Complications of acute panctratitis

1. Local Complication of Pancreatitis
and its Management
Anup Shrestha
Dept of Surgery
CMC

2. Local Fluid Collection

3.  A pancreatic pseudocyst is defined as a fluid
collection within or adjacent to the pancreas that
becomes completely encapsulated with a mature,
nonepithelialized, fibrous, inflammatory wall.
 Its formation requires at least 4 weeks by definition.
 typically homogeneous with minimal or no necrosis
present and without a significant solid component on
CECT imaging .
Pancreatic Pseudocyst

4. Computed tomography scan showing a large horseshoe-
shaped pancreatic pseudocyst (PP) after acute gallstone
pancreatitis.

5.  Common- abdominal pain and early satiety
 Less frequent- jaundice, intestinal obstruction, intracystic
hemorrhage , peritonitis and pseudocyst rupture.
 Imaging -Contrast-enhanced CT imaging is highly sensitive
(closeto 100%) for the presence of pancreatic cystic lesions
but does not reliably exclude the possibility of a cystic
neoplasm. The presence of nonenhancing internal dependent
debris on T2-weighted magnetic resonance imaging (MRI)
sequences was a highly specific finding for pseudocysts in a
recent review of pancreatic cystic lesions
 new or worsening abdominal, flank, or back pain, intolerance
of oral intake and weight loss, mechanical obstruction
(gastric, duodenal, or biliary), evidence of infection (gas in a
non-intervened-on lesion), or concerns for PD leakage
(fistula) should prompt concerns for symptomatic pseudocyst
development
CM of Pseudocysts

6. Cystic Fluid Analysis

7.  Nealon classification of
pancreatic ductal disruption and
pseudocyst formation.
 Type I is a normal main pancreatic
duct.
 Type II is a pancreatic duct
stricture.
 Type III is pancreatic duct
occlusion (disconnected
pancreatic duct syndrome).
 Type IV depicts chronic
pancreatitis with dilatation of
pancreatic duct
Classification

8.  Likelihood of resolution :pseudocyst with diameter
less than 5 cm .
 Nealon Classification was significant predictor of
spontaneous resolution .
 Type I pseudocyst mostly resolution was seen
 Type II, III, IV were typically symptomatic and require
intervention
Non- Operative Management

9.  Cystogastrostomy: This technique involves a
longitudinal gastrotomy at the level of the anterior
wall of the stomach, typically in the body. The
pseudocyst is entered by incision (or excisional
biopsy) of the posterior stomach wall at least 3 cm
long and the pseudocyst contents are suctioned out.
a cystogastrostomy anastomosis is fashioned with a
running, locking, absorbable 2-0 or 3-0 suture such as
polydioxanone (PDS). The anterior gastrotomy is then
closed with sutures or a surgical stapler.
Treatment :
Surgical Options for internal drainage
Basic Principle : the wall of the pseudocyst must be mature
and thick enough to hold suture for anastomosis

10. Steps

11.  Performed in a Roux-en-Y configuration
and it is anastomosed to the pseudocyst
through the window in the right or left
side of the transverse mesocolon.
 The proximal jejunum is divided about
30 cm from the ligament of Treitz and
jejunojejunostomy is made creating a
Roux limb apprx 40 to 60 cm long. A
two-layered anastomosis is done using
silk for the outer layer and continuous
absorbable suture for the inner layer.
Closure of the mesenteric defect is
routine.
Cystojejenostomy

12.  Done when the pseudocyst is located in the
pancreatic head and immediately abutting the
duodenal wall. A longitudinal duodenotomy should
be used to expose the medial wall of the duodenum.
Injury to the gastroduodenal artery , CBD, main
pancreatic duct should be avoided
 Complication like anastomotic dehiscence and
abscess formation . So it is rarely performed .
Cystoduodenostomy

13.  EUS-guided approach has a higher technical success rate and
safety profile than CTD and is the preferred method in
nonbulging pseudocysts, portal hypertension, or coagulopathy.
 The major complications associated with endoscopic pseudocyst
drainage—infection, bleeding, stent migration/ obstruction,
perforation.
EUS Guided Drainage transmural
drainage

14.  Endoscopic transpapillary drainage is effective for
pseudocyst & that communicate with the pancreatic
duct.
 Pancreatic duct sphincterotomy should be performed
regardless of whether there is successful pseudocyst
drainage.
Endoscopic guided
Transpapillary Drainage

15. Transmural Drainage

16.  In the emergency pseudocyst rupture , external
drainage may temporary solution.
 If the pseudocyst wall is unexpectedly too thin and
immature for anatomosis , external drainage can be
performed.
 Also if internal drainage is anatomically unachievable
due to adhesions, then external drainage is a
reasonable bailout option.
External Drainage

17. Algorithm for elective management
of pancreatic pseudocysts

18.  APFCs are predominantly fluid-filled
collections that occur subsequent to an
episode of acute interstitial pancreatitis
with no radiologic evidence of
parenchymal or peripancreatic necrosis.
 are identified radiographically as
“puddles” in the vicinity of the pancreas
 vast majority, approximated to be 85% to
90%, undergo spontaneous, self-
resolution within 7 to 10 days
Acute Pancreatic Fluid
Collection(APFC)

