TOTAL PANCREATECTOMY FOR FULMINANT PANCREATITIS

Surgery for Acute Pancreatitis

Surgery for acute pancreatitis has undergone significant changes over the last 3 decades. A better understanding of the pathophysiology has contributed to this, but the greatest driver for change has been the rise of less invasive interventions in the fields of laparoscopy, endoscopy and radiology. Surgery has a very limited role in the diagnosis of acute pancreatitis. The most common indication for intervention in acute pancreatitis is for the treatment of complications and most notably the treatment of infected walled off necrosis. Here, the step-up approach has become established, with prior drainage (either endoscopic or percutaneous) followed by delay for maturing of the wall and then debridement by endoscopic or minimally invasive surgical methods. Open surgery is only indicated when this approach fails. Other indications for surgery in acute pancreatitis are for the treatment of acute compartment syndrome, non-occlusive intestinal ischaemia and necrosis, enterocutaneous fistulae, vascular complications and pseudocyst. Surgery also has a role in the prevention of recurrent acute pancreatitis by cholecystectomy. Despite the more restricted role, surgeons have an important contribution to make in the multidisciplinary care of patients with complicated acute pancreatitis.

The role of open necrosectomy in the current management of acute necrotizing pancreatitis: a review article

The optimal management of necrotizing pancreatitis continues to evolve. Currently, conservative intensive care treatment represents the primary therapy of acute severe necrotizing pancreatitis, aiming at prevention of organ failure. Following this mode of treatment most patients with sterile necroses can be managed successfully. Surgery might be considered as an option in the late phase of the disease for patients with proven infected pancreatic necroses and organ failure. For these patients surgical debridement is still considered the treatment of choice. However, even for this subgroup of patients, the concept of operative strategy has been recently challenged. Nowadays, it is generally accepted that necrotizing pancreatitis with proven infected necroses as well as septic complications directly caused by pancreatic infection are strong indications for surgical management. However, the question of the most appropriate surgical technique for the treatment of pancreatic necroses remains unsettled. At the same time, recent advances in radiological imaging, new developments in interventional radiology, and other minimal access interventions have revolutionised the management of necrotizing pancreatitis. In light of these controversies, the present paper will focus on the current role of surgery in terms of open necrosectomy in the management of severe acute necrotizing pancreatitis.

Clinical pancreatology I: Pancreatic medical history

The present article and subsequent reviews will not be to report all what has been published, but rather to give an introduction samples that hopefully make the reader eager to read the whole article or articles with "a taste of clinical pancreatology in 2010". The main sources of literatures were PubMed, and the additional Journals such as Pancreas, Pancreatology and Journal of the Pancreas were also scrutinized. Only some full articles in almost all languages were included in the review, other articles, however, that were too superficial or too poor in other ways, were omitted, and the publications of non-human study were excluded.

Treatment of acute pancreatitis: an attempted historical review

This attempt at a historical review of the treatment of acute pancreatitis summarizes the findings of studies carried out in decades long past and shows their impact on the therapy of this disease today. It identifies in retrospect the correct avenues of research and the blind alleys, and describes the ebb and flow of interest in various forms of management. Acquaintance with the work of previous investigators may prevent the unnecessary rediscovery of old principles of treatment. Not all of the studies discussed can be found with search engines: they come from the author's personal library, collected over his 40 years as an active pancreatologist, and from the knowledge of the early literature bequeathed to him by his teachers and mentors.

No debridement is necessary for symptomatic or infected acute necrotizing pancreatitis: delayed, mini-retroperitoneal drainage for acute necrotizing pancreatitis without debridement and irrigation

We sought to determine if necrosectomy can be omitted for complicated acute necrotizing pancreatitis (ANP). Since 1996, we prospectively performed retroperitoneal drainage by introducing a sump drain to the pancreatic head area via a small left flank incision without debridement and irrigation on 19 consecutive complicated ANP patients. We purposely delayed surgery until liquefaction of retroperitoneal tissue reached the left flank. Our patients had a mean Ranson's and APACHE II score of 5.9 (range, 4-8) and 20.1(range, 4-45), respectively. Sixteen available CT showed retroperitoneal liquefaction after 21.3 days (range, 14-26). Operations were delayed for 4.7 weeks (range, 1.3-9.0). No patient succumbed during this period. The indications were infected necrosis in 16 and severe abdominal pain/food intolerance in 3 patients. Average skin incision was 4.0 cm (range, 3-9). Fungi or bacteria were cultured in 15 patients (80.0%). The recovery courses were surprisingly uneventful. Oral intake began within 2.4 days (range, 1-5) and mean hospital stay (16 survivals) was 23.2 days (range, 4-120) after operation. Drains were completely removed 120.6 days (range, 60-250) later from these outpatients. One gastric perforation and one minor duodenal leak were the only procedure-related complications (10.5%). Three patients died (15.8%), although one had a healed ANP. In conclusion, this delay-until-liquefaction strategy without necrosectomy is an easy and effective treatment method.

