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(BQ) Part 1 book The washington manual of surgery presentation of content: Common postoperative problems, nutrition for the surgical patient, critical care, chest trauma, abdominal trauma, extremity trauma, common surgical procedures, the surgical management of obesity, acute abdomen, small intestine,... and other contents.
UnitedVRG - Tahir FRONT OF BOOK ↑ [+] Cover [+] Authors - Foreword - Preface TABLE OF CONTENTS [+] - General and Perioperative Care of the Surgical Patient [+] - Common Postoperative Problems [+] - Nutrition for the Surgical Patient [+] - Fluid, Electrolytes, and Acid-Base Disorders [+] - Anticoagulation, Hemostasis, and Transfusions [+] - Anesthesia [+] - Critical Care [+] - Burns [+] - Wound Care [+] 10 - Head, Neck, and Spinal Trauma [+] 11 - Chest Trauma [+] 12 - Abdominal Trauma [+] 13 - Extremity Trauma [+] 14 - Common Surgical Procedures [+] 15 - Acute Abdomen [+] 16 - Esophagus [+] 17 - Stomach [+] 18 - The Surgical Management of Obesity [+] 19 - Small Intestine [+] 20 - Surgical Diseases of the Liver [+] 21 - Surgical Diseases of the Biliary Tree [+] 22 - Surgical Diseases of the Pancreas [+] 23 - Spleen [+] 24 - Colon and Rectum [+] 25 - Anorectal Disease [+] 26 - Cerebrovascular Disease [+] 27 - Thoracoabdominal Vascular Disease [+] 28 - Peripheral Arterial Disease [+] 29 - Venous and Lymphatic Disease ↑ [+] 30 - Hemodialysis Access [+] 31 - Transplantation [+] 32 - Pediatric Surgery [+] 33 - Cardiac Surgery [+] 34 - Lung and Mediastinal Diseases [+] 35 - Breast [+] 36 - Skin and Soft-Tissue Tumors [+] 37 - Fundamentals of Laparoscopic, Robotic and Endoscopic Surgery [+] 38 - Hernias [+] 39 - Diseases of the Adrenal and Pituitary Gland and Hereditary Endocrine Syndromes [+] 40 - Thyroid and Parathyroid Glands [+] 41 - Otolaryngology for the General Surgeon [+] 42 - Plastic and Hand Surgery [+] 43 - Urology for the General Surgeon [+] 44 - Obstetrics and Gynecology for the General Surgeon [+] 45 - Biostatistics for the General Surgeon [+] 46 - Patient Safety and Quality Improvement in Surgery BACK OF BOOK [+] Answer Key [+] Index ↑ > Table of Contents > Authors Editors Mary E Klingensmith MD1 1Department of Surgery Washington University School of Medicine St Louis, Missouri Chandu Vemuri MD1 1Department of Surgery Washington University School of Medicine St Louis, Missouri Oluwadamilola M Fayanju MD1 1Department of Surgery Washington University School of Medicine St Louis, Missouri Jason O Robertson MD1 1Department of Surgery Washington University School of Medicine St Louis, Missouri Pamela P Samson MD1 1Department of Surgery Washington University School of Medicine St Louis, Missouri Dominic E Sanford MD1 1Department of Surgery Washington University School of Medicine St Louis, Missouri Foreword by Timothy J Eberlein, MD Bixby Professor and Chair of Surgery Director, Siteman Cancer Center Washington University School of Medicine St Louis, Missouri Contributors Bola Aladegbami, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri Michael S Avidan, MBBCh Professor of Anesthesiology and Cardiothoracic Surgery Washington University School of Medicine St Louis, Missouri Michael M Awad, MD, PhD Assistant Professor of Surgery Washington University School of Medicine St Louis, Missouri Joshua A F Balderman, MD Resident in Vascular Surgery Washington University School of Medicine St Louis, Missouri Lauren M Barron, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri Michael J Beckman, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri Grant Bochicchio, MD Professor of Surgery Washington University School of Medicine St Louis, Missouri Stephanie L Bonne, MD Assistant Professor of Surgery Washington University School of Medicine St Louis, Missouri David G Brauer, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri L Michael Brunt, MD Professor of Surgery Washington University School of Medicine St Louis, Missouri Sara A Buckman, MD Assistant Professor of Surgery Washington University School of Medicine St Louis, Missouri Stephanie H Chang, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri William C Chapman, MD Eugene M Bricker Professor of Surgery Washington University School of Medicine St Louis, Missouri Chun-Cheng (Richard) Chen, MD, PhD Resident in Surgery Washington University School of Medicine St Louis, Missouri Pamela M Choi, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri Haniee Chung, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri Graham A Colditz, MD Niess-Gain Professor of Surgery Washington University School of Medicine St Louis, Missouri Alana C Desai Assistant Professor of Urologic Surgery Washington University School of Medicine St Louis, Missouri Jose L Diaz-Miron, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri Maria B Majella Doyle, MD Associate Professor of Surgery Washington University School of Medicine St Louis, Missouri Bernard J DuBray Jr., MD Resident in Surgery Washington University School of Medicine St Louis, Missouri J Christopher Eagon, MD Associate Professor of Surgery Washington University School of Medicine St Louis, Missouri Leisha C Elmore, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri Paul M Evans, MD, PhD Resident in Surgery Washington University School of Medicine St Louis, Missouri Oluwadamilola M Fayanju, MD, MPHS Resident in Surgery Washington University School of Medicine St