Indian J Surg (September–October 2015) 77(5):446–452

DOI 10.1007/s12262-015-1357-x

ORIGINAL ARTICLE

Surgery for Acute Pancreatitis

Suresh Navadgi 1 & Sanjay Pandanaboyana 1,2 & John A. Windsor 1,2

Received: 24 September 2015 / Accepted: 30 September 2015 / Published online: 13 October 2015
# Association of Surgeons of India 2015

Abstract Surgery for acute pancreatitis has undergone signif- Keywords Acute pancreatitis . Pancreatic necrosis . Infected
icant changes over the last 3 decades. A better understanding necrosis . Laparostomy . Minimally invasive . Percutaneous
of the pathophysiology has contributed to this, but the greatest drainage . Necrosectomy
driver for change has been the rise of less invasive
interventions in the fields of laparoscopy, endoscopy
and radiology. Surgery has a very limited role in the Introduction
diagnosis of acute pancreatitis. The most common indi-
cation for intervention in acute pancreatitis is for the There have been dramatic changes in the role of surgery for
treatment of complications and most notably the treat- acute pancreatitis (AP) over the last 20 years, and some have
ment of infected walled off necrosis. Here, the step-up predicted its demise. While it is true that open surgery now has
approach has become established, with prior drainage a more restricted role in patients with severe and critical AP,
(either endoscopic or percutaneous) followed by delay there are still a range of indications for which surgery remains
for maturing of the wall and then debridement by en- an important and sometimes life-saving treatment (Table 1).
doscopic or minimally invasive surgical methods. Open The most common indication for intervention is for infected
surgery is only indicated when this approach fails. Other local complications of AP, and these have recently been re-
indications for surgery in acute pancreatitis are for the defined (Fig. 1) [1]. Other indications for intervention include
treatment of acute compartment syndrome, non- complications of acute pancreatitis, and these may require
occlusive intestinal ischaemia and necrosis, surgery alone or combined with other treatment modalities,
enterocutaneous fistulae, vascular complications and including interventional radiologic and endoscopic tech-
pseudocyst. Surgery also has a role in the prevention niques. The purpose of this chapter is to provide a current
of recurrent acute pancreatitis by cholecystectomy. De- overview of the role of surgery in AP, in the context of these
spite the more restricted role, surgeons have an impor- wider changes in intervention.
tant contribution to make in the multidisciplinary care
of patients with complicated acute pancreatitis.
Surgical Diagnosis of Acute Pancreatitis

Acute pancreatitis is now rarely diagnosed by surgery in ad-

* John A. Windsor vanced healthcare systems. The situation where this might still
[email protected] be the case is when patients with AP present late, and there is a
non-diagnostic elevation of serum pancreatic enzyme concen-
1
Hepatopancreatobiliary / Upper GI Unit, Auckland City Hospital,
tration. The other indication is when a patients presents with
Park Road, Grafton, Auckland, New Zealand signs of severe peritonitis, warranting an urgent laparotomy. If
2
Department of Surgery, Faculty of Medical and Health Sciences,
these patients can be stabilised, cross-sectional imaging will
University of Auckland, Private Bag 92019, Victoria Street West, usually allow the radiological diagnosis of acute pancreatitis,
Auckland 1142, New Zealand avoiding the need for surgical diagnosis.
Indian J Surg (September–October 2015) 77(5):446–452 447

