Conservative management

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Much controversy surrounds whether, when, and why patients with severe acute pancreatitis should be subjected to surgery. Whatever the stage of the attack, two extremes of therapeutic strategy have been advocated, although neither has yet been substantiated by a controlled trial.

The first strategy is early surgical removal of necrotic material (necrosectomy). Reported indications for surgery during either the early or the late phase of the attack are based on clinical, morphological, and/or microbiological criteria. Massive retroperitoneal hemorrhage, an acute abdomen, early infected pancreatic necrosis, extensive regional necrosis, and persistence of remote organ dysfunctions despite ICU therapy for 3 to 5 days usually dictate surgery during the toxemic phase. Pancreatic abscess, symptomatic acute pseudocyst, fistula, or compression/perforation of a hollow viscus also mandate operative procedures during the necrotic phase. Almost half of those who undergo surgery do so for persistent organ failures without pancreatic infection and on the basis of CT findings of large necrotic areas and laboratory/clinical signs of inflammation which cannot differentiate between sterile and infected necrosis. Morphological data such as extensive sterile pancreatic necrosis are used as criteria for surgery. Some even claim that prophylactic necrosectomy, irrespective of the patient's condition and the bacteriological status of the necrosis, may reduce the incidence of sepsis, and that waiting for proof of infection delays operative intervention and increases mortality in those with large necrotic areas. Regardless of the surgical procedure undertaken, early, aggressive, complete, and often repeated debridement of unviable tissues is performed. This is because necrosis persists due to oozing of activated pancreatic enzymes and toxic substances, thus demanding prolonged drainage and repeated operative interventions. When undertaken during the toxemic phase, this surgical drainage results not only in continuous removal of necrotic and/or infected tissues but also in diversion of toxic substances and active enzymes released in the pancreatic region. These act synergistically, lessening the inflammatory necrotizing process and reducing the mortality of severe acute pancreatitis to 7 or 15 per cent, depending on whether the necrosis is sterile or infected. Whatever surgical approach and method of drainage are used, about 20 per cent require reoperation because of hemorrhage, fistula, or, most commonly, recurrent or incompletely drained infected areas with ongoing sepsis. Additional morbidity includes mechanical ileus, stomach outlet stenosis, and incisional hernias.

The objectives of the step-care conservative approach are to prevent and/or treat any organ damage in the early phase and to allow spontaneous healing of regional necrosis during the later phase, with precautions against emergence of local complications, in particular bacterial invasion of necrotic areas. Aggressive surgical debridement of necrosis, with its attendant morbidity, is avoided unless regional infection, severe hemorrhage, or symptomatic pseudocyst occur and fail to settle on conservative therapeutic options (Fig 1) (RaueLal 1995). The step-care conservative management of the early 'toxemic' phase of severe acute pancreatitis includes percutaneous peritoneal lavage, thoracic duct drainage, and endoscopic retrograde cholangiopancreatography (ERCP) with emergent papillotomy for acute gallstone pancreatitis and impacted ampullary stones.

Fig. 1 Schematic representation of the conservative therapeutic strategy that may be considered in both phases of severe acute pancreatitis. In addition to basic medical therapy and intensive care support, non-surgical removal of toxic substances released by the inflammatory necrotizing process is carried out while serial monitoring of necrotic areas is undertaken to avoid missing the emergence of regional infection. Surgery is contemplated only if severe retroperitoneal hemorrhage, complicated pseudocyst, or infected pancreatic necrosis/abscess supervene. A shift from a conservative to a surgical approach remains controversial in the case of extensive sterile necrosis and worsening multisystem organ dysfunction syndrome.

The last procedure should be carried out without delay since early endoscopic dislodgement of impacted stones reduces morbidity when undertaken within 72 h of admission (Wd^M. eta[ 1991). However, it remains largely unproven that relief of ductal hypertension by whatever means lessens the inflammatory process and impedes progression toward pancreatic necrosis. Although this procedure is achieved at no risk of exacerbating the disease process, hemorrhage, or pseudocyst formation, it still carries a substantial risk of introducing bacteria into necrotic areas. Thus it should not be considered routinely in severe gallstone pancreatitis, but only when signs of cholangitis develop or when suspicion of stone impaction arises on clinical, biochemical, and ultrasonic grounds in a patient not responding to ICU therapy. Alternatively, temporary relief from cholangitis may be obtained by percutaneous or nasobiliary drainage of the biliary tree. As the stone is impacted in the ampulla for some time in more than 60 per cent of patients during the first 48 to 72 h of the attack, some authors have advocated early (within 48 h) cholecystectomy and common duct exploration with subsequent choledocotomy. However, since 95 per cent of stones pass spontaneously into the intestine during the first week and early biliary surgery carries a prohibitive mortality in severe acute pancreatitis, it is common practice to delay cholecystectomy until signs of the inflammatory phase have subsided. Cholecystectomy should be performed during the same hospital admission. In poor surgical candidates a wide endoscopic sphincterotomy may obviate the need for a cholecystectomy.

