Surgical Pancreas

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Surgicalurgical

diseases of theiseases of thePancreasancreasDr Dr .. J. I J. I .. vanvan BeljonBeljon



Anatomy of thenatomy of the

Pancreasancreas



Physiology of thehysiology of the

Pancreasancreas Exocrine pancreasExocrine pancreas Trypsin Chymotrypsin Elastase Carboxypeptidase A Carboxypeptidase B Colipase

Pancreatic lipase Cholesterol ester hydrolase Pancreatic α amylase Ribonuclease Deoxyribonuclease Phospholipase A²

Endocrine PancreasEndocrine Pancreas InsulinInsulin



Acute Pancreatitiscute Pancreatitis

Def. Acute inflammation, usually withDef. Acute inflammation, usually with

rapid onset of pain and tenderness, oftenrapid onset of pain and tenderness, often

accompanied by vomiting, and systemicaccompanied by vomiting, and systemicinflammatory responses. Regionalinflammatory responses. Regional

tissues and remote organ systems aretissues and remote organ systems are

sometimes involved. Elevated pancreaticsometimes involved. Elevated pancreaticenzymes in blood or urine usually occur,enzymes in blood or urine usually occur,

but not invariably.but not invariably.



Etiology of A.P.tiology of A.P.

Metabolic Mechanical Vascular Infection

Alcohol

Hyperlipoproteinemia

Hypercalcemia

Drugs

Genetic

Scorpion venom

Cholelithiasis

Postoperative

Pancreas divisum

Post-traumatic

E.R.P.

Pancreatic ductobstruction

Pancreatic ductbleeding

Duodenalobstruction

Post-operative

Periarteritisnodosa

Atheroembolism

Mumps

Coxsakie B

Cytomegalovirus

Cryptococcus



PATHOGENESISATHOGENESIS



Clinical Picturelinical Picture

CLINICAL PICTURE

HISTORY SYMPTOMS SIGHNS



Historyistory

Risk factorsRisk factors

Previous attacks?Previous attacks?



Symptomsymptoms

Pain-Pain- upper abdominal,constant,radiates toupper abdominal,constant,radiates to

the back(50%),Often starts after alcohol bingethe back(50%),Often starts after alcohol bingeor heavy meal,increases in intensity rapidly.or heavy meal,increases in intensity rapidly.Dominant symptom in 85%-100%.Dominant symptom in 85%-100%.

NauseaNausea Vomiting-Vomiting- not coupious,gastric and duodenalnot coupious,gastric and duodenal

contentscontents



Signsigns

RestlessnessRestlessness

Rapid pulseRapid pulse

Rapid respiratory rateRapid respiratory rate Arterial hypotension Arterial hypotension

Abdomen moderately distended, Abdomen moderately distended,

epigastric fullness.epigastric fullness. Grey-turner signGrey-turner sign

Cullen signCullen sign

Fox signFox sign



Special investigationspecial investigations

Confirm diagnosisConfirm diagnosis

S-amilase ( remember diff.)S-amilase ( remember diff.)

U-amilaseU-amilase S-lipaseS-lipase

CRPCRP

ABG ABG FBCFBC

S-CalsiumS-Calsium



RADIOLOGYADIOLOGY

CXRCXR Sympathetic pleural effusionSympathetic pleural effusion Atelectasis Atelectasis A.R.D.S. A.R.D.S.

AXR AXR Sentinal loopSentinal loop

Colon cutoff signColon cutoff sign

Duodenal ileusDuodenal ileus CalcificationsCalcifications Obscured psoas linesObscured psoas lines

79% will have radiological signs !!!79% will have radiological signs !!!



HOW DO WE DETERMINEOW DO WE DETERMINE

PROGNOSIS? ( TREATMENT)ROGNOSIS? ( TREATMENT)

80% Will recover without any complications80% Will recover without any complications

20% Will develop severe cardio-pulmonary20% Will develop severe cardio-pulmonary

complications or septic complicationscomplications or septic complications Prognostic assessment :Prognostic assessment :

RansonRanson

ImrieImrie APACHE 2 APACHE 2

CRPCRP

Classify into mild or severe acuteClassify into mild or severe acute

pancreatitis ( Atlanta clessification 1992)pancreatitis ( Atlanta clessification 1992)



TREATMENT OF ACUTEREATMENT OF ACUTE

PANCREATITISANCREATITIS NON-OPERATIVE To limit severity of pancreatic inflammation

Inhibition of pancreatic secreationInhibition of pancreatic secreation Nasogastric suctionNasogastric suction PharmacologicPharmacologic HypothermiaHypothermia

Pancreatic irradiationPancreatic irradiation Inhibition of pancreatic enzymesInhibition of pancreatic enzymes CorticosteroidsCorticosteroids ProstaglandinsProstaglandins

To interrupt the pathogenesis of complications Antibiotics Antibiotics Antacids Antacids HeparinHeparin Low molecular weight dextranLow molecular weight dextran

