Acute pancreatitis- surgical aspect

1. Wondwossen M.
ACUTE
PANCREATITIS
SURGICAL ASPECT

2. Agendas
Diagnosis
CT - scan
Severity Assessment ???
Issue of Antibiotics ???
Issue of Nutrition ???
Necrotizing Pancreatitis
Role of Surgery

3. Etiology80% - Gallstones or Alcohol related
Gallstone pancreatitis
• Female
• Common channel theory
• Ductal hypertension theory
• Sphincter incompetence theory
Alcoholic pancreatitis
• Male, alcoholic
• Direct toxicity
• Sphincter oddi spasm
• Viscosity theory

4. Diagnosis
• Clinical :
Abdominal pain
• Laboratory:
Serum Amylase/Lipase >3x
• Imaging :
proven (US/CT/MRI)
2
out
of
3
Previous
pancreatitis
 Hx of Gallstones
 Alcohol History
 Drugs
 Trauma

5. • Sentinel loop
• colon cut off
Plain
abdominal
X-ray
• Gallstones
• CBD
stones/dilation
• Pancreatic edema
• Ascites
Ultrasound

6. CT-SCAN
• Contrast CTWhat type?
• Diagnostic dilemma
• Failure to improve after 72 hr
• Suspicion of local complications
• Severity scoring Balthazar (CTSI)
• Guided FNAc
Why?
• After 72 hrWhen?
• Contrast allergy / Renal failure
• MRI
If
contraindicated?

9. ERCP
 Most gallstones causing AP pass to the doudenum
Severe gallstone AP or AP with concurrent
cholangitis(persistent stone)
Within 72 hr of admission
Diagnostic / Therapeutic
Sphincterotomy
Reduce infective complications/mortality
EUS
 Repeated idiopathic AP
 Occult Biliary ds--- small stone/sludge
 Exclude malignancy(5% of pancreatic ca. present as
AP)
 Age>40 with prolonged/recurrent attack of AP

10. Severity Assessment
Clinical
• Rebound
tenderness
• Grey
Turner/Culle
n
•
• BMI >30
Laborator
y
• CRP
>100mg/dl
• Hct >50%
• Ranson/Glasc
ow
Radiologi
c
• Balthazar
CT
severity
Index

11. Modified Atlanta
Mild AP (80%)
• No local complication &
No organ failure
Moderate severe AP
• Local complications
with/without transient
organ failure(<48hr)
Severe AP
• Persistent(>48hr) organ
failure with/without local
complication

13. Where to admit patients?
Mild pancreatitis  Wards
 Persistent SIRSICU
Moderate severe
pancreatitisICU
Severe pancreatitisICU

14. Management
Two distinct phases of APEarly phase (<
2wks)
Late phase (>
2wks)
Characterized by
SIRS+/-/organ failure
Severity assessed by
clinical scoring systems
Management – Medical
 Characterized by Local
Cpxn.
 Severity assessed by
Morphological scoring
system(baltazar)
 Management– Medical
+/- Surgery

15. Fluid Resuscitation
Early aggressive fluid resuscitation
• Correction of volume depletion
• Prevent pancreatic necrosis
• Most beneficial over the first 24 hr
Ringer Lactate  Ideal fluid
• (RCT)  after 24hr of resuscitation with RL,
84% reduction in SIRS & significant reduction in
CRP

16.  In severe volume depletion
• 30ml/kg over 30 min followed by
3-5ml/kg/hr for 12-24hr
 Resuscitation Goals
 HR <120/min
 MAP = 65-85mmhg
 Urine output = 0.5ml/kg/hr
 Hct, creatinine, BUN

17. Prophylactic Antibiotic ????
 Rational For:
 Early unblinded trials prevent
infection of sterile necrosis
 Rational Against:
 (Meta analysis ) prophylactic antibiotics Vs
placebo in CT proven necrotizing AP concluded
No statistically significant
oReduction of mortality
oReduction in infection rate of the
pancreatic necrosis

18.  Prospective RCT demonstrated prophylactic
antibiotic use
 3 fold increase in incidence of local & systemic
fungal infection with candidia albicans(from 7%
to 22%)
 Clostridial difficle colitis
 Indications for Antibiotic include
 Infected necrosis confirmed by FNA or CT
 Carbapenems /flouroquinolones
/metronidazole/high dose cephalosporins
 Extrapancreatic infections
 Sterile necrosis >50%
 Antifungal Rx?????????? NOT
RECOMMONDED

19. NUTRITION
 Nil Per Oral : Traditional school of
thought
Rational For: prevent stimulation
of exocrine pancreas
Rational Against:
AP – inflammatory stress
Altered gut mucosal integrity
Increased chance of infection