Surgery in acute pancreatitis. The Japanese experience

Seventy-eight cases of severe acute pancreatitis were admitted to Mie University and its affiliated hospitals. These were subdivided into Group I (1976-1983) and Group II (1984-1989). The rate of early death was 34.8% in Group I and 9.3% in Group II. Among operated cases, peritoneal drainage alone was not effective with the worst mortality rate of 47.1%, especially in gallstone pancreatitis, with a 100% mortality rate. Early detection of infected necrosis or abscess using enhanced CT and subsequent drainage should be performed in cases of severe acute pancreatitis. A total 1182 cases of severe acute pancreatitis out of 12,309 cases of acute pancreatitis were collected in Japan by Saito et al., who belong to the Research Committee of Intractable Diseases of the Pancreas supported by the Japanese Ministry of Health and Welfare. Furthermore, 473 cases of severe acute pancreatitis in the Japanese literature reported from 1987 to 1990 were reviewed. Then, surgical indications and procedures were discussed. The incidence of necrosectomy has been increased to 10.3% from 3%, and biliary drainage procedure increased for severe acute pancreatitis. Indication of necrosectomy with or without open drainage method should be carefully evaluated in each institution.

The role of surgery in the management of acute pancreatitis

Surgical intervention in acute pancreatitis may have varied goals. Early laparotomy may be required for diagnostic purposes. There is, however, no convincing evidence that attempts to reduce the morbidity of severe pancreatitis by early operative pancreatic drainage, early formal pancreatic resection, or early biliary procedures have been effective. In fact, they may be harmful. Peritoneal lavage by catheter induced under local anesthesia may ameliorate early cardiovascular and respiratory complications in some patients. Preliminary experience suggests that early operative debridement of devitalized pancreatic tissue with postoperative lavage may be helpful in selected patients. Patients with infections of devitalized pancreatic or peripancreatic tissue require operative debridement and drainage or packing. Other complications such as colonic necrosis or pseudocysts also require operative treatment. Rarely do patients require operation to relieve protracted pancreatitis. Patients with gallstone-associated pancreatitis should usually undergo surgical correction of their cholelithiasis as soon as their pancreatitis has subsided.

Surgical management of acute pancreatitis

This review examines the lack of improvement in terms of mortality and outcome in patients with acute pancreatitis. Energetic fluid replacement is the only treatment of proven value. There is a strong case for identification of patients with severe disease who may benefit from early operative intervention. Eradication of gallstones may prevent further attacks in patients with gallstone pancreatitis. The benefits of pancreatic resection and necrosectomy still require full evaluation.

Clinical pathology of acute necrotising pancreatitis

Seventy nine pancreatic specimens were obtained from patients treated with pancreatic resection for acute necrotising pancreatitis. The necrotising process had started in the periphery of the gland, so that eight of seventy nine cases contained peripancreatic (mainly fat) necrosis only without any parenchymal necrosis. Peripheral parenchymal necrosis was characterised by a severe inflammatory reaction, with multinucleated leucocytes and microabscess. In the deep parts of the pancreas coagulation necrosis was found. Vascular changes (thrombosis, vessel necrosis) correlated with postoperative haemorrhagic complications, but they did not seem to have any important role in the necrotising process. The vascular changes seemed to be a secondary phenomenon. In clinical practice the most important aspects in reporting the histology of acute necrotising pancreatitis are the extent of parenchymal necrosis, because the surgeon may overestimate its extent, and the existence of vascular changes, because of the correlation with postoperative recovery.

Long-term results after pancreas resection for acute necrotizing pancreatitis

This study was designed to investigate the long-term effects of early pancreatic resection for acute necrotizing pancreatitis. During 1973-1978 40 resections were performed in our clinic. Eleven patients died initially (28 per cent). None of the four further deaths was due to pancreatitis or associated disorders. Twenty-four patients were re-examined 5-11 years after resection--one patient refused to participate. Five had not been able to return to work because of severe polyneuropathy; one more had retired because of chronic pancreatitis in the pancreatic remnant. Polyneuropathy was found in five further patients. The reason for this high incidence of polyneuropathy (42 per cent) remains unknown. Eight patients still drank excessive alcohol; three of them had had recurrent pancreatitis and dyspepsia, and insulin requiring diabetes. All but 2 (92 per cent) had diabetes, 14 needing insulin--half of them at 6 months to 6 years after the resection. Moreover, 11 patients (46 per cent) suffered from dyspeptic symptoms. The results suggest that because of the high frequency of late complications, in addition to the early complications, early resection of pancreas should be critically re-evaluated as the treatment for acute necrotizing pancreatitis. If resection is used in patients with extreme pancreatic necrosis, careful and continuous postoperative follow-up will be needed.

