Pancreatic disease surgery

2021-05-11 01:34 PM

The endocrine pancreas consists of the islets of Langerhans, which are clumped cells on a thin fibrous stroma rich in blood vessels.

The pancreas of an adult is about 15 cm long, weighs 60-100g, including the head of the pancreas, the body of the pancreas and the tail of the pancreas. At the top of the pancreas, there is a Wirsung tube that drains the exocrine fluid into the duodenum. The pancreas is a hidden organ because it cannot be touched when examining the abdomen, but it is closely related to the organs and surrounding tissues such as the duodenum, the transverse colon, the left lobe of the liver ... so diseases of the pancreas such as inflammation, tumour, often cause secondary diseases of the above organs.

In histological and physiological terms, the pancreas consists of the endocrine pancreas and the exocrine pancreas. The exocrine pancreas consists of many small glandular cysts that converge into lobules on a thin fibrous stroma. The glandular cysts are lined by tall cylindrical cells, arranged in a pyramidal shape leaving a very small lumen. These cells also have microvilli, alkaline dark cytoplasm due to the abundance of granular endoplasmic reticulum, the growing golgi set, and the cell apex containing zymogen particles. The pancreatic duct system connects the follicles and leads to the growing tubes, eventually pouring into the Wirsung and Santorini tubes. Cell cylindrical lining is low and mucus production.

The endocrine pancreas consists of the islets of Langerhans, which are clumped cells on a thin fibrous stroma rich in blood vessels. The islets are scattered in pancreatic tissue, separated from the glandular follicles by a thin layer of sagging fibres.

Birth defects

Pancreatic infertility is rare. The more common malformations are:

(1) The head of the pancreas separates the pancreas tail,

(2) Pancreas ring: the head of the pancreas forms a loop around the duodenum, sometimes obstructing the duodenum,

(3) Pancreatic duct malformation: Wirsung tube and Santorini tube are completely separated. Wirsung tube poured into the common bile duct or poured into a hole in the Vater bulb.

Out of place

Quite common: about 2% of autopsies have the pancreas out of place. Common location: stomach, duodenum, followed by Meckel diverticulum and ileum. The exception is when the pancreas gets lost in the oesophagus, lungs. The pancreas in the place can be one or more nests, several mm to several cm in diameter, solid density, yellow-brown, in the submucosa, so it is easy to confuse with malignant lesions. Microscopic, the lost pancreas consists of pancreatic cysts that resemble normal pancreatic tissue, sometimes including the isle of Langerhans.

Pancreatic pigment capacitors

Hemosiderin is deposited in the follicles and islets of the pancreas, making the pancreas dark brown.

Pancreatic fat accumulation

Fat penetrates the pancreas, covering the pancreatic tissue, creating an image of pancreatic tissue replaced by fat, but in fact, the pancreas still has a normal mass. Pathogenesis is unknown.

Pancreas in diabetes

In diabetes, the isle of Langerhans suffers from fibrosis. In adolescent diabetes, there is beta-cell necrosis, eosinophil infiltration, and lymphocytes. In adult diabetes, there is amyloidosis.     

Pancreatic malnutrition

Reason:

(1) Pancreatic arteriosclerosis causes anaemia,

(2) Malnutrition,

(3) Pancreatic duct obstruction due to congenital stenosis, inflammation, stones, tumours ...

In pancreatic insufficiency due to obstruction of the pancreas, the pancreas is atrophy, fibrosis. Under the microscope, the adipose stroma completely replaced the pancreatic follicles, or only a few dilated, sparse islets remained.

Pancreas in haemolytic disease

About half of patients who die of kidney failure have microscopic changes in the pancreas: enlarged glandular sacs filled with mucus, stromal tissue permeates many lymph cells. Pathogenesis is unknown.

Pancreatitis

Haemorrhagic acute pancreatitis

Usually occurs in middle age, is clearly associated with biliary tract disease and or with alcohol consumption. In children, haemorrhagic acute pancreatitis is associated with a genetic predisposition. Other rarer causes: trauma, peptic ulcer, septicaemia, abdominal infection, viral infection, hyperthyroidism, hyperlipidaemia, hypercalcemia. Certain drugs, such as corticosteroids, sulphonamides, and birth control pills, can also cause pancreatitis. About 10% of patients with acute pancreatitis have no obvious cause.

