Pancreas part 2 By Dr Ali Adil - PowerPoint Presentation

Slide1

Pancreas part 2

By Dr Ali Adil

1

Slide2

Management

After assessing the attack into mild or sever, the treatment is started:

In mild pancreatitis:

Nursing in surgical departmentNil by mouthintravenous fluid administrationAnalgesics and antiemeticfrequent, but non-invasive, observationNo need for antibioticCT scanning is unnecessary unless there is evidence of deterioration

2

Slide3

In sever pancreatitis:

Early management of severe acute pancreatitis.

Admission to HDU/ICU

AnalgesiaAggressive fluid rehydration

Supplemental oxygen

Invasive monitoring of vital signs, central venous pressure, urine output, blood gasesFrequent monitoring of haematological and biochemical parameters (including liver and renal function, clotting, serumcalcium, blood glucose

3

Slide4

Nasogastric drainage (only initially)

Antibiotics if cholangitis suspected; prophylactic antibiotics can be considered

CT scan essential if organ failure, clinical deterioration or signs of sepsis develop

ERCP within 72 hours for severe gallstone pancreatitis or signs of cholangitisSupportive therapy for organ failure if it develops (inotropes, ventilatory support, haemofiltration, etc.)

If nutritional support is required, consider enteral (nasogastric) feeding

4

Slide5

Systemic complications

should be managed by a multidisciplinary team

appropriate supportive therapies may include:

inotropic support for haemodynamic instabilityhaemofiltration in the event of renal failureventilatory support for respiratory failure

correction of coagulopathies.

5

Slide6

Figure: complication of acute pancreatitis

6

Slide7

Local complications

The management approach is conservative on the whole, with surgery restricted to situations in which conservative

management has failed .

ACUTE PERIPANCREATIC FLUID COLLECTIONEarly in the course of mild pancreatitis without necrosis.

Has no encapsulating wall.

The fluid is sterileMost resolve spontaneouslyNo intervention is necessary unless a large collection causes symptoms or pressure effects.

So treatment may include:

Percutaneous aspiration under ultrasound or CT guidance.

Transgastric drainage under EUS guidance is another option.

7

Slide8

STERILE AND INFECTED PANCREATIC NECROSIS

The term ‘

pancreatic necrosis

’ refers to a diffuse or focal area of non-viable parenchyma.Divided into sterile and infected necrosis (sterile often become subsequently infected, probably due to translocation of gut bacteria)Begin as acute necrotic collection

(

ANC)After 4 weeks it evolve into walled-off necrosis (WON).If sterile with no signs of sepsis, observe.

If infected:

Needle aspiration under CT guidance, if infected so:

Do percutaneous drainage ( by a placement of tube drain with frequent flushing)

If sepsis continue; then a pancreatic necrosectomy should be considered

8

Slide9

9

Slide10

Necrosectomy should be necessary in a very small proportion of patients.

Midline

approach if necrosis involving the

head of pancreas.Retroperitoneal approach if necrosis involving the body or tail.

Can be done by rigid

laparoscopeOnce a necrosectomy has been completed, further necrotic tissue may form, so drain by one of:Closed continuous lavage

:

Tube drains are left in and the raw area flushed.

Closed

drainage:

The

incision is closed, but the cavity is packed with gauze-filled Penrose drains and closed suction drains.

Open

packing:

The incision is left open.

Closure and

relaparotomy:

The incision is closed with drains with the intention of performing a series of planned relaparotomies every 48–72 hours until the raw area granulates.

10

Slide11

PANCREATIC ABSCESS

This is a circumscribed intra-abdominal collection of pus, usually in proximity to the pancreas.

It may be an ANC or a WON that has become infected.

Diagnosis and treatment is just like that of infected pancreatic necrosis.11

Slide12

PANCREATIC ASCITES

This is a chronic, generalised, peritoneal, enzyme-rich effusion usually associated with pancreatic duct disruption

Paracentesis will reveal turbid fluid with a high amylase level.

Treatment:Adequate drainage with wide-bore drains placed under imaging guidance

Suppressing pancreatic secretion by:

parenteral or nasojejunal feedingAdministration of octreotide.ERCP may allow demonstration of the duct disruption and placement of a pancreatic stent.

PANCREATIC EFFUSION

There may be a communication with an intra-abdominal collection

Require drainage

12

Slide13

HAEMORRHAGE

Bleeding may occur into the gut, into the retroperitoneum or into the peritoneal cavity.

