ANTIBIOPROPHYLAXIS Selective gut decontamination One human clinical study »Luiten EJT and al Ann Surg 222,57, patients with severe AP Oral colistin,amphoB and norfloxacin plus rectal enema Decrease moratlity 35% vs 22% Decrease of laparotomy/pts 0,33 vs 0,08

INDICATIONS FOR SURGERY IN SEVERE AP Infected necrosis Pancreatic abscess Local complications Massive bleeding Perforation of the bowel Portal vein thrombosis Sterile necrosis with MOF ???

SURGICAL TECHNIQUES Conventionnal technique Débridement an penrose/sump drainage Highest mortality rate ( around 40% ) More than 35% of the patients need reexploration Low threshold for rexploration is imperative

SURGICAL TECHNIQUES Open and semi-open technique Laparotomy then packing with gaze Use of syntetic mesh or zipper thereafter As needed bedside rexploration under anesthesia Healing by secondary intention

SURGICAL TECHNIQUES Open technique=> the zipper suture of a marlex sheet to the abdo. fascia or skin a zipper is sewn in the middle of the marlex daily manual exploration of the abdomen and lavage

SURGICAL TECHNIQUES

Closed technique Closing of the abdominal wall Intraoperative and postoperative lavage of the lesser sac and the necrosectomy area Continuous lavage by large bore single or double- lumen catheters

SURGICAL TECHNIQUES »BEGER and al Surg Clinics N A,79;4 1999

Retrospective study of 73 consecutives patients The presence of infected vs non-infected necrosis do not correlate with mortality

retrospective study No control group for sterile necrosis Surgical indication ? Conclusion of the study is not to the good question

So it does not answer to the question if the patient has only sterile necrotic pancreatitis and no other surgical indication The better study show that observation is adequate in almost all patient even with MOF »Bradley EL 1991 Am J Surg;161:19-24

NUTRITION Putting the pancreas to rest… traditionnaly NPO and TPN Now four prospective studies with enteral feeding

NUTRITION Role of the gut in SIRS modulation of inflammatory response bacteria translocation mucosal injury downregulation of the acute phase reaction with enteral feeding

NUTRITION TEN feasible with jejunostomy on patients requiring laparotomy for AP »Kudsk K and al Nutr Clin Pract1990;5:14 Enteral feeding decrease the acute phase response in AP compare to TPN »Windsor ACJ and al Gut 1998;42:

NUTRITION TEN decrease the risk of infection and the total number of complications vs TPN »Kalfarentzos F and al Br Jour Surg 1997;84,1665 TEN is well tolerated in almost all patients with severe pancreatitis »Eatok F and al Br Jour Surg 1998;85,10

OCTREOTIDE Recent multicenter RCT on octreotide Uhl W and al Gut 1999,Jul;45(1): pts with severe acute pancreatitis Octreotide vs placebo No difference in death, MODS, complications, LOS and surgery

OCTREOTIDE Recent review article on octreotide »Uhl W and al Digestion 1999;60 Suppl 2:23-31 A lot of controversial studies with a small amount of patients No strong evidence of any benefit as treatment of severe AP

LEXIPAFANT Systemic complications of acute pancreatitis are associated with pro- inflammatory response cytokines Platelet-activating factor is one of them induced plts aggregation and activation increase vascular permeability activation of monocyte...

LEXIPAFANT Two human studies Multicenter RCT severe pancreatitis ( 11 cewnters ) Severe pancreatitis Lexipafant vs placebo Result –Decrease in MODS and systemic complications –Trend in reduce mortality »Mckay CJ and al Brit Jour Surg 1997,84, Ongoing multicenter trial

Conclusion All significant acute pancreatitis should be evaluated with prognosis scale to assess the risk of mortality and morbidity and to determine the patients more likely to benefit from agressive monitoring and treatment either with –clinical scale –and/or ct-scan

Conclusion All necrotizing pancreatitis should be considered for an antibioprophylaxis of 14 days with an appropriate antibiotic.

Conclusion All severe pancreatitis should have a trial of enteral feeding with NJT if there is no contraindications. All acute severe pancreatitis should be considered for a jejunostomy if they have a laparotomy.

Conclusion Patients with infected necrosis need necrosectomy for most of them by laparotomy. The type of surgical approach thereafter is quite unclear with the actual litterature in the absence of control trial. The main factor is the local surgical expertise.

Conclusion There is no clear indication for surgery in patient with sterile necrosis.

Conclusion Patients with severe acute pancreatitis associated with cholestasis,suspected cholangitis or progressive jaundice should be considered for early ERCP to reduce the local complications and the severity of the disease

Conclusion There is no actual clear role for gabexate,lexipafant and other antiproteinase in the treatment of acute severe pancreatitis otherwise than inside a study protocol