24. Pancreatic tumors – surgical treatment, Cysts and abscesses of the liver & Pleural exudates from surgical point of view

What is the definition of PANCREATIC TUMORS?

Pancreatic tumors are most commonly ductal adenocarcinoma, often located in the pancreatic head. They are usually asymptomatic in early stages but can present with belt-like epigastric pain that radiates to the back.

What is the epidemiology of PANCREATIC TUMORS?

Pancreatic tumors typically affect individuals 60-80 years old and have an extremely poor prognosis. This includes very low 1-year and 5-year relative survival rates across all stages.

What are the risk factors of PANCREATIC TUMORS?

Risk factors for pancreatic tumors include smoking, high alcohol consumption, and chronic pancreatitis.

What are the clinical features of PANCREATIC TUMORS?

Clinical features can include belt-like epigastric pain radiating to the back, jaundice, and an enlarged gallbladder. Patients may also experience weight loss, poor appetite, pale stools, dark urine, pruritus, and various forms of thrombosis.

What are the signs of PANCREATIC TUMORS?

Jaundice affecting skin, tongue, and eyes can be observed, along with ascites upon abdominal palpation. Courvoisier sign, characterized by an enlarged, painless gallbladder with jaundice, and Trousseau syndrome, involving recurring thrombophlebitis, are also classic signs.

What are the symptoms of PANCREATIC TUMORS?

Early stages are often asymptomatic, but later symptoms can include belt-like epigastric pain radiating to the back. Other symptoms are pruritus, decreased appetite, weight loss, nausea, weakness, and diarrhoea, possibly due to exocrine pancreas insufficiency.

What are the diagnostic methods of PANCREATIC TUMORS and their positive results?

Diagnosis involves blood tests showing increased lipase, and tumor markers like CA 19-9 and CEA. Imaging includes abdominal CT, which may reveal a double-duct sign, and endoscopic ultrasound to determine cancer location and size. Needle biopsy or excision is also used, and staging is done by CT. ERCP/MRCP can rule out choledocholithiasis if biliary decompression is needed.

What are the treatment methods of PANCREATIC TUMORS?

Treatment options include surgical resection, often the Whipple procedure for localized disease in the pancreatic head. Adjuvant or neoadjuvant chemoradiotherapy can be offered to reduce tumor size and prolong life, though it cannot cure without surgery. For inoperable patients, palliative chemotherapy, pain management (analgesia), and procedures like celiac plexus block or stent implantation for cholestasis are used.

What is the palliative treatment of PANCREATIC TUMORS?

Palliative treatment includes chemotherapy and analgesia for pain management. For cholestasis, ERCP with stent implantation or Percutaneous transhepatic bile duct drainage (PTCD) can be performed. Other palliative interventions include gastroenterostomy for gastric outlet stenosis, celiac plexus block for pain, and PEG tube insertion for severe palliative patients with chronic ileus.

What is the surgical treatment of PANCREATIC TUMORS?

Surgical resection is suitable for about 20% of patients with localized disease. For pancreatic head carcinoma, the Whipple procedure (pancreaticoduodenectomy) is most common, involving resection of the pancreatic head, duodenum, gallbladder, and bile duct, with reattachment of remaining organs for digestion. This includes creating a gastrojejunostomy for food bypass and a cholecystojejunostomy to drain bile. A modified Whipple, the pylorus-preserving pancreaticoduodenectomy, can preserve parts of the stomach and duodenum for more physiologic emptying. For pancreatic body and tail carcinoma, resection of the left side of the pancreas with splenectomy is performed.

What are the complications of PANCREATIC TUMORS?

Complications include lymphogenic and hematogenous metastasis, which can occur early to lymph nodes and liver, and later to visceral organs like the duodenum, stomach, colon, and lungs. Other complications are stenosis leading to gastric outlet obstruction or common bile duct cholestasis, secondary diabetes, and disseminated intravascular coagulation (DIC).

What is the definition of LIVER CYSTS?

A cyst is similar to an abscess but without the pus, and it has an epithelial lining. Benign hepatic cysts are often incidental findings and are mainly asymptomatic.

What are the types of LIVER CYSTS and their features?

