Indication and timing for surgical management

Surgical intervention in patients with severe necrotizing pancreatitis with local and systemic complications should be based on the patient's response to optimum ICU treatment as shown in T.able.3. Several clinical and morphological criteria may be considered as indications for surgery if the patient fails to improve after 3 to 5 days. Clinical criteria are signs of acute abdomen with peritonitis and ileus, persisting or deteriorating organ failure such as pulmonary or renal insuffuciency, and systemic complications such as persisting or progressing sepsis syndrome, metabolic derangement, coagulation disorders, and shock. With respect to morphological criteria, documented infection of pancreatic necrosis is a generally accepted indication for surgical intervention if clinical signs of sepsis are present ( Ta.bl.e 4). It should be stressed that no controlled data exist regarding optimum treatment, either surgical or conservative, in patients with complicated sterile necrotizing pancreatitis.

Table 4 Indications for surgery in necrotizing pancreatitis

Ongoing discussion persists regarding the optimum timing of surgery in necrotizing pancreatitis which can be performed early within the first 7 days or late during the postacute phase in the second week. Operative intervention in the second week of the disease is recommended for patients who do not respond to maximum ICU treatment The rationale for delayed surgery is to wait until demarcation of necrosis has occurred. Early intervention in the acute phase (days 1 to 7) is indicated only in those few patients with a fulminant course or with proven infection of necrosis ( Fig 1).

Fig. 1 Management of acute pancreatitis: AP, acute pancreatitis; AIP, interstitial edematous pancreatitis; NP, necrotizing pancreatitis; ERCP, endoscopic retrograde cholangiopancreatography; EPT, endoscopic papillotomy; CRP, C-reactive protein; LDH, lactate dehydrogenase; CECT, contrast-enhanced CT; FNAB, fine-needle aspiration biopsy.

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