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assessment,but many centersuse them asaprimary option.Wedid a
few minimal access necrosectomies a couple years ago but found it
cumbersome and it left a nasty feeling of not doing enough. So we
abortedtheexperiment…
Opennecrosectomy
Whenyou do open necrosectomyforthe right indications attheright
time, removing the black clay-like stuff by scooping with your fingersis
easy. Getting through the gastrocolic ligament (yes, I prefer not to go
through the transverse mesocolon), opening the correct tissue planes
withbluntdissectionandutilizingtheHarmonicScalpel®orold-fashioned
ligaturesgivesgoodexposure.
Usuallythenecrosis is mostly found around thepancreas while
the pancreas itself is firm and protrudes like a transverse ridge.
Leave it alone! If on the other hand (and pre-operative CT helps) the
necrotizingprocesshasdestroyedthepancreas(thedisconnectedduct
syndrome),youcansqueezeitoutdistallywithgentlefingerdissection,
butbecarefulwiththesplenicvesselsandleavethespleenalone.Once
youhaveremovedthedeaddistalpancreas( Figure19.6) (sometimes
only a small proximal remnant is left), you can try to find the divided
pancreatic duct and ligate it. Usually you don’t see it, and apancreatic
fistulaoccurs,butyoucandealwiththatlateron.Packtheareaforafew
minutes and check hemostasis. Deal with clear bleeders, don’t worry
about minor oozing. Draining the peripancreatic area with a couple of
well-placeddrains (onecomingbehind theleft colon intothe pancreatic
areaif thenecrosis ismainly ontheleftside)completes theprocedure.
Usually, in 80-90% of cases, we close the abdomen after
necrosectomyunlesstheIAPwasclearly elevatedpriorto surgery
orifthereisconsiderableintestinaloedema. Obviously, in a patient
alreadywithan‘openabdomen’(forACSforexample),andwho,lateron,
needs necrosectomy, we almost always leave the abdomen open and
continuewiththemesh-mediatedVACsystem.
The vacuum and mesh-mediated fascial traction is a temporary
abdominalclosure(TAC)methoddescribedbyourSwedishcolleagues
4
.Itcombinesthevacuumeffect with mechanical traction induced by a
mesh.Theintra-abdominal contents are firstcoveredbya polyethylene
sheetfollowedbysuturingofanoval-shapedpolypropylenemeshtothe
fascial edges. A polyurethane sponge is then placed on the mesh and
coveredwith an airtightocclusiveplastic sheet. A vacuumisintroduced
by connecting the dressing to a suction apparatus creating continuous
negative pressure (usually minus 125mmHg). TAC changes are
performedevery2-3daysintheoperatingtheatreoratthebedside
intheICU.DuringtheTACchanges,fascialedgesareapproximated
by tightening the mesh by suturing it in the midline (the mesh is
divided at the midline during the first change to allow changing of the
underlyingplasticsheet).Whenthegapbetweenthefascialedgeshas
been reduced to about 5cm, the mesh is removed, and thefascia
and skin are closed with sutures. Using this method the delayed
fascial closure rate is about 80-90%, higher than with any other TAC
methodpublished.Furthermore,theenteralfistularateisalsothelowest
amongTACmethods.
Figure19.6.Removeddeadpancreas.
About two out of three cases need only a single procedure
(probablybecausewedoitlateenoughandcandoafairlycomplete
necrosectomy). These days reoperations are not ‘planned’ but
performed ‘on demand’ for complications such as disconnected
ductsyndrome(seeabove).
Complicationsafternecrosectomy
Afternecrosectomy,don’texpecteverythingtogosmoothly...
Postoperativebleedingiscommon sodon’t panic!The drainagefluid
tends to be bloody in the first couple of days; it then turns brown and
ugly,andfinally grey-brown or pus-like. But iftheblood in the drainage
bag is ‘pure’ or the patient becomes hemodynamically unstable and
requiresmultiplebloodtransfusions,don’thesitatetogoin,evacuatethe
bloodand clots,stop anybleeding fromvisible sourcesorjust packthe
area and leave the abdomen open. Angio-embolization is an
alternativetoreoperation—ifitisreadilyavailable.
