SURGICAL MANAGEMENT OF ACUTE PANCREATITIS T.KIRAN KUMAR IInd YEAR PG
INTRODUCTION • A very common disease with increasing incidence over past 20 years. • All age groups and both genders vulnerable. • Multiple causes. • Highly variable disease course. • High mortality rates even in the centers of excellence . • Difficult to standardize the treatment options.
SURGICAL INTERVENTION-INDICATIONS ABSLOUTE INDICATION ABSLOUTE INDICATION ABSLOUTE INDICATION ABSLOUTE INDICATION INFECTED PANCREATIC NECROSIS INFECTED PANCREATIC NECROSIS INFECTED PANCREATIC NECROSIS INFECTED PANCREATIC NECROSIS OBLIGATORY INDICATION PERFORATED VISCUS HAEMORRHAGE OBLIGATORY INDICATION OBLIGATORY INDICATION OBLIGATORY INDICATION PERFORATED VISCUS HAEMORRHAGE PERFORATED VISCUS HAEMORRHAGE PERFORATED VISCUS HAEMORRHAGE SEVERE STERILE NECROSIS SEVERE STERILE NECROSIS SEVERE STERILE NECROSIS SEVERE STERILE NECROSIS DEBATED INDICATION DEBATED INDICATION DEBATED INDICATION DEBATED INDICATION SYMPTOMATIC ORGANIZED NECROSIS SYMPTOMATIC ORGANIZED NECROSIS SYMPTOMATIC ORGANIZED NECROSIS SYMPTOMATIC ORGANIZED NECROSIS OBSELETE INDICATION DIAGNOSTIC UNCERTAINITY OBSELETE INDICATION OBSELETE INDICATION OBSELETE INDICATION DIAGNOSTIC UNCERTAINITY DIAGNOSTIC UNCERTAINITY DIAGNOSTIC UNCERTAINITY 3
Management - Overview Mild Mild Mild Mild Acute pancreatitis Acute pancreatitis Acute pancreatitis Acute pancreatitis Severe Severe Severe Severe ICU admission ICU admission ICU admission ICU admission Symptomatic Symptomatic Symptomatic Symptomatic improvment Supportive treatment improvment improvment improvment Supportive treatment Supportive treatment Supportive treatment treatment treatment treatment treatment Ct abdomen>72hrs Ct abdomen>72hrs Ct abdomen>72hrs Ct abdomen>72hrs FNA if no improvement for FNA if no improvement for FNA if no improvement for FNA if no improvement for No infection No infection No infection No infection 2 weeks 2 weeks 2 weeks 2 weeks Continue Continue Continue Continue infected infected infected infected supportive supportive supportive supportive Plan discharge Plan discharge Plan discharge Plan discharge treatment treatment treatment treatment Surgical Surgical Surgical Surgical improvement improvement No improvement No improvement improvement improvement No improvement No improvement intervention intervention intervention intervention
