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4 Acute Pancreatitis: Surgical Therapies
Open Necrosectomy Pitfalls
• Gastrocutaneous or pancreatico-cutaneous stula
• Duodenal perforation, leak
• Gastroduodenal artery injury/pseudoaneurysm with bleeding
77
Management ofPseudocyst
Pseudocysts are the chronic (>4weeks old) forms of peripancreatic uid collections
that arise from acute pancreatitis without associated pancreatic or peripancreatic
necrosis. Majority of these peripancreatic uid collections resolve without any
intervention. However, a few persist and transform into pseudocysts by developing
a mature thick wall made of granulation, non-epithelialized tissue. Traditional management was based on chronicity and size with pseudocysts >4–6cm and older than
6weeks often being intervened on. However, intervention is reserved for symptomatic pseudocysts.
It is of critical importance to accurately differentiate a pseudocyst from a walledoff pancreatic necrosis (WOPN) since the management of each is vastly different
(see above). Pseudocysts can present with either compressive symptoms that lead to
pain, nausea, emesis, early satiety, bowel obstruction, or erosive symptoms including bleeding from vascular erosion or pseudoaneurysm, erosion into the biliary tree,
and the alimentary tract with internal stula.
The understanding of the pathophysiology of acute pancreatic and peripancreatic
uid collection that subsequently leads to pseudocyst formation is key to decisionmaking about their management. Acute peripancreatic uid collections without
associated necrosis arise from pancreatic main or side branch ductal disruption with
pancreatic uid leakage. A pseudocyst that develops from these collections may still
retain communication with the pancreatic ductal system. As a result, a percutaneous
drainage will result in a persistent pancreatico-cutaneous stula.
Internal drainage into the alimentary tract is the preferred option, with endoscopic internal drainage being the rst-line option.
Surgical Management ofPseudocyst by
Surgical Cystogastrostomy
This is a second-line option to endoscopic approach and is only indicated for symptomatic often large pseudocysts. The choice between open and minimally invasive
approach depends on a number of factors including the location of the pseudocyst
(retroperitoneal vs. peritoneal), relationship with the alimentary tract, associated
extent of inammation and visceral adherence, and feasibility of establishment of
pneumoperitoneum/pneumo-retroperitoneum (Fig.4.9a).
78
cd
O. Alser et al.
ba
Fig. 4.9 (a) Parts A–D: CT abdomen showing a large WOPN with EUS of the same lesion show-
ing anechoic cystic lesion with large amount of heterogeneous echogenic material within consistent with WOPN (A and C). LAMS and DPPS in situ of the WOPN, note hemorrhagic WON uid
exiting through LAMS (C). WOPN cavity 1week after LAMS with necrotic debris (D). (b)
Endoscopic cystogastrostomy. An axios stent is placed connecting the stomach with the necrotic
peri-pancreatic cavity through which an endoscopic grasper can be used to remove necrotic debris
Open Trans-Gastric Cystogastrostomy
Pre-op Preparation Pearls
• A thorough review of the patient’s preoperative imaging is critical to inform the
operative intervention, including the anatomy around the pseudocyst.
• Nasogastric decompression should be done preoperatively if gastric outlet
obstruction from the pseudocyst is present and is causing gastric dilation. This is
both for patient safety to avoid aspiration during induction of general anesthesia,
as well as facilitate easier performance of the trans-gastric cystogastrostomy.
4 Acute Pancreatitis: Surgical Therapies
79
Procedure Details
• Open internal drainage to the stomach is the best option for patients with large
symptomatic pseudocyst with extrinsic compression of the stomach and associ-
ated frozen abdomen, all of which preclude endoscopic or minimally invasive
approaches.
• In these cases, a thorough preoperative evaluation and review of imaging is per-
formed to determine the best interventional approach. Supine position is usually
best. A limited upper midline incision usually provides great access to the body
of the stomach and the lesser sac and the most common location of pseudocyst
in the mid pancreas. Intraoperative ultrasound is recommended to locate the best
site of close apposition between the posterior gastric wall with the pseudocyst
wall and conrm mature thick pseudocyst wall to anastomose to the stomach.
• Ultrasound evaluation is also used to ensure absence of vasculature traversing
the site if intended cystogastrostomy.
• Once these conditions are met, an anterior gastrotomy is made preferably with an
ultrasonic energy device. Once intragastric, pseudocyst bulge may be identied
underneath the posterior gastric wall.
