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DR Fiaz Maqbool Fazili Lecturer, SIMS

DR Fiaz Maqbool Fazili Lecturer, SIMS . What Surgeons Should Know About Pancreatitis. MAGNITUDE OF THE PROBLEM. The disease may be mild and self limiting, 70-80% take course of edematous interstitial inflammation Necrotizing pancreatitis develops in 20-25% pts .

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DR Fiaz Maqbool Fazili Lecturer, SIMS

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  1. DR Fiaz Maqbool Fazili Lecturer, SIMS What Surgeons Should Know About Pancreatitis

  2. MAGNITUDE OF THE PROBLEM • The disease may be mild and self limiting, 70-80% take course of edematous interstitial inflammation • Necrotizing pancreatitis develops in 20-25% pts . • 20-30% will develop local or systemic complications • Approx 1 in 4 pts who develop complications will die

  3. WHAT IS THE BASIS OF PROBLEMS(PATHOLOGY) • NP shows interstitial edematous inflammation with EXTENSIVE NECROSIS OF PANCREATIC EXOCRINE AND ENDOCRINE PARENCHYMA,fatty necrosis of peripancreatic and retroperitoneal tissue compartment

  4. PATHOLOGY (CONTD) • Peripancreatic fluid collection of phospholipase,endtotoxin,prostacyclin, activated trypsin (TAP\) ,complement, thromboxane,elastase,TNFRand IL-6,8 • Others(vasoactive and toxic substances

  5. AP & QUESTIONS • WHAT IS THE CORRCT DIAGNOSIS? • What is the prognosis? • Are complications developing? • Can an associated condition to be identified? • What is the ideal timing for surgery?

  6. OBJECTIVE • To give pts of AP best chance of survival, from the outset to be managed by surgeon • Identification of pts likely to develop complications • Management (prevention)of systemic complications • Timing and choice for surgical Intervention for gall stones or local complications

  7. PANCREATITIS (terminology) • MILD-uncomplicated recovery • SEVERE-AP with evidenceoffailure of one or more systems ,or local complication. • These terms are defined retrospectively,when outcome is known • Prospectively defined on the basis of scoring systems.Predicted Mildor Predicted Severe

  8. ACUTE PANCREATITS-various terms • COMPLICATED-local or systemic complications • EDEMATOUS-Swollen, red ,with or without fat necrosis;Histology fluid,debris,leukocytes present • PERIPANCREATIC NECROSIS-Necrosis of retroperitoneal fat, other organs rarely involved, occasionally infarction by vascular thrombosis.This change may be present alone or may coexist with or be absent in presence of pancreatic necrosis

  9. ACUTE NECROTIZING PANCREATITITS • Definition • Diagnosis CRITERIA • Conservative approach or Surgical Intervention

  10. AP-local complications ……contd • Pancreatic necrosis; • Patchy or diffuse superficial or parenchymal necrosis, unequivocally demonstrated by inspection after opening of the pancreatic capsule , or histological criteria; local or diffuse areas of non enhancement on CT, sterile necrosis • Infected pancreatic necrosis; Necrosis with positive bacterial cultures • Pancreatic abscess;Loculated walled off collections of pus as a late complication of AP, usually after 3 weeks

  11. MANIFESTATIONS OF AP • LOCAL; • MILD; • EDEMA, INFLAMMATION, NECROSIS • SEVERE; • PHLEGMON, NECROSIS, HYG, INFECTION, FLUID COLLECTION, ABSCESS

  12. A p MANIFESTATIONS(C0NT • Extension into ; • Retoperitoneum,perirenal spaces, mesocolon, major and minor omentum, mediastinum.

  13. Bacterial contamination • Risk of bacterial infection on necrotic tissue • 60% in proven cases of NP • Risk in ist week =25% • Risk in 2nd week = 35-40% • Risk in 3rd week =60% • Organisms are Gram negative E-coli,Proteus,Pseudomonas,staphylococci

  14. SYSTEMIC COMPLICATIONS • Respiratory-Interstitial pulmonary edema;gas transfer impairment,Pt may need ventilation • Renal-oliguria-require aggressive circulatory support,#Dialysis • Cardiovascular-Hypotension, edema,aggressive fluid therapy and Ionotropes • Disturbance in Haemopoiesis, Coagulation system, Endocrine systems

  15. PANCREATITIS • How to diagnose it? • How to evaluate severity? • RANSON CRITERIA • IMRIES CRITERIA • APACHE scoring • GLASGOW Criteria • Atlanta score • Lab and Radiology Help ;

  16. Diagnosis of Pancreatitis • Clinical Diagnosis • Lab studies; • Serum amylase;Levels Rise within 2-12hrs, • 3x times normal is cut off . (n35-118 IU/liter • levels normal in 2-3days. • Persistence of ^ levels >10days denote complication like cyst,abscess. • 5%cases no increase value

