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Acute Pancreatitis

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Emergency Laparoscopy

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Abstract

Acute pancreatitis is an inflammatory process of the pancreas with a highly variable clinical course. Its severe complications are still a tough challenge for surgeons. A consensus about the classification has not been reached yet: too many scoring systems exist; they typically require 48 h to become accurate, when the assessment of an experienced surgeon provides evaluation of the disease outcome as good as any grading score. An accurate early prediction of the acute pancreatitis evolution remains uncertain, and a unique reliable classification is still an open matter.

Biliary etiology is the leading cause, and recurrent biliary events are common in the first 30 days from index episode. Subsequent attacks could be more severe than the first one; so they have to be prevented. In mild acute pancreatitis, if no common bile duct obstruction but gallstones are detected, laparoscopic cholecystectomy should be performed during the index hospitalization, as soon as pancreatitis symptoms cool off.

20 % of biliary pancreatitis have persistent bile duct stones. In case of common bile duct stones clearance should be obtained by preoperative ERCP or, in selected centers, by laparoscopic removal of bile duct stones during cholecystectomy. Probably a waiting period of 48 h may give more opportunities to a small stone wedged in the papilla of Oddi to pass spontaneously into the duodenum. Acute cholangitis and persistent bile duct obstruction are indications for urgent ERCP.

Surgery is contraindicated in severe acute pancreatitis: the only permitted surgical indications requiring an emergency laparotomy are acute complications such as abdominal compartment syndrome, bowel ischemia, ongoing acute bleeding, or gastric outlet, intestinal, or biliary obstruction.

When pancreatic necrosis requires treatment for clinical signs of sepsis or multiorgan failure that does not improve despite optimal therapy, a step-up approach consisting of percutaneous drainage, followed, if necessary, by minimally invasive retroperitoneal debridement should be undertaken. Open surgery should be reserved to patients not responding to minimally invasive treatment and in acute complications, because it does not maintain abdominal compartmentalization and may cause intra-abdominal spread of the infection.

The abdominal compartment syndrome is the most lethal complication in the course of severe acute pancreatitis. It should be managed by prompt laparostomy or fasciotomy; today laparoscopy is formally contraindicated in these cases.

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Authors and Affiliations

  1. Division of Surgery, “Nuova Itor” Private Health Facility, Rome, Italy

    Mario Campli MD & Alessandra Cerioli MD, PhD Candidate

  2. Department of General Surgery, Tor Vergata University, Rome, Italy

    Alessandra Cerioli MD, PhD Candidate

  3. Second Department of Surgery, Meilahti Hospital, Helsinki, Finland

    Ari Leppäniemi MD, PhD

  4. Department of Surgical Sciences, University of Torino, Torino, Italy

    Alberto Arezzo MD

  5. SOD Chirurgia Generale, d’Urgenza e Mini-invasiva, AOU Careggi, Firenze, Italy

    Carlo Bergamini MD

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  1. Mario Campli MD
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  2. Alessandra Cerioli MD, PhD Candidate
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  3. Ari Leppäniemi MD, PhD
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  4. Alberto Arezzo MD
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  5. Carlo Bergamini MD
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Correspondence to Mario Campli MD .

Editor information

Editors and Affiliations

  1. Department of General Surgery, Azienda ULSS19 del Veneto, Adria, Italy

    Ferdinando Agresta

  2. AUSL Viterbo, Ospedale San Giovanni Decollato Andosill, Civita Castellana, Italy

    Fabio Cesare Campanile

  3. Dept of Morfology, Surgery and Experime, School of Medicine, Univ of Ferrara, Ferrara, Italy

    Gabriele Anania

  4. Careggi University Hospital, Florence, Italy

    Carlo Bergamini

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Campli, M., Cerioli, A., Leppäniemi, A., Arezzo, A., Bergamini, C. (2016). Acute Pancreatitis. In: Agresta, F., Campanile, F., Anania, G., Bergamini, C. (eds) Emergency Laparoscopy. Springer, Cham. https://doi.org/10.1007/978-3-319-29620-3_3

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