Percutaneous peritoneal lavage (usually 1-2 l/h of dialysis fluid or normal saline) should be considered early whenever dark brown ascitic fluid is obtained. Lavage is usually discontinued when the returned fluid is clear. Striking reduction of early cardiorespiratory dysfunction and early mortality has been demonstrated, in particular for alcohol-induced pancreatitis. These benefits are ascribed to the early removal of toxic substances before they reach the systemic circulation. Peritoneal lavage is also useful in patients with coexisting renal failure and/or fluid overload. However, it seems unlikely that enough lavage fluid gains access to the lesser sac where the concentration of toxic agents must be greatest. This therapy neither slows progression of local tissue injury nor prevents the development of necrosis and infection, and thus fails to influence overall mortality. A dramatic reduction in the incidence and subsequent mortality from pancreatic infection has been obtained by using peritoneal lavage for an extended period (> 7 days). Since evidence exists that bacteria can translocate transperitoneally to the pancreas as viable organisms within macrophages, the removal of these phagocytic cells containing gut-derived bacteria and chemotactic factors may account for these benefits. Hazards of this procedure include the risk of visceral injury when introducing the catheter into the peritoneum, increased respiratory distress due to abdominal distension by lavage fluid, fluid overload if the lavage fluid is not returned, hyperglycemia, and bacterial contamination of the peritoneal cavity.

Lymphatic pathways play a pivotal role in the systemic transfer of active enzymes and toxic products released by the pancreas. Diversion of these substances by drainage of the thoracic duct lymph should be considered in those patients with persistent or worsening remote organ dysfunctions ( DugernjeLetal,: 1989). This is carried out surgically with a 7 Fr pulmonary artery catheter. This type of drainage has been found to be particularly useful for patients with persistent cardiocirculatory failure and/or impaired pulmonary gas exchange, including acute respiratory distress syndrome, during the toxemic phase of the disease. Thoracic duct drainage should be considered early in the course of failure of conventional conservative maximum supportive therapy. The beneficial effects of lymphatic drainage with regard to prevention and correction of life-threatening complications of the early phase are substantiated by the finding of substantial amounts of enzymatically active trypsin, neutrophil myeloperoxidase and elastase, and cytokines in the lymph. Like peritoneal lavage, lymphatic drainage fails to influence the incidence of locoregional complications of acute pancreatitis.

Although the role of surgery in severe hemorrhage, hollow viscus perforation, complicated pseudocyst, and pancreatic infection remains undisputed, the step-care conservative approach helps to manage the early remote organ dysfunctions. The question arises as to whether these patients with extended regional necrosis and systemic complications but without infection should be subjected to early surgery and its attendant morbidity. The success of early surgical debridement is partly attributed to the prolonged postoperative lavage of the peripancreatic region. This removal of toxic substances can be achieved almost non-invasively by the conservative approach. Nevertheless, the major challenge for those who adopt this strategy is early differentiation between sterile and infected necrosis. Patients with abdominal sepsis not treated by surgical or percutaneous drainage will be jeopardized, since this condition is almost 100 per cent lethal if left undrained. Precise criteria for moving from intensive conservative therapy to surgery are essential. Apart from severe arterial hemorrhage and an acute abdomen (usually by early perforation of a hollow viscus), a more rational basis for operative intervention is provided by a reliable and rapid differentiation between sterile and infected necrosis. This diagnostic work-up is best achieved by serial CT examination, repeated needle-aspiration sampling of necrotic areas, and monitoring of C-reactive protein or elastase.

As an increasing number of patients survive the early phase of severe acute pancreatitis without operative debridement of necrosis, many enter the necrotic stage with large areas of necrosis. Considering the rate of spontaneous and uneventful resolution of even extensive necrotic areas, a policy of conservative medical management remains sensible during this phase of the attack.

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