Louis, Missouri Ryan C Fields, MD Assistant Professor of Surgery Washington University School of Medicine St Louis, Missouri Bradley D Freeman, MD Professor of Surgery Washington University School of Medicine St Louis, Missouri Patrick J Geraghty, MD Associate Professor of Surgery and Radiology Washington University School of Medicine St Louis, Missouri William E Gillanders, MD Professor of Surgery Washington University School of Medicine St Louis, Missouri Andrea R Hagemann, MD Assistant Professor of Obstetrics and Gynecology/Gynecologic Oncology Surgery Washington University School of Medicine St Louis, Missouri Bruce Lee Hall, MD, PhD, MBA Professor of Surgery Washington University School of Medicine St Louis, Missouri William G Hawkins, MD Neidorff Family and Robert C Packman Professor of Surgery Washington University School of Medicine St Louis, Missouri Matthew C Henn, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri Gwendolyn Hoben, MD Resident in Plastic and Reconstructive Surgery Washington University School of Medicine St Louis, Missouri Ashley M Holder, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri Jessica L Hudson, MD Resident in Surgery Washington University School of Medicine St Louis, Missouri TABLE 22-3 Prognosis Based on CTSI Score Index Predicted Morbidity Predicted Mortality 0-3 8% 3% 4-6 35% 6% 7-10 92% 17% P.393 Because of the proximity of the splenic, superior mesenteric, and portal veins, venous thrombosis is not uncommon in patients with acute pancreatitis E Treatment End-organ failure is associated with poorer outcomes Therefore, the initial approach to managing acute pancreatitis focuses on supporting patients with aggressive fluid resuscitation and close monitoring Supportive care a Volume resuscitation with isotonic fluids is crucial; urinary output is monitored with a Foley catheter targeting greater than 0.5 mL/kg/hour During the course of resuscitation, patients should be maintained on continuous pulse oximetry as patients often require large volume fluid resuscitation and frequent monitoring of electrolytes b Gastric rest with nutritional support Nasogastric decompression is performed to decrease neurohormonal stimulation of pancreatic secretion Acute pancreatitis is a hypercatabolic state, and nutritional support has been shown to have a significant impact on outcomes in critically ill patients Enteral feeding is generally preferred to parenteral nutrition Early enteral feeding in patients with severe acute pancreatitis is associated with lower rates of infection, surgical intervention, and length of stay (BMJ 2004;328:1407) c Analgesics are required for pain relief d Respiratory monitoring and arterial blood gases are usually necessary in severe pancreatitis to assess oxygenation and acidÑbase status Hypoxemia is common, even in mild cases of acute pancreatitis given the volume of fluid resuscitation and the potential for development of sympathetic effusions Pulmonary complications occur in up to 50% of patients e Antibiotics The routine use of antibiotic prophylaxis in acute pancreatitis, especially in mildto-moderate cases, is not supported in the literature Conflicting data exist regarding antibiotics in severe cases, as there are small prospective, randomized trials demonstrating significantly lower rates of septic complications in patients receiving antibiotics (Ann Surg 2006;243:154) and subsequent data from an RCT that found differences in infection or surgical intervention (Ann Surg 2007;245:674) However, a meta-analysis demonstrated no difference in mortality, infected necrosis, or overall infections with antibiotic therapy (Cochrane Database Syst Rev 2010;5:CD002941) When infection is confirmed or suspected, patients should be treated with broad-spectrum systemic antibiotics that cover Gram-negative bacteria and, depending on length of hospitalization, common hospital-acquired pathogens, including fungal organisms, as super infection can be seen commonly Interventional and surgical treatment is necessary in a small percent of cases, fluid collections and/or pancreatic necrosis needs to be treated The indications are clinical deterioration, sepsis, hypotension, P.394 and evidence of gastrointestinal obstruction due to the collections Debridement of necrotic pancreas should be delayed to at least 18 to 20 days after onset of attack to allow sequestration of the necrosis In severely ill patients percutaneous or endoscopic drainage using multiple and/or large drains is often used as a first step to stabilize patients Resection of necrosis by endoscopic or minimally invasive or open surgery is performed as a second procedure several weeks later if necessary (NEJM 2010;362(16):1491-1502; Br J Surg 2011;98(1):18-27) Open surgery was the mainstay of treatment but is needed uncommonly today Rarely surgery is needed for bleeding or organ perforation Treatment of gallstone pancreatitis In mild cases of acute pancreatitis, laparoscopic cholecystectomy with operative cholangiogram is indicated on the index admission or soon thereafter in healthy patients Delay has resulted in the occurrence of a second attack, which may be more severe In patients with severe gallstone pancreatitis, cholecystectomy should be performed when general and local conditions permit Operative cholangiography is needed to rule out persistent choledocholithiasis, although since acute pancreatitis is caused by small stones only 