Evolution and Results of the Surgical Management of 143 Cases of Severe Acute Pancreatitis in a Referral Center (original) (raw)
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Changing concepts in the surgical management of acute pancreatitis
Best Practice & Research Clinical Gastroenterology, 1999
Most episodes of acute pancreatitis are mild and self-limiting, but severe disease complicated by multiple system organ failure develops in up to 20% of cases. Early detection of those patients who subsequently develop necrotizing pancreatitis allows the start of supportive treatment in the intensive care unit before organ failure occurs. Conservative treatment in the intensive care unit, including the administration of intravenous antibiotics, is the gold standard. Surgery is indicated in patients with infected pancreatic necrosis but not in patients with sterile necrosis in the absence of deteriorating multi-organ failure despite maximal intensive care unit treatment, or other specific surgical complications. At our institution, out of 44 patients with necrotizing pancreatitis 29 (66%) had sterile necrosis and were managed conservatively while 15 (34%) had infected pancreatic necrosis and were treated by necrosectomy and continuous closed retroperitoneal lavage. There were two deaths resulting in an overall mortality of 5% in patients with severe acute pancreatitis.
Management of Severe Acute Pancreatitis: A Surgical Odyssey
Annals of Surgery, 2010
Purpose of review There have been significant advancements in different aspects of management of severe acute pancreatitis (SAP). Our review of the most recent literature focuses on severity prediction, fluid resuscitation, analgesic administration, nutrition, and endoscopic intervention for SAP and its extra-pancreatic complications. Recent findings Recent studies on serum cytokines for the prediction of SAP have shown superior prognostic performance when compared with conventional laboratory tests and clinical scoring systems. In patients with established SAP and vascular leak syndrome, intravenous fluids should be administered with caution to prevent intra-abdominal hypertension and volume overload. Endoscopic retrograde cholangiopancreatography improves outcomes only in AP patients with suspected cholangitis. Early enteral tubefeeding does not appear to be superior to on-demand oral feeding. Abdominal compartment syndrome is a highly lethal complication of SAP that requires percutaneous drainage or decompressive laparotomy. Endoscopic transmural drainage followed by necrosectomy (i.e., "step-up approach") is the treatment strategy of choice in patients with symptomatic or infected walled-off pancreatic necrosis. Summary SAP is a complex clinical syndrome associated with a high mortality rate. Early prediction of SAP remains challenging due to the limited accuracy of the available prediction tools. Early fluid resuscitation, organ support, enteral nutrition, and prevention of/or prompt recognition of abdominal compartment syndrome remain cornerstones of its management. A step-up, minimally invasive drainage/debridement is the preferred approach for patients with infected pancreatic necrosis.
International journal of surgery science, 2022
To evaluate the indication and outcome of different surgical management modalities in local complications of acute pancreatitis. Methodology: A hospital-based observational study was conducted in the department of surgery Shri Shankaracharya Institute of medical sciences, Bhilai, India after approval from the institutional ethical committee. A purposive sampling method was utilized to recruit the patients. Patients who underwent laparoscopic or open surgical procedures transperitoneal or retroperitoneal for the management of local complications of acute pancreatitis for the period of 1 year were included. Clinical, laboratory and imaging findings including, contrast-enhanced CT scan findings of all the cases, were recorded as per the proforma. In addition, the indication of each procedure, perioperative outcome and associated complications were evaluated in all the studied cases. All minimally invasive procedures were performed under general anesthesia by the surgical team experienced in pancreatic surgery. Results: Total 496 patients were admitted to the surgery department with the diagnosis of acute pancreatitis or with complications of acute pancreatitis. Among them, 80 patients had local complications due to acute pancreatitis. All patients were managed using the step-up approach, starting with conservative management and minimally invasive intervention when warranted. 24 patients required surgical intervention due to failure of endoscopic or radiological intervention or positions of lesions being inaccessible to these techniques. Among the 24 patients in the study, 4 patients had PPC, all of whom were managed with external drainage due to persistent symptoms. 6 patients who had ANC were initially subjected to conservative management. In addition, WON was noted in 4 patients and 10 patients had pseudocyst. Due to clinical deterioration and high suspicion of infected necrosis in patients with WON, FNAC was performed in all patients, revealing growth in culture. Conclusion: Patients who have local complications of pancreatitis respond best to treatment at a tertiary care centre that is staffed with pancreatic surgeons. Surgery is still the primary treatment option for pancreatic necrosis and pancreatic fluid collection, despite the proliferation of endoscopic procedures designed to treat these conditions.
