Presentation at rajkot

A Presentation

ON

CONSENSUS IN PANCREAS MANAGEMENT

DR. TAPAN SHAH

Dr Tapan Shah, M.S, M.Ch

Fellow Digestive Surgery, UPMC, USA

Ph.D ( Liver transplantation) UPMC, USA

SURGICAL GASTROENTEROLOGY AND

HEPATOBILIARY SURGEON in AHMEDABAD AND BARODA

A Prof. & Research Fellow (USA)

LETS CUDDLE IN PANCREAS MUDDLE

Discussing few cases with pancreatic pathology

• Pancreatic fistula

• Acute pancreatitis

• Chronic pancreatitis

CASE I : PANCREATIC FISTULA

• A 54 year old man presented with anasarca, later

proved to have left adrenal gland tumor on CT scan, a

laparoscopic approach was opted and during the

surgery spleen got injured, surgeon pushed ahead with

splenectomy, later on 4th day, drain shows almost bout

500-600 ml of juices that keeps increasing and

decreasing irrelevantly.

HOW TO DEFINE PANCREATIC FISTULA

• Presence of high amylase in fluid should be

consider pancreatitis almost to 5 folds

PF is surgeon’s bane, grave where you bury alive

WHAT NEXT?

• CECT 41%

• MRCP 10%

• ERCP 49%

• FLUID AMYLASE <1%

Voss and Pappas,[1] et al 2007

MANAGEMENT OF PANCREATIC FISTULA

• Conservative

• endoscopic

• Operative

• Plugs and sclerosant ( cynoacrylate or paralime)

CONSERVATIVE MANAGEMENT

• Naso Jejunostomy or feeding jejunostomy enteral feeding or total parenteral nutrition,

• nasogastric suction,

• imaging-guided percutaneous drainage of collection when necessary

• and somatostatin or its analogues.

• Correction of electrolyte imbalance

• Prophylaxis for secondary infection

ENDOSCOPIC PROCEDURES

• Cant be done

• Dislocated duct syndrome

• Island of pancreas

• Best done in

• Small disruption

• Tail disruption ( distal pancreatectomy)

WEIRD TECHNIQUES BUT WORKS

• percutaneous embolization using a sclerosing substance, prolamine, injected into the Wirsung duct via drainage catheter.

• Injection of cyanocarylate into external fistulous tracts

• Temporary fibrin glue occlusion pre operatively of main pancreatic duct

SURGERY

• RESECTION

• Generally opted

• With or without enterostomy

• ENTEROSTOMY

• Multiple

• Body generally involved or head involvement

CASE 2

• A 41 years old alcoholic male presented with

severe pain in abdomen with nausea and

vomiting. During all the investigation pateint was

found to have raised lipase , with tachcardia and

low blood volume, how would we manage him?

OVERVIEW OF ACUTE PANCREATITIS

• 85% of patients have interstitial pancreatitis; 15 (range 4 – 47%) have necrotizing pancreatitis

• Among patients with necrotizing pancreatitis, 33% (range 16-47%) have infected necrosis

• Approximately 10% of patients with interstitial pancreatitis experience organ failure, but in the majority it is transient

• Mortality in acute pancreatitis overall, is approximately 5%: 3% in interstitial pancreatitis, 17% in necrotizing pancreatitis

• In necrotizing pancreatitis, mortality 3-fold infected vs. sterile necrosis

• Mortality increases with development of organ failure ~ 3% (0-8%) and with multi-system organ failure 47% (range 28-69)

ACG Practice Guidelines in Acute Pancreatitis

Am J Gastroenterol 2006;101:2379-2400

ACUTE PANCREATITIS:WHAT SHOULD WE DO

1) Volume replacement is the foundation of therapy

2) Establish severity

Utilize initial laboratory data

standardized modalities i.e. Ranson criteria require 48 hrs

CT abnormalities correlate with severity

No need for early CT to establish severity

3) Establish etiology

Importance is to prevent recurrence

4) Biliary Pancreatitis

Utilize laboratory markers for diagnosis of retained CBD

ERCP is only for treating patients with cholangitis

5) Do not use prophylactic antibiotics

6) CT guided aspiration is the diagnostic test for pancreatic

infection & allows directed antibiotic therapy

7) Surgical intervention in patients with infected pancreatic

necrosis but rarely in sterile necrosis

8) Early enteral feeding is safe, prevents leaky gut and is

associated with less complications than TPN

Acute Pancreatitis:Concepts 2009

CAUSES OF MORTALITYDEATH

Early (< one week)

