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Acute Pancreatitis

Necrosectomy


Pancreas is digestive as well as endocrine organ; helps in fat digestion and blood sugar maintenance, Inflammation of pancreas is Acute Pancreatitis; there are two main reasons one is Alcohol intake and other is Gallstone, Diagnosis is based on increased serum amylase and lipase level and the typical pain abdomen localized to epigastric region and radiating to back; CECT abdomen is done after 72 hrs of onset of pain abdomen to assess the severity of acute pancreatitis.

The course of disease is counted from the day of onset of pain abdomen, Organ failure in the first 72 hr carry a bad prognosis and high mortality rate; Initial phase is body inflammatory response to pancreatitis and can last up to 2-3 weeks, during this phase chances of pancreatic infection is less; After 4th week patient can develop pancreatic abscess and later on acute fluid collection may organize to pseudocyst.

First 2-3 weeks patients require critical care; Respiratory and Inotropic supports if required, Enteral nutrition should be started as early as possible; Most common indication of surgery in these patients is a Pancreatic abscess.

Pesudocyst Pancreas

Pseudocyst drainage

After an episode of acute pancreatitis if peri-pancreatic fluid collection does not resolve then after four weeks these are termed as pseudocysts, Not all pseudocyst require intervention because many of these pseudocysts remain stable or regress; however cyst which are increasing in size and causing pressure symptoms or develop complication require intervention, As many of this Pancreatic Pseudocyst communicate with pancreatic duct simple external drainage is not effective, these require some type of internal drainage into bowel; these drainages can be done either by endoscopy or surgical intervention; MRI abdomen will tell whether the contents of the cyst are liquidified or solid, because if the contents are solid endoscopy drainage will not be success; Surgical intervention are cysto-gastrostomy or cysto-jejunostomy depending on location and size of cyst.

Chronic Pancreatitis

Freys Procedure

Chronic alcohol intake is the most common cause, Main symptom is pain abdomen, if the patient stop taking alcohol pain intensity and frequency may decrease, patient may develop steatorrhea and Diabetes, Chronic pancreatitis is a risk factor for pancreas cancer and if these patients develop sudden onset diabetes, pancreatic cancer should be suspected, Inflammatory mass in the head of pancreas may obstruct the CBD and duodenum and patient may develop jaundice and vomiting and then it is difficult to differentiate it from pancreatic head malignancy, Generally jaundice due to inflammatory mass resolves but if it is due to cancer jaundice increases; Most common indication for surgery is pain not controlled by analgesia, Surgery done is Pancreatico-jejunostomy with head coring (Freys procedure).

Pancreatic head cancer

Whipple procedure

Risk factors for pancreas cancer include smoking, alcohol, chronic pancreatitis; Pancreas is divided into three parts head, neck and body region, Symptoms depend at the site of tumor location, if the cancer is located in the head region patient present with jaundice/vomiting and if in neck and body region pain and abdomen mass as the main symptom; weight loss and decreased appetite are common symptom; CECT abdomen is done which show any local and distant spread; If the tumor is resectable the standard surgical procedure is Whipple procedure (Pancreatico-duodenectomy) if the tumor is located in the head region; and if the tumor is located in body and tail region the standard surgical procedure is distal pancreatectomy with splenectomy

Patient with Pancreas Cancer in the head region can present with jaundice, if there is no history s/o cholangitis (Fever/pain abdomen), nutrition status is good then surgery can be done even at bilirubin up to 15, otherwise pre-operative biliary drainage is done to lower down the bilirubin and the preferred method is internal drainage

Distal Pancreatic Cancer

Distal Pancreatectomy

Most common presentation is pain abdomen and lump, generally these tumor are advanced as compared to tumor located in head of pancreas as these tumor grow without producing much symptoms that’s why if open surgery is planned for these patients diagnostic laparoscopy should be done for distal pancreatic cancer as chances for metastases is high in these patients; Surgery done is distal pancreatectomy with splenectomy.

Traumatic Pancreatic injury

Distal Pancreatectomy

Because pancreas is retro-peritoneal organ, pancreas injury is rare in trauma; Generally pancreas trauma is managed conservatively, pancreas injury is divided into proximal when it involves head and distal when it involves body and tail, when there is complete transaction of the pancreatic duct distal pancreatectomy is done, Pancreatic injury patients may develop pancreatic fistula later on.