Residualnecrosisafter‘incomplete’necrosectomyismorecommonif
youdo theinitialnecrosectomy tooearly.Completing thenecrosectomy
in a second (or more) operation is acceptable, so don’t try to remove
every tiny bit of necrosis at the first operation if it causes more harm
(usuallybleeding).
Pancreatic fistula is common especially after necrosectomy that
involvesdistalpancreatectomy.Youcannotmeasureamylaselevelsfrom
the drains if the secretion is thick but eventually you will find out that
there is a fistula. Keep the drains and, when feasible, ask your
endoscopistfriends toinsert astent intothe pancreaticduct.Someuse
octreotide,weroutinelydonot.
Bile-stained secretion from the drains is a bad sign. Accidental
injury to the duodenum during necrosectomy sometimes happens. If
theduodenalfistulaiscontrolled(bilenotfloatingallovertheplace)and
the patient is not septic, have patience. Closing the duodenum at this
stage is virtually impossible; itis betterto havea controlledfistula and
dealwiththeduodenumlater(ifnecessary).
Pleasenote:
Inmanaging patients with severeacute pancreatitis, theemphasis is EARLYand
AGGRESSIVE supportive management, and LATE and MEASURED surgical
treatment.
These patients are best treated in centers which can provide long-term ICU
support, combined with radiological, endoscopic and surgical expertise — by
peoplewhorememberandunderstandalltheacronymsusedinthischapter(!)—
notinthesmall‘high-careunit’inyourlittlecommunityhospital.Soshipthemoutto
theexperts…
LetmeconcludewithsomeFinnishwisdom…
Remember—weFinnsdrinkalotsoweseetonsofthesecases.
WhenourhospitalinHelsinkiwasbuilt(about1965),themortalityrate
forsevereacute pancreatitiswasover90%.When Istartedmy surgical
residency (early 1980s), it was still around 50%. Gradually it came
downto20%withhighlyimprovedintensivecareandearlysurgical
conservatism.Thelast10yearshaveseentremendousprogressinour
understandingofthisverycomplexdisease.Recognizingandtreatingthe
ACSassociatedwithaggressivefluidresuscitationandtissueedemahas
further improved the prognosis, especially when we have been more
aggressiveinopening the abdomen and leaving itopen.We see about
20 patients likethis every year, and with modern temporary abdominal
closure methods, suchas the mesh-mediated vacuum-assisted closure
technique,we can closethe fascia (andskin)in about90%of patients.
Onlyasmallproportionendupwithskingraftingandsubsequent
abdominalwallreconstruction.
So,untila‘magicpill’isinventedthatstopstheinflammatorycascade
at its beginning, we still need — with the help ofour intensivists —to
treatthesepatientsas‘surgical’patients.
Thepropermanagementofsevereacutepancreatitisrequiresthatyou
understanditsnaturalhistoryandbearmedwithlotsofpatience.During
theearlyphasesofthedisease“ourpatiencewillachievemorethanour
force”(EdmundBurke);lateron,whencalledtooperateonnecroticand
infectedcomplications,rememberthat“patienceanddiligence,likefaith,
removemountains”(WilliamPenn).
Iwish toconcludewith somewise words fromthe famouspancreatic
surgeonKennethW.Warren(1911-2001).
“The most common errors in the surgical treatment of
acutepancreatitisare to operate too earlyin the course
ofthediseaseandtodotoomuch,orinthesecondaryor
septicphaseofthediseasetooperatetoolateandtodo
toolittle.”
KennethW.Warren
1
http://clincalc.com/IcuMortality/SOFA.aspx.
2
IAP/APA evidence-based guidelines for the management of acute pancreatitis.
Pancreatology2013;13(4Suppl2):1-15.
3
van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open
necrosectomyfornecrotizingpancreatitis.NEnglJMed2010;362:1491-502.
4
Peterson U, Acosta S, Björck M. Vacuum-assisted wound closure and mesh-mediated
fascial traction — a novel technique for late closure of the open abdomen. World J Surg
2007;31:2133-7.
Chapter20
Gallbladderandbiliaryemergencysurgery
DannyRosin,MosheScheinandB.Ramana
Thischapterhasbeensubdividedintothefollowingthree
sections:
1.