10% are found to have residual stones at the time of surgery In patients not fit for surgery endoscopic sphincterotomy may protect against further attacks of pancreatitis II CHRONIC PANCREATITIS A Etiology Alcohol (EtOH) abuse is the most common cause (70%); however, other etiologies include idiopathic, metabolic (hypercalcemia, hypertriglyceridemia, hypercholesterolemia, hyperparathyroidism), drugs, trauma, genetic (SPINK1, cystic fibrosis), and congenital abnormalities (sphincter of Oddi dysfunction or pancreas divisum) It also appears that tobacco abuse plays an important role in the development of chronic pancreatitis and particularly in patients with EtOH-related disease (Arch Intern Med 2009;169:1035-1045) A history of recurrent acute pancreatitis is present in some but not all patients with chronic pancreatitis B Pathophysiology Chronic pancreatitis is characterized by diffuse scarring and strictures in the pancreatic duct and commonly leads to endocrine or exocrine insufficiency, although substantial glandular destruction must occur before secretory function is lost Most patients who develop diabetes already have pancreatic exocrine insufficiency and steatorrhea Reduced food intake, due to pain, and malabsorption lead to malnutrition C Diagnosis is based on history and examination, complemented by appropriate investigative studies Upper midepigastric pain radiating to the back is the cardinal symptom and is present in 85% to 90% of cases, and becomes progressively worse over time Changes in bowel habits and bloating are other common early symptoms, followed later by steatorrhea P.395 and diabetes as the disease progresses Weight loss is common and food fear may be present Upper abdominal tenderness may be present Less common findings include jaundice secondary to stricture of the common bile duct, enlarged spleen secondary to thrombosis of the splenic vein, or ascites secondary to a pancreatic peritoneal fistula Laboratory tests a Amylase and lipase levels are elevated in acute pancreatitis but rarely are useful in chronic pancreatitis and are commonly normal due to progressive loss of pancreatic function b Pancreatic secretin stimulation tests have proven to be highly sensitive (90% to 100%) and specific (>90%) test for the diagnosis of chronic pancreatitis c Pancreatic endocrine function Fasting and 2-hour postprandial blood glucose levels or glucose tolerance tests may be abnormal in 14% to 65% of patients with early chronic pancreatitis and in up to 90% of patients when calcifications are present d A 72-hour fecal collection for estimation of daily fecal fat is relatively simple and cheap, but plays a limited role in the definitive diagnosis of chronic pancreatitis as patients must have a high degree of pancreatic insufficiency to have a positive test Radiologic studies a Plain films of the abdomen may show diffuse calcification of the pancreas in 30% to 40% of patients b Ultrasound Transabdominal ultrasound has low sensitivity and is subject to limitations related to user dependency, body habitus, and overlying bowel gas, and plays a limited role in the diagnosis of chronic pancreatitis c CT is 80% sensitive and 75% to 90% specific for the diagnosis of parenchymal or ductal disease Common findings include ductal dilatation, calcifications, atrophy, and cystic lesions CT is also useful to evaluate for mass lesions and sequelae of chronic pancreatitis d MRI is less sensitive than CT for detection of calcification MR pancreatography is more sensitive in visualizing a dilated duct and strictures but loses sensitivity relative to ERCP in evaluating sidebranch disease (i.e., small duct disease) e ERCP provides the greatest detail of pancreatic duct anatomy, demonstrating strictures and areas of dilation The presence of both may give the characteristic Òchain of lakesÓ picture ERCP may also be beneficial for evaluation of pancreatic mass lesions, cytology, and can be therapeutic There are drawbacks, however, in that images must be interpreted by specialized individuals, and there is a 3% to 7% risk of causing acute pancreatitis f Endoscopic ultrasound (EUS) EUS has come to play a more important role in the diagnosis of biliary obstruction Criteria for the diagnosis of chronic pancreatitis is based on EUS characteristics, such as lithiasis within the main pancreatic duct and parenchymal honeycombing, referred to as the Rosemont criteria (Gastrointest Endosc 2009;69(7):1251-1261) P.396 D Complications Common bile duct obstruction may result from transient obstruction from pancreatic inflammation and edema or from stricture of the intrapancreatic common bile duct When present, strictures are often long and smooth (2 to cm in length) and must be distinguished from malignancy Intestinal obstruction Duodenal obstruction can occur due to acute pancreatic inflammation, chronic fibrotic reaction, pancreatic pseudocyst, or neoplasm Rarely the colon may become obstructed Pancreaticoenteric fistulas result from spontaneous drainage of a pancreatic abscess cavity or pseudocyst into the stomach, duodenum, transverse colon, or biliary tract They are often asymptomatic but may become infected or result in hemorrhage Pancreaticopleural fistulas often have communication from the distal duct traversing the esophageal hiatus Pseudocyst (see Section V.A) Splenic vein thrombosis (see Section I.D.5) Pancreatic carcinoma Chronic pancreatitis has been suggested