Surgical treatment of acute pancreatitis, these 3 points you need to know!

Acute pancreatitis is a disease characterized by acute inflammation of the pancreas and histologically destruction of acinar cells, and is one of
the common digestive emergencies.
At UEG Week 2022, Professor Jan-Hendrik Egberts from Israel gave an in-depth discussion
on the minimally invasive surgical treatment of acute pancreatitis.
"Medical community" specially invited Dr.
Tan Ying, Department of Gastroenterology, West China Hospital of Sichuan University, to bring us a wonderful conference report
.

01

(1) Suspected or confirmed presence of infectious necrosis
.
The surgeon may not intervene later, but be sure to let them know
.

(2) Abdominal compartment syndrome
.

(3) Bleeding
.

(4) Unstable vital signs, severe aseptic necrosis, sepsis
.

(5) Symptomatic tissue necrosis
.

(6) Organ perforation
caused by non-pancreatic causes.

(7) Dissociative pancreatic duct syndrome
.

Professor Jan-Hendrik Egberts believes that early multidisciplinary discussions are necessary
to guide the choice of treatment modalities for patients.
Communicate with the surgeon as early as possible, as many cases are complex and difficult, and the surgeon needs time to prepare for the operation
.

02

The timing of surgical treatment has always been a hot issue
in the treatment of acute pancreatitis.

Previous guidelines recommended surgery within 16 hours of symptom onset in patients with acute pancreatitis
.
However, clinical studies have found that early surgery does not reduce mortality
from severe pancreatitis.

In the early stage of acute pancreatitis, the boundary between necrotic pancreas and normal tissue is not clear, and forced debridement is very easy to damage adjacent blood vessels and organs
.
If the operation can be postponed until 4 weeks after the onset of the disease, avoid the systemic inflammatory reaction period, and then operate when the infected necrotizing lesion is fully liquefied and the necrosis boundary is easier to distinguish, surgical intervention can achieve the desired effect, so it is currently more recommended to follow the principle of deferral, that is, follow the "3D" principle (Delay, Drain, Debride) [1]:

• Surgical intervention is relatively delayed until about 4 weeks after onset;

  
  

• Mainly drainage and decompression;

  
  

• If drainage is not effective, escalation to debridement is the preferred minimally invasive surgical treatment rather than open surgical resection
  for acute necrotizing pancreatitis in view of the lower morbidity.
  

A variety of minimally invasive procedures are currently feasible and effective, including video-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement
.

The choice of treatment is best determined by the type of disease, the patient's physiology, the experience of the multidisciplinary team, and available resources
.
Open surgical debridement continues to play an important role in the current treatment of acute necrotizing pancreatitis, particularly in patients
who cannot undergo minimally invasive endoscopic and/or surgical treatment.

03

(1) Endoscopic transgastric necrotic tissue removal
.

(2) Percutaneous drainage
.

(3) Laparoscopic necrotic tissue removal
.

(4) Retroperitoneal necrotic tissue removal
.

The choice of surgical method depends mainly on the location of the necrotic site and what surgical route the surgeon wants to take to enter the abdominal cavity, such as through the gastrocolic ligament and through the transverse mesentery
.

04

Professor Jan-Hendrik Egberts shared a study on endoscopic "step-up" and surgical "step-up" treatment of infectious necrotizing pancreatitis [2].

The study compared the long-term clinical outcomes
of endoscopic "step-up" and surgical "step-up" treatment for infectious necrotizing pancreatitis.
After a mean follow-up of seven years, there was no significant difference in mortality and morbidity rates between the endoscopic "step-up" group (n=42) and the surgical "step-up" group (n=41), and similar outcomes
in quality of life.
During the first six months of follow-up, there was a lower
incidence of pancreatic leakage in the endoscopic "step-up" group.
Studies have concluded that endoscopic "step-up" treatment of infectious necrotizing pancreatitis is a better option
.
Therefore, minimally invasive surgery is also a good option
for some patients.