Extra-hepatic Biliary Disease and the Pancreas Disclosures No relevant financial disclosures to report Jeffrey Coughenour MD FACS Clinical Associate Professor of Surgery and Emergency Medicine Division of Acute Care Surgery Objectives Discuss management of common surgical diseases related to the pancreas Gallstone pancreatitis Pseudocysts Pancreatic abscess and necrosis Pancreatitis Annual incidence of 40/100,000 adults, increasing Improved minimally invasive techniques and critical care, morbidity and mortality constant Severity varies widely 1
Pancreatitis Protective mechanism fails, allowing intracellular activation of proenzymes Animal model Normal secretion from acinar cell blocked, contact with lysosomal hydrolases, activate proteases Pro-inflammatory cytokines initiated Presentation Pain depends on severity of disease May present in shock, large volume requirements Calculated resuscitation Ileus common Severity Prediction Challenging, determines care Scoring systems developed, none universally accepted Ranson Criteria APACHE-II Balthazar CT Severity Index Severity Prediction Organ failure Shock, pulmonary insufficiency, AKI, GIB Local complications Necrosis, abscess, pseudocyst Ranson score 3 APACHE-II score 8 Gallstone Pancreatitis Gallstone Pancreatitis Gallstones, microlithiasis, sludge Most common cause in Western world 35 50% cases Inconsistent association with symptomatic cholelithiasis 2
Gallstone Pancreatitis Serum lipase high sensitivity and specificity ALT 3x or total bilirubin 2x 95% PPV gallstone-related AP US best to confirm stones Contrast-enhanced CT best to evaluate severity of disease Mild Disease Supportive care Prophylactic antibiotics not supported Cholecystectomy performed during hospitalization Decreases recurrence rate to < 10% No operation 50% 90-day recurrence rate Mild Disease Timing of surgery up for debate Improvement in disease Selective evaluation of the CBD Pre-operative studies MRCP, ERCP/EUS Intra-operative choleangiogram Severe Disease Standard ICU care ERCP/EUS within 24-48 hours 50% risk of pancreatic necrosis Fever, leukocytosis, sepsis Delay surgery Risk of conversion, CBD/duodenal injury Ayub K, Slavin J, Imada R. ERCP in gallstone-associated acute pancreatitis. Cochrane Database Syst Rev (4):CD003630, 2009 Severe Disease Resolution of symptoms, physical exam Contrast-enhanced CT scan Timing of surgery Have other complications developed that need addressed? Special Situations Patients unfit for surgery ERCP/ES definitive therapy Low risk of recurrence, 5% Cholecystitis, cholangitis, symptomatic cholelithiasis 20% Surgery during second trimester of pregnancy Hernandez V, Pascual I, Almela P, et al. Recurrence of acute GSP and relationship with cholecystectomy or endoscopic sphincterotomy. Am J Gastroenterol 99:2417, 2004 3
Pseudocyst Pancreatic Pseudocysts Chronic fluid collections associated with the pancreas, lacking an epithelial lining Disruption of major or minor ducts Traditionally persisted beyond 4-6 weeks Local inflammatory reaction Pseudocyst Single or multiple Intraparenchymal or adjacent to the pancreas Commonly retrogastric, lesser sac Small bowel mesentery Transverse mesocolon Right or left pericolic gutters Pseudocyst Often asymptomatic Common Abdominal pain, early satiety, nausea, vomiting, back pain Less common Weight loss, pruritis and jaundice, lower extremity edema Fistula formation or rupture Diagnostic Evaluation Contrast-enhanced CT Pancreatic parenchyma, necrosis, atrophy, calcification, duct dilatation MRI may be necessary to differentiate from neoplasm ERCP useful, but not without risk Cyst aspiration Asymptomatic Cysts Cysts may resolve for up to a year Complication rate of less than 10% Even in lesions larger than 6 cm After acute pancreatitis, re-image about 3 months Longer interval if remains asymptomatic Shorter if enlarging, concern for neoplasm Bradley EL, Gonzalez AC. The natural history of pancreatic pseudocysts: unified concept of management. Am J Surg 137:135, 1979 4