to increase the risk of pancreatic carcinoma by two- to threefold E Treatment Medical management a Malabsorption or steatorrhea Most patients will experience improvement in steatorrhea and fat absorption with pancreatic enzyme supplementation In addition, there is some evidence that adequate enzyme supplementation improves pain control b Diabetes initially is responsive to careful attention to overall good nutrition and dietary control; however, use of oral hypoglycemic agents or insulin therapy often is required c Narcotics are often required for pain relief In selected patients, tricyclic antidepressants and gabapentin may be effective d Abstinence from alcohol results in improved pain control in approximately 50% of patients e Cholecystokinin antagonists and somatostatin analogs have been considered for treatment of chronic pancreatitis, but have yet to show improvements in pain control f Tube thoracostomy or repeated paracentesis may be required for pancreatic pleural effusions or pancreatic ascites Approximately 40% to 65% of patients respond to nonsurgical management within to weeks Endoscopic therapy Endoscopic sphincterotomy, stenting, stone retrieval, and lithotripsy have all been used with moderate success in the management of patients with ductal complications from chronic pancreatitis Endoscopic celiac plexus block may improve symptoms in patients with severe pain See Section V.A for the discussion of pancreatic pseudocysts Surgical drainage of the pancreatic duct has been demonstrated to be effective than endoscopic treatment in patients with obstruction of the pancreatic duct due to chronic P.397 pancreatitis in a small randomized clinical trial (N Engl J Med 2007; 15:356(7):676-84) Surgical principles a Indications for surgery By far the most common indication is unremitting pain, but others include the inability to rule out neoplasm and management of complications (pseudocyst, aneurysm, and fistula) b Choice of procedure The goals of surgical therapy are drainage and/or resection of the diseased pancreas to alleviate pain and complications associated with chronic pancreatitis Most modern procedures combine drainage with some resection of the pancreas c Drainage/resection procedures (1) The Frey procedure is a major modification of earlier operations which removed duct stones and opened ductal strictures in the body of the gland and then provided new drainage of the duct by lateral pancreatojejunostomy (Puestow, PartingtonÑ Rochelle) These operations and the Frey procedure are best suited for patients with dilated ducts The earlier operations often failed because the pancreatic duct in the head of the gland was not drained adequately In the Frey procedure, the proximal pancreatic duct is also cleared by extensive coring of the head of the gland This is the most common procedure performed at our institution and throughout North America The Frey procedure has shown to provide excellent pain control and patient satisfaction in chronic pancreatitis (2) The Beger procedure is a duodenum-preserving resection of most of the pancreatic head This operation preserves a small amount of pancreatic tissue within the C-loop of the duodenum and also in front of the portal vein The pancreas is then transected at the pancreatic neck This procedure has also shown excellent long-term results (Ann Surg 1999;230(4):512-519); however, the procedure is more difficult because it requires dissection along the SMV It is rarely performed in North America d Pancreatectomy (1) PD (Whipple procedure) is indicated in cases in which the pancreatitis disproportionately involves the head of the pancreas, the pancreatic duct is of small diameter, or cancer cannot be ruled out in the head of the pancreas The Whipple has been shown to be inferior to both the Beger (Int J Pancreatol 2000;27(2):131-142) and Frey (Ann Surg 1998;228:771) procedures for this indication (2) Distal subtotal pancreatectomy is used for disease in the tail of the gland and in patients with previous ductal injury from blunt abdominal trauma with fracture of the pancreas and stenosis of the duct at the midbody level (3) Total pancreatectomy is performed only as a last resort in patients whose previous operations have failed and who appear to P.398 be capable of managing an apancreatic state Some centers have combined this procedure with islet cell transplantation The latter seems particularly applicable in cases of juvenile pancreatitis e Celiac plexus block can be achieved surgically by either ganglionectomy or direct injection of sclerosing agents However, today endoscopic injection is used most commonly Its effect is temporary III PANCREATIC DUCTAL ADENOCARCINOMA A Incidence and Epidemiology Pancreatic cancer is the fourth-leading cause of cancerrelated mortality in the United States Most patients have incurable disease at the time of diagnosis, and the overall 5-year survival is approximately 6% The median age at diagnosis is 65 years The survival or resected patients is about 20% B Risk Factors An increased risk of pancreatic ductal adenocarcinoma (PDAC) has been associated with smoking, alcoholism, family history, hereditary disorders (hereditary nonpolyposis colon cancer [HNPCC], von HippelÑLindau disease [VHL], PeutzÑJeghers syndrome, familial breast cancer [BRCA2], familial atypical multiple mole melanoma [FAMMM]), and chronic pancreatitis C Pathology PDAC accounts for the majority