Acute pancreatitis surgery: Difference between revisions
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==Surgery== | ==Surgery== | ||
=== Indications === | |||
Surgery is indicated for | Surgery is indicated for | ||
# Infected pancreatic necrosis | # Infected pancreatic necrosis | ||
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*Closed management - necrosectomy with closed continuous lavage | *Closed management - necrosectomy with closed continuous lavage | ||
*Open management - necrosectomy with planned staged reoperations at definite intervals (up to 7 reoperations in some cases) | *Open management - necrosectomy with planned staged reoperations at definite intervals (up to 7 reoperations in some cases) | ||
=== Minimally Invasive Approach === | |||
==== Endoscopic Retrograde Cholangiopancreatography ==== | |||
ERCP is indicated in patients with acute pancreatitis where gallstones are the underlying cause. This includes patients with cholangitis or choledocholithiasis secondary to gallstones and have clinical findings suggestive of bile duct obstruction. It is not indicated in the absence of the aforementioned features. | |||
ERCP is additionally indicated in cases of necrotizing pancreatitis which progressed to walled off necrosis. This typically occurs after 4-6 weeks. ERCP intervention is typically and ideally delayed to the point of walled off necrosis whenever possible when the patient is stable. In the interim, antiobiotic therapy may sustain the patient in cases of infected necrosis. | |||
==== Percutaneous Drainage ==== | |||
In patients who are not stable (e.g. develop sepsis or hemodynamic instability), placement of a percutaneous drain for peripancreatic fluid collection is often sufficient to reduce sepsis and afford the pancreas time to develop an operable walled-off-necrosis. | |||
==== Other Approaches ==== | |||
Other minimally invasive approaches may be considered such as laparoscopy, and retroperitoneal approach. | |||
=== Open Surgery === | |||
In 40% of patients, minimally invasive surgery is not achievable, traditional open necrosectomy may be considered. | |||
==References== | ==References== | ||
Revision as of 01:24, 27 November 2016
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Acute pancreatitis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Acute pancreatitis surgery On the Web |
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American Roentgen Ray Society Images of Acute pancreatitis surgery |
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Risk calculators and risk factors for Acute pancreatitis surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
Overview
Surgery in the treatment of acute pancreatitis is indicated for infected pancreatic necrosis, in cases of diagnostic uncertainty and in the presence of complications.
Surgery
Indications
Surgery is indicated for
- Infected pancreatic necrosis
- Diagnostic uncertainty
- Complications.
The most common cause of death in acute pancreatitis is secondary infection. Infection is diagnosed based on 2 criteria:
- Gas bubbles on CT scan (present in 20 to 50% of infected necrosis)
- Positive bacterial culture on FNA (fine needle aspiration, usually CT or US guided) of the pancreas.
Surgical options for infected necrosis include:
- Conventional management - necrosectomy with simple drainage
- Closed management - necrosectomy with closed continuous lavage
- Open management - necrosectomy with planned staged reoperations at definite intervals (up to 7 reoperations in some cases)
Minimally Invasive Approach
Endoscopic Retrograde Cholangiopancreatography
ERCP is indicated in patients with acute pancreatitis where gallstones are the underlying cause. This includes patients with cholangitis or choledocholithiasis secondary to gallstones and have clinical findings suggestive of bile duct obstruction. It is not indicated in the absence of the aforementioned features.
ERCP is additionally indicated in cases of necrotizing pancreatitis which progressed to walled off necrosis. This typically occurs after 4-6 weeks. ERCP intervention is typically and ideally delayed to the point of walled off necrosis whenever possible when the patient is stable. In the interim, antiobiotic therapy may sustain the patient in cases of infected necrosis.
Percutaneous Drainage
In patients who are not stable (e.g. develop sepsis or hemodynamic instability), placement of a percutaneous drain for peripancreatic fluid collection is often sufficient to reduce sepsis and afford the pancreas time to develop an operable walled-off-necrosis.
Other Approaches
Other minimally invasive approaches may be considered such as laparoscopy, and retroperitoneal approach.
Open Surgery
In 40% of patients, minimally invasive surgery is not achievable, traditional open necrosectomy may be considered.