20. Oral Feeding
May be difficult due to  aggravation of pain with
intake
 nausea & Recurrent
vomiting
 ileus causing distention
 In mild pancreatitis can be started
immediately if
 No nausea & vomiting
 Abdominal pain has resolved
 Low fat diet is recommended

21. Total Parentral Nutrition
Rational For:
Maintenance of proper nutrition avoiding GI
cpxn.
Rational Against:
Increased chance of altered gut mucosal
integrity
Portal of infection introduction
High Cost
Nasogastric Vs Nasojejunal Feeding

22.  Severe pancreatitis ENTERAL nutrition
whenever tolerable
 Nasogastric Vs Nasojejunal
 TPN only if not tolerated /fail to met the
metabolic demand of the patient
 Meta analysis study (Enteral Vs TPN)
 Reduced mortality
 Reduced MOF
 Reduced operations
 Reduced local septic complications

23. Necrotizing Pancreatitis
 Progression to necrosis- 20 -30% of patients
with SAP
International Symposium on Acute
Pancreatitis
 Presence of one/more diffuse/focal areas of non
viable parenchyma, usually associated with
peripancreatic fat necrosis
Diffuse/focal area of non viable pancreatic
parenchyma >3cm / >30%
 The Acute pancreatitis classification working
group

24.  Can be Sterile or Infected
Sterile necrosis
 Early operative intervention even with MOF
obsolete b/c of No mortality benefit rather
may increase morbidity
 Rare indications
• Failure to improve after 4-6wks of non
operative mgt
• Worsening organ failure despite maximal
support
• Inability to tolerate enteral nutrition
• Worsening jaundice, fever

25. • Deterioration/fail to improve after 7-10dy of hospitalization
• CT guided FNAc for gram stain and culture
• Gas on CT-scan
• CT guided FNAc for gram stain and culture
• Empiric antibiotic Rx
Infected Necrosis
• Necrotic tissue will be well demarcated
• Necrosis will be walled off
• Less bleeding
Stable patients surgery should be delayed for >
4wks
Unstable patients  urgent
intervention

26. Role Of Surgery
Designed to ameliorate the emergent problems
associated with ongoing inflammatory state
Designed to ameliorate chronic sequele
Designed to prevent a subsequent episode of acute
pancreatitis

27. necrosis
 “Everything should be made as simple as
possible but not simpler.” Albert Einstein
 Pancreatic debridement should be as
minimally invasive as possible but not more
so.
 Step up approach
Percutaneous/endoscopic drainage
Minimally invasive retroperitoneal
necrostomy
Open Necrostomy

28. • Death/Major complication 69%
vs 40%
• New onset MOF 40% vs 12%
• Incisional hernia 24% vs 7%
• New onset diabetes 38% vs
16%
(RCT)
Open
Necrostomy
Vs
Step up
approach

29. Minimally invasive surgery
approach
 Semi open technique /VIDEOSCOPIC
 Gaining popularity
 Minimize operative trauma
 Avoidance of bacterial contamination
 Decreased incidence of incisional hernia
 Limitations
 Poor surgical exposure
 Difficulty of removing solid necrotic tissue
through small ports
 Need for multiple procedures
 Need for reliance on interventional radiology

30. Open Necrostomy
 Necrostomy & closure
with surgical drains MR-
4-19%
 Necrostomy with open
packing -- MR- 4-18%
 with repeat
laparatomy q48hr
 high risk of
pancreatic fistulas,
bleeding
 Necrostomy & closure
with large bore drains &
 Midline / Bilateral Kocher
 Lesser sac/Transverse
Mesocolon
 Blunt Necrostomy

31. Gallstone
pancreatitis
Problem:
 Recurrence 29-63%
 Index cholecystectomy
for mild pancreatitis
 Interval cholecystectomy
for severe pancreatitis
 If cholecystectomy is
contraindicated b/c of
comorbidities------ERCP
sphicterotomy

32. Pseudocysts
 Pancreatic juice
contained in a fibrous
granulation tissue
 Dx- contrast CT
 Spontaneous
resolution-20%
 Acute intervention
 Symptomatic pts.
 Signs of infection
 Complications
 Suspicion of cystic
 Options of mgt
 Endoscopic drainage
 Percutaneous
drainage
 Open internal drainage
o Cystogastrostomy
o Cystoduodenosto
my
o Roux-en-y
cystojej.
o Distal
pancreatectomy

33. Reference
s
American College of
Gastroenterology Guideline
Clinical Practice Guideline
Uptodate
Maingot’s Abdominal
Surgery, 12th ed.
Shackelford’s surgery of GI
Tract, 7th ed.

34. Thanks