SURGERY

PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

OUTLINE ANATOMY OF PANCREAS
I. Anatomy of Pancreas
a. Location and relations LOCATION AND RELATIONS
b. Blood supply
c. Nerve supply
II. Functions of Pancreas
a. Exocrine
b. Endocrine
III. Acute Pancreatitis
a. Causes of Acute Pancreatitis
b. Pathophysiology
c. Signs and Symptoms
d. Diagnosis
e. Gallstone Pancreatitis
f. Types of Acute Pancreatitis
g. Management
h. Local Complications
i. Other Complications
IV. Chronic Pancreatitis
a. Etiology • Retroperitoneal
b. Symptomatology • Sometimes adheres with the spinal
c. Classification column
d. Diagnosis • The head is located in the C-Loop of the
e. Treatment duodenum
V. Neoplasms of the Pancreas • Closely related to the 2nd portion of the
a. Adenocarcinoma duodenum; where the opening of the
b. Pancreatic Cancer Ampulla of Vater and common bile duct
c. Borderline Resectable (CBD) is located
Tumors
d. Other Tumors BLOOD SUPPLY
e. Cystic Neoplasm

• At the superior border of the pancreas is
• the SMV (+ splenic vein = PV)
• The portal vein opens to the neck of the
pancreas

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

NERVE SUPPLY • Iatrogenic
• Splanchnic nerve • Pancreatic Duct Obstruction
• Parasympathetic innervations by way o Gall stone tends to impede the
of Vagus nerves from Celiac Division opening of the pancreatic
of Posterior Vagus enzymes → auto digestion
o Inflammatory reaction →
FUNCTIONS OF PANCREAS inflammatory cascade
• Hypercalcemic State
EXOCRINE • Hyperlipidemia
• Localized effect • Hereditary
• Acinar cells • Protein Deficiency
• Cholecystokinin + vagal cholinergic • Trauma
stimulation → Digestive enzymes
(proteases, lipases, amylase) Mnemonic:

ENDOCRINE
• Systemic effect
• Islets of Langerhans
• Insulin (β cells), glucagon (α cells),
somatostatin (δ cells), pancreatic
polypeptide (PP), gherlin (ε cells)

ACUTE PANCREATITIS
• Most common medical problem of the
pancreas

CAUSES OF ACUTE PANCREATITIS
• Biliary Tract Disease

o Gall stone – most common
PATHOPHYSIOLOGY
cause
• Alcoholic Binge
o Due to the increase pancreatic
work → increase enzyme
secretion → digestion of food
and autodigestion of the
pancreas itself →initial insult

SIGNS AND SYMPTOMS
• Types of pain in pancreatitis
o Boring - pancreas
o Colicky - On/Off pain and felt
in the gallbladder and ureters
o Cramping – colon and small

intestine

• Epigastric Pain

• Back Pain

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

• Cullen’s Sign Diagnosis Requires Two of the Following
o Found in hemorrhagic (2012 revision of Atlanta Classification; by
pancreatitis international consensus)
o Bruising in the umbilicus • Abdominal pain consistent with acute
• Grey Turner’s Sign pancreatitis (acute onset of persistent,
o Found in hemorrhagic severe, epigastric pain often radiating
pancreatitis to the back.
o Bruising in the flanks • Serum lipase activity (or amylase
activity) at least three times greater
than the upper limit of normal; and
• Characteristic acute findings of acute
pancreatitis on contrast enhanced
computed tomography (CECT) and
less commonly magnetic resonance
imaging (MRI) or transabdominal
ultrasonography

Ranson’s Prognostic Criteria for Acute
Pancreatitis
• Present on admission
o Age >55 years old
o WBC > 16,000

DIAGNOSIS o Blood Glucose > 200 mg/dL
o Serum LDH (Lactate
Dehydrogenase) 350 I.U/L
Pancreatic Duct Obstruction Diagnostic
o Serum AST (Aspartate
Studies
Transferase) >250 I.U/dL
• Serum amylase o 0-2 = 2% mortality; 3-4 =
• Urinary amylase 15%
• Serum lipase • Developed during the first 48 hours
• C-reactive protein o Hematocrit falls >10 points
o Degree of inflammatory o BUN increase > 5 mg/dL
reaction o Serum Ca <8 mg/dL
• Scout film of the abdomen o Arterial PO2 <60 mmHg
• Ultrasound o Base Deficit >4 mEq/L
o Accessible and cheaper o Estimated fluid sequestration
• CT scan = 6000 mL
o Gold standard
o No longer immediately requested Note:
• 0-2 s/sx present = 2% mortality
• 3-4 s/sx present = 15% mortality
• 5-6 s/sx present = 40% mortality
• 7-8 s/sx present = 100% mortality

