Acute pancreatitis surgery: Difference between revisions

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==Overview==
==Overview==
[[Surgery]] in the treatment of acute pancreatitis is indicated for infected pancreatic necrosis, in cases of diagnostic uncertainty and in the presence of complications.
[[Surgery]] in the treatment of acute pancreatitis is indicated for [[infected]] [[pancreatic]] [[necrosis]], in cases of diagnostic uncertainty and in the presence of complications. Additionally, surgery is indicated for [[gallstone]] [[pancreatitis]] in order to resolve the underlying cause.
 
Surgical options include [[endoscopic retrograde cholangiopancreatography]] (ERCP), [[percutaneous]] drainage of peripancreatic fluids, [[retroperitoneal]] approach, [[laparoscopic]] surgery, or traditional open necrosectomy. Minimally invasive approaches are preferred; however, timing of the surgery is of utmost importance. Ideally, patients with an indication for surgery are to be stabilized for up to four weeks and given [[antibiotics]] in the interim. After the development of walled off necrosis, surgery is considered more safe and effective.<ref name="acutepancreatitis">{{cite journal
| last      = Forsmark
| first      = Chris E.
| last2      = Vege
| first2    = Santhi Swaroop
| last3      = Wilcox
| first3    = Mel
| date      = November 17,2016
| title      = Acute Pancreatitis
| url        = http://www.nejm.org/doi/full/10.1056/NEJMra1505202
| journal    = The New England Journal of Medicine
| volume    =
| issue      =
| pages      = 1972 - 1981
| doi        = 10.1056/NEJMra1505202
| pmc        =
| pmid      =
| access-date = November 25,2016
| name-list-format = vanc
}}</ref>