Possible causes include bleeding into:

a pseudocyst cavity, diffuse bleeding from a large raw surface, a pseudoaneurysm.

Recurrent , could be fatal

Diagnosis by CT, angiography or MR angiographyTreatment involves embolisation or surgery

PORTAL OR SPLENIC VEIN THROMBOSIS

A marked rise in the platelet count should raise suspicions.

13

Slide14

PSEUDOCYST

A pseudocyst is a collection of amylase-rich fluid enclosed in a well-defined wall of fibrous or granulation tissue

typically arise following an attack of

mild acute pancreatitisRepresent an APFC that has not resolved and matured.It requires 4 weeks or more to develop.

50% have a communication with the main pancreatic duct, usually single.

Diagnosis by ultrasound or a CT scan.ERCP and MRCP may demonstrate communication of the cyst with the pancreatic duct system 14

Slide15

Differential diagnosis:

APFC

cystic neoplasm

Pseudocysts will resolve spontaneously in most instances, but complications can develop:15

Slide16

Factors making a Pseudocyst less likely to resolve spontaneously:

thick-walled Pseudocysts

large (over 6 cm in diameter

lasted for a long time (over 12 weeks)had arisen in the context of chronic pancreatitis Indications of surgery:

If the pseudocyst causes symptoms

If complications developIf a distinction has to be made between a pseudocyst and a tumour 16

Slide17

Treatment:

percutaneous

Percutaneous drainage

percutaneous transgastric cystgastrostomyendoscopic:

transgastric endoscopic drainage

ERCP and placement of a pancreatic stentSurgical drainage involves internally draining the cyst into the gastric or jejunal lumenRecurrence rates should be no more than 5%

17

Slide18

Outcomes and follow-up of acute pancreatitis:

The overall mortality from acute pancreatitis has remained at10–15%

We should determine the aetiology of the attack of pancreatitis.

Patients in the idiopathic group who suffer repeated attacks may prove to have biliary microlithiasis.In a patient who has gallstone pancreatitis, the gallbladder and gallstones should be removed as soon as the patient is fit to undergo surgery.

18

Slide19

Chronic pancreatitis

Chronic pancreatitis is a progressive inflammatory disease in which there is

irreversible destruction

of pancreatic tissue.Clinically : sever pain (attacks of acute pancreatitis)later on, exocrine and endocrine insufficiency

The disease occurs more frequently in men (male: female ratio of 4:1), and the mean age of onset is about 40 years.

19

Slide20

Aetiology and pathology

High alcohol consumption

is the most frequent cause of chronic pancreatitis, accounting for 60–70% of cases.

Only 5–10% of people with alcoholism develop chronic pancreatitis.Hyperlipidemia and hypercalcaemia can lead to chronic pancreatitis.Other causes

include Pancreatic duct obstruction resulting from stricture formation:

After trauma.After acute pancreatitisOcclusion of the duct by pancreatic cancer

Pancreas divisum and annular pancreas

are rare causes of chronic pancreatitis.

20

Slide21

Hereditary pancreatitis

, CF, infantile malnutrition and a large unexplained idiopathic group make up the remainder.

In Hereditary pancreatitis there is mutation in SPINK1 (responsible for destruction of activated trypsinogen), also this mutation predisposes to idiopathic pancreatitis.

Idiopathic chronic pancreatitis accounts for approximately 30% of cases.Hereditary pancreatitis and pancreatitis occurring at a young age had a markedly increased risk of developing pancreatic cancer especially in smoker patients

21

Slide22

Tropical pancreatitis

is a form of idiopathic pancreatitis that begins at a young age and is associated with a high incidence of diabetes mellitus and stone formation , caused by either:

Malnutrition

ingestion of cyanogenic glycosides in cassavaexposure to hydrocarbons released by kerosene or paraffin lampsAutoimmune pancreatitis is a recently described cause of chronic pancreatitis,

May occur alone or as part of autoimmune process.

May cause changes in the biliary tree (autoimmune cholangiopathy)Autoantibodies may be present, and levels of the immunoglobulin subtype IgG4 are elevated.

22

Slide23

Pathology:

The pancreas enlarges and becomes hard as a result of fibrosis.

The ducts become distorted and dilated with areas of both stricture formation and ectasia

Calcified stonesBecome occluded with a gelatinous proteinaceous fluid and debris.