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

GALLSTONE PANCREATITIS TYPES OF ACUTE PANCREATITIS

Interstitial Edematous
• Diffuse (or occasionally localized)
enlargement of the pancreas due to
inflammatory edema.
• Clinical symptoms may resolve within
the first week.

Necrotizing Pancreatitis
• Most common cause of acute
• 5-10% of patients develop necrosis of:
pancreatitis
o pancreatic parenchyma
• Transient obstruction of the
o peripancreatic tissue
pancreatic duct by a gallstone in the
• Both natural history of pancreatic and
common bile duct at the ampulla of
peripancreatic necrosis is variable
vater
because it may:
• Request an ERCP (Endoscopic o Remain solid or liquefy,
Retrograde o Remain sterile or become
Cholangiopancreatography)
infected, persist, or disappear
• Do not operate because of the over time.
elevated amylase; manipulation may
increase pancreatic work-up
Infected Pancreatic Necrosis
• Only operate on gall bladder stone
removal (Cholecystectomy) after the • When there is extraluminal gas in the
serum amylase had normalize within pancreatic and/or peripancreatic
a week tissues of CECT
• Antibiotics is only given when • When percutaneous, image-guided,
necessary fine-needle aspiration (FNA) is
positive for bacteria and/or fungi on
Gram stain and culture. There may be
Criteria for Acute Gallstone Pancreatitis
a varying amount of suppuration
• At admission (pus) associated with infected
o Age >70 years pancreatic necrosis, and this
o WBC > 18,000 suppuration tends to increase with
o Blood Glucose > 220 mg/dL liquefaction.
o Serum LDH >400 IU/L • Diagnosis of the infected pancreatic
o Serum AST >250 U/dL necrosis is important because of the
• During the initial 48 Hours need for antibiotic treatment and
o Hematocrit fall >10 points likely active intervention
o BUN elevation >2 mg/dL
o Serum Ca <8 mg/dL
o Base deficit >5 mEq/L Note:
o Estimated fluid sequestration • Pancreatitis is sterile. The patient may
= 4000 mL be having SIRS.
• Prolonged pancreatitis may be infected
by necrosis
• Recently: FNA is not required; CT scan
results showing presence of fluid →
therapeutic drainage of fluid → no need
for FNA

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

MANAGEMENT – MEDICAL TREATMENT APFC (ACUTE PERIPANCREATIC FLUID
• Fluid replacement COLLECTION)
• Pain management • Peripancreatic fluid associated with
• Nutritional support interstitial edematous pancreatitis
o Early enteral feeding (4-6 with no associated peripancreatic
hours upon admission) necrosis
§ As long as the patient • This term applies only to areas of
can tolerate peripancreatic fluid see within the
o Nasogastric tube first 4 weeks after onset of interstitial
§ If vomiting is present edematous pancreatitis and without
o Nasoduodenal tube the features of a pseudocyst.
o Parenteral feeding
§ If previous methods CECT criteria
not fails • Occurs in the setting of interstitial
• ERCP (Endoscopic Retrograde edematous pancreatitis
Cholangiopancreatography) • Homogenous collection with fluid
• Interventional Radiology density
• Antibiotic (only when infected) • Confined by normal peripancreatic
fascial planes
SURGICAL MANAGEMENT • Undefinable wall encapsulating the
collection
• Adjacent to pancreas (no
intrapancreatic extension)

PANCREATIC PSEUDOCYST

LOCAL COMPLICATIONS
• There is persistence or recurrence of • A fluid collection in the peripancreatic
abdominal pain tissues (occasionally it may be partly
• Secondary increases in serum or wholly intrapancreatic).
pancreatic enzyme activity • Surrounded by a well-defined wall
• Increasing organ dysfunction, and/or • Contains essentially no solid material
the development of clinical signs of • Arise from disruption of the main
sepsis, such as fever and leukocytosis pancreatic duct or its intra-pancreatic
• Acute pancreatic accumulation branches without any recognizable
(Pancreatic Ascites); Unencapsulated pancreatic parenchymal necrosis;
this theory suggests that consequent
leakage of pancreatic juice results in
persistent, localized fluid collection,
usually after more than 4 weeks.

