Treatment of severe acute pancreatitis and its complications.pptx
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Treatment of severe acute pancreatitis and its complications.pptx
- 1. MANAGEMENT OF SEVERE ACUTE PANCREATITIS AND ITS COMPLICATIONS Maj. Hasnain Afzal Resident General Surgery
- 2. DEFINITION Acute Pancreatitis An acute condition presenting with abdominal pain- usually associated with raised blood pancreatic enzymes as a result of pancreatic inflammation 2
- 3. DIAGNOSTIC CRITERIA Characteristic Abdominal Pain Elevated Serum Amylase/Lipase >3 Times Radiological Findings (2 out of 3 criteria Required For Diagnosis) 3
- 4. PHASES 4
- 5. ETIOLOGY Gallstones (50 – 70%) Alcoholism (25%) Post ERCP Abdominal trauma Following biliary, upper gastrointestinal or cardiothoracic surgery Ampullary tumour Drugs (corticosteroids, azathioprine, asparaginase, valproic acid, thiazides, oestrogens) Hyperparathyroidism Hypercalcaemia Pancreas divisum Autoimmune pancreatitis Hereditary pancreatitis Viral infections (mumps, coxsackie B) Malnutrition Scorpion bite Idiopathic 5
- 6. CLINICAL PRESENTATION Abdominal Pain – Cardinal symptom Nausea/Vomiting Abdominal Distension 6
- 7. SEVERITY CLASSIFICATION Revised Atlanta Classification Mild Acute Pancreatitis no organ failure; no local or systemic complications Moderately Severe Acute Pancreatitis organ failure that resolves within 48 hours (transient organ failure); and/or local or systemic complications without persistent organ failure Severe Acute Pancreatitis persistent organ failure (>48 hours) 7
- 8. EARLY MANAGEMENT OF SEVERE ACUTE PANCREATITIS Admission to HDU/ICU Analgesia Aggressive fluid rehydration Supplemental oxygen Invasive monitoring Nasogastric drainage (only initially) Antibiotics if cholangitis suspected CT scan ERCP within 72 hours for severe gallstone pancreatitis or signs of cholangitis Supportive therapy for organ failure If nutritional support is required, consider enteral (nasogastric) feeding 8
- 9. LOCAL COMPLICATIONS Revised Atlanta Definitions of Peripancreatic Fluid Collections 9
- 10. A. Acute peripancreatic fluid collection B. Pancreatic Pseudocyst D. Walled-Off Necrosis C. Acute Necrotic collection 10
- 11. INDICATIONS FOR PERCUTANEOUS / ENDOSCOPIC DRAINAGE OF PANCREATIC COLLECTIONS Clinical deterioration with signs or strong suspicion of infected necrotizing pancreatitis is an indication to perform intervention (percutaneous/endoscopic drainage) 11
- 12. INDICATIONS FOR SURGICAL INTERVENTION The following are indications for surgical intervention: Step-up approach Abdominal compartment syndrome Acute on-going bleeding Bowel ischaemia or acute necrotizing cholecystitis Bowel fistula 12
- 13. TIMING OF SURGERY Postponing surgical interventions for more than 4 weeks after the onset of the disease results in less mortality 13
- 14. SURGICAL APPROACH TO NECROTIZING PANCREATITIS OPEN NECROSECTOMY WITH OPEN PACKING OPEN NECROSECTOMY WITH CLOSED PACKING OPEN NECROSECTOMY WITH CONTINOUS POSTOPERATIVE LAVAGE PROGRAMMED OPEN NECROSECTOMY 14
- 15. CONCLUSION Classification of complications according to revised Atlanta Classification system The step-up Approach Close monitoring, Percutaneous or endoscopic drainage, Minimally invasive Retroperitoneal debridement Open Necrosectomy 15
- 16. REFERENCES Leppäniemi et al. World Journal of Emergency Surgery (2019) 14:27 https://doi.org/10.1186/s13017-019-0247-0 Zerem E. Treatment of severe acute pancreatitis and its complications. World J Gastroenterol 2014; 20(38): 13879-13892 Bailey & Love’s short practice of surgery 27th Edition Fischer’s Mastery of surgery 7th edition 16
- 17. THANK YOU! 17
Editor's Notes
- Bismillah Arehman Arraheem. Worthy DG surgery Respected seniors and my dear colleagues Assalam o alaikum I am maj. Hasnain resident in gen surgery I will be presenting management of SAP and its complications
- It is
- According to the revised Atlanta classification, the diagnosis of AP can be made when two of three criteria are met: (1) characteristic abdominal pain; (2) serum amylase or lipase levels greater than three times the upper limit of normal; and (3) characteristic findings on cross-sectional imaging.
- Acute pancreatitis has an early phase that usually lasts a week. It is characterised by a systemic inflammatory response syndrome (SIRS) which – if severe – can lead to transient or persistent organ failure (deemed persistent if it lasts for over 48 hours). The late phase is seen typically in those who suffer a severe attack, and can run from weeks to months. It is characterised by persistent systemic signs of inflammation, and/or local complications, particularly fluid collections and peripancreatic sepsis
- The two major causes of acute pancreatitis are Gallstones, which occur in 50–70% of patients, and alcohol abuse, which accounts for 25% of cases. Rest of the etiologic factors are as flashed
- In clinical presentation Pain is the cardinal symptom. Pain is usually experienced first in the epigastrium but may be localised to either upper quadrant or felt diffusely throughout the abdomen radiating to back in 50% of patients. Nausea vomiting and abdominal distension are other common presenting symptoms
- A Revised Atlanta classification of acute pancreatitis recommends that patients with acute pancreatitis be stratified into 3 groups: ●● Mild acute pancreatitis: in which there is no organ failure; ●● no local or systemic complications. ●● Moderately severe acute pancreatitis: in which organ failure that resolves within 48 hours (transient organ failure); and/or ●● local or systemic complications without persistent organ failure. Severe acute pancreatitis: in which persistent organ failure (>48 hours); ●● single organ failure; ●● multiple organ failure.
