acute and chronic pancreatitis · 2. to identify pancreatic necrosis necrosis often takes days to...
TRANSCRIPT
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Acute and Chronic Pancreatitis
Major Kenneth Lee, IV, MD, PhD
Resident Conference 2017
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GOALS
Acute pancreatitis: Early management from
initial evaluation through stabilization
Chronic pancreatitis: Operative options and
who gets what operation
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Acute Pancreatitis: The Basics
Acute pancreatitis is an inflammatory condition
characterized by intrapancreatic activation of proteolytic
enzymes.
It is usually mild and self-limited. Mortality of acute
pancreatitis among all comers is 1-5%.
Necrosis complicates pancreatitis in approx. 15-20% of
cases. Mortality among patients with necrotizing
pancreatitis is 10-40%. Lower rates are noted in the
setting of sterile necrosis (5-10%) vs. infected necrosis
(30-40%)
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28yF presents to the ED with epigastric abdominal
pain. Pain started yesterday, was at its worst last
night, and is currently slightly improved. She has
no PMH.
Afebrile, hemodynamically stable
Benign exam
WBC 8, Hgb 15, Tbili 1.0
Amylase 2400, Lipase 1500
How do we secure a diagnosis?
What is your preferred singular imaging test for
this patient? (CT, US, MRCP)?
Your Patient
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The diagnosis of acute pancreatitis requires 2 of
the following:
1. CLINICAL--Abdominal pain consistent with
pancreatitis
2. LABORATORY--Elevation of amylase/lipase to 3-
5 times above the upper limit of normal )
3. RADIOGRAPHIC--Imaging evidence of
pancreatitis (US, CT, or MR)
Diagnosis of acute pancreatitis
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1. Make the diagnosis of acute pancreatitis
2. To identify pancreatic necrosis
3. To see how “bad” the pancreatitis is
4. To see if there is “anything to do”
Rationales for early CT in pancreatitis
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1. Make the diagnosis of acute pancreatitis
The diagnosis of pancreatitis does not require CT
2. To identify pancreatic necrosis
Necrosis often takes days to evidence, and the eventual
extent of necrosis is frequently underestimated on CT
3. To see how “bad” the pancreatitis is
There is not a strong correlation between the extent of organ
failure and the morphologic appearance of pancreatitis on CT
4. To see if there is “anything to do”
Rarely is there “anything to do” in the early phase
Better indications: Diagnostic uncertainty, evaluation of
associated issue (perforation), failure to respond initially
Rationale for early CT in pancreatitis
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Early CT
Underestimation of extent of pancreatitis
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Early CT
Underestimation of extent of pancreatitis
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Symptoms improve. Amy/Lip are near
normal by PAD3.
You recommend cholecystectomy.
She wants to leave and pay her bills.
What do you tell her?
Your Patient, Cont’d
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28yM presents to the ED with abdominal pain. Pain
worsened into this morning after a drinking binge
last night.
Afebrile, HR 140, SBP 85
WBC 21, Hgb 17, Plt 600
Creat 1.8
Amylase 9000, Lipase 7000
Distended abdomen
Noncontrast CT suggests pancreatitis
How bad is his pancreatitis? (Mild,
moderate, severe) Can we predict?
Your Patient
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Scoring systems for pancreatitis
Clinical severity scores
Ranson criteria
Glasgow/Imrie score
APACHE II
BISAP
Imaging severity scores
Balthazar
CT severity index (CTSI)
MOP/EP/EPIC/MRSI/MCTSI
Most clinical systems have good NPV (up to 95%) but
poor PPV. Overall the clinical severity scores are
relatively equivalent
No radiographic score has proven to be superior to
clinical scores
Only Japanese guidelines (not ACG or IAP) recommend
using scoring systems in evaluation of pancreatitis
Best marker at admission and 48 hrs: SIRS
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28yM presents to the ED with abdominal pain. Pain
started this morning after a drinking binge last
night.
Afebrile, HR 120, SBP 95
WBC 21, Hgb 17, Plt 600
Creat 1.6
Amylase 9000, Lipase 7000
Distended abdomen
Noncontrast CT suggests pancreatitis
What is your plan?
