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The Role of Surgery in of Acute Pancreatitis

the Management JOHN H. C. RANSON, B.M., B.CH.

Surgical intervention in acute pancreatitis may have varied goals. Early laparotomy may be required for diagnostic purposes. There is, however, no convincing evidence that attempts to reduce the morbidity of severe pancreatitis by early operative pancreatic drainage, early formal pancreatic resection, or early biliary procedures have been effective. In fact, they may be harmful. Peritoneal lavage by catheter induced under local anesthesia may ameliorate early cardiovascular and respiratory complications in some patients. Preliminary experience suggests that early operative debridement of devitalized pancreatic tissue with postoperative lavage may be helpful in selected patients. Patients with infections of devitalized pancreatic or peripancreatic tissue require operative debridement and drainage or packing. Other complications such as colonic necrosis or pseudocysts also require operative treatment. Rarely do patients require operation to relieve protracted pancreatitis. Patients with gallstone-associated pancreatitis should usually undergo surgical correction of their cholelithiasis as soon as their pancreatitis has subsided.

From the Department of Surgery, New York University Medical Center, New York, New York

During the past 30 years, however, it has become increasingly clear that some patients with more severe forms of pancreatitis do not survive with nonoperative treatment alone, and interest in the value of surgical measures has been renewed. Operative intervention now may be considered in patients with acute pancreatitis for five general purposes: diagnosis, amelioration of pancreatitis, treatment of specific complications, relief of protracted pancreatitis, and prevention of recurrent acute pancreatitis. Diagnosis In most patients with acute pancreatitis, the diagnosis can be made with reasonable certainty on the basis of clinical, radiographic, and laboratory findings. In some patients, however, the diagnosis can be extraordinarily difficult. This point is emphasized by a recent report from Scotland in which 42% of patients who died from acute pancreatitis had their diagnosis made for the first time at autopsy examination.4 In patients with acute abdominal pain and suspected acute pancreatitis, it may be difficult or impossible to exclude life- threatening extrapancreatic disease by nonoperative means. Diagnostic laparotomy to exclude or treat such extrapancreatic disease may be required in up to 5% of patients with pancreatitis. In this regard, it should be stressed that strong positive evidence of acute pancreatitis does not exclude the possibility of coexisting extrapancreatic pathologic conditions in some patients. When uncomplicated acute pancreatitis is found at diagnostic laparotomy, it is essential that the abdominal exploration should be complete and should establish the diagnosis unequivocably. If gallstones are present and the pancreatitis is mild, operative correction of biliary disease

A CUTE PANCREATITIS FIRST became widely recognized as a clinical and pathologic condition at the end of the 19th century. In 1886, Senn,' a

Chicago surgeon, speculated that operative intervention might benefit patients with pancreatic necrosis or abscess. Three years later, Fitz,2 a Boston physician, considered that early operative intervention would be ineffective and hazardous. During the first three decades of the 20th century, acute pancreatitis was usually diagnosed at operation or at autopsy. Because a significant proportion of those diagnosed at surgery survived, early operative intervention was recommended.3 After the introduction of methods for measurement of amylase levels, the nonoperative diagnosis of acute pancreatitis became more frequent and early surgical intervention was thus widely regarded as unnecessary or harmful. Address requests reprints to John H. C. Ranson, M.D., S. A. Localio Professor of Surgery, New York University Medical Center, 530 First Avenue, New York, NY 10016. Accepted for publication September 29, 1989.

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at this time is usually safe and will reduce the risk of recurrent pancreatitis. In patients with severe gallstone pancreatitis, it may be safer to limit biliary surgery to

cholecystostomy and cholangiography.5 In patients with mild pancreatitis, most authors agree that no further operative procedure is appropriate.6'7 It has been our experience that placing pancreatic drains in such patients causes increased late pancreatic sepsis and thus should be avoided.8 The role of other surgical procedures such as pancreatic resection or drainage in patients with severe pancreatitis is discussed later. It should be recognized, however, that once laparotomy has been undertaken, the choice of further surgical intervention is a different question from that of whether early surgery is beneficial as compared to early nonoperative treatment. Early Therapeutic Surgery A variety of surgical measures have been recommended early in acute pancreatitis to limit the severity of pancreatic inflammation or to interrupt the pathogenesis of complications. They fall into the following categories: pancreatic drainage, pancreatic resection or debridement, biliary procedures, peritoneal lavage, and thoracic duct drainage. Reported experience with thoracic duct drainage is very limited and will not be discussed further.91'2 Much controversy has surrounded the value of early therapeutic surgery in patients with acute pancreatitis. A

Cholecystostomy

FIG. 1. Diagramatic representation of sump drainage of the pancreas combined with gastrostomy, cholecystostomy, and feeding jejunostomy.