Systemic inflammatory response syndrome (SIRS)

Multiorgan failure

Late (> one week)

Multiorgan failure

Pancreatic infections/sepsis

SYSTEMIC INFLAMMATORY RESPONSE

SYNDROME (SIRS)

Defined by two or more of the following criteria:

Pulse > 90 beats/min

Respiratory rate > 20/min or PCO2 <32 mmHg

Rectal temperature <36° C or >38°C

White blood count <4,000 or >12,000/mm3

ACG Practice Guidelines in Acute PancreatitisAm J Gastroenterol 2006;101:2379-2400

Diagnosis

Prognosis

Detect complications

INDICATIONS FOR COMPUTED TOMOGRAPHY (CT)

IN ACUTE PANCREATITIS

WHEN TO DO CT

Contrast-Enhanced CT Scan

Not on admission if diagnosis is determined -

• A few days (5-7days)after admission to distinguish interstitial

from necrotizing pancreatitis when there is clinical evidence of

increased severity. Level of Evidence III

• To guide aspiration in patients with fluid collection to determine

if infected

• When patient is deteriorating

COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE

IMAGING IN THE ASSESSMENT OF ACUTE PANCREATITIS

Method: MRI was performed with intravenous secretin and contrast medium

Results

• EQUAL RESULTS

• Costly

• To be opted when patient having contra indication of contrast dye

Arvanitakis M, et al. Gastroenterology 2004;126(3):715-23

DIAGNOSTIC GUIDELINE III

DETERMINATION OF SEVERITY DURING HOSPITALIZATION

Contrast-Enhanced CT Scan

Not on admission if diagnosis is determined -

• A few days after admission to distinguish interstitial from

necrotizing pancreatitis when there is clinical evidence of

increased severity. Level of Evidence III

• To guide aspiration in patients with fluid collection to

determine if infected ACG Practice Guidelines in Acute Pancreatitis


ACUTE IDIOPATHIC PANCREATITIS:

DOES IT REALLY EXIST OR IS IT A MYTH?Background:

• Gallstones and alcohol abuse are the most frequent

causes (75% of patients) of acute pancreatitis

• Consider hyperlipidemia, hypercalcemia and drugs

• In 10% to 40%, no cause is identified

Van Brummelen SE, et al. Scand J

Gastroenterol (Suppl) 2003;(239):117-22

MICROLITHIASIS IS THE MOST COMMON

CAUSE ACUTE IDIOPATHIC PANCREATITIS

Results:

• Microlithiasis or biliary sludge is an important cause of acute ‘idiopathic’ pancreatitis in up to 80% of patients

• Microlithiasis can be detected by trans-abdominal/endoscopic ultrasonography or polarizing light microscopy of bile

• Acute pancreatitis can be prevented by performing cholecystectomy and opening the sphincter of Oddi

Adapted from: Van Brummelen SE, et

al. Scand J Gastroenterol (Suppl)

2003;(239):117-22

CONTD:-

• Interstitial or necrotising, unidentified etiology based pancreatitis

are recommended to proceed for cholecystectomy

• Sphincterotomy &

• Long term use of ursodeoxycholic acid

Adapted from: Van Brummelen SE, et al. Scand J

Gastroenterol (Suppl) 2003;(239):117-22

BILIARY PANCREATITIS: WHAT HAPPENS TO

CBD STONES?

Stone or concretion is found in CBD

a) within 48 hours after admission in 62% – 75%

a) After 48 hours post admission CBD stones are found in 3% – 33%

The natural history of CBD stones is passage

TREATMENT GUIDELINE VIII

ROLE OF ERCP AND BILIARY SPHINCTEROTOMY IN

GALLSTONE PANCREATITIS

• Indicated for clearance of bile duct stones in patients with severe pancreatitis, in those with cholangitis

• ERCP should be performed primarily in patients with high suspicion of bile duct stones when therapy is indicated

• EUS or MRCP can be used to identify common bile duct stones

Level of Evidence: I

ACG Practice Guidelines in Acute Pancreatitis.


