← All decks
General Surgery
Perspective on Management of Patients with Severe Acute Pancreatitis
Built from Maingot's Abdominal Operations
What’s inside
7 sections · 77 slides
Overview
- What this topic covers
- Terms used in severe acute pancreatitis
Presentation and initial assessment
Who arrives, when they arrive, and what state they are in
- The pancreas and its duct system
- Referral to a high-volume tertiary centre
- Consequences of delayed referral
- Condition of patients on arrival
- Overview of management after transfer
The first 24 to 48 hours
Resuscitate, image properly, and find out whether it is infected
- Admission to intensive care
- Review of outside records and specialist consults
- Repeat imaging on arrival
- What the scan is looking for
- The pancreatic protocol CT
- Why the timing of contrast matters
- Recognising necrosis on CT
- Signs of infection on CT
- Peripancreatic exudate on contrast CT
- Capillary leak and the depleted circulation
- Choice of imaging by kidney function
- Protecting the kidney during contrast CT
- Limits of gadolinium in renal failure
- What a non-contrast scan cannot show
- Why prophylactic antibiotics are avoided
- Antibiotic decisions on transfer
- Indications for antifungal treatment
- Indications for fine-needle aspiration
- Avoiding a drain at the time of aspiration
- Handling of the aspirated fluid
- Action on the aspiration result
- Timing of the first percutaneous drain
- Image-guided placement of a percutaneous drain
- Roles of the percutaneous drain
- Upsizing inadequate drains
- Discussion with the patient and family
Definitive drainage: who and when
Which patients need an operation, and at what point
- Need for definitive surgical drainage
- Timing of the operation
- Indications for earlier surgery
- The late group with sterile walled-off necrosis
- Symptoms in the late group
- Walled-off fluid collection on axial CT
- Large upper-abdominal collection on coronal CT
- Clear fluid versus fluid containing debris
- Preference for open debridement in sterile necrosis
How the operation is done
Access, debridement, drains and the gallbladder
- The two principles of every drainage operation
- Choice between open and laparoscopic access
- Choice of incision
- Closure of the abdominal wall
- Entering the lesser sac
- Finding a safe entry through the mesocolon
- Debridement of necrotic tissue
- Bleeding as a guide to viability
- Choice of suture material
- The three lumens of the Axiom drain
- Placement of the operative drains
- The laparoscopic route
- Gallbladder, bile ducts and pancreas
- Cholecystectomy at the initial operation
- <10%
- Interpretation of the outcome figures
Postoperative management
Washing the cavity, feeding the patient, removing the drains
- Return to intensive care after surgery
- Continuous drain irrigation
- Criteria for reducing the irrigation rate
- Weaning the drains
- Timing of drain exchange
- Keeping drains patent after irrigation stops
- Early enteral feeding
- Nutritional depletion and parenteral support
- Choice of feeding tube
- Risks of surgically placed feeding tubes
Follow-up and the long recovery
Removing drains, handling a fistula, and what to tell the patient
- Outpatient follow-up schedule
- Withdrawing the drains
- Management of a pancreatic fistula
- The overall course of the illness
- Prognosis and the message for families
- Take-home points
- Take-home points on surgery and recovery
- References
- Maingot's Abdominal Operations, 12th Edition