Pancreas Content Review Reviewer Name* Title*Copy and Paste the title of this activity. HiddenInventory ID Number Hiddentype Access Instructions To access this video, visit the site below and log in with the following credentials: username:sagesreview password:foregut Leave the Institution ID blank Access Instructions To access this video, visit the site below and log in with your sages.org account: Please review this content item based on the Pancreas Pathway Goals and Objectives . HiddenIs this content relevant to the Foregut Masters Pathway* Relevant Somewhat Relevant Not Relevant HiddenIs this content relevant to any of the below Masters Pathways?*Select all that apply Acute Care Surgery Bariatric Biliary Colorectal Flexible Endoscopy Hernia Leadership & Professional Development Liver Pancreas Robotics Difficulty Level*Select the level to which this content applies. Select All that Apply. Select All Competency Level: Equip the surgeon with the requisite knowledge of the anatomical and other patient considerations to perform MIS distal pancreatectomy with splenectomy Proficiency Level: Equip the surgeon with the requisite knowledge of the anatomical and other patient considerations to perform MIS spleen preserving distal pancreatectomy SPDP Mastery Level: Equip the surgeon with the requisite knowledge of the anatomical and other patient considerations to perform MIS radical antegrade modular pancreatosplenectomy (RAMPS) Competency LevelCompetency Goals*Select whether the content relates to either Pre-operative or Intra-operative goals. Select All the Apply. Select All Pre-Operative: Equip the surgeon with the requisite knowledge of the anatomical and other preoperative patient considerations to perform MIS distal pancreatectomy with splenectomy. Intra Op: Assist the surgeon in acquiring the required knowledge and operative skills to perform MIS distal pancreatectomy with splenectomy Post Op: Manage post-operative issues in MIS distal pancreatectomy with splenectomy Competency Level: Pre-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Select All Presentation: Typical and atypical presenting signs & symptoms of a patient with left sided pancreatic lesion DDx: Other clinical conditions to consider in the differential (ie: pancreatic pseudocyst, cystic neoplasm, neuroendocrine tumor, adenocarcinoma) Diagnostic work-up: Which tests? How are they performed? How to interpret them? Management considerations: Understand correct work-up of mass vs. cystic neoplasm. Competency Level: Pre-Operative SME Objectives*Select the Objectives covered by this content. Select All the Apply. Select All Describe the typical presentation of patients with left sided pancreatic lesions. Distinguish between a solid mass versus cystic neoplasm. Explain the diagnostic work-up for cystic neoplasms based on guidelines for management. Discuss the utility of and indications for CT, MRI, and endoscopic ultrasound with fine needle aspiration biopsy. Interpret fluid analysis findings from cystic neoplasms of the pancreas. Describe a strategy for patient selection that incorporates the patient’s comorbidities, diagnostic workup, and choice of procedure. List the appropriate pre-operative vaccinations for a patient undergoing splenectomy. Competency Level: Intra-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Select All Describe patient position and trocar placement. Explain the critical steps of a distal pancreatectomy and splenectomy Demonstrate the key anatomic landmarks for distal pancreatectomy and splenectomy Assess which clinical scenarios require further intraoperative modalities such as intraoperative ultrasound Describe bail-out techniques for bleeding/intraoperative complications and conversion to hand-assisted vs open surgery Competency Level: Intra-Operative SME Objectives*Select the Objectives covered by this content. Select All the Apply. Select All Describe patient positioning and trocar placement for distal pancreatectomy with splenectomy. Explain at least 1 method for mobilizing and retracting the greater curvature of the stomach and exposing the pancreatic tail. List at least 2 techniques for verifying adequate parenchymal margin prior to pancreas transection. Explain at least 3 methods of parenchymal transection. Describe at least 3 methods of major peripancreatic vessel transection. List at least 3 factors that increase the risk of pancreatic fistula. Discuss the advantages and disadvantages of drain placement. Describe a strategy for managing intraoperative bleeding. List at least 3 indications for conversion to an open/hybrid approach. Competency Level: Post-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Select All Pathway: Typical immediate post-op pathway (e.g., diet, activity, med changes, drain management, etc) Outcomes: Typical expected outcomes (e.g., % of patients with curative surgery vs those who require ongoing surveillance