Theacutegallbladder.
2.
Bileductemergencies.
3.
Biliarypancreatitis.
1
Theacutegallbladder
DannyRosinandMosheSchein
Indropsy ofthe gallbladder…and ingallstoneswe should
not wait ‘til the patient’s strength is exhausted, or ‘til the
bloodbecomes poisonedwith bile,producing hemorrhage;
weshouldmakeanearlyabdominalincision,ascertainthe
truenature of the disease, and thencarry out the surgical
treatmentthatnecessitiesofthecasedemand.
JamesMarionSims
Biliary surgery, and especially gallbladder surgery, is considered as
oneofthepillarsof‘generalsurgery’.Yetyouwillfindagreatdiversityof
clinicalpresentations, treatment optionsandlocal customs and dogmas
—thatwillallaffecttheselectedapproach.Inacutebiliarysurgerythe
disagreements are even greater, and the debate between nonoperative treatment and endoscopic, radiologic and surgical
interventionsismore heated. Therefore, in thischapter wewill tryto
simplify this maze for you, and lead you through a common-sense
approach,focusingonproblemareas.Asalways,youwillbeabletofind
in the literature a large spectrum of views and approaches which
contradictsours —but bynow youknowwhoisright... Wetrustyouto
knowthebasics (and more) from your medical school, surgical training
andpractice.
For the sake of simplicity we will divide the chapter between
gallbladderemergenciesandbileductemergencies—butyoushould
rememberthatthe clinicalpicturemaybe‘mixed’—it’sthepatientwith
acute cholecystitis andsimultaneous elevation of bilirubin and amylase
thatwillforceyoutothinkhardaboutthenextstep.
Acutecholecystitis
Acutecholecystitis(AC)iseithercalculousor,muchlesscommonly,
acalculous.Sincetheclinicalpictureofthesetwoentitiesdifferstheyare
discussedseparately.Wewillstartwiththecalculousentity.
Obstructionofthegallbladderoutletbyastoneisbyfarthemost
commonetiologyforacutecholecystitis(AC).Itisaspectrum:
•
Short-term obstruction with spontaneous dislodgment of the
obstructingstonecausesabiliarycolic.
•
Impaction of the stone at the neck of the gallbladder will lead to
distension, pressure elevation, ischemic changes and, if left to
progress, secondary bacterial infection — AC. Untreated, it may
progress to complications such as necrosis, perforation,
empyema,liverabscess,peritonitisandsystemicsepsis.
Howdoyouknowwherethepatientisalongthisspectrum?You
usealltheinformationyoucangatherfromhistory,physicalexamination,
laboratoryresultsandimagingstudies.Biliarycolicisself-limitedand
ofshortduration:thepain—typicallyintheepigastrium,butmaybein
therightupperquadrant,radiatingtotherightloin,backand/orshoulder
andassociatedwithnausea/vomiting—lastsnomorethanafewhours,
andtherearenoclinical/laboratorymarkersofinflammation.Incontrast,
AC will last longer, as a persisting pain, and will be associated with
local (tenderness — hey, you don’t wantto hear again about Murphy’s
sign,eh?—peritonealsigns,amass—denotingapalpablegallbladder)
aswellassystemic(fever,leukocytosis)inflammatorysigns.Remember:
inflammationalone cannotalwaysdifferentiatebetween the ‘early’,
mechanical/chemical acute cholecystitis and the ‘late’, bacterial
phase.Often at surgery, wearesurprised by how advancedthe AC is,
whichclinicallyhadbeenassessedas‘mild’.Moreadvancedforms,such
asgangrenous cholecystitisor gallbladderempyema, willbe associated
with higher levels of inflammation, greater leukocytosis, and more
systemicmanifestationsofsepsis.
Diagnosis
Diagnosis is not considered complete without supporting
imaging.
