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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1841_Библиотеки_им_академика_М_И_Перельмана.pdf
PANCREATITIS
13
Fig. 1.9 As the disc is excised, sutures are placed taking the full thickness of the
pseudocyst and stomach walls. Additional sutures may be required to ensure
haemostasis and accurate approximation.
Fig. 1.8 A Foley catheter is inserted and gentle traction applied, lifting the stomach
and pseudocyst forward and allowing a 2–3-cm disc to be excised.
PANCREAS
14
favour a laparotomy with cholecystectomy (if the patient still has a gallbladder)
and Roux-en-Y drainage.
The pseudocyst wall is treated in the same way as for pancreaticocystgastros-
tomy (although there is no adherent stomach wall) with aspiration and inser-
tion of a Foley catheter. A disc of the wall is excised and sent for histology and
a jejunal loop is then prepared. The technique of anastomosis is the same for
stomach or jejunal loop and the loop should be 70cm long (standard length
wherever we use an isolated loop). The jejunal loop is opened on its anti-
mesenteric border and, after evacuation of the contents of the pseudocyst, the
anastomosis is performed with interrupted full thickness 3/0 PDS sutures and
a single tube drain is left after washing out the abdomen.
Problems can occur dealing with very large pseudocysts, both intraopera-
tively and postoperatively. The usual intraoperative problem is bleeding from
the pseudocyst when it is opened and it is almost always associated with pseu-
docysts in the lesser sac. This can occasionally be dramatic and difficult to
control. These patients often have some signs such as abdominal pain and
sometimes a slight fall in the haemoglobin level. In those where the granulation
tissue making up the wall is responsible, this haemorrhage generally stops
spontaneously. Occasionally visceral vessels are involved but should be detecta-
ble on intraoperative ultrasound, particularly when duplex scanning is avail-
able which demonstrates flow within the cyst. This, together with aspiration
Fig. 1.10 Drainage of a pancreatic pseudocyst into a Roux loop. The anastomotic
technique is the same as for pancreaticocystgastrostomy although because the walls are
not fixed or fused the disc has to be completely excised before sutures can be inserted.
PANCREATITIS
15
(which may be heavily blood stained), should forewarn the surgeon. If unex-
pected significant bleeding is encountered it can be controlled by local pres-
sure and packing until its source can be identified. If bleeding from a visceral
vessel does occur, skilled assistance and better exposure are essential. Vessels
other than the major vessel trunks can be controlled by under running. We
have seen a patient with an unremarkable ultrasound with aspiration of clear
fluid but the superior mesenteric artery (SMA) running in the cyst ruptured
when it was opened. The SMA was repaired with a saphenous patch after initial
control with two Fogarty catheters inserted proximally and distally.
With very large pseudocysts, problems may occur postoperatively with cyst
emptying, particularly when the patient starts to eat. This generally resolves
as the cyst reduces in size but some patients may benefit from lying prone,
encouraging the cyst to drain. This is particularly important after a meal but
should also be encouraged at night if possible.
Ascites and pleural effusions
Ascites and pleural effusions are frequent findings after acute attacks of pan-
creatitis and they often occur together. The common aetiological factor is
hypoproteinaemia and, in the case of ascites, compression of the portal vein
exacerbates the problem and the ascites can be tense. This produces secondary
problems such as compartment syndrome, splinting of the diaphragm, and
problems eating. The majority of these symptoms will resolve after the acute
attack and do not need any specific treatment. Aspiration is not recommended
as this is, at best, a temporary expedient, introduces the risk of infection, and
removes valuable protein-rich fluid. Some patients will nevertheless need
treatment, usually due to mechanical problems. Chest drains are effective and
safe for pleural effusions and the ongoing fluid loss is generally small. With
ascites the situation is different and we find that the indication is a combina-
tion of a mechanical problem together with an undiagnosed source of sepsis.