- Early management of SAP includes Continuous vital signs monitoring in high dependency unit if organ dysfunction occurs. Persistent organ dysfunction or organ failure occurrence despite adequate fluid resuscitation is an indication for ICU admission Analgesia No evidence or recommendation about any restriction in pain medication is available. Nonsteroidal anti-inflammatory drugs (NSAID) should be avoided in acute kidney injury (AKI) Aggressive fluid rehydration to optimize tissue perfusion targets, without waiting for hemodynamic worsening Supplemental oxygen Frequent monitoring of haematological and biochemical parameters Nasogastric drainage (only initially) There are no data to support a practice of ‘resting’ the pancreas and feeding only by the parenteral or nasojejunal routes. If nutritional support is felt to be necessary, enteral nutrition (e.g. feeding via a nasogastric tube) should be used. Antibiotics if cholangitis suspected; prophylactic antibiotics can be considered CT scan is essential if organ failure, clinical deterioration or signs of sepsis develop ERCP within 72 hours for severe gallstone pancreatitis or signs of cholangitis Supportive therapy for organ failure if it develops (inotropes, ventilatory support, haemofiltration, etc.)
- The revised Atlanta classification has characterized these fluid collections according to timing (> or <4 weeks) and the presence or absence of pancreatic necrosis Peripanreatic fluid collection without necrosis before 4 weeks is termed as Acute peripancreatic fluid collection. Whereas after 4 weeks it is termed as pancreatic pseudocyst Peripancreatic fluid collection with necrosis before 4 weeks is termed as Acute nectrotic collection and after 4 weeks is called walled-off necrosis
- shows an ill-defined peripancreatic collection and stranding around the body and tail of the pancreas (arrows) with mild heterogeneity of the pancreatic tail (*) acute necrotizing pancreatitis shows ill-defined hypoattenuating areas in the head and body of the pancreas (*) and an ill-defined, heterogeneous peripancreatic collection (white arrows) with interspersed fat (black arrow) and stranding around the head, body, and tail. well-defined, homogeneous peripancreatic collection around the tail of the pancreas (arrows), a finding that is compatible with a pseudocyst relatively well-defined, walled-off combined necrosis in the region of the head and body of the pancreas (white arrows), with peripancreatic necrosis seen around the tail (black arrow)
- Clinical deterioration with signs or strong suspicion of infected necrotizing pancreatitis is an indication to perform percutaneous/endoscopic Drainage. After 4 weeks after the onset of the disease: – On-going organ failure without sign of infected necrosis. On-going gastric outlet, biliary, or intestinal obstruction due to a large walled off necrotic collection – Disconnected duct syndrome – Symptomatic or growing pseudocyst After 8 weeks after the onset of the disease: – On-going pain and/or discomfort
- As a continuum in a step-up approach after percutaneous/ endoscopic procedure with the same indications Abdominal compartment syndrome Acute on-going bleeding when endovascular approach is unsuccessful Bowel ischaemia or acute necrotizing cholecystitis during acute pancreatitis Bowel fistula extending into a peripancreatic collection IAH: A sustained or repeated pathological elevation in IAP more than or equal to 12 mmhg ACS: A sustained IAP . 20 mmHg that is associated with new organ dysfunction/failure.
- Surgical approaches include: OPEN NECROSECTOMY WITH OPEN PACKING after necrosectomy, the abdomen maybe left open and repeatedly debrided until there is no residual necrosis, and is allowed to close by secondary intention OPEN NECROSECTOMY WITH CLOSED PACKING after the removal of necrotic tissue, the abdomen is closed, packing with external drains left in place. The drains are removed singly every other day, starting 5-7 d postoperatively OPEN NECROSECTOMY WITH CONTINOUS POSTOPERATIVE LAVAGE the procedure is based on the insertion of 2 or more double lumen catheters. Repeated open necrosectomy is performed and the packing is removed when there is no residual necrosis. The smaller lumen of the drains is used for the inflow of the lavage, and the larger lumen is used for the outflow. The drains can be removed after 2-3 wk PROGRAMMED OPEN NECROSECTOMY necrosectomy of necrotic tissue is performed using multiple procedures. After necrosectomy, the pancreatic bed is packed with sponges and soft drains are placed on the top of the packs. The abdomen is closed using a zipper
- In the end I would like to conclude by saying that Classifying the complications of SAP according to the revised Atlanta classification system is important before deciding the appropriate treatment strategy because different complications of SAP are treated in different ways, either conservatively by interventional imaging techniques or by surgery. Although no universally accepted treatment algorithm exists, the step-up approach using close monitoring, percutaneous or endoscopic drainage, followed by minimally invasive video-assisted retroperitoneal debridement has been shown to produce superior outcomes to traditional open necrosectomy and may be considered as the reference standard intervention for this disorder.