Acute Necrotizing Pancreatitis Yoram Klein MD

MAGNITUDE OF THE PROBLEM The disease may be mild and self limiting, 70-80% take course of edematous interstitial inflammation Necrotizing pancreatitis develops in % pts % will develop local or systemic complications Approx 1 in 4 pts who develop complications will die

* AP & QUESTIONS WHAT IS THE CORRCT DIAGNOSIS? What is the prognosis? Are complications developing? Can an associated condition to be identified? What is the ideal timing for surgery?

OBJECTIVE To give pts of AP best chance of survival, from the outset to be managed by surgeon Identification of pts likely to develop complications Management (prevention)of systemic complications Timing and choice for surgical Intervention for gall stones or local complications

PANCREATITIS (terminology) MILD-uncomplicated recovery SEVERE-AP with evidence of failure of one or more systems, or local complication.  These terms are defined retrospectively,when outcome is known Prospectively defined on the basis of scoring systems.Predicted Mild or Predicted Severe

ACUTE PANCREATITITS- TERMINOLOGY COMPLICATED- local or systemic complications EDEMATOUS-Swollen, red,with or without fat necrosis;Histology fluid,debris,leukocytes present PERIPANCREATIC NECROSIS- Necrosis of retroperitoneal fat, other organs rarely involved, occasionally infarction by vascular thrombosis.This change may be present alone or may coexist with or be absent in presence of pancreatic necrosis

AP-local complications …… contd Pancreatic necrosis; Patchy or diffuse superficial or parenchymal necrosis, unequivocally demonstrated by inspection after opening of the pancreatic capsule, or histological criteria; local or diffuse areas of non enhancement on CT, sterile necrosis Infected pancreatic necrosis ; Necrosis with positive bacterial cultures Pancreatic abscess; Loculated walled off collections of pus as a late complication of AP, usually after 3 weeks

MANIFESTATIONS OF AP LOCAL; LOCAL; MILD; EDEMA, INFLAMMATION, NECROSIS SEVERE; PHLEGMON, NECROSIS, INFECTION, FLUID COLLECTION, ABSCESS

Bacterial contamination  Risk of bacterial infection on necrotic tissue  60% in proven cases of NP  Risk in ist week =25%  Risk in 2 nd week = 35-40%  Risk in 3 rd week =60%  Organisms are Gram negative E-coli,Proteus,Pseudomonas,staphylococci

SYSTEMIC COMPLICATIONS o Respiratory- Interstitial pulmonary edema;gas transfer impairment,Pt may need ventilation o Renal-o liguria-require aggressive circulatory support,#Dialysis Cardiovascular- Hypotension, edema,aggressive fluid therapy and Ionotropes Haemopoiesis, Coagulation system, Endocrine systems

PANCREATITIS How to diagnose it? How to evaluate severity? RANSON CRITERIA IMRIES CRITERIA APACHE scoring GLASGOW Criteria Lab and Radiology Help ;

Diagnosis of Pancreatitis Clinical Diagnosis  Lab studies; Serum amylase ;Levels Rise within 2-12hrs, o 3x times normal is cut off. (n IU/liter o levels normal in 2-3days. o Persistence of ^ levels >10days denote complication like cyst,abscess. o 5%cases no increase value

Diagnosis of pancreatitis(contd) Serum lipase ^^ 2x times the normal( IU/L) n=3-5days CR protein,LDH,Serum Neutrophil – elastase,IL-6, and alpha macroglobulin Trypsin like Immunoreactivity

RANSON CRITERIA Initial 24 hrs 1.Age >55 years 2.Glucose >than 200 mgm/dl 3.WBC > 16,000 cells/mic L 4.LDH >350 IU/liter 5.AST >250IU/liter Subsequent 48 hrs 1.Art o 2 tension <60mmHg 2.Bun Increase >8mg/dl 3.Ca < 8mg/dl 4.Base deficit >4meq/liter 5.Estimated fluid sequestration >6liters 6.Fall n Hct >10%

Mortality prediction (as per Ranson criteria)  A. < 3 signs = 1%  B. Three to Four signs=11%  C. Five to six signs=33%  D. >Six signs= 100%

APACHEII 1. Temp 2. Mean Art Pressure 3. Heart Rate 4. Resp rate 5. Oxygenation(Pao 2) 6. Arterial Ph 1. Serum sodium 2. SerumPottasium 3. Serum creatinine 4. Haematocrit 5. WCC 6. Glasgow coma scale

Apache II score(Sum of A+B+C) A=+4 to 0 points TEMP>41=4,<29=4 Mean Art Pr>160=4 <49=4 Heart & Resp rate OXYGENATION ART PH Ser Na,K,Creat, HCT,WBC GLASGOW COMA Score B=Age <44=0 pts >75=6points C=Chronic Health points H/o organ insufficiency Liver,CVS,Resp,Renal,,Immunocompromised APACHE SCORE42=90% Mort

GLASGOW CRITERIA Any time during First 48hrs after admission  1.WBC >15000 Cu/mm  2.Blood glucose>10mmol/l  3.BUN >16mmol/L  4.Art po 2,< 60mmHg  5.Ser ca. <2.0 ml/l  6.Ser Albumin<32gm/l  7.Ser LDH >600u/L(n=250)  8.AST Or ALT >200u/l

