SURGICAL MANAGEMENT OF ACUTE PANCREATITIS T.KIRAN KUMAR IInd YEAR - - PowerPoint PPT Presentation
SURGICAL MANAGEMENT OF ACUTE PANCREATITIS T.KIRAN KUMAR IInd YEAR PG INTRODUCTION A very common disease with increasing incidence over past 20 years. All age groups and both genders vulnerable. Multiple causes. Highly variable
3
ABSLOUTE INDICATION ABSLOUTE INDICATION ABSLOUTE INDICATION ABSLOUTE INDICATION INFECTED PANCREATIC NECROSIS INFECTED PANCREATIC NECROSIS INFECTED PANCREATIC NECROSIS INFECTED PANCREATIC NECROSIS OBLIGATORY INDICATION OBLIGATORY INDICATION OBLIGATORY INDICATION OBLIGATORY INDICATION PERFORATED VISCUS HAEMORRHAGE PERFORATED VISCUS HAEMORRHAGE PERFORATED VISCUS HAEMORRHAGE PERFORATED VISCUS HAEMORRHAGE DEBATED INDICATION DEBATED INDICATION DEBATED INDICATION DEBATED INDICATION SEVERE STERILE NECROSIS SEVERE STERILE NECROSIS SEVERE STERILE NECROSIS SEVERE STERILE NECROSIS SYMPTOMATIC ORGANIZED NECROSIS SYMPTOMATIC ORGANIZED NECROSIS SYMPTOMATIC ORGANIZED NECROSIS SYMPTOMATIC ORGANIZED NECROSIS OBSELETE INDICATION OBSELETE INDICATION OBSELETE INDICATION OBSELETE INDICATION DIAGNOSTIC UNCERTAINITY DIAGNOSTIC UNCERTAINITY DIAGNOSTIC UNCERTAINITY DIAGNOSTIC UNCERTAINITY
Acute pancreatitis Acute pancreatitis Acute pancreatitis Acute pancreatitis Mild Mild Mild Mild Severe Severe Severe Severe Symptomatic Symptomatic Symptomatic Symptomatic treatment treatment treatment treatment ICU admission ICU admission ICU admission ICU admission Supportive treatment Supportive treatment Supportive treatment Supportive treatment Ct abdomen>72hrs Ct abdomen>72hrs Ct abdomen>72hrs Ct abdomen>72hrs improvment improvment improvment improvment Plan discharge Plan discharge Plan discharge Plan discharge FNA if no improvement for FNA if no improvement for FNA if no improvement for FNA if no improvement for 2 weeks 2 weeks 2 weeks 2 weeks No infection No infection No infection No infection improvement improvement improvement improvement No improvement No improvement No improvement No improvement infected infected infected infected Surgical Surgical Surgical Surgical intervention intervention intervention intervention Continue Continue Continue Continue supportive supportive supportive supportive treatment treatment treatment treatment
PANCREATIC RESECTIONS - PANCREATIC RESECTIONS - PANCREATIC RESECTIONS - PANCREATIC RESECTIONS - HISTORICAL HISTORICAL HISTORICAL HISTORICAL PANCREATIC NECROSECTOMY PANCREATIC NECROSECTOMY PANCREATIC NECROSECTOMY PANCREATIC NECROSECTOMY –
– – – DEBRIDEMENT OF NECROTIC PANCREATIC TISSUE DEBRIDEMENT OF NECROTIC PANCREATIC TISSUE DEBRIDEMENT OF NECROTIC PANCREATIC TISSUE DEBRIDEMENT OF NECROTIC PANCREATIC TISSUE CURRENT STANDARD OF PRACTICE CURRENT STANDARD OF PRACTICE CURRENT STANDARD OF PRACTICE CURRENT STANDARD OF PRACTICE
MINIMAL INVASIVE INTERVENTIONS MINIMAL INVASIVE INTERVENTIONS MINIMAL INVASIVE INTERVENTIONS MINIMAL INVASIVE INTERVENTIONS