19.  In the initial 2-week time period, Acute Necrotic Collections
(ANC)s are typically sterile and should be treated with
aggressive medical management.
 Surgical débridement of ANCs in the early stages should be
avoided unless infection is confirmed
 If the patient develops recurrent systemic symptoms, such as
fever, new or worsening abdominal pain, rising leukocytosis,
an infected ANC should be suspected. In these cases,
antibiotics with adequate pancreatic penetration should be
initiated in an attempt to allow time for the transition from
ANC to WON defined by the development of a mature, well-
defined wall
Acute Pancreatic Necrosis

20.  a mature, encapsulated collection of pancreatic and/ or
peripancreatic necrosis that has developed a well defined
inflammatory wall.” WON typically develops as an evolution of an
ANC 4 weeks after an episode of severe acute necrotizing
pancreatitis.
 If sterile, treatment is conservative
 If infected, drainage and culture of the collection, antibiotics and
invasive therapy are warranted
 Standard of therapy for WON has been a multimodality “step up
approach,” consisting of percutaneous catheter drainage followed
by surgical necrosectomy
 Int Association of Pancreatology and the American Pancreatic
Association evidence-based guidelines endorse percutaneous
catheter or endoscopic transmural drainage as the first step in the
treatment, followed by either endoscopic or minimally invasive
surgical necrosectomy
Walled-off
necrosis (WON)

21.  For patients with an organized WON located within close
proximity (~1 cm) to the gastric or duodenal wall
 The technique involves initial guidewire access to the
necroma either via direct puncture (in the case of a luminal
bulge) or through the use of endoscopic ultrasound (EUS)-
guided needle puncture and subsequent wire guided access.
Once access is secured, the tract is dilated using a graduated
dilating catheter, needle knife sphincterotome, or
cystotome, and subsequent dilation to 15 to 20 mm is
performed using a balloon dilator to allow passage of an
upper endoscope into the necroma. Débridement is then
performed using a combination of endoscopic accessories.
Preservation of the tract is achieved by the placement of
stents into the cavity across the gastric or duodenal wall.
ENDOSCOPIC NECROSECTOMY

22. Endoscopic walled-off pancreatic
necrosis drainage

23.  Patients with infected pancreatic necrosis were
randomized to either open necrosectomy or a step-up
approach based on endoscopic or percutaneous
drainage as the initial intervention, with progression to
retroperitoneal debridement with lavage if no
improvement was observed.
 In patients with infected necrotizing pancreatitis,
endoscopic necrosectomy reduced the inflammatory
response, had a lower rate of complications, and
prevented new-onset multiple organ failure.
The PANTER (PAncreatitis, Necrosectomy
versus sTEp up appRoach) trial from Dutch
Pancreatitis Group

24.  Minimally Invasive Retroperitoneal Pancreatic Necrosectomy (MIRP)
Retroperitoneal Step-Up Management
Techniques

25. Video-Assisted Retroperitoneal
Debridement(VARD)

26.  Open Necrosectomy With Open Packing: sepsis control being
achieved by leaving the abdomen open following
debridement, packing the cavity as a laparostomy.
 Open Necrosectomy With Closed Packing: Primary closure of the
abdomen is the intention over gauze-stuffed Penrose drains,
with the intention to fill the cavity and provide some
compression.
 Open Necrosectomy With Continuous Closed Postoperative
Lavage:
 Programmed Open Necrosectomy: conservative debridement,
with the intention of performing repeat procedures every 48
hours until debridement is no longer required.
Open surgical necrosectomy

27.  DPDS is a condition in which there is complete disruption of
the main pancreatic duct, resulting in a normal upstream
pancreatic gland having no communication with the
gastrointestinal tract. Traditional management approach
has been surgical intervention with either distal
pancreatectomy or drainage procedures.
 Endoscopic approach: use of permanent indwelling
transmural stents. This allows for creation and maintenance
of a fistulous tract for pancreatic secretions to drain into the
gastrointestinal lumen.
DISCONNECTED PANCREATIC DUCT
SYNDROME(DPDS)

29.  External Fistula : Failure of percutaneous drain
placement. Sepsis, electrolyte disturbances, and skin
excoriation are common in high output fistulas.
 Internal Fistula : can occur after pancreatitis due to a
local peripancreatic necrotizing inflammatory process . It
may develop de novo or as a complication following
manipulation by necrosectomy or close drain. Most
commonly, these fistulas occur between the pancreas
and the splenic flexure or transverse colon.
PANCREATIC FISTULAS

30.  Treatment : Percutaneous drainage of the associated
fluid collection. Diet restriction , octreotide and
parenteral nutrition are often required to decrease
fistula output. Early intervention shows faster time to
closure of fistula and less complication.
 Distal pancreatectomy is reserved for fistulas of the
tail. Fistulas originating from the head, neck, or body
are usually treated by Roux-en-Y pancreatico-
jejunostomy
Pancreatic Fistulas

31.  Recommended for recalcitrant non healing external
fistulas
Fistula Tract-jejunostomy

32.  Splenic Vein thrombosis: can cause gastric or
esophageal varices. If bleeding occurs splenectomy is
reccomended. Splenic artery embolization is also
another option for unfit patients .
 Pseudoaneurysm and hemorrhage: less frequent and
late presentation. Rx : Angiographic embolization.
 Obstruction: paralytic ileus due to compression from
pseudocyst. After decompression ileus is resolved.
Extrapancreatic Complication

33. THE END