With this combination of compartment syndrome and sepsis we are increas-
ingly resorting to laparoscopy, which allows a thorough washout and safe
placement of a drain, avoiding any inadvertent bowel injury. This is not
necessary with simply a tense ascitic collection.
Compartment syndrome
Compartment syndrome can occur together with ascites or alone due to small
bowel oedema, an inflammatory mass, or retroperitoneal swelling. The advent
of transducers has highlighted this problem and pressures can now be easily
measured by a Foley catheter in the urinary bladder. This is very valuable
when the trend is for increasing pressures and is associated with clinical signs
such as reduced urine output and increased ventilator pressures. Under these
PANCREAS
16
circumstances, after discussion with the Intensive Care Unit (ICU) staff, we
believe a laparotomy and laparostoma can be life saving.
Laparostoma ( Fig. 1.11 ) We use a transverse incision and a double layer bowel
bag sutured into the wound. This allows some control of the fluid loss and aids
postoperative management of the bowel. We also always leave tube drains in
potentially infected spaces (subphrenic, pelvic) as they may not be adequately
treated by the laparostoma.
If there is rapid resolution, we will attempt to close the wound at 10 days.
This is often just a loose approximation of the full thickness of the abdominal
wall using suction drainage (Redivac®) tubing as sutures. The majority of
patients are left to allow the wound to granulate and heal. Only about half of
these patients will require any intervention to treat the abdominal wall in the
long term (Fugger et al ., 1992 ).
Pancreatic necrosis
Our approach to pancreatic necrosis is becoming increasingly conservative as
the care of the patients in ICU improves and results of intervention continue
to disappoint.
Newer minimally invasive techniques are employed in some centres after
radiological placement of a wire and dilation of the tract to allow the entry of
Fig. 1.11 Transverse incision laparostoma with additional drains to subphrenic space
and pelvis.
PANCREATITIS
17
a urological resectoscope, or laparoscopic approaches to the collection through
the stomach (Gambiez et al ., 1998 ; Carter et al ., 2000 ; Horvath et al . 2001 ;
Castellanos et al . 2002 ; Connor et al ., 2003 ). The results are encouraging and
although they have not been shown to have an impact on the survival, they
may, however, reduce hospital stay (Carter et al ., 2000 ). We rarely operate on
these patients and now realize that even the presence of a progressive reduc-
tion in the vascularity of the pancreas or gas in the gland or retroperitoneal
tissue, in otherwise stable patients, is not an absolute indication for interven-
tion. Intervention should, however, be considered in young patients, where
the clinical condition is deteriorating and where a necrotic or devascularized
pancreas has been demonstrated. In these patients we favour a transverse inci-
sion, which gives fewer long-term wound problems (particularly if it is decided
to leave the wound as a laparostoma) and is easier to close. Necrotic pancreas
and fat should be removed as far as possible although no formal resection
should be attempted. The important point of this procedure is to ensure that
there are no residual pockets of infected material or interloop abscesses.
Washout is essential and despite usually leaving the abdominal wall as a
laparostoma, as in compartment syndrome, we also drain dependent areas
(pelvis, subphrenic space, lesser sac).
Pancreatic abscess
Pancreatic abscesses generally occur a few weeks after the initial attack, due to
the infection of an unresolved collection. Unlike pseudocysts, these should
always be treated to prevent not only continued sepsis but also to reduce
the risk of bleeding from the potentially involved visceral vessels. The vast
majority of these can be treated by a percutaneous approach under ultra-
sound or computed tomography (CT) guidance and we routinely ask the
radiologist to place two drains of as large a calibre as possible to allow irriga-
tion. This approach has dramatically reduced the number of abscesses
that require surgical intervention. This is now usually only necessary as part
of another procedure (laparostoma, pancreatic necrosis, open treatment of
pseudocyst).