– – – – CURRENT INTEREST OF RESEARCH CURRENT INTEREST OF RESEARCH CURRENT INTEREST OF RESEARCH CURRENT INTEREST OF RESEARCH RAPIDLY BEING ACCEPTED IN PRACTICE RAPIDLY BEING ACCEPTED IN PRACTICE RAPIDLY BEING ACCEPTED IN PRACTICE RAPIDLY BEING ACCEPTED IN PRACTICE
GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS GOOD QUALITY PREOPERATIVE CONTRAST ENHANCED CT ABDOMEN IS ESSENTIAL FOR IDENTIFICATION OF ESSENTIAL FOR IDENTIFICATION OF ESSENTIAL FOR IDENTIFICATION OF ESSENTIAL FOR IDENTIFICATION OF – – – – ALL AREAS OF NECROSIS ALL AREAS OF NECROSIS ALL AREAS OF NECROSIS ALL AREAS OF NECROSIS LOCALIZED COLLECTIONS LOCALIZED COLLECTIONS LOCALIZED COLLECTIONS LOCALIZED COLLECTIONS
WIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUE WIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUE WIDE REMOVAL OF ALL DEVITALIZED AND NECROTIC TISSUE UNROOFING OF ALL COLLECTIONS UNROOFING OF ALL COLLECTIONS UNROOFING OF ALL COLLECTIONS UNROOFING OF ALL COLLECTIONS STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION STRATSZIZE TO REMOVE THE PRODUCTS OF ONGOING INFLAMMATION AND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMY AND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMY AND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMY AND INFECTION THAT PERSISTS AFTER THE INITIAL NECROSECTOMY
MIDLINE INCISION MIDLINE INCISION MIDLINE INCISION MIDLINE INCISION BILATERAL SUBCOSTAL BILATERAL SUBCOSTAL BILATERAL SUBCOSTAL BILATERAL SUBCOSTAL INCISION INCISION INCISION INCISION PANCREAS & PANCREAS & PANCREAS & PANCREAS & LESSER SAC LESSER SAC LESSER SAC LESSER SAC THROUGH THROUGH THROUGH THROUGH GASTROCOLIC GASTROCOLIC GASTROCOLIC GASTROCOLIC LIGAMENT LIGAMENT LIGAMENT LIGAMENT THROUGH THROUGH THROUGH THROUGH TRANSVERSE - TRANSVERSE - TRANSVERSE - TRANSVERSE - MESOCOLON MESOCOLON MESOCOLON MESOCOLON
8
The lesser sac can be approached through the base of the mesocolon; attention should be paid to avoid injury to the middle colic artery.
Approach to lesser sac via gastrocolic ligament.
NECROTIC PANCREATIC TISSUE
NECROTIC TISSUE
INFLAMED & DOUBTFUL VIABLE TISSUE
RELEASE OF SPLENIC/HEPATIC RELEASE OF SPLENIC/HEPATIC RELEASE OF SPLENIC/HEPATIC RELEASE OF SPLENIC/HEPATIC FLEXURES FLEXURES FLEXURES FLEXURES EXTENSIVE KOCHERIZATION EXTENSIVE KOCHERIZATION EXTENSIVE KOCHERIZATION EXTENSIVE KOCHERIZATION OPENENING OF PARACOLIC GUTTERS, OPENENING OF PARACOLIC GUTTERS, OPENENING OF PARACOLIC GUTTERS, OPENENING OF PARACOLIC GUTTERS, PARARENAL SPACES AND PARARENAL SPACES AND PARARENAL SPACES AND PARARENAL SPACES AND GASTROHEPATIC LIGAMENT GASTROHEPATIC LIGAMENT GASTROHEPATIC LIGAMENT GASTROHEPATIC LIGAMENT
OPTIONS OPTIONS OPTIONS OPTIONS CLOSED DRAINAGE CLOSED DRAINAGE CLOSED DRAINAGE CLOSED DRAINAGE PLANNED PLANNED PLANNED PLANNED REXPLORATIONS REXPLORATIONS REXPLORATIONS REXPLORATIONS CLOSED LAVAGE CLOSED LAVAGE CLOSED LAVAGE CLOSED LAVAGE