VasopressinVasopressin Peritoeal lava ePeritoeal lava e




PANCREATITISANCREATITIS

To support the patient and treatTo support the patient and treatcomplicationscomplications Restoration and maintenance of Restoration and maintenance of

intravascular volumeintravascular volume Electrolite replacementElectrolite replacement Respiratory supportRespiratory support Nutritional supportNutritional support Analgesia Analgesia HeparinHeparin




PANCREATITISANCREATITIS Operative treatmentOperative treatment Diagnostic laparotomyDiagnostic laparotomy To limit the severity of the pancreatic inflammationTo limit the severity of the pancreatic inflammation

Biliary proceduresBiliary procedures To interrupt the pathogenesis of complicationsTo interrupt the pathogenesis of complications

Pancreatic drainagePancreatic drainage Pancreatic resectionPancreatic resection Pancreatic debridementPancreatic debridement

Peritoneal lavagePeritoneal lavage To support the patient and treat complicationsTo support the patient and treat complications

Drainage of pancreatic infectionDrainage of pancreatic infection Feeding jejenostomyFeeding jejenostomy

To prevent recurrent pancreatitisTo prevent recurrent pancreatitis



Summary of treatmentummary of treatment All patients All patients

Nasogastric suctionNasogastric suction NPONPO Monitor and maintenance of intravascular volumeMonitor and maintenance of intravascular volume Respiratory monitoring and supportRespiratory monitoring and support

Antibiotics(selective) Antibiotics(selective) Early laparotomy only fordiagnosisEarly laparotomy only fordiagnosis Estimate prognosis by early signsEstimate prognosis by early signs

Patients with severe pancreatitisPatients with severe pancreatitis

Peritoneal lavagePeritoneal lavage Nutritional supportNutritional support Suspect and treat pancreatic sepsisSuspect and treat pancreatic sepsis Heparin if hypercoagulableHeparin if hypercoagulable



Complications of acuteomplications of acute

pancreatitisancreatitis

Systemic complications:Systemic complications: Fluid imbalanceFluid imbalance Electrolite imbalanceElectrolite imbalance Cardiac impairmantCardiac impairmant

Renal impairmantRenal impairmant

Respiratory impairmandRespiratory impairmand Liver failureLiver failure

Local complications:Local complications: IleusIleus Duodenal obstructionDuodenal obstruction Biliary obstructionBiliary obstruction Pseudocyst formationPseudocyst formation Infected necrosisInfected necrosis Colon necrosisColon necrosis



Pancreatic pseudocystancreatic pseudocyst

Def. Pseudocysts are localized collections of Def. Pseudocysts are localized collections of pancreatic juice occurring as a result of pancreaticpancreatic juice occurring as a result of pancreaticinflammation, trauma or duct obstruction.They areinflammation, trauma or duct obstruction.They aredistinguished from other types of pancreatic cysts bydistinguished from other types of pancreatic cysts bytheir lack of an epithelial lining.their lack of an epithelial lining.

Presenting symptoms:Presenting symptoms: Epigastric painEpigastric pain NauseaNausea

VomitingVomiting Weight lossWeight loss Epigastric massEpigastric mass Fever Fever JaundiceJaundice



Pancreatic pseudocystancreatic pseudocyst

Investigations:Investigations: Elevated s-amylase (50%)Elevated s-amylase (50%) UltrasoundUltrasound CTCT ? E.R.C.P.? E.R.C.P.

Natural history:Natural history: Most will resolve spontaneouslyMost will resolve spontaneously

Treatment:Treatment: Only if symptomaticOnly if symptomatic

Treatment options:Treatment options: DrainageDrainage

ExternalExternal InternalInternal

EndoscopicEndoscopic

surgicallysurgically



CHRONICHRONIC


DEF.DEF. Chronic pancreatitis is an inflammatory diseaseChronic pancreatitis is an inflammatory disease

of the pancreas characterized by destruction of itsof the pancreas characterized by destruction of its

exocrine and endocrine tissue and by their replacementexocrine and endocrine tissue and by their replacement

with fibrous scar.with fibrous scar.

It is the difference in the ability to recover that is theIt is the difference in the ability to recover that is the

basis for the classification of pancreatitis into acute andbasis for the classification of pancreatitis into acute and

chronic forms.chronic forms.



