PANCREATITIS

  ACUTE PANCREATITIS   (see Gastroenterology Notes )   usually no surgical management in uncomplicated acute pancreatitis  ...

 

ACUTE PANCREATITIS

 

(see Gastroenterology Notes)

 

1. usually no surgical management in uncomplicated acute pancreatitis 
2. surgical indications in acute pancreatitis
   • secondary pancreatic infections - abscess, infected pseudocysts/necrosis
   • gallstone-associated pancreatitis
   • uncertainty of clinical diagnosis
   • worsening clinical condition despite optimal supportive care

Complications

Pseudocyst (2-10%)

1. collection of pancreatic secretions in a cyst lacking true epithelium
2. risk of rupture, hemorrhage and infection (rare)
3. 2-3 weeks post-attack: persistent pain, fever, ileus, mass, nausea/vomiting, early satiety, persistent elevation of amylase
4. 40% resolve spontaneously within 6-12 weeks (keep NPO and on TPN)
5. Diagnosis: clinical, U/S, CT
6. Treatment: internal (prefered) or external drainage (latter if infected or sick patient) once pseudocyst matures
7. biopsy to rule out malignancy
8. recurrence rate 10%

Abscess (5%)

1. 1-4 weeks post-attack: fever, toxic, abdominal pain, distention
2. Diagnosis: increased amylase, increased AST/ ALT (50%), elevated WBC, CT (fluid and gas)
3. high mortality - requires extensive surgical debridement and broad-spectrum antibiotics
   

Ascites

1. secondary to pseudocyst disruption (common) or direct pancreatic duct disruption
2. diagnose by paracentesis: high amylase, high protein
3. treatment: NPO, TPN 2-3 weeks, somatostatin
4. ERCP if not resolved to determine anatomy; Rou-en-Y jejunostomy to site of leak
   

Necrosis

1. diagnosis by CT
2. treatment: debridement

Hemorrhage

1. erosion of arterial pseudoaneurysm secondary to pseudocyst, abscess, or necrotizing pancreatitis
2. Clinical presentation: increased abdominal mass, abdominal pain, hypotension
3. Diagnosis: angiography
4. Treatment: immediate surgery
   

sepsis

MOSF

 

prognosis of all complications

1. 80% improve rapidly
2. 20% have at least one complication from which 1/3 die

CHRONIC PANCREATITIS

 

(see Gastroenterology Notes)

Surgical treatment

1. indications for surgical treatment: debilitating abdominal pain, CBD
   obstruction, duodenal obstruction, persistent pseudocyst
2. ERCP for planning surgical management - dilated ducts with areas of stricture (chain of lakes)
3. drainage procedure if ducts > 8 mm
4. Puestow (longitudinal pancreatico-jejunostomy)
• 80-90% have pain relief, but 5 years post-op only 50-60% remain pain-free
5. Whipple (pancreaticoduodenectomy) 80% have pain relief
6. pancreatectomy
• use when no dilated ducts
• amount of resection depends on disease focus (i.e. limited vs. subtotal vs. total pancreatectomy)
7. do not percutaneously access a pseudocyst unless immediate drainage of infection required.  Goal is to allow wall of  pseudocyst to mature (3-4 weeks) followed by internal drainage through stomach