Diseases caused by pancreatic enzymes (about 22 types: 15 types of proteases, 5-6 types of amylase, lipase and phospholipase) are activated causing pancreatic self-destruction. But what triggers the activation of pancreatic enzymes and which enzymes play a key role remains unclear. Activated pancreatic enzymes cause destruction of pancreatic tissue, blood vessel necrosis, haemorrhage. In the early stage, pancreatic oedema, tense, gradual, pale gray necrosis, with dark green petechial spots intermingled with areas of pale-yellow fat necrosis, shiny (also called candlestick) as the surface the pancreas resembles a map. The abdomen contains pale brown fluid, with fat droplets resembling chicken sauce, which are characteristic of abdominal fluid in acute inflammation. This fluid can become superinfected causing purulent peritonitis.

The disease has a sudden onset, acute abdominal pain after a large party with a lot of alcohol. Persistent, severe, rapid heart failure due to haemorrhage, electrolyte disturbances and vasodilators such as bradykinin, prostaglandins. If the patient has a pre-existing biliary disease or has complications with acute cholecystitis, jaundice is present. In the first 24 hours, blood amylase increased, blood lipase increased slowly in 72 - 96 hours later, but both to normal after 5-6 days. A slight increase in blood sugar is caused by a dysfunction of the pancreas. However, there are some patients with true diabetes following acute pancreatitis

Chronic pancreatitis

As a result of acute attacks of pancreatitis. There are 2 possible:    

Chronic pancreatitis in alcoholics

Pancreatic tissue is divided into many lobules, enlarged inter-lobe tubes, deposition of protein particles in the lumen, atrophy of the glandular sacs, glandular cells that can produce spikes. However, the pancreatic islets are less affected. Pancreatic palpation shows that the pancreas is harder than usual because there are many calcium deposits or calcium carbonate stones in the pancreas. This form of pancreatitis often leads to the formation of a pseudo-pancreatic sheath.

Chronic pancreatitis due to biliary obstruction

Oddi sphincter stenosis or gallstones causes biliary obstruction and chronic pancreatitis complications. The damage is mainly in the head of the pancreas, less damage to the follicular mucosa in the upper body.

Pancreatic wrap

Uncommon, but clinically, with signs of an abdominal mass, may cause misdiagnosis with real tumours.

Congenital pancreatic wrap

Due to the development of the pancreatic duct. During the formation of the pancreas, the pancreatic duct system develops gradually into adulthood. If the primitive ducts persist, there may be secretory cells of the tube that secrete fluid to form cysts.

Usually, there are multiple covers but sometimes only one, 3 to 5 cm in diameter, lined with a soft and smooth film. These membranes are atrophic epithelial cells that are juxtaposed or low or flattened cubic epithelial cells. Outside is a thin fibre sheath. The inside of the wrap contains a fluid or mucus. Sometimes there is a haemorrhage or superinfection that changes the morphology of epithelial cells and fluid.

The congenital disease of the pancreas, liver, and kidney occurs very rarely in the same patient. Particularly in the same very rare disease, Lindau-von Hippel's disease, the patient has wrapped in the 3 above organs with vascular tumours in the retina and cerebellum or cerebellum.

Imitation of the pancreas

About 75% of the pancreatic sheaths are pseudo-sheaths. Other types of wrap include real hump, congenital wrap, and congenital wrap.

The pseudomembrane is sheathed with inflammatory fibrous tissue. The bundle can be located in pancreatic tissue, but is usually extrinsic and only adheres to pancreatic tissue by inflammatory tissue, especially in the pancreatic tail. Sometimes it is wrapped in a small connective sac. Wrapping is a consequence of self-destruction and tissue necrosis following acute alcohol, bile, and traumatic pancreatitis.

Form:

Wrapping is usually 3-10 cm in diameter, filled with turbid fluid with necrotic-haemorrhagic tissue and many enzymes of pancreatic juice. The inner wall of the lining has no lining, only fibrin, granulomatous tissue (with hemosiderin and macrophage pigments) and sparse collagen. If the cover is long, the wall is thicker and has more collagen.

The wrap can open up the duct system, can quickly block the walls of the main blood vessels of the portal system, causing embolism, haemorrhage or fat necrosis spread. Adjacent pancreatic tissue may become either severe acute inflammation or chronic inflammation. Occasionally, wrapping can cause abdominal pain.

Differential diagnosis with 2 types of pancreatic tumour are:

Mucous tumours of the pancreas.

Pancreatic characteristic tumour of the pancreas.

Both types of tumour have a macroscopic appearance resembling pancreatic pseudo-sheath but can be easily distinguished under a microscope because both have parietal cells in the sheath. In addition, these 2 types of true tumour are more common in women, while pancreatic prostheses are more common in men.

