acute pancreatitis · for the most of the deaths of acute pancreatitis patients. • unresolved...

T.KIRAN KUMAR

IInd YEAR PG

SURGICAL MANAGEMENT OF ACUTE PANCREATITIS

INTRODUCTION

• A very common disease with increasing incidence over past

20 years.

• All age groups and both genders vulnerable.

• Multiple causes.

• Highly variable disease course.

• High mortality rates even in the centers of excellence .

• Difficult to standardize the treatment options.

3

SURGICAL INTERVENTION-INDICATIONS

ABSLOUTE INDICATION ABSLOUTE INDICATION ABSLOUTE INDICATION ABSLOUTE INDICATION INFECTED PANCREATIC NECROSISINFECTED PANCREATIC NECROSISINFECTED PANCREATIC NECROSISINFECTED PANCREATIC NECROSIS

OBLIGATORY INDICATIONOBLIGATORY INDICATIONOBLIGATORY INDICATIONOBLIGATORY INDICATION PERFORATED VISCUS HAEMORRHAGEPERFORATED VISCUS HAEMORRHAGEPERFORATED VISCUS HAEMORRHAGEPERFORATED VISCUS HAEMORRHAGE

DEBATED INDICATIONDEBATED INDICATIONDEBATED INDICATIONDEBATED INDICATION SEVERE STERILE NECROSISSEVERE STERILE NECROSISSEVERE STERILE NECROSISSEVERE STERILE NECROSISSYMPTOMATIC ORGANIZED NECROSISSYMPTOMATIC ORGANIZED NECROSISSYMPTOMATIC ORGANIZED NECROSISSYMPTOMATIC ORGANIZED NECROSIS

OBSELETE INDICATIONOBSELETE INDICATIONOBSELETE INDICATIONOBSELETE INDICATION DIAGNOSTIC UNCERTAINITYDIAGNOSTIC UNCERTAINITYDIAGNOSTIC UNCERTAINITYDIAGNOSTIC UNCERTAINITY

Management - Overview

Acute pancreatitisAcute pancreatitisAcute pancreatitisAcute pancreatitisMildMildMildMild SevereSevereSevereSevere

Symptomatic Symptomatic Symptomatic Symptomatic treatmenttreatmenttreatmenttreatment

ICU admissionICU admissionICU admissionICU admissionSupportive treatmentSupportive treatmentSupportive treatmentSupportive treatment

Ct abdomen>72hrsCt abdomen>72hrsCt abdomen>72hrsCt abdomen>72hrsimprovmentimprovmentimprovmentimprovment

Plan dischargePlan dischargePlan dischargePlan discharge

FNA if no improvement for FNA if no improvement for FNA if no improvement for FNA if no improvement for 2 weeks2 weeks2 weeks2 weeksNo infectionNo infectionNo infectionNo infection

improvementimprovementimprovementimprovement No improvementNo improvementNo improvementNo improvement

infectedinfectedinfectedinfected

Surgical Surgical Surgical Surgical interventioninterventioninterventionintervention

Continue Continue Continue Continue supportive supportive supportive supportive treatment treatment treatment treatment

Surgical interventions

PANCREATIC RESECTIONS - PANCREATIC RESECTIONS - PANCREATIC RESECTIONS - PANCREATIC RESECTIONS - HISTORICALHISTORICALHISTORICALHISTORICAL

PANCREATIC NECROSECTOMY PANCREATIC NECROSECTOMY PANCREATIC NECROSECTOMY PANCREATIC NECROSECTOMY ––––�DEBRIDEMENT OF NECROTIC PANCREATIC TISSUEDEBRIDEMENT OF NECROTIC PANCREATIC TISSUEDEBRIDEMENT OF NECROTIC PANCREATIC TISSUEDEBRIDEMENT OF NECROTIC PANCREATIC TISSUE�CURRENT STANDARD OF PRACTICECURRENT STANDARD OF PRACTICECURRENT STANDARD OF PRACTICECURRENT STANDARD OF PRACTICE

MINIMAL INVASIVE INTERVENTIONSMINIMAL INVASIVE INTERVENTIONSMINIMAL INVASIVE INTERVENTIONSMINIMAL INVASIVE INTERVENTIONS ––––�CURRENT INTEREST OF RESEARCHCURRENT INTEREST OF RESEARCHCURRENT INTEREST OF RESEARCHCURRENT INTEREST OF RESEARCH�RAPIDLY BEING ACCEPTED IN PRACTICE RAPIDLY BEING ACCEPTED IN PRACTICE RAPIDLY BEING ACCEPTED IN PRACTICE RAPIDLY BEING ACCEPTED IN PRACTICE