==Surgery==
==Surgery==
Surgery is indicated for
According to the American college of gastroenterology, following are the guidelines for surgery in acute pancreatitis:<ref name="pmid23896955">{{cite journal| author=Tenner S, Baillie J, DeWitt J, Vege SS, American College of Gastroenterology| title=American College of Gastroenterology guideline: management of acute pancreatitis. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 9 | pages= 1400-15; 1416 | pmid=23896955 | doi=10.1038/ajg.2013.218 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23896955  }}</ref><ref name="pmid17163108">{{cite journal |vauthors=Larson SD, Nealon WH, Evers BM |title=Management of gallstone pancreatitis |journal=Adv Surg |volume=40 |issue= |pages=265–84 |year=2006 |pmid=17163108 |doi= |url=}}</ref><ref name="pmid7811319">{{cite journal |vauthors=Steinberg W, Tenner S |title=Acute pancreatitis |journal=N. Engl. J. Med. |volume=330 |issue=17 |pages=1198–210 |year=1994 |pmid=7811319 |doi=10.1056/NEJM199404283301706 |url=}}</ref><ref name="pmid17032204">{{cite journal |vauthors=Banks PA, Freeman ML |title=Practice guidelines in acute pancreatitis |journal=Am. J. Gastroenterol. |volume=101 |issue=10 |pages=2379–400 |year=2006 |pmid=17032204 |doi=10.1111/j.1572-0241.2006.00856.x |url=}}</ref><ref name="pmid18086987">{{cite journal |vauthors=Besselink MG, Verwer TJ, Schoenmaeckers EJ, Buskens E, Ridwan BU, Visser MR, Nieuwenhuijs VB, Gooszen HG |title=Timing of surgical intervention in necrotizing pancreatitis |journal=Arch Surg |volume=142 |issue=12 |pages=1194–201 |year=2007 |pmid=18086987 |doi=10.1001/archsurg.142.12.1194 |url=}}</ref><ref name="pmid12023003">{{cite journal |vauthors=Hartwig W, Maksan SM, Foitzik T, Schmidt J, Herfarth C, Klar E |title=Reduction in mortality with delayed surgical therapy of severe pancreatitis |journal=J. Gastrointest. Surg. |volume=6 |issue=3 |pages=481–7 |year=2002 |pmid=12023003 |doi= |url=}}</ref><ref name="pmid15782093">{{cite journal |vauthors=Runzi M, Niebel W, Goebell H, Gerken G, Layer P |title=Severe acute pancreatitis: nonsurgical treatment of infected necroses |journal=Pancreas |volume=30 |issue=3 |pages=195–9 |year=2005 |pmid=15782093 |doi= |url=}}</ref><ref name="pmid12526943">{{cite journal |vauthors=Adler DG, Chari ST, Dahl TJ, Farnell MB, Pearson RK |title=Conservative management of infected necrosis complicating severe acute pancreatitis |journal=Am. J. Gastroenterol. |volume=98 |issue=1 |pages=98–103 |year=2003 |pmid=12526943 |doi=10.1111/j.1572-0241.2003.07162.x |url=}}</ref><ref name="pmid21136562">{{cite journal |vauthors=van Baal MC, van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG |title=Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis |journal=Br J Surg |volume=98 |issue=1 |pages=18–27 |year=2011 |pmid=21136562 |doi=10.1002/bjs.7304 |url=}}</ref><ref name="pmid22416101">{{cite journal |vauthors=Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL, van Eijck CH, Fockens P, Hazebroek EJ, Nijmeijer RM, Poley JW, van Ramshorst B, Vleggaar FP, Boermeester MA, Gooszen HG, Weusten BL, Timmer R |title=Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial |journal=JAMA |volume=307 |issue=10 |pages=1053–61 |year=2012 |pmid=22416101 |doi=10.1001/jama.2012.276 |url=}}</ref><ref name="pmid21741922">{{cite journal |vauthors=van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM, Boermeester MA, van Goor H, Dejong CH, van Eijck CH, van Ramshorst B, Schaapherder AF, van der Harst E, Hofker S, Nieuwenhuijs VB, Brink MA, Kruyt PM, Manusama ER, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, Cuesta MA, Wahab PJ, Gooszen HG |title=A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome |journal=Gastroenterology |volume=141 |issue=4 |pages=1254–63 |year=2011 |pmid=21741922 |doi=10.1053/j.gastro.2011.06.073 |url=}}</ref>
# Infected pancreatic necrosis
{| class="wikitable" style="width:70%;"
!Recommendation
!Evidence Level
!Strength of Recommendation
|-
|In patients with mild AP, found to have gallstones in the gallbladder, a cholecystectomy should be performed before discharge to prevent a recurrence of AP
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|-
|In a patient with necrotizing biliary AP, in order to prevent infection, cholecystectomy is to be deferred until active inflammation subsides and fluid collections resolve or stabilize
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|-
|The presence of asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis do not warrant intervention, regardless of size, location, and/or extension
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|-
|In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed preferably for more than 4 weeks to allow liquefication of the contents and the development of a fibrous wall around the necrosis (walled-off necrosis) 
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Strong]]
|-
|In symptomatic patients with infected necrosis, minimally invasive methods of necrosectomy are preferred to open necrosectomy
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Strong]]
|}
 
=== Indications ===
Surgery is indicated for:<ref name="pmid20410514">{{cite journal| author=van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH et al.| title=A step-up approach or open necrosectomy for necrotizing pancreatitis. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 16 | pages= 1491-502 | pmid=20410514 | doi=10.1056/NEJMoa0908821 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20410514  }} </ref><ref name="pmid22416101">{{cite journal| author=Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL et al.| title=Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. | journal=JAMA | year= 2012 | volume= 307 | issue= 10 | pages= 1053-61 | pmid=22416101 | doi=10.1001/jama.2012.276 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22416101  }} </ref><ref name="acutepancreatitis">{{cite journal
| last      = Forsmark
| first      = Chris E.
| last2      = Vege
| first2    = Santhi Swaroop
| last3      = Wilcox
| first3    = Mel
| date      = November 17,2016
| title      = Acute Pancreatitis
| url        = http://www.nejm.org/doi/full/10.1056/NEJMra1505202
| journal    = The New England Journal of Medicine
| volume    =
| issue      =
| pages      = 1972 - 1981
| doi        = 10.1056/NEJMra1505202
| pmc        =
| pmid      =
| access-date = November 25,2016
| name-list-format = vanc
}}</ref>
# Infected [[pancreatic]] [[necrosis]]
# Diagnostic uncertainty  
# Diagnostic uncertainty  
# Complications.
# Complications


