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Toronto Notes 2019 Pancreas General Surgery and Thoracic Surgery GS51 Pancreas
Acute Pancreatitis
• seeGastroenterology,G44
GALLSTONE PANCREATITIS (45% of Acute Pancreatitis)
Pathogenesis
• obstructionofpancreaticductbylargeorsmallgallstonesandbiliarysludge • backupofpancreaticenzymescancauseautodigestionofthepancreas
Clinical Features (Pancreatitis of Any Etiology)
• pain(epigastricpainradiatingtoback),N/V,ileus,peritonealsigns,jaundice,andfever • Inglefinger’ssign:painworsewhensupine,andbetterwhensittingforward
• mayhavecoexistentcholangitisorpancreaticnecrosis
• Ranson’scriteriafordeterminingprognosisofacutepancreatitis(seesidebar)
■ APACHE II score for determining prognosis of severe acute pancreatitis
• physicalexammayshow:tachypnea,tachycardia,hypotension,abdominaldistentionandtenderness,
Cullen’s sign, and Grey Turner’s sign
Investigations
• lipase(mostSnandSp),elevatedamylase(higherthanalcoholicpancreatitis),andleukocytosis • elevatedALT(>150IU/L),ASTstronglysuggestgallstoneetiologyofpancreatitis
• U/Smayshowmultiplestones(mayhavepassedspontaneously),andedematouspancreas
• CXR,AXR,andCT(ifseveretoevaluateforcomplications)
Treatment
• supportive:e.g.NPO,hydration,analgesia,andearlyentericnutrition
• antibioticsforseverecasesofnecrotizingpancreatitisorsignsofsepsis
• stoneoftenpassesspontaneously(~90%);usuallynosurgicalmanagementinuncomplicatedacute
pancreatitis
• cholecystectomyduringsameadmission(25-60%recurrenceifnosurgery)
• mayneedurgentERCP+sphincterotomyifCBDstoneimpactedorcholangitis • surgicalindicationsinacutepancreatitis(rare):
■ drain placement and debridement for necrotizing pancreatitis if refractory to medical management, if septic, or in ICU without other sources of sepsis
Complications
• Localcomplications
■ acute fluid collections
■ walled-off pancreatic fluid collection/pseudocyst (>4 wk old) ■ abscess/infection, necrosis
• Systemic complications
■ splenic/mesenteric/portal vessel thrombosis ■ pancreatic ascites/pancreatic pleural effusion ■ DM(b/cpancreatic&insulininsufficiency) ■ ARDS/sepsis/multiorganfailure
■ coagulopathy/DIC
■ severe hypocalcemia
Chronic Pancreatitis
• seeGastroenterology,G45
Surgical Treatment
• treatmentisgenerallymedical • indicationsforsurgery
■ failure of medical treatment
■ debilitating abdominal pain
■ pseudocyst complications: persistence, hemorrhage, infection, and rupture
■ CBD obstruction (e.g. strictures), and duodenal obstruction
■ pancreatic fistula, variceal hemorrhage secondary to splenic vein obstruction
■ rule out pancreatic cancer (present in 15% of chronic pancreatitis treated surgically) ■ anatomical abnormality causing recurrent pancreatitis
• pre-operativeCTand/orERCParemandatorytodelineateanatomy • minimallyinvasiveoptions
■ endoscopic pancreatic duct decompression: less effective than surgery
■ extracorporeal shockwave lithotripsy: if pancreatic duct stones
■ celiac plexus block: lasting benefit in 30% patients, less effective in those <45 yr or with prior
Ranson’s Criteria A. At admission 1. Age >55 yr
2. WBC >16 x 109/L
3. Glucose >11 mmol/L 4. LDH ≥350 IU/L
5. AST >250 IU/L
B. During initial 48 h
1. Hct drop >10%
2. BUN rise >1.8 mmol/L 3. Arterial PO2 <60 mmHg 4. Base deficit >4 mmol/L 5. Calcium <2 mmol/L
6. Fluid sequestration >6 L
C. Interpretation
≥2 = difficult course
≥3 = high mortality (≥15%)
The hallmark of chronic pancreatitis is epigastric pain radiating to the back
pancreatic surgery