e.g. IPMN vs adenocarcinoma) Short-term post-op complications: (e.g., PE, DVT, hemorrage, pancreatic fistula) – incidence, diagnostics, how to manage them Long-term post-op complications: (e.g., diabetes, post-splenectomy sepsis) – incidence, diagnostics, how to manage them Competency Level: Post-Operative SME Objectives*Select the Objectives covered by this content. Select All the Apply. Select All Describe the typical immediate post-operative pathway following a distal pancreatectomy and splenectomy (including diet, activity, medications, and drain management). Discuss the post-operative surveillance algorithm for a patient with IPMN and for a patient with adenocarcinoma. List at least 4 potential short-term post-operative complications and describe a diagnostic and management strategy for each. List at least 2 potential long-term post-operative complications and desribe a diagnostic and management strategy for each. Proficiency LevelProficiency Goals*Select whether the content relates to either Pre-operative or Intra-operative goals. Select All the Apply. Select All Pre Op: Equip the surgeon with the requisite knowledge of the anatomical and other preoperative patient considerations to perform MIS SPDP Intra-Op: Assist the surgeon in acquiring the required knowledge and operative skills to perform MIS SPDP Post Op: Manage post-operative issues in MIS SPDP Proficiency Level: Pre-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Select All Describe the proper cilical and radiological evaluation for a patient presenting with a central or distal cystic or solid tumor of the pancreas that can be a candidate for spleen preserving distal pancreatectomy (SPDP) Evaluate the anatomical implications and planning of the operation based on integration of the clinical and radiological results Describe the various management options and steps of the operation based on individual cases Proficiency Level: Pre-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Select All List the benefits of MIS SPDP Outline the recommended pre-operative workup for a patient prior to MIS SPDP Describe a treatment strategy for a specific patient who is a candidate for MIS SPDP. Explain the pre- and post-operative findings that constitute an oncologically safe and effective procedure List at least 3 contraindications for splenic preservation during MIS distal pancreatectomy. Proficiency Level: Intra-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Select All Preparation: Appropriate identification and listing of pathways for operative clearance (E.g., bowel prep diet, antibiotics, clearance by anesthesia, preop labs, staging etc.) Positioning: How is the patient to be positioned and secured for the procedure? Instrument selection: Ports, staples, energy device, drains, sutures. Operative steps: Describe and execute the proper steps and its sequence along with trouble shooting common pitfalls. Discribe differences between splenic vessel preserving SPDP versus Warshaw technique. List possible reasons for need to convert to open surgery Debrief: Analize, describe and sumarize events and results of the operation along with feedback discussion with a surgeon who is a master in MIS SPDP Proficiency Level: Intra-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Select All Describe different options for conducting the appropriate intraoperative steps including vascular control, pancreas dissection, R0 margins and node harvesting Explain at least one intraoperative strategy for vascular control, pancreas dissection, node harvesting, and obtaining R0 margins. Describe appropriate patient positioning and trocar placement. List the key anatomic landmarks related to the pancreas and spleen, and explain at least 2 common anatomic variations. Discuss at least 2 indications for conversion to a hand-assisted or open procedure. Compare and contrast splenic vessel-preserving SPDP versus the Warshaw technique. Discuss the advantages and disadvantages of drain placement. Proficiency Level: Post-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Select All Typical immediate post-op pathway (e.g., diet, activity, med changes, drain management etc) Outcomes: Typical expected outcomes (e.g., % of patients with curative surgery vs those who require ongoing surveillance e.g. IPMN vs adenocarcinoma) Short-term post-op complications: (e.g., PE, DVT, hemorrage, pancreatic fistula, wound infection) – incidence, diagnostics, how to manage them timely and appropriately Long-term post-op complications: (e.g., diabetes, collections, etc) – incidence, diagnostics, how to manage them Proficiency Level: Post-Operative SME Objectives*Select the topics covered by this content. Select All the Apply. Select All Describe the typical immediate post-operative pathway following a distal pancreatectomy and splenectomy (including diet, activity, medications, and drain management). Discuss the post-operative