Pancreatic embryos, which almost always occur with pancreatitis, can also occur after an abdominal injury with direct damage and bleeding of the pancreas. 9/10 pancreatic prostheses have a history of pancreatitis or inflammation.

In recent years, diagnostic techniques such as ultrasound, computed tomography X-ray have been very helpful in the definitive diagnosis of the pancreatic wrap. The pseudomembranous pancreas usually has no inner septum.

Newly created upholstery

This can be an adenoma or an adenocarcinoma. Very rare.

Tumour are usually solitary, with a diameter of 5 - 15cm, often have a septum in the tumour divided into many small capsules. U lined by an epithelium with papillae protruding into the lumen.

If the tumour is benign, the highly cylindrical epithelium is regularly arranged with a clear basal membrane and no degenerative cells, no cell superposition, and no infiltration.

If it is carcinoma, the epithelium carries the properties of malignancies, the epithelial cells are piled up, unevenly, invading the sheath and surrounding tissue.

Pancreatic carcinoma

A type of cancer of the exocrine part of the pancreas.

In normal pancreatic tissue, pancreatic duct cells make up only 4% of pancreatic cells. But most pancreatic carcinomas originate from pancreatic ductal epithelial cells. Only 1% is derived from vesicular cells.

The disease has high mortality because often having late symptoms, diagnosed only when it is late. According to Nguyen Chan Hung et al., In the city. In Ho Chi Minh City, in 1997, among the 10 types of cancer with the highest incidence, pancreatic cancer ranked 8th among men. Patients often arrive late when they show signs of obstructive jaundice. In the United States, the disease accounts for 5% of all deaths and every year 25,000 new illnesses occur with 22,000 deaths. The incidence of the disease has tripled since 40 years, perhaps due to tobacco (smokers are 2 to 2.5 times more susceptible to pancreatic cancer than non-smokers), food (high fat, many calories) , cancer-causing chemicals (high disease incidence in people in regular contact with industrial chemicals, especially b-naphthylamine, benzidine). In laboratory animals, nitrosamines can cause pancreatic cancer.

Age is most often 60 to 80 years old. Only 10% are found in young people. The incidence of the disease is higher in blacks than whites, in men rather than women, in people with diabetes than in people without diabetes.

Lesions are found at the head of the pancreas is 60%, pancreas body 15 - 20%, pancreas tail at 5%. In 20% of cases, the lesion is diffuse or has spread unable to determine the original location. In the damaged sites, the head of the pancreas has many early clinical manifestations: because there, tumour compresses Vater balloon, bile duct, duodenum causing bile obstruction. As a result, cysts are usually detected early when they are young and have not spread yet.

In the body and tail of the pancreas, the tumour is often detected late, when they have grown and have distant metastases.

Carcinoma of the head of the pancreas

The tumour is usually small, only makes the head of the pancreas slightly larger, or sometimes has a small lump form that is difficult to recognize from the outside. Rarely, the tumour grows to 8-10 cm. A homogeneous, fibrous, unobstructed tumour tissue with a clear, gray-white edge replacing normal pancreatic tissue yellow and lobed. U can eat spread to the edge of the duodenum and bile duct, sometimes forming a warty lesion on the lumen of the duodenum or ulcer.

U can penetrate causing obstruction of the bile ducts, balloon Vater. Patients with head-pancreatic carcinoma are more likely to have severe biliary obstruction, possibly with obstructive cirrhosis, and often die from liver failure rather than from widespread tumour.

Micro:

Most are differentiated adenocarcinoma, with or without mucus secretion. Cancer glands are usually atypical, irregular, small, lined with cuboid cells or degenerative cylinders. In rare cases, the tumour has an undifferentiated structure, 10% has a glandular-glandular structure, or has many malformed macrophages, many mitochondria, 0.5% originates from the sac and is called adenocarcinoma. wrap. Rarely, a tumour originates from adenocarcinoma, which is a special type of adenocarcinoma in children.

Carcinoma of pancreatic stem and tail

The tumour is usually large, stiff, irregular, sometimes occupying the entire tail and body of the pancreas. Macroscopic and microscopic properties similar to pancreatic head carcinoma.

Tumour often spread more widely than early pancreatic carcinoma, spread to the nearby spine, eating spread up and down to the retroperitoneal space, to the spleen and adrenal, to the stomach and colon.

Tumour for metastasis to pancreatic lymph nodes, around the stomach, mesenteric membranes, macula, liver stem. Liver metastasis in the form of nodules made the liver 2 to 3 times larger than normal.

