The role of computed tomography in the management of acute pancreatitis

Sixty-three patients with the clinical diagnosis of acute pancreatitis were submitted to contrast enhanced CT examination. As compared to Ranson's objective clinical parameters, CT grading according to Hill et al. as modified by Balthazar et al. was found to reflect accurately the severity of acute pancreatitis. Evaluation of serial CT examination did not reveal any significant progression in classification during the course of acute pancreatitis. The presence of hypodense areas in the pancreas as a single parameter seems to have a distinct prognostic value. In only one out of five pancreatic abscesses was the presence of gas bubbles observed on CT. It is concluded that contrast enhanced CT has a definite place in the management of acute pancreatitis.     

Role of surgery in the management of acute pancreatitis

Three important aspects of the surgical therapy of acute pancreatitis are discussed: the time at which operation appears to be indicated, the procedure to be chosen (in accord with operative findings), and the results. After initial medical treatment, the timing of intervention should be based on clinical and biological information. Classification of acute pancreatitis in 3 degrees of severity may facilitate the decision. When edematous pancreatitis is found, irrigation and drainage are indicated. For distal necrosis, a left or subtotal pancreatectomy should be carried out. Necrotic lesions of the isthmus should be excised locally; if necessary, local isthmus excisions may be combined with left pancreatic resection. Resections of the head of the pancreas have been abandoned because of their high mortality rate; intervention is now limited to local excision of necrotic tissue (necrosectomy), with drainage and irrigation. In all cases, complementary biliary drainage by choledochostomy or at least cholecystostomy, drainage of areas of necrosis, and gastric suction are also mandatory. Forty-nine patients who were operated upon according to these principles with a mortality rate of 36.7 % are discussed.

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Résumé Nous discutons trois aspects importants du traitement chirurgical de la pancréatite aigüe: le moment de l'opération, la technique à utiliser (en fonction des découvertes opératoires), les résultats. Après le traitement médical initial, le moment de l'opération doit être choisi en fonction des données cliniques et biologiques. La classification des pancréatites aigües en trois types de gravité croissante peut faciliter la décision. Si l'on trouve une pancréatite oedémateuse, irrigation et drainage suffisent. En cas de nécros distale, il faut faire une pancréatectomie gauche ou subtotale. Les lésions nécrotiques de l'isthme demandent une excision locale, éventuellement complétée par une pancréatectomie gauche. Les résections de la tête pancréatique ont été abandonnées à cause de leur mortalit é élevée. L'opération doit, à l'heure actuelle, se limiter à l'exérèse des tissus nécrosés (nécrosec tomie), avec drainage et irrigation. Il faut, de plus, faire dans tous les cas un drainage de la voie biliaire par cholédocotomie ou au moins cholécystostomie, un drainage de la zone nécrosée et une aspiration gastrique. Nous avons opéré en suivant ces principes 49 malades avec une mortalité de 36.7%.

     

Severe acute pancreatitis: role for laparoscopic surgery

Minimally invasive surgery is a new and promising treatment modality in the management of patients with severe acute pancreatitis (SAP). Aim of our study was the evaluation of our first experiences with laparoscopic surgery in the management of patients with SAP. METHODS: A total of 65 patients complied with Atlanta recommendations for SAP and were included into this retrospective study. Indications for laparoscopic surgery were SAP presented with intraabdominal or retroperitoneal exudates and detected by ultrasound (US) and/or contrast enhanced computer tomography (CT) scan, and the presence of acute calculous cholecystitis when 3 to 5 days of conservative treatment did not show clinical improvement and surgical treatment was considered. Patients with improvement after initial therapy received conservative therapy only. Bacteriological cultures were done for abdominal exudates and necrotic tissue obtained during surgery. RESULTS: Totally, 39 patients were operated and 26 were treated conservatively only. Laparoscopic surgery was started in 31 patients and completed in 26 patients. The overall conversion rate was 16.1 %. Laparoscopic drainage of the intraabdominal exudate was done in 26 patients including drainage of the lesser sac in five of them. Laparoscopic cholecystectomy in 25 cases and laparoscopically assisted jejunostomy in 6 cases were performed as a part of the procedure. Conventional surgery was the primary procedure in 8 patients. Peripancreatic abscess formation was observed in one case one month after laparoscopic procedure and was cured with conventional surgical drainage. Bile leakage from the cystic stump was successfully treated with endoscopic papillotomy in one case. All patients survived after laparoscopic procedures. Overall complication rate was 7.7 % and mortality reached 3.1 %. CONCLUSIONS: Laparoscopic drainage of the abdominal cavity, drainage of the lesser sac and revision of the retroperitoneal compartment can be safely carried out as an alternative to the conventional surgical approach. Laparoscopic cholecystectomy and/or jejunostomy may be additionally performed if indicated.     