Surgical interventions PANCREATIC RESECTIONS - PANCREATIC RESECTIONS - PANCREATIC RESECTIONS - PANCREATIC RESECTIONS - HISTORICAL HISTORICAL HISTORICAL HISTORICAL PANCREATIC NECROSECTOMY – PANCREATIC NECROSECTOMY PANCREATIC NECROSECTOMY PANCREATIC NECROSECTOMY – – – � DEBRIDEMENT OF NECROTIC PANCREATIC TISSUE DEBRIDEMENT OF NECROTIC PANCREATIC TISSUE DEBRIDEMENT OF NECROTIC PANCREATIC TISSUE DEBRIDEMENT OF NECROTIC PANCREATIC TISSUE � CURRENT STANDARD OF PRACTICE CURRENT STANDARD OF PRACTICE CURRENT STANDARD OF PRACTICE CURRENT STANDARD OF PRACTICE MINIMAL INVASIVE INTERVENTIONS MINIMAL INVASIVE INTERVENTIONS MINIMAL INVASIVE INTERVENTIONS MINIMAL INVASIVE INTERVENTIONS – – – – � CURRENT INTEREST OF RESEARCH CURRENT INTEREST OF RESEARCH CURRENT INTEREST OF RESEARCH CURRENT INTEREST OF RESEARCH � RAPIDLY BEING ACCEPTED IN PRACTICE RAPIDLY BEING ACCEPTED IN PRACTICE RAPIDLY BEING ACCEPTED IN PRACTICE RAPIDLY BEING ACCEPTED IN PRACTICE
Necrosectomy – Principles GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS ESSENTIAL FOR IDENTIFICATION OF ESSENTIAL FOR IDENTIFICATION OF ESSENTIAL FOR IDENTIFICATION OF ESSENTIAL FOR IDENTIFICATION OF – – – – � ALL AREAS OF NECROSIS ALL AREAS OF NECROSIS ALL AREAS OF NECROSIS ALL AREAS OF NECROSIS � LOCALIZED COLLECTIONS LOCALIZED COLLECTIONS LOCALIZED COLLECTIONS LOCALIZED COLLECTIONS � WIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUE WIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUE WIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUE WIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUE UNROOFING OF ALL COLLECTIONS UNROOFING OF ALL COLLECTIONS UNROOFING OF ALL COLLECTIONS UNROOFING OF ALL COLLECTIONS STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION AND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMY AND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMY AND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMY AND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMY
Necrosectomy -Approach THROUGH THROUGH THROUGH THROUGH GASTROCOLIC GASTROCOLIC GASTROCOLIC GASTROCOLIC BILATERAL SUBCOSTAL BILATERAL SUBCOSTAL BILATERAL SUBCOSTAL BILATERAL SUBCOSTAL PANCREAS & PANCREAS & PANCREAS & PANCREAS & LIGAMENT LIGAMENT LIGAMENT LIGAMENT INCISION INCISION INCISION INCISION LESSER SAC LESSER SAC LESSER SAC LESSER SAC THROUGH THROUGH THROUGH THROUGH TRANSVERSE - TRANSVERSE - TRANSVERSE - TRANSVERSE - MIDLINE INCISION MIDLINE INCISION MIDLINE INCISION MIDLINE INCISION MESOCOLON MESOCOLON MESOCOLON MESOCOLON
The lesser sac can be approached through the base of the mesocolon; attention should be paid to avoid injury to the middle colic artery. 8
Approach to lesser sac via gastrocolic ligament.
Necrosectomy- technique • IDENTIFICATON OF VIABLE AND NECROTIC PANCREATIC TISSUE • BLUNT FINGER DISSECTION OF THE NECROTIC TISSUE • AVOID OVERZELOUS HANDLING OF INFLAMED & DOUBTFUL VIABLE TISSUE � RELEASE OF SPLENIC/HEPATIC RELEASE OF SPLENIC/HEPATIC RELEASE OF SPLENIC/HEPATIC RELEASE OF SPLENIC/HEPATIC • CONTROL OF BLEEDING FLEXURES FLEXURES FLEXURES FLEXURES � EXTENSIVE KOCHERIZATION EXTENSIVE KOCHERIZATION EXTENSIVE KOCHERIZATION EXTENSIVE KOCHERIZATION • ADDITIONAL EXPOSURE � OPENENING OF PARACOLIC GUTTERS, OPENENING OF PARACOLIC GUTTERS, OPENENING OF PARACOLIC GUTTERS, OPENENING OF PARACOLIC GUTTERS, PARARENAL SPACES AND PARARENAL SPACES AND PARARENAL SPACES AND PARARENAL SPACES AND GASTROHEPATIC LIGAMENT GASTROHEPATIC LIGAMENT GASTROHEPATIC LIGAMENT GASTROHEPATIC LIGAMENT