MULTIPLE DRAINS IN THE MULTIPLE DRAINS IN THE MULTIPLE DRAINS IN THE MULTIPLE DRAINS IN THE LESSER SAC LESSER SAC LESSER SAC LESSER SAC RETAINED TILL OUTPUT RETAINED TILL OUTPUT RETAINED TILL OUTPUT RETAINED TILL OUTPUT IS INSIGNIFICANT IS INSIGNIFICANT IS INSIGNIFICANT IS INSIGNIFICANT LAPAROSTOMY/ LAPAROSTOMY/ LAPAROSTOMY/ LAPAROSTOMY/ TEMPORARY ABDOMINAL TEMPORARY ABDOMINAL TEMPORARY ABDOMINAL TEMPORARY ABDOMINAL CLOSURE CLOSURE CLOSURE CLOSURE RE-EXPLORATION ONCE IN RE-EXPLORATION ONCE IN RE-EXPLORATION ONCE IN RE-EXPLORATION ONCE IN 2-3 DAYS TILL ALL 2-3 DAYS TILL ALL 2-3 DAYS TILL ALL 2-3 DAYS TILL ALL NECROTIC MATERIAL NECROTIC MATERIAL NECROTIC MATERIAL NECROTIC MATERIAL CLEARS CLEARS CLEARS CLEARS
DRAINS PLACED IN LESSER
DRAINS PLACED IN LESSER DRAINS PLACED IN LESSER DRAINS PLACED IN LESSER SAC SAC SAC SAC CONTINOUS CONTINOUS CONTINOUS CONTINOUS POSTOPERATIVE LAVAGE POSTOPERATIVE LAVAGE POSTOPERATIVE LAVAGE POSTOPERATIVE LAVAGE TILL EFLUENT IS CLEAR TILL EFLUENT IS CLEAR TILL EFLUENT IS CLEAR TILL EFLUENT IS CLEAR
Necrosectomy and closed packing with stuffed Penrose drains.
closed lavage of the lesser sac.
The lesser sac is closed by suturing the greater omentum to the transverse colon for closed postoperative lavage.
STUDIES BETWEEN 1980-1998
PATIENTS n MORALITY RE- EXPLORATION GI FISTULA BLEEDING CLOSED CLOSED CLOSED CLOSED DRAINAGE DRAINAGE DRAINAGE DRAINAGE 236 236 236 236 6-30% 6-30% 6-30% 6-30% 16-40% 16-40% 16-40% 16-40% 3-26% 3-26% 3-26% 3-26% 1-30% 1-30% 1-30% 1-30% PLANNED PLANNED PLANNED PLANNED RE- RE- RE- RE- EXPLORATIO EXPLORATIO EXPLORATIO EXPLORATIO N N N N 297 297 297 297 14-27% 14-27% 14-27% 14-27% 100% 100% 100% 100% 5-40% 5-40% 5-40% 5-40% 5-29% 5-29% 5-29% 5-29% CLOSED CLOSED CLOSED CLOSED LAVAGE LAVAGE LAVAGE LAVAGE 405 405 405 405 8-36% 8-36% 8-36% 8-36% 9-64% 9-64% 9-64% 9-64% 7-43% 7-43% 7-43% 7-43% 5-13% 5-13% 5-13% 5-13%
Maingot Maingot Maingot Maingot’ ’ ’ ’s s s s Abdominal operations -11 Abdominal operations -11 Abdominal operations -11 Abdominal operations -11th
th th th edition
edition edition edition
LACK OF STANDARD DEFINITIONS OF THE LACK OF STANDARD DEFINITIONS OF THE LACK OF STANDARD DEFINITIONS OF THE LACK OF STANDARD DEFINITIONS OF THE CONDITIONS FOR WHICH EACH OF THESE CONDITIONS FOR WHICH EACH OF THESE CONDITIONS FOR WHICH EACH OF THESE CONDITIONS FOR WHICH EACH OF THESE OPTIONS WERE UTILIZED OPTIONS WERE UTILIZED OPTIONS WERE UTILIZED OPTIONS WERE UTILIZED THE OPTIONS HAVE NOT BEEN COMPARED THE OPTIONS HAVE NOT BEEN COMPARED THE OPTIONS HAVE NOT BEEN COMPARED THE OPTIONS HAVE NOT BEEN COMPARED ADEQUATELY BY RANDOMIZED PROSPECTIVE ADEQUATELY BY RANDOMIZED PROSPECTIVE ADEQUATELY BY RANDOMIZED PROSPECTIVE ADEQUATELY BY RANDOMIZED PROSPECTIVE STUDIES STUDIES STUDIES STUDIES OPTIONS INDVIDUALIZED OPTIONS INDVIDUALIZED OPTIONS INDVIDUALIZED OPTIONS INDVIDUALIZED TO THE PATIENT TO THE PATIENT TO THE PATIENT TO THE PATIENT EARLY NECROSECTOMY - EARLY NECROSECTOMY - EARLY NECROSECTOMY - EARLY NECROSECTOMY -
