Pancreatic Necrosis

QUESTION: What is the classic picture on CT scan? Who needs an operation?
ANSWER: Soap bubbles.  If septic and infected (CT guided aspirate) then antibiotics and drainage (necrosectomy)

Pancreatic Lymphoma

Very Rare, one time where CT guided biopsy might help with pancreatic mass
QUESTION: Management of primary pancreatic lymphoma
ANSWER: Chemotherapy, not surgery

Pancreatic Cancer

Most significant risk factor is smoking
90% adenocarcinoma (2/3 on the head of pancreas)
Ca-19-9, Ca-50. K-Ras
QUESTION: What are is the palliative surgery for obstruction secondary to pancreatic cancer?
ANSWER: Cholecystojejunostomy or choledochojejunostomy  and Gastrojejunostomy

Pancreatic Fistula

QUESTION: What is the management of a persistent pancreatic internal fistula
ANSWER: Drain pancreatic fluid and keep NPO, then ERCP, then pancreatic resection or drainage procedure depending on location of fistula

Chronic Pancreatitis

Recurrent bouts of pancreatitis with chronic pain usually due to alcohol
QUESTION: What is the surgical management of chronic pancreatitis
ANSWER: Peustow (Lateral pancreatico-jejunostomy) if diffusely dilated duct > 8mm, Pancreatectomy for pain with normal duct

Serous Cystadenoma

Presentation - Older Woman with central scar on CT scan
QUESTION: Management of serous cystadenomas
ANSWER: Malignancy = very RARE - therefore, resection is for symptoms or unknown diagnosis

Mucinous Cystic Neoplasm

Presentation - Older Woman with peripheral eggshell calcifications on CT scan
QUESTION: Management of MCNs?
ANSWER: High risk features = size > 3cm, thick wall, peripheral calcifications, mural nodules (RESECT) - Therefore - lesions < 3cm without symptoms can be watched with serial imaging

Intraductal papillary mucinous neoplasm

Presentation - Older Male, PREMALIGNANT
QUESTION: Management of IPMNs?
ANSWER: Types (as determined radiographically) dictates treatment:
1. Main duct - high CA risk if main duct > 6mm, mucin on endoscopy, mural nodularity - resect all
2. Side branch - usually multifocal, lower malignancy risk
3. Mixed type (both main and side branch)

Pancreatic divisum

QUESTION: Why do patients with divisum have an increased risk of pancreatitis?
ANSWER: Minor Duct (Santorini) fails to fuse with Major Duct (Wirsung) and thus pancreas has to drain in minor papilla and sometimes can't handle drainage

Hereditary Pancreatitis

QUESTION: What is the etiology of hereditary pancreatitis? - treatment?
ANSWER: autosomal dominant trypsin inactivation gene that leads to uncontrolled enzymatic degeneration and greatly increases cancer risk - pancreatectomy

Gallstone Pancreatitis

5% of symptomatic patients with choleliathiasis can get gallstone pancreatitis
30% recurrence if gallbladder not removed
QUESTION: In gallstone pancreatitis, when do you do a lap chole? and who gets an ERCP?
ANSWER: wait for lipase to decrease to near normal and near resolution of symptoms and BEFORE DISCHARGE - if concerned for biliary obstruction (hyperbilirubinemia) or prior cholangitis get a pre op ERCP to clear duct

Gastrinoma

QUESTION: What are the important points of diagnosis for Gastrinomas?
ANSWER: Secretin stimulation test paradoxically increases gastrin levels (> 120) and octreotide scan is very helpful for localization due the high concentration of somatostatin receptors
QUESTION: What is Passaro's Triangle or Gastrinoma Triangle
ANSWER: the junction of the cystic and common bile duct superiorly, the junction of the second and third portion of the duodenum laterally, the junction of the neck and body of the pancreas medially

Insulinoma

MOST COMMON functioning neuroendocrine tumor but usually 90% benign

Whipple's triad - Hypoglycemic symptoms when fasting; <50 mg/dl blood glucose; Symptoms resolve with glucose

QUESTION: Diagnosis of insulinoma? and Treeatment
ANSWER: low fasting glucose with elevated C-peptide and localization with CT scan - enucleate if < 2cm, formal resection for > 2cm

VIPoma

WDHA syndrome or Verner-Morrison Syndrome - watery diarrhea, hypokalemia, and other achlorhydia or hypochlorydia
QUESTION: Why are VIPomas so bad and what is mangement?
ANSWER: VIPomas cause massive fluid loss and electrolyte abnormalities and are usually malignant at diagnosis.  Management includes resection but often patients are palliated with octreotide.

Somatostatinoma

Diabetes, gallstones, steatorrhea, hypochlorhydria (everything slows) QUESTION: Younger patient with exocrine pancreatic dysfunction and pancreatic head mass - diagnosis? Malignant? Treatment?
ANSWER: Somatostatinoma, usually malignant at time of diagnosis, resection

Glucagonoma

Diabetes, stomatitis, dermatitis (necrolytic migratory erythema - usually abdominal wall and perineum)
QUESTION: CT scan uses mass in tail of pancreas with diabetes and skin rash to perineum - diagnosis? management?
ANSWER: Glucagonoma - octreotide but if refractory to medical management than resection (distal pancreatectomy)

Pancreatic Pseudocyst

Due to pancreatitis (20%) and trauma
QUESTION: Chronic pancreatitis patient with large epigastric fullness - Diagnosis? Management?
ANSWER: Pseudocyst - allow to mature for 3 months, then ERCP and if duct involved cystogastrostomy and if not then perc drain

Tropical Pancreatitis

Hereditary pattern with mutation in trypsinogen inhibitor SPINK1 gene, associated with pancreatic duct stones
QUESTION: young patient who lives in the tropics with abdominal pain and diabetes - diagnosis? management?
ANSWER: tropical pancreatitis - pain medication and enzyme supplementation and possible endoscopic decompression