Table 1 Indications for surgery in acute pancreatitis as the heart, lungs and kidneys has not been established. The
1. Surgery for diagnosis gut-lymph hypothesis [6] is a plausible explanation, with im-
2. Surgery to treat complications of pancreatitis pairment of gut microcirculation leading to a breakdown of
a. Abdominal compartment syndrome
the gut barrier and the generation of toxic gut lymph which
b. Infected necrosis
bypasses the liver entering the circulation immediately
c. Non-occlusive intestinal ischaemia and necrosis
upstream of the organs affected [7].
Non-operative strategies [8] to prevent and reverse IAH in
d. Enterocutaneous fistulae
the setting of AP should be initially considered, with surgical
e. Vascular complications
intervention usually reserved for the setting of persistent organ
f. Pseudocyst
dysfunction. Medical interventions to lower IAP target three
3. Surgery to prevent recurrent acute pancreatitis
important contributors: (1) distension and volume of hollow
organs (such as with paralytic ileus), (2) space occupying
lesions (such as ascites, blood and fluid collections) and (3)
Surgical Treatment of Abdominal Compartment conditions that limit abdominal wall expansion (such as agi-
Syndrome tation or incomplete relaxation in ventilated patients). The
levels of sedation and analgesia should be optimised to avoid
The incidence of intra-abdominal hypertension (IAH) and ab- agitation and increased abdominal wall tone. A brief trial with
dominal compartment syndrome (ACS) in AP appears to be neuromuscular blocking agents helps to decrease abdominal
related to a more aggressive resuscitation strategy [2]. The muscular tone and increases abdominal wall compliance thus
consensus definition of IAH is a persistent increase of intra- reducing IAP. Enteral decompression with nasogastric or rec-
abdominal pressure (IAP)>12 mm Hg, and ACS is defined as tal tubes can be helpful in managing ileus and gastric dilation.
the combination of IAP >20 mm Hg and new-onset organ Prokinetic agents such as erythromycin and metoclopramide
dysfunction [2]. Pressures are usually measured by a catheter may help mitigate paralytic ileus. Another drug, neostigmine,
in the bladder, but this is far from routine practice. In patients a parasympathomimetic agent, has been used for treatment of
with AP, ACS is associated with extensive pancreatic necrosis, ACS related to acute colonic pseudo-obstruction (ACPO) af-
multi-organ failure, a longer stay in ICU and hospital and ter conservative measures have failed. It exerts its effect by
higher mortality [3]. In a combined series of 6 studies com- two mechanisms: increasing the amount of available acetyl-
prising 93 patients with ACS the mortality ranged from 25 to choline and indirectly stimulating nicotinic and muscarinic
75 % [4]. Patients with IAP exceeding 25 mm of Hg within the receptors in the smooth muscles of intestine. Valle et al. [9]
first 14 days in the ICU have been shown to have a mortality concluded from a meta-analysis that the effectiveness to re-
rate of more than 50 % [4]. Early recognition and prompt solve ACPO with a single dose of neostigmine was 89.2 %.
treatment of ACS help to decrease morbidity and improve The use of neostigmine in AP is not included in any current
patient survival. guidelines [10]. Percutaneous drainage of ascites and/or fluid
Although IAH is associated with a significantly higher collection(s) should be considered as a useful intervention to
APACHE II and multiple organ dysfunction (MODS) scores reduce intra-abdominal pressure.
in patients with severe acute pancreatitis (SAP), a causal rela- Currently, there is no consensus regarding the optimal
tionship between ACS and MODS has not been established timing for surgical decompression of ACS or the best tech-
[5]. It has been found that the duration of IAH is of greater nique in patients with AP. The most commonly used method
importance than the absolute increase in intra-abdominal pres- for surgical decompression is a midline laparostomy extend-
sure. The mechanism by which IAH affects end-organs such ing from the xiphisternum to the pubis. This approach allows
an inspection of bowel viability and the diagnosis of ischae-
mia. Although early complications, such as intestinal fistulas,
have been greatly reduced with careful management and im-
proved understanding of the open abdomen, there is still the
medium-term requirement of skin grafting and longer-term
requirement for elective repair of the ensuing incisional ven-
tral hernia. Another approach is to use transverse bilateral
extended incision below the costal margins to form a full-
thickness laparostomy. This incision is more likely to achieve
primary closure than the midline incision. A third op-
Fig. 1 The local complications of acute pancreatitis defined by
tion is subcutaneous vertical linea alba fasciotomy
chronicity, infection and content (adapted from Windsor JA, Petrov which is achieved through three short horizontal skin
MS. Acute pancreatitis re-classified. Gut 2013; 62: 4–5) incisions. This allows the linea alba to be split,
448 Indian J Surg (September–October 2015) 77(5):446–452