Surgical management of acute pancreatitis

Acute pancreatitis is a formidable problem that infrequently necessitates surgical intervention. Indications for operation may be divided into four main categories: (1) uncertain diagnosis, (2) deteriorating condition, (3) biliary pancreatitis, and (4) pancreatic abscess. One of the most important contributions concerning acute pancreatitis has been the development of predictive criteria that allow quantitation of the severity of disease and precise comparison of various reported series. During a 2-year period, 222 patients with acute pancreatitis were seen at our institution, and 62 of these patients (28%) underwent operation. Biliary pancreatitis accounted for 63% of our cases. The overall mortality of 24% was directly related to the severity of the pancreatitis. Cholecystectomy, during the same hospital admission, is advised for treatment of biliary pancreatitis.

Pancreatic resection versus peritoneal lavation for acute fulminant pancreatitis. A randomized prospective study

Thirty-five patients with acute fulminant (hemorrhagic) pancreatitis, verified at laparotomy, were allocated to either pancreatic resection (18 patients) or peritoneal lavation (17 patients) therapy groups. Pancreatic resection was carried out by removing the distal pancreas well cephalad to the portal vein. For peritoneal lavation, two inlet silicone catheters were inserted at laparotomy around the pancreas and an outlet catheter was inserted in the lower abdomen, and the peritoneal cavity was thereafter lavated (1000 ml/hr) with a standard peritoneal dialysis fluid for 7 to 12 days (or until death if met earlier). In other respects, the postoperative care was similar, including intravenous fluids with total parenteral nutrition until oral intake of food was resumed, prophylactic antibiotics (tobramycin and clindamycin) and stress ulcer prophylaxis (cimetidine and antacids). In the resection group, four of the 18 patients (22.2%) died, while in the lavation group eight of the 17 patients (47.1%) died. The most common cause of death was septic complications with multiple organ failure, but one patient in each group died accidentally of airway complications. There was no difference in the incidence of septic complications (sepsis and/or intra-abdominal abscesses), but the incidence and severity of pulmonary and renal complications were greater in the lavation group. However, these complications accumulated to patients who ultimately died. Also, the need for reoperation was greater in the lavation group (20 reoperations/10 patients versus 12 reoperation/eight patients). Yet, the length of overall hospital stay was equal in the two groups. Six of the 14 survivors in the resection group developed diabetes, whereas none of the nine survivors in the lavation group got this complication. The results suggest that pancreatic resection is superior to peritoneal lavation in the management of acute fulminant (hemorrhagic) pancreatitis, decreasing mortality and affording smoother postoperative course. However, these benefits are gained at the expense of higher incidence of postoperative diabetes.

Founder's lecture. The vicissitudes of pancreatic surgery

Using Senn's treatise as the benchmark from which to measure the advances of pancreatic surgery during the last century, it may be said that acceptable, if not totally successful, progress has been achieved in a number of areas. Injuries to the head of the pancreas, particularly those combined with duodenal trauma, continue to pose difficult operative and management problems. Persistent pancreatic and intestinal fistulas and infection substantially increase morbidity and prolong the hospital stay of some patients with injuries of the body and tail of the gland. Means to control or eliminate the effects of extravasated activated pancreatic juice are needed. Severe hemorrhagic gangrenous pancreatitis, with its excessive morbidity and mortality, offers numerous opportunities for improvement in management. The role of peritoneal lavage and of early resection have not been completely settled and require further carefully controlled evaluation. Why in one case of acute pancreatitis does the mild edematous variety develop and in the next the devastating gangrenous type? Although the majority of patients with chronic pancreatitis can be successfully treated, surgery often falls short of complete rehabilitation. Careful selection of patients and procedures as well as collaboration with colleagues in the psychologic and rehabilitative fields are essential to achieve optimal results. What are the important events within the pancreas that lead to the pathologic changes of chronic pancreatitis? Cancer of the pancreas remains one of the most discouraging problems of pancreatic surgery, and unfortunately, major surgical therapeutic break-throughs do not appear at hand. Earlier diagnosis or technical improvements may add a few percentage points to the survival rate, but our greatest hope for improvement may lie in adjunctive therapies that will help to control the basic biologic aggressiveness of this tumor. What accounts for the biologic aggressiveness of this tumor and how might this characteristic be modified? Of the endocrine tumors the best surgical results by far have been achieved with insulinomas. Diagnosis, localization, and excision are usually successful although occult and multiple tumors still pose a problem. Malignancy is rare (10 percent) in insulinomas, common in vipomas (35 percent), and frequent (66 percent) in gastrinomas and glucagonomas. Although the incidence of malignancy in the latter three tumors diminishes the efficacy of surgical excision, prolonged palliation and occasional cures are achieved. Operation is once again assuming an important role in the management of gastrinoma.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute pancreatitis in Hong Kong