Ultrasound
Ultrasoundisyourbestfriend:available,cheap,simple,radiationfree,
and usually accurate. It will demonstrate the stones, the distended
gallbladder with its thickened walls, and provide information about
associated findings such as pericholecystic fluid collection, bile duct
dilatationandthenearbystructures—liver,kidneyandpancreas.Note,
however,thatoften,ultrasonographicfeaturesofAClagbehindthe
clinicalpicture—apatientcanhaveanadvancedACevenifthewallof
thegallbladderisnotthickenedand/orthegallbladderisnotsurrounded
withfluid.RememberalsothatanalmostconstantfeatureofACisa
dilatedgallbladder(afeaturewhichissometimesnotmentionedby
the radiologist) — so: a non-distended gallbladder on imaging is
usuallynotAC!
CT
ManypatientswillalreadyhavehadaCTscanoftheabdomenwhen
you are called for a consult, and a distended, thick-walled gallbladder
withsurroundingfat strandingwillsupport thediagnosis,even whenthe
USis‘notdiagnostic’.However,theUSismoreaccurateinthissituation
and will show stones missed by the CT. Often we ask for an US to
confirmtheCTdiagnosis.Youmaybecorrectifyoucallthisa‘defensive
approach’…
HIDAscan
Indoubtful casesyou canstill usetheoldandtrusted HIDA(hepatic
imino-diacetic acid) radionuclide scan. It is highly sensitive for non-
visualization of the gallbladder in cases of cystic duct obstruction (a
typicalfeatureofAC),althoughspecificityisaffectedbyimpairedhepatic
bile secretion with hyperbilirubinemia. A negative scan (i.e.
visualization of the gallbladder) will exclude the diagnosis of AC
andmakeyouthinkagain.
Again, remember that some findings may be lacking, without
excluding the diagnosis. We have seen AC without gallbladder
distension(dueto chronic changes), with a thin wall (about to burst) or
withstonessosmallthattheyareeasilymissedbyimaging.Don’trushto
labelthe conditionas ‘acalculouscholecystitis’, asthis rarediagnosisis
usuallylimitedtosick,ICUpatients—buttomakeourlifecomplex,seen
occasionallyinotherwiseperfectlyhealthypatients.
You may also get confused by some abnormal associated
parameters. For example, mild jaundice (bilirubin levels of up to
5mg/dL [85mmol/L]) and minimal elevation of liver enzymes can
accompany AC, even without choledocholithiasis and cholangitis.
Whether this is caused by pressure on the bile ducts, reactive
inflammation around the gallbladder or absorption of bile from the
gallbladderthroughitspressurized,ischemicwall,doesnotreallymatter.
What matters isthat you know todifferentiate this conditionfrom
ascending cholangitis (see below) that merits a different plan of
action.Thetrickisnottojumptoconclusionsbutholdtoyourgunsand
remeasure liver functions a day later: if improving, go ahead withyour
gallbladder operation; if deteriorating, you have to image the duct —
preferably with magneticresonance cholangiopancreatography (MRCP)
asdiscussedbelow.
Management
Have you ever popped a potato out of the oven in your
mouth?Whathappens?Andwhatifyouletitcoolandthen
enjoyit!
AmjadSirajMemon
Here lies the main dissociation between what’s recommended in the
literature and what is practiced in many places around the globe. The
simple,‘correct’managementofacutecholecystitisissurgery,and
nowadays it means laparoscopic cholecystectomy. So whyisn’t it
alwayspracticed?
Non-operativemanagement
Conservative management will be successful in most cases to
relieve the acute episode. Antibiotics, to cover Gram-negative
enteric bacteria (adding anti-anaerobe agents in sicker patients),
along with i.v. fluids, analgesicsand anti-emetics,will make more
than90%ofyourpatientsbetterwithinafewdays.Thepriceforthis
approachisprolongedhospitalstay,adefinedriskoffailure—whichin
turn may necessitatea more invasive approach in worse conditions —
andarisk of recurrent episodes duringthewaiting period of 6-8 weeks
forthe‘interval’cholecystectomythatisnecessaryanyway.
So why not ‘just take it out’? The reasons vary, but the most
common around the world is the lack of an immediate OR/surgeon
availability. If you are lucky to work in a system where early
cholecystectomy is feasible (next day is OK, even the day after
tomorrowisfine)—thengoforit!Youwillfindtheoperationeasier,
with the gallbladder wall edema allowing you a relatively easy
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