Your Patient
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AGGRESSIVE FLUID
RESUSCITATION
Analgesics
NPO (bowel rest)
Moderate/Severe Pancreatitis
Initial Management
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Now PAD7
T 102, HR 121, SBP 110
Intubated but stable
WBC 24, Hgb 13, Creat 1.1
Abdominal distension is improved--moderate
CT shows “large peripancreatic fluid collections,
extensive pancreatic necrosis, no evidence of
infected necrosis”
Your Patient, Cont’d
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Should we operate?
If yes, what operation?
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A. Nutrition
TPN vs TEN
When to start
B. Antibiotics (yes/no)
What agent
C. Interval re-imaging
Routine reimaging (yes/no)
When
Non-Operative Management
of Severe Acute Pancreatitis
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Now PAD14
T 99.2, HR 95, SBP 110
Extubated, 2L
Rickety but OK
WBC 9, Hgb 13, Creat 1.1
Moderately distended abdomen
Tolerating TEN and oral intake
How about a repeat CT?
Your Patient, Cont’d
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What now?
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A. Antibiotics only
B. Percutaneous drainage
C. Minimally invasive debridement
(laparoscopic, retroperitoneal,
endoscopic)
D. Open debridement
What Now?
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Concept: Can infected necrosis be managed with
control of the infectious issue thus delaying or
eliminating the need for necrosectomy
Randomized pts with suspected/confirmed infected
necrosis to undergo open necrosectomy vs
percutaneous drainage followed by minimally invasive
debridement if necessary
Mortality was similar (19% vs 16%) but step-up
approach had significantly lower rates of major
complications. There was also a reduction in long-term
complications (diabetes, incisional hernia)
35% of patients were treated with percutaneous
drainage only
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A. Antibiotics only
B. Percutaneous drainage
C. Minimally invasive debridement
(laparoscopic, retroperitoneal,
endoscopic)
D. Open debridement
What Now?
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Acute pancreatitis
Management SummarySecure Diagnosis
Predict Severity (SIRS)
Aggressively hydrate
Image as indicated
~ 72 hrs if scenario suggests moderate/severe pancreatitis
Ride the wave
Critical Care
Decide on nutrition (TEN strongly preferred)
Decide on antibiotics (generally not needed)
Intervene only when necessary
Minimal Maximal
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Chronic pancreatitis: Operative
options
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Chronic pancreatitis is a benign inflammatory process
of the pancreas which leads to irreversible damage of
the gland with loss of functional parenchyma
Etiologic factors: TIGAR-O classification
Toxic-metabolic (alcohol/tobacco)
Idiopathic
Genetic (Trypsinogen gene mutations)
Autoimmune
Recurrent and severe acute pancreatitis
Obstructive (divisum or tumor)
Predominant symptoms: pain, endocrine insufficiency
(diabetes mellitus), exocrine insufficiency (steatorrhea)
Chronic Pancreatitis: The Basics
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Anatomic considerations
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Anatomic considerations
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Anatomic considerations
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1. Distal pancreatectomy
2. Duct Drainage Procedures
A. Puestow procedure
B. Duodenum-Preserving Pancreatic Head
Resections
Frey Procedure
Beger Procedure
3. Whipple Procedure
4. Total Pancreatectomy (+/- islet
autotransplantation)
Chronic Pancreatitis
Types of resection
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1. Distal pancreatectomy
2. Duct Drainage Procedures
A. Puestow procedure
B. Duodenum-Preserving Pancreatic Head
Resections
Frey Procedure
Beger Procedure
3. Whipple Procedure
4. Total Pancreatectomy (+/- islet
autotransplantation)
Chronic Pancreatitis
Types of resection
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Surgical Procedures
Distal Pancreatectomy/Splenectomy
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Indications
Localized severe complications of the pancreatic
body/tail
-Pancreatic duct stricture
-Pseudoaneurysm
-Pseudocyst
Downsides
Does not address pancreatic head
Few anatomic applications
DM, exocrine insufficiency
Distal Pancreatectomy
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Distal Pancreatectomy
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1. Distal pancreatectomy
2. Duct Drainage Procedures
A. Puestow procedure
B. Duodenum-Preserving Pancreatic Head
Resections
Frey Procedure
Beger Procedure
3. Whipple Procedure
4. Total Pancreatectomy (+/- islet
autotransplantation)
Chronic Pancreatitis
Types of resection
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Puestow Procedure
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Puestow Procedure
