For when your supervisor surprises you

1. Surgical Management of
Acute Pancreatitis
Dr. Hanzla Khalid

2. Indications
• Infected necrosis(absolute indication).
• Non-pancreatic causes like perforated viscus.
• Hemorrhage.
• Severe sterile necrosis.
• Symptomatic organized pancreatic necrosis(WON)
• Sepsis

3. Surgical Interventions
For Etiology;
• Cholecystectomy.
• ERCP.
• CBD exploration.
For Complications;
• Pancreatic resection.
• Pancreatic Necrosectomy(current standard of practice).
• Minimal invasive interventions(rapidly being accepted).

4. Necrosectomy
• Good quality preoperative CT-scan is essential for identification of;
a. All areas of necrosis.
b. Localized collections.
• Wide removal of all devitalized and necrotic tissue.
• Deroofing of all collections.
• Plan to remove the products of ongoing inflammation and infection
that persists after initial Necrosectomy.

5. Necrosectomy-Approach
Midline Incision

6. Pancreas and Lesser sac
Through
gastrocolic
ligaments
Through Transverse Mesocolon

7. • The lesser sac can be approached through the base of the mesocolon.
• Attention should be paid to avoid injury to the middle colic artery.

8. Approach to lesser sac via gastrocolic ligament

9. Necrosectomy- technique
• Identification of viable and necrotic pancreatic tissue.
• Blunt finger dissection of the necrotic tissue.
• Avoid overzealous handling of inflamed and doubtful viable tissue.
• The tissues are inevitably friable, and one should be careful not to
precipitate excessive bleeding or inadvertently breach the bowel wall.
• A feeding jejunostomy may be a useful adjunct to the procedure.

10. Post-Necrosectomy management
• Closed continuous lavage.
• Closed drainage.
• Open packing.
• Closure and relaparotomy.
(The last two approaches make greater logistic demands as one is committed to a
re-exploration every 48–72 hours)

11. Closed continuous lavage
• Continuous postoperative closed lavage of the lesser sac as
advised by Beger.
• Lavage is carried out through several double-lumen and
single-lumen catheters.
• Each time, 1 liter of saline is infused through and then
drained over a period of hours, and the process is repeated.

12. Necrosectomy and closed packing with stuffed Penrose drains

13. Minimal Access Interventions
• Endoscopic Transgastric Necrosectomy.
• Percutaneous Drainage.
• Laparoscopic Necrosectomy.
• Retroperitoneal Necrosectomy.

14. Endoscopic Transgastric Necrosectomy

15. Percutaneous Drainage

16. CT guided Percutaneous Drainage

17. Laproscopic Necrosectomy

18. Pancreatic Abscess
• Percutaneous drainage with the widest possible drains placed under
imaging guidance is the treatment.
• Drains may need to be flushed, repositioned or re-inserted.
• Appropriate antibiotics and supportive care.

19. Pseudocyst
• Collection of amylase-rich fluid enclosed in a well-defined wall of
fibrous or granulation tissue.
• Requires 4 weeks or more from the onset of acute pancreatitis.
• Most of the times resolves spontaneously.
• Therapeutic interventions are advised only if the pseudocyst becomes
symptomatic.

20. Intervention
Three approaches of surgical drainage of pseudocyst;
• Percutaneous.
• Endoscopic.
• Surgical.

21. Percutaneous Drainage
• Continuous drainage until output <50ml/day & decreased amylase
activity
• High rate of recurrence
• Can lead to infected pseudocyst
• High risk of formation of pancreaticocutaneous fistula.

22. Endoscopic Drainage
Transenteric Drainage;
• Cystogastostomy
• Cystoduodenostomy
Transpapillary Drainage;
• ERCP with sphincterotomy, balloon dilatation of pancreatic strictures,
and stent placement beyond strictures

23. Surgical Drainage
Excision
External drainage
Internal drainage;
• Cystogastrostomy
• Cystojejunostomy(High rate of resolution)
• Cystoduodenostomy

24. External Drainage

25. Cystogastrostomy

26. Cystogastrostomy

27. Cystojejunostomy

28. Cystoduodenostomy

29. Preferred Intervention
• Surgical drainage is the traditional approach – gold standard
• Percutaneous drainage – high chance of persistent pancreatic fistula
• Endoscopic drainage – less invasive, technically demanding