Surg in ac pancreatitis

Surgery in Acute Pancreatitis

Dr SD Sanyal Lt Col Priyaranjan

Cl Spl Surg & GI Surgeon

Algorithm for Mgt of Acute Pancreatitis

Role of surgery• Pancreatic infection = Major risk factor in necrotizing

pancreatitis

• Surgical interventions :- only in selected cases within the first 2 weeks after onset of the disease

• Surgery and minimally invasive interventional procedures are important treatment options in the latter phase of the disease

• Ideal timing : after 04 weeks

Indications for Surgery

• Infected necrosis• Sterile necrosis• Persistent necrotizing pancreatitis• Acute fulminant pancreatitis• Complications:

- Bowel perforation- Bleeding

Rationale for late surgery

• Demarcation of necrosum• Reduced vital tissue loss• Less bleeding

Aims of Surgical Mgt

1. Control the septic focus2. Diminishing complications by:

- Halting the progress of infection- Arrest the release of pro-inflammatory mediators

3. Organ preservation based approach

Standard Techniques

1. Necrosectomy combined with open packing (Bradley,1987)

2. Planned, staged relaparotomies with repeated lavage (Sarr et al, 1991)

3. Closed continuous lavage of the lesser sac and retroperitoneum (Beger et al, 1982, 1988)

4. Closed packing (Fernandez-del Castillo et al, 1998)

Necrosectomy & debridement• Traditionally undertaken by an open route • Longitudinal midline incision • Irrigation of the entire abdomen + diverting ileostomy for pts

with involvement of the retrocolic area Abdominal cavity is opened

Gastrocolic and the Duodenocolic ligaments divided close to the greater curvature of the stomach

Pancreas is exposed

Blunt débridement of the focus of necrosis

Necrosectomy & debridement

• This technique avoids :- removal of vital tissue - reduces bleeding

• Sharp dissection should be avoided• Irrigation of retro-peritoneum with saline after

removal of loose necrotic tissue• Necrosectomy remains the common step for

all procedures

Exposure of the Lesser sac & Necrosum

Open packing

• Cavity lined with a non-adherent dressing and packed

• Kerlix rolls • Pt is returned to OT every 48 hours • Debridement may be performed under sedation

in the ICU • Appearance of healthy granulation tissue• Abdomen closed over drains +/- lavage of the

cavity

Planned Staged Re-laparotomy & Lavage

• Planned reoperations for repeated necrosectomies on an every-other-day basis granulation tissue has started to form

• Abdominal wall zippers:- for ease of repetitive surgical access

• Abdomen finally closed in a delayed primary fashion over peri-pancreatic drains

Complications

• GI fistulae- Colonic- Pancreatic

• Stomach outlet stenosis• Bleeding• Incisional hernia• Indication:

- Early intervention

Continuous Lavage of the Lesser Sac and Retroperitoneum

02 or more double lumen Salem sump tubes (20-Fr to 24-Fr) +

Single lumen silicone rubber tubes (28-Fr to 32-Fr) inserted from each side

Directed to the left and right and placed with the tip at: - the tail of the pancreas

- behind the descending colon - the head of the gland - ascending colon


• Smaller lumen of the Salem drains for inflow • Larger lumen used for outflow

• Gastro-colic and Duodenocolic ligaments re-approximated

• 35 to 40 L of lavage fluid (standard peritoneal dialysis fluid) is used initially

• Lavage volume reduced based on:- appearance of effluent - clinical course

• Drains removed within the next 2-3 wks



Salem Sump Tube

Closed Packing• Principle same as continuous postoperative lavage:

- Ensures continuing easy egress of residual necrotic material

After removal of necrotic tissue

Cavity irrigated with saline Residual cavity filled with multiple, large, gauze-filled Penrose and closed-suction drains

Drains brought out laterally to ease drainage

Closed Packing

Drains removed successively after a minimum of 7 days of continuous drainage

Gauze packing must be removed gradually Slow collapse of the cavity

Penrose drain

Advantages

• Reduced post-operative morbidity• Necrosectomy + Closed continuous lavage is

the preferred modality

Special considerations

• Pre-op ERCP + Papillotomy:- CBD injury

• CBD exploration to be avoided• Diverting Ileostomy:

- Early institution of enteral feeding

Complications

Comparison of outcomes

Minimally Invasive Procedures

• Rationale:- To minimise peri & post-operative stress in

critically ill patients with septicaemia & MOF• Modalities:

- Radiological- Endoscopic- Minimally invasive surgery

Percutaneous drainage

• Role of CT and Intervention Radiologists• May serve as a bridge for critically ill pts, prior

to definitive surgery• Involves multiple catheter changes• May not be successful for necrosis involving

the body of pancreas with disruption of the MPD

• Scanty data on outcome

Endoscopic therapy

• Must be combined with surgery• Use of:

- Trans-gastric/trans-duodenal catheters- Naso-pancreatic irrigation tubes

• Complications:- Perforation- Bleeding- Iatrogenic infection of necrosum

Minimally Invasive Surgery• Laparoscopy/ Retro-peritineoscopy• Entry made by dilatation of previously made catheter

tract or directly under CT guidance• Access gained most commonly through a left/right flank

approach• Scanty data available• Limited studies project:

- Success rate: 60-100%- Morbidity: 30-60%- Mortality: 0-27%

VARD

Step up approach• Minimally invasive step-up approach vs Primary open

necrosectomy

• Reduced the rate of the composite end point of :- major complications or death- long-term complications- health care resource utilization - total costs

• With the step-up approach:- > 1/3rd of pts successfully managed by percutaneous drainage - no major abdominal surgery

Step up approach• Reasons for the favorable outcome:

1. Infected necrosis similar to an abscess & contains infected fluid (pus) under pressure

- Abscess is resolved with percutaneous drainage - After the infected fluid is drained, the pancreatic necrosis can be left in situ• Rationale :

- conversion of infected necrosis to sterile 2. Less surgical trauma

- Reduced pro-inflammatory trigger

Thank You

Health & Medicine

Surg in ac pancreatitis