Necrosectomy – Principles

GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS ESSENTIAL FOR IDENTIFICATION OF ESSENTIAL FOR IDENTIFICATION OF ESSENTIAL FOR IDENTIFICATION OF ESSENTIAL FOR IDENTIFICATION OF ––––�ALL AREAS OF NECROSISALL AREAS OF NECROSISALL AREAS OF NECROSISALL AREAS OF NECROSIS�LOCALIZED COLLECTIONSLOCALIZED COLLECTIONSLOCALIZED COLLECTIONSLOCALIZED COLLECTIONS�

WIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUEWIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUEWIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUEWIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUE

UNROOFING OF ALL COLLECTIONSUNROOFING OF ALL COLLECTIONSUNROOFING OF ALL COLLECTIONSUNROOFING OF ALL COLLECTIONS

STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION AND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMYAND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMYAND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMYAND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMY

Necrosectomy -Approach

MIDLINE INCISIONMIDLINE INCISIONMIDLINE INCISIONMIDLINE INCISION

BILATERAL SUBCOSTAL BILATERAL SUBCOSTAL BILATERAL SUBCOSTAL BILATERAL SUBCOSTAL INCISIONINCISIONINCISIONINCISION PANCREAS & PANCREAS & PANCREAS & PANCREAS &

LESSER SACLESSER SACLESSER SACLESSER SAC

THROUGH THROUGH THROUGH THROUGH GASTROCOLIC GASTROCOLIC GASTROCOLIC GASTROCOLIC

LIGAMENTLIGAMENTLIGAMENTLIGAMENT

THROUGH THROUGH THROUGH THROUGH TRANSVERSE - TRANSVERSE - TRANSVERSE - TRANSVERSE - MESOCOLONMESOCOLONMESOCOLONMESOCOLON

8

The lesser sac can be approached through the base of the mesocolon; attention

should be paid to avoid injury to the middle colic artery.

Approach to lesser sac via gastrocolic ligament.

Necrosectomy- technique • IDENTIFICATON OF VIABLE AND

NECROTIC PANCREATIC TISSUE

• BLUNT FINGER DISSECTION OF THE

NECROTIC TISSUE

• AVOID OVERZELOUS HANDLING OF

INFLAMED & DOUBTFUL VIABLE

TISSUE

• CONTROL OF BLEEDING

• ADDITIONAL EXPOSURE

� RELEASE OF SPLENIC/HEPATIC RELEASE OF SPLENIC/HEPATIC RELEASE OF SPLENIC/HEPATIC RELEASE OF SPLENIC/HEPATIC FLEXURES FLEXURES FLEXURES FLEXURES� EXTENSIVE KOCHERIZATION EXTENSIVE KOCHERIZATION EXTENSIVE KOCHERIZATION EXTENSIVE KOCHERIZATION� OPENENING OF PARACOLIC GUTTERS, OPENENING OF PARACOLIC GUTTERS, OPENENING OF PARACOLIC GUTTERS, OPENENING OF PARACOLIC GUTTERS, PARARENAL SPACES AND PARARENAL SPACES AND PARARENAL SPACES AND PARARENAL SPACES AND GASTROHEPATIC LIGAMENT GASTROHEPATIC LIGAMENT GASTROHEPATIC LIGAMENT GASTROHEPATIC LIGAMENT

Post-Necrosectomy management

OPTIONSOPTIONSOPTIONSOPTIONS

CLOSED DRAINAGE CLOSED DRAINAGE CLOSED DRAINAGE CLOSED DRAINAGE PLANNED PLANNED PLANNED PLANNED

REXPLORATIONSREXPLORATIONSREXPLORATIONSREXPLORATIONSCLOSED LAVAGECLOSED LAVAGECLOSED LAVAGECLOSED LAVAGE

MULTIPLE DRAINS IN THE MULTIPLE DRAINS IN THE MULTIPLE DRAINS IN THE MULTIPLE DRAINS IN THE LESSER SACLESSER SACLESSER SACLESSER SAC

RETAINED TILL OUTPUT RETAINED TILL OUTPUT RETAINED TILL OUTPUT RETAINED TILL OUTPUT IS INSIGNIFICANTIS INSIGNIFICANTIS INSIGNIFICANTIS INSIGNIFICANT