Pancreatic carcinoma usually has a late clinical manifestation, after several months or years. The main symptoms include weight loss (70% of cases), abdominal pain (50%), back pain (25%), poor appetite, nausea, vomiting, weakness. Pancreatic carcinoma is painless until progressive disease that causes jaundice without pain (50% of early pancreatic carcinoma has jaundice).

The average time from symptom to the onset of diagnosis is 4 months and from diagnosis to death is 3 to 5 months. Thus, a way has been sought to diagnose the disease at an early stage by looking for a tumour marker, which is measuring serum isoenzyme galactosyltransferase. This isoenzyme is elevated when cancer of the pancreas or digestive tract is present.

Diagnosis and location of the cancer are based on ultrasound, on computed tomography X-ray, which can be combined with needle biopsy through the skin without investigating abdominal surgery.

Pancreatic carcinoma (and carcinoma of the lung) can give thrombophlebitis, as a Trousseau sign in 10% of cases.

Surgical treatment, if done properly, the survival rate after one year is 10% and 3 years is 2%.

Pancreatic islets

As a tumour of the endocrine part, rarer than the endocrine pancreatic part. Adults have a higher incidence of illness than children. Tumour can be in any location of the pancreas, can be benign or malignant (if malignant, then metastatic liver and lymph nodes), can have a single mass or multiple foci (when there are many nipples, the tumour can there are different types of cells), may or may not have hormonal secretory activity.

The three most common and pronounced clinical syndromes associated with increased activity in the islets of Langerhans are:

(1) Hyper insulin and hypoglycaemia,

(2) Zollinger-Ellison syndrome

(3) Multiple endocrine neoplasms.

Each of the above syndromes can be caused by: diffuse hyperplasia of the islets of Langerhans, benign or multiple benign tumours, malignancies of the islet.

Beta cell tumour and hypoglycemia

Also called an insulin tumour (insulinoma) is the most common type of tumour of the islet cell.

Insulin secreting tumour cause clinical symptoms of hypoglycemia. There are 3 distinctive clinical signs of this type:        

There are episodes of hypoglycaemia with serum glucose less than 50 mg/dl.

Patients with symptoms of the central nervous system such as confusion, loss of consciousness, especially when hungry and at the motor.

These signs subside when the patient is fed or given an intravenous glucose infusion.

There are other diseases that cause the above 3 signs, but the cause must first be thought of is the pancreas.

In the lesions of the islets that cause hyperinsulinemia, the following is found:

About 70% of adenomas (benign) are solitary.

Approximately 10% of adenomas (benign) multiple foci.

About 10% of cancer has metastasis, often with carcinoma from elsewhere.

About 10% are mixed groups of diffuse hyperplasia of the islet and benign adenomas occurring on ectopic pancreatic tissue.

Adenomas (benign) secrete insulin

Also called an insulin tumour, ranging in size from very small, barely recognizable to very large to a mass weighing over 1,500 g, often solitary (only 1/7 of cases with multiple masses), with firm density, greyish-yellow in colour, with a clear envelope, compressing surrounding pancreatic tissue.

Tumour is composed of well-differentiated beta-cell chains and nests like normal beta cells. Under an electron microscope, tumour cells resemble normal cells, with particles 150 - 200 min diameter attached to the cell membrane. The immunohistochemical survey showed that insulin contained in cells.

Islet cell carcinoma

Very little for a picture of regression, difficult to distinguish from the benign tumour, even though it sometimes penetrates the sheath and spreads to surrounding pancreatic tissue, is only diagnosed as cancer when there is lymph node metastasis or infiltration to other places. pancreas. Tumour often causes symptoms of hyperinsulinism.

Spill over-proliferation of the isle

Can be found in adults, but usually in children’s children of mothers with diabetes. During the fetal period, the baby is influenced by the mother's high blood sugar, thus increasing the number and size of islets. After the baby is born, this reaction can trigger periods of severe hypoglycaemia.

Hypoglycaemia

It can also occur due to other damage, or sometimes idiopathic without any physical damage.

Other physical injuries, in addition to the aforementioned islets, include:

Insulin-sensitive states such as diabetes in the early stages after partial stomach amputation, starvation.

Leucine-sensitive states.

Diffuse liver disease.

Glycogen disease.

Reduced activity of the pre-lobe and adrenal cortex

Some non-pancreatic tumour such as fibroids and fibrosarcoma behind the peritoneum, near the diaphragm or in the chest, carcinomas of the liver, adrenals, stomach, bile ducts. Most often accompanied by hypoglycaemia are the first two types.

The cause is unknown, although some studies have shown an increase in the no suppressible insulin-like activity (no suppressible insulin-like activity) NSILA, presumably somatomedin, in patients with these tumours.