ETIOLOGY OF CHRONICTIOLOGY OF CHRONIC


Alcohol Alcohol

Ductal obstructionDuctal obstruction

Congenital or acquired strictures of the pancreaticCongenital or acquired strictures of the pancreatic

ductduct Pancreas divisumPancreas divisum

Ductal obstruction due to tumorsDuctal obstruction due to tumors

Inflammation of the ampulla of Vater Inflammation of the ampulla of Vater

Protein malnutritionProtein malnutrition Cyctic fibrosisCyctic fibrosis

Hypercacemic statesHypercacemic states

Hereditary pancreatitisHereditary pancreatitis

Idiopathic pancreatitisIdiopathic pancreatitis



CLINICALLINICAL

MANIFESTATIONSANIFESTATIONS

Abdominal pain (95%) Abdominal pain (95%)

Exocrine dysfunction (steatorrhea &Exocrine dysfunction (steatorrhea &

creatorrhea)creatorrhea) Endocrine dysfunction ( DM)Endocrine dysfunction ( DM)

Weight loss (75%)Weight loss (75%)

Few clinical findingsFew clinical findings



SPECIALPECIAL

INVESTIGATIONSNVESTIGATIONS Blood testsBlood tests

Radiology (mainstay of the diagnosis)Radiology (mainstay of the diagnosis)

AXR AXR

Pancreatic calcifications (30-50%)Pancreatic calcifications (30-50%)

CTCT

Dilated pancreatic ductDilated pancreatic duct

Calcification of pancreasCalcification of pancreas

PseudocyctsPseudocycts E.R.C.P.E.R.C.P.

““Chain of lakes” appearanceChain of lakes” appearance

Distal bile duct stenosisDistal bile duct stenosis



EXTRAPANCREATICXTRAPANCREATIC

INVOLVEMENTNVOLVEMENT

Common bile duct obstruction (10%)Common bile duct obstruction (10%)

Duodenal obstruction (1%)Duodenal obstruction (1%)

Colonic obstructionColonic obstruction



TREATMENT OFREATMENT OF

CHRONICHRONIC

PANCREATITISANCREATITIS MEDICALMEDICAL

PancreaticPancreatic

insufficiencyinsufficiency Diabetes mellitisDiabetes mellitis

PainPain

SURGICALSURGICAL

ResectionsResections

Drainage proceduresDrainage procedures



PANCREAS TUMORSANCREAS TUMORS

Benign v/s malignantBenign v/s malignant

Exocrine v/s Endocrine ( Pancreatic isletExocrine v/s Endocrine ( Pancreatic islet

cell tumors )cell tumors )



ENDOCRINE TUMORSNDOCRINE TUMORS

Alpha cell Glucagon Glucagonoma Alpha cell Glucagon Glucagonoma

Beta cell Insulin InsulinomaBeta cell Insulin Insulinoma

Delta cell Somatostatin SomatostatinomaDelta cell Somatostatin Somatostatinoma

Delta-2-cells VIP WDHA (Vipoma)Delta-2-cells VIP WDHA (Vipoma)

G-cells Gastrin ZES (Gastrinoma)G-cells Gastrin ZES (Gastrinoma)



EXOCRINE TUMORSXOCRINE TUMORS

Adenocarcinomas Adenocarcinomas Most common pancreas tumor Most common pancreas tumor Etiology unknownEtiology unknown

Risk factorsRisk factors Sigaret smokingSigaret smoking High intake animal fat and meatHigh intake animal fat and meat Chronic pancreatitisChronic pancreatitis

Several hereditary disordersSeveral hereditary disorders Hereditary pancreatitisHereditary pancreatitis Von Hippel-Lindau syndromeVon Hippel-Lindau syndrome Lynch-syndromeLynch-syndrome Ataxiatelangiectasia Ataxiatelangiectasia



CLINICALLINICAL

PRESENTATIONRESENTATION

Symptoms:Symptoms: Early non-spesificEarly non-spesific Anorexia Anorexia

Weight lossWeight loss Abdominal discomfort Abdominal discomfort NauseaNausea Spesific symptomsSpesific symptoms

JaundiceJaundice PruritisPruritis Moderate painModerate pain DMDM Unexplained attack of pancreatitisUnexplained attack of pancreatitis



CLINICALLINICAL

PRESENTATIONRESENTATION Physical findingsPhysical findings JaundiceJaundice

Enlarged liver Enlarged liver

Palpable gallbladder ( Courvoisier`s law)Palpable gallbladder ( Courvoisier`s law) Palpable mass ( Big pancreas tumor)Palpable mass ( Big pancreas tumor)

Ascites Ascites

Virchow-Troisier nodeVirchow-Troisier node

Blumer shelf Blumer shelf

Sister Josephs nodeSister Josephs node

WastingWasting



LABORATORY DATAABORATORY DATA

LFT ( raised ALP, Bili.)LFT ( raised ALP, Bili.)

CA 19-9CA 19-9

CA 494CA 494



RADIOLOGYADIOLOGY

UltrasoundUltrasound

CT scanCT scan

MRIMRI

CholangiographyCholangiography E.R.C.P.E.R.C.P.

P.T.C.P.T.C. M.R.C.P.M.R.C.P.



TREATMENTREATMENT

PalliationPalliation

Jaundice ( pruritis)Jaundice ( pruritis)

PainPain

Duodenal obstructionDuodenal obstruction

CurritaveCurritave Resection of the tumor (WhippleResection of the tumor (Whipple

procedure / Pancreaticoduodenectomy )procedure / Pancreaticoduodenectomy )

Surgical Pancreas

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