dr fiaz maqbool fazili lecturer sims l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
DR Fiaz Maqbool Fazili Lecturer, SIMS PowerPoint Presentation
Download Presentation
DR Fiaz Maqbool Fazili Lecturer, SIMS

Loading in 2 Seconds...

play fullscreen
1 / 61

DR Fiaz Maqbool Fazili Lecturer, SIMS - PowerPoint PPT Presentation


  • 148 Views
  • Uploaded on

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 .

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'DR Fiaz Maqbool Fazili Lecturer, SIMS' - khuyen


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
dr fiaz maqbool fazili lecturer sims

DR Fiaz Maqbool Fazili Lecturer, SIMS

What Surgeons Should Know About Pancreatitis

magnitude of the problem
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
what is the basis of problems pathology
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
pathology contd
PATHOLOGY (CONTD)
  • Peripancreatic fluid collection of phospholipase,endtotoxin,prostacyclin, activated trypsin (TAP\) ,complement, thromboxane,elastase,TNFRand IL-6,8
  • Others(vasoactive and toxic substances
ap questions
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?
objective
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
pancreatitis terminology
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
acute pancreatits various terms
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
acute necrotizing pancreatitits
ACUTE NECROTIZING PANCREATITITS
  • Definition
  • Diagnosis CRITERIA
  • Conservative approach or Surgical Intervention
ap local complications contd
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
manifestations of ap
MANIFESTATIONS OF AP
  • LOCAL;
    • MILD;
      • EDEMA, INFLAMMATION, NECROSIS
    • SEVERE;
      • PHLEGMON, NECROSIS, HYG, INFECTION, FLUID COLLECTION, ABSCESS
a p manifestations c0nt
A p MANIFESTATIONS(C0NT
  • Extension into ;
    • Retoperitoneum,perirenal spaces, mesocolon, major and minor omentum, mediastinum.
bacterial contamination
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
systemic complications
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
pancreatitis
PANCREATITIS
  • How to diagnose it?
  • How to evaluate severity?
    • RANSON CRITERIA
    • IMRIES CRITERIA
    • APACHE scoring
    • GLASGOW Criteria
    • Atlanta score
    • Lab and Radiology Help ;
diagnosis of pancreatitis
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
diagnosis of pancreatitis contd
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
ranson criteria
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
mortality prediction as per ranson criteria
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%
imrie s criteria
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
apache ii score sum of a b c
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)
apacheii variables
Temp

Mean Art Pressure

Heart Rate

Resp rate

Oxygenation(Pao2)

Arterial Ph

Serum sodium

SerumPottasium

Serum creatinine

Haematocrit

WCC

Glasgow coma scale

APACHEII-variables
glasgow criteria
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
glasgow criteria24
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
interstitial and necrotizing pancreatitis discrimination
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
ideal predictor
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???
radiology
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?
the ct severity index balthazar et al
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
ctsi score ct grade necrosis score
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
ct findings in acute pancreatitis
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
indications of ercp in ap
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
ercp indications contd
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
systemic treatments
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
lexipafant paf antagonist
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
operative measures for ap
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
operative measures contg
Operative measures(contg)
  • D.To support the patient and treat complications
    • Drainage of pancreatic abscesses
    • Feeding jejunostomy
  • To prevent recurrent pancreatitis
indications of surgical intervention
Diagnostic uncertainty

Gall stone induced pancreatitis

Pancreatic drainage and defunctioning

Pancreatic resection

Peritoneal Lavage

Operation for complications

Indications Of Surgical intervention
gall stone pancreatitis
GALL STONE PANCREATITIS
  • TIMING OF SURGERY
    • TRADITIONAL APPROACH
    • EARLY OR DELAYED
    • TWO DAYS OR TWO WEEKS
bile duct stones strategy
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
early or delayed operation
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
early or delayed surgery
EARLY OR DELAYED SURGERY
  • Early operation ;good results mortality only2%(same admission Cholecystectomy)
  • Delayed surgery mort 16%
  • Ideal timing?still debatable
delayed operation
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
timing of operation in gall stone pancreatitis
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
timing of surgery contd
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
non respondents of medical treatment
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.
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

Indications of Operation IN NP
technique of debridement
Technique of Debridement
  • Closed cavity Lavage
  • Open abdomen
  • Surgical drainage
  • Posterior approach
  • Pancreatic resection
surgical approaches choices
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
necrosectomy closed cavity lavage
Necrosectomy +CLOSED CAVITY LAVAGE
  • Surgical debridement –Necrosectomy–supplemented by intraoperative and post operative closed continuous local Lavage of of the lesser sac and the necrotic cavities.(mort8 –15%)
  • Debridement- either digital or by the careful use of of instruments –Elimination of all demarcated ,devitalized tissue , preserving the vital pancreatic parenchyma.
necrosectomy cc lavage contd
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
necr closed lavage
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
open abdomen approach
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%
surgical drainage
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%
posterior approach
POSTERIOR APPROACH
  • Pancreatic necrosis through L retro perit approach
  • No advantage in terms of complications, restriction in incision,cant drain Abdominal ascites
pancreatic resection
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)
pancreatic abscess
Pancreatic abscess
  • Late stage
  • Wide surgical exploration +closed drainage or open packing
  • Hemorrhage and fistula are common complications
role of antibiotics in ap
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)
pseudo cyst
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%)
conclusion
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