LAPAROSTOMY/ LAPAROSTOMY/ LAPAROSTOMY/ LAPAROSTOMY/ TEMPORARY ABDOMINAL TEMPORARY ABDOMINAL TEMPORARY ABDOMINAL TEMPORARY ABDOMINAL

CLOSURE CLOSURE CLOSURE CLOSURE

RE-EXPLORATION ONCE IN RE-EXPLORATION ONCE IN RE-EXPLORATION ONCE IN RE-EXPLORATION ONCE IN 2-3 DAYS TILL ALL 2-3 DAYS TILL ALL 2-3 DAYS TILL ALL 2-3 DAYS TILL ALL

NECROTIC MATERIAL NECROTIC MATERIAL NECROTIC MATERIAL NECROTIC MATERIAL CLEARSCLEARSCLEARSCLEARS

DRAINS PLACED IN LESSER DRAINS PLACED IN LESSER DRAINS PLACED IN LESSER DRAINS PLACED IN LESSER SACSACSACSAC

CONTINOUS CONTINOUS CONTINOUS CONTINOUS POSTOPERATIVE LAVAGE POSTOPERATIVE LAVAGE POSTOPERATIVE LAVAGE POSTOPERATIVE LAVAGE

TILL EFLUENT IS CLEARTILL EFLUENT IS CLEARTILL EFLUENT IS CLEARTILL EFLUENT IS CLEAR

Necrosectomy and closed packing with stuffed Penrose drains.

closed lavage of the lesser sac.

The lesser sac is closed by suturing the greater omentum to the transverse colon for closed postoperative lavage.

Comparison of options

STUDIES BETWEEN 1980-1998

NO. OF PATIENTSn

MORALITY RE-EXPLORATION

GI FISTULA BLEEDING

CLOSED CLOSED CLOSED CLOSED DRAINAGEDRAINAGEDRAINAGEDRAINAGE

236236236236 6-30%6-30%6-30%6-30% 16-40%16-40%16-40%16-40% 3-26%3-26%3-26%3-26% 1-30%1-30%1-30%1-30%

PLANNED PLANNED PLANNED PLANNED RE-RE-RE-RE-EXPLORATIOEXPLORATIOEXPLORATIOEXPLORATIONNNN

297297297297 14-27%14-27%14-27%14-27% 100%100%100%100% 5-40%5-40%5-40%5-40% 5-29%5-29%5-29%5-29%

CLOSEDCLOSEDCLOSEDCLOSED LAVAGELAVAGELAVAGELAVAGE

405405405405 8-36%8-36%8-36%8-36% 9-64%9-64%9-64%9-64% 7-43%7-43%7-43%7-43% 5-13%5-13%5-13%5-13%

MaingotMaingotMaingotMaingot’’’’ssss Abdominal operations -11 Abdominal operations -11 Abdominal operations -11 Abdominal operations -11thththth edition edition edition edition

Recommendations

LACK OF STANDARD DEFINITIONS OF THE LACK OF STANDARD DEFINITIONS OF THE LACK OF STANDARD DEFINITIONS OF THE LACK OF STANDARD DEFINITIONS OF THE CONDITIONS FOR WHICH EACH OF THESE CONDITIONS FOR WHICH EACH OF THESE CONDITIONS FOR WHICH EACH OF THESE CONDITIONS FOR WHICH EACH OF THESE OPTIONS WERE UTILIZEDOPTIONS WERE UTILIZEDOPTIONS WERE UTILIZEDOPTIONS WERE UTILIZED

THE OPTIONS HAVE NOT BEEN COMPARED THE OPTIONS HAVE NOT BEEN COMPARED THE OPTIONS HAVE NOT BEEN COMPARED THE OPTIONS HAVE NOT BEEN COMPARED ADEQUATELY BY RANDOMIZED PROSPECTIVE ADEQUATELY BY RANDOMIZED PROSPECTIVE ADEQUATELY BY RANDOMIZED PROSPECTIVE ADEQUATELY BY RANDOMIZED PROSPECTIVE STUDIESSTUDIESSTUDIESSTUDIES

OPTIONS INDVIDUALIZED OPTIONS INDVIDUALIZED OPTIONS INDVIDUALIZED OPTIONS INDVIDUALIZED TO THE PATIENTTO THE PATIENTTO THE PATIENTTO THE PATIENT

