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The first 25 slides, exactly as they appear. The full deck has 171 content slides.
General Surgery
Complications of Acute Pancreatitis (Including Pseudocysts)
Built from Maingot's Abdominal Operations
What’s inside
17 sections · 171 slides
Overview
- What this deck covers
- <10%
- Why outcomes have improved
Grading severity
Four categories built from local and systemic complications
- Four categories for the severity of acute pancreatitis
- The four severity categories
- Reading the severity grid
Naming the collections
Why the old Atlanta words were replaced
- From the Atlanta terms to the current names
- Contents decide the other half
- Two extra questions about any collection
Acute fluid collections
The earliest and commonest local complication
- What an acute fluid collection is
- Routes the fluid tracks along
- Diagnosis and timing
- Acute fluid collection and its appearance one month later
- The same collection two years on, as a mature pseudocyst
- Management of an acute fluid collection
- When the main pancreatic duct is torn
- Pleural effusions and pancreatic fistula
Postnecrotic collections and walled off necrosis
When the collection contains dead tissue
- What a postnecrotic collection is
- Diagnosis of a postnecrotic collection
- Gas within infected pancreatic necrosis on axial CT
- The same infected necrosis on coronal CT
- Why the word abscess was abandoned
Pseudocysts
A walled collection of pancreatic juice with no dead tissue inside
- Definition of a pancreatic pseudocyst
- Pseudocyst versus cystic neoplasm
- How a pseudocyst forms, and what is in it
- Pseudocysts after trauma and in chronic pancreatitis
- The D'Egidio classification
- D'Egidio types and their primary treatment options
- Duct anatomy drives the choice
Complications of a pseudocyst
Infection, rupture, bleeding, and pressure on neighbours
- Four things a pseudocyst can do
- How often complications happen, and infection
- Rupture and internal fistula
- Why pseudocysts bleed
- Pseudoaneurysm arising from the splenic artery
- Angiogram of a left gastric artery pseudoaneurysm before and after embolisation
- Treating a bleeding pseudocyst
- Mass effect from a large pseudocyst
Diagnosing a pseudocyst
Suspicion, then the right scan, then the duct
- When to suspect a pseudocyst
- CT scanning for a pseudocyst
- Ultrasound, endoscopic ultrasound, and MRI
- The role of ERCP and MRCP
- Recognising a complication clinically
- Not missing a cystic tumour
- Algorithm for investigating and treating a pancreatic pseudocyst
Treating a pseudocyst
When to wait, and which drainage to choose
- Natural history
- Indications for treatment
- The shift towards waiting
- Two rules that must not be broken
- Treatment approaches for pancreatic pseudocyst
- Features that steer the choice of treatment
- Open surgical treatment: the principle
- Cystogastrostomy: the operation
- Opening the pseudocyst through the back wall of the stomach
- Closing the anterior gastrotomy after cystogastrostomy
- Roux-en-Y cystojejunostomy
- Draining a pseudocyst into a Roux-en-Y limb of jejunum
- Resection and external drainage
- Percutaneous radiological drainage
- Percutaneous transgastric drainage
- Percutaneous transgastric drainage of a pseudocyst on CT
- Double Malecot stent cystogastrostomy on plain radiograph
- 14,914
- Endoscopic treatment: through the papilla
- Endoscopic treatment: through the stomach wall
- How well endoscopic drainage works
- Laparoscopic and track-based options
- Choosing treatment by D'Egidio type
Pancreatic necrosis
Dead pancreatic and peripancreatic tissue, and what follows it
- What pancreatic necrosis means
- ~20%
- Infection risk climbs with time
- <=1%
- How early necrosis declares itself
- How the pancreas destroys itself
- Two phases of severe acute pancreatitis
- What the gland looks like
- How dead patches resolve, by size
- Timetable of the wall around a large necrotic area
Infection of necrosis, and how it is found
Routes, organisms, markers, and the aspiration needle
- Five routes bacteria reach pancreatic necrosis
- Which organisms are found, and when
- No sign is specific for necrosis
- Scoring systems and their limits
- Measuring how much gland is dead
- Alternatives to contrast CT
- C-reactive protein as the working marker
- Other markers, and why CRP survives
- Prophylactic antibiotics
- Suspecting infected necrosis
- Fine-needle aspiration
- Why FNA is now debated
- Algorithm for the management of infected necrosis
Intervening on necrosis
Who needs it, when, and by which route
- Indications for intervention
- Sterile necrosis: a much shorter list
- Why early surgery was abandoned
- Why later is better
- Two philosophies of repeat surgery
- Step-up versus step-down
- Step-up approach in practice
- What the PANTER trial showed
- Describing an intervention: how you see it
- Describing an intervention: route and purpose
- Open and minimally invasive approaches to pancreatic necrosis
- General principles at operation
- Avoiding catastrophic bleeding
- Drains and feeding after necrosectomy
Open necrosectomy
Three ways to provide an exit for infected debris
- Three open approaches
- Getting to the pancreas
- Necrosectomy through the lesser sac
- Necrosectomy through the transverse mesocolon
- Open necrosectomy with closed packing
- Open necrosectomy with open packing
- Continuous closed postoperative lavage
- Programmed open necrosectomy
Minimally invasive and radiological necrosectomy
Scopes, sheaths, and catheters instead of a laparotomy
- From open surgery to keyhole surgery
- Laparoscopic routes
- Video-assisted retroperitoneal debridement
- Percutaneous necrosectomy with a nephroscope
- Operating through the flank tract
- Flexible endoscopic necrosectomy
- Endoscopy through a skin incision
- The PENGUIN trial
- Radiological drainage: why it matters
- Catheter routes, sizes, and lavage
- What percutaneous drainage achieves
- ~25%
Regional complications
Veins, arteries, and the bowel next door
- Venous thrombosis: why it happens
- Splenic, portal, and mesenteric vein thrombosis
- Treating venous thrombosis
- Arterial bleeding: which vessels
- How arterial bleeding presents
- Treating arterial bleeding
- When bleeding needs a laparotomy
- Ileus, intestinal ischaemia, and obstruction
- Cholestasis
Systemic complications
Whole-body inflammation and failing organs
- Systemic inflammatory response syndrome
- What drives SIRS
- From inflammation to organ failure
- Organ failure on admission
- Multiple organ dysfunction syndrome
- Change in APACHE II over the first 48 hours and predicted mortality
- Predicting organ failure
- The scoring systems, and their limits
- Respiratory complications
- Acute respiratory distress syndrome
- Renal complications
- Cardiovascular complications
- Supporting the circulation
- Calcium and glucose
- Other metabolic complications
- Nutrition and body protein
- Pancreatic encephalopathy
Summary
What to carry away, and the sources behind it
- Take-home points: the collections
- Take-home points: necrosis
- Take-home points: the whole patient
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- Maingot's Abdominal Operations, 12th Edition