ACUTE BILIARY PANCREATITIS: FIRST 24 TO

48 HOURS

Jaundice with Bilirubin > 1.35 @

24 hrs

ERCP MRCP

PosNeg

Stone

removal

Elective surgical

cholecystectomy

Neg Pos

ROLE OF SURGERY IN PATIENTS WITH SEVERE

ACUTE PANCREATITIS

Indication Timing

Biliary pancreatitis

Infected necrosis

Laparoscopic cholecystectomy during hospitalization or < 6 weeks after episodes

Later: > 10 days unless

unstable with infected

necrosis

EARLY VERSUS LATE NECROSECTOMY IN SEVERE

NECROTIZING PANCREATITISPatients were randomly allocated to two treatment arms as

follows:

Group A included early necrosectomy (within 48 to 72 hours of onset)

Group B included late necrosectomy (at least 12 days after onset)

Results:

Difference in the mortality rate (58% vs. 27%) was not statistically significant, the odds ratio for mortality was much higher in the early operation group

Early surgery in severe acute pancreatitis is only required in cases with proven early infection of the pancreatic necrosis (and not stable)

Mier J, et al. Am J Surg 1997;173:71-7

Buchler MW, et al Dig Dis 1992;10:354-62

Mai G, et al Berlin, Blackwell Science 1999;475-85

ROLE OF PROPHYLACTIC

ANTIBIOTICS IN PATIENTS WITH

SEVERE ACUTE PANCREATITIS

Adapted from H. Beger et al., Gastroenterology 1986;

91:433

%Cases

0

20

40

60

80

100

< 7 days 7-14 days 14-21 days > 21 days

THE INCIDENCE OF PANCREATIC INFECTIONS

INCREASES WITH TIME

LOCAL AND SYSTEMIC INFECTIONS IN ACUTE

PANCREATITIS

• After week 1, the prognosis . is mainly determined by bacterial infection of pancreatic and peripancreatic necrosis

• Mortality increases from 5% - 25% in patients with sterile necrosis to 15% - 28% in patients with infected necrosis

Rau B, et al. J Am Coll Surg 1995;181:279-288

Rau B, et al. World j Surg 1997;21:155-161

Isenmann R, et al.Br J Surg 1999;86:1020-1024

Wilson PG, et al. J Antimicrob Chemother 1998;41(suppl A):51-63

Tenner S, et al. Gastroenterology 1997;113:899-903

Buchler MW, et al. Ann Surg 2000;232:619-626

ANTIBIOTIC THERAPY FOR PROPHYLAXIS AGAINST

INFECTION OF PANCREATIC NECROSIS IN ACUTE

PANCREATITIS

Aim: to determine the effectiveness and safety of prophylactic antibiotic therapy in patients with severe acute pancreatitis who have developed pancreatic necrosis

Results

• A survival advantage for antibiotic therapy (Odds ratio 0.32, p=0.02) was demonstrated

• Pancreatic sepsis showed an advantage for therapy (Odds ratio 0.51, p=0.04)

• Extra-pancreatic infection could be evaluated in three studies, but showed no significant advantage for therapy (Odds ratio 0.47, p=0.05)

Cochrane Database Syst Rev

2003;(4):CD002941

ANTIBIOTIC THERAPY FOR PROPHYLAXIS AGAINST INFECTION

OF PANCREATIC NECROSIS IN ACUTE PANCREATITIS

(Cont)

• Surgery rates were not significantly reduced (Odds ratio 0.55, p=0.08)

• Fungal infections showed no strongly increased preponderance with therapy (Odds ratio o.83, p=0.7)

Reviewers’ Conclusion

• Strong evidence that intravenous antibiotic prophylactic therapy for 10 to 14 days decreased the risk of super-infection of necrotic tissue and mortality in patients with severe acute pancreatitis with proven pancreatic necrosis at CT

Cochrane Database Syst Rev 2003;(4):CD002941

TREATMENT GUIDELINE IVANTIBIOTICS IN NECROTIZING PANCREATITISLevel of Evidence III

• Not recommended at this time in patients with necrotizing pancreatitis

• During the first 7 – 10 days, patients with pancreatic necrosis may appear septic with leukocytosis, fever, and/or organ failure