PLANNED RE-EXPLORATION/ PLANNED RE-EXPLORATION/ PLANNED RE-EXPLORATION/ PLANNED RE-EXPLORATION/ CLOSED LAVAGE CLOSED LAVAGE CLOSED LAVAGE CLOSED LAVAGE
DELAYED NECROSECTOMY DELAYED NECROSECTOMY DELAYED NECROSECTOMY DELAYED NECROSECTOMY – – – –
CLOSED DRAINAGE CLOSED DRAINAGE CLOSED DRAINAGE CLOSED DRAINAGE
TIMING OF SURGERY MORTALITY <14 DAYS <14 DAYS <14 DAYS <14 DAYS 75% 75% 75% 75% 15-29DAYS 15-29DAYS 15-29DAYS 15-29DAYS 45% 45% 45% 45% >30DAYS >30DAYS >30DAYS >30DAYS 8% 8% 8% 8% WHY MINIMAL ACCESS ? WHY MINIMAL ACCESS ? WHY MINIMAL ACCESS ? WHY MINIMAL ACCESS ? TO REDUCE THE TO REDUCE THE TO REDUCE THE TO REDUCE THE ACCESS TRAUMA AND ACCESS TRAUMA AND ACCESS TRAUMA AND ACCESS TRAUMA AND ASSOCIATED ASSOCIATED ASSOCIATED ASSOCIATED PROINFLAMMATORY PROINFLAMMATORY PROINFLAMMATORY PROINFLAMMATORY RESPONSE WITH RESPONSE WITH RESPONSE WITH RESPONSE WITH OPEN NECROSECTOMY OPEN NECROSECTOMY OPEN NECROSECTOMY OPEN NECROSECTOMY TO DELAY TO DELAY TO DELAY TO DELAY NECROSECTOMY AS NECROSECTOMY AS NECROSECTOMY AS NECROSECTOMY AS MUCH AS POSSIBLE MUCH AS POSSIBLE MUCH AS POSSIBLE MUCH AS POSSIBLE
Arch Arch Arch Arch Surg Surg Surg Surg 142: 142: 142: 142: 1194-1201,2007 1194-1201,2007 1194-1201,2007 1194-1201,2007
INTERVENTIONS INTERVENTIONS INTERVENTIONS INTERVENTIONS ROUTES USED ROUTES USED ROUTES USED ROUTES USED INSTRUMENTATION INSTRUMENTATION INSTRUMENTATION INSTRUMENTATION PERCUTANEOUS PERCUTANEOUS PERCUTANEOUS PERCUTANEOUS TRANSGASTRIC TRANSGASTRIC TRANSGASTRIC TRANSGASTRIC PERITONEUM PERITONEUM PERITONEUM PERITONEUM RETROPERITONEUM RETROPERITONEUM RETROPERITONEUM RETROPERITONEUM RADIOLOGICAL GUIDANCE RADIOLOGICAL GUIDANCE RADIOLOGICAL GUIDANCE RADIOLOGICAL GUIDANCE ENDOSCOPY ENDOSCOPY ENDOSCOPY ENDOSCOPY LAPAROSCOPY LAPAROSCOPY LAPAROSCOPY LAPAROSCOPY OPERATING NEPHROSCOPE OPERATING NEPHROSCOPE OPERATING NEPHROSCOPE OPERATING NEPHROSCOPE
ENDOSCOPIC TRANSGASTRIC ENDOSCOPIC TRANSGASTRIC ENDOSCOPIC TRANSGASTRIC ENDOSCOPIC TRANSGASTRIC NECROSECTOMY NECROSECTOMY NECROSECTOMY NECROSECTOMY
PERCUTANEOUS DRAINAGE PERCUTANEOUS DRAINAGE PERCUTANEOUS DRAINAGE PERCUTANEOUS DRAINAGE
HAND ASSISTED LAPAROSCOPIC HAND ASSISTED LAPAROSCOPIC HAND ASSISTED LAPAROSCOPIC HAND ASSISTED LAPAROSCOPIC NECROSECTOMY PORT POSITIONING NECROSECTOMY PORT POSITIONING NECROSECTOMY PORT POSITIONING NECROSECTOMY PORT POSITIONING LAPAROSCOPIC NECROSECTOMY LAPAROSCOPIC NECROSECTOMY LAPAROSCOPIC NECROSECTOMY LAPAROSCOPIC NECROSECTOMY
RETROPERITONEAL NECROSECTOMY RETROPERITONEAL NECROSECTOMY RETROPERITONEAL NECROSECTOMY RETROPERITONEAL NECROSECTOMY OPEN TECHNIQUE OPEN TECHNIQUE OPEN TECHNIQUE OPEN TECHNIQUE VIDEO-ASSISTED VIDEO-ASSISTED VIDEO-ASSISTED VIDEO-ASSISTED TECHNIQUE TECHNIQUE TECHNIQUE TECHNIQUE