Symptomatic Cysts Surgical drainage Cystgastrostomy, cystduodenostomy, Roux-en-Y cystjejunostomy, distal pancreatectomy Percutaneous drainage Reported success of 40 to 90% in the literature Endoscopic drainage Following Acute Pancreatitis Most simply managed endoscopically Surgery reserved for cysts that fail to resolve with endoscopic drainage Distal cysts likely require ERCP Isolated percutaneous drainage Communication surgical drainage Nealon WH, Riall TS, et al. A unifying concept: pancreatic ductal anatomy predicts and determines major complications resulting from pancreatitis. J Am Coll Surg 208:790, 2009 Following Necrosis Early intervention if documented infection Percutaneous drainage to mitigate sepsis, followed by formal surgical drainage Otherwise, reasonable to delay Timing individualized Generally would not recommend endoscopic approach Associated with Chronic Pancreatitis Often involve strictured or abnormal duct Symptoms may NOT be from pseudocyst Endoscopic procedures yield mixed results Would involve surgical subspecialist Pancreatic Abscess and Necrosis 5
Abscess Complicates about 5% of cases Infected pseudocysts, abscess, infected necrosis often overlapping and blurred 40% may achieve symptom resolution with radiographic drain placement Polymicrobial E.Coli, Enterococcus, Klebsiella, Pseudomonas, Staph, B.Fragilis, Clostridium Necrosis Dead parenchyma from local inflammatory process, cellular damage Controversy remains sterile necrosis with failure to improve, symptoms 30-50% will progress to infected necrosis Intervention may become necessary Necrosis Delay in surgery increases mortality refuted by several observational studies Optimize physiology, allow for demarcation of necrosis and compartmentalization of infection 3-4 weeks Abdominal compartment syndrome always requires prompt intervention Diagnosis Severe acute pancreatitis with on-going organ dysfunction or failure Serial imaging, tissue culture primary tools CT-guided FNA gold standard Radiographic Drainage Allows for direct sampling Aspiration may be curative Mitigate progression of sepsis; allow for improvement of patient Operative Planning Clinical condition guides nature of intervention Immune status, infective organism, success or failure of previous source control Which approach? 10-20% mortality early operation 6
Operative Planning Step-down approach Open necrosectomy, followed by less-invasive procedures for residual or subsequent collections Step-up approach Necrosectomy only as last resort Receiving more and more support Open Surgery Midline or subcostal incision Intraperitoneal or intracavitary laparoscopy Surgeon preference Location of necrosis Time course Physiologic stability Open Surgery Early debridement problematic Risk to normal pancreas, bleeding, adjacent-structure injury high Late necrosectomy more easily facilitated Scoop out necrotic tissue loosely adherent to adjacent structures Open Surgery Direct approach via division of the gastrocolic omentum Lateral and inferior mesocolic approach Survey the upper abdomen, US may be helpful Packing, damage-control temporary closures, and return in 24-48 hours may be necessary Rodriguez JR, Razo AO, et al. Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 247:294-299, 2008 Endoscopic Necrosectomy Transgastric or transduodenal approach EUS often used to guide Limited size of instruments, suction tubing may limit effectiveness Laparoscopic Necrosectomy Requires comprehensive pre-operative planning Approach, avoid vascular structures Similar to sinus-tract endoscopy Visualization may be limited, technically challenging Not currently utilized 7
Special Situations Liberal use of angiography if vascular anatomy is unclear or pseudoaneurysm present Delay surgery 27% vs. 56% mortality delay beyond 12 days vs. first 48 hours Isaji S, Takada T, Kawarada Y, et al. JPN guidelines for the management of acute pancreatitis: Surgical management. J Hepatobiliary Pancreat Surg 13:48-55, 2006 Summary Points Gallstone pancreatitis Mild to moderate disease: Operation during index hospitalization Severe disease: Supportive care, delayed surgery Observe asymptomatic pseudocysts Serial imaging helpful Summary Points CT-guided FNA to sample, prove infection Delay surgery as long as possible for necrosis/abscess if clinically able Step-up vs. step-down approach based on severity of disease, peri-operative risk 8