Step 8: Manage complications and surgery

(A)Pseudocyst

•A pseudocyst is a collection of pancreatic juice, which is enclosed by a wall of granulation tissue. This takes at least 4 weeks to form.

•Drainage—percutaneous ultrasound-guided endoscopic or surgical—is required in those with large and/or symptomatic pseudocysts.

•The common complication of the pseudocyst includes compression of adjacent structures, rupture, infection, and bleeding in 5% of cases.

(B)CT-guided drainage of infected collection

•Multiple drains may be required.

(C)Surgery

•This is indicated in the following conditions:

–Pancreatic necrosectomy is advised in patients of infected pancreatic necrosis not doing well or when percutaneous/other techniques are not possible. Effort should be made to delay intervention to the fourth week as the results before that are not good.

–Pancreatic necrosis with pseudoaneurysms and massive intra-abdominal hemorrhage is best managed by angiographic embolization.

–Abdominal compartment syndrome in which percutaneous/other drainage techniques are not successful.

–Local complications of the pseudocyst.

•Bowel infarction.

(D)Controversial indications of surgery

•Extensive (>50%) sterile pancreatic necrosis with persisting multiple-organ failure despite intensive care therapy.

•Most surgeons avoid surgery for this indication as this is associated with increased mortality.

Step 9: Removal of the gallbladder

•Removal of the gallbladder should be scheduled early to avoid recurrence of biliary pancreatitis (30%).

•In severe attacks, it is recommended to wait 4–6 weeks to allow inflammation to subside.

•The laparoscopic approach has proved to be feasible and safe, even in cases where surgical debridement is required.

Suggested Reading

1.Talukdar R, Vega Santhi S. Early management of severe acute pancreatitis. Curr Gastroentrol Rep. 2011;13:123–30.

A recent article on the early management of acute severe pancreatitis

2.Gardner TB, Vege SS, Chari ST, Petersen BT, Topazian MD, Clain JE, et al. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology. 2009;9:770–6.

Patients with severe acute pancreatitis who do not receive at least one-third of their initial 72-h cumulative intravenous fluid volume during the first 24 h are at risk of greater mortality than those who are initially resuscitated more aggressively.

3.Jafri NS, Mahid SS, Idstein SR, Hornung CA, Galandiuk S. Antibiotic prophylaxis is not protective in severe acute pancreatitis: a systematic review and meta-analysis. Am J Surg. 2009;197:806–13.

Antibiotic prophylaxis of SAP does not reduce mortality or protect against infected necrosis, or frequency of surgical intervention.

4.Petrov MS, Pylypchuk RD, Emelyanov NV. Systematic review: nutritional support in acute pancreatitis. Aliment Pharmacol Ther. 2008;28:704–12.

The use of either enteral or parenteral nutrition, in comparison with no supplementary nutrition, is associated with a lower risk of death in acute pancreatitis. Enteral nutrition is associated with a lower risk of infectious complications compared with parenteral nutrition.

5.Forsmark CE, Baillie J. AGA Institute technical review on acute pancreatitis. Gastroenterology. 2007;132:2022–44.

6.Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174:331–6.

A CT severity index, based on a combination of peripancreatic inflammation, phlegmon, and the degree of pancreatic necrosis as seen at initial CT study, was developed. Patients with a high CT severity index had 92% morbidity and 17% mortality; patients with a low CT severity index had 2% morbidity, and none died.

Website

1. http://gut.bmjjournals.com/cgi/content/full/54/suppl_3/iii1