The most common cause of death in acute pancreatitis is secondary [[infection]]. Infection is diagnosed based on 2 criteria:
The most common cause of death in acute pancreatitis is secondary [[infection]]. [[Infection]] is diagnosed based on 2 criteria:
*Gas bubbles on [[CT]] scan (present in 20 to 50% of infected necrosis)
*Gas bubbles on [[CT]] scan (present in 20 to 50% of infected necrosis)
*Positive bacterial culture on FNA ([[fine needle aspiration]], usually CT or US guided) of the [[pancreas]].  
*Positive bacterial culture on FNA ([[fine needle aspiration]], usually [[Computed tomography|CT]] or US guided) of the [[pancreas]].  


Surgical options for infected necrosis include:
Surgical options for infected necrosis include:
Line 20: Line 88:
*Closed management - necrosectomy with closed continuous lavage
*Closed management - necrosectomy with closed continuous lavage
*Open management - necrosectomy with planned staged reoperations at definite intervals (up to 7 reoperations in some cases)
*Open management - necrosectomy with planned staged reoperations at definite intervals (up to 7 reoperations in some cases)
=== Minimally Invasive Approach ===
==== Endoscopic Retrograde Cholangiopancreatography ====
ERCP is indicated in patients with acute pancreatitis where [[Gallstone disease|gallstones]] are the underlying cause. This includes patients with [[cholangitis]] or [[choledocholithiasis]] secondary to [[Gallstone disease|gallstones]] and have clinical findings suggestive of [[bile duct]] obstruction. It is not indicated in the absence of the aforementioned features.<ref name="acutepancreatitis">{{cite journal
| last      = Forsmark
| first      = Chris E.
| last2      = Vege
| first2    = Santhi Swaroop
| last3      = Wilcox
| first3    = Mel
| date      = November 17,2016
| title      = Acute Pancreatitis
| url        = http://www.nejm.org/doi/full/10.1056/NEJMra1505202
| journal    = The New England Journal of Medicine
| volume    =
| issue      =
| pages      = 1972 - 1981
| doi        = 10.1056/NEJMra1505202
| pmc        =
| pmid      =
| access-date = November 25,2016
| name-list-format = vanc
}}</ref>
ERCP is additionally indicated in cases of necrotizing pancreatitis which progressed to walled off necrosis. This typically occurs after 4-6 weeks. ERCP intervention is typically and ideally delayed to the point of walled off necrosis whenever possible when the patient is stable. In the interim, antiobiotic therapy may sustain the patient in cases of infected necrosis.<ref name="pmid21741922">{{cite journal| author=van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM et al.| title=A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. | journal=Gastroenterology | year= 2011 | volume= 141 | issue= 4 | pages= 1254-63 | pmid=21741922 | doi=10.1053/j.gastro.2011.06.073 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21741922  }} </ref><ref name="pmid23086243">{{cite journal| author=Freeman ML, Werner J, van Santvoort HC, Baron TH, Besselink MG, Windsor JA et al.| title=Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference. | journal=Pancreas | year= 2012 | volume= 41 | issue= 8 | pages= 1176-94 | pmid=23086243 | doi=10.1097/MPA.0b013e318269c660 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23086243  }} </ref><ref name="pmid20410514">{{cite journal| author=van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH et al.| title=A step-up approach or open necrosectomy for necrotizing pancreatitis. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 16 | pages= 1491-502 | pmid=20410514 | doi=10.1056/NEJMoa0908821 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20410514  }} </ref><ref name="pmid22416101">{{cite journal| author=Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL et al.| title=Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. | journal=JAMA | year= 2012 | volume= 307 | issue= 10 | pages= 1053-61 | pmid=22416101 | doi=10.1001/jama.2012.276 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22416101  }} </ref><ref name="acutepancreatitis">{{cite journal
| last      = Forsmark
| first      = Chris E.
| last2      = Vege
| first2    = Santhi Swaroop
| last3      = Wilcox
| first3    = Mel
| date      = November 17,2016
| title      = Acute Pancreatitis
| url        = http://www.nejm.org/doi/full/10.1056/NEJMra1505202
| journal    = The New England Journal of Medicine
| volume    =
| issue      =
| pages      = 1972 - 1981
| doi        = 10.1056/NEJMra1505202
| pmc        =
| pmid      =
| access-date = November 25,2016
| name-list-format = vanc
}}</ref>
==== Percutaneous Drainage ====