The role of acetaldehyde in the pathogenesis of acute alcoholic pancreatitis.

Acetaldehyde (AA), the first product of ethanol metabolism, has been suggested as an important mediator in alcoholic pancreatitis, but experimental evidence has not been convincing. Prior work using the isolated perfused canine pancreas preparation has suggested that toxic oxygen metabolites generated by xanthine oxidase (XO) may mediate the early injury in pancreatitis. Xanthine oxidase is capable of oxidizing AA, and during this oxidation free radicals are released. The hypothesis that acute alcoholic pancreatitis may be initiated by AA in the presence of active XO (converted from xanthine dehydrogenase [XD]) was tested in the authors' experimental preparation by converting XD to XO by a period of ischemia, and infusing AA. Control preparations remained normal throughout the 4-hour perfusion (weight gain, 7 +/- 4 g; amylase activity, 1162 +/- 202 U/dL). One hour of ischemia or infusion of AA at 25 mg/hr or at 50 mg/hr without ischemia did not induce changes in the preparation. Acetaldehyde at 250 mg/hr induced minimal edema and weight gain (16 +/- 4 g; p less than 0.05), but not significant hyperamylasemia. Changes also were not observed when 1-hour ischemia was followed by a bolus of ethanol (1.5 g) or sodium acetate (3.0 g), or by infusion of 25 mg/hr of AA. One hour of ischemia followed by infusion of AA at 50 mg/hr or at 250 mg/hr induced edema, hemorrhage, weight gain (22 +/- 7 g [p less than 0.05] and 26 +/- 17 g [p less than 0.05]) and hyperamylasemia (2249 +/- 1034 U/dL [p less than 0.05] and 2602 +/- 1412 U/dL [p less than 0.05]). Moreover infusion of AA at 250 mg/hr after 2 hours of ischemia potentiated the weight gain (62 +/- 20 g versus 30 +/- 14 g [p less than 0.05]), but not the hyperamylasemia (3404 +/- 589 U/dL versus 2862 +/- 1525 U/dL) as compared with 2 hours of ischemia alone. Pancreatitis induced by 1 hour of ischemia followed by AA at 50 mg/hr could be inhibited by pretreatment with the free radical scavengers superoxide dismutase and catalase and ameliorated with the XO inhibitor allopurinol. The authors conclude that AA, in the presence of active XO, can initiate acute pancreatitis in the isolated canine pancreas preparation and may be important in the initiation of acute alcoholic pancreatitis in man. Toxic oxygen metabolites appear to play an important intermediary role.     

The role of intraoperative cholangiogram in the management of patients recovering from acute biliary pancreatitis

Background Use of the standard management for gallstone-associated acute pancreatitis calls for cholecystectomy with cholangiography performed during the same hospitalization after acute symptoms has decreased. No previous studies, however, have objectively addressed the usefulness of intraoperative cholangiography (IOC) for the management of this condition. This study aimed to determine the incidence of common bile duct (CBD) stones after an acute episode of gallstone pancreatitis. Methods The medical records of all patients who underwent a cholecystectomy and IOC after an episode of gallstone pancreatitis during the same admission between 1999 and 2004 at the University of Alberta and Royal Alexandra hospitals were examined to determine the incidence of CBD stones after resolution of gallstone pancreatitis. Results After a chart review for a series of 86 patients, 63 met the inclusion criteria. All except for one patient had undergone successful IOC (98%). Among the patients who had no evidence of CBD obstruction on preoperative imaging or lab work, three were found to have a filling defect on IOC and stones on their postoperative endoscopic retrograde cholangiopancreatography (ERCP) (3/63, 5%). This is not significantly different from the 4.6% incidence of CBD stones among patients with cholelithiasis who had normal preoperative imaging and blood work. Conclusion In the setting of normal preoperative imaging and lab work, the incidence of CBD stones among patients recovering from acute mild to moderate gallstone pancreatitis is not significantly higher than among patients with no history of pancreatitis. Therefore, an IOC for post-gallstone pancreatitis does not alter management. Presented in oral form at the Canadian Surgery Forum, Montreal, Quebec, September 2005     