• Antibiotic therapy is appropriate while an evaluation for a source of infection is undertaken

• Once blood and other cultures (including CT-guided fine needle aspiration) are found to be negative, discontinue antibiotic therapy



SEVERE ACUTE PANCREATITIS – 2009

CT

No

Necrosis

Necrosis >

30%

No

antibiotic

?AntibioticsMeropenem for 10-14 days

ESAP

MANAGEMENT OF PANCREATITIS PRIOR TO CT-

FNA

• The extent of leukocytosis or temperature does not

reliably distinguish severe sterile from infected

necrosis

• The development of organ failure (or multi-system

organ failure) and serum markers are not reliable

indicators of infected necrosis

Buchler MW, et al. Ann Surg 2000;232(5):619-26

Mier J, et al. Am J Surg 1997;173(2):71-5

Rau B, et al. Br J Surg 1998;85(2):179-84

SEVERE ACUTE PANCREATITIS: ROLE OF CT-GUIDED

NEEDLE ASPIRATIONInfected Necrosis

Suspicion

Tº > 100 F

elevated WBC

unresolved organ failure

Recurrence of SIRS or persistence > 7 days

Diagnosis

CT guided aspirate for gram stain and Culture and sensitivity

PERCUTANEOUS ASPIRATION OF PANCREATIC

FLUID COLLECTION – GRAM STAIN AND CULTURE

10% aspirate gram stain negative and culture positive

No history of antibiotic administered

Aspirant gram stain positive with negative cultures in 2 of

34 (6%) patients

Effect of antibiotics on aspirate

Barkin JS, et al. Dig Dis Sci 1981;26(7):585Freeny PC, et al AJR 1998;170:969-975

TREATMENT GUIDELINE V:

TREATMENT OF INFECTED NECROSIS

• CT-guided percutaneous aspiration with Gram’s stain and

culture aspirate is recommended when infected necrosis is

suspected

• Treatment of choice in infected necrosis is surgical

debridement

Level of Evidence III



TPN

Cost – high

No pancreas stimulation

Increased infections

Electrolyte disturbances

Detrimental to gut integrity

Enteral

Cost – moderate

May stimulate pancreas

Reduced infections

Electrolytes undisturbed

May retain gut integrity

ROUTE OF ALIMENTATION

TOTAL PARENTERAL NUTRITION (TPN) AND

ENTERAL NUTRITION (EN)

TPN – causes intestinal mucosal atrophy alterations in

the gut associated lymphoid tissue (GALT) system

and a reduction in intestinal secretory IgA (S-IgA)

levels

EN – prevents hypermetabolism, maintains immunocompetence and improves wound healing; considered to reduce septic complications, shorten hospital stay and reduce the risk of death

Levine GM, et al Gastro 1974:67:975King BK, et al. Arch Surg

Kudsk KA, et al Ann Surg 1996:223:629Mochizuk H, et al Ann Surg 1984;200:297-310

Alverdy J, et al. Ann Surg 1985;202:681Schroeder D, et al JPEN 1991;15:376

Moore FA, et al. J Trauma 1989;29:916.

TREATMENT GUIDELINE III

NUTRITIONAL SUPPORT

• Enteral feeding rather than total parenteral nutrition is

suggested for patients who require nutritional support

Level of Evidence II

• In severe necrotizing pancreatitis (especially when most or all

of the pancreas is necrotic) provide potent pancreatic

enzymes and then evaluate later in the course

• It is prudent to use a proton pump inhibitor because of the

likelihood that bicarbonate secretion by the pancreas is

severely diminished ACG Practice Guidelines in Acute Pancreatitis


TREATMENT GUIDELINE I:

SUPPORTIVE CARE

Level of Evidence III

1. Carefully monitored during the first 24 h of vital signs, oxygen saturation and fluid balance - hypoxemia and inadequate fluid resuscitation may be unrecognized for prolonged periods of time

Result: Early aggressive fluid resuscitation and improved delivery of

oxygen prevent or minimize pancreatic necrosis and improve

survival

2. Consequence of hypovolemia is intestinal ischemia, which increases

intestinal permeability to bacteria and endotoxin

Result: Translocation of bacteria cause secondary pancreatic infection

and contribute to on-going pancreatic injury and also to organ

failure

ACG Practice Guidelines in Acute Pancreatitis


Positive

Suggestion of infection after

day 5

Support and stabilize

APPROACH TO PATIENTS WITH SEVERE ACUTE PANCREATITIS

Negative

Observe and re-

aspirate

Organ system failure -Antibiotics ?