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major factor in this controversy has been that, in general, surgical measures have been proposed only for patients with severe, hemorrhagic, or necrotizing pancreatitis and yet identification of such patients has usually been based on subjective features. During the past 15 years, a number of objective methods have been described for stratifying populations of patients with pancreatitis. These have been reviewed in detail elsewhere, '3 but it is clear that objective identification of specific groups of patients with acute pancreatitis is essential for both individual patient management and for the evaluation of proposed treatments. Pancreatic Drainage Procedures As mentioned earlier, pancreatic drainage was advocated at the beginning of this century. After the report of Waterman in 1968,14 it has received further attention, although usually for patients judged to have severe pancreatitis. In 1970 Lawson described operative drainage of 15 such patients.'5 He combined sump drainage of the pancreas with cholecystostomy, gastrostomy, and feeding jejunostomy (Fig. 1) and 74% of patients survived. In a further report from Boston, 82% of patients drained early for fulminating disease were believed to have benefitted from surgery and 64% survived.7 A more recent report by McCarthy described experience with pancreatic drainage in 40 patients.16 Only 50% of these patients were operated on because their pancreatitis

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thought to be severe. The others underwent surgery for diagnostic reasons or to treat complications. Nonetheless 59% of the 29 patients operated on during the initial 48 hours of treatment died. In 1974 we described a very small controlled clinical trial that compared conventional nonoperative treatment to early operative sump drainage of the pancreas.'7 Only 10 severely ill patients were included, but morbidity, especially respiratory failure and pancreatic sepsis, was dramatically increased in patients undergoing surgery. Presently there is no evidence to support the use of simple operative drainage of the pancreas in patients with uninfected acute pancreatitis. was

Pancreatic Resection

or

Debridement

The rationale for pancreatic resection in acute pancreatitis is marked by two strains of thought. The first is the proposal that surgical removal of devitalized or necrotic tissue is beneficial. Certainly general surgical experience supports this principle. The second is that the presence of an actively secreting pancreas with a disrupted ductal system may contribute to the morbidity and mortality of severe acute pancreatitis.'8 The first report of pancreatic resection for fulminant pancreatitis was in 1963 by Watts.'9 Since this report there has been extensive interest, primarily in Europe, in the possibility that pancreatic resection may ameliorate the course of necrotizing acute pancreatitis.2035 Evaluation of reported experience has been clouded by three issues. The first is identification of the risk of death or major complication in the patients treated. They are always described as having fulminant, necrotizing, or hemorrhagic pancreatitis, but recent reports have emphasized a wide discrepancy between the superficial appearance of the pancreas and the actual pathologic findings.3638 Current studies in which the severity of pancreatitis has been objectively estimated have found no benefit from early formal pancreatic resection.3 90 The second issue that makes the evaluation of resectional treatment difficult is the variable extent of resection. Some authors have favored formal resection of part or all of the pancreas,20'27 while others have advocated debridement of necrotic tissue only.4'42 The third issue that complicates interpretation of reported results is the timing of pancreatic resection. Some advocate operation within the first 2 or 3 days of treatment,29'33 while others have urged resection at days 7 to 14 or later.42'43 A prospective randomized study comparing early operation and subtotal distal pancreatic resection to early operation and placement of catheters for postoperative peritoneal lavage has been reported from Finland.44 This

study

Ann. Surg. * April 1990

was

interpreted

as

justifying early distal subtotal

pancreatectomy in necrotizing pancreatitis. However the differences in morbidity and mortality rates among treatment groups did not achieve statistical significance. Fur-