GLASGOW CRITERIA Any time during First 48hrs after admission;  WBC >15000 Cu/mm  Blood glucose>10mmol/l  BUN >16mmol/L  Art po 2,< 60mmHg  Ser ca. <2.0 ml/l  Ser Albumin<32gm/l  Ser LDH >600u/L(n=250)  AST Or ALT >200u/l

Comparsion Of Scales Predicti on of complic ApacheRansonGlasgow Few hours More accurate Less 48hrs88%69%84% 72 hrs+++++ Dying ptRisingFalling

INTERSTITIAL AND NECROTIZING PANCREATITIS (Discrimination)  Markers of Necroses  C-reactive protein>120 mgm/L  PMN-Elastase>120mgm/L  PLA>15U/L  PLA 2 >3.5U/L  Dynamic angio – CT  Guided needle aspiration of necroses for detection of bacteria

RADIOLOGY Plain Films Ultrasonography Sens;62-95%,Specif>95%, pancreas not visualized in> 40%pts CT scan;Sens 90% Specif+100% ERCP PTC. Pancreatitis is due to gallstone? Or Alcoholic?

CT findings in Acute Pancreatitis  Enlargement of Gland  Ill defined margins  Abnormal enhancement  Thickening of peripancreatic planes  Blurring of fat planes  Intra & retroperitoneal fluid collection  Pleural effusion Pancreatic gas indicative of necrosis /abscess Pseudocyst formation

ERCP; Indications In AP Preop evaluation with suspected traumatic pancreatitis to see Pancreatic duct disruption Pts with suspected biliary Pancreatitis and severe disease and not clinically improving by 24hrs after admission. Do ERCP for stone extraction

ERCP-indications (contd  In pts >40 with no identifiable disease to rule out occult CBD stones,pancreatic or ampullary Ca or other causes of obstruction; Pts <40 at a post Cholecystectomy status or more than one attacks of unexplained pancreatitis

SYSTEMIC TREATMENTS Basic principles-ICU,Rest GIT and Pancreas,analgesia,oxygenation Pancreatic inhibition (Glucagon, Somatostatin)? Antibiotics  Nutrition (Enteral route is safe& preferred )

Role of Antibiotics in AP Traditional teaching Prophylactic antibiotics do not prevent abscess- Mezlocillin, Metrionidazole, Imipnem good concentration in pancreatic juice Cefotaxime, Ceftazidime Clindamycin, Ciprofloacin good levels in p. juice They can limit rate of infection of this necr material(Bossi1992)

Operative Measures For AP A.Diagnostic laparotomy B.To limit the severity of pancreatic inflammation Biliary operations C.To interrupt the pathogenesis of complications Pancreatic drainage Pancreatic resection Peritoneal drainage

Operative measures(contg) D.To support the patient and treat complications Drainage of pancreatic abscesses Feeding jejunostomy To prevent recurrent pancreatitis

Surgical treatment-indications Diagnostic uncertainty Gall stone induced pancreatitis Pancreatic drainage and defunctioning Pancreatic resection Peritoneal Lavage Operation for complications

Bile duct stones-strategy Acosta (1974), recovered gall stones from Faeces of pts with gall stone pancreatitis. Neptolemos (1989) ;Passage of stone through ampulla precipitates pancreatitis attack, persistence of stones in CBD; Pt is at risk of complications and death Early surgery or to deal with CBD stones endoscopically (ERCP) 14 %pts of AP have coexisting cholangitis

Timing OF Operation IN Gall Stone Pancreatitis Mild pancreatitis: Operated At Any Stage during first admission Severe disease.Cholecystectomy during first admission, timing depends on clinical indicators

Timing of Surgery-contd RECOVERING PT.Allow pt to settle completely before elective early operation is taken prior to discharge. UNSTABLE PT- Who will require surgery to deal with local complications of pancreas, Cholecystectomy to be performed at this time Early Cholecystectomy within hours of admission is best avoided in these all patients

Indications of Operation IN NP  Clinical criteria  Surgical acute abdomen  Sepsis syndrome  Shock syndrome  Non response to ICU Morphologic +Bacteriologic Infected necroses Extended pancreatic necrosis>50% Extnd. intrapancreatic +retroperitoneal necroses

Technique of Debridement Closed cavity Lavage Open abdomen Surgical drainage Posterior approach Pancreatic resection

Pseudo cyst Delineation of main Pancreatic duct by ERP if no communication -drain by ERP If main duct is abnormal Stricture Or Truncated – Surg. Drainage Rarely normal P.Duct communicating with Pseudo Cyst – Drain Percut CT control (Recurrence =50%)

Conclusion Management of AP is complex Mortality is high Increasing Dx procedures available has not simplified decisions about timing of operation or choice of technique. Individualized approach IS NECESSARY Decision based on clinical judgment rather than on numerical or imaging. SURGEON IS THE BEST TO MANAGE#He has CLINICAL AND SURGICAL EXPERTISE