Acute Pancreatitis following Extracorporeal Circulation

Transcription

1 Acute Pancreatitis following Extracorporeal Circulation A. C. Panebianco, M.D., S. M. Scott, M.D., C. H. Dart, Jr., M.D., T. Takaro, M.D., and H. M. Echegaray, M.D. F rom 6 to 3% of all cases of pancreatitis occur after operation [lo,. This serious and often fatal complication is usually associated with upper abdominal procedures. Only rarely has it been reported following thoracic and cardiac surgery. Harjola and associates [4] described a 27-year-old woman who had a sigmoid volvulus three days after aortic valve replacement and developed acute pancreatitis on the eighth postoperative day. She recovered. Peterson et al. [ll] reported 22 cases of postoperative pancreatitis, one of which followed aortic valve replacement in a 50-year-old woman who died on the third postoperative day. Horton and co-workers [5], in describing 5 patients with hemorrhagic small-bowel necrosis following cardiopulmonary bypass, reported acute hemorrhagic pancreatitis in one of them, a 56-year-old housewife who died four days after aortic valve replacement. Recently, we observed at autopsy acute pancreatitis in 2 patients who had undergone open-heart operations. This prompted us to review our total experience to determine the incidence and significance of postperfusion pancreatitis. CLINICAL MATERIAL Between August, 958, and July, 969, 276 operations requiring extracorporeal circulation were performed at the Veterans Administration Hospital, Oteen, North Carolina. Autopsies were performed on 34 of the 49 patients who died within three months after operation. Acute pancreatitis (Table ) was encountered in 8 patients. During this same period, pancreatitis was found in 63 of 2,25 other autopsies. Nine of these 63 patients developed pancreatitis following the approximately eleven thousand major surgical procedures other than those requiring cardiopulmonary bypass (Table 2). The ages of patients who died following perfusion and who were found at autopsy to have pancreatitis ranged from 43 to 72 years. Seven patients had a From the Surgical Service, Veterans Administration Hospital, Oteen, N.C. Presented at the Sixteenth Annual Meeting of the Southern Thoracic Surgical Association, Washington, D.C., Nov. 3-5, 969. We wish to acknowledge the assistance of Dr. Robert C. Dunn, Chief, Laboratory Service, Veterans Administration Hospital, Oteen, N.C. Address reprint requests to Dr. Scott, Veterans Administration Hospital, Oteen, N.C

2 TABLE. PANCREATITIS FOLLOWING EXTRACORPOREAL CIRCULATION IN EIGHT PATIENTS 'p 2 0 Patient Patient's No. Age&Sex 5, M 49, M 53, M 50, M 53, M Q, 43, M 4 C -3 L (0 < 0 CTI Q, w 72, M Operative Procedure Mitral valve ; mitral valve Mitral valve ; mitral valvuloplasty Resection of dissecting thoracic aortic aneurysm Postop. Day of Death Highest Serum Lowest Amylase Mean History Level Perfusion Perfusion of High Biliary Pancreatic (Somogyi Time Pressure Thiazide Alcohol Tract Lesion units) (min.) (mm. Hg) Therapy Intake Disease Oliguria Comments Acute hemor Pancreatitis a rhagic necrosis 34 of pancreas necrosis with fat destroyed normal kidneys of death Cardiac death; major cause Scattered fat 240 necrosis and inflammation Localized fat 25 necrosis Scattered fat 36 necrosis Scattered fat - pancreas of tail of exudate Fat necrosis purulent necrosis; , M 5 Fat necrosis 875 of /0 of pancreas Renal failure tube nasogastric loss from cessive fluid following excessive Cardiac arrest; pancrea ti tis incidental Pancreatitis in ddental; died following acute hemorrhage from duodenal ulcer Low cardiac output; cardiac arrest ulcer duodenal to perforated Cerebral death