thermore there was no group treated without formal laparotomy. The severity of pancreatitis in the reported patients, as estimated by objective prognostic signs, was only moderate. The reported mortality was 22% to 47% and substantially greater than the 13% mortality, which would have been expected after early nonoperative treatment of patients with pancreatitis of comparable severity. Experimental studies of early formal pancreatic resection in dogs with acute pancreatitis has not provided support for this approach.45'46 Follow-up data of surviving patients who were treated by resection for severe pancreatitis indicate that 40% to 92% of patients develop diabetes mellitus.38 ' The incidence of diabetes in patients surviving less radical treatment may be lower, but this is hard to establish.47 During the past 7 years, there has been increasing interest in the use of contrast-enhanced computed tomography to identify areas of pancreatic necrosis.48-53 When studied by computed tomography, the normal pancreas shows dramatic enhancement after the rapid intravenous injection of a large bolus of contrast material (400 mg I/ kg). Failure of the gland to appear enhanced after contrast injection has been interpretted as evidence that that portion of the pancreas was unperfused or necrotic (Figs. 2 and 3). To support this interpretation, Block52 has shown that there is a reasonably close relationship between contrast-enhanced CT estimates of nonperfused pancreas and the degree of pancreatic necrosis determined at surgery. Beger and his associates have used failure of contrast enhancement on computed tomography combined with clinical factors to identify patients for an operative approach, which includes debridement of devitalized tissue and postoperative lavage of the lesser omental sac.54'55 A recent report54 described 95 such patients. The median duration of illness before operation was 7 days, and the median period of postoperative lavage of the lesser sac was 25 days. The extent of pancreatic necrosis was described as focal in 39 patients, extended in 32, and subtotal or total in 24. In 37 (42%) of 89 patients studied, bacterial cultures from surgery were positive. Overall mortality was 8.4%. Mortality was 5.1% in patients with focal necrosis, 6.3% with extended necrosis, and 16.7% in those with total or subtotal necrosis. Fourteen per cent of patients with positive operative cultures died, compared to 6% of those with sterile cultures. The overall mortality rate achieved by this approach in a group of patients with pancreatitis of moderate to marked severity is impressively low. Most surgeons agree

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FIG. 2. Computed tomographic scan showing good enhancement of the pancreas (arrows) after the injection of intravenous contrast. Considerable inflammatory changes are seen anterior to the neck of the gland.

FIG. 3. Computed tomographic scan showing failure of enhancement of a portion ofthe pancreas (arrows) after injection ofintravenous contrast material.

SURGICAL MANAGEMENT OF ACUTE PANCREATITIS

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that patients with infected pancreatic necrosis require operative debridement and the 14% mortality rate achieved by Beger in this group is comparable to that in other recent reports.56'57 Whether surgical debridement benefitted those patients who had sterile necrosis is impossible to assess. Furthermore it is not clear what the relative contributions of operative debridement and prolonged peritoneal lavage were to the excellent results achieved. Nonetheless the results reported with this approach are impressive and deserve further evaluation. Biliary Procedures Among nonalcoholic patients with acute pancreatitis, approximately 60% have gallstones.58 It is reasonable to hope that in these patients in whom the initiation of pancreatitis is presumably related to mechanical events involving the stones, manipulation of the biliary tree may influence the course of acute pancreatitis. Two major factors have contributed to the controversy that surrounds this issue. The first is difficulty in determining the presence or absence of acute pancreatitis, and the second is the wide variability in the natural history of gallstone pancreatitis. Many authors consider that acute gallstone pancreatitis is present if the patient has abdominal pain, vomiting, elevated amylase levels, and demonstrated gallstones.5945 Unfortunately 12.5% to 79% of such patients have no evidence of pancreatitis at early operation or autopsy.59'66-7' Some authors consider that pancreatitis is present if serum amylase levels exceed 800 to 1200 IU/ L,70'72-74 while others have found an inverse relationship between amylase levels and pancreatic pathology.6675 Acosta7677 and Kelly72'73'78 have added the presence of jaundice to their criteria for diagnosing gallstone pancreatitis. Second, as in pancreatitis of other etiologies, most patients with gallstone pancreatitis recover without complications. It is patients with severe disease in whom management may make the most critical difference in outcome. Rational treatment of individual patients and the evaluation of therapeutic regimens requires that patient populations be stratified according to disease severity by objective criteria. Although early biliary surgery occasionally has been advocated in the past,5 the current era of interest in early biliary intervention in gallstone pancreatitis was initiated by a report by Acosta in 1978.76 He reviewed a series of 86 patients who were managed initially by nonoperative means between 1964 and 1972. Sixteen per cent of this group died and the mean hospital stay was 25 days. Subsequently 46 patients were operated on within 48 hours