Post-Necrosectomy management OPTIONS OPTIONS OPTIONS OPTIONS PLANNED PLANNED PLANNED PLANNED CLOSED DRAINAGE CLOSED LAVAGE CLOSED DRAINAGE CLOSED DRAINAGE CLOSED DRAINAGE CLOSED LAVAGE CLOSED LAVAGE CLOSED LAVAGE REXPLORATIONS REXPLORATIONS REXPLORATIONS REXPLORATIONS LAPAROSTOMY/ LAPAROSTOMY/ LAPAROSTOMY/ LAPAROSTOMY/ TEMPORARY ABDOMINAL TEMPORARY ABDOMINAL TEMPORARY ABDOMINAL TEMPORARY ABDOMINAL MULTIPLE DRAINS IN THE MULTIPLE DRAINS IN THE MULTIPLE DRAINS IN THE MULTIPLE DRAINS IN THE DRAINS PLACED IN LESSER DRAINS PLACED IN LESSER DRAINS PLACED IN LESSER DRAINS PLACED IN LESSER CLOSURE CLOSURE CLOSURE CLOSURE LESSER SAC LESSER SAC LESSER SAC LESSER SAC SAC SAC SAC SAC RE-EXPLORATION ONCE IN RE-EXPLORATION ONCE IN RE-EXPLORATION ONCE IN RE-EXPLORATION ONCE IN RETAINED TILL OUTPUT RETAINED TILL OUTPUT RETAINED TILL OUTPUT RETAINED TILL OUTPUT CONTINOUS CONTINOUS CONTINOUS CONTINOUS 2-3 DAYS TILL ALL 2-3 DAYS TILL ALL 2-3 DAYS TILL ALL 2-3 DAYS TILL ALL IS INSIGNIFICANT IS INSIGNIFICANT IS INSIGNIFICANT IS INSIGNIFICANT POSTOPERATIVE LAVAGE POSTOPERATIVE LAVAGE POSTOPERATIVE LAVAGE POSTOPERATIVE LAVAGE NECROTIC MATERIAL NECROTIC MATERIAL NECROTIC MATERIAL NECROTIC MATERIAL TILL EFLUENT IS CLEAR TILL EFLUENT IS CLEAR TILL EFLUENT IS CLEAR TILL EFLUENT IS CLEAR CLEARS CLEARS CLEARS CLEARS
Necrosectomy and closed packing with stuffed Penrose drains.
closed lavage of the lesser sac.
The lesser sac is closed by suturing the greater omentum to the transverse colon for closed postoperative lavage.
Comparison of options STUDIES NO. OF MORALITY RE- GI FISTULA BLEEDING BETWEEN PATIENTS EXPLORATION 1980-1998 n CLOSED CLOSED 236 236 6-30% 6-30% 16-40% 16-40% 3-26% 3-26% 1-30% 1-30% CLOSED CLOSED 236 236 6-30% 6-30% 16-40% 16-40% 3-26% 3-26% 1-30% 1-30% DRAINAGE DRAINAGE DRAINAGE DRAINAGE PLANNED PLANNED 297 297 14-27% 14-27% 100% 100% 5-40% 5-40% 5-29% 5-29% PLANNED PLANNED 297 297 14-27% 14-27% 100% 100% 5-40% 5-40% 5-29% 5-29% RE- RE- RE- RE- EXPLORATIO EXPLORATIO EXPLORATIO EXPLORATIO N N N N CLOSED 405 8-36% 9-64% 7-43% 5-13% CLOSED CLOSED CLOSED 405 405 405 8-36% 8-36% 8-36% 9-64% 9-64% 9-64% 7-43% 7-43% 7-43% 5-13% 5-13% 5-13% LAVAGE LAVAGE LAVAGE LAVAGE Maingot Maingot Maingot Maingot’ ’ ’ ’s s Abdominal operations -11 s s Abdominal operations -11 Abdominal operations -11 Abdominal operations -11 th th th th edition edition edition edition
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