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19 Acute Pancreatitis 17 7
subcostal incision. The area of necrosis can be accessed through the transverse
mesocolon, but to avoid injury to mesenteric vessels, entering the lesser sac through
the gastrocolic ligament allows a wider exposure of the lesser sac and is usually
more prudent.
A newer approach to necrosectomy in selected patients is by minimally in-
vasive techniques, such as peroral endoscopic interventional techniques or percu-
taneous and/or laparoscopic techniques. Using the former method, a skilled
interventional endoscopist accesses the area of necrosis via a transluminal, endoscopically created duodenotomy or gastrotomy, in the area of the duodenum or
stomach where the pancreatic necrosis is adjacent and adherent; typically, this
area bulges into the lumen and is relatively obvious. The necrotic material is re-
moved and debrided using a combination of endoscopic graspers and irrigation.
The resultant cavity is then drained by a series of transnasal or internal pigtail
catheters. Good outcomes require substantial experience on the part of the endoscopist. In the future, this approach will likely be the procedure of choice for treating patients with isolated necrosis and WOPN accessible via the gut lumen.
Similarly, a laparoscopic approach can be employed for accessible localized areas
of necrosis. Currently, however, the standard therapy remains open debridement.
Practicing surgeons should be comfortable and well versed with open debridement as their primary approach.
Debridement for Infected Necrosis
Once infected necrosis is diagnosed, some form of intervention is indicated. Although minimally invasive techniques for treating infected necrosis
have been described, such techniques should be reserved for those centers
experienced with these techniques. Open debridement via laparotomy remains,
however, the standard of care in most centers. The goals of operative treat-
ment are:
As complete a necrosectomy as possible.·
Allow egress of resultant exudative fluid or extravasated pancreatic exo-·
crine secretions.
Treat the cause of biliary pancreatitis if safe and possible (e.g., cholelithia-·
sis, choledocholithiasis).
Provide a means for enteral nutrition (feeding jejunostomy) or gastric de-·
compression (tube gastrostomy)—necrosis of the head and uncinate process
often leads to a prolonged mechanical or functional outlet obstruction.
There are four main approaches to the operative treatment of infected
necrosis. The mortality rates for each approach are generally felt to be similar,
but complication types and rates differ.
178 Joshua G. Barton · Michael G. Sarr · Moshe Schein
1. Necrosectomy and closed drainage: one operation with fascial closure,
multiple drains placed within necrosectomy site.
Advantages Disadvantages
One-stage
necrosectomy
Low mortality High recurrent abscess rate requiring reoperation
2. Necrosectomy and open drainage: marsupialization of lesser sac by suturing
omentum to fascial edges with open packing (peritoneostomy). This allows the
area of necrosectomy to be re-dressed repeatedly, allegedly at the bedside.
Advantages Disadvantages
Open drainage Increased risk of hemorrhage and fistula
Few recurrent abscesses Open wound—loss of abdominal domain, fluid
3. Necrosectomy and closed lavage: operative debr idement followed by continu-
ous, high-volume lavage of pancreatic bed via operatively placed drains.
Potential for overaggressive debridement with
subsequent hemorrhage
or repeated percutaneous drainage (20–40%)
formation
loss
Advantages Disadvantages
One-stage necrosectomy Difficult to treat extensive necrosis extending
inferiorly in the retroperitoneum
One operation (intended) Actual or reintervention rate to treat
recurrence or complications as high as 20–40%
4. Planned repeated necrosectomy
(a) Debridement followed by temporary abdominal closure
(b) Return to the operating room in 48 hrs and as often as needed for further
debridement
Advantages Disadvantages
By returning to the OR, subsequent
issues can be addressed (persistent
areas of necrosis, enteral access,
bile duct exploration, etc.)
Very low unplanned reoperative rate Loss of domain—abdominal wall defect
Repeated anesthetics and
reoper ation(s)
19 Acute Pancreatitis 17 9
Surgical Wisdom
The key advance in the last decade that has allowed surgeons to avoid early
operation for pancreatic necrosis is the aggressive use of intravenous antibiotics.