EARLY NECROSECTOMY -EARLY NECROSECTOMY -EARLY NECROSECTOMY -EARLY NECROSECTOMY -PLANNED RE-EXPLORATION/PLANNED RE-EXPLORATION/PLANNED RE-EXPLORATION/PLANNED RE-EXPLORATION/

CLOSED LAVAGECLOSED LAVAGECLOSED LAVAGECLOSED LAVAGE

DELAYED NECROSECTOMY DELAYED NECROSECTOMY DELAYED NECROSECTOMY DELAYED NECROSECTOMY ––––

CLOSED DRAINAGECLOSED DRAINAGECLOSED DRAINAGECLOSED DRAINAGE

Minimal Access Interventions

TIMING OF SURGERY

MORTALITY

<14 DAYS<14 DAYS<14 DAYS<14 DAYS 75%75%75%75%

15-29DAYS15-29DAYS15-29DAYS15-29DAYS 45%45%45%45%

>30DAYS>30DAYS>30DAYS>30DAYS 8%8%8%8%

WHY MINIMAL ACCESS ?WHY MINIMAL ACCESS ?WHY MINIMAL ACCESS ?WHY MINIMAL ACCESS ?

TO REDUCE THE TO REDUCE THE TO REDUCE THE TO REDUCE THE ACCESS TRAUMA AND ACCESS TRAUMA AND ACCESS TRAUMA AND ACCESS TRAUMA AND

ASSOCIATED ASSOCIATED ASSOCIATED ASSOCIATED PROINFLAMMATORY PROINFLAMMATORY PROINFLAMMATORY PROINFLAMMATORY

RESPONSE WITH RESPONSE WITH RESPONSE WITH RESPONSE WITH OPEN NECROSECTOMYOPEN NECROSECTOMYOPEN NECROSECTOMYOPEN NECROSECTOMY

TO DELAY TO DELAY TO DELAY TO DELAY NECROSECTOMY AS NECROSECTOMY AS NECROSECTOMY AS NECROSECTOMY AS MUCH AS POSSIBLEMUCH AS POSSIBLEMUCH AS POSSIBLEMUCH AS POSSIBLE

Arch Arch Arch Arch SurgSurgSurgSurg 142: 142: 142: 142:1194-1201,20071194-1201,20071194-1201,20071194-1201,2007


INTERVENTIONSINTERVENTIONSINTERVENTIONSINTERVENTIONS

ROUTES USEDROUTES USEDROUTES USEDROUTES USED INSTRUMENTATIONINSTRUMENTATIONINSTRUMENTATIONINSTRUMENTATION

PERCUTANEOUSPERCUTANEOUSPERCUTANEOUSPERCUTANEOUSTRANSGASTRICTRANSGASTRICTRANSGASTRICTRANSGASTRICPERITONEUMPERITONEUMPERITONEUMPERITONEUM

RETROPERITONEUM RETROPERITONEUM RETROPERITONEUM RETROPERITONEUM

RADIOLOGICAL GUIDANCERADIOLOGICAL GUIDANCERADIOLOGICAL GUIDANCERADIOLOGICAL GUIDANCEENDOSCOPYENDOSCOPYENDOSCOPYENDOSCOPY

LAPAROSCOPYLAPAROSCOPYLAPAROSCOPYLAPAROSCOPYOPERATING NEPHROSCOPEOPERATING NEPHROSCOPEOPERATING NEPHROSCOPEOPERATING NEPHROSCOPE

ENDOSCOPIC TRANSGASTRIC ENDOSCOPIC TRANSGASTRIC ENDOSCOPIC TRANSGASTRIC ENDOSCOPIC TRANSGASTRIC NECROSECTOMYNECROSECTOMYNECROSECTOMYNECROSECTOMY



PERCUTANEOUS DRAINAGEPERCUTANEOUS DRAINAGEPERCUTANEOUS DRAINAGEPERCUTANEOUS DRAINAGE


HAND ASSISTED LAPAROSCOPIC HAND ASSISTED LAPAROSCOPIC HAND ASSISTED LAPAROSCOPIC HAND ASSISTED LAPAROSCOPIC NECROSECTOMY PORT POSITIONINGNECROSECTOMY PORT POSITIONINGNECROSECTOMY PORT POSITIONINGNECROSECTOMY PORT POSITIONING

LAPAROSCOPIC NECROSECTOMYLAPAROSCOPIC NECROSECTOMYLAPAROSCOPIC NECROSECTOMYLAPAROSCOPIC NECROSECTOMY

Minimal Access InterventionsRETROPERITONEAL NECROSECTOMYRETROPERITONEAL NECROSECTOMYRETROPERITONEAL NECROSECTOMYRETROPERITONEAL NECROSECTOMY

OPEN TECHNIQUEOPEN TECHNIQUEOPEN TECHNIQUEOPEN TECHNIQUEVIDEO-ASSISTED VIDEO-ASSISTED VIDEO-ASSISTED VIDEO-ASSISTED

TECHNIQUETECHNIQUETECHNIQUETECHNIQUE

Percutaneous necrosectomy using operating nephroscope and supplemental laparoscopic port.

