Selected cases of retroperitoneal hemorrhage without infection and prolonged circulatory embarrassment are successfully managed conservatively or with ultrasound-
or CT-guided percutaneous drainage. However, in the majority, surgical vessel ligation (pseudoaneurysm) and thorough debridement are mandatory to control sepsis-associated hemorrhage and prevent recurrence of bleeding. Angiography and arteriographic embolization, when feasible, should precede the operative procedure.
Ultrasound- or CT-guided percutaneous drainage of infected collections using large-bore drainage tubes, apart from its therapeutic potential in selected cases, may buy time for severely ill patients until they can withstand formal surgical debridement and drainage ( Lee eta.L 199.2). This therapeutic approach is highly demanding as it usually requires insertion of multiple catheters and a prolonged drainage/lavage period with close clinical scrutiny, regular abdominal CT scans, and catheter repositionings. The rather small caliber of the drains and the thick necrotic material often preclude complete evacuation of the collections, so that septic recurrences are common and dictate surgical operative intervention. Factors that adversely affect percutaneous drainage include complex and not fully liquified collections, as well as a central localization. Complications are common and include gastrointestinal and colocutaneous fistulas, bleeding, pneumothorax, and, in particular, the possibility of delaying necessary surgery.
Up to half of patients with pseudocyst remain free of symptoms and can be safely managed non-operatively with careful clinical and ultrasound follow-up studies. Some clinicians consider that, irrespective of symptoms, a diameter of more than 5 cm mandates drainage owing to the risk of complications. Ultrasonic- or CT-guided percutaneous aspiration and drainage has a role as a temporary measure in severely ill patients who are poor candidates for surgery. This approach increases the risk of secondary infection of a sterile pseudocyst, and the small caliber of the catheter often precludes complete aspiration of necrotic material. A 50 per cent recurrence rate has been reported, particularly if obstruction of the downstream part of the duct is outlined on pancreatography and if pancreatic ductal communication to the cyst persists. Percutaneous catheter cystogastrostomy and endoscopic cystogastrostomy or duodenostomy have been proposed. Internal drainage should be avoided in patients with pancreatic ascites unless the cyst leak can be incorporated into a Roux-en-Y cyst jejunostomy. In selected cases, total parenteral nutrition, percutaneous drainage, and somatostatin may lead to fistula closure in cases of recurrent pseudocyst or persistent pancreatic ascites.
Pancreaticopleural fistula should be managed conservatively with somatostatin, total parenteral nutrition, and tube thoracostomy for up to 2 to 3 weeks. Pleural effusion recurs in half of cases and requires operative intervention (excision or decompression of the leak) after visualization of the site of disruption of the pancreatic duct with a pancreatogram.
Early and late therapeutic interventions during severe acute pancreatitis are summarized in Ta.ble.2 and T§b.!e..3 respectively.
Table 2 Therapeutic interventions during the early phase of severe acute pancreatitis
Table 3 Therapeutic interventions during the late phase of severe acute pancreatitis
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