Acute pancreatitis and its management.pptx

Acute pancreatitis and its surgical management

1. Surgical Management of Acute Pancreatitis Name: Abdullah Masood Roll no: 93

2. Indications Infected necrosis(absolute indication). Non-pancreatic causes like perforated viscus. Hemorrhage. Severe sterile necrosis. Symptomatic organized pancreatic necrosis(WON) Sepsis

3. Surgical Interventions For Etiology; Cholecystectomy. ERCP. CBD exploration. For Complications; Pancreatic resection. Pancreatic Necrosectomy(current standard of practice). Minimal invasive interventions(rapidly being accepted).

4. Necrosectomy Good quality preoperative CT-scan is essential for identification of; All areas of necrosis. Localized collections. Wide removal of all devitalized and necrotic tissue. Deroofing of all collections. Plan to remove the products of ongoing inflammation and infection that persists after initial Necrosectomy.

5. Necrosectomy- technique Identification of viable and necrotic pancreatic tissue. Blunt finger dissection of the necrotic tissue. Avoid overzealous handling of inflamed and doubtful viable tissue. The tissues are inevitably friable, and one should be careful not to precipitate excessive bleeding or inadvertently breach the bowel wall. A feeding jejunostomy may be a useful adjunct to the procedure.

6. Post-Necrosectomy management Closed continuous lavage. Closed drainage. Open packing. Closure and relaparotomy. (The last two approaches make greater logistic demands as one is committed to a re-exploration every 48–72 hours)

7. Closed continuous lavage Continuous postoperative closed lavage of the lesser sac as advised by Beger . Lavage is carried out through several double-lumen and single-lumen catheters. Each time, 1 liter of saline is infused through and then drained over a period of hours, and the process is repeated.

8. Minimal Access Interventions Endoscopic Transgastric Necrosectomy. Percutaneous Drainage. Laparoscopic Necrosectomy. Retroperitoneal Necrosectomy.

9. Endoscopic Transgastric Necrosectomy

10. Percutaneous Drainage

11. CT guided Percutaneous Drainage

12. Laproscopic Necrosectomy

13. Pancreatic Abscess Percutaneous drainage with the widest possible drains placed under imaging guidance is the treatment. Drains may need to be flushed, repositioned or re-inserted. Appropriate antibiotics and supportive care.

14. Pseudocyst Collection of amylase-rich fluid enclosed in a well-defined wall of fibrous or granulation tissue. Requires 4 weeks or more from the onset of acute pancreatitis. Most of the times resolves spontaneously. Therapeutic interventions are advised only if the pseudocyst becomes symptomatic.

15. Intervention Three approaches of surgical drainage of pseudocyst; Percutaneous. Endoscopic. Surgical.

16. Percutaneous Drainage Continuous drainage until output <50ml/day & decreased amylase activity High rate of recurrence Can lead to infected pseudocyst High risk of formation of pancreaticocutaneous fistula.

17. Endoscopic Drainage Transenteric Drainage; Cystogastostomy Cystoduodenostomy Transpapillary Drainage; ERCP with sphincterotomy, balloon dilatation of pancreatic strictures, and stent placement beyond strictures

18. Surgical Drainage Excision External drainage Internal drainage; Cystogastrostomy Cystojejunostomy (High rate of resolution) Cystoduodenostomy

19. Preferred Intervention Surgical drainage is the traditional approach – gold standard Percutaneous drainage – high chance of persistent pancreatic fistula Endoscopic drainage – less invasive, technically demanding