Ann. Surg. * April 1990

of the onset of symptoms. Cholecystectomy, bile duct exploration, and transduodenal sphincterotomy were undertaken as indicated. In this second group, the mortality rate fell to 2% and the mean hospital stay was 13 days. In 72% of the more recent group of patients, a stone was found impacted at the ampulla of Vater. The authors interpretted these findings as indicating that persistent calculous obstruction of the ampulla of Vater was responsible for the progression of pancreatic inflammation.77 Early surgical relief of such obstruction was urged. In evaluating the high incidence of ampullary calculous impaction in Acosta's report, it is important to note that elevated bilirubin levels were one of their criteria for the diagnosis of gallstone pancreatitis. In 1979 we reviewed our own experience with 80 episodes of gallstone-associated pancreatitis and found that, contrary to Acosta's experience, early surgical intervention was associated with a dramatically increased incidence of morbidity in patients with severe acute pancreatitis.5 Our experience with early surgery in 133 patients with gallstone-associated pancreatitis is shown in Figure 4. In 1981 Stone64 reported a controlled clinical trial in which patients were randomly assigned either to early (less than 73 hours) cholecystectomy, transduodenal sphincteroplasty, and pancreatic septotomy, or to early nonoperative management followed by elective surgery after 3 months. Jaundice was not a prerequisite for admission to this study and ampullary obstruction was present in only two patients undergoing early surgery. Thirty-six patients underwent early surgery, with one death (2.8%), and 13.9% had major complications. None ofthe patients treated nonoperatively died, and their average hospital stay was 3 days shorter than that of those who underwent early surgery. These data convincingly demonstrate that in unselected patients with abdominal pain, hyperamylasemia, and gallstones, early operative intervention does not reduce the morbidity of the acute illness. Stone, however, combined the morbidity of elective surgery with that ofthe initial hospital stay and concluded that early surgery was preferable. This interpretation is related to the fact that elective biliary surgery was associated with a mortality rate of 6.9%, and a 13.8% incidence of major complications. This is clearly an unacceptable rate of morbidity for such surgery. Furthermore a sample of patients selected by the presence of abdominal pain and elevated amylase levels would include many patients with either no pancreatitis or very mild disease. In these groups, early biliary surgery should be safe. Kelly79 has recently reported a randomized study evaluating the timing of early biliary surgery in gallstone-associated pancreatitis. In this study, 165 patients were randomly assigned to operation within 48 hours of admission

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"MILD" 100

FIG. 4. Morbidity and mortality in patients with mild and severe gallstone-associated pancreatitis related to early operation. Severity of pancreatitis was judged by early objective signs.5 OP, operation within 48 hours of admission. NONOP, no operation within 48 hours of

w

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2

Dead

E[3

>7 doys ICU

CZ

q)

50 _q)

admission.

"SEVERE"

83

50

5

Early Treatment Patients

0

op 8

or to delayed surgery, which was undertaken after pancreatitis had subsided. In patients who underwent early operation, the mortality rate was 15.1% and 30.1% developed complications. In contrast, in those patients in whom surgery was delayed, the mortality rate was 2.4% and morbidity decreased to 5.1%. Among those patients who had severe acute pancreatitis by objective signs, the differences in morbidity rates were even more striking. In this group, patients who underwent early operation had a 47.8% mortality rate and 82.6% morbidity rate. Among those in whom surgery was deferred, 11.8% died and 17.6% developed complications. It is of note that only 3 of the 15 patients who died in this study had stones impacted in the ampulla of Vater. Two were in the early intervention group. Retrospective reviews by Osborne,74 Welch,65 Tondelle,80 and Ong8' all support an early nonoperative approach. An alternative approach has been advocated in recent years, which consists of early endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES). A controlled prospective evaluation of this approach has been published in 1988.82 Fifty-nine patients were randomly assigned to early ERCP, which was successfully accomplished in 52 patients. Endoscopic sphincterotomy was undertaken if common bile duct stones were present. Sixty-two patients were managed by early noninterventional management. In nine patients in each group, gallstones were not demonstrated. In the early