• Intraoperative ultrasound may again be performed to guide location of the poste-
rior gastrostomy and pseudocyst puncture. Posterior gastrotomy and pseudocyst
puncture is then performed, and the pseudocyst uid is drained completely. A
pseudocyst should have minimal to no debris.
• Examination of the cyst cavity is performed. The cystogastrostomy anastomosis
can then be created using a stapler or running suture depending on surgeon’s
preference.
• The anterior gastrostomy is then closed by stapling or two-layer suture closure.
• If needed, cholecystectomy is performed if the patient had biliary pancreatitis. A
drain may be placed if deemed necessary; however, this is usually not needed.
Postoperative Care andFollow-up
No upper gastrointestinal contrast study is necessary after operative cystogastrostomy. The patient can usually resume a liquid diet the day after surgery and be discharged on soft diet. If surgical drain is placed, this can be removed prior to discharge
if drain uid amylase if low. Endoscopic cystogastrostomy patients will usually
need to repeat endoscopy in 2–4weeks for stent removal (Figs.4.9b and 4.10a–j).
Patients should follow-up at 2–6 weeks postoperatively.
80
cd
ef
O. Alser et al.
a
b
Fig. 4.10 CT abdomen and endoscopic ultrasound showing a large pseudocyst (a and b). EUSguided LAMS placement in progress (c). LAMS deployed, notice serous uid drainage through
the LAMS (d) and LAMS+DPPS within pseudocyst (e). CT of the abdomen following
LAMS+DPPS showing resolution of pseudocyst (f). CT abdomen following LAMS+DPPS showing resolution of pseudocyst (g). The LAMS is subsequently removed but the DPPS left in situ (h).
CT abdomen and EUS 2months after removal of the LAMS, showing no pseudocyst recurrence
noted (i and j)
ij
4 Acute Pancreatitis: Surgical Therapies
81
g
Fig. 4.10 (continued)
h
Disconnected Distal Pancreatic Duct Syndrome
Introduction
Disconnected distal pancreatic duct syndrome (DDPDS) or disconnected left pancreatic remnant refers to a sequelae of necrotizing pancreatitis whereby pancreatic
neck/body necrosis leads to neck/body parenchymal and ductal disruption, and loss
of the continuity of the pancreatic ductal system between the tail, body, neck, and
head of the pancreas (Fig.4.11). This results in an isolated viable upstream pancreatic distal body/tail parenchyma and ductal system that is not in continuity with the
pancreatic head ductal system, and is therefore not connected to the alimentary tract
[33, 34].
DDPDS usually occurs from necrotizing pancreatitis but can also occur from
traumatic injury to pancreas, malignancy, postoperative complications, and chronic
pancreatitis [34]. DDPDS occurs in 30–50% of cases of necrotizing pancreatitis.
Maatman etal. in their retrospective review of 647 patients with necrotizing pancreatitis reported a DDPDS prevalence of 36% [33].
Disconnected pancreatic duct syndrome remains the most common cause of
recurrent PFCs. The size of the disconnected viable pancreatic tail remnant varies
depending on the extent of pancreatic neck/body necrosis and disruption. The most
common site of necrosis and pancreatic ductal disruption is the pancreatic neck and
82
Fig. 4.11 Disconnected
distal pancreatic duct
syndrome. Central
pancreatic necrosis with a
large uid collection
containing necrotic debris
leading to a discontinuous
pancreatic duct between
the body and tail of the
pancreas
O. Alser et al.
proximal body. This is due to the fact that this is a vascular watershed area that falls
between the transverse pancreatic arteries from the splenic artery and the anterior
and posterior pancreaticoduodenal arteries from the gastroduodenal and superior
mesenteric arteries.
The diagnosis of DDPDS may be difcult to determine in the rst week after
onset of necrotizing pancreatitis since necrosis may still be patchy and not complete. After the rst week, contrast-enhanced CT imaging will conrm the diagnosis
by identifying the necrosis and showing a central pancreatic uid collection of
>2cm that replaced the neck and body parenchyma and will be enlarging over time.
Management ofDDPDS
Management depends on a number of factors including size of the disconnected
viable distal pancreatic remnant, size of the intervening necrosis cavity between the
pancreatic head and the viable distal pancreatic remnant, pancreatic head, and distal
remnant pancreatic main ductal communication with the necrosis cavity,
among others.