sometimes using a laparoscope for visual control al- Another notable trend has been the move away from early to
though the least effective for decompression is associat- delayed intervention.
ed with less complications, such as fistulae [11]. The early surgical mindset was to operate early to remove
The judicious use of intravenous resuscitation fluids im- all necrotic tissue, both sterile and infected. The first success-
proved non-operative management, and the wider use of per- ful total pancreatectomy for ‘fulminant’ AP was first reported
cutaneous drainage for collections has resulted in a decrease in by Watts in England [16], and this approach was subsequently
the incidence of ACS in patients with AP. Although surgical adopted by other surgeons [17–19]. The logic was that with-
decompression results in prompt recovery from ACS, it is out surgical intervention, the mortality would be close to
associated with a significant morbidity including intra- 100 %, which might explain why there was an apparent ac-
abdominal bleeding, persistent infection, development of ceptance of a 60 % mortality rate, at least for a time.
post-operative fistulas, and hernias [12]. Open surgical debridement has been the standard treatment
not only for the removal of infected pancreatic and peri-
pancreatic necrosis but also for symptomatic sterile necrosis
Surgical Treatment of Non-occlusive Intestinal especially through the 1980–1990s. The trend for early inter-
Ischaemia and Necrosis vention was not persisted with. A randomised trial was pre-
maturely closed because the mortality associated with early
A number of factors contribute to the risk of non-occlusive surgery (within 2–3 days) was doubled (56 versus 27 %) when
mesenteric ischaemia (NOMI) and intestinal infarction in pa- compared with more delayed surgery (after 12 days) [20].
tients with AP. Risk factors may include under-resuscitation Open necrosectomy is most performed using a pancreas pre-
with significant persisting reflex splanchnic vasoconstriction, serving technique with gentle finger blunt debridement of de-
the metabolic demand of early enteral feeding, non-selective marcated non-viable tissue (‘pancreatic sequestrum’) with the
inotropes and the development of intra-abdominal hyperten- avoidance of formal pancreatic resections and a reduced risk
sion [13]. When NOMI occurs, it is usually an early event and of bleeding, fistulae and avoiding the removal of viable pan-
within the first week of the onset of symptoms. When creatic tissue. Different strategies were advocated following
suspected, due to the development of an acute abdomen and debridement, including closing the abdomen over packs, wide
a rising serum lactate, an urgent CT scan should be arranged. bore drains with postoperative irrigation or leaving the abdo-
There may be evidence of pneumatosis intestinalis with intra- men open to facilitate further debridements [21]. Irrespective of
mural gas in the intestinal wall, and sometimes in the portal the approach, open necrosectomy was associated with an ap-
vein and liver. Occasionally mild NOMI can be managed con- preciable morbidity (34–95 %) and mortality (11–39 %) [22].
servatively by addressing the risk factors, but usually, it re- Open necrosectomy is no longer considered the standard of
quires surgery and bowel resection [14]. As surgery is usually care for the management of infected APFC and WON. Less
within the first week, the abdomen can be lavaged and any invasive techniques have been developed and implemented
early collections drained, but the surgeon should not be [23], and these have largely replaced the need for open proce-
tempted to expose, drain or debride the pancreas (‘don’t poke dures. The development of minimally invasive necrosectomy
the skunk’). Probiotics have been shown to reduce infectious has been in the context of the trend towards less invasive
complications by limiting small-bowel bacterial overgrowth, treatments generally, and an increasing convergence of the
restoring gastrointestinal barrier function and modulating the technologies within the fields of laparoscopic surgery, inter-
immune system. However, a double-blind randomised trial ventional radiology and therapeutic endoscopy. Nine different
investigating probiotics failed to reduce infectious complica- minimally invasive intervention techniques, based on the
tions in AP and was associated with increase mortality related method of visualisation (laparoscopic, endoscopic,
to NOMI (PROPATRIA Trial) [15]. Probiotic prophylaxis nephroscopic) and the route of entry (transperitoneal, retroper-
should therefore not be administered in this category of itoneal and transmural) have been published [23]. A more
patients. comprehensive classification of interventions for AP, based
on visualisation, route and purpose, includes the increasingly
important contributions of interventional radiology [24]. Two
Surgical Treatment of Infected Acute Necrotic other important trends have occurred, including the recogni-
Collections and Walled off Necrosis tion that a delay in intervention allows a lesser procedure with
better outcomes because it allows the development of a wall
Historically, the most common reason for surgical interven- (i.e., inflammatory capsule) and for the necrosum to become
tion in patients with AP was to treat pancreatic necrosis, and it demarcated. The other realisation is that there is a role for non-
is this indication for surgery that has undergone the most operative management in selected patients, including all unfit
change. There have been phases in the evolving role of sur- patients, most patients with sterile necrosis and some with
gery in AP, going from resection to debridement to drainage. infected necrosis.
Indian J Surg (September–October 2015) 77(5):446–452 449