3 PANEBIANCO ET AL. TABLE 2. POSTOPERATIVE PANCREATITIS IN 2,59 AUTOPSIES Type of Operation Common duct exploration Cholecystectomy and gastroenterostomy Appendectomy Resection of abdominal aortic aneurysm Insertion of epicardial pacemaker electrodes Transurethral prostatic resection Resection of thoracic aortic aneurysms Cardiac valve replacementa Total 'With extracorporeal circulation. No. of Patients history of chronic congestive heart failure and had been treated with digitalis preparations and diuretics. Hydrochlorothiazide alone or in combination with triamterene, furosemide, or mercurials had been used in 7 patients. Ethacrynic acid and furosemide were used in 2 patients. One patient received guanethidine sulfate and reserpine preoperatively as medical treatment for a dissecting aneurysm. Biliary tract disease was present in patient who had chronic cholecystitis without cholelithiasis. Four patients had a history of alcohol intemperance. External cardiac massage was performed on patient at least 24 hours before death. Dissection of the thoracic and abdominal aorta occurred in patient before operation. Perfusion resulted in retrograde dissection of the aorta in patient at the time of operation. Excessively long periods of cardiopulmonary bypass- 56 and 269 minutes -and low perfusion pressures-35 mm. Hg and 39 mm. Hg-were observed in 2 patients with extensive pancreatitis; however, 5 other patients with prolonged perfusion times and low perfusion pressures did not have pancreatitis at autopsy. The average perfusion time of all 34 patients autopsied was 36 minutes, and the lowest average perfusion pressure was 46 mm. Hg. Following the initial observations of postoperative pancreatitis, we began to record serum amylase for one to five postoperative days. Elevated serum amylase levels (above 50 Somogyi units) were seen in 8 of 54 patients in whom serum amylase levels were determined following open-heart operations (Fig. l), while normal values were present in 36 patients (Fig. 2). The ages of patients with elevated serum amylase values ranged from 30 to 59 years. Eight of these patients died; 4 had pancreatitis at autopsy, and 4 did not have pancreatitis. One of the 8 patients with pancreatitis at autopsy had normal serum amylase values on the third and fourth postoperative days, but determinations were not made on the first or second day. All but patient with elevated serum amylase values had been in congestive failure and had taken hydrochlorothiazide alone or in combination with other diuretics. None had biliary tract disease. Six were known to drink alcohol excessively, and 3 had histories of peptic ulcer. Perfusion times in the 8 patients with elevated amylase ranged from 49 to 204 minutes, averaging 25 minutes. The lowest mean perfusion pressure averaged 53 mm. Hg. The average perfusion time for the 36 patients with normal serum amylase values was 02 minutes, and the mean low perfusion pressure was also 53 mm. Hg. The patient with the highest serum amylase value had the longest perfusion time; he had undergone a double-valve replacement. This patient and 9 others with elevated serum amylase levels survived and had no postoperative symptoms resulting from pancreatitis. All had nasogastric suction routinely after operation

4 Pancreatitis after Open-Heart Surgery L.- c '< 600 W Y v) 2 < 400 > z < 300 f Y v) 200 I POST- 0 PE RAT I V E FIG.. Serum amylase determinations in 8 patients with one or more abnormal values following extracorporeal circulation. The range (shaded area) and the average (broken line) are maximum in 24 hours and approach normal by the third day. DAY POST- 0 PE RAT IV E FIG. 2. Serum amylase determinations in 36 patients following extracorporeal circulation. All values were considered normal, below 50 Somogyi units. The range is shown as the shaded area, and the average is represented by the broken line. DAY VOL. 9, NO. 6, JUNE,

5 PANEBIANCO ET AL. COMMENT Reports of acute pancreatitis following extracorporeal circulation have been extremely rare, which implies that this is a very unusual complication. Our experience is different. We found a 3% incidence of pancreatitis in postperfusion patients; this is at least 30 times the incidence following major operations without extracorporeal circulation in our hospital. Thirty percent of patients studied had elevations of serum amylase levels after cardiopulmonary bypass. This would indicate that a significant number of patients may have had subclinical pancreatitis. Horton and associates [5] have observed several patients with small foci of pancreatic fat necrosis after perfusion and suggest that this is more common than is generally appreciated. Pancreatitis is commonly associated with alcoholism and biliary tract disease, and indeed 4 of our patients were known to drink excessively and patient had chronic cholecystitis (Table ). Duodenal ulcer, often the cause of pancreatitis either by perforation or inflammation, was the cause of death in 2 patients. In Patient 7 (Table ) perforation of the duodenal ulcer caused peritonitis; however, pancreatitis was limited to the tail of the pancreas. Patient 5 hemorrhaged from a duodenal ulcer. He also had cholecystitis and only a minor degree of focal pancreatitis. All except of our 8 patients had been treated for congestive heart failure with digoxin and diuretics. Terminal pancreatitis is sometimes seen in cardiovascular failure [3]; however, in our study of 63 patients who were not perfused and who had pancreatitis at autopsy, only 2 (3%) had been in congestive heart failure. The diuretics chlorothiazide and chlorthalidone have been implicated as causes of acute pancreatitis [l, 6, 7, 9. Seven of our patients received chlorothiazide. The manner in which these drugs cause pancreatitis is not clear. They may conceivably be related to dehydration and subsequent changes in the viscosity of pancreatic secretions. Increased viscosity, thought to be a factor in the development of pancreatitis, was found by Dunphy and co-workers [3] in 8 patients following pancreatic manipulation. Trauma is a well-known cause of pancreatitis. Cowan [2] reported acute pancreatitis following external cardiac massage. One of our patients had external cardiac massage 24 hours before death. Pancreatitis may evolve from injury to the parenchyma or to the blood supply of the pancreas during operation. Popper and associates [ 2 emphasized the importance of vascular occlusion in the development of pancreatitis. In dogs they produced pancreatic edema by ductal ligation and secretin stimulation. Whh they then ligated a major pancreatic artery in these animals, acute pancreatitis was produced. 566