of pancreatic malignancies (90%) Seventy percent of PDAC occur at the head, 20% in the body, and 10% in the tail D Diagnosis Symptoms associated with pancreatic cancer are almost always gradual in onset and are nonspecific History and examination In cancer of the head of the pancreas bile duct obstruction, which is frequent, leads to the classical presentation of painless jaundice, pruritus, dark urine, and pale stools Malaise, nausea, fatigue, and weight loss are common and some patients have epigastric or back pain Epigastric abdominal pain improved with leaning forward (Ingelfinger sign) is also sometimes present In cancer of the distal pancreas pain and weight loss predominate Some patients present just with steatorrhea when the pancreatic duct alone is obstructed New-onset diabetes within the year prior to diagnosis is found in 15% of patients with pancreatic cancer Trousseau sign (migratory thrombophlebitis) has been associated with pancreas cancer Laboratory tests a Elevated serum bilirubin with >50% direct reacting bilirubin b Elevated alkaline phosphatase c Prolonged obstruction may lead to mild increase in AST and ALT a, b, and c are seen with biliary obstruction d Tumor markers Serum CA19-9 is often elevated It is a useful marker to follow in patients with elevated levels prior to initiation of therapy; however, it is often low in patients with resectable disease and can be elevated in nonmalignant biliary obstructive disease CA19-9 levels pretreatment may also have some role in determining P.399 prognosis (Cancer 2009;115(12):2630-2639) Carcinoembryonic antigen (CEA) is elevated in 40% to 50% of patients with pancreas cancer Radiologic studies a CT imaging should be a fine-cut, Òpancreatic protocol CTÓ including three phases (arterial, venous, and portal venous) and thin slices (≤3 mm) to allow for assessment of the relationship of the mass to vascular structures as this is crucial to determine resectability Pancreatic cancer on CT usually appears as a hypoattenuating indistinct mass that distorts the normal architecture of the gland, often paired with findings of a dilated pancreatic and biliary ductal system (the socalled Ịdouble-ductĨ sign) The CT criteria used to define resectability have been outlined in an expert consensus statement (Ann Surg Oncol 2009;16(7):1727-1733): (1) Locally resectable disease: No distant metastases; no radiographic evidence of SMV and portal vein abutment, distortion, tumor thrombus, or venous encasement; clear fat planes around the celiac axis, hepatic artery, and SMA (2) Borderline resectable: No distant metastases; venous involvement of SMV/portal vein demonstrating tumor abutment with or without impingement and narrowing of the lumen, encasement of the SMV/portal vein but without encasement of the nearby arteries, or short segment venous occlusion resulting from either tumor thrombus or encasement but with adequate vessels above and below site of malignancy to allow for safe resection and reconstruction; gastroduodenal artery encasement up to the hepatic artery with either short segment encasement or direct abutment of the hepatic artery, without extension to the celiac axis; tumor abutment of the SMA not to exceed greater than 180 degree of the vessel circumference (3) Unresectable: Distant metastases; major venous thrombosis of the SMV or portal vein for several centimeters; encasement of SMA, celiac axis, or hepatic artery b EUS and ERCP, especially the former, play an important role in patients in whom a mass is not seen on CT, obtaining tissue diagnosis when necessary (e.g., to determine candidacy for neoadjuvant therapy or when the diagnosis is in doubt) In addition, ERCP can be performed for drainage of biliary obstruction Preoperative stenting is controversial as it has been associated with an increase in postoperative complications (NEJM 2010;362(2):129-137) However, it is advisable in patients whose bilirubin is very high and in those whose surgery will be delayed due to neoadjuvant therapy or treatment of comorbidities c MRI and MRCP can provide information similar to that in conventional CT d Staging laparoscopy is used sparingly in cancer of the head of the pancreas where palliative operations are useful A high suspicion for metastatic disease would be an indication (e.g., high CA19-9) It is P.400 advisable for cancers of the distal pancreas where peritoneal metastases are common and surgical palliation is not performed E Treatment Resection a PD (Whipple procedure) consists of en bloc resection of the head of the pancreas, distal common bile duct, duodenum, jejunum, and gastric antrum Pylorus-sparing PD has been advocated by some, but there are no data demonstrating improved survival or lower morbidity (Cochrane Database Syst Rev 2011;2:CD006053) There has been a sharp decline in morbidity and mortality in specialized centers, with a 30-day mortality of less than 3% b Distal pancreatectomy The procedure of choice for lesions of the body and tail of the pancreas is distal pancreatectomy Distal pancreatectomy consists of resection of the pancreas, generally at the SMV laterally to include the spleen We have described a technique that provides a more radical resection with improved R0 resection rates, the radical antegrade modular pancreatosplenectomy (RAMPS), when compared to traditional series which is the procedure of choice for malignant tumors of the distal pancreas at our