  17. Diagnosis of pancreatitis(contd) • Serum lipase ^^ 2x times the normal( 2.3-20.0 IU/L) n=3-5days • CR protein,LDH ,Serum Neutrophil –elastase,IL-6, and alpha macroglobulin • Trypsin like Immunoreactivity

  18. Initial 24 hrs 1.Age >55 years 2.Glucose >than 200 mgm/dl 3.WBC > 16,000 cells/mic L 4.LDH >350 IU/liter 5.AST >250IU/liter Subsequent 48 hrs 1.Art o2tension <60mmHg 2.Bun Increase >8mg/dl 3.Ca < 8mg/dl 4.Base deficit >4meq/liter 5.Estimated fluid sequestration >6liters 6.Fall n Hct >10% RANSON CRITERIA

  19. Mortality prediction (as per Ranson criteria) • A. < 3 signs = 1% • B. Three to Four signs=11% • C. Five to six signs=33% • D. >Six signs= 100%

  20. During first 24 hours 1.Age>55 yrs 2.WBC >15x 10 9/l 3.Blood glucose >10mmol/l 4.Plasma Urea>16mmol/l 5.Pao2<8Kpa 6.Pl ca<2.0mmo/l 7.Pl albumin<32g/l 8.LDH>600 u/l(n=250) 9.AST or ALT >100 u/l IMRIE,S CRITERIA

  21. A=+4 to 0 points TEMP>41=4,<29=4 Mean Art Pr>160=4 <49=4 Heart & Resp rateOXYGENATIONART PHSer Na,K,Creat, HCT,WBC GLASGOW COMA Score B=Age <44=0 pts >75=6points C=Chronic Health points H/o organ insufficiency Liver,CVS,Resp,Renal, ,Immunocompromised APACHE SCORE42=90% Mort Apache II score(Sum of A+B+C)

  22. Temp Mean Art Pressure Heart Rate Resp rate Oxygenation(Pao2) Arterial Ph Serum sodium SerumPottasium Serum creatinine Haematocrit WCC Glasgow coma scale APACHEII-variables

  23. GLASGOW CRITERIA • Any time during First 48hrs after admission • 1.WBC >15000 Cu/mm • 2.Blood glucose>10mmol/l • 3.BUN >16mmol/L • 4.Art po2,< 60mmHg • 5.Ser ca. <2.0 ml/l • 6.Ser Albumin<32gm/l • 7.Ser LDH >600u/L(n=250) • 8.AST Or ALT >200u/l

  24. Any time during First 48hrs after admission; WBC >15000 Cu/mm Blood glucose>10mmol/l BUN >16mmol/L Art po2,< 60mmHg Ser ca. <2.0 ml/l Ser Albumin<32gm/l Ser LDH >600u/L(n=250) AST Or ALT >200u/l GLASGOW CRITERIA

  25. Comparison of scores

  26. INTERSTITIAL AND NECROTIZING PANCREATITIS (Discrimination) • Markers of Necroses • C-reactive protein>120 mgm/L • PMN-Elastase>120mgm/L • PLA>15U/L • PLA2>3.5U/L • Dynamic angio –CT • Guided needle aspiration of necroses for detection of bacteria

  27. Accurate Simple Safe(non invasive) Rapidly formed Early in attack Reproducible Cheap Not influenced by etiology and co –morbidities Capable of monitoring course of disease and response to therapy IDEAL PREDICTOR???

  28. RADIOLOGY • Plain Films • Ultrasonography • Sens;62-95%,Specif>95%, pancreas not visualized in> 40%pts • CT scan;Sens 90% Specif+100% • ERCP • PTC. Pancreatitis is due to gallstone? Or Alcoholic?

  29. CT severity index

  30. FLUID COLLECTIONS-points 0-Normal pancreas 1-Gland enlargement 2-peripancreatic inflammation 3-one fluid collection 4-Multiple fluid collections Necrosis points 30% ---2pnts 30-50%--4pnts >50%----6pnt Total=10 points Predicted mortality Ctsi<3 3% Ctsi>7 17% The CT severity index-Balthazar et al

  31. CTSI SCORE=CT GRADE+NECROSIS SCORE • Acute pancreatitis CT grade • A Normal pancreas • B Pancreatic enlargement • C Inflammation of peripancreatic fat • D Single peripancreatic fluid collection • E two or more fluid collections or retroperitoneal air

  32. Enlargement of Gland Ill defined margins Abnormal enhancement Thickening of peripancreatic planes Blurring of fat planes Intra & retroperitoneal fluid collection Pleural effusion Pancreatic gas indicative of necrosis /abscess Pseudocyst formation CT findings in Acute Pancreatitis

