Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (42 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
In 1988, before laparoscopic surgery, Kelly and Wagner
111
randomised 165 patients with gallstone-induced acute pancreatitis to either early (
n
= 83) or late (
n
= 82) biliary surgery, with early surgery being undertaken within 48 hours of admission. In those with mild acute pancreatitis (
n
= 125) there was no significant difference in outcome between the two groups (morbidity: early 6.7% vs. late 3.3%,
P
> 0.10; mortality: early 3.1% vs. late 0%,
P >
0.10). However, in those with severe acute pancreatitis (
n
= 40) early biliary surgery resulted in a significant increase in morbidity and mortality (morbidity: early 82.6% vs. late 17.6%,
P
< 0.001; mortality: early 47.8% vs. late 11%,
P
< 0.025). A recent prospective study
112
randomised 50 patients with mild gallstone pancreatitis to laparoscopic cholecystectomy performed within 48 hours of admission, regardless of the resolution of abdominal pain or serum biochemistry, or performed once pain had resolved and biochemistry was normalising. The primary end-point, hospital length of stay, was significantly shorter in the early surgery group, with no apparent impact on the technical difficulty of the procedure or perioperative complication rate. However, careful patient selection for such early surgery remains important as other considerations may influence decision-making, such as further investigation and/or treatment of abnormal LFTs, persistent fever and so on, which may complicate assessment of the patient after laparoscopic cholecystectomy. As a result most surgeons still prefer to wait a few days until the acute attack has resolved before proceeding (still during the same hospital admission) with removal of the gallbladder.
British Society of Gastroenterology guidelines recommend that patients with gallstone-induced mild acute pancreatitis should undergo cholecystectomy (laparoscopic) during the same hospital admission unless a clear plan for definitive treatment within the following 2 weeks has been made.
51
In patients with severe comorbid disease contraindicating cholecystectomy, definitive treatment may be provided by ERCP and ES. In those with gallstone-induced severe disease, cholecystectomy should be delayed until disease resolution or undertaken as an additional procedure during surgery for a complication of the acute pancreatitis.
Infected necrosis
Many patients with pancreatic necrosis require minimal if any local intervention.
113
In those patients requiring intervention, an individualised approach is required. The interventional approaches to infected necrosis can be viewed as lying along a spectrum of ‘invasiveness’. The optimal therapeutic approach will depend on the patient's condition and the morphology and extent of the pancreatic or peripancreatic necrosis. Many patients with infected necrosis can be managed with radiologically guided percutaneous drainage alone. Minimally invasive necrosectomy techniques, e.g. minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) and videoscopic-assisted retroperitoneal debridement (VARD), as well as radiologically guided limited incision open necrosectomy, have gained popularity and may result in lesser physiological insult than more traditional open necrosectomy. These patients should be managed within a specialist pancreatic unit where appropriate repertoire of interventional techniques is available.
Advances in imaging and endovascular intervention capabilities have increased the options available for patients that develop acute bleeding in association with pancreatic necrosis, often the result of pseudoaneurysm or true aneurysm formation. CT angiography is generally the preferred initial modality to localise the site of haemorrhage. Once the bleeding vessel is localised, directed transarterial embolisation can be attempted and, in many cases, obviates the need for a technically challenging laparotomy in an unwell patient with a ‘hostile abdomen’.
ERCP-related complications
The most common complications of ERCP and ES are pancreatitis, cholangitis, haemorrhage and duodenal perforation. Pancreatitis is managed in the same way as pancreatitis of any other aetiology. Cholangitis will commonly respond to antibiotic treatment, provided biliary drainage has been achieved at ERCP, either by effective stent placement or by clearing the biliary tree. Haemostasis can frequently be achieved endoscopically using local adrenaline injection into the papilla. However, should endoscopic haemostasis be ineffective, an operative approach may be required, particularly in a haemodynamically unstable patient. Generally, haemostasis can be achieved at laparotomy via a duodenotomy. Localisation of the ampulla, placement of the duodenotomy and initial tamponade can be facilitated by insertion of a Fogarty catheter via the cystic duct, through the ampulla. Definitive haemostasis can then achieved by direct suture similar to that carried out during a surgical ‘sphincteroplasty’. Care should be taken to avoid suturing the pancreatic duct and the use of a small cannula or probe can be helpful here.
Perforation may be apparent at the time of ERCP, but should be suspected in patients who develop severe pain or systemic physiological compromise following ERCP. CT is the preferred modality for diagnosis of perforation as the perforation is frequently retroperitoneal (
Fig. 8.12
). Small perforations may seal spontaneously and can, in some cases, be managed non-operatively by placing the patient nil by mouth, then initiating nasogastric tube drainage and systemic antibiotic treatment. The patient's nutritional status also requires careful attention. Should sepsis develop, a collection should be suspected and actively sought. Percutaneous drainage of the retroperitoneum may be required, although operative debridement should not be delayed if the patient's condition is not improved by percutaneous drainage, or if this approach is ineffective in controlling the collection. Again, referral to a specialist unit may be advisable as these complications can be difficult to treat and have a significant mortality.
Figure 8.12
CT image demonstrates retroperitoneal gas in a patient with iatrogenic perforation at ERCP.
This potentially life-threatening complication is fortunately relatively uncommon but may present to the non-pancreatic surgeon. A ‘herald bleed’ may precede major haemorrhage and in most cases following pancreaticoduodenectomy, the bleeding arises from the gastroduodenal artery stump. In patients sufficiently stable for transfer to radiology, CT angiography and endovascular treatment with embolisation may be sufficient to control haemorrhage. In patients requiring emergency laparotomy, mortality rates are significant.
Key points
Laparoscopic cholecystectomy is the gold standard intervention for the management of biliary colic and acute cholecystitis. Laparoscopic cholecystectomy during the index admission is both feasible and safe in patients with acute cholecystitis.
Percutaneous cholecystostomy may be undertaken in those patients with acute cholecystitis who do not respond to conservative management and who have significant comorbidity contraindicating emergency surgical intervention. Percutaneous cholecystostomy may be the definitive therapy in patients with acute acalculous cholecystitis.
Intravenous antibiotics and endoscopic drainage of the biliary tree form the basis of management for patients with acute cholangitis. Definitive management of acute cholangitis secondary to choledocholithiasis includes cholecystectomy in order to reduce the risk of further gallstone-related complications.
Acute pancreatitis is an increasingly common life-threatening illness. Initial management of severe acute pancreatitis involves appropriate resuscitation and organ support.
Routine administration of prophylactic antibiotics to all patients with predicted severe acute pancreatitis is not indicated, but should be considered in those patients with evidence of pancreatic necrosis who appear septic.
Early ERCP and ES should be undertaken in patients with gallstone-induced severe acute pancreatitis and evidence of either acute cholangitis or significant biliary obstruction (serum bilirubin > 90 μmol/L).
Surgery has little role in the initial management of severe acute pancreatitis.
Cholecystectomy should be undertaken in all patients with gallstone-induced acute pancreatitis during the index admission or within the next 2 weeks unless they have ongoing problems from severe disease or are unfit for surgery. In those unfit for surgery ERCP and ES should be considered as definitive treatment.
Complicated severe acute pancreatitis should be managed in a specialist unit.
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