Inflammatory cysts may form.

23

Slide24

Clinical features

Pain is the outstanding symptom in the majority of patients, the site of pain depend on the part of pancreas affected:

Epigastric and right subcostal pain if the head of pancreas is diseased.

Left subcostal and back pain if the disease limited to the left side of the pancreas.In some patients, the pain is more diffuse. Radiation to the shoulder can occur.

The pain is often dull and gnawing. Severe flare-ups of pain may be superimposed on background discomfort.

The pain prevents sleep and time off work is frequent.24

Slide25

Nausea is common during attacks, and vomiting may occur.

Weight loss

Loss of exocrine function leads to steatorrhoea in more than 30% of patients.

Loss of endocrine function leads to the development of diabetes, incidence increases as the disease progresses.Infection is not infrequent, possibly related to the diabetes mellitus.

25

Slide26

Investigations

a rise in serum amylase (Only in the early stages of the disease)

Pancreatic calcifications may be seen on abdominal X-ray and CT scan.

CT or MRI scan will show the outline of the gland, the main area of damage and the possibilities for surgical correction (a normal looking pancreas on CT or MRI does not rule out chronic pancreatitis).MRCP will identify the presence of biliary obstruction and the state of the pancreatic duct.

ERCP is the most accurate way of elucidating the anatomy of the duct and, in conjunction with the whole organ morphology, can help to determine the type of operation required, if operative intervention is indicated.

Histology in case of unproven chronic pancreatitis.EUS26

Slide27

27

Slide28

28

Slide29

Treatment

Most patients can be managed with medical measures. There is no single therapeutic agent that has been shown to relieve symptoms.

The role of surgery is to

overcome obstruction and remove mass lesions.Patients have a mass in the head of the pancreas, for which either a pancreatoduodenectomy or a Beger procedure (duodenum-preserving resection of the pancreatic head) is appropriate.

If the duct is markedly dilated, then a longitudinal pancreatojejunostomy or Frey procedure can be of value.

29

Slide30

The rare patient with disease limited to the tail will be cured by a distal pancreatectomy.

Patients with intractable pain and diffuse disease may plead for a total pancreatectomy.

Total pancreatectomy and islet autotransplantation has been reported in selected patients.

30

Slide31

31

Slide32

Prognosis

Patients often suffer a gradual decline in their professional, social and personal lives.

After a surgical or percutaneous intervention, the pain disappears but tends to return over a period of time.

After many years, there may be disappearance of the pain, leaving only the exocrine and endocrine insufficiencies.Development of pancreatic cancer is a risk in those who have had the disease for more than 20 years.

32

Slide33

Sphincter of Oddi dysfunction

The sphincter of Oddi is 6–10 mm long and lies within the duodenal wall. A part of it encircles the common channel, and then there are separate biliary and pancreatic components.

33

Slide34

Sphincter of Oddi dyskinesia or dysfunction (SOD)

is a clinical syndrome in which pain, biochemical abnormalities and dilatation of the bile duct and/or pancreatic duct are attributed to abnormal function of the sphincter of Oddi.

Females are more commonly affected than males.

Biliary-type SODIs characterised by biliary pain, which may be accompanied by abnormally raised liver enzymes and/or dilation of the bile duct and/or evidence of delayed emptying on biliary scintigraphy.It may be a cause of persistent post-cholecystectomy symptoms.

34

Slide35

pancreatic-type SOD

Predominance of pancreatic problems, especially recurrent episodes of acute pancreatitis.

Should be excluded in patients with recurrent acute pancreatitis of unexplained aetiology.

CT and MRCP can demonstrate dilatation of the biliary and pancreatic ducts.MRCP with intravenous secretin injection can particularly demonstrate pancreatic duct dilatation due to raised sphincter pressures.

HIDA scan may demonstrate delayed biliary transit.

The gold standard for diagnosing SOD is ERCP with manometry of the biliary and pancreatic sphincters,(Sphincter pressure higher than 40 mm Hg is the manometric criterion used to diagnose SOD).

35

Slide36

Treatment:

Endoscopic sphincterotomy

Medical therapy

should be tried before proceeding to manometry. Proton pump inhibitors, spasmolytic drugs, calcium blockers (nifedipine), and psychotropic agents have all been tried with varying degrees of success.Injection of botulinum toxin (which can cause a chemical sphincterotomy for up to 3 months) or placement of a pancreatic stent (these are usually removed after 6 weeks) do not provide lasting relief, but can be used to identify patients who may benefit from a sphincterotomy.

