pancreatitis

1. SURGICAL MANAGEMENT OF
ACUTE PANCREATITIS
Dr. Prashant

2. Indications for surgical management
1. Diagnostic uncertainty
2. Non pancreatic causes like perforated viscus
3. Infected necrosis
4. Severe sterile necrosis
5. Symptomatic organized pancreatic necrosis

3. Infected pancreatic necrosis
• Fever and leucocytosis inconclusive
• FNA
• CT – emphysematous or gas in parenchyma
• Suspected in severe pancreatitis, organ failure
or do not improve in first 2 weeks clinically.
• 100% mortality if not treated

4. Severe Sterile Pancreatic Necrosis
• Ranson score of 5 or 6.
• More than 50% necrosis on CT.
• Challenged by Bradley and Allen in 1991.
• Current dictum is conserve all sterile
pancreatic necrosum as far as possible unless
infection is stablished or patient detoriates.

5. Organized pancreatic necrosis
• According to Baron it is the pathological
correlate of Warshaw’s “persistent
unwellness”.
• There is good demarcation between necrosed
and healthy parenchyma.
• As per Fernanadez del Castillo optimal timing
is not later than 4 weeks.

6. Surgical procedures
• For etiology:
1. Cholecystectomy
2. ERCP
3. CBD exploration
4. Longitudnal pancreaticojejunostomy(Frey’s
procedure and Puestow’s procedure)

7. For complications:
1. Pancreatic resection
2. Pancreatic debridement
3. Drainage of pancreatic abscess
4. Cystogastrostomy or cystoduodenostomy or
Roux en Y cystojejunostomy

8. Cholecystectomy
• For gall stone pancreatitis.
• Defer till acute pancreatic inflammation resolve.
• If pre op ERCP is not done then during
cholecystecomy intra op cholangio gram and CBD
exploration.

9. Endoscopic retrograde Cholangio
pancreatogram
• For diagnosing choledocholithiasis.
• Simultaneous CBD clearance with or witout
papillotomy can be done.

10. Pancreatico jejunostomy
• Is a pancreatic drainge procedure done in chronic
pancreatitis for stricture dilated tortous duct.
• If done by lateral opening of pancreatic body and
head known as Puestow’s procedure.
• If done by coring of head -Frey’s procedure

11. Puestow’s procedure

12. Frey’s procedure

13. Resection
• Historical importance
• Principle: Remaining pancreatic tissue source of
inflammation
• Mortality 60%

14. Pancreatic debridement
(necrosectomy)
Principle:
1. Wide removal of devitalized and necrotic tissue
with through exploration and unroofing of all
collections.
2. Assurance of post operative removal of products of
ongoing local inflammation and infection.

16. Types
Open:
1. Debridement with closure over drains.
2. Debridement with closure over packing.
3. Debridement with closure over irrigation drains
and postoperative lavage.
Minimally invasive:
1. Laparoscopic/gastroscopic/nephroscopic
necrosectomy
2. Radiology guided necrosectomy

17. Approaches
• Gastrocolic:
1. Tissue planes obscured by inflammation.
2. Drain cannot be placed in depth.
• Transmesocolic :
1. Middle colic obscures the path
2. Way to whole of abdomen is opened for
inflammation to spread.