Factors influencing mortality in patients undergoing surgery for acute pancreatitis
Pancreas, 2014
Objectives: The aims of present study were to analyze the mortality risk factors in patients who had surgery for acute pancreatitis and to assess the importance of culturing peripancreatic tissue or fluid infection to ascertain the infection status. Methods: Surgery was indicated both in patients with infected severe acute pancreatitis and in those with sterile pancreatitis with an unfavorable course. During surgery, cultures were taken of tissues (pancreatic necrosis and peripancreatic fat), intra-abdominal fluid, and bile. Results: Of 107 patients operated on, fluid culture was analyzed in 94 patients, pancreatic necrosis in 61 patients, peripancreatic fat in 39 patients, and bile in 38 patients. Sterile pancreatitis with sterile ascites was found in 17 patients, sterile pancreatitis with infected ascites in 22, and pancreatic tissue infection in 60. Multivariate analysis demonstrated that sterile tissue cultures, age over 65 years, and fewer than 12 days between the beginning of pain and surgery were risk factors for mortality. Sterile pancreatitis with sterile ascites and sterile pancreatitis with infected ascites had similar postoperative mortality (41% and 50%, respectively); the group with pancreatic tissue infection had a lower mortality (20%). Conclusions: Early surgery, advanced age, and sterility of tissue cultures have been demonstrated as mortality factors for acute pancreatitis. Intra-abdominal fluid may be infected in the presence of sterile necrosis.
Surgery in the treatment of acute pancreatitis--open pancreatic necrosectomy
Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society, 2005
Management of acute necrotizing pancreatitis has changed significantly over the past years. Early management is non-surgically and solely supportive. Today, more patients survive the early phase of severe pancreatitis due to improvements of intensive-care-medicine. Pancreatic infection is the major risk factor with regard to morbidity and mortality in the late phase of severe acute pancreatitis. Whereas early surgery and surgery for sterile necrosis can only be recommended in selected cases, pancreatic infection is a well accepted indication for surgical treatment. Surgery should ideally be postponed until four weeks after the onset of symptoms as necrosis is well demarcated at that time. Four surgical techniques can be performed with comparable results regarding mortality: necrosectomy combined with (1) open packing, (2) planned staged relaparotomies with repeated lavage, (3) closed continuous lavage of the retroperitoneum, and (4) closed packing. However, closed continuous lavage ...
Therapeutic intervention and surgery of acute pancreatitis
Journal of hepato-biliary-pancreatic sciences, 2010
The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80-90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10-20% of acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry...
Prognostic intraoperative factors in severe acute pancreatitis
Journal of Medicine and Life, 2014
Acute pancreatitis is a serious disease. Triggered by the local inflammation of the pancreas, it can cause inflammation in various organs and systems in the body. It is important to identify severe forms of acute pancreatitis with an increased morbidity and mortality rate. Lately, internationally, numerous clinical and paraclinical factors predicting the severity of acute pancreatitis have been proposed. The purpose of the study is to identify the prognostic intraoperative factors of severity. The prospective study was conducted over a period of four years, between 2007 and 2010 and included 238 patients treated in a surgical clinic in Bucharest. 103 patients experienced a severe form of acute pancreatitis, which means 67.95% of all operations practiced. We monitored intraoperative factors, in particular: the presence and/ or the extent of pancreatic necrosis, common bile duct lithiasis and intraperitoneal fluid, parameters proposed to become statistically prognostic factors in the ...
Gastroenterology, 2012
(17%), trauma (4%) and others (5%). Eighty patients (72%) had acute necrotizing pancreatitis, 17 (15%) patients had only PPN and 14 (13%) patients had no pancreatic or peripancreatic necrosis. Ninety three (84%) patients had PPN and of these 19 (20%) patients had extensive PPN, 17 (15%) patients had only PPN with no pancreatic necrosis and 18 (16%) patients had no PPN. Twenty three of 111 (20%) patients died whereas surgery or radiological/ endoscopic intervention was needed in 11 (10%) and 43 (39%) patients respectively. Forty (43%) of patients with PPN required radiological or endoscopic intervention whereas 3 /18 (16.6%) of patients without PPN required radiological or endoscopic intervention (p=0.03). Eleven (12%) of patients with PPN required surgery whereas none of the patients without PPN required surgery (p>0.05). Twenty (22%) patients with PPN succumbed to the illness whereas 3 /18 (16%) patients without PPN expired (p>0.05). Extensive PPN had significant association with the need for surgery (p=0.009). On comparison of patients with PPN only with the patients having no pancreatic or peripancreatic necrosis, there was no significant difference in the mortality and need for surgery between the two groups (p=0.39 and 0.37 respectively). However, 6/17 (35%) patients with PPN only required radiological/endoscopic intervention whereas 1/14 (7%) patients with no necrosis required intervention (p=0.06). Conclusion: In acute pancreatitis, presence of PPN may predict the need for intervention, with patients having extensive PPN more likely to undergo surgery.
Surgery Management of Pancreatitis with Complication: A Review Article
Endocrinology and Disorders, 2022
Introduction: Acute pancreatitis is an inflammatory disease of the pancreas with clinical manifestations that vary from mild to severe manifestations to death. The incidence of pancreatitis varies in various countries in the world and depends on the cause such as alcohol, gallstones, and metabolic factors. The clinical picture and the main symptom in patients with acute pancreatitis is abdominal pain. Abdominal pain varies from mild to severe and excruciating. Abdominal pain that is felt is constant and dull, and is usually felt in the epigastrium and periumbilicus and often spreads to the back, chest, waist, and lower abdomen. Discussion: The onset of acute pancreatitis, the patient should be evaluated for hemodynamic status immediately and receive the necessary resuscitation measures. Patients with acute pancreatitis should receive aggressive intravenous rehydration (250 - 500 ml/hour with isotonic crystalloid fluid) as early as possible with close monitoring, unless contraindicat...