NONOP 87

OP 12

NONOP 26

ERCP and endoscopic sphincterotomy groups, overall complications were significantly less (17% vs. 34%) and the hospital mortality rate was reduced from 8% to 2%. This latter difference was not statistically significant. In patients with mild pancreatitis, no benefit was demonstrated after endoscopic biliary intervention. Among patients who were considered to have severe acute pancreatitis, the morbidity rate was significantly lower (24% vs. 61%) in the ERCP ± ES group and, the mortality rate was also less (4% vs. 18%). In evaluating the results ofthis study, it is important to remember that all the procedures were performed by one extremely gifted endoscopist. Because ERCP and endoscopic sphincterotomy have a significant risk for inducing pancreatitis, great care must be taken in considering whether these findings justify wider application of this procedure. Also it was impossible to know how many of the patients being treated endoscopically were, in fact, successfully managed for obstructive cholangitis with hyperamylasemia, rather than for acute pancreatitis. Peritoneal Lavage In 1965 Wall83 reported marked clinical improvement in patients with acute pancreatitis in whom peritoneal dialysis had been instituted because of renal failure. Subsequently extensive experimental and clinical experience has been reported.84 In 1980 Stone reported a controlled clinical trial in which 85% of 34 patients with severe acute

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RANSON

pancreatitis treated by early peritoneal dialysis or lavage showed "decided improvement in overall condition" at the end of 24 hours.85 Only 36% of 36 similar patients treated without peritoneal lavage showed comparable improvement. Interpretation of the subsequent results of this study is clouded by the fact that 17 patients in the control group were subsequently moved to the lavage group. Nonetheless of a total of 51 patients who received early peritoneal lavage, there were eight deaths (15.6%). In contrast, in the 19 patients who were managed without lavage, there were six deaths (31.6%). A small controlled trial by Ihse86 and a larger controlled study by Mayer and associates87 found no benefit from peritoneal lavage in patients with severe acute pancreatitis. Although Mayer's study included 91 patients, these patients were apparently cared for in 24 hospitals and it is possible that variations in treatment in the different institutions was a more important determinant of outcome than whether the patient received peritoneal lavage. Our own prospective but not randomly controlled experience84 has been that early peritoneal lavage in patients with severe pancreatitis is often associated with dramatic improvement in cardiovascular and respiratory function. However lavage for periods of 2 to 4 days has not reduced the incidence of late pancreatic sepsis and has not decreased overall mortality.

Treatment of Specific Complications Pancreatic Sepsis Infection of fluid and of devitalized pancreatic and peripancreatic tissue occurs in 1% to 9% of patients with acute pancreatitis.88 Reported experience89,90 suggests that the early identification of pancreatic infection may be facilitated by needle aspiration under computed tomographic guidance and bacteriologic examination of suspected areas of pancreatic inflammation. If, however, pancreatic infection is suspected strongly on the basis of this study or on other clinical or radiologic grounds, surgical intervention is required. Infection occurring in the context of acute pancreatitis is almost always associated with extensive tissue necrosis. The infected material is semisolid and attempts at percutaneous catheter drainage are usually futile and sometimes hazardous. Most surgeons now recommend an anterior abdominal approach with debridement of as much devitalized tissue as can safely be removed by blunt dissection. The approach that we have favored88'91'92 is illustrated in Figure 5. The patient is placed supine, with the left side of the trunk elevated approximately 15 degrees. The arms are widely abducted to allow exposure of the flanks. A long subcostal incision is made from the anterior axillary line on the right to the mid-axillary line on the left. The lesser omental sac is opened widely by dividing the gastrocolic

FIG.

5.

