Page created on October 11, 2021. Not updated since.
For introduction, etiology, and pathology, see the corresponding pathology 2 topic. For see clinical features, diagnosis, and non-surgical treatment, see internal medicine final topic 63.
Indications for surgical treatment in acute pancreatitis
Surgery is playing a smaller and smaller role in the management of acute pancreatitis, as supportive and non-invasive therapy have improved and research has shown that these are superior to surgery in many cases. As such, acute pancreatitis is no longer a surgical disease but rather a disease of internal medicine, and surgery is only very rarely performed for this disease. Nevertheless, there remain a few indications for surgery in acute pancreatitis.
- Infected necrotising pancreatitis (acute necrotic collection or walled-off necrosis)
- Biliary pancreatitis
- Abdominal compartment syndrome
Acute necrotic collection is an early complication of acute pancreatitis characterised by non-encapsulated necrotic material. Walled-off necrosis is a late (> 4 weeks) complication which is similar but encapsulated. Both may be sterile or infected.
Abdominal compartment syndrome is defined as intraabdominal hypertension (> 20 mmHg) and new-onset organ dysfunction. Severe pancreatitis may cause abdominal compartment syndrome due to tissue oedema.
Treatment of infected pancreatic necrosis
Infected pancreatic necrosis (infected acute necrotic collection or infected walled-off necrosis) is the main indication for surgery in acute pancreatitis, and requires treatment for drainage or removal, as well as antibiotics. Treatment usually follows a step-up approach, where percutaneous drainage with radiological guidance is the first line, with endoscopic transgastric necrosectomy being second line and surgical necrosectomy being third line.
Necrosectomy refers to removal of infected pancreatic necrosis. Surgical necrosectomy is usually performed in a minimal invasive (laparoscopic) manner with retroperitoneal access, necrosectomy, and drainage. Necrosectomy is never performed for sterile necrosis; for that, only conservative therapy is used.
Treatment of biliary pancreatitis
If the pancreatitis is caused by gallstones and the patient has cholangitis, they should be treated with urgent ERCP and sphincterotomy. If the pancreatitis is caused by gallstones but there is no cholangitis, cholecystectomy should be performed after recovery of the acute illness.
In mild biliary pancreatitis, cholecystectomy is performed during the same admission, after the patient has stabilised. In severe biliary pancreatitis, early biliary surgery worsens the prognosis and so cholecystectomy is performed later as an elective procedure instead. Endoscopic sphincterotomy is an alternative for those unfit for surgery.
Treatment of abdominal compartment syndrome
Surgical decompression of the abdominal cavity is indicated for abdominal compartment syndrome. Decompression can be achieved with a midline incision (laparotomy) or percutaneously. The incision is then temporarily closed with a patch, negative pressure systems, or with a silo. This technique is called temporary abdominal closure and prevents fluid loss and prevents evisceration.
Abdominal compartment syndrome was not described in the lecture and is therefore probably not important.