final EARLY SURGICAL INTERVENTION IN NECROTISING PANCREATITIS

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EARLY SURGICAL INTERVENTION IN NECROTISING PANCREATITIS

Definition:

Nonviable pancreatic parenchyma, Peripancreatic fat necrosis, Extensive interstitial fat necrosis, vessel damage Affect acinar cells, islet cells, and pancreatic ductal system Increasing severity, morbidity and mortality Importance of recognition for appropriate management Definition

Statistical Results about Necrotizing Acute Pancreatitis :- NEJM :

Necrosis: 20 ~ 30% of acute pancreatitis Mortality: sterile necrosis 10% infected necrosis 100% without surgery >15%, usually 20~40% with surgery Infected necrosis: 30~70% of necrotizing pancreatitis account for more than 80% of deaths from acute pancreatitis Statistical Results about Necrotizing Acute Pancreatitis :- NEJM

Surgical debridement Who? When? and How?:

Acute necrotizing pancreatitis: sterile v.s infected Infected ANP: Uniformly fatal without intervention(100%), Necrosectomy soon after confirmation of infected necrosis Sterile ANP: Mortality 10%, benefit of surgery remain unproved, Frequently indicated for surgical debridement Surgical debridement Who? When? and How?

Surgical debridement Who? When? and How?:

Diagnosis of infected necrosis: CT-guided fine-needle aspiration: safe, Sensitivity 96%, Specificity 99% Surgical debridement Who? When? and How?

Surgical debridement Who? When? and How?:

CT-guided fine-needle aspiration Surgical debridement Who? When? and How?

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Mortality among patients with infected necrosis Surgical Treatment of Infected Necrosis ~ from World J. Surg. 1997 ~

what has been in research mostly in animal models (non surgeons):

INFLIXIMAB , a monoclonal TNF antibody, was experimentally tested in rats and it was able to significantly reduce the pathologic score and serum amylase activity, and also alleviate alveolar edema and acute respiratory distress syndrome INTERLEUKIN 10, was efficacious in decreasing the severity and mortality of lethal pancreatitis in rats, as GABEXATE MESILATE , LEXIPAFANT and somatostatin which should be probably administered in a different manner what has been in research mostly in animal models (non surgeons)

Pathophysiology and Clinical Phases of Acute Pancreatitis:

1st week 2nd week Hours 3rd-4th week EARLY MIDDLE INITIAL LATE Inappropriate activation of proteases Necrosis Microcirculatory disorders Progression of necrosis Gut and biliary bacteria Infection of necrosis Altered intra-acinar protein traffic Accumulation of trypsinogen in the interstitial space Macrophage activation PHASE TIMING MAJOR EVENTS ? 19% 37% 32% 12% DEATHS ? ? 0 0 12% 28% 26% 0% 0% 5% M.O.F. Infection Causes Pathophysiology and Clinical Phases of Acute Pancreatitis

THERAPEUTIC WINDOW :

THERAPEUTIC WINDOW

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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

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Contd.. D. To support the patient and treat complications Drainage of pancreatic abscesses Feeding jejunostomy To prevent recurrent pancreatitis

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

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GALL STONE PANCREATITIS TIMING OF SURGERY EARLY OR DELAYED TWO DAYS OR TWO WEEKS STOP THINKING …. SEND HOME NOT BEFORE REMOVING GALL BLADDER

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

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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

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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

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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.

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Indications of Operation IN NP 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

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

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Surgical Approaches 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 RP space, packing of abdomen, which is left open , subsequent changes of packs is a planned procedure.

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 Closed lavage of the debrided cavity. Werner J et al. Gut 2005;54:426-436 Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

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 Closed lavage of the debrided cavity. Werner J et al. Gut 2005;54:426-436 Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

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NECROSECTOMY +CLOSED CAVITY LAVAGE Surgical debridement – Necrosectomy – supplemented by intraoperative and post operative closed continuous local Lavage of the lesser sac and the necrotic cavities. (mort 8 – 15%) Debridement- either digital or by the careful use of instruments – Elimination of all demarcated ,devitalized tissue , preserving the vital pancreatic parenchyma.

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Necrosectomy+CC Lavage(contd) Thorough haemostasis with monofilament transfixing stitches. Don ’ t remove every gram of devitalized tissue Extensive intraoperative Lavage is performed with 6-12 L of normal saline Post operative closed continuous local Lavage with two large double lumen silicone rubber tubes (34) are inserted in R and L retro peritoneum

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Necr+Closed Lavage Drains are at level of RP space in L and R retroperitoneum. Gastro colic and duodenocolic ligaments are sutured to create closed system . Drains in pelvis or gutters Monitor Lavage fluid for enzymes ,toxins,etc When to Stop Lavage -no signs of AP,culture negative., fluid less enzymes or necr tissue output is <7gm /24 hrs

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OPEN ABDOMEN approach Debridement and open packing. Disadvantages;Prolonged ICU multiple dressings,Multiple reoperations Int. fistulas 30 %, gastric outlet obst, ileus, Stenosis of T colon, incisional hernia(29%) Pancr. fistula % Mort is 28%

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SURGICAL DRAINAGE Extensive debridement to remove necrotic tissue followed by Abd. closure with drains Disadvantages=High reoperation rate Suitable for pts in whom no further intervention is required. No benefit over c c drainage Mort is <25%

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POSTERIOR APPROACH Pancreatic necrosis through L retro perit approach No advantage in terms of complications, restriction in incision,cant drain Abdominal ascites

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Pancreatic resection Hardly ever warranted except as a part of Necrosectomy No beneficial effect in terms of systemic complications. Incidence of DM 100%, high incidence of neuropathy (Eriksson 1992)

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Pancreatic abscess Late stage Wide surgical exploration +closed drainage or open packing Hemorrhage and fistula are common complications

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Role of Antibiotics in AP Traditional teaching is Prophylactic antibiotics do not prevent abscess- Mezlocillin, Metrionidazole, Imipnem good concentration in pancreatic juice Cefotaxime, Ceftazidime Clindamycin, Ciprofloacin good levels in p. juice They can limit rate of infection of this necr material(Bossi1992)

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Pseudo cyst Delineation of main Pancreatic duct by ERP if no communication -drain by ERP If main duct is abnormal Stricture Or Truncated – Surg. Drainage Rarely normal P.Duct communicating with Pseudo Cyst – Drain Percut CT control (Recurrence =50%)

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Conclusion Management of AP is complex Mortality is high-Realization Increasing Dx procedures available has not simplified decisions about timing of operation or choice of technique. Individualized approach IS NECESSARY Decision based on clinical judgment rather than on numerical or imaging. SURGEON IS THE BEST TO MANAGE as he has CLINICAL AND SURGICAL EXPERTISE

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