In patients who are not stable (e.g. develop sepsis or hemodynamic instability), placement of a percutaneous drain for peripancreatic fluid collection is often sufficient to reduce sepsis and afford the pancreas time to develop an operable walled-off-necrosis.<ref name="pmid21741922">{{cite journal| author=van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM et al.| title=A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. | journal=Gastroenterology | year= 2011 | volume= 141 | issue= 4 | pages= 1254-63 | pmid=21741922 | doi=10.1053/j.gastro.2011.06.073 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21741922  }} </ref><ref name="pmid23086243">{{cite journal| author=Freeman ML, Werner J, van Santvoort HC, Baron TH, Besselink MG, Windsor JA et al.| title=Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference. | journal=Pancreas | year= 2012 | volume= 41 | issue= 8 | pages= 1176-94 | pmid=23086243 | doi=10.1097/MPA.0b013e318269c660 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23086243  }} </ref><ref name="pmid20410514">{{cite journal| author=van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH et al.| title=A step-up approach or open necrosectomy for necrotizing pancreatitis. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 16 | pages= 1491-502 | pmid=20410514 | doi=10.1056/NEJMoa0908821 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20410514  }} </ref><ref name="pmid22416101">{{cite journal| author=Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL et al.| title=Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. | journal=JAMA | year= 2012 | volume= 307 | issue= 10 | pages= 1053-61 | pmid=22416101 | doi=10.1001/jama.2012.276 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22416101  }} </ref><ref name="acutepancreatitis">{{cite journal
| last      = Forsmark
| first      = Chris E.
| last2      = Vege
| first2    = Santhi Swaroop
| last3      = Wilcox
| first3    = Mel
| date      = November 17,2016
| title      = Acute Pancreatitis
| url        = http://www.nejm.org/doi/full/10.1056/NEJMra1505202
| journal    = The New England Journal of Medicine
| volume    =
| issue      =
| pages      = 1972 - 1981
| doi        = 10.1056/NEJMra1505202
| pmc        =
| pmid      =
| access-date = November 25,2016
| name-list-format = vanc
}}</ref>
==== Other Approaches ====
Other minimally invasive approaches may be considered such as [[laparoscopy]], and retroperitoneal approach.<ref name="pmid23086243">{{cite journal| author=Freeman ML, Werner J, van Santvoort HC, Baron TH, Besselink MG, Windsor JA et al.| title=Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference. | journal=Pancreas | year= 2012 | volume= 41 | issue= 8 | pages= 1176-94 | pmid=23086243 | doi=10.1097/MPA.0b013e318269c660 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23086243  }} </ref><ref name="pmid22416101">{{cite journal| author=Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL et al.| title=Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. | journal=JAMA | year= 2012 | volume= 307 | issue= 10 | pages= 1053-61 | pmid=22416101 | doi=10.1001/jama.2012.276 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22416101  }} </ref><ref name="acutepancreatitis">{{cite journal
| last      = Forsmark
| first      = Chris E.
| last2      = Vege
| first2    = Santhi Swaroop
| last3      = Wilcox
| first3    = Mel
| date      = November 17,2016
| title      = Acute Pancreatitis
| url        = http://www.nejm.org/doi/full/10.1056/NEJMra1505202
| journal    = The New England Journal of Medicine
| volume    =
| issue      =
| pages      = 1972 - 1981
| doi        = 10.1056/NEJMra1505202
| pmc        =
| pmid      =
| access-date = November 25,2016
| name-list-format = vanc
}}</ref>
=== Open Surgery ===
In 40% of patients, minimally invasive [[surgery]] is not achievable, traditional open necrosectomy may be considered.<ref name="pmid20410514">{{cite journal| author=van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH et al.| title=A step-up approach or open necrosectomy for necrotizing pancreatitis. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 16 | pages= 1491-502 | pmid=20410514 | doi=10.1056/NEJMoa0908821 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20410514  }} </ref><ref name="pmid22416101">{{cite journal| author=Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL et al.| title=Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. | journal=JAMA | year= 2012 | volume= 307 | issue= 10 | pages= 1053-61 | pmid=22416101 | doi=10.1001/jama.2012.276 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22416101  }} </ref><ref name="acutepancreatitis">{{cite journal
| last      = Forsmark
| first      = Chris E.
| last2      = Vege
| first2    = Santhi Swaroop
| last3      = Wilcox
| first3    = Mel
| date      = November 17,2016
| title      = Acute Pancreatitis
| url        = http://www.nejm.org/doi/full/10.1056/NEJMra1505202
| journal    = The New England Journal of Medicine
| volume    =
| issue      =
| pages      = 1972 - 1981
| doi        = 10.1056/NEJMra1505202
| pmc        =
| pmid      =
| access-date = November 25,2016
| name-list-format = vanc
}}</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


