Severe acute pancreatitis: surgical indications and treatment
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REVIEW ARTICLE
Severe acute pancreatitis: surgical indications and treatment Max Heckler 1 & Thilo Hackert 1 John P. Neoptolemos 1
&
Kai Hu 1 & Cristopher M. Halloran 2
&
Markus W. Büchler 1 &
Received: 11 July 2020 / Accepted: 21 July 2020 # The Author(s) 2020
Abstract Background Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas of sudden onset. Around 25% of patients have either moderately severe or severe disease with a mortality rate of 15–20%. Purpose The aim of this article was to summarize the advances being made in the understanding of this disease and the important role of surgery. Results and conclusions An accurate diagnosis should be made a soon as possible, initiating resuscitation with large volume intravenous fluids and oxygen by mask. Predicted severe disease will require intensive monitoring. Most deaths within the first week are due to multi-organ failure; thus, these patients will require intensive therapy unit management. During the second phase of the disease, death is due to local complications arising from the pancreatic inflammation, requiring accurate identification to determine the correct form of treatment. Acute peripancreatic fluid collections arise < 4 weeks after onset of interstitial edematous pancreatitis, not requiring any treatment. Most pancreatic pseudocysts arise > 4 weeks and largely resolve on conservative management. Necrotizing pancreatitis causing acute necrotic collections and later walled-off necrosis will require treatment if symptomatic or infected. Initial endoscopic transgastric or percutaneous drainage will resolve less serious collections but necrosectomy using minimally invasive approaches will be needed for more serious collections. To prevent recurrent attacks of AP, causative factors need to be removed where possible such as cholecystectomy and cessation of alcohol. Future progress requires improved management of multi-organ failure and more effective minimally invasive techniques for the removal of necrosis. Keywords Pancreatic necrosis . Infection . Minimally invasive surgery . Necrosectomy . Endoscopic . Percutaneous
Introduction Etiology, incidence, financial aspects Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas with a sudden onset of symptoms, which, in the absence of post necrotic damage to the gland, results in complete resolution of histology, physiology, and symptoms and provided the initiating cause is removed there will be no further attacks. The commonest causes for AP are gallstones (40–65%) and alcohol (25–40%), and the
* John P. Neoptolemos [email protected] 1
Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Baden-Württemberg, Germany
2
Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
remainder (10–30%) are due to a variety of causes including autoimmune and genetic risk factors (Table 1) [1, 2]. Irrespective of etiology,
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