Types include simple cysts, multiple cysts linked to polycystic liver disease (PCLD), and hydatid (echinococcal) cysts. Simple cysts are usually asymptomatic but may cause pain in the right upper quadrant if large. Polycystic cysts can cause abdominal and right upper quadrant pains and involve many scattered cysts of various sizes. Hydatid cysts are caused by a helminthic infection, typically presenting as cystic lesions in the liver in 75% of cases.

What is the etiology of types of LIVER CYSTS?

Simple and polycystic cysts are congenital. Polycystic liver disease is caused by a genetic disease and is related to polycystic kidney disease. Hydatid cysts are caused by a helminthic infection from cestodes of the genus Echinococcus, acquired by ingesting eggs from infected dog faeces.

What is the epidemiology of LIVER CYSTS?

Simple hepatic cysts have a peak incidence in individuals over 50 years of age at the time of diagnosis.

What is the clinical presentation of LIVER CYSTS?

Simple cysts are usually asymptomatic, but increased size may cause pain in the right upper quadrant. Polycystic cysts can present with abdominal and right upper quadrant pains, and may be first noticed during puberty or as an accidental finding.

What are the symptoms of LIVER CYSTS?

Simple cysts are typically asymptomatic, but a large size can lead to pain in the right upper quadrant. Polycystic cysts may cause abdominal and right upper quadrant pains.

What are the diagnostic methods of LIVER CYSTS and their positive results?

Diagnosis of cysts is performed using USG, CT, and MRI. On sonography, simple cysts appear as anechoic, round lesions with dorsal acoustic enhancement, while CT shows them as well-defined lesions with no contrast enhancement. Polycystic liver disease is often found accidentally or during diagnosis of kidney disease.

What is the treatment of LIVER CYSTS?

Symptomatic simple cysts that are large or painful are drained and surgically removed via laparoscopic deroofing. Polycystic liver cysts rarely require treatment, but if they do, laparoscopic deroofing may be used. Hydatid cysts are treated medically with Albendazole, or through USG/CT-guided percutaneous drainage. Surgical resection is indicated for hydatid cysts larger than 10cm or if they are complicated, with the goal of resecting the whole cyst to prevent spillage.

What is the definition of LIVER ABSCESS?

An abscess is a solitary or multiple collection of pus, consisting of thick fluid of blood, dead tissue, and germs. It is caused by bacterial, parasitic, or fungal organisms, commonly originating from the digestive tract.

What is the etiology of LIVER ABSCESS?

Liver abscesses are caused by bacterial, parasitic, or fungal organisms spreading from the digestive tract, with E. coli being the most common pathogen. About 60% of cases originate from the biliary tract due to conditions like choledocholithiasis or cholangitis, while about 20% stem from the portal vein due to issues such as acute appendicitis or diverticulitis.

What are the risk factors of LIVER ABSCESS?

Risk factors include diabetes mellitus, hepatobiliary diseases like cholelithiasis, and hepatic tumours. Pancreatitis, gastrointestinal malignancies (especially colorectal carcinoma), and Crohn's disease also increase the risk.

What is the clinical presentation of LIVER ABSCESS?

Liver abscesses typically present with fever, right upper quadrant pain, and malaise. Patients may also experience anorexia, sickness, weight loss, and weakness.

What are the signs of LIVER ABSCESS?

Physical examination may reveal jaundice, particularly in late stages. Other signs include tender hepatomegaly and epigastric tenderness.

What are the symptoms of LIVER ABSCESS?

Common symptoms include fever, malaise, and pain in the right upper quadrant. Patients might also report anorexia, weight loss, nausea, vomiting, and symptoms of diaphragmatic irritation such as right shoulder pain or hiccups.

What are the diagnostic methods of LIVER ABSCESS and their positive results?

Diagnosis involves blood tests showing neutrophilic leukocytosis, raised liver function tests (ALP, AST, ALT), hyperbilirubinemia, and elevated inflammatory markers (ESR, CRP). Abdominal imaging like USG or CT can confirm an abscess, with USG showing fluid-filled hypoechoic lesions and CT revealing peripheral rim enhancement with IV contrast. Percutaneous aspiration and culture of the aspirate, guided by USG or CT, is both diagnostic and therapeutic.

What are the treatment methods of LIVER ABSCESS?

Treatment primarily involves intravenous antibiotics and percutaneous drainage in most cases. In severe situations, such as a ruptured abscess or if percutaneous drainage is insufficient, open surgery may be necessary.

What is the pharmacological treatment of LIVER ABSCESS?