36

Slide37

CARCINOMA OF THE PANCREAS

Pancreatic cancer is the sixth leading cause of cancer death in the UK.

The incidence is 10 cases per 100 000 population per year.

37

Slide38

38

Slide39

Pathology

More than 85% of pancreatic cancers are ductal adenocarcinomas.

Endocrine tumours of the pancreas are rare.

Ductal adenocarcinomas arise most commonly in the head of the gland.They are solid, scirrhous tumours, characterised by neoplastic tubular glands within a markedly desmoplastic fibrous stroma.Fibrosis is also a characteristic of chronic pancreatitis, and histological differentiation between tumour and pancreatitis can cause diagnostic difficulties

39

Slide40

Proliferative lesions in the pancreatic ducts can precede invasive ductal adenocarcinoma. These are termed pancreatic intraepithelial neoplasia or PanIN.

Cystic tumours of the pancreas may be

serous

or mucinous.Serous cystadenomasfound in older women

Are large aggregations of multiple small cysts, almost like bubblewrap.

Benign.40

Slide41

Mucinous tumours

Have the potential for malignant transformation.

They include mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs).

MCNs:Perimenopausal women.

Show up as multilocular thick-walled cysts in the pancreatic body or tail.

Histologically, contain an ovarian-type stroma.41

Slide42

IPMNs:

More common in the pancreatic head and in older men.

IPMNs arising within the main duct are often multifocal and have a greater tendency to prove malignant.

IPMN arising from a branch duct can be difficult to distinguish from an MCN.Thick mucus seen extruding from the ampulla at ERCP is diagnostic of a main duct IPMN.Solid pseudopapillary tumour

is a rare, slowly progressive but malignant tumour, seen in women of childbearing age, and manifests as a large, part-solid, part-cystic tumour

42

Slide43

Peri-ampullary tumors

Tumours arising from the

ampulla

or from the distal common bile duct.Present as a mass in the head of the pancreas.Constitute around a third of all tumours in that area.

Patients with familial adenomatous polyposis (FAP) can present with multiple

duodenal polyps.Malignant transformation in a duodenal polyp is a significant cause of mortality in these patients.Ampullary carcinomas are relatively small when diagnosed, which may account for their better prognosis than pancreatic ductal adenocarcinoma 43

Slide44

Clinical features

Jaundice secondary to obstruction of the distal bile duct is the most common symptom.

It is characteristically painlessPruritus, dark urine and pale stools with steatorrhoea are common accompaniments of jaundice.Associated with nausea and epigastric discomfort.

In the absence of jaundice, symptoms are often non-specific, namely vague discomfort, anorexia and weight loss.

44

Slide45

Patients should suspected and followed are:

Upper abdominal symptoms in a recently diagnosed diabetic, especially in one above50 years.

a patient with an unexplained attack of pancreatitis.

Tumours of the body and tail of the gland often grow silently, and present at an advanced unresectable stage.Back pain is a worrying symptom, raising the possibility of retroperitoneal infiltration.

45

Slide46

On examination:

Jaundice

weight loss

a palpable liver A palpable gall bladder, Courvoisier,

s law

: when the common duct is obstructed by a stone, distension of the gall bladder (which is likely to be chronically inflamed) is rare; when the duct is obstructed in some other way, such as a neoplasm, distension of the normal gall bladder is common.46

Slide47

Investigation

CBP and LFTs

U

/S : it may shows CBD dilatation, if so:The preferred test is the contrast- enhanced CT scan, it can show tumour in the pancreas and if it is resectable.

contraindications to surgical resection

:hepatic or peritoneal metastaseslymph node metastases distant from the pancreatic headencasement of the superior mesenteric, hepatic or coeliac artery by tumour

47

Slide48

ERCP and biliary stenting

should be carried out if there is

any suggestion of cholangitis,

If there is diagnostic doubt.Jaundiced with distressing pruritus.Besides imaging, ERCP also provide a brush cytology or biopsy specimen to confirm the diagnosis.The prothrombin time should be checked, and clotting abnormalities should be corrected with vitamin K or fresh-frozen plasma prior to ERCP

48

Slide49

EUS

is indicated in:

If CT fails to demonstrate a tumour.