The role of early surgery in the treatment of acute hemorrhagic necrotizing pancreatitis (AHNP)

A retrospective study of the effect of surgical treatment and the value of different biochemical criteria in the early identification of AHNP in 33 patients with this condition, as proven by laparotomy, is presented. Biochemical criteria were not specific for AHNP and could only infrequently be used for assessment of the severity of acute pancreatitis. Surgical treatment consisted of pancreatic resection in 22 patients and drainage in 11 patients. Twenty-six of the 33 patients died regardless of the type of surgery. Mortality was due to multiple organ failure, either shortly after operation (eight patients) or after a protracted septic clinical course (18 patients). In total AHNP early subtotal pancreatectomy is probably not the treatment of choice since it did not improve the outcome.     

The potential role of therapeutic cytokine manipulation in acute pancreatitis.

The central, detrimental role of the inflammatory cytokines IL-1 and TNF and the biologically active phospholipid PAF in the pathogenesis of AP has been established over the past 8 years. A number of antagonists to these mediators have been used successfully in the laboratory setting and are currently being examined in prospective randomized trials. The effectiveness of any antagonist depends not only on its ability to block the effects of the inflammatory mediators but also on its administration early enough in the course of the pancreatitis before pancreatic necrosis or organ dysfunction.     

The role of oxygen-derived free radicals in the pathogenesis of acute pancreatitis.

Acute pancreatitis may be initiated in the ex vivo, perfused canine pancreas preparation by a variety of stimuli. These include oleic acid infusion (FFA), partial duct obstruction with secretin stimulation (POSS), and a 2-hour period of ischemia (ISCH). In each model, pancreatitis is characterized by weight gain, edema, and hyperamylasemia. Oxygen-derived free radicals such as superoxide, hydrogen peroxide, and the hydroxyl radical are highly reactive toxic substances that are normally produced in small amounts during oxidative metabolism. Ordinarily, these substances are detoxified by endogenous intracellular enzymes called free radical scavengers (FRS), such as superoxide dismutase (SOD) and catalase (CAT). These studies were undertaken to evaluate the possible role of oxygen-derived free radicals in the initiation of acute pancreatitis in the isolated canine model. All preparations were perfused for 4 hours with autologous blood. Controls (N = 6): these glands remained normal in appearance, gained minimal weight (6 +/- 1 g), and serum amylase remained normal (less than 1000 u/dl). FFA pancreatitis, FFA alone (N = 6): these glands became edematous, gained weight (113.5 +/- 27.0 g), and developed hyperamylasemia (2087 +/- 387 u/dl). FFA + FRS (N = 6), SOD (50 mg) and CAT (50 mg) were added to the perfusate at time zero: these glands became only minimally edematous, gained less weight (31.8 +/- 10.1 g, p less than 0.05), and amylase remained normal (p less than 0.05). POSS pancreatitis, POSS alone (N = 8): these glands became edematous, gained weight (38.6 +/- 4.6 g), and developed marked hyperamylasemia (9522 +/- 3226 u/dl). POSS + FRS (N = 6): these glands did not develop edema, gained less weight (15.1 +/- 2.6 g, p less than 0.05), and serum amylase only increased to 1815 +/- 343 u/dl, (p less than 0.05). ISCH pancreatitis, ISCH alone (N = 6): these glands became edematous, gained weight (75.8 +/- 25 g), and developed hyperamylasemia (1679 +/- 439 u/dl). ISCH + FRS (N = 6): these glands did not develop edema, gained only 18.3 +/- 9.0 g (p less than 0.005), and serum amylase remained normal (p less than 0.05). These studies demonstrate that, in this canine preparation, acute pancreatitis is significantly ameliorated by oxygen-free radical scavengers. Since this was true whether the pancreatitis was produced by FFA infusion, POSS, or ischemia, it suggests that oxygen-derived free radicals may mediate a common essential step in the pathogenesis of all forms of pancreatitis.     