institution (J Am Coll Surg 2012;214(1):46-52) Postoperative considerations Delayed gastric emptying, pancreatic fistula, and wound infection are the three most common complications of PD Delayed gastric emptying almost always subsides with conservative treatment The rate of pancreatic fistula may be reduced by meticulous attention to the blood supply of the pancreaticoenteric duct-to-mucosa anastomosis (J Am Coll Surg 2002;194:746) Most surgeons routinely place abdominal drains, and this supported by a recent distal pancreatectomy has a higher morbidity and leak rates than PD with an approximately 20% pancreatic leak rate in most series; however, this is usually amenable to percutaneous treatment, and distal pancreatectomy has a similar mortality to PD Radiotherapy and chemotherapy a Neoadjuvant therapy Some groups routinely use preoperative chemotherapy with or without radiation, while others use this selectively b Adjuvant therapy There is a clear benefit to adjuvant therapy in pancreatic cancer (J Gastrointest Surg 2008;12(4):657-661); however, the choice between chemoradiation and chemotherapy is less clear The role of radiation therapy in pancreatic cancer and what role clinicpathologic factors may play in selecting patients for radiation therapy has yet to be fully elucidated Prognosis Surgical resection increases survival over patients with similar stage disease that not undergo resection Overall 5-year survival rates are approximately 20% for patients after resection In patients with small tumors, negative resection margins, and no evidence of nodal metastases, the 5-year survival rate is as high as 40% Median survival for unresectable locally advanced disease is 12 months, and for hepatic metastatic disease it is months P.401 F Pseudotumors of the Pancreas Inflammatory and fibrosing conditions of the pancreas may form dense, fibrotic masses, and segmental fibrosis that are difficult to differentiate from carcinoma preoperatively Lymphoplasmacytic sclerosing pancreatitis is often misdiagnosed as pancreatic cancer Patients are typically young (30s to 50s) and may be associated with other autoimmune disorders (Sjögren, ulcerative colitis, sclerosing cholangitis) When compared to patients with pancreatic cancer of all stages, these patients may have increased levels of serum IgG4, which can aid in making this diagnosis (Ann Surg Oncol 2008;15(4):1147-1154) IV NEUROENDOCRINE NEOPLASMS OF THE PANCREAS (See Chapter 39) V RARE NEOPLASMS OF THE PANCREAS A Acinar cell carcinoma is more common in men, and treatment is resection Prognosis is slightly better than with pancreatic adenocarcinoma, but recurrence is common B Solid pseudopapillary tumor is most commonly seen in young females, especially AfricanAmerican These tumors are typically large at presentation and are less frequently metastatic Treatment is resection, and prognosis is generally favorable C Metastatic tumors to the pancreas are most commonly renal cell carcinomas (RCC) Less common primaries include ovarian, colon, and melanoma When isolated to the pancreas, resection in the setting of RCC has been associated with 60% 5-year survival (J Am Coll Surg 2010;211(6):749-53) D Lymphoma can be primary or metastatic to the pancreas Treatment is combined multimodality therapy with chemotherapy and radiation, without surgical resection VI CONGENITAL ABNORMALITIES A Failure of the ventral and dorsal pancreatic buds to fuse during the sixth week of development results in pancreatic divisum In this condition, the dorsal duct of Santorini becomes the means of pancreatic drainage from the bulk of pancreatic tissue (body, tail, and superior portion of head) The condition is present in about 10% of the population Pancreas divisum is associated with an increased risk of pancreatitis Minor papilla endotherapy may improve outcomes in patients with recurrent pancreatitis Patients with severe symptomatic pancreas divisum may require surgical therapy B Malrotation of the ventral primordium during the fifth week results in annular pancreas: A thin, flat band of normal pancreatic tissue surrounding the second part of the duodenum The annular pancreas usually contains a duct that connects to the main pancreatic duct Annular pancreas may cause duodenal obstruction usually early in life but sometimes later in life The treatment of choice is duodenoduodenostomy or duodenojejunostomy P.402 VII CYSTIC DISEASES A Pancreatic Pseudocysts It is important to distinguish pseudocysts from tumors, cystic pancreatic neoplasms, and other fluid collections An acute pancreatic fluid collection follows in approximately 25% of patients with acute pancreatitis It is characterized by acute inflammation, cloudy fluid, a poorly defined cyst wall, and necrotic but sterile debris, and many resolve spontaneously Pseudocysts differ from true cysts in that the wall is reactive inflammatory tissue as opposed to an epithelial-lined sac that secretes fluid By definition, a fluid collection appearing in the first weeks after the onset of pancreatitis is an acute fluid collection; after weeks, it becomes an acute pseudocyst Pseudocysts become chronic and may require treatment months after the acute attack has subsided Causes Pseudocysts develop after disruption of the pancreatic duct with or without proximal obstruction, usually occurring after an episode of acute pancreatitis Diagnosis a Clinical presentation The most common complaint is