General Surgery Case Study

Hi there folks,
Here’s the study: A 65-year-old gentleman presents with painless jaundice. A dynamic CT scan with contrast reveals a mass in the head of the pancreas. The patient has been generally in good health, does not drink and does not smoke.
What’s the workup?
How am I going to treat him? what is the name of the most commonly performed procedure and how is is performed?

Why is this procedure performed in this manner? If the patient has a mass in the head of his pancreas, why am I doing this “radical” surgery? I want specific reasons for this.

If you know your anatomy and physiology, this is a very easy question to answer. (This is a hint)

Natalie

LOL, never call a surgeon unless you want an operation?
Looks like its time for a Whipple. Ready for it? Is the Pt?

Quote:

LOL, never call a surgeon unless you want an operation?
Looks like its time for a Whipple. Ready for it? Is the Pt?


Hi there,
You got the name of the procedure but what about the answers to the questions.
Natalie

OK, not being a physician, I am only guessing, but if the mass is in the head of the pancreas, it seems likely to metastesize (sp?) into the duodenum via lymph drainage. I am not really up on the lymphatic system, but could the spleen be involved too?
Just thinking “out loud.”

Okay Dr. Belle,
Let me try. First get some lab work. Bilirubin, prothrombin time, partial thromboplastin time, hepatic enzymes, serum hepatitis antigen assays, amylase and lipase levels, blood sugar, CBC, sed rate.
You already have the CT scan, so further x-rays are probably not necessary. Without it, though, you would have ordered flat plates of the abdomen and maybe some barium studies of the GI tract.
The surgery itself involves a bilateral subcostal incision and resection of the lower portion of the stomach (the gastric antrum and pyloris), the head of the pancreas, the entire duodenum, the gallbladder, and the terminal end of the common bile duct. The surgeon must mobilize the pancreas from the superior mesenteric vessels very carefully, usually being performed by finger dissection.
Because of the vascular supply for the pancreas and the duodenum are essentially identical, the resection has to include the duodenum.
Anyway, that’s about all I can tell you right now.

The Physiology is fairly str8 forward. You need the lower section of the duodenum because without that you are going to have all sorts of problems with Peptide and pancreatic enzyme metabolism for the rest of your life. evidently there is a blockage and the person has acute pancreatitis. I gather what you are attempting to do is to allow fat and peptide digestion to remain uninterrupted so he has a positive outcome and a normal quality of life.
It is possible for a retroperitoneal hemmorhage to also manifest itself if not already done so. Look for periumbilical blueness.Notable Lab values would include leukocytosis, elevated amylase and lipase and a CT would have shown an enlarged edematous pseduocyst or abscess.
He is 65 so following the Ranson Criteria (Old, infected, bleeding, comorbities) help establish the Px. He is not an alsoholic so I assume from the surgical need that it is advanced and warranted.
anything else u want?

Quote:

Okay Dr. Belle,





Let me try. First get some lab work. Bilirubin, prothrombin time, partial thromboplastin time, hepatic enzymes, serum hepatitis antigen assays, amylase and lipase levels, blood sugar, CBC, sed rate.





You already have the CT scan, so further x-rays are probably not necessary. Without it, though, you would have ordered flat plates of the abdomen and maybe some barium studies of the GI tract.





The surgery itself involves a bilateral subcostal incision and resection of the lower portion of the stomach (the gastric antrum and pyloris), the head of the pancreas, the entire duodenum, the gallbladder, and the terminal end of the common bile duct. The surgeon must mobilize the pancreas from the superior mesenteric vessels very carefully, usually being performed by finger dissection.





Because of the vascular supply for the pancreas and the duodenum are essentially identical, the resection has to include the duodenum.





Anyway, that’s about all I can tell you right now.







Hey there,


The winner is: Dr. Linda Wilson because she correctly stated that the blood supply for the duodenum and the head of the pancreas are practically the same! Congratulations, you have won a medical school care package!





Now for some further information:





Why remove the gallbladder, duodenum and stomach if the problem is in the pancreas? Once the Ampulla of Vater is removed (this is in the second portion of the duoy) the gallbladder does not function well and will form gallstones. The second and third portions of the duoy share the blood supply with the pancreas and will not have one if the head of the pancreas is removed. The gastric antrum is removed to improve resection margins (this dude has painless jaundice i.e. one of the hallmarks of pancreatic cancer) so add a vagotomy to reduce the chances of marginal ulcers at the site where the gastric remnant is anastomosed to the small bowel. You can elect to do a pylorus preserving surgery as removal of the gastric antrum adds little to the effectiveness of the surgery; do the gastroenterostomy way downstream from where the bile and pancreatic secretions enter the gut. This surgery does not change the survival rate much and makes for better long term function. Anytime you do not disrupt the pylorus, you do not have to do a vagotomy thus more natural function is achieved.





In terms of workup, mets will be the most dreaded complications and I already have my dynamic CT scan which is the best way to look for mets. LFTs, CBC, lytes and coags are all good as well as determinations of nutritional status (albumin, pre-albumin and transferrin) because good nutrition is going to be the key to getting this not-so-elderly gentleman through this big piece of surgery. (I have never ordered a sed rate in my life but if you feel that it gives you useful information, by all means order one).





Post op, I would watch for signs of diabetes (A Whipple is a proximal pancreatectomy) which may not occur as the distal pancreas is still present and functional.





Still, the mortality rate for pancreatic cancer is pretty high with one year survival generally 20% or less and five year survival under 10%. Still, this is an elegant piece of surgery and technically challenging.





I hope you enjoyed this case!





Natalie

Howdy Natalie!
Having just finished my surgery clearkship involving multiple Whipples (My faculty was Dr. William Nealon, a bigtime liver/pancreas guy) I can tell you that you’ve left out what is clearly the most important part of the whole procedure…
a medical student’s arm to hold the retractor for 6-7 hours!
Your question about why the radical surgery must occur to everyone 'cause I certainly wanted to know as I was reading about it prior to my first one. Thank God for us non-surgeons, there’s Surgery Secrets.
In case anyone is looking for some good, high-yield pimp-protection, I whole-heartedly recommend Secrets. Not all that great for the shelf, but wonderful for rounds.
Take care,
Jeff