surveillance algorithm for a patient with IPMN and for a patient with adenocarcinoma. List at least 4 potential short-term post-operative complications and describe a diagnostic and management strategy for each. List at least 2 potential long-term post-operative complications and desribe a diagnostic and management strategy for each. Mastery LevelMastery Goals*Select whether the content relates to either Pre-operative or Intra-operative goals. Select All the Apply. Select All Pre-Operative: Equip the surgeon with the requisite knowledge of the anatomical and other preoperative patient considerations to perform MIS RAMPS Intra-Operative: Assist the surgeon in acquiring the required knowledge and operative skills to perform MIS RAMPS Post-Operative: Manage post-operative issues in MIS RAMPS Mastery Level: Pre-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Select All Presentation: Discuss the typical and atypical presenting signs & symptoms of a patient with left sided pancreatic adenocarcinoma. Indications: Discuss the oncologic foundations for RAMPS. Discuss which pancreatic neoplasms require RAMPS. Diagnostic work-up: Discuss the Endoscopic Studies needed to establish the diagnosis? What anatomic features (vascular, local invasion into adjacent organs) must be assessed on Cross-Sectional Imaging? Management considerations: Discuss the tumor characteristics in the Cross-Sectional Imaging that will be important in operative planning for RAMPS Neoadjuvant Chemotherapy: Discuss the role of Neoadjuvant Chemotherapy for Pancreatic Adenocarcinoma Mastery Level: Pre-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Select All Describe the typical presentation of a patient with left sided pancreatic adenocarcinoma. Explain the oncologic rationale for RAMPS. Discuss the utility of and indications for CT, MRI, and endoscopic ultrasound with fine needle aspiration biopsy. Interpret CT and MRI images for vascular (portal vein, SMV, SMA, celiac axis) and adjacent organ involvement (left adrenal, stomach, transverse colon). Describe a strategy for selecting patients for RAMPS that incorporates the patient’s comorbidities and diagnostic workup. Discuss the role of neoadjuvant chemotherapy for left-sided pancreatic adenocarcinoma. Mastery Level: Intra-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Select All Preparation: Any patient prep needed? (E.g., bowel prep, vaccinations) Positioning: What are the choices for patient positioning? Explain the critical steps of MIS RAMPS Exposure: Techniques for exposing pancreatic body/tail Parenchymal transection: Discuss options for division of pancreas Vascular Dissection: Discuss dissection along SMV/PV, SMA and Celiac Axis Body/Tail Mobilization: Describe the plane followed for RAMPS, and the margins of resection tangentially Discuss the different techniques of Anterior RAMPS and Posterior RAMPS Discuss the indication for Multivisceral Resection (Adrenal, Stomach, Colon) and vascular resection (SMV-PV or celiac axis resection) Discuss the indications for post-operative drain placement Intraoperative complications: most common and how to manage Mastery Level: Intra-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Select All Describe patient positioning and trocar placement for MIS RAMPS. Explain the steps for complete RAMPS including lymph node harvest and tangential resection margin. Compare and contrast Anterior versus Posterior RAMPS Discuss the advantages and disadvantages of drain placement. Describe a method for multivisceral resection for local invasion of: i. adrenal ii. stomach iii. colon Describe at least one strategy for the management of intra-operative bleeding. Mastery Level: Post-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Select All Pathway: Typical immediate post-op pathway (e.g., diet, activity, med changes, drain management, etc) Outcomes: Typical expected oncologic outcomes (indications for adjuvant chemotherapy and/or radiation). Short-term post-op complications: (e.g., PE, DVT, hemorrhage, pancreatic fistula) – incidence, diagnostics, how to manage them Long-term post-op complications: (e.g., diabetes, post-splenectomy sepsis) – incidence, diagnostics, how to manage them Mastery Level: Post-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Select All Describe the typical immediate post-operative pathway following a distal pancreatectomy and splenectomy (including diet, activity, medications, and drain management). Explain the indications for adjuvant chemotherapy and radiation. List at least 4 potential short-term post-operative complications and describe a diagnostic and management strategy for each. List at least 2 potential long-term post-operative complications and desribe a diagnostic and management strategy for each. General CommentsPlease list any general comments regarding this content.NameThis field is for validation purposes and should be left unchanged.