重症急性胰腺炎的早期处理和手术时机

重症急性胰腺炎(SAP)是一种来势凶险的急腹症，因其起病急骤、病情变化迅速且复杂多变，临床诊治难度大，而成为医学界同仁们关注的热点和治疗决策的难点。综观近30年来我国重症急性胰腺炎治疗徘徊的历程，从上个世纪70～80年代主张早期手术，甚至SAP一经诊断就立即手术及过分强调手术切除的彻底性，     

NF-κB在重症急性胰腺炎中作用研究进展

近年来，细胞因子在重症急性胰腺炎(SAP)发生、发展中的作用再次受到重视，其与SAP并发MODS有密切关系。然而，对细胞因子产生机制却知之甚少。笔者综述介绍NF-κB组成成分、激活与抑制机制、NF-κB与炎症介质产生关系，以及在SAP中NF-κB对炎症介质产生的调节作用，企以为临床治疗SAP寻找新的治疗方法。     

JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis

The basic principles of the initial management of acute pancreatitis are adequate monitoring of vital signs, fluid replacement, correction of any electrolyte imbalance, nutritional support, and the prevention of local and systemic complications. Patients with severe acute pancreatitis should be transferred to a medical facility where adequate monitoring and intensive medical care are available. Strict cardiovascular and respiratory monitoring is mandatory for maintaining the cardiopulmonary system in patients with severe acute pancreatitis. Maximum fluid replacement is needed to stabilize the cardiovascular system. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with necrotizing pancreatitis. Although the efficacy of the intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional measures, blood purification therapy and continuous regional arterial infusion of a protease inhibitor and antibiotics, depending on the patient's condition.     

The role of laparoscopic surgery for the management of acute large bowel obstruction

Aim The aim of this study was to analyse the outcome of laparoscopic management of large bowel obstruction (LBO). Method A prospective electronic database (April 2001–June 2009) was used to identify outcomes in consecutive patients presenting with LBO. Results Twenty‐four patients (13 male) median age 68 years (range 56–92 years), ASA grade I (2), II (6), III (14) and IV (2), underwent surgery for LBO secondary to cancer (21) and diverticulosis (3). Supervised trainees performed four operations. Operations included anterior resection (10), Hartmann’s resection (6), right/extended hemicolectomy (7) and colectomy with ileorectal anastomosis (1). The median operating time was 100 min (range 65–180 min). There were two (8%) conversions. The median time to normal diet was 24 h (range 2–192 h) and median hospital stay 3 days (range 1–30 days). Complications, seen in six patients, included atrial fibrillation (2), wound infection (2), ileus (2), CO₂ retention (1), stoma necrosis (1), circulatory collapse/bowel ischaemia (1) and anastomotic leak (1). There was one (4%) readmission and two (8%) returns to theatre. One patient died. Conclusion Laparoscopic resectional surgery in acute LBO is feasible and safe with a low complication rate that enables early hospital discharge.     

Symposium on pancreatitis: 1. Conservative management of acute pancreatitis.

Acute pancreatitis may present as the mild edematous type or the more rare and dangerous hemorrhagic form. The effects of the latter are believed to be due to the activation of pancreatic enzymes, notably trypsin. Therefore attempts are being directed towards suppression of pancreatic enzyme activation in the management of the condition. Aprotinin and glucagon are the agents for this purpose that have received most attention. Patients with acute hemorrhagic pancreatitis are subject to respiratory failure, which is not detectable early by clinical evidence, so that early monitoring of pulmonary function by the determination of arterial blood-gas pressures is desirable. This is borne out by the findings in six fatal cases.     

Symposium on pancreatitis: 2. Surgical management of acute pancreatitis

While there is general agreement on the indications for surgery in acute pancreatitis, the preferred operation is controversial and the approach ranges from one that is very conservative to one that is extremely aggressive. The author believes that in all cases the gallbladder should be opened to permit exploration and that cholangiography should be performed. If gallstones are discovered they should be removed and the organ drained; cholecystectomy is advised if the procedure is at all feasible. In a personal series of 50 cases of acute pancreatitis, 10 patients had early operation and 19 surgical procedures were performed.