Management options include nonoperative intervention, cystogastrostomy/cysto
jejunostomy, pancreaticojejunostomy, or distal pancreatic remnant resection [34].
(a) Nonoperative Management
Some cases of DDPDS will spontaneously resolve over time. This is likely in
cases where the communication of the main pancreatic duct is maintained
between the distal pancreatic remnant into the necrosis cavity, which also still
maintains communication to the pancreatic duct in the head. This internal drainage may lead to spontaneous resolution over time. In these situations, the necrosis resolves over time and the continuity of the duct is restored via a stula tract
4 Acute Pancreatitis: Surgical Therapies
connecting the distal pancreatic duct to the pancreatic head duct into the alimentary tract.
(b) Cystogastrostomy/cystojejunostomy
Operative internal drainage should be considered for symptomatic DDPDS.Due
to the common location in the mid pancreas in the retrogastric lesser sac, a
cystogastrostomy following necrosectomy is a great option for managing mid
pancreatic necrosis that is still communicating with the main duct of the distal
pancreatic remnant duct. Cystojejunostomy may be done if the cavity is adjacent to the proximal jejunum and not in close apposition to the posterior gastric
wall. Cystogastrostomy or cystojejunostomy allows for internal drainage into
the alimentary tract. Procedure steps are the same as described above.
(c) Distal Pancreaticojejunostomy
Pancreaticojejunostomy is reasonable for patients with a sizable distal pancreatic duct remnant >5–6cm who continue to have symptoms or develop recurrent distal remnant pancreatitis. Adequate time should be allowed between the
acute necrotizing pancreatitis episode and the pancreaticojejunostomy, in order
to allow the associated inammation and scarring to resolve. This may be
6months to a year. If the pancreatic remnant can be accessed and exposed, a
jejunal Roux is used to create a distal pancreaticojejunostomy for internal
drainage. Distal pancreaticojejunostomy should especially be considered for
younger patients with substantial distal remnant pancreatic parenchyma volume
and length to preserve and prevent future development of diabetes mellitus.
(d) Distal Remnant Pancreatectomy
Distal pancreatic remnant resection is an ideal option in patients with recurrent
symptoms of distal remnant pancreatitis who have a small <5cm viable pancreatic remnant. Due to the small size, internal drainage via pancreatico- enteric
anastomosis is a great option. Due to preceding inammation from necrotizing
pancreatitis and the subsequent scarring, the surrounding tissue planes will be
obliterated, and the remnant pancreas will likely be rmly adherent to the
splenic vessels and splenic hilum. While an attempt may be made to preserve
the spleen, splenic preservation is often extremely difcult due to dense postinammatory peripancreatic and splenic hilar scarring, and the scirrhous obliteration of normal planes that often leads to en bloc splenectomy. Due to this
possibility of splenectomy, these patients should receive post-splenectomy vaccinations preoperatively.
83
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85
Chapter 5
Acute Pancreatitis: Complications
JacksonA.Baril, RachelC.Kim, andEugeneP.Ceppa
Introduction
Acute pancreatitis (AP) is a systemic and local pathology that can affect nearly
every organ system. Therefore, complications of AP occur both near the pancreas,
its adjacent vessels and viscera as well as distant organs. These complications contribute signicantly to the overall mortality associated with pancreatitis and warrant
early recognition, careful monitoring, and prompt treatment. Many complications
are mitigated by treatment of the underlying AP.However, some require specic
complication-targeted interventions including medical therapy, therapeutic endoscopy, image-guided percutaneous interventions, and/or surgery via a multidisciplinary approach.
Visceral Artery Pseudoaneurysm andHemorrhage
Arterial complications in AP are uncommon yet carry a profound risk of mortality
up to 19–34% [1, 2]. The incidence of pseudoaneurysm or hemorrhagic complications of AP is between 1.3 and 10% [3–5]. The exact onset of arterial complications
varies dramatically with a mean time of detection ranging from 64days to 2.3years
after initial episode of pancreatitis [3, 5]. This correlates with other published data
J. A. Baril · R. C. Kim
Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
e-mail: jbaril@iu.edu; rckim@iu.edu
E. P. Ceppa (
Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
e-mail: eceppa@iu.edu
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_5
*)
87© The Author(s), under exclusive license to Springer Nature