Zollinger-Ellison syndrome, Gastrin-secreting cell tumour, and ulcerative isomer cell tumour

Zollinger and Ellison described a syndrome consisting of an islet cell tumour with increased gastric secretion and peptic ulcer. These tumours that secrete a lot of gastrin should be called gastrin-secreting cell tumour. With radiological immunoassays, gastrin is found in tumour and secreted in tumour cell cultures. Gastrin increases gastric acid secretion and causes peptic ulcers.

Gastrin-producing cells have not been clearly identified in normal pancreatic tissue. However, in the well-distinguished tumour, these cells have a viral morphology similar to the G-cells of the gut and stomach (which normally produce gastrin in the gut and stomach).

In terms of location, 85 to 90% of tumour area in the pancreas, 10-15% in the duodenum.

In terms of anatomical characteristics, 60% of tumour are cancer (with 2/3 cases of metastasis at the time of discovery), 40% are benign tumour. An only benign tumour can be distinguished from cancer thanks to the metastatic and distant metastatic properties. These lesions are also often small and difficult to detect.

Some benign adenomas have multiple foci and are accompanied by endocrine gland tumour elsewhere, which are then called polygamous endocrine neoplasm.

In Zollinger-Ellison syndrome, ulcers are usually not treatable, may be in the stomach or the first and second segments of the duodenum (75%), in the distal part of the duodenum and jejunum (25%).). 10% of patients have multiple ulcers at the same time. The stomach also has hyperplasia of acid-secreting parietal cells. Patients may experience diarrhoea (with severe disorders of water and electrolytes), with malabsorption syndrome.

Endocrine neoplasm syndrome in many places

Consists of many endocrine adenomas, usually of the brain lobe, pancreas, parathyroid.

Tumour is familial, due to dominant genes on chromosomes, incomplete inheritance. It is found that, in many families with this disease, there are people with this syndrome, there are people with Zollinger-Ellison syndrome, so it is thought that the two syndromes are just different types of the same. a mutated gene.

Some tumour in this syndrome may be malignant, so the term multiple endocrine neoplasias (MEN, multiple endocrine neoplasias) is used to replace the old term, multiple endocrines. adenomatosis).

This syndrome, (referred to as MEN syndrome), is divided into several categories depending on where the injury is and whether or not a peptic ulcer is involved.

According to Table 12.1, MEN I includes tumour or hyperplasia of the parathyroid glands, brain lobe, adrenal cortex, pancreas with peptic ulcer and increased secretion in the stomach. MEN II: (also called Sipple's syndrome) with multiple adenocarcinomas of the adrenal medulla, multicellular carcinoma of the thyroid gland, hyperplasia, or adenoma of the parathyroid gland, but no tumour of the pancreatic islet and ulcer. In some families with MEN II, in addition to the aforementioned tumour, there are more lesions of the mucosa and skin, that is, nerve fibroids in the eyelids, tongue, lips, intestines, bronchi, bladder. that is, grouped under MEN IIB or MEN III.

The clinical manifestations of this syndrome are very complex, can have many manifestations according to the lesions.

Table: Types of endocrine neoplasm syndrome and pathological manifestations

Injury

MEN I

MEN IIA

MEN IIB hay III

The lobe cerebral gland

++++

0

0

Multicellular carcinoma of the thyroid gland

+

++++

++++

Parathyroid glands

++++

+++

+

Adrenal marrow

++++

+

+

Adrenocytoma

0

++++

++++

Pancreas

++++

0

0

Peptic ulcer

++++

0

0

Nerve fibroids in the mucosa and skin

0

0

++++

A rare tumour of islet cells

Alpha cell tumour or glucagon tumour

Increased serum glucagon, with a syndrome consisting of moderate diabetes, anaemia, necrotic erythematous lesions in the skin.

Delta cell tumour or Somatostatin tumour

Accompanying diabetes, gallbladder stones, fat digestion, decreased acid in gastric juice. It is difficult to detect before surgery.

Islet cell tumour secrete polypeptides

Usually does not cause hormonal symptoms.

Vipom (Vipoma)

Causes syndromes including watery diarrhoea, hypokalaemia, no acid in gastric juice, because tumour secrete vasoactive intestinal peptides (VIP).

Pancreatic carcinoids

Serotonin production, but rare for carcinoid syndrome.

Multiple hormones

Some pancreatic and extra-pancreatic tumour simultaneously produce a variety of hormones. In addition to insulin, glucagon, gastrin, islet cell tumour also produces ACTH, MSH, vasopressin, norepinephrine, and serotonin.