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General Surgery
Management of Acute Pancreatitis
Built from Maingot's Abdominal Operations
What’s inside
11 sections · 154 slides
Overview
- Scope of the topic
- 185,000
- Mild versus severe disease
- How this topic is organised
Causes and mechanism
What starts the attack, and how a local injury becomes a whole-body illness
- Intra-acinar activation of trypsinogen
- Ischaemia-reperfusion injury and inflammatory mediators
- From gland injury to systemic illness
- The two dominant causes
- Alcohol as a cause
- Procedure-related and drug-related causes
- Idiopathic acute pancreatitis
- Groups of causes
- Etiologic factors in acute pancreatitis
Diagnosis and severity
Recognising the attack, then deciding early who is going to be seriously ill
- Clinical presentation
- Cullen's and Grey-Turner's signs
- Serum amylase and lipase
- Enzyme levels do not grade severity
- Rationale for early severity assessment
- Ranson and Glasgow scoring systems
- The Ranson score: early prognostic signs
- Limitations of the Ranson and Glasgow scores
- The APACHE II score
- Variables measured in APACHE II
- APACHE III and the APACHE-O modification
- Haemoconcentration and C-reactive protein
- Cytokine and inflammatory markers
- Trypsinogen activation peptide
- Organ failure as the leading prognostic indicator
Computed tomography
The scan that shows dead pancreas, and the needle that shows whether it is infected
- Computed tomography findings in acute pancreatitis
- Peripancreatic fluid collection without necrosis
- Contrast enhancement and pancreatic necrosis
- Absent pancreatic enhancement in necrotising pancreatitis
- Radiological criteria for necrosis
- Timing of the first scan
- Practical scanning policy
- Distinguishing infected from sterile necrosis
- Gas within the pancreas on computed tomography
- CT-guided fine-needle aspiration
- Accuracy of needle aspiration for infection
- Needle sampling of necrotic pancreas under CT guidance
- What the aspiration result means
- Time course of pancreatic infection
- Need for repeat aspiration
Classification
Agreed definitions so that clinicians and studies mean the same thing
- The Atlanta classification
- Definitions from the Atlanta symposium
- Key defined terms
- Shortcomings and revision of the classification
Nonoperative management
Fluids, monitoring, feeding, and the place of endoscopy
- Aggressive fluid resuscitation
- Monitoring and supportive care
- Use of nasogastric tubes
- The historical concept of pancreatic rest
- Metabolic consequences of starvation in severe illness
- Advantages of enteral nutrition
- Randomised trials of enteral versus parenteral feeding
- Further trial evidence on enteral feeding
- Enteral versus parenteral nutrition: where the evidence stands
- Practical approach to feeding
- Nasogastric versus nasojejunal feeding
- Indications for ERCP in acute pancreatitis
- Randomised trials of early ERCP
- Current recommendation on ERCP
- Magnetic resonance cholangiopancreatography
Prophylactic antibiotics
A management principle that has reversed direction twice
- Infection as the cause of death in severe disease
- Microbiology of infected necrosis
- Rationale and risks of prophylaxis
- Antibiotic penetration into the pancreas
- Early randomised trials of prophylaxis
- Conflicting early evidence
- The Isenmann trial and the meta-analyses
- The consensus of the previous decade
- Fungal superinfection
- Evidence that reversed the consensus
- Current position on prophylactic antibiotics
- Selective gut decontamination
Indications for surgery
Infected necrosis, sterile necrosis, and organised necrosis: three different arguments
- Surgery in mild acute pancreatitis
- Urgent surgery for reasons unrelated to pancreatitis
- Three indications in necrotising pancreatitis
- Indications for surgical intervention in necrotising pancreatitis
- Infected pancreatic necrosis
- Historical approach to sterile necrosis
- Criteria that failed to select patients for surgery
- Two large series supporting conservative management
- Patients who never needed intervention
- Management strategy used in a necrotising pancreatitis series
- Proposed markers of who might benefit from debridement
- Organ failure and mortality
- Timing of debridement and perioperative mortality
- Settings in which sterile necrosis may be debrided
- Organised pancreatic necrosis and persistent unwellness
- Outcomes of delayed debridement
- How long to wait
- Management algorithm for acute pancreatitis
- Sequence of care in severe disease
Operative techniques
Reaching the pancreatic bed, removing dead tissue, and managing what is left behind
- Surgery directed at the cause
- Pancreatic resection is of historical interest
- Two principles of pancreatic debridement
- Three postdebridement strategies
- Why comparison between techniques is difficult
- Preoperative imaging and incision
- Operative approaches to open pancreatic debridement
- Routes into the lesser sac
- Transmesocolic approach to the lesser sac
- Approach to the lesser sac via the gastrocolic ligament
- Technique of blunt debridement
- Control of haemorrhage during debridement
- Extending the exploration
- Debridement and closed drainage
- Irrigation and drainage of the pancreatic bed
- Postoperative drain management
- Outcomes after debridement and closed drainage
- Rationale for open packing
- Technique of open packing
- Dressing and packing the cavity
- Wound handling and repeat exploration
- Debridement with continuous closed postoperative lavage
- Conduct and results of continuous lavage
- Claimed advantages of continuous lavage
- Published series of pancreatic debridement: closed packing and open drainage
- Published series of pancreatic debridement: open drainage and closed lavage
- What the collected series show
- The argument over recurrent sepsis
- Complications of open packing
- How delayed surgery changes the choice of technique
- Outcomes of delayed debridement with closed drainage
Minimally invasive approaches
Percutaneous, endoscopic and retroperitoneal routes to the necrotic pancreas
- Rationale for minimally invasive techniques
- Percutaneous catheter drainage
- Limits of percutaneous drainage
- Internal drainage and endoscopic transmural drainage
- Results and limits of endoscopic drainage
- Retroperitoneal endoscopy via transgastric fenestration
- Video-assisted retroperitoneal debridement
- Percutaneous necrosectomy and sinus tract endoscopy
- Conduct and early results of sinus tract endoscopy
- Standing of minimally invasive techniques
Summary
What has changed, and what has not
- Advances in the management of severe disease
- The settled and unsettled questions
- Points to carry away
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- Maingot's Abdominal Operations, 12th Edition