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General Surgery
Complications of Acute Pancreatitis (Including Pseudocysts)
Built from Maingot's Abdominal Operations
What’s inside
17 sections · 171 slides
Overview
- What this deck covers
- <10%
- Why outcomes have improved
Grading severity
Four categories built from local and systemic complications
- Four categories for the severity of acute pancreatitis
- The four severity categories
- Reading the severity grid
Naming the collections
Why the old Atlanta words were replaced
- From the Atlanta terms to the current names
- Contents decide the other half
- Two extra questions about any collection
Acute fluid collections
The earliest and commonest local complication
- What an acute fluid collection is
- Routes the fluid tracks along
- Diagnosis and timing
- Acute fluid collection and its appearance one month later
- The same collection two years on, as a mature pseudocyst
- Management of an acute fluid collection
- When the main pancreatic duct is torn
- Pleural effusions and pancreatic fistula
Postnecrotic collections and walled off necrosis
When the collection contains dead tissue
- What a postnecrotic collection is
- Diagnosis of a postnecrotic collection
- Gas within infected pancreatic necrosis on axial CT
- The same infected necrosis on coronal CT
- Why the word abscess was abandoned
Pseudocysts
A walled collection of pancreatic juice with no dead tissue inside
- Definition of a pancreatic pseudocyst
- Pseudocyst versus cystic neoplasm
- How a pseudocyst forms, and what is in it
- Pseudocysts after trauma and in chronic pancreatitis
- The D'Egidio classification
- D'Egidio types and their primary treatment options
- Duct anatomy drives the choice
Complications of a pseudocyst
Infection, rupture, bleeding, and pressure on neighbours
- Four things a pseudocyst can do
- How often complications happen, and infection
- Rupture and internal fistula
- Why pseudocysts bleed
- Pseudoaneurysm arising from the splenic artery
- Angiogram of a left gastric artery pseudoaneurysm before and after embolisation
- Treating a bleeding pseudocyst
- Mass effect from a large pseudocyst
Diagnosing a pseudocyst
Suspicion, then the right scan, then the duct
- When to suspect a pseudocyst
- CT scanning for a pseudocyst
- Ultrasound, endoscopic ultrasound, and MRI
- The role of ERCP and MRCP
- Recognising a complication clinically
- Not missing a cystic tumour
- Algorithm for investigating and treating a pancreatic pseudocyst
Treating a pseudocyst
When to wait, and which drainage to choose
- Natural history
- Indications for treatment
- The shift towards waiting
- Two rules that must not be broken
- Treatment approaches for pancreatic pseudocyst
- Features that steer the choice of treatment
- Open surgical treatment: the principle
- Cystogastrostomy: the operation
- Opening the pseudocyst through the back wall of the stomach
- Closing the anterior gastrotomy after cystogastrostomy
- Roux-en-Y cystojejunostomy
- Draining a pseudocyst into a Roux-en-Y limb of jejunum
- Resection and external drainage
- Percutaneous radiological drainage
- Percutaneous transgastric drainage
- Percutaneous transgastric drainage of a pseudocyst on CT
- Double Malecot stent cystogastrostomy on plain radiograph
- 14,914
- Endoscopic treatment: through the papilla
- Endoscopic treatment: through the stomach wall
- How well endoscopic drainage works
- Laparoscopic and track-based options
- Choosing treatment by D'Egidio type
Pancreatic necrosis
Dead pancreatic and peripancreatic tissue, and what follows it
- What pancreatic necrosis means
- ~20%
- Infection risk climbs with time
- <=1%
- How early necrosis declares itself
- How the pancreas destroys itself
- Two phases of severe acute pancreatitis
- What the gland looks like
- How dead patches resolve, by size
- Timetable of the wall around a large necrotic area
Infection of necrosis, and how it is found
Routes, organisms, markers, and the aspiration needle
- Five routes bacteria reach pancreatic necrosis
- Which organisms are found, and when
- No sign is specific for necrosis
- Scoring systems and their limits
- Measuring how much gland is dead
- Alternatives to contrast CT
- C-reactive protein as the working marker
- Other markers, and why CRP survives
- Prophylactic antibiotics
- Suspecting infected necrosis
- Fine-needle aspiration
- Why FNA is now debated
- Algorithm for the management of infected necrosis
Intervening on necrosis
Who needs it, when, and by which route
- Indications for intervention
- Sterile necrosis: a much shorter list
- Why early surgery was abandoned
- Why later is better
- Two philosophies of repeat surgery
- Step-up versus step-down
- Step-up approach in practice
- What the PANTER trial showed
- Describing an intervention: how you see it
- Describing an intervention: route and purpose
- Open and minimally invasive approaches to pancreatic necrosis
- General principles at operation
- Avoiding catastrophic bleeding
- Drains and feeding after necrosectomy
Open necrosectomy
Three ways to provide an exit for infected debris
- Three open approaches
- Getting to the pancreas
- Necrosectomy through the lesser sac
- Necrosectomy through the transverse mesocolon
- Open necrosectomy with closed packing
- Open necrosectomy with open packing
- Continuous closed postoperative lavage
- Programmed open necrosectomy
Minimally invasive and radiological necrosectomy
Scopes, sheaths, and catheters instead of a laparotomy
- From open surgery to keyhole surgery
- Laparoscopic routes
- Video-assisted retroperitoneal debridement
- Percutaneous necrosectomy with a nephroscope
- Operating through the flank tract
- Flexible endoscopic necrosectomy
- Endoscopy through a skin incision
- The PENGUIN trial
- Radiological drainage: why it matters
- Catheter routes, sizes, and lavage
- What percutaneous drainage achieves
- ~25%
Regional complications
Veins, arteries, and the bowel next door
- Venous thrombosis: why it happens
- Splenic, portal, and mesenteric vein thrombosis
- Treating venous thrombosis
- Arterial bleeding: which vessels
- How arterial bleeding presents
- Treating arterial bleeding
- When bleeding needs a laparotomy
- Ileus, intestinal ischaemia, and obstruction
- Cholestasis
Systemic complications
Whole-body inflammation and failing organs
- Systemic inflammatory response syndrome
- What drives SIRS
- From inflammation to organ failure
- Organ failure on admission
- Multiple organ dysfunction syndrome
- Change in APACHE II over the first 48 hours and predicted mortality
- Predicting organ failure
- The scoring systems, and their limits
- Respiratory complications
- Acute respiratory distress syndrome
- Renal complications
- Cardiovascular complications
- Supporting the circulation
- Calcium and glucose
- Other metabolic complications
- Nutrition and body protein
- Pancreatic encephalopathy
Summary
What to carry away, and the sources behind it
- Take-home points: the collections
- Take-home points: necrosis
- Take-home points: the whole patient
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- Maingot's Abdominal Operations, 12th Edition