If tissue diagnosis is required prior to surgery.If vascular invasion needs to be confirmed.in separating cystic tumours from pseudocysts

Histological confirmation

of malignancy is desirable but not essential, particularly if the imaging clearly demonstrates a resectable tumour.Tissue diagnosis should be obtained prior to starting palliative therapy.Diagnostic laparoscopy is useful in identifying small peritoneal and liver metastases.

CA19-9

is not highly specific or sensitive, but a baseline level should be established; if it is initially raised, it can be useful

49

Slide50

Management

At the time of presentation, more than 85% of patients with ductal adenocarcinoma are unsuitable for resection because the disease is too advanced.

If imaging shows that the tumour is potentially resectable, the patient should be considered for surgical resection.

For those patients who have inoperable disease, palliative treatment should be offered.50

Slide51

Surgical resection

The standard resection for a tumour of the pancreatic head or the ampulla is a pylorus-preserving pancreatoduodenectomy (PPPD).

This involves removal of the duodenum and the pancreatic head, including the distal part of the bile duct.

The original pancreatoduodenectomy as proposed by Whipple included resection of the gastric antrum.The Whipple procedure is now reserved for situations in which:the entire duodenum has to be removed (e.g. in FAP)

Where the tumour encroaches on the first part of the duodenum or the distal stomach and a PPPD would not achieve a clear resection margin.

Total pancreatectomy is warranted only in situations where one is dealing with:A multifocal tumour (e.g. a main duct IPMN).The body and tail of the gland are too inflamed or too friable to achieve a safe anastomosis with the bowel.

51

Slide52

Distal pancreatectomy with splenectomy is the standard for tumours of the body and tail.

When resecting the pancreatic tail for a benign lesion, one may attempt to preserve the spleen if possible.

Laparoscopic and robotic approaches can be used nowadays.

52

Slide53

PPPD should carry a mortality of no more than 3–5%.

The morbidity remains high, with some 30–40% of patients developing a complication in the postoperative period.

The complications are usually infective, but a leak from the anastomosis between the pancreas and the bowel is known to occur in at least 10% of patients.

53

Slide54

ADJUVANT THERAPY

Adjuvant radiotherapy or chemoradiotherapy was shown to confer no advantage, but chemotherapy with 5-fluorouracil (5-FU) provided an overall benefit.

Median survival with chemotherapy was 20 months compared with 16 months without.

Gemcitabine works equally well.Most patients with resected ductal adenocarcinoma are now offered 6 months of adjuvant chemotherapy with gemcitabine and/or 5-FU. 54

Slide55

Palliation

The median survival of patients with unresectable,

locally

advanced, non-metastatic pancreatic cancer is 6–10 months.In patients with metastatic disease, it is 2–6 months.If unresectable disease is found in the course of a laparotomy:

Do a bypass surgery in the form of choledochoenterostomy and a gastroenterostomy to relieve (or pre-empt) jaundice and duodenal obstruction.

A coeliac plexus block can also be administered.A transduodenal Trucut biopsy of the tumour should be obtained 55

Slide56

In patients found to have unresectable disease on imaging

jaundice

is relieved by stenting at ERCP

A percutaneous transhepatic stent can be placed if can’t be done endoscopically.Obstruction of the duodenum (occurs in approximately 15% of cases) is treated by expanding metal stents inserted endoscopically.

If both biliary and duodenal metal stents are to be placed endoscopically, the biliary one should be placed first

56

Slide57

.

(a)

Endoscopic retrograde cholangiography and placement of a biliary

stent;

(b)

percutaneous transhepatic cholangiography followed bycannulation of the biliary system and percutaneous placement of abiliary stent (mesh metal in this instance

57

Slide58

);

(c)

endoscopic placement of a duodenal stent (mesh metal58

Slide59

If no operative procedure is undertaken, an EUS-guided or percutaneous biopsy of the tumour

should be performed before consideration of chemotherapy or chemoradiation

.

Lymphomas of the pancreas are rare and constitute less than3% of all pancreatic cancersThese respond to chemoradiotherapy and surgical resection is not indicated.

For patients with ductal adenocarcinoma, 5-FU or gemcitabine will produce a remission in 15–25%.

Downstaging is usually non useful. Steatorrhoea is treated with enzyme supplementationDiabetes mellitus, if it develops, is treated with oral hypoglycaemics or insulin.

Pain with either analgesics or an appropriate nerve block.

59

Slide60

60

Slide61

Thanks

61