{{WS}}
{{WH}}
{{WH}}
{{WS}}
[[Category:Gastroenterology]]
[[Category:Medical emergencies]]
[[Category:Surgery]]
[[Category:Emergency medicine]]
[[Category:Disease]]
[[Category:Needs overview]]

Latest revision as of 19:11, 21 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]

Overview

Surgery in the treatment of acute pancreatitis is indicated for infected pancreatic necrosis, in cases of diagnostic uncertainty and in the presence of complications. Additionally, surgery is indicated for gallstone pancreatitis in order to resolve the underlying cause.

Surgical options include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage of peripancreatic fluids, retroperitoneal approach, laparoscopic surgery, or traditional open necrosectomy. Minimally invasive approaches are preferred; however, timing of the surgery is of utmost importance. Ideally, patients with an indication for surgery are to be stabilized for up to four weeks and given antibiotics in the interim. After the development of walled off necrosis, surgery is considered more safe and effective.[1]

Surgery

According to the American college of gastroenterology, following are the guidelines for surgery in acute pancreatitis:[2][3][4][5][6][7][8][9][10][11][12]

Recommendation Evidence Level Strength of Recommendation
In patients with mild AP, found to have gallstones in the gallbladder, a cholecystectomy should be performed before discharge to prevent a recurrence of AP Moderate Strong
In a patient with necrotizing biliary AP, in order to prevent infection, cholecystectomy is to be deferred until active inflammation subsides and fluid collections resolve or stabilize Moderate Strong
The presence of asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis do not warrant intervention, regardless of size, location, and/or extension Moderate Strong
In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed preferably for more than 4 weeks to allow liquefication of the contents and the development of a fibrous wall around the necrosis (walled-off necrosis)  Low Strong
In symptomatic patients with infected necrosis, minimally invasive methods of necrosectomy are preferred to open necrosectomy Low Strong

Indications

Surgery is indicated for:[13][11][1]

  1. Infected pancreatic necrosis
  2. Diagnostic uncertainty
  3. Complications

The most common cause of death in acute pancreatitis is secondary infection. Infection is diagnosed based on 2 criteria:

Surgical options for infected necrosis include:

  • Conventional management - necrosectomy with simple drainage
  • Closed management - necrosectomy with closed continuous lavage
  • Open management - necrosectomy with planned staged reoperations at definite intervals (up to 7 reoperations in some cases)

Minimally Invasive Approach

Endoscopic Retrograde Cholangiopancreatography

ERCP is indicated in patients with acute pancreatitis where gallstones are the underlying cause. This includes patients with cholangitis or choledocholithiasis secondary to gallstones and have clinical findings suggestive of bile duct obstruction. It is not indicated in the absence of the aforementioned features.[1]

ERCP is additionally indicated in cases of necrotizing pancreatitis which progressed to walled off necrosis. This typically occurs after 4-6 weeks. ERCP intervention is typically and ideally delayed to the point of walled off necrosis whenever possible when the patient is stable. In the interim, antiobiotic therapy may sustain the patient in cases of infected necrosis.[12][14][13][11][1]

Percutaneous Drainage

In patients who are not stable (e.g. develop sepsis or hemodynamic instability), placement of a percutaneous drain for peripancreatic fluid collection is often sufficient to reduce sepsis and afford the pancreas time to develop an operable walled-off-necrosis.[12][14][13][11][1]