Operative approach

for debridement and sump

drainage

of

infected

creatic necrosis.

pan-

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omentum and the entire anterior surface of the pancreas

is explored, including the pancreatic head. Fat overlying the pancreas may appear remarkably normal, and it should be opened to expose the pancreas itself. The duodenum is mobilized anteriorly and the area posterior to the pancreatic tail is explored by dissection carried out posteriorly at the inferior margin of the left one third of the pancreas. The areas posterior to the ascending and descending colon and the root of the small bowel mesentery are closely examined. As much necrotic material as possible is debrided. Penrose and soft sump drains are placed anterior and posterior to the head, body, and tail of the pancreas. Additional drains are placed in any large abscess cavities. These drains are brought through separate stab incisions as far posterior as possible. Finally a feeding jejunostomy is constructed, and, if gallstones are identified, appropriate surgical treatment is carried out. Because the material to be evacuated is often semisolid, it is essential that the drains are large in caliber. To minimize visceral injury, the drains should also be soft. The sump drains that we use are maintained on continuous suction and are irrigated by a continuous infusion of saline to reduce clog-

ging.92 Warshaw and associates have advocated a similar procedure but have favored approaching the pancreas through the transverse mesocolon. They have stressed that recent improvements in diagnosis and supportive care have led to reduction in the overall mortality rate from this condition. It was 38% in 26 cases treated between 1974 and 1978 and fell to 5% in 19 patients treated between 1979 and 1983.57 We have treated 36 patients with infected necrosis by radical debridement and sump drainage during the past 4 years. the hospital mortality rate was 13.9% and 58.3% of patients who required only one operative procedure. An alternative surgical approach has been to debride and pack the pancreatic abscesses. In 1907 Mayo Robson and Cammidge93 advocated "gauze packing and gauze drainage" in the treatment of pancreatic abscess. The essential features of this approach, as advocated recently by Bradley, are to debride necrotic tissue and cover the viscera with nonadherent porous gauze followed by packing of the wound with moist laparotomy pads. The dressings are changed under general anesthesia every 2 or 3 days until sufficient granulation has formed to permit changes on the ward. Redebridement is carried out at each dressing change. A mortality rate of 10.7% has been achieved with this approach in 28 patients reported by Bradley56 in 1987. Pemberton94 found that this approach was associated with a mortality of 18% in 17 patients compared to a mortality rate of 44% in patients managed by closed drainage.

389

It is clear that infected abscess/necrosis in acute pancreatitis requires radical debridement and wide drainage. Frequently redebridement is necessary, and open packing forces this step on the surgeon. I have not accepted open packing as a routine procedure because it is certainly not necessary in every patient and is associated with the morbidity of repeated anesthesia and the risk of bleeding and intestinal fistula.

Gastrointestinal Perforations Perforations of the stomach, duodenum, small bowel, and colon may occur in patients with severe acute pancreatitis. In some instances, these may be the result of radiographic catheter drainage techniques, operative injury, or erosion into the viscera by drains. Spontaneous necrosis and perforation may occur, however, especially in the colon.9598 Most of these perforations are in the splenic flexure of the colon or upper descending colon. Management depends on the patient's clinical situation. Early in the course of severe pancreatitis, the best treatment is resection of the perforated segment of colon with colostomy and mucous fistula construction. Ifthis cannot be accomplished safely, a proximal diversion of the fecal stream and drainage of the enteric perforation are indicated. If the feculent drainage occurs along a well-formed drain tract late in the course of management without evidence of sepsis, no surgical intervention may be required. Pancreatic Pseudocysts Ill-defined peripancreatic fluid collections are common in patients with acute pancreatitis. If they do not become infected, they usually resolve99 without any intervention. Pseudocysts may be defined as persistent localized collections of enzyme-rich fluid with a clearly defined wall made of fibrous tissue and adjacent viscera. They occur in only 1% to 2% of patients with acute pancreatitis. If enlarging, symptomatic, or persistant at more than 5 cm in diameter, such pseudocysts require treatment. Percutaneous needle aspiration of pancreatic cysts has been described for many years. The technique has been reintroduced after the ability to localize cysts radiographically. Simple needle aspiration is, however, associated with a high recurrence rate.'"0°'° Percutaneous catheter drainage, 102 percutaneous catheter cystogastrostomy, 103 and endoscopic cystoduodenostomy'04 have been proposed on the basis of preliminary experience. The safety and efficacy of these approaches remains unknown. Operative measures for the treatment of pancreatic pseudocysts may be broadly classed into three categories: external drainage, internal drainage, and resection.