CT guided needle

aspiration

Adjust

Antibiotics

Stable

Follow

Unstabl

e

Surger

y

CHRONIC PANCREATITIS

• Defined as chronic inflammatory condition that causes irreversible damage to pancreatic

structure and function

• Causes: ETOH abuse, malnutrition, hyperPTH, pancreas divisum, ampullary stenosis,

cystic fibrosis, hereditary, trauma, idiopathic


• Chronic pancreatitis results in interstitial inflammation w/duct obstruction and dilation

leading to parenchymal loss and fibrosis.

• Loss of both exocrine and endocrine

• Clinicically significant malabsorption occurs when 90% of pancreas is lost.


• Pathophys - irreversible parenchymal destruction leading to pancreatic dysfunction

• Persistent, recurrent episodes of severe pain

• Anorexia, nausea

• Constipation, flatulence

• Steatorrhea

• Diabetes


• #1- etiology is chronic EtOH abuse (90%)

• Gallstones

• Hyperparathyroidism

• Congenital malformation

(pancreas divisum)

• Idiopathic

• MRCP of pancreas

divisum

http://radiology.rsnajnls.org/content/vol217/issue2/images/large/r00nv29g3d.jpeg

http://radiology.rsnajnls.org/content/vol217/issue2/images/large/r00nv29g3d.jpeg

MANAGEMENT

• Medical

• Analgesic ( opiods and non opiods)

• Enzyme replacement

• Endotherapy

• Surgery

• Intraventional radiology

ENZYME REPLACEMENT

• DOES THE TYPE MATTERS?

• ACID PROTECTIVE

• SIZE OF THE DELIVERY SUBSTANCES

First, prior endoscopic treatment

SOME PRINCIPLES……..

ENDOSCOPIC TREATMENT

OF CHRONIC PANCREATITIS

PRINCIPLE 2:

TO TREAT ONLY IN CASE OF SYMPTOMS AND COMPLICATIONS

• Pain: yes

• Pseudocyst: yes if symptoms or complications

• Fistula: yes

• Biliary stenosis: +/- discussed

• Duodenal stenosis: no

• Vascular stenosis (portal vein, splenic vein): no

• Pancreatic exocrine function: +/- discussed

• Diabetes: no

PAIN

Endoluminal Stenting

Aim: drainage of the main pancreatic duct (wirsung,santorini)

Bases: results of surgical bypass

Immediate effect on pain: 70-90%

(Sarles 82, Bradley 87, Longnecker 96, Prinz 90)

PAIN

Indications

MRCP +++

PAIN

Indications

MRCP +++1: No stenosis

ES alone

+/- biliary sphinctero

3: Stenosis, no stones

Sphinctero + stent

OR FREY PROCEDURE

2: Stenosis, stones

Extracorp litho (nber ?)

then

ES + stent

(type ?)

Type IV Cremer

PAIN

Indications

to be

discussedLong stenosis

Ex: familial CP

Discussion: length of

the stenosis

Recommendation of

lat. PJMinor modif

Cremer Type I

Discussion: Tt at the early

asymptomatic stage

PAIN

Contraindications

Distal stenosis

Cremer type II

Recommendation: left

pancreatectomy

PAIN: ResultsIn the absence of prospective studies,

in the absence of randomized studies,

analysis of the literature is difficult:

Role of abstinence from alcohol ?

Role of medical therapy: enzymes ?

Variable presentation of pain (chronic, attacks)

Role of the complications (pseudocyst, bile duct) ?

Fragile psychology of the patient

Different endoscopic treatments

WHEN PAIN REMAINS …celiac neurolysis

EUS GUIDANCE

STEROIDS

PSEUDOCYSTENDOLUMINAL TT

versus

CYSTOENTEROSTOMY

CystogastrostomyCystoduodenostomy

Cystowirsungostomy

Main panc duct drainageEUS guided

by drtapan

PANCREAS SURGERY PHOTO ALBUM

THANK

YOU!

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