> depending on location of lesion
► Pancreatic head
Pancreaticoduodenectomy
► Pancreatic body or tail
Distal pancreatectomy
► Diffuse type and MPD dilation along pancreas
Total pancreatectomy
30. Other treatment
Limit resection (excision, enucleation, uncinatectomy)
Consider for BD-IPMN without clinical, radiologic,
cytopathogic or serologic suspicion of invasive carcinoma
Associated with leakage of mucin causing pseudomyxoma
peritonei
Higher incidence of postoperative pancreatic fistula (POPF)
and recurrence
31. Role of mucosal ablation
Pancreatic cyst > 2cm, unilocular or oligolocular (no MPD communication)
Cysts in patient who refuse surgery or are high-risk surgical candidates
BD-IPMN >> Not recommended..!!
Cyst resolution rate
Short term 33-79%
Complete or partial 75% (median follow up 27 month)
Dewitt JM, et al. Endoscopy 2014;46:457-64
Gomez V, et al. Gastrointes Endosc 2016;83:914-20
32. Role of mucosal ablation
Complication
Acute pancreatitis (4.5-10%)
Abdominal pain (<20%)
Peritonitis
Splenic vein obliteration
Steve Pereira, Cystic tumors of the pancreas, London pancreas update meeting 2017
33. Approach to multifocal BD-IPMN
25-41% of all BD-IPMN
Treatment as unifocal BD-IPMN
Segmental resection >> IPMNs with the highest oncological risk
and perform surveillance of the remaining lesions
Total pancreatectomy >> patients with a strong family history of
pancreatic duct adenocarcinoma (PDAC)
Tanaka M, et al. Pancreatology 2017;17:738-53
34. Follow up
Non-resected
IPMN
Surgically resected
IPMN
For observe recurrent and progressive of IPMN (non-invasive
IPMN to Inv-IPMN)
For observe characteristic of cyst >> mural nodule, size and
number
Tanaka M, et al. Pancreatology 2017;17:738-53
35. Follow up of non-resected IPMN
History and physical examination
MRI/MRCP (or pancreatic protocol CT)
EUS (in patient with mural nodule)
Serum CEA, CA 19-9
Tanaka M, et al. Pancreatology 2017;17:738-53
36. Follow up of non-resected IPMN
BD-IPMN without high risk stigmata and worrisome features
Size of largest cyst Management
<1 cm
CT/MRI in 6 months then
Every 2 years if no change
1-2 cm
CT/MRI q 6 months x 1 year then
Yearly x 2 then
Every 2 years if no change
2-3 cm EUS q 3-6 months then yearly alternating MRI with EUS as
Consider surgery in young, fit patient or prolong surveillance
>3 cm
MRI/EUS q 3-6 months
Strongly consider surgery in young, fit patients
Tanaka M, et al. Pancreatology 2017;17:738-53
37. Follow up of non-resected IPMN
High risk stigmata
Fit patients - go on surgery
Unfit patients or high risk for surgery - surveillance q
3-6 month
Worrisome feature
Increase risk of invasive carcinoma and HGD
Short surveillance
Tanaka M, et al. Pancreatology 2017;17:738-53
38. Follow up of non-resected IPMN
Incidence of the development of concomitant PDAC
5 year : 3%
10-year : 8.8%
Uehara H, et al. Gut 2008;57:1561-5.
Tanno S, et al. Pancreas 2010;39: 36-40.
Long-term surveillance over 5 years is necessary for detection
of concomitant PDAC
39. Follow up of surgically resected IPMN
Non-invasive IPMN with negative surgical margin
For detect the development of a new IPMN or concomitant PDAC
CT or MRI at least twice a year in high risk group
High risks group
Family history of PDAC
Surgical margin positive for HGD
Non-intestinal subtype
Non high risks group CT or MRI every 6-12 months
Tanaka M, et al. Pancreatology 2017;17:738-53
40. Follow up of surgically resected IPMN
Invasive IPMN
Clinical evaluation, CA19-9, CT whole abdomen with
contrast every 3–6 months for 2 years, then annually
NCCN Guidelines for Pancreatic Adenocarcinoma. v.1.2019
41. Progression of IPMN within the pancreatic remnant
Jin He, et al. Journal of American College of Surgeons 2013;216:657.