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External drainage is usually the simplest and least demanding procedure. Reported experience suggests that it is associated with high morbidity and mortality rates. However this is in large part due to the patients in whom it has been applied. External drainage should be selected if the wall of the cyst is immature or friable. External drainage may also be used for patients who are septic due to pseudocyst abscesses and for those who present difficult anatomic problems such as mediastinal dissection. A persistant fistula may be anticipated in 10% of patients. Internal drainage into the stomach, duodenum, or jejunum is applicable to most mature pseudocysts. It is the preferred treatment for patients with uncomplicated pseudocysts and those with anatomic complications such as duodenal or biliary obstruction. As noted below, it should not be used for cysts that have a major vascular communication. It should also be avoided in patients with pancreatic ascites unless the cyst leak can be identified and incorporated into a Roux-y-cyst-jejunostomy. Drainage into the stomach or duodenum should only be undertaken if these viscera form part of the pseudocyst wall. Otherwise a Roux-y-pseudocyst-jejunostomy should be constructed. The wall of the cyst should be biopsied in all drainage procedures."0

-05-109

Resection Because the walls of pancreatic pseudocysts consist of adjacent viscera, it is usually not practical to resect the cyst itself. In most instances resection is of that portion of the pancreas that communicates with the pseudocyst. This approach may be preferable for some patients for anatomic reasons such as multiple cysts of the pancreatic tail. A special circumstance in which resection should be strongly considered is that of pseudocyst hemorrhage. If major vascular communication with a pseudocyst has occurred, internal or external drainage is associated with a high risk of major postoperative bleeding from the cyst. In such patients resection should be undertaken whenever practical. With current therapy, the mortality rate for the treatment of uncomplicated mature pseudocysts should be close to zero."1' Morbidity and mortality are increased by the presence of cyst complications."12 Protracted Pancreatitis There is a small group of patients in whom acute pancreatitis does not subside completely with nonoperative management. This group represents no more than 1% of patients. They usually do not have evidence of severe pancreatitis and respond well initially to conventional treatment. When, however, attempts are made to reintro-

Ann.

Surg * April 1990

duce oral feedings, pain, nausea, fever, and hyperamylesamia recur. These findings resolve with the reintroduction of treatment but recur when oral feedings are reinstituted. When this course of events repeats itself during several weeks, a local mechanical cause must be sought.' 13 Full evaluation includes ultrasonography, computed tomography and, as indicated, endoscopic retrograde cholangiopancreatography. In our experience, small common bile duct stones are the most frequent cause of protracted pancreatitis. Small pseudocysts and pancreatic ductal obstruction also may lead to this picture. In these patients, the pancreatitis will not resolve completely until the mechanical cause is corrected."14 Recurrent Acute Pancreatitis A number of rare mechanical causes of recurrent acute pancreatitis have been described. Each of these may require surgical intervention, but they are extraordinarily uncommon. They include conditions such as ampullulary stenosis, pancreas divisum, duodenal diverticulum, choledochocele, and pancreatic duct hemorrhage.14 By far the most common cause of recurrent acute pancreatitis is, however, biliary lithiasis. Sixty per cent of nonalcoholic patients with acute pancreatitis harbor gallstones.58 If cholelithiasis is not corrected, the incidence of recurrent acute pancreatitis is 25% to 63% 60,61,97,115-117 If cholelithiasis is corrected, recurrent pancreatitis is seen in 0% to 9.3% of cases.59'68'69'71"115'117"118 In the past it has been recommended that operative intervention to correct cholelithiasis should be postponed for a period of 6 weeks to 3 months after an episode of acute pancreatitis. Such waiting, however, exposes the patient to a significant risk of recurrent acute pancreatitis.5 Several reports have documented the fact that surgical correction of cholelithiasis to prevent recurrent pancreatitis can be safely accomplished as soon as clinical evidence of acute pancreatitis has subsided.5'60'65"115"116 This is usually within the first several days of hospitalization. Because a longer delay has no benefit and carries some risk of further pancreatitis, surgical correction of cholelithiasis should be performed at this time in most patients. An exception to this general approach is the patient who has been severely ill with acute pancreatitis and who has developed a large inflammatory pancreatic mass. Adequate exploration of the common bile duct may be technically difficult in such patients. Therefore, if the patient is clinically stable, it may be preferable to allow a period of several weeks or even months for a resolution of the inflammation before undertaking biliary surgery. Such patients are uncommon. Diagnostic surgical exploration may be required in up to 5% of patients with suspected acute pancreatitis to ex-