recurrent or persistent upper abdominal pain Other symptoms include nausea, vomiting, early satiety, anorexia, weight loss, back pain, and jaundice Physical examination may reveal upper abdominal tenderness, a mass b Laboratory tests (1) Amylase Serum concentrations are elevated in approximately one-half of cases (2) Liver function tests occasionally are elevated and may be useful if biliary obstruction is suspected (3) Cystic fluid analysis is discussed in Section V.B.2 c Radiologic studies (1) CT is the radiographic study of choice for initial evaluation of pancreatic pseudocysts CT scan findings that determine prognosis include the following: (a) Pseudocysts smaller than cm usually resolve spontaneously (b) Pseudocysts with wall calcifications generally not resolve (c) Pseudocysts with thick walls are resistant to spontaneous resolution (2) MRI and MRCP can be useful to delineate ductal anatomy and are not associated with the risks of pancreatitis and infection with ERCP MRCP is not as sensitive for small duct involvement as ERCP d ERCP allows for the determination of pancreatic duct anatomy and influences therapeutic intervention Approximately one-half of pseudocysts have ductal abnormalities identified by ERCP, such as proximal obstruction, stricture, or communications with the pseudocyst ERCP itself risks infection of a communicating pseudocyst Complications a Infection is reported in 5% to 20% of pseudocysts and requires external drainage P.403 b Hemorrhage results from erosion into surrounding visceral vessels The most common arteries are the splenic (45%), gastroduodenal (18%), and pancreaticoduodenal (18%) arteries Immediate angiographic embolization has emerged as the initial treatment of choice c Obstruction Compression can occur anywhere from the stomach to the colon The arteriovenous system also can be subject to compression, including the vena caval and portal venous system Hydronephrosis can result from obstruction of the ureters Biliary obstruction can present as jaundice, cholangitis, and biliary cirrhosis d Rupture occurs in fewer than 3% of cases Approximately onehalf of patients can be treated nonsurgically, with total parenteral nutrition and symptomatic paracentesis or thoracentesis However, rupture is occasionally a surgical emergency e Enteric fistula can occur spontaneously and usually results in resolution of the cyst Treatment depends on symptoms, age, pseudocyst size, and the presence of complications Pseudocysts smaller than cm and present for less than weeks have low complication rates The chance of spontaneous resolution after weeks is low, and the risk of complications rises significantly after weeks a Nonoperative If the pseudocyst is new, asymptomatic, and without complications, the patient can be followed with serial CT scans or US to evaluate size and maturation b Percutaneous drainage can be considered for patients in whom the pseudocyst does not communicate with the pancreatic duct and for those who cannot tolerate surgery or endoscopy External drainage is indicated when the pseudocyst is infected and without a mature wall c Excision, including resection is only performed in unusual settings including bleeding, systemic sepsis, and concern for malignancy d Internal drainage Cystoenteric drainage is the procedure of choice in uncomplicated pseudocysts requiring intervention Drainage can be undertaken by either surgical or endoscopic means Endoscopic cystogastrostomy or cystoduodenostomy has a 60% to 90% success rate, and is the initial treatment of choice at our center Endoscopic therapy also allows transsphincteric stenting in the case of duct-cyst communication In the event drainage cannot be accomplished by endoscopic methods, surgical methods include Roux-en-Y cystojejunostomy, loop cystojejunostomy, cystogastrostomy, and rarely cystoduodenostomy A biopsy of the cyst wall should be obtained to rule out neoplasia in the cyst B True pancreatic cysts are most commonly serous cystadenomas (SCAs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs) The latter two are mucin-secreting premalignant cysts and depending on circumstances may require resection in asymptomatic patients SCAs become malignant very rarely and are resected only if symptomatic Cyst fluid, usually obtained by EUS is analyzed to determine whether the cyst is an SCA or an MCN/IPMN Cyst fluid CEA >192 is P.404 diagnostic of the latter two while CEA of 4 cm) They are more common in women, are most commonly located in the head of the pancreas, and account for 30% of all cystic pancreatic neoplasms Lesions are characterized by an epithelial lining, nonviscous fluid, and low CEA and amylase on cyst fluid analysis They are usually multicystic and in some a honeycomb of cystic cells with a calcified center These may be mistaken for solid tumors Asymptomatic SCAs not require treatment MCNs are considered premalignant lesions and account for approximately 50% of all cystic pancreatic neoplasms At presentation they are usually asymptomatic, twice as likely to present in women, and more commonly located in the body or tail These cystic lesions not communicate with the pancreatic ductal system Invasive cancer is present in 17.5% of resected MCN, and malignancy is associated with larger size (>4 cm) and advanced age (>55) Five-year survival was 100% for noninvasive MCN and 57% for patients with malignant lesions (Ann Surg 2008;247(4):571-579) As there