SURGICAL MANAGEMENT OF ACUTE PANCREATITIS

Dr. Prashant

Indications for surgical management

1. Diagnostic uncertainty

2. Non pancreatic causes like perforated viscus

3. Infected necrosis

4. Severe sterile necrosis

5. Symptomatic organized pancreatic necrosis

Infected pancreatic necrosis

• Fever and leucocytosis inconclusive

• FNA

• CT – emphysematous or gas in parenchyma

• Suspected in severe pancreatitis, organ failure or do not improve in first 2 weeks clinically.

• 100% mortality if not treated

Severe Sterile Pancreatic Necrosis

• Ranson score of 5 or 6.

• More than 50% necrosis on CT.

• Challenged by Bradley and Allen in 1991.

• Current dictum is conserve all sterile pancreatic necrosum as far as possible unless infection is stablished or patient detoriates.

Organized pancreatic necrosis

• According to Baron it is the pathological correlate of Warshaw’s “persistent unwellness”.

• There is good demarcation between necrosedand healthy parenchyma.

• As per Fernanadez del Castillo optimal timing is not later than 4 weeks.

Surgical procedures

• For etiology:

1. Cholecystectomy

2. ERCP

3. CBD exploration

4. Longitudnal pancreaticojejunostomy(Frey’s procedure and Puestow’s procedure)

For complications:

1. Pancreatic resection

2. Pancreatic debridement

3. Drainage of pancreatic abscess

4. Cystogastrostomy or cystoduodenostomy or Roux en Y cystojejunostomy

Cholecystectomy

• For gall stone pancreatitis.

• Defer till acute pancreatic inflammation resolve.

• If pre op ERCP is not done then during cholecystecomy intra op cholangio gram and CBD exploration.

Endoscopic retrograde Cholangiopancreatogram

• For diagnosing choledocholithiasis.

• Simultaneous CBD clearance with or witoutpapillotomy can be done.

Pancreatico jejunostomy

• Is a pancreatic drainge procedure done in chronic pancreatitis for stricture dilated tortous duct.

• If done by lateral opening of pancreatic body and head known as Puestow’s procedure.

• If done by coring of head -Frey’s procedure

Puestow’s procedure

Frey’s procedure

Resection

• Historical importance

• Principle: Remaining pancreatic tissue source of inflammation

• Mortality 60%

Pancreatic debridement (necrosectomy)

Principle:

1. Wide removal of devitalized and necrotic tissue with through exploration and unroofing of all collections.

2. Assurance of post operative removal of products of ongoing local inflammation and infection.

Types

Open:

1. Debridement with closure over drains.

2. Debridement with closure over packing.

3. Debridement with closure over irrigation drains and postoperative lavage.

Minimally invasive:

1. Laparoscopic/gastroscopic/nephroscopic necrosectomy

2. Radiology guided necrosectomy

Approaches

• Gastrocolic:

1. Tissue planes obscured by inflammation.

2. Drain cannot be placed in depth.

• Transmesocolic :

1. Middle colic obscures the path

2. Way to whole of abdomen is opened for inflammation to spread.