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clude or treat life-threatening extrapancreatic disease. The role of early operative intervention to ameliorate acute pancreatitis has been controversial. There is no convincing evidence to support the use of early pancreatic drainage or formal pancreatic resection. There is evidence that early biliary surgery increases morbidity. Available data do not provide any proof for the efficacy of peritoneal lavage, but the author continues to believe, on the basis of experience, that this measure is a valuable adjunct to the management of early cardiovascular and respiratory failure. Early surgical debridement of devitalized tissue combined with prolonged lavage of the pancreatic bed may have a valuable role and requires further evaluation. Infection of devitalized pancreatic and peripancreatic tissues requires surgical debridement, and a small group of patients may require drainage of pseudocysts. Very few patients require surgical correction of a cause of protracted pancreatitis. In patients with gallstones, correction of cholelithiasis is required to prevent recurrent pancreatitis. References 1. Senn N. The Surgery of the Pancreas. Philadelphia: WJ Doran, 1886. pp. 71-107. 2. Fitz RH. Acute pancreatitis. Boston Med Surg J 1889; 120:181, 205, 299. 3. Moynihan B. Acute pancreatitis. Ann Surg 1925; 81:132-42. 4. Wilson C, Imrie CW, Carter DC. Fatal acute pancreatitis. Gut

1988; 29:782-788. 5. Ranson JHC. The timing of biliary surgery in acute pancreatitis. Ann Surg 1979; 189:654-660. 6. Schroder T. Surgical treatment of acute and chronic pancreatitis. Dig Dis 1987; 5:116-124. 7. Warshaw AL, Imbembo AL, Civetta JM, Daggett WM. Surgical intervention in acute necrotizing pancreatitis. Am J Surg 1974;

127:484-490. 8. Ranson JHC. Early operative management of acute pancreatitis. In Glazer G, Ranson JHC, eds. Acute Pancreatitis. London: Balliere Tindall, 1988. pp. 366-89. 9. Brzek V, Bartos V. Therapeutic effect of the prolonged thoracic duct lymph fistula in patients with acute pancreatitis. Digestion 1964; 2:43-50. 10. Dreiling DA. The lymphatics, pancreatic ascites, and pancreatic inflammatory disease. Am J Gastroenterol 1970; 53:119-131. 11. Dumont AE, Doubilet H, Mulholland JH. Lymphatic pathway to pancreatic secretion in man. Ann Surg 1960; 152:403-409. 12. Egdahl RH. Mechanism of blood enzyme changes following the production of experimental pancreatitis. Ann Surg 1958; 148: 389-399. 13. Ranson JHC. Prognostication in acute pancreatitis. In Glazer G, Ranson JHC, eds. Acute Pancreatitis. London: Balliere Tindall, 1988. pp. 366-389. 14. Waterman Ng, Walsky R, Kasdan ML, Abram BL. The treatment of acute hemorrhagic pancreatitis by sump drainage. Surg Gynecol Obstet 1968; 126:963-971. 15. Lawson DW, Daggett WM, Civetta JM, et al. Surgical treatment of acute necrotizing pancreatitis. Ann Surg 1970; 172:605-617. 16. McCarthy MC, Dickerman RM. Surgical management of severe acute pancreatitis. Arch Surg 1982; 117:476-480. 17. Ranson JHC, Rifkind KM, Roses DF, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974; 139:69-81. 18. Maclean N. The role of the surviving pancreas in late fatalities of acute pancreatitis. Br J Surg 1977; 62:345-346.

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