Retroperitoneal bleeding
Retroperitoneal bleeding is fortunately a rare complication, occurring in only
1–3% of cases of acute pancreatitis (Stroud et al ., 1981 ). This is surprising with
estimates of pseudoaneurysm formation in acute pancreatitis being, in some
series, as high as 10% (Balthazar and Fisher, 2001 ). It produces many of the
same problems as free intraperitoneal haemorrhage or bleeding into an abscess
or pseudocyst. The onset is usually sudden and associated with collapse, often
in an already compromised patient. The bleeding is always difficult to localize
PANCREAS
18
and almost impossible to control surgically. A CT scan (if the patient is suffi-
ciently stable) will differentiate between retroperitoneal bleeding and bleeding
that otherwise might be surgically controlled (pseudocyst, abscesses). Only
when these treatable causes have been excluded should a non-surgical approach
be adopted.
Tamponade will stop the bleeding in some of these patients and interven-
tional radiologists are very successful if bleeding is from a large non-essential
vessel, such as the splenic or gastroduodenal arteries. While splenic artery
embolism is frequently associated with postoperative fever, and sometimes
splenic necrosis, it is by far the best approach to this difficult problem (Balthazar
and Fisher, 2001 ; Beattie et al ., 2003 ).
Chronic pancreatitis ( Figs. 1.12 and 1.13 )
Chronic pancreatitis is a different entity to acute pancreatitis and although a
few of the sequelae are the same, the only other similarity is the extreme range
of problems and subsequent prognosis (Conwell and Banks, 2008 ). A small
number of patients will present with a calcified gland having never had any
pain; conversely, severe disabling pain can be experienced, particularly in
young patients, with a gland which is virtually normal to all presently available
diagnostic modalities. The majority will, however, normally present with pain
or mechanical consequences (dilated bile duct, gastric outlet obstruction)
together with weight loss. The weight loss is usually a result of a reduced intake
associated with postprandial pain, early satiety due to some gastric outlet
obstruction, and a degree of exocrine insufficiency. Gastric outlet obstruction
is underestimated in these patients and the presence of a normal lumen at
endoscopy does not preclude it. Infiltration or fixity of the medial wall of the
duodenum prevents effective peristalsis and it is common in patients who are
found to have a patent, apparently normal lumen at gastroscopy or at ERCP to
have an abnormal contrast study (meal and follow through) with clearly
delayed gastric emptying.
In the management of these patients, any form of intervention or surgery is
reserved exclusively for those who have exhausted the medical armamentar-
ium. Judicious use of exocrine supplements, acid reduction, specialist pain
services, and control of diarrhoea and steatorrhoea is very effective in the
majority of patients. ‘Diarrhoea’ can be confusing and it is common, when
patients have loose stools and a diagnosis of chronic pancreatitis, to assume
the problem is fat malabsorption. Increasing the exocrine supplements makes
no appreciable difference in some patients whose stools are frequently most
loose when the pain is worse (a useful diagnostic feature), probably due to the
imbalance of pancreatic polypeptides.
PANCREATITIS
19
These patients should be encouraged to add an antidiarrhoeal agent when this
occurs, and this is usually effective. A small number will have intractable diar-
rhoea, which is long-standing, and any intervention in these patients it must be
understood (and explained), will generally worsen this and can make manage-
ment very difficult. In a small number of patients we have found that long-
acting somatostatin analogues such as lanreotide are helpful and work better
than could be expected from an understanding of the basic pharmacology.
Unfortunately, despite a multidisciplinary approach to these patients and
frequent review in specialist clinics, a number will inexorably deteriorate and
their quality of life becomes very poor with frequent domestic problems and
the inability to maintain employment. Holidays become impossible and con-
tinued weight loss, pain, and the need for medication, particularly analgesics,
Fig. 1.12 Initial assessment of chronic pancreatitis.
