Severe acute pancreatitis: surgical indications and treatment

Abstract

Background: Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas of sudden onset. Around 25% of patients have either moderately severe or severe disease with a mortality rate of 15-20%.

Purpose: The aim of this article was to summarize the advances being made in the understanding of this disease and the important role of surgery.

Results and conclusions: An accurate diagnosis should be made a soon as possible, initiating resuscitation with large volume intravenous fluids and oxygen by mask. Predicted severe disease will require intensive monitoring. Most deaths within the first week are due to multi-organ failure; thus, these patients will require intensive therapy unit management. During the second phase of the disease, death is due to local complications arising from the pancreatic inflammation, requiring accurate identification to determine the correct form of treatment. Acute peripancreatic fluid collections arise < 4 weeks after onset of interstitial edematous pancreatitis, not requiring any treatment. Most pancreatic pseudocysts arise > 4 weeks and largely resolve on conservative management. Necrotizing pancreatitis causing acute necrotic collections and later walled-off necrosis will require treatment if symptomatic or infected. Initial endoscopic transgastric or percutaneous drainage will resolve less serious collections but necrosectomy using minimally invasive approaches will be needed for more serious collections. To prevent recurrent attacks of AP, causative factors need to be removed where possible such as cholecystectomy and cessation of alcohol. Future progress requires improved management of multi-organ failure and more effective minimally invasive techniques for the removal of necrosis.

Keywords: Endoscopic; Infection; Minimally invasive surgery; Necrosectomy; Pancreatic necrosis; Percutaneous.

Fig. 1

Distribution of deaths in patients with severe pancreatitis. Most deaths occur in the first week or so from multi-organ dysfunction syndrome (MODS) consequent to an excessive systemic inflammatory response syndrome (SIRS). In the second phase, deaths tend to occur from pancreatic necrosis and are associated with sepsis, leading to secondary MODS

Fig. 2

The serial treatment of necrotizing pancreatitis by MARPN (a). In the radiology department, the guidewire is inserted into the center of the necrotic mass, taking a line between the lower pole of the spleen, the splenic flexure of the colon, and the upper pole of the left kidney (b, c). Then in the operating room, the surgeon dilates the guidewire track using increasing diameter nephrectomy dilators, under X-ray control using the vertebral column and the position of a nasogastric tube as a reference point (d). Following multiple skunk procedures using a straight rigid nephroscope, the necrosis has largely been cleared and the necrotic cavity has collapsed around the 28-French chest drain (e); the tract will heal by granulation tissue on steady withdrawal then downsizing of the drain over several weeks as an outpatient