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

• An encapsulated collection of fluid External Drainage
with a well-defined inflammatory wall
usually outside the pancreas with
minimal or no necrosis.
o Occurs more than 4 weeks
after onset of interstitial
edematous pancreatitis to
mature.

CECT criteria
• Well-circumscribed, usually round or
oval
• Homogenous fluid density
• No non-liquid component
• Well-defined wall; that is completely
encapsulated
• Maturation usually requires > 4

weeks after onset of acute ANC (ACUTE NECROTIC COLLECTION)
pancreatitis; occurs
• A collection containing variable
• after interstitial edematous
amounts of both fluid and necrosis
pancreatitis
associated with necrotizing

pancreatitis.
Internal Drainage
• The necrosis can involve the
pancreatic parenchyma and/or the
peripancreatic tissues.

CECT criteria
• Occurs only in the setting of acute
necrotizing pancreatitis
• Heterogenous and nonliquid density
of varying degrees in different
locations (some appear homogenous
early in their course)
• Cytogastrostomy • No definable wall encapsulating the
o 1 cm thick collection
o To open the stomach down to • Location – intrapancreatic and/or
the pancreatic pseudocyst extrapancreatic
wall and suture the stomach
to the pancreas Principles of surgical management of
• Cytojejunustomy infected pancreatic necrosis
o When pancreas does not • Debridement of all infected necrotic
abate to the stomach material.
o Join the pancreas with the o Debridement is done bluntly
jejunum and gently.
o Hyrdosonic irrigation
frequently used to avoid
vascular injury.
• Drainage of the remaining pancreatic
bed.

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

WON (WALLED-OFF NECROSIS) ETIOLOGY
• A mature, encapsulated collection of • Alcohol
pancreatic and/or peripancreatic • Cigarette Smoking
necrosis that has developed a well- • Hyperparathyroidism
defined inflammatory wall. • Hyperlipidemia
• Occurs >4 weeks after onset of • Drugs
necrotizing pancreatitis. • Gallstone
• Stricture
CECT criteria • Idiopathic
• Heterogenous with liquid and non-
liquid density with varying degrees of SYMPTOMATOLOGY
loculations (some may appear • Abdominal pain
homogenous) • Weight loss
• Well-defined wall, that is, completely • Diabetes
encapsulated • Malabasorption
• Location – intrapancreatic and/or
extrapancreatic CLASSIFICATION
• Maturation usually requires 4 weeks • Chronic Calcific (Lithogenic)
after onset of acute necrotizing • Chronic Obstructive
pancreatitis
• Chronic Inflammatory

• Chronic Autoimmune
OTHER COMPLICATIONS
• Asymptomatic Pancreatic
• Systemic / Organ Failure
• Fibrosis
• Pulmonary

• Cardiovascular
DIAGNOSIS
• Renal
• Ultrasound
• GI hemorrhage
• Endoscopic Ultrasound
• Hematologic
• ERCP
• Metabolic
• CT Scan
• Central Nervous System

• Fat Necrosis
TREATMENT

CHRONIC PANCREATITIS • Decompressive Procedures
• A progressive inflammatory disease of • Neural Ablative Procedures
the pancreas, characterized by: • Drainage Procedures
o Irreversible morphological o Puestow Procedure
changes o Frey Procedure
o Gradual fibrotic replacement o Beger Procedure
of the gland o Pancreatic Resection
• Loss of exocrine & endocrine function
results from parenchymal fibrosis
• The primary symptoms of CP are:
o Abdominal pain
o Maldigestion
• Essential pathologic features:
o Include irregular and patchy
loss of acinar tissue
o Chronic inflammation
o Ductal changes
o fibrosis

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

Puestow Procedure Frey Procedure

• Pour out the head of the pancreas
• With a loop of the jejunum that is
mobilized and attached over the
exposed pancreatic duct to allow
better drainage

