Acute Pancreatitis in the Postoperative Course after Esophagectomy: A Major Complication Described in 4 Patients

Assessment of changes in blood pancreatic lipase activities using FDC-v-LIP in dogs that underwent various surgical procedures

OBJECTIVE

To describe the perioperative changes in blood pancreatic lipase activity and explore the contributing clinical factors associated with these changes.

DESIGN

Prospective observational study.

SETTING

University teaching hospital.

ANIMALS

One hundred and four dogs underwent various surgical procedures under general anesthesia.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Blood pancreatic lipase activities, which were measured using FUJI DRI-CHEM v-Lip-P (FDC-v-Lip), significantly increased postoperatively compared to preoperative measurements (premedian 58.5 U/L [range, 23-157] vs. postmedian 80 U/L [range, 22-1000], P < 0.0001). The patient with a postoperative increase in FDC-v-Lip over the normal range (35 dogs [33.6%]) had significantly higher preoperative FDC-v-Lip values.

CONCLUSIONS

In this study, dogs had significantly increased pancreas-specific lipase activities after surgical procedures under general anesthesia. Direct contributors to the increase and its relevance to clinical and histological pancreatitis should be determined in the future.

Severe Acute Pancreatitis in Autopsies Associated With Surgeries and Severe Inflammatory Diseases

OBJECTIVE

We clarified clinicopathological characteristics of acute pancreatitis in terminal patients.

METHODS

Pathological changes in the entire pancreas from serial autopsies (N = 183) classified lesions into the following 3 categories: focal neutrophil infiltration, focal necrotizing pancreatitis, and diffuse necrotizing pancreatitis. The former two are possible precursors of diffuse necrotizing pancreatitis. Immunohistochemical staining was performed to analyze pancreatic stellate cells and inflammatory cells.

RESULTS

There were pathologically acute pancreatitis in 45 patients (24.6%), and no patients were diagnosed with it before autopsy. Focal neutrophil infiltration was present in 22 cases, focal necrotizing pancreatitis in 18 cases, and diffuse necrotizing pancreatitis in 5 cases. Severe inflammatory disease and surgery were associated with acute pancreatitis. Sepsis due to viral or bacterial infection was the most common cause of acute pancreatitis. Patients with diffuse necrotizing pancreatitis showed low white blood cell counts, while amylase levels were not increased. Increase in α-smooth muscle actin and nestin-positive stellate cell numbers in acute pancreatitis was correlated to increase in numbers of CD34-positive vascular endothelium, CD68- or CD163-positive macrophages, CD138-positive plasmacytes, CD3-positive T lymphocytes, and myeloperoxidase-positive leucocytes.

CONCLUSIONS

Necrotizing pancreatitis without typical clinical signs was frequently detected in autopsy samples. Clinicians must be mindful of necrotizing pancreatitis in terminal patients.

Acute necrotic pancreatitis after esophagectomy: a case report

Acute pancreatitis after esophagectomy is a very rare but fatal complication. This case report describes a 74-year-old man diagnosed with cT2N0M0, cStage IB esophageal squamous cell carcinoma (Union for International Cancer Control, seventh edition). On the basis of the patient's condition, it was decided that he should undergo esophagectomy without thoracotomy. The patient developed pyrexia 3 days after the operation. Chest and abdominal computed tomography revealed severe acute pancreatitis and gastric tube necrosis; therefore, gastrectomy was performed. Subsequent surgical exploration indicated pancreatic necrosis that was diagnosed as acute necrotic pancreatitis. Postoperative management of acute pancreatitis and the general condition of the patient were quite challenging, and rapid deterioration of the respiratory status was observed. The patient experienced multiple organ failure and died 57 days after the second surgery (60 days after the first surgery). This is a report of a patient with acute necrotic pancreatitis after esophagectomy.

Clinico-pathological particularities of the shock-related pancreatitis

Acute pancreatitis can develop in patients with shock due to the underlying diseases, surgical interventions or because of severe hypoperfusion. The aim of our work was to study the histological alterations of the pancreas in patients dying after cardiogenic, hypovolemic or septic shock, to demonstrate the presence and severity of pancreatic injury. We performed a retrospective study which included patients who died and who were autopsied after different types of shock, hospitalized between 2007-2009 in general and cardiac intensive care units. We excluded the patients with known pancreatic diseases. From 223 patients included in our study 39 presented necrotising hemorrhagic alteration of the pancreatic tissue. There were no differences in histological and immunohistochemical findings between the different etiopathogenetic types of shock. None of the patients had characteristic clinical signs for acute pancreatitis. The digestive symptoms, they presented, could be related to the underlying disease or to postoperative state. The common findings in these patients were prolonged and severe hypotension, associated renal dysfunction, leucocytosis, hyperglycemia and hypocalcemia. Pancreatitis can occur in patients with shock, due to prolonged hypoperfusion of the pancreas. It is difficult to diagnose it because clinical signs are altered due to severity of underlying disease or analgo-sedation commonly used in intensive care. We therefore recommend in patients with shock to consider the possible development of ischemic pancreatitis for prompt and efficient treatment.