Evidence in favour of minimal invasive approach

Out-come Open -necrosectomy

Step-up approach

P -value

New onset New onset New onset New onset MODSMODSMODSMODS

42%42%42%42% 12%12%12%12% 0.0010.0010.0010.001

DeathDeathDeathDeath 16%16%16%16% 19%19%19%19% 0.70.70.70.7

HospitalHospitalHospitalHospital stay stay stay stay 60 days60 days60 days60 days 50 days50 days50 days50 days 0.530.530.530.53

New New New New ––––onset DMonset DMonset DMonset DM 38%38%38%38% 16%16%16%16% 0.020.020.020.02

PancreaticPancreaticPancreaticPancreatic insufficiencyinsufficiencyinsufficiencyinsufficiency

33%33%33%33% 7%7%7%7% 0.0020.0020.0020.002

Incisional Incisional Incisional Incisional herniaherniaherniahernia

24%24%24%24% 7%7%7%7% 0.030.030.030.03

A multicenter RCT including 88 patients A multicenter RCT including 88 patients A multicenter RCT including 88 patients A multicenter RCT including 88 patients with confirmed or suspected infected with confirmed or suspected infected with confirmed or suspected infected with confirmed or suspected infected

pancreatic necrosispancreatic necrosispancreatic necrosispancreatic necrosis

45 underwent 45 underwent 45 underwent 45 underwent open necrosectomyopen necrosectomyopen necrosectomyopen necrosectomy

43 underwent 43 underwent 43 underwent 43 underwent step-up approachstep-up approachstep-up approachstep-up approach

(initial percutaneous (initial percutaneous (initial percutaneous (initial percutaneous drainage followed by drainage followed by drainage followed by drainage followed by

VARD)VARD)VARD)VARD)

A minimally invasive step-up approach, as A minimally invasive step-up approach, as A minimally invasive step-up approach, as A minimally invasive step-up approach, as compared with open necrosectomy, compared with open necrosectomy, compared with open necrosectomy, compared with open necrosectomy, reduced the rate of the composite end reduced the rate of the composite end reduced the rate of the composite end reduced the rate of the composite end point of major complications or death point of major complications or death point of major complications or death point of major complications or death among patients with necrotizing among patients with necrotizing among patients with necrotizing among patients with necrotizing pancreatitis and infected necrotic tissuepancreatitis and infected necrotic tissuepancreatitis and infected necrotic tissuepancreatitis and infected necrotic tissue.

HjalmarHjalmarHjalmarHjalmar C. van C. van C. van C. van SantvoortSantvoortSantvoortSantvoort etaletaletaletal ““““A Step-up Approach A Step-up Approach A Step-up Approach A Step-up Approach or Open Necrosectomy for Necrotizing Pancreatitisor Open Necrosectomy for Necrotizing Pancreatitisor Open Necrosectomy for Necrotizing Pancreatitisor Open Necrosectomy for Necrotizing Pancreatitis””””N N N N EnglEnglEnglEngl J Med 2010;362:1491-502 J Med 2010;362:1491-502 J Med 2010;362:1491-502 J Med 2010;362:1491-502

To conclude……

• Necrotizing pancreatitis though less common is responsible

for the most of the deaths of acute pancreatitis patients.

• Unresolved issues in the management of this condition.

• Open necrosectomy is still the standard of care but is

associated with high mortality and morbidity.

• Minimal access interventions give some hope.

References –� Sabiston text book of surgery-19th edition

� Maingot’s abdominal surgeries -11th edition

� Hjalmar C. van Santvoort et al “Step-up Approach or Open

Necrosectomy for Necrotizing Pancreatitis.” N Engl J Med

2010;362:1491-502.

� www.google.com-images

acute pancreatitis · for the most of the deaths of acute pancreatitis patients. • unresolved...

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