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Pancreatitis- Surgical management, ERCP, Prognosis

Pancreatitis- Surgical Management

SURGERY IS REQUIRED TO

  • Remove damaged and infected tissue
  • Drain an abscess
  • Maintain pancreatic duct patency
  • Relief pain in chronis pancreatitis

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

In ERCP, a specialist inserts a tube-like instrument through the mouth and down into the duodenum to access the pancreatic and biliary ducts and the gallstones is removed.

BILIARY DRAINAGE

Placement of biliary drains (for external drainage) and stents (indwelling tubes) in the pancreatic duct through endoscopy has been performed to reestablish drainage of the pancreas. This has resulted in decreased pain and increased weight gain.

SURGICAL INTERVENTION

  1. Diagnostic laparotomy: To know the cause of pancreatitis and to establish pancreatic drainage, or to resect or debride a necrotic pancreas. The patient who undergoes pancreatic surgery may have multiple drains in place postoperatively as well as a surgical incision that is left open for irrigation and repacking every 2 to 3 days to remove necrotic debris.
  2. Pancreaticojejunostomy: With a side-to-side anastomosis or joining of the pancreatic duct to the jejunum allows drainage of the pancreatic secretions into the jejunum. Pain relief occurs by 6 months in more than 80% of the patients who undergo this procedure, but pain returns in a substantial number of patients as the disease itself progresses.
  3. Whipple resection (pancreaticoduodenectomy): It has been carried out to relieve the pain of chronic pancreatitis.
  4. Pancreatectomy: Total removal or excision of the pancreas.
  5. Autotransplantation: Implantation of the patient’s pancreatic islet cells has been attempted to preserve the endocrine function of the pancreas in patients who have undergone total pancreatectomy. Testing and refinement of this procedure continue in an effort to improve outcomes.
  6. Sphincterotomy: When chronic pancreatitis develops as a result of gallbladder disease, the obstruction is treated by surgery to explore the common duct and remove the stones; usually, the gallbladder is removed at the same time. In addition, an attempt is made to improve the drainage of the common bile duct and the pancreatic duct by dividing the sphincter of Oddi, a muscle that is located at the ampulla of Vater. A T-tube usually is placed in the common bile duct, requiring a drainage system to collect the bile postoperatively.

 

POSTACUTE MANAGEMENT

  • Antacids
  • Oral feedings low in fat and protein are initiated gradually
  • Caffeine and alcohol are eliminated from the diet
  • If the episode of pancreatitis occurred during treatment with thiazide diuretics, corticosteroids, or oral contraceptives, these medications are discontinued

 

COMPLICATIONS

Acute (early) complications

  • Shock
  • Hypocalcemia (low blood calcium)
  • High blood glucose
  • Dehydration, and kidney failure ( from inadequate blood volume)
  • Respiratory complications such as Pleural effusion, Atelectasis, Pneumonitis and Acute Respiratory Distress Syndrome
  • Systemic Inflammatory Response Syndrome(SIRS)
  • Hemorrhagic Pancreatitis
  • Pancreatic Acitis

Late complications

  • Pancreatic Pseudocysts
  • Pancreatic abscess

PROGNOSIS

Several scoring systems are used to help predict the severity of an attack of pancreatitis.

(A)Ranson criteria—

The criterion for point assignment is that a certain breakpoint be met at any time during that 48-hour period, so in some situations points can be calculated shortly after admission. This system is applicable to both biliary and alcoholic pancreatitis.

At admission

  1. age in years > 55 years
  2. white blood cell count > 16000 /mcL
  3. blood glucose > 11 mmol/L (>200 mg/dL)
  4. serum AST > 250 IU/L
  5. serum LDH > 350 IU/L

After 48 hours

  1. Hematocrit decrease > 10%
  2. Increase in BUN of 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
  3. Hypocalcemia (serum calcium < 2.0 mmol/L (<8.0 mg/dL))
  4. Hypoxemia (PO2 < 60 mmHg)
  5. Base deficit > 4 Meq/L
  6. Estimated fluid retention or sequestration > 6 L

Interpretation

  • If the score ≥ 3, severe pancreatitis is likely.
  • If the score < 3, severe pancreatitis is unlikely.

OR

  • Score 0 to 2: 2% mortality
  • Score 3 to 4: 15% mortality
  • Score 5 to 6: 40% mortality
  • Score 7 to 8: 100% mortality

(B)Glasgow criteria–

Glasgow criteria: The original system used nine data elements. This was subsequently modified to eight data elements with removal of assessment for transaminase levels (either AST (SGOT) or ALT (SGPT) greater than 100 U/L).

On Admission

  1. Age >55 yrs
  2. WBC count >15 x106/L
  3. Blood glucose >200 mg/dL (no diabetic history)
  4. Serum urea >16 mmol/L (no response to IV fluids)
  5. Arterial oxygen saturation <76 mmHg

Within 48 hours

  1. Serum calcium <2 mmol/L
  2. Serum albumin <34 g/L
  3. LDH >219 units/L
  4. AST/ALT >96 units/L

(C)Modified Glasgow criteria for predicting severity – P.A.N.C.R.E.A.S.

  • PaO2 < 60mmHg/7.9kPa
  • Age > 55 years
  • Neutrophils (WBC > 15)
  • Calcium < 2 mmol/L
  • Renal function: Urea > 16 mmol/L
  • Enzymes Lactate dehydrogenase (LDH) > 600iu/L, Aspartate transaminase (AST) > 200iu/L
  • Albumin < 32g/L (serum)
  • Sugar BSL > 10 mmol/L

Three or more positive factors detected within 48 hours of onset suggest severe pancreatitis.

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