Pharmacological treatment primarily involves intravenous antibiotics as the first line of therapy. Common antibiotic regimens include ampicillin with sulbactam, piperacillin with tazobactam, or third-generation cephalosporins with metronidazole.

What is the surgical treatment of LIVER ABSCESS?

Percutaneous drainage, guided by USG or CT, is a common intervention for abscesses, involving needle aspiration for smaller ones (

What is the definition of PLEURAL EXUDATES?

Pleural exudate is extravascular fluid with protein content, caused by changes in capillary permeability due to inflammation or infiltration of the pleura. It escapes into the pleural cavity through lesions in blood and lymph vessels and has a high specific gravity (>1.020).

What are the types of PLEURAL EXUDATES and their features?

Malignant pleural effusion is a type of exudate often found in patients with malignancy, characterized by large amounts of fluid and a poor prognosis. Hemothorax and chylothorax are also mentioned as types of exudative effusions.

What is the etiology of PLEURAL EXUDATES?

The etiology includes infections such as pneumonia, tuberculosis, and pleural empyema. Malignancies like lung cancer, metastatic breast cancer, mesothelioma, and ovarian cancer are also common causes. Other causes include autoimmune conditions (SLE, rheumatoid arthritis, vasculitis), pancreatitis, trauma, infarction, hemothorax, chylothorax, and pulmonary embolism, where the fluid is often exudative.

What is the pathophysiology of PLEURAL EXUDATES?

The pathophysiology involves increased capillary permeability due to inflammation or infiltration of the pleura. This allows fluid with protein content to escape into the pleural cavity through lesions in blood and lymph vessels.

What is the clinical presentation of PLEURAL EXUDATES?

Small pleural effusions are often asymptomatic. Larger effusions typically present with dyspnoea, pleuritic chest pain, and a dry, non-productive cough.

What are the signs of PLEURAL EXUDATES?

Signs can include decreased ipsilateral chest expansion, dullness to percussion, and decreased breath sounds over the effusion on auscultation. Crepitations may also be heard.

What are the symptoms of PLEURAL EXUDATES?

Patients with a small pleural effusion are often asymptomatic. For larger effusions, common symptoms include dyspnoea, pleuritic chest pain, and a dry, non-productive cough.

What are the diagnostic methods of PLEURAL EXUDATES and their positive results?

Diagnostic methods include imaging studies such as chest radiograph (X-ray), USG, and CT to show pleural effusions and lesions. An X-ray can detect effusions greater than 300 mL, showing obliteration of the costophrenic angle or a dense shadow. Thoracocentesis with pleural fluid analysis confirms an exudate if the pleural fluid protein/serum protein ratio is > 0.5 and the pleural LDH/serum LDH ratio is > 0.6.

What is the conservative treatment of PLEURAL EXUDATES?

Conservative treatment involves solving the underlying cause of the exudate. This approach is used unless the fluid is empyema.

What is the management measures for PLEURAL EXUDATES?

Management often involves an aggressive approach, including surgical drainage, tube thoracostomy, or surgical pleurectomy (open or thoracoscopic). For malignant pleural effusions, palliative therapy with tube thoracostomy followed by pleurodesis (mechanical or chemical) may be used. A pleuroperitoneal shunt is also an option.

What are the complications of PLEURAL EXUDATES?

Complications include infection and empyema (pus in the pleural space). Other potential complications are treatment failure with recurrence of the pleural effusion, and damage to the underlying lung parenchyma, possibly leading to prolonged air leak and bronchoalveolar air leak.

What is the definition of CHYLOTHORAX?

Chylothorax is lymph in the pleural space, occurring when the thoracic duct is disrupted.

What are the types of CHYLOTHORAX and their features?

Chylothorax is characterised by its appearance as a milky fluid with a high triglyceride content.

What is the etiology of CHYLOTHORAX?

The primary causes of chylothorax include trauma, most frequently thoracic surgery, or tumors of the mediastinum.

What is the pathophysiology of CHYLOTHORAX?

The pathophysiology of chylothorax involves the disruption of the thoracic duct, leading to the accumulation of lymph within the pleural cavity.

What is the clinical presentation of CHYLOTHORAX?

No information in the sources.

What are the signs of CHYLOTHORAX?