Broad-spectrum antibiotics should be initiated prophylactically in all patients
with severe pancreatitis early on, especially patients with SIRS, MOD, and sepsis
syndrome.
During operations for pancreatic necrosis, blood loss can be minimized by
avoiding overly aggressive sharp debridement. One should focus on bluntly removing only the tissue that gives way easily. Sponge forceps or the fingertips are
good instruments for debriding necrotic pancreatic and peripancreatic tissue. If
the completeness of debridement is in doubt, temporary closure of the abdomen
and return to the operating room 48 hrs later can be advantageous.
Pseudocysts
Of those with AP, fluid collections occur in 5–10% of patients. Over 80% of
these collections resolve spontaneously. A pseudocyst usually follows extravasation
of pancreatic ductal secretions secondary to duct disruption. The ductal communication persists, and the fluid collection organizes into discrete areas surrounded by
a fibrous capsule. At the time of diagnosis, pseudocysts often but not always communicate with the pancreatic ductal system. Nevertheless, one must assume that
communication with the ductal system exists; therefore, the type of operative intervention must be designed to manage this presumed communication.
Some form of active intervention is reserved typically for symptomatic
pseudocysts. Symptoms are most often related to pain. In most patients, it is pru-
dent to allow the pseudocyst to mature beyond 6 weeks; this approach allows sufficient time not only for potential resolution but also for the fibrous capsule of
granulation tissue to mature enough to hold sutures to allow internal enteric
drainage.
Prior to any procedure for a pseudocyst, an endoscopic retrograde cholangiopancreatography (ERCP) is usually advisable to assess for the site of connection between the pseudocyst and pancreatic duct as well as to look for associated
ductal strictures proximal to the connection to the duct (and possibly for biliary
obstruction that would require treatment as well either before or at the time of
operative intervention). Pancreatic ductal strictures should be addressed prior to
intervention, either via endoscopic treatment at the time of the initial ERCP or
by operative treatment at the time of operative internal drainage. The ERCP can
show etiologic causes of pancreatitis from the biliary tree (stones, duodenal
diverticula).
180 Joshua G. Barton · Michael G. Sarr · Moshe Schein
Approaches to Pseudocyst Intervention
Percutaneous drainage. This approach is less desirable due to the possibility of formation of a pancreatico-cutaneous fistula. This technique should be
reserved for when the cyst wall has not matured and intervention is required.
The usual indication in this setting would be infection of the pseudocyst (per the
Atlanta classification, this would technically be a “pancreatic abscess”). In any
situation, minimizing the risk of cutaneous fistulas and complete resolution of
the cyst requires absence of any proximal pancreatic ductal obstruction.
Open internal drainage. Internal drainage by either transgastric cyst-
gastrostomy, transduodenal cyst-duodenostomy, or cyst-jejunostomy to a Roux-en-Y
limb is the gold standard for internal drainage of pancreatic pseudocysts. Several factors make internal drainage superior to other means. Internal drainage is the most
flexible means of drainage in terms of accessing cysts in myriad locations. Perhaps the
biggest advantage is that biopsy of the cyst wall is attained easily; this biopsy allows
excluding cystic neoplasms in patients with a less-classic history of pancreatitis.
Of the various forms of operative internal drainage, enteric drainage into ·
the stomach is the most common route. To ascertain whether a cyst-gastrostomy
is possible, preoperative imaging should ensure the presence of a pseudocyst
adherent closely to the posterior wall of the stomach (> Fig. 19.5a). The procedure
can be performed through a small upper midline or left subcostal incision. A
gastrotomy is first made in the anterior wall of the stomach, which should reveal the extraluminal pseudocyst bulging into the posterior gastric wall. Needle
aspiration of pancreatic fluid will confirm the location of the cyst. An oval-shaped,
full-thickness incision of the fused stomach and cyst walls is then made. A fullthickness biopsy of the cyst wall should be sent for pathologic analysis to rule out
a cystic neoplasm. A formal cyst-gastrostomy anastomosis is then accomplished
by “reefing” the fused stomach/pseudocyst with permanent suture material or
with long-lasting absorbable suture to prevent bleeding.