is a clear survival advantage for those patients who undergo resection prior to the development of invasive cancer, and it is felt that there is an adenomaÑ adenocarcinoma sequence, it is recommended that all patients with MCN undergo resection IPMNs account for 25% of all cystic pancreatic neoplasms and have a slight male predominance IPMNs communicate with the pancreatic ductal system Characteristics of IPMN on ERCP include diffuse gland involvement; ductal dilation; and thick, viscous fluid within the cyst IPMNs are separated into three subgroups based on ductal involvement: Main duct, side branch, and mixed; and therapy is different depending on subgroup Main duct IPMN carries a malignant potential, up to 50% in some series (Ann Surg 2004;239(6):788-799) and requires resection Usually the dilation of the main duct is diffuse, but resection is limited to the head of the pancreas unless carcinoma in situ is identified at the resection margin SideÑbranch IPMN is a more controversial topic, and consensus guidelines are evolving (Pancreatology 2012;12(3):183-197) Generally accepted criteria for resection of side-branch IPMN include, size greater than cm, symptomatic patient, and mural nodules Patients with side-branch IPMN requiring resection should undergo a standard oncologic resection (Whipple or distal pancreatectomy) The current recommendation is to extend resection based on the invasive component or high-grade dysplasia only, rather than obtaining margins free of IPMN (World J Gastrointest Surg 2010;2(10):352-358) Other rare cystic pancreatic neoplasms (remaining 10%) include acinar cell cystadenocarcinoma, cystic choriocarcinoma, cystic teratoma, and angiomatous neoplasms All lesions with carcinoma noted on preoperative biopsy or with a concern for malignancy should undergo resection if tolerated P.405 CHAPTER 22: SURGICAL DISEASES OF THE PANCREAS Multiple Choice Questions A 60-year-old male alcoholic with diabetes presents with 12 hours of abdominal pain and an elevated amylase and lipase At admission, his white blood cell count is 11,000, AST is 100, and total bilirubin is Which of the following findings in his history is associated with increased mortality according to Ranson criteria? a Age b White blood cell count c AST d Total bilirubin e Diabetes View Answer A 45-year-old female presents with abdominal pain and an elevated amylase and lipase The rest of her laboratory values are remarkable for a mildly elevated AST of 100 and elevated white blood cell count of 15,000 On hospital day 3, her pain is resolved and she is tolerating a regular diet Which of the following should be performed prior to discharge? a ERCP b RUQ ultrasound c Amylase and/or lipase d CT scan of abdomen e Serum ethanol level View Answer A 73-year-old male is referred for evaluation of an incidentally discovered 2-cm cyst in the tail of his pancreas On examination the patient has no abdominal pain, and his laboratory values are unremarkable He undergoes an endoscopic ultrasound which shows a cyst lesion that appears to communicate with the pancreatic duct, originating from a side branch Which of the following is the next step in management? a Distal pancreatectomy b Total pancreatectomy c Observation d Enucleation e Biopsy View Answer P.406 A 35-year-old female is found to have an incidentally discovered 3cm cystic lesion in the tail of her pancreas on a CT scan She undergoes an endoscopic ultrasound which reveals a 3.5-cm cyst without communication with the pancreatic duct Analysis of cyst fluid reveals high levels of mucin What is the next step in the management of this patient? a Distal pancreatectomy b Repeat CT scan in year c MRCP d Total pancreatectomy e Endoscopic drainage View Answer A 59-year-old male is weeks out from a pancreaticoduodenectomy for pancreatic adenocarcinoma complicated by a pancreatic fistula He presents to the ED with new onset of bloody output in his drain He is tachycardic to the 110s, but otherwise looks well His Hgb is 10 What is the best course of management for this patient? a CT scan b ERCP c Angiogram d Exploratory laparotomy e Remove the drain View Answer A 60-year-old physically fit female with painless jaundice and a 20-lb weight loss presents for evaluation of a 2-cm hypodense mass in the head of the pancreas on CT scan The patient was referred to you from a gastrointestinal medicine colleague, who performed an endoscopic ultrasound with biopsy and ERCP with stent The biopsy is suspicious for malignancy By imaging, the lesion appears to be clearly resectable without evidence of malignancy Which of the following is the most appropriate management of this patient? a Repeat endoscopic ultrasound with biopsy b Pancreaticoduodenectomy c Total pancreatectomy d MRI pancreatogram e Neoadjuvant chemoradiation View Answer UnitedVRG ... in the current edition of The Washington Manual of Surgery The educational focus of our Department of Surgery has a rich tradition The first full-time head of the Department of Surgery at Washington. .. School of Medicine St Louis, Missouri Oluwadamilola M Fayanju MD1 1Department of Surgery Washington University School of Medicine St Louis, Missouri Jason O Robertson MD1 1Department of Surgery Washington. .. School of Medicine St Louis, Missouri Pamela P Samson MD1 1Department of Surgery Washington University School of Medicine St Louis, Missouri Dominic E Sanford MD1 1Department of Surgery Washington