6 Pancreatitis after Open-Heart Surgery Pancreatic infarction may occur in a variety of ways. Dunphy et al. [3 pointed out the vulnerability of the inferior pancreaticoduodenal artery during gastric surgery. Probstein et al. [3] showed that the pancreas is extremely susceptible to atheromatous emboli. They studied 2 patients with demonstrable emboli and found pancreatitis in all but 2. We found two cases of pancreatitis following resection of abdominal aortic aneurysms (Table 2). It is interesting to speculate about the role that aortic dissection may have played in the development of pancreatitis in Patients 7 and 8 (Table ). We did not find pancreatitis associated with dissecting aneurysm in any other autopsied patients. Inadequate tissue perfusion of the pancreas secondary to prolonged perfusion times, hypotension, air, fat, or fibrin emboli, and intravascular coagulation may play an important role in the development of acute pancreatitis. A prolonged period of bypass alone does not result in pancreatitis, but it may be a factor when combined with other conditions such as alcoholism, trauma, or preexisting disease. Symptoms in the immediate postoperative period can be masked by the presence of pain and hypotension from other causes. In the presence of unexplained shock, abdominal pain, distension, or oliguria, pancreatitis should be considered. The serum amylase level may be elevated, especially during the first 24 hours. Ordinarily, serum amylase does not rise following perfusion. This is also true following abdominal surgery if the pancreas is not handled [3, 8. Treatment is limited and includes nasogastric suction, parasympatholytic drugs, and control of fluid and electrolytes. Our use of the Levin tube and Wangensteen suction postoperatively in all patients who have undergone open-heart surgery is perhaps a beneficial routine. SUMMARY Eight patients were observed at autopsy to have developed pancreatitis following extracorporeal circulation. This is an incidence of 3%, which is high compared to the number of cases of pancreatitis found at autopsy following general surgical procedures (less than 0. %). Although impairment of circulation could not be specifically identified, all these patients had undergone prolonged periods of bypass, and 2 patients had experienced vascular complications. Serum amylase determinations in 54 patients following cardiopulmonary bypass were elevated in 8 and normal in 36. Pancreatitis was present in 4 of the 8 patients who had elevated serum amylase levels and later died. Again the average bypass time of patients with elevated serum amylase levels was slightly greater than the average of those with normal serum amylase levels. Pancreatitis should be suspected in patients with unexplained shock or abdominal distress following cardiopulmonary bypass.

7 PANEBIANCO ET AL. REFERENCES Cornish, A. L., McClellan, J. T., and Johnston, D. H. Effects of chlorothiazide on the pancreas. New Eng. J. Med. 265:673, 96. Cowan, D. Pancreatitis and pulmonary hemorrhage complicating closedchest cardiac massage. Canad. Med. Ass. J. 95:976, 966. Dunphy, J. E., Brooks, J. R., and Achroyd, F. Acute postoperative pancreatitis. New Eng. J. Med. 248:445, 953. Harjola, P. T., Siltanen, P., Appelqvist, P., and Laustela, E. Abdominal complications after open heart surgery. Ann. Chir. Gynaec. Fenn. 57:272, 968. Horton, E. H., Murthy, S. K., and Seal, R. M. E. Haemorrhagic necrosis of small intestine and acute pancreatitis following open-heart surgery. Thorax 23:438, 968. Johnston, D. H., and Cornish, A. L. Acute pancreatitis in patients receiving chlorothiazide. J.A.M.A. 70:2054, 969. Jones, M. F., and Caldwell, J. R. Acute hemorrhagic pancreatitis associated with administration of chlorthalidone: Report of a case. New Eng. J. Med. 267: 029, 962. Keighley, M. R. B., Johnson, A. G., and Steven, A. E. Raised serum amylase after upper abdominal operation. Brit. J. Surg. 56:424, 969. Minkowitz, S., Soloway, H. B., Hall, E. J., and Yermakov, V. Fatal hemorrhagic pancreatitis following chlorothiazide administration in pregnancy. Obstet. Gynec. 24:337, 964. Paloyan, E. The forms of pancreatitis. Curr. Probl. Surg. p. 23, June, 967. Peterson, L. M., Collins, J. J., Jr., and Wilson, R. E. Acute pancreatitis occurring after operation. Surg. Gynec. Obstet. 27:23, 968. Popper, H. L., Necheles, H., and Russell, K. C. Transition of pancreatic edema into pancreatic necrosis. Surg. Gynec. Obstet. 87:79, 948. Probstein, J. G., Joshi, R. A., and Blumenthal, H. T. Atheromatous embolization: An etiology of acute pancreatitis. A.M.A. Arch. Surg. 75:566,