Acute pancreatitis surgery
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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. Additionally, surgery is indicated for gallstone pancreatitis in order to resolve the underlying cause.
Surgical options include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage of peripancreatic fluids, retroperitoneal approach, laparoscopic surgery, or traditional open necrosectomy. Minimally invasive approaches are preferred; however, timing of the surgery is of utmost importance. Ideally, patients with an indication for surgery are to be stabilized for up to four weeks and given antibiotics in the interim. After the development of walled off necrosis, surgery is considered more safe and effective.[1]
Surgery
According to the American college of gastroenterology, following are the guidelines for surgery in acute pancreatitis:[2][3][4][5][6][7]
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| In patients with mild AP, found to have gallstones in the gallbladder, a cholecystectomy should be performed before discharge to prevent a recurrence of AP | Moderate | Strong |
| In a patient with necrotizing biliary AP, in order to prevent infection, cholecystectomy is to be deferred until active inflammation subsides and fluid collections resolve or stabilize | Moderate | Strong |
| The presence of asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis do not warrant intervention, regardless of size, location, and/or extension | Moderate | Strong |
| In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed preferably for more than 4 weeks to allow liquefication of the contents and the development of a fibrous wall around the necrosis (walled-off necrosis) | Low | Strong |
| In symptomatic patients with infected necrosis, minimally invasive methods of necrosectomy are preferred to open necrosectomy | Low | Strong |
Indications
Surgery is indicated for:[8][9][1]
- 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.[1]
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.[10][11][8][9][1]
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.[10][11][8][9][1]
Other Approaches
Other minimally invasive approaches may be considered such as laparoscopy, and retroperitoneal approach.[11][9][1]
Open Surgery
In 40% of patients, minimally invasive surgery is not achievable, traditional open necrosectomy may be considered.[8][9][1]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ Tenner S, Baillie J, DeWitt J, Vege SS, American College of Gastroenterology (2013). "American College of Gastroenterology guideline: management of acute pancreatitis". Am J Gastroenterol. 108 (9): 1400–15, 1416. doi:10.1038/ajg.2013.218. PMID 23896955.
- ↑ Larson SD, Nealon WH, Evers BM (2006). "Management of gallstone pancreatitis". Adv Surg. 40: 265–84. PMID 17163108.
- ↑ Steinberg W, Tenner S (1994). "Acute pancreatitis". N. Engl. J. Med. 330 (17): 1198–210. doi:10.1056/NEJM199404283301706. PMID 7811319.
- ↑ Banks PA, Freeman ML (2006). "Practice guidelines in acute pancreatitis". Am. J. Gastroenterol. 101 (10): 2379–400. doi:10.1111/j.1572-0241.2006.00856.x. PMID 17032204.
- ↑ Besselink MG, Verwer TJ, Schoenmaeckers EJ, Buskens E, Ridwan BU, Visser MR, Nieuwenhuijs VB, Gooszen HG (2007). "Timing of surgical intervention in necrotizing pancreatitis". Arch Surg. 142 (12): 1194–201. doi:10.1001/archsurg.142.12.1194. PMID 18086987.
- ↑ Hartwig W, Maksan SM, Foitzik T, Schmidt J, Herfarth C, Klar E (2002). "Reduction in mortality with delayed surgical therapy of severe pancreatitis". J. Gastrointest. Surg. 6 (3): 481–7. PMID 12023003.
- ↑ 8.0 8.1 8.2 8.3 van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH; et al. (2010). "A step-up approach or open necrosectomy for necrotizing pancreatitis". N Engl J Med. 362 (16): 1491–502. doi:10.1056/NEJMoa0908821. PMID 20410514.
- ↑ 9.0 9.1 9.2 9.3 9.4 Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL; et al. (2012). "Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial". JAMA. 307 (10): 1053–61. doi:10.1001/jama.2012.276. PMID 22416101.
- ↑ 10.0 10.1 van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM; et al. (2011). "A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome". Gastroenterology. 141 (4): 1254–63. doi:10.1053/j.gastro.2011.06.073. PMID 21741922.
- ↑ 11.0 11.1 11.2 Freeman ML, Werner J, van Santvoort HC, Baron TH, Besselink MG, Windsor JA; et al. (2012). "Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference". Pancreas. 41 (8): 1176–94. doi:10.1097/MPA.0b013e318269c660. PMID 23086243.