Other Approaches

Other minimally invasive approaches may be considered such as laparoscopy, and retroperitoneal approach.[14][11][1]

Open Surgery

In 40% of patients, minimally invasive surgery is not achievable, traditional open necrosectomy may be considered.[13][11][1]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in: |access-date=, |date= (help)
  2. ↑ Tenner S, Baillie J, DeWitt J, Vege SS, American College of Gastroenterology (2013). "American College of Gastroenterology guideline: management of acute pancreatitis". Am J Gastroenterol. 108 (9): 1400–15, 1416. doi:10.1038/ajg.2013.218. PMID 23896955.
  3. ↑ Larson SD, Nealon WH, Evers BM (2006). "Management of gallstone pancreatitis". Adv Surg. 40: 265–84. PMID 17163108.
  4. ↑ Steinberg W, Tenner S (1994). "Acute pancreatitis". N. Engl. J. Med. 330 (17): 1198–210. doi:10.1056/NEJM199404283301706. PMID 7811319.
  5. ↑ Banks PA, Freeman ML (2006). "Practice guidelines in acute pancreatitis". Am. J. Gastroenterol. 101 (10): 2379–400. doi:10.1111/j.1572-0241.2006.00856.x. PMID 17032204.
  6. ↑ Besselink MG, Verwer TJ, Schoenmaeckers EJ, Buskens E, Ridwan BU, Visser MR, Nieuwenhuijs VB, Gooszen HG (2007). "Timing of surgical intervention in necrotizing pancreatitis". Arch Surg. 142 (12): 1194–201. doi:10.1001/archsurg.142.12.1194. PMID 18086987.
  7. ↑ Hartwig W, Maksan SM, Foitzik T, Schmidt J, Herfarth C, Klar E (2002). "Reduction in mortality with delayed surgical therapy of severe pancreatitis". J. Gastrointest. Surg. 6 (3): 481–7. PMID 12023003.
  8. ↑ Runzi M, Niebel W, Goebell H, Gerken G, Layer P (2005). "Severe acute pancreatitis: nonsurgical treatment of infected necroses". Pancreas. 30 (3): 195–9. PMID 15782093.
  9. ↑ Adler DG, Chari ST, Dahl TJ, Farnell MB, Pearson RK (2003). "Conservative management of infected necrosis complicating severe acute pancreatitis". Am. J. Gastroenterol. 98 (1): 98–103. doi:10.1111/j.1572-0241.2003.07162.x. PMID 12526943.
  10. ↑ van Baal MC, van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG (2011). "Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis". Br J Surg. 98 (1): 18–27. doi:10.1002/bjs.7304. PMID 21136562.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL, van Eijck CH, Fockens P, Hazebroek EJ, Nijmeijer RM, Poley JW, van Ramshorst B, Vleggaar FP, Boermeester MA, Gooszen HG, Weusten BL, Timmer R (2012). "Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial". JAMA. 307 (10): 1053–61. doi:10.1001/jama.2012.276. PMID 22416101.
  12. ↑ 12.0 12.1 12.2 van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM, Boermeester MA, van Goor H, Dejong CH, van Eijck CH, van Ramshorst B, Schaapherder AF, van der Harst E, Hofker S, Nieuwenhuijs VB, Brink MA, Kruyt PM, Manusama ER, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, Cuesta MA, Wahab PJ, Gooszen HG (2011). "A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome". Gastroenterology. 141 (4): 1254–63. doi:10.1053/j.gastro.2011.06.073. PMID 21741922.
  13. ↑ 13.0 13.1 13.2 13.3 van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH; et al. (2010). "A step-up approach or open necrosectomy for necrotizing pancreatitis". N Engl J Med. 362 (16): 1491–502. doi:10.1056/NEJMoa0908821. PMID 20410514.
  14. ↑ 14.0 14.1 14.2 Freeman ML, Werner J, van Santvoort HC, Baron TH, Besselink MG, Windsor JA; et al. (2012). "Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference". Pancreas. 41 (8): 1176–94. doi:10.1097/MPA.0b013e318269c660. PMID 23086243.

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