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Puestow Procedure
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Indications
Obstructed, dilated pancreatic duct (>8mm)
No clear inflammatory mass or calcification of the
pancreatic head
Patient with multiple comorbidities
Downsides
Pure drainage procedure
Minimal application (dilated pancreatic duct without
clear involvement of the pancreatic head)
Prone to long term failure
Puestow Procedure
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Puestow Procedure
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1. Distal pancreatectomy
2. Duct Drainage Procedures
A. Puestow procedure
B. Duodenum-Preserving Pancreatic Head
Resections
Frey Procedure
Beger Procedure
3. Whipple Procedure
4. Total Pancreatectomy (+/- islet
autotransplantation)
Chronic Pancreatitis
Types of resection
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Frey Procedure
Limited/subtotal pancreatic head resection
Lateral pancreaticojejunostomy
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Frey Procedure
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Frey Procedure
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Beger Procedure
Subtotal pancreatic head resection
Transection of the pancreatic neck above the portal vein
End to side or side to side pancreaticojejunostomy
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Indications
Calcified/involved pancreatic head
Obstructed, dilated pancreatic duct (>8mm)
No concern for malignancy
Downsides
Requires ideal anatomy
Techniques are not widespread
Non-standardized pancreatic head resection
DPPHR (Frey and Beger procedure)
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DPPHR (Frey and Beger procedure)
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DPPHR (Frey and Beger procedure)
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DPPHR (Frey and Beger procedure)
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1. Distal pancreatectomy
2. Duct Drainage Procedures
A. Puestow procedure
B. Duodenum-Preserving Pancreatic Head
Resections
Frey Procedure
Beger Procedure
3. Whipple Procedure
4. Total Pancreatectomy (+/- islet
autotransplantation)
Chronic Pancreatitis
Types of resection
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Whipple Procedure
Extent of Resection
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Whipple Reconstruction
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Indications
Inflammatory mass in head
Inability to exclude malignancy in pancreatic head
Pancreatic head disease with non-dilated duct (i.e.
small duct disease)
Downsides
Morbidity
Pancreatic leak (15-40%)
Delayed gastric emptying
Mortality (2% UPENN)
DM, exocrine insufficiency
Whipple Procedure
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Whipple Procedure
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Whipple Procedure
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1. Distal pancreatectomy
2. Duct Drainage Procedures
A. Puestow procedure
B. Duodenum-Preserving Pancreatic Head
Resections
Frey Procedure
Beger Procedure
3. Whipple Procedure
4. Total Pancreatectomy (+/- islet
autotransplantation)
Chronic Pancreatitis
Types of resection
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TPIAT: Operative Procedure
Resection
Pancreas
Duodenum and proximal jejunum
Gallbladder
Bile duct
[Spleen]
Reconstruction
Hepaticojejunostomy
Duodenojejunostomy or Gastrojejunostomy
Roux-en-Y preferred in some institutions
Pancreas processing (3-6 hours)
Enzymatic Digestion
Centrifugation
Islet infusion
Infusion through a stump in the splenic vein
Leftover cells left in peritoneum
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TPIAT
Complications
High reoperation rate (16%)
9.5% rate of reoperation for bleeding
Delayed gastric emptying (40-50%)
Anastomotic leak 4.2% (G-J 2.8%, H-J 1.4%)
Portal vein thrombosis
Overall low mortality (1.2% at Minnesota)
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TPIAT: Operative Procedure
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TPIAT: Operative Procedure
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TPIAT: Operative Procedure
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1. Distal pancreatectomy
2. Duct Drainage Procedures
A. Puestow procedure
B. Duodenum-Preserving Pancreatic Head
Resections
Frey Procedure
Beger Procedure
3. Whipple Procedure
4. Total Pancreatectomy (+/- islet
autotransplantation)
Chronic Pancreatitis
Types of resection
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Summary: Operative Approaches
Operation Patient Head Duct Malignancy Downsides
Distal Any Not involved Any Any
Pt selection
DM
Exoc. Insuf.
Puestow AnyRelatively
sparedDilated No
Pt selection
Long-term
Outcome
DPPHR Any Involved Dilated No
Ideal anatomy
Not
widespread
Whipple Healthy Involved Any Any
Morbidity
QoL
DM
Exoc. insuf
TPIATHealthy
Non-diabeticAny Any No
Morbidity
Not
widespread
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