1. Selective gut decontamination with oral and rectal antibiotics can decrease mortality and need for laparotomy in severe acute pancreatitis. 2. Indications for surgery in severe acute pancreatitis include infected necrosis, pancreatic abscess, local complications, bleeding, bowel perforation, and portal vein thrombosis. 3. Several surgical techniques are used to treat infected necrosis including open packing, zipper techniques, and closed lavage methods, but there is no consensus on the best approach.

1. ANTIBIOPROPHYLAXIS
• Selective gut decontamination
• One human clinical study
» Luiten EJT and al Ann Surg 222,57,1995
• 102 patients with severe AP
• Oral colistin,amphoB and norfloxacin plus rectal
enema
• Decrease moratlity 35% vs 22%
• Decrease of laparotomy/pts 0,33 vs 0,08

3. INDICATIONS FOR SURGERY
IN SEVERE AP
• Infected necrosis
• Pancreatic abscess
• Local complications
• Massive bleeding
• Perforation of the bowel
• Portal vein thrombosis
• Sterile necrosis with MOF ???

4. SURGICAL TECHNIQUES
• Conventionnal technique
• Débridement an penrose/sump drainage
• Highest mortality rate ( around 40% )
• More than 35% of the patients need reexploration
• Low threshold for rexploration is imperative

5. SURGICAL TECHNIQUES
• Open and semi-open technique
• Laparotomy then packing with gaze
• Use of syntetic mesh or zipper thereafter
• As needed bedside rexploration under anesthesia
• Healing by secondary intention

6. SURGICAL TECHNIQUES
• Open technique=> the zipper
• suture of a marlex sheet to the abdo. fascia or skin
• a zipper is sewn in the middle of the marlex
• daily manual exploration of the abdomen and lavage

7. SURGICAL TECHNIQUES

8. SURGICAL TECHNIQUES
• Closed technique
• Closing of the abdominal wall
• Intraoperative and postoperative lavage of the lesser
sac and the necrosectomy area
• Continuous lavage by large bore single or double-
lumen catheters

9. SURGICAL TECHNIQUES
» BEGER and al Surg Clinics N A,79;4 1999

10. » BEGER and al Surg Clinics N A,79;4 1999

12. • Retrospective study of 73 consecutives
patients
• The presence of infected vs non-infected
necrosis do not correlate with mortality

13. • retrospective study
• No control group for sterile necrosis
• Surgical indication ?
• Conclusion of the study is not to the good
question

14. • So it does not answer to the question if the
patient has only sterile necrotic pancreatitis
and no other surgical indication
• The better study show that observation is
adequate in almost all patient even with
MOF
» Bradley EL 1991 Am J Surg;161:19-24

15. NUTRITION
• Putting the pancreas to rest…
• traditionnaly NPO and TPN
• Now four prospective studies with enteral
feeding

16. NUTRITION
• Role of the gut in SIRS
• modulation of inflammatory response
• bacteria translocation
• mucosal injury
• downregulation of the acute phase reaction with
enteral feeding

17. NUTRITION
• TEN feasible with jejunostomy on patients
requiring laparotomy for AP
» Kudsk K and al Nutr Clin Pract1990;5:14
• Enteral feeding decrease the acute phase
response in AP compare to TPN
» Windsor ACJ and al Gut 1998;42:431-435

18. NUTRITION
• TEN decrease the risk of infection and the
total number of complications vs TPN
» Kalfarentzos F and al Br Jour Surg 1997;84,1665
• TEN is well tolerated in almost all patients
with severe pancreatitis
» Eatok F and al Br Jour Surg 1998;85,10

19. OCTREOTIDE
• Recent multicenter RCT on octreotide
• Uhl W and al Gut 1999,Jul;45(1):97-104
• 302 pts with severe acute pancreatitis
• Octreotide vs placebo
• No difference in death, MODS,
complications, LOS and surgery

20. OCTREOTIDE
• Recent review article on octreotide
» Uhl W and al Digestion 1999;60 Suppl 2:23-31
• A lot of controversial studies with a small
amount of patients
• No strong evidence of any benefit as
treatment of severe AP

21. LEXIPAFANT
• Systemic complications of acute
pancreatitis are associated with pro-
inflammatory response cytokines
• Platelet-activating factor is one of them
• induced plts aggregation and activation
• increase vascular permeability
• activation of monocyte...

22. LEXIPAFANT
• Two human studies
• Multicenter RCT severe pancreatitis ( 11 cewnters )
• Severe pancreatitis
• Lexipafant vs placebo
• Result
– Decrease in MODS and systemic complications
– Trend in reduce mortality
» Mckay CJ and al Brit Jour Surg 1997,84,1239-1243
• Ongoing multicenter trial

23. Conclusion
• All significant acute pancreatitis should be
evaluated with prognosis scale to assess the
risk of mortality and morbidity and to
determine the patients more likely to benefit
from agressive monitoring and treatment
either with
– clinical scale
– and/or ct-scan

24. Conclusion
• All necrotizing pancreatitis should be
considered for an antibioprophylaxis of 14
days with an appropriate antibiotic.

25. Conclusion
• All severe pancreatitis should have a trial of
enteral feeding with NJT if there is no
contraindications.
• All acute severe pancreatitis should be
considered for a jejunostomy if they have a
laparotomy.

26. Conclusion
• Patients with infected necrosis need
necrosectomy for most of them by
laparotomy.
• The type of surgical approach thereafter is
quite unclear with the actual litterature in
the absence of control trial. The main factor
is the local surgical expertise.

27. Conclusion
• There is no clear indication for surgery in
patient with sterile necrosis.

28. Conclusion
• Patients with severe acute pancreatitis
associated with cholestasis,suspected
cholangitis or progressive jaundice should
be considered for early ERCP to reduce the
local complications and the severity of the
disease

29. Conclusion
• There is no actual clear role for
gabexate,lexipafant and other antiproteinase
in the treatment of acute severe pancreatitis
otherwise than inside a study protocol