A series of 311 Chinese patients with acute pancreatitis admitted to Queen Mary Hospital, Hong Kong, over a 10-year period is reviewed. Biliary tract disease was associated with pancreatitis in 52.4 per cent of patients and 77.9 per cent of them had stones, mud or parasites in the common bile duct. Fever and jaundice were present in 55 per cent and 41.2 per cent of patients respectively. Because of the prevalence of recurrent pyogenic cholangitis among the indigenous population, emergency operation, with the aim of common duct decompression, was conducted in 54.3 per cent of patients during the acute episode, with a mortality rate of 14.8 per cent. Five of 142 patients (3.5 per cent) died whilst on conservative treatment and all 5 had haemorrhagic pancreatitis. The overall mortality rate was 9.6 per cent. Exploration of the common bile duct, which was carried out in 57.4 per cent of patients in the acute phase, was not associated with a higher mortality than when laparotomy alone was performed, and 19 patients had sphincteroplasty without any death. Subtotal pancreatectomy was performed in 2 patients with haemorrhagic pancreatitis with 1 death.

Sequestrectomy and hyperalimentation in the treatment of hemorrhagic pancreatitis

Surgical treatment has been used in those patients with hemorrhagic pancreatitis who deteriorate after several days of intensive medical therapy, or in those patients in whom the diagnosis cannot be established early in the course of treatment. Initial therapy consisted of: cholecystostomy or T-tube drainage in those patients who have gallstones, jaundice, or distended biliary tree; gastrostomy for prolonged gastric decompression; jejunostomy to provide a portal for enteroalimentation; and appropriate soft rubber drainage of the pancreatic bed as a simple, safe, and effective means of treating severe hemorrhagic pancreatitis. Adjunctive daily hyperalimentation and later sequestrectomy of necrotic pancreatic tissue provided a mortality of 20 per cent and complete rehabilitation of sixteen of thirty patients so treated. Delaying the initial approach to necrotic pancreas allows precise delineation of necrotic material so that sequestrectomy, leaving behind normal pancreas, can be carried out to avoid exocrine and endocrine deficiencies after the acute episode has passed.

The role of surgery in acute pancreatitis

Due to the lack of randomized controlled studies comparing medical with surgical therapy, the role of surgery in acute pancreatitis is not clear. This is especially true in critically ill patients who are rapidly deteriorating with hemorrhagic or necrotizing pancreatitis. Surgical intervention may be of benefit in those patients who do not have a clearcut diagnosis of pancreatitis and may have a surgically correctable disorder, who have biliary or pancreatic duct disease, or who have developed a complication such as abscesses or a pseudocyst. The mortality rate of performing a laparotomy on patients with acute pancreatitis is not prohibitive.

Total pancreatectomy in the treatment of acute necrotising and hemorrhagic pancreatitis. Indications-technique

The place of total pancreatectomy in the treatment of pancreatitis is still not clear: the author is in favour of this operation and gives the indications, surgical technique, complications and results. The operation is indicated in cases of necrosis involving more than 2/3rds of the whole of the head and part of the body of the pancreas. The duodenum and pancreas should be removed in one piece and intestinal continuity should be restored performing choledocho-jejunal and gastro-jejunal anastomoses. It is important to carry out this operation early, between the 3rd and 6th days, treating all areas of necrosis before the lesions become the site of uncontrollable infection. Seven patients out of 9 are still alive, on the 25th of July 1975; they all have easily controlled diabetes, a low fat diet and are receiving pancreatic extract. We have recently operated a 10th case, and the patient is alive 2 months later.

Ablative surgery for necrotizing pancreatitis

We have confirmed again that bile and trypsin injected in dogs under high pressure produce highly lethal necrotizing pancreatitis responsive to fluid resuscitation. Animals undergoing pancreatectomy show a reduction in serum amylase levels and hemoconcentration (reflected in hematocrit levels) after pancreatectomy, an effect that may be related to removal of the source of vasoactive substances liberated in pancreatitis. Qualitatively, survivors of pancreatectomy exhibit accelerated convalescence. Pancreatectomy, however, does not increase survival once the disease process is established and may be harmful. This experimental study does not support the clinical use of pancretectomy but rather emphasizes the utility of adequate fluid resuscitation in the treatment of severe pancreatitis.

Surgical treatment of acute necrotizing pancreatitis

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