If the pseudocyst is located in areas not adjacent to the posterior stomach, two ·
other options exist. Pseudocysts arising from the pancreatic head may be amenable
to transduodenal drainage via cyst-duodenostomy (> Fig. 19.5b) in a fashion simi-
lar to transgastric cyst-gastrostomy. In other locations not adherent to stomach or
duodenum, the pseudocyst may be drained into a Roux-en-Y limb of jejunum.
Minimal access drainage. The mentioned open procedures can all be accomplished via laparoscopic or laparoendoscopic means depending on the experience
of the surgeon. The most common and the least technically complex operation is a
laparoscopic cyst-gastrostomy. As with an open cyst-gastrostomy, an anterior gastrotomy is performed into the stomach, and a square or triangular shaped cystgastrostomy is made in the posterior gastric wall with endoscopic stapling devices.
Peroral endoscopic drainage. In a procedure similar to endoscopic treatment of pancreatic necrosis, cysts adjacent to the stomach or duodenum can be
19 Acute Pancreatitis 181
Fig. 19.5. (a) Computed tomography revealing a pseudocyst closely adherent to the
posterior wall of the stomach suitable for cyst-gastrostomy drainage. (b) Computed tomography revealing a pseudocyst arising from the head of the pancreas in close apposition to the duodenum suitable for transduodenal drainage into the duodenum
drained endoscopically. A cystotomy is made through the wall of the duodenum
or stomach into the adjacent pseudocyst. This entry into the pseudocyst is then
kept open via multiple, internal, pigtail catheters. This procedure has produced
excellent outcomes. Currently, endoscopic drainage of pseudocysts is eclipsing
open internal drainage as the procedure of choice in many centers.
Pancreatic Fistula
Pancreaticocutaneous fistulas may complicate the operative treatment of
pancreatic necrosis. Fortunately, most fistulas can be managed nonoperatively.
Once a fistula is diagnosed, initiation of bowel rest and parenteral nutrition
are traditionally recommended. Tube feeding directly into the jejunum, thus
182 Joshua G. Barton · Michael G. Sarr · Moshe Schein
“bypassing” the duodenum and pancreas, does the same job. ERCP can be performed to define the pancreatic ductal anatomy and both to stent any ductal
obstruction proximal to the fistula and to perform a pancreatic ductal sphincterotomy. For fistulas that persist after a trial of bowel rest, a regular diet can be
reintroduced provided there is no increase in fistula output.
For persistent fistulas, it is reasonable to continue conservative therapy for 6
months. Thereafter, the likelihood of successful closure diminishes, and operative
treatment should be entertained. Waiting 6 months not only provides adequate
time for spontaneous closure of the fistula but also allows the abdominal cavity as
a whole to recover such that operating becomes easier and the fistula tract matures.
The ductal anatomy and, specifically, the point at which the fistula communicates
with the pancreatic duct dictate which operation is most appropriate. For fistulas
in the body and tail of the pancreas, a distal pancreatectomy would be most prudent. For more proximal fistulas, anastomosing a Roux-en-Y limb of jejunum to the
fistula opening as an onlay pancreatojejunostomy is the best means of treatment.
Conclusion
Acute pancreatitis, while typically a mild disease, can be devastating in its
severe form. The last two decades have witnessed major advances not only in
our understanding of the etiology and pathogenesis of the disease but also in its
treatment—necrosectomy, antibiotic suppression/prophylaxis, minimal-access
approaches, delayed necrosectomy, and more. Knowing the indications for operative intervention will have an impact not only on the morbidity but also on the
mortality of the disease.
operate too early in the course of the disease, and to do too much, or in the secondary
or septic phase of the disease to operate too late and to do too little.” (Kenneth
W. Warren, 1911–2001)
Editorial Commentary
Indications for pancreatic necrosectomy are suggested in > Table 19.2.
Drs. Sarr and Barton described the various operative strategies but which
is the “best”?