  33. Indications of ERCP; In AP • Preop evaluation with suspected traumatic pancreatitis to see Pancreatic duct disruption • Pts with suspected biliary Pancreatitis and severe disease and not clinically improving by 24hrs after admission. Do ERCP for stone extraction

  34. ERCP-indications (contd • In pts >40 with no identifiable disease to rule out occult CBD stones,pancreatic or ampullary Ca or other causes of obstruction; • Pts <40 at a post Cholecystectomy status or more than one attacks of unexplained pancreatitis

  35. SYSTEMIC TREATMENTS • Basic principles-ICU,Rest GIT and Pancreas,analgesia,oxygenation • Pancreatic inhibition(Glucagon,Somatostatin) • Antiproteases • Antibiotics(cefuroxime) • LEXIPAFANT • Lavage • Nutrition (Enteral route is safe& preferred ) • Thoracic duct drainage

  36. LEXIPAFANT-PAF antagonist • Cause of organ failure and tissue damage in AP is activation of immune system involving interactions of cytokines and mediators.Role of PAF platelet activating factor is evident in pancreatic injury and SIRS • LAXIPAFANT is PAF antagonist; Results are encouraging ;They reduce severity of organ failure. If given within 72 hrs

  37. Operative Measures For AP • A.Diagnostic laparotomy • B.To limit the severity of pancreatic inflammation • Biliary operations • C.To interrupt the pathogenesis of complications • Pancreatic drainage • Pancreatic resection • Peritoneal drainage

  38. Operative measures(contg) • D.To support the patient and treat complications • Drainage of pancreatic abscesses • Feeding jejunostomy • To prevent recurrent pancreatitis

  39. Diagnostic uncertainty Gall stone induced pancreatitis Pancreatic drainage and defunctioning Pancreatic resection Peritoneal Lavage Operation for complications Indications Of Surgical intervention

  40. GALL STONE PANCREATITIS • TIMING OF SURGERY • TRADITIONAL APPROACH • EARLY OR DELAYED • TWO DAYS OR TWO WEEKS

  41. Bile duct stones-strategy • Acosta (1974), recovered gall stones from Faeces of pts with gall stone pancreatitis. • Neptolemos (1989) ;Passage of stone through ampulla precipitates pancreatitis attack, persistence of stones in CBD; Pt is at risk of complications and death • Early surgery or to deal with CBD stones endoscopically(ERCP)14 %pts of AP have coexisting cholangitis

  42. Early or Delayed OPERATION • Pts who have early Cholecystectomy (48hrs) of admission with AP as compared to pts who were treated conservatively, D/C and readmission . Mort was 2% in early surgery group and 16 % in retrospective group, (same adm OR) • Ideal timing ;Those who Advocate early OR, say that it removes potential septic focus in GB ,remove CBD stones causing CBD obst and pptng pancreatitis,Thus shortens hospital stay

  43. EARLY OR DELAYED SURGERY • Early operation ;good results mortality only2%(same admission Cholecystectomy) • Delayed surgery mort 16% • Ideal timing?still debatable

  44. DELAYED OPERATION • Delay operation(until 7 to 10days) till acute attack subsides • Most of CBD stones will pass spontaneously and don’t need OR • Most pts have mild pancreatitis and don’t need early OR,( indeed there won be evidence of inflammation till one week ) • Complications of early operation are high

  45. Timing OF Operation IN Gall Stone Pancreatitis • Mild pancreatitis:Operated At Any Stage during first admission • Severe disease.Cholecystectomy during first admission, timing depends on clinical indicators

  46. Timing of Surgery-contd • RECOVERING PT.Allow pt to settle completely before elective early operation is taken prior to discharge. • UNSTABLE PT- Who will require surgery to deal with local complications of pancreas, Cholecystectomy to be performed at this time • Early Cholecystectomy within 48-72 hours of admission is best avoided in these all patients

  47. NON respondents of medical treatment • Persistent or increase signs of pulmonary, Renal or cardio vascular insufficiency, • Develops sepsis syndrome during max of 3 days of ICU, PT belongs to non responders with high risk of morbidity and mortality. • Switch from Medical to surgical treatment.

  48. Clinical criteria Surgical acute abdomen Sepsis syndrome Shock syndrome Non response to ICU Morphologic +Bacteriologic Infected necroses Extended pancreatic necrosis>50% Extnd. intrapancreatic +retroperitoneal necroses Stenosis of CBD,Duodenum, large bowel Indications of Operation IN NP

  49. Technique of Debridement • Closed cavity Lavage • Open abdomen • Surgical drainage • Posterior approach • Pancreatic resection

  50. Limited Peritoneal exploration , digital debridement, closed cavity drainage (Beger et al) Combination of ext debridement with closed cavity drainage Bradley approach Thorough and extensive surgical debridement of retro perit space, packing of abdomen, which is left open , subsequent changes of packs is a planned procedure. Surgical Approaches-choices

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