• Most common
• Incise the pancreas to have a clear
view of the pancreatic ducts
• Get the tip of the jejunum and suture
it to the ducts to relieve the
obstruction
• It may sometime not drain the head of
the pancreas

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

Beger Procedure NEOPLASMS OF THE PANCREAS

ADENOCARCINOMA
• Periampullary tumor
o Pancreas
o Ampulla of Vater
§ Best prognosis
o Duodenum
o Bile Duct

PANCREATIC CANCER
• Head, Body or Tail in Location
o Head – most common

Clinical Manifestations
• Obstructive, painless jaundice
• Abdominal/ back pain
• Abdominal obstruction
• Weight loss
• Abdominal mass

Risk Factors
• >60 years old
• Cigarette smoking
• Diets high in fat and low in fiber fruits
and vegetables
• Preexisting type II diabetes
• Genetic (10%)

Diagnostic Procedures
• Ultrasound
• Endoscopic Ultrasound
• CT scan – tri-phasic contrast
• MRCP / MRI
• ERCP / PTC
• PET scan
• CA 19-9 (tumor marker)
• Pre-op biopsy (+/-)

Staging Methods
• TIS: confined to pancreas
• T1: </= 2 CM
• T2: >2CM
• T3: beyond no celiac involvement
• T4: with involvement of celiac axis
• Removal of the head of the pancreas
and attachment of a part of the

jejunum into the removed head of the
pancreas

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

Prognosis • Gastroduodenal artery encasement up
• Stage 1, T1-T2, no LN – 20.3% 5 years to the hepatic artery and short
• Stage 2, T3, with LN – 8.0% 5 years segment encasement/direct tumor
• Stage 3, T4 abutment of the hepatic artery with
• Stage 4, any T, + M1 – 1.7% no extension to the celiac axis
• Tumor-SMA involvement <180°
• Unstaged – 4.1%


Whipple’s Procedure
Treatment
• Stenting
• Pancreatic Resection; Distal
• Pancreatotomy
• Whipple’s Procedure
• (Pancreaticodudodenectomy)
• Double by-pass surgery
• Chemotherapy:
o Gemcitabine Folfirinox
(oxaliplatin 85 mg/m2,
irinotecan 180 mg/m2,
leucovorin 400 mg/m2, 5-
fluorouracil 2400mg/m2)
o Followed by external beam
radiation therapy (50.4 Gy)
with capecitabine (825
mg/m2)

Contraindicating Resection
• Liver Metastasis
• Celiac Lymph Node involvement
• Peritoneal implants
• Hepatic Hilar Lymph Node
• involvement
• Involvement of major vessels

Findings Not Contraindicating Resection
• Invasion at duodenum or distal
stomach
• Peripancreatic lymph nodes
• Lymph nodes along the porta hepatis
that can be swept down with the
specimen

BORDERLINE RESECTABLE TUMORS
• Venous involvement of the SMV/PV
demonstrating tumor abutment,
encasement or short segment venous
occlusion but with suitable vessel
proximal and distal to the area of
vessel involvement allowing for safe
resection and reconstruction

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 SURGERY
PANCREAS
Dr. Christine Trespeces; 10/11/2019, 1:30-3:30 pm

Complications
• <5% in high volume centers
• Sepsis, hemorrhage and CV events
• Most common cause of death
• Delayed gastric emptying
• Pancreatic leak • Treatment: pancreatic resection
• Glucagonoma, VIP secreting tumor,
NEOPLASMS OF ENDOCRINE PANCREAS somatostinoma

Insulinoma CYSTIC NEOPLASM
• Most common pancreatic endocrine • Serous Cystadenoma
tumor. o Low malignant potential
o Surgery only for symptomatic
• Whipple’s Triad
patients
o Symptomatic fasting
hypoglycemia • Mucinous cystic neoplasms
o Documented serum glucose o Potentially aggressive
level <50 mg/dL malignant tumor
o Relief of symptoms with o Pancreatic resection
glucose administration

• 90% are benign and solitary

• Treatment

o Enucleation

o Pancreatectomy



Gastrinoma
• Endocrine tumor that secretes gastrin
causing Zollinger-Ellison syndrome
• 70% located in Passaro’s triangle
o Junction of cystic duct and
common duct
o 2nd and 3rd portion of
duodenum
o Neck and body of pancreas

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