Mild pain no
complications
Pain and
complications
Observe
Gastric outlet
obstruction
Obstructive
jaundice
Gastric outlet
obstruction
Consider
definitive
surgery
Obstruction
jaundice
Mild pain
Severe pain
Intractable
pain
Medically fit
Unfit consider
bypass/
stents
Chronic
pancreatitis
Intractable
pain and
complications
Surgical
treatment if
medically fit
PANCREAS
20
Fig. 1.13 Surgical treatment of chronic pancreatitis.
Unfit
Gastrojejunostomy
Roux loop to CBD
Biliary and
gastric bypass
Beger/Frey
procedure
Total
Pancretectomy
Fit
Painful
Chronic
Pancreatitis
Assess gland
Dilated PD
Distal
Distal pancreatectomy
(spleen preserving)
Head of
pancreas
Whole gland
Drainage
procedure
Consider
Whipple’s (Beger
or Frey)
Pancreatic
stent
Pain relief
Painless with
complications
ERCP/
endoscopic
stenting
Gastric outlet
obstruction
Obstruction
jaundice
Both
Mass in head
of pancreas
Minimal change
disease/small
duct disease
PANCREATITIS
21
may make even routine activities very difficult. In these patients intervention
should be contemplated if investigations indicate that some of the symptoms
can be improved. When considering an approach, the nature of the gland is
important and we broadly separate the patients (for the sake of management
only) into large duct disease, small duct/minimal change disease, focal damage
or strictures, and an expanded head. Although the surgical approach to these
different pathological entities must be tailored, if medical therapy has failed
then the long-term problems are those of end-stage pancreatitis.
Large duct disease
Many attempts have been made to treat patients with large duct disease in the
belief that the increase in size results from an increased intraductal pressure,
which produces the pain. It is now known that the majority of these patients
have problems due to fibrosis and disease in the gland. This results in the duct
being pulled open with intraductal pressures that are generally not elevated.
A small number will nevertheless benefit from improved drainage, whether it
is endoscopic (generally temporary) or some form of surgery. In these patients,
our approach is initially endoscopic and we try to place pancreatic stents at
ERCP. Straight, 7-French stents are used rather than the short, 5-French pan-
creatic stents which are useful only for sphincter dysfunction. Problems can
occur in heavily calcified glands particularly with multiple intraduct stones,
which have a very rough surface (like coral). This may either prevent the wire
being advanced or will not allow the passage of even a 7-French stent. Usually,
however, this is technically possible and stents can be inserted ( Fig. 1.13 ). If
this produces an improvement, we leave the stent in situ for 6 weeks before
removing it. A recurrence of the symptoms, which is relieved, again by a sec-
ond endoscopically placed stent some weeks later is considered an excellent
indication that surgical drainage is likely to produce a significant long-term
improvement in symptoms.
In these patients there are a number of options such as the Puestow proce-
dure or recent variations such as the Frey procedure (Frey and Amikura, 1994 ;
Ho and Frey, 2001 ). However, the improvement in symptoms is rarely perma-
nent and generally lasts 2–5 years. We consequently prefer a smaller surgical
procedure, especially in young patients, to minimize the problems with any
further procedures that may become necessary. We employ a simple pancreati-
codochogastrostomy with good effect and very low complication rate and believe
that this represents an excellent compromise, draining the duct effectively by
means of a relatively straightforward procedure (using a transverse incision in
case of further pancreatic procedures).
PANCREAS
22
Pancreaticodochogastrostomy ( Figs. 1.14 – 1.16 ) The stomach is mobilized
from the front of the pancreas and the pancreatic duct identified by ultra-
sound. The duct is opened longitudinally and the stones removed as far as
possible.
A suitable T-tube (20–24 French) is inserted and sutured in place with 3/0 or
4/0 PDS ( Fig. 1.16 ). The T-tube is then routed through the back wall of the
stomach, the front wall of the stomach, and the abdominal wall.
Fig. 1.14 The duct is opened longitudinally.
Fig. 1.15 Stones are removed as far as possible.