Percutaneous necrosectomy using operating nephroscope and supplemental laparoscopic port.
Out-come Open - necrosect
Step-up approach P - value New onset New onset New onset New onset MODS MODS MODS MODS 42% 42% 42% 42% 12% 12% 12% 12% 0.001 0.001 0.001 0.001 Death Death Death Death 16% 16% 16% 16% 19% 19% 19% 19% 0.7 0.7 0.7 0.7 Hospital Hospital Hospital Hospital stay stay stay stay 60 days 60 days 60 days 60 days 50 days 50 days 50 days 50 days 0.53 0.53 0.53 0.53 New New New New – – – –onset DM
38% 38% 38% 38% 16% 16% 16% 16% 0.02 0.02 0.02 0.02 Pancreatic Pancreatic Pancreatic Pancreatic insufficiency insufficiency insufficiency insufficiency 33% 33% 33% 33% 7% 7% 7% 7% 0.002 0.002 0.002 0.002 Incisional Incisional Incisional Incisional hernia hernia hernia hernia 24% 24% 24% 24% 7% 7% 7% 7% 0.03 0.03 0.03 0.03
A multicenter RCT including 88 patients A multicenter RCT including 88 patients A multicenter RCT including 88 patients A multicenter RCT including 88 patients with confirmed or suspected infected with confirmed or suspected infected with confirmed or suspected infected with confirmed or suspected infected pancreatic necrosis pancreatic necrosis pancreatic necrosis pancreatic necrosis
45 underwent 45 underwent 45 underwent 45 underwent
43 underwent 43 underwent 43 underwent 43 underwent step-up approach step-up approach step-up approach step-up approach (initial percutaneous (initial percutaneous (initial percutaneous (initial percutaneous drainage followed by drainage followed by drainage followed by drainage followed by VARD) VARD) VARD) VARD)
A minimally invasive step-up approach, as A minimally invasive step-up approach, as A minimally invasive step-up approach, as A minimally invasive step-up approach, as compared with open necrosectomy, compared with open necrosectomy, compared with open necrosectomy, compared with open necrosectomy, reduced the rate of the composite end reduced the rate of the composite end reduced the rate of the composite end reduced the rate of the composite end point of major complications or death point of major complications or death point of major complications or death point of major complications or death among patients with necrotizing among patients with necrotizing among patients with necrotizing among patients with necrotizing pancreatitis and infected necrotic tissue pancreatitis and infected necrotic tissue pancreatitis and infected necrotic tissue pancreatitis and infected necrotic tissue.
Hjalmar Hjalmar Hjalmar Hjalmar C. van
Santvoort Santvoort Santvoort etal etal etal etal “ “ “ “A Step-up Approach A Step-up Approach A Step-up Approach A Step-up Approach
” ” ” N N N N Engl Engl Engl Engl J Med 2010;362:1491-502 J Med 2010;362:1491-502 J Med 2010;362:1491-502 J Med 2010;362:1491-502