It appears that the more aggressive approach (planned reoperations and laparostomy) is associated with increased morbidity, including hemorrhage, fistulization
of the transverse colon, and abdominal wall defects. Each of the methods described
may succeed in a certain patient and should be used selectively depending on the
19 Acute Pancreatitis 183
Table 19.2. Indication for pancreatic necrosectomy (Uhl et al. 2002)
Presence of infected pancreatic necrosis (IPN) on CT (extraintestinal air) or
fine-needle aspiration biopsy culture
Irreversible clinical deterioration despite maximum supportive care for at least
2 weeks from onset of symptoms
Suspicion of IPN in the absence of above features (item 1) in patients with more than
50% of their pancreas assessed as necrotic on CT
Extensive (>50%) necrosis and a prolonged ileus or continuing symptoms (pain,
vomiting, inability to eat) despite resolution of distant organ dysfunction
extent of IPN and severity of the illness in the individual patient. The less-aggres-
sive approach may suffice in a patient with a localized process and small quantity of
necrosis. Extensive IPN, however, may require the most aggressive treatments.
Practical Operative Points for the Tyro
When operating on pancreatic necrosis or IPN, you must understand that it
is often impossible to be performing a definitive debridement. Leave the rest for
tomorrow (i.e., reoperation). Overenthusiastic debridement will debride the bowel
(which will leak) or adjacent vessels (which will bleed). Follow the necrotizing
process down the retroperitoneum; it may extend behind the left and right colon
into the pelvis. Only the soft necrotic black/gray Camembert cheese-like material
should be removed. By using your fingers or blunt sponge forceps to pick up the
material, you will avoid the hard, nonnecrotic pancreas and other structures.
Enter the lesser sac from whichever direction is easiest, but expose it com-
pletely. Try not to add insult to injury. This is easier said than done while burrow-
ing within inflamed and friable tissues. Safeguard the vessels in the transverse
mesocolon; these are commonly injured during transmesocolon entry into the
lesser sac or by drains placed through this route. It is tempting to remove the
spleen, which may take part in an inflammatory mass in the pancreatic tail. This is
not necessary; try not to injure the spleen during reoperations. The adherent duodenum and loops of small bowel are frequently injured during reoperations; this,
together with the corrosive action of activated pancreatic enzymes, causes intestinal leaks. Be extremely gentle with the bowel and avoid rigid drains near the duodenum for they will erode. Often after necrosectomy, there is diffuse ooze from the
resulting cavity. Pack it. Try not to place packs directly on exposed veins; they will
be eroded and bleed. Safeguard the omentum and place it between the packs and
exposed vessels. For more on the conduct of laparostomy, see > Chap. 52.2.
184 Joshua G. Barton · Michael G. Sarr · Moshe Schein
Final Words
The proper management of severe AP requires that you understand its natural history and be armed with lots of patience. During the early phases of the
disease “our patience will achieve more than our force” (Edmund Burke); later,
when called to operate on necrotic and infected complications, remember that
“patience and diligence, like faith, remove mountains” (William Penn). If you
can, refer these patients to centers of excellence (occasionally of arrogance),
which have the expertise to do the job better, and less invasively, than you.
“Everything in surgery is complicated until one learns to do it well, then it is
easy.” (Robert E. Condon)
Reference
Uhl W, Warshaw A, Imrie C, et al. (2002) International Association of Pancreatology.
Guidelines for the surgical management of acute pancreatitis. Pancreatology 2:565–573.
Gallbladder and Biliary
Emergencies
Moshe Schein · Ahmad Assalia ·
Gary Gecelter · B. Ra mana
In dropsy of the gallbladder … and in gallstones we should not wait ‘til the
patient’s strength is exhausted, or ’til the blood becomes poisoned with bile,
producing hemorrhage; we should make an early abdominal incision, ascertain
the true nature of the disease, and then carry out the surgical treatment that
necessities of the case demand. (James Marion Sims, 1813–1883)
20
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_20, © Springer-Verlag Berlin Heidelberg 2010
185
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