42. Predictors of recurrence
Presence of HGD in resected specimens
Margin positive resection
>> conflicting outcomes reported by different centers
(margin positive vs margin negative)
He et al. (27% vs 22%, p = ns) and Kang et al. (12.1% vs 10.4%, p =
0.704)1
Marchegiani et al. (25% vs 14%, p = 0.008)
Family history of PDAC (family history of PDAC vs non-family history of
PDAC)
He et al. >> recurrent rate 23% vs 7% (p < 0.05)
Jin He, et al. Journal of American College of Surgeons 2013;216:657.
Marchegiani G, et al. Annual of Surgery 2015;261:976-83.
43. Predictors of recurrence
Ideno et al
IPMN having concomitant PDAC - gastric subtype
Miyasaka et al
Pancreatobiliary subtype of IPMN - predictor for metachronous
development of concomitant PDAC
Gastric and pancreatobiliary subtypes of IPMN (MUC2- negative non-
intestinal subtype) - should be considered as a high risk for the
development of concomitant PDAC
Idena, et al. Annual of Surgery 2013;258:141-51.
Miyasaka Y, et al. Annual of surgery 2016;263: 1108-14.
44. Surveillance protocol
Risk of progression of IPMN does not diminish over time following
resection
Surveillance should continue indefinitely as long as the patient
remains fit for surgery
In IPMN patients with two or more affected first-degree relatives
cross-sectional imaging at least twice a year, and surveillance
should not be discontinued as long as the patient remains fit
Wang W, et al. Journal of clinical oncology 2007;25:1417-22.
45. Surveillance protocol
Genetic defect that associated with increase risk of PDAC
BRCA2/Fanconi anemia pathway defects (3.5-10 folds)
Familial atypical mole malignant melanoma syndrome (9-47 folds)
Peutz-Jeghers syndrome (132 folds)
Couch FJ, et al. Cancer Epidemiol Biomarkers Prev 2007;16:342-6.
Goggins M, et al. Cancer RES 1996;56:5360-4.
Giardiello FM, et al. The New England Journal of Medicine 1987;316:1511-4.
46. Surveillance protocol
Synchronous and metachronous occurrence of malignant diseases
in extrapancreatic organs in patients with IPMNs occur in 20-30%
Gastrointestinal cancer Asian countries
Skin, breast, and prostatic cancers United States
At present no screening recommendations for detecting
extrapancreatic malignancies
Once diagnosis of IPMN consideration of extrapancreatic
neoplasms
Yamaguchi K, et al. European Journal of Surgery 1999;165:223-9.
Reid-Lombardo, et al. Annual of Surgery 2010;251:64-9.
Lee SY, et al. Pancreas 2006;32:186-9.
1.MD-IPMN >> การมี segment หรือ diffuse dilatation ของ main pancreatic duct ที่มีขนาด > 5mm และไม่พบสาเหตุของ obstruction
อุบัติการณ์การเกิด Inv-IPMN and HGD in MD-IPMN is 61.6% (Inv-IPMN 43.1%) , 5 year survival rates 31-54%
Worrisome features ; MPD diameter 5-9 mm
High-risk stigmata ; MPD diameter ≥10 mm
2.BD-IPMN >> pancreatic cyst ที่มีขนาด >5mm และมีการเชื่อมต่อกับ MPD
อุบัติการณ์การเกิด Inv-IPMN and HGD in MD-IPMN is 31.1% (Inv-IPMN 18.5%)
3.Mixed type IPMN >> มีทั้ง MD-IPMN + BD-IPMN
- Minimal MPD involvement (microscopic appearance)
- Extensive MPD involvement (macroscopic appearance)
The gastric type shows tall columnar cells with basally oriented nuclei and abundant pale mucinous cytoplasm.
The intestinal type is composed of tall papillae lined by columnar cells with pseudostratified nuclei and basophilic cytoplasm with variable amounts of apical mucin
The pancreatobiliary type has thin branching papillae with high-grade dysplasia. The cells are cuboidal and have round hyperchromatic nuclei, prominent nucleoli, and moderately amphophilic cytoplasm with a less mucinous appearance.