Physical findings that may indicate a pleural effusion, which could be chylothorax, include asymmetric chest expansion and unilateral lagging on the affected side upon inspection and palpation. There may also be reduced tactile fremitus due to fluid in the pleural space, and faint or absent breath sounds on auscultation.

What are the symptoms of CHYLOTHORAX?

No information in the sources.

What are the diagnostic methods (labs, imaging, physical examination) of CHYLOTHORAX and their findings?

Diagnostic methods include imaging studies such as a Chest X-Ray, where a lateral decubitus view allows for the detection of fluid collections as small as 5 mL, showing unilateral blunting of the costophrenic angle. For large effusions, Chest X-Ray findings may include complete opacification of the lung, mediastinal shift, and tracheal deviation away from the affected side. USG (ultrasound) can also be used for quick assessment and to help with thoracentesis. On physical examination, findings may include asymmetric chest expansion and unilateral lagging on the affected side, reduced tactile fremitus, and faint or absent breath sounds. The definitive diagnostic finding for chylothorax is when the pleural fluid appears milky and demonstrates a high triglyceride content.

What is the conservative treatment of CHYLOTHORAX?

No information in the sources.

What is the management measures for CHYLOTHORAX?

Management for chylothorax typically involves chest tube insertion and the administration of octreotide, which is a somatostatin analogue. If these initial measures are ineffective, a pleuro-peritoneal shunt should be placed. General management techniques for pleural effusions, which may be applicable, include therapeutic thoracentesis involving the removal of 400-500 mL of fluid, typically from the 5th intercostal space mid-axillary line, which is usually sufficient to relieve symptoms. An indwelling pleural catheter may also be used.

What is the treatment of CHYLOTHORAX?

Treatment for chylothorax involves chest tube insertion and the administration of octreotide, which is a somatostatin analogue. If these measures are ineffective, a pleuro-peritoneal shunt should be placed.

What are the complications of CHYLOTHORAX?

No information in the sources.

What is the definition of HEMOTHORAX?

Hemothorax is the presence of blood in the pleural space, specifically defined by a hematocrit of the pleural fluid that is more than half of the peripheral blood hematocrit.

What are the types of HEMOTHORAX and their features?

No information in the sources.

What is the etiology of HEMOTHORAX?

Hemothorax is most commonly due to trauma, the rupture of a blood vessel, or the presence of a tumor.

What is the pathophysiology of HEMOTHORAX?

No information in the sources that explicitly details the pathophysiology beyond the causes.

What is the clinical presentation of HEMOTHORAX?

No information in the sources.

What are the signs of HEMOTHORAX?

Physical findings that may indicate a pleural effusion, which could be hemothorax, include asymmetric chest expansion and unilateral lagging on the affected side upon inspection and palpation. There may also be reduced tactile fremitus due to fluid in the pleural space, faint or absent breath sounds on auscultation, and a pleural friction rub may also be heard.

What are the symptoms of HEMOTHORAX?

No information in the sources.

What are the diagnostic methods (labs, imaging, physical examination) of HEMOTHORAX and their findings?

Diagnostic methods include imaging studies such as a Chest X-Ray, where a lateral decubitus view allows for the detection of fluid collections as small as 5 mL, showing unilateral blunting of the costophrenic angle. For large effusions, Chest X-Ray findings may include complete opacification of the lung, mediastinal shift, and tracheal deviation away from the affected side. USG (ultrasound) can also be used for quick assessment and to help with thoracentesis. On physical examination, findings may include asymmetric chest expansion and unilateral lagging on the affected side, reduced tactile fremitus, faint or absent breath sounds, and a pleural friction rub. The definitive positive diagnostic finding for hemothorax is when the hematocrit of the fluid in the pleural space is more than half of the peripheral blood hematocrit.

What is the conservative treatment of HEMOTHORAX?

No information in the sources.

What is the management measures for HEMOTHORAX?

Management for hemothorax typically involves thoracostomy, which is the insertion of a chest tube. General management techniques for pleural effusions, which may be applicable, include therapeutic thoracentesis involving the removal of 400-500 mL of fluid, typically from the 5th intercostal space mid-axillary line, which is usually sufficient to relieve symptoms. An indwelling pleural catheter may also be used.

What is the treatment of HEMOTHORAX?

Treatment for hemothorax is with thoracostomy, which is the insertion of a chest tube.

What are the complications of HEMOTHORAX?

No information in the sources.