The oncocytic type usually exhibits complex arborizing papillae lined by two to five layers of cuboidal to columnar cells with large, round, fairly uniform nuclei containing single, prominent, eccentrically located nucleoli, and abundant eosinophilic granular cytoplasm sometimes in a cribriform or solid growth pattern.
งามเรืองพล และคณะ ศึกษาเพื่อยืนยันว่าการตรวจ EUS-FNA ไม่สัมพันธ์กับการเกิดซ้ำของ gastric cancer and peritoneal cancer ภายหลังการผ่าตัด pancreatic cancer or IPMN
จากการศึกษาของ Hirono และคณะพบว่า ขนาด mural nodule ที่ใหญ่กว่า 5 mm และ CEA level ใน pancreatic juice ที่มากกว่า 30 ng/ml มีประโยชน์ช่วยในการวินิจฉัย HGD and Inv-IPMN ได้
HRS ตรวจพบจาก CT,MRI,EUS
Main duct features suspicious for involvement (thickened wall or intraductal mucin or mural nodule)
ใน MD-IPMN มีอุบัติการณ์รวมของ Inv-IPMN and HGD 61.6% (Inv-IPMN43.1%) 5 year survival rate 31-54%
- Strongly recommend for Sx in MPD > 10 mm, jaundice, มี mural nodule
- MPD 5-9 mm ยังไม่เป็นข้อบ่งชี้ของการผ่าตัด ควรได้รับการรวจเพิ่มเติมเนื่องจาก MPD อาจจะมีสาเหตุมาจากโรคอื่นได้ เช่น chronic pancreatitis
- ในปัจจุบัน ยังไม่มีขนาดของ mural nodule ที่ช่วยทำนาย HGD หรือ Inv-IPMN ใน MD-IPMN
ใน In diffuse MPD dilation & no focal lesion ควรส่ง ERCP เพื่อแยกโรค chronic pancreatitis ถ้ามี mucin extrusion or mural nodule ช่วยในการวินิจฉัย IPMN
** fish mouth deformity >> secondary to mucin overproduction & extrusion pathognomonic for IPMN
Frozen section ใช้เพื่อบอกขอบเขตที่เหมาะสมของการผ่าตัด
Frozen พบ HGD or Inv-IPMN -> ตัดเพิ่มจนกว่า negative margin
ถ้า final patho พบ Inv-IPMN ที่ pancreatic transected margin แต่ใน frozen ได้ negative margin follow up ในระยะสั้นๆ ถ้าprogress ขึ้น -> total pancreatectomy
IPMN guildeline2016 advice long term surveillance เพื่อ follow up ดู concomitant PDAC หรือ Inv-IPMN ในส่วนของ pancreatic remnant ภายหลังการผ่าตัด pancreatectomy
Field defect ศึกษาผู้ป่วย 130 ราย ที่ได้รับการผ่าตัด standard pancreatectomy พบว่า non-invasive IPMN มีความเสี่ยงของการเกิด IPMN ใหม่ที่ 1,5,10 yr อยู่ที่ 4, 25, 62 ตามลำดับ
และคนในกลุ่มนี้ได้รับการผ่าตัดอยู่ที่ 2,14,18% ตามลำดับ โดยมีความเสี่ยงที่จะเกิด Inv-IPMN อยู่ที่ 0,7,38% ตามลำดับ
Kang et al reported a recurrence rate of 5.4% in non-invasive IPMN
Marchegiani et al 9.4% in non-invasive IPMN
Previous literature, which reports a recurrence rates ranging from 1% to 20% (in non-invasive), and invasive recurrence rates of 2%e7.8%
Present of HGD, margin positive, family history of PDAC Most commonly associated with progression in the pancreatic remnant
family history was the only independent preoperative predictor of recurrence
He et al. reported that 17% of patients with HGD discovered in their primary resected IPMNs developed new or progressive disease in their pancreatic remnant
Miller et al reported that 10% ,,,
Rezaee et al over 8-fold more likely to subsequently develop an invasive cancer