The key development in this field was the first randomised In summary, several key points can be made about the
controlled trial (PANTER) [25]. In this multicentre study, 88 surgical treatment of infected acute fluid collections and
patients with necrotising pancreatitis were randomly assigned walled off necrosis.
to open necrosectomy or ‘step-up’ approach treatment. The
major end-point was a combination of major complications 1. Resection and early surgery are associated with prohibi-
and mortality. The results from this study have changed the tive risk and mortality.
surgical approach to AP. Just over a third of the patients who 2. Debridement of sterile necrosis is rarely, if ever, indicated.
would have undergone open necrosectomy only required cath- 3. Treatment of infected acute fluid collections and walled
eter drainage (radiologic or endoscopic) as the definitive pro- off necrosis should be delayed as long as possible (by
cedure, although 44 % required another drainage procedure. providing optimum intensive care support and drainage)
Sixty per cent of patients who were drained went on to have a to allow for encapsulation.
minimally invasive necrosectomy, and two patients required 4. The step-up approach is the standard of care, with initial
open necrosectomy out of 43 patients in the step-up arm. An- drainage (percutaneous or endoscopic) followed by min-
other important finding was that new onset multi-organ failure imally invasive necrosectomy (percutaneous or endoscop-
was seen only in 12 % in the step-up group compared with ic), and open necrosectomy only if these approaches fail.
40 % in the open necrosectomy group. This study concluded
that a minimally invasive step-up approach reduced the rate of
major complications/death in patients with infected pancreatic
necrosis, and this study established a new standard of care. Surgical Treatment of Fistulae
The Dutch Acute Pancreatitis Group has since coined the 3
D’s approach to treatment: ‘Delay, Drain and Debride’ [26]. The decrease in the use of laparostomy, open necrosectomy
The principle of delay is now embedded within the latest and packing for the treatment of AP has contributed to a de-
guidelines [27]. cline in the incidence of enterocutaneous (small and large
There are many approaches to minimally invasive bowel) fistulae in these patients. The majority of these fistulas
necrosectomy [23]. The selection of the best approach de- can be managed conservatively, using established principles
pends on the availability of relevant expertise and the topog- [31]. This includes defining the anatomy, controlling sepsis,
raphy of the lesion to be treated. When the WON is central, optimising nutrition and undertaking surgical resection after
transgastric approaches are the best approach. When there are failed conservative management. Although fistulae increase
prominent extensions into paracolic gutters, then flank percu- the morbidity, they do not appear to increase the mortality of
taneous drainage is preferred, and the drain is used to access patients with necrotising pancreatitis [32].
these more lateral lesions. This can be done by cutting down
onto the drain to create a short transverse incision to facilitate
extraction of the necrosum with blunt forceps and laparoscop- Surgical Treatment of Pseudocyst
ic guidance, as in the videoscope-assisted retroperitoneal de-
bridement (VARD procedure) [28]. This is an efficient method The reclassification of the local complications has led to a
for debridement. An alternative approach is to use the ap- narrower definition of pseudocyst. It is now defined as an
proach used by urologists for percutaneous nephrolithotomy, encapsulated collection of fluid with a well-defined inflamma-
with dilation of the drain track, insertion of an Amplatz sheath tory wall usually outside the pancreas with minimal or no
and high flow operating rigid nephoscope [29]. This less effi- necrosis [33]. And, it is only defined when it has been present
cient method of debridement is often done as an adjunct to for a least 4 weeks after the onset of interstitial oedematous
upsizing and placement of wide-bore drains (e.g., 32 Fr). pancreatitis. If the patient has necrotising pancreatitis, the col-
The diminishing role of open surgical treatment of infected lection will almost always contain necrotic pancreatic and
local complications of AP and the rise of minimally invasive sometimes peripancreatic tissue. This is not called a
necrosectomy has almost been eclipsed by the evolution in the pseudocyst, but rather ‘walled off necrosis’ when present for
role of percutaneous drainage (PCD). Initially, PCD was an 4 or more weeks (Fig. 1), determining the presence of absence
adjunctive treatment, being used to drain infected residual or of necrotic tissue within the collection with ultrasound or MR
recurrent collections after open surgery. To this has been the scanning. This is a limitation of CT scanning in AP patients.
evolution of PCD as a primary treatment. This effectively The majority of fluid collections and pseudocysts resolve
buys time and this allows the systemic response to settle and spontaneously without active treatment. Those that persist
for the maturation (encapsulation) of target lesions for later and are associated with symptoms or complications should
(and safer) definitive treatment. And now, PCD is being in- be treated. Persistence without symptoms or complications is
creasingly used as definitive and sole treatment, although not an indication for intervention, despite the widely held
there remains significant room for improvement [30]. surgical opinion that a cysto-gastrostomy is required when a
450 Indian J Surg (September–October 2015) 77(5):446–452

pseudocyst of greater than 6 cm and present for more than AP (70–80 %) results in unnecessary intervention in some
6 weeks [34]. In the absence of symptoms or complications, patients and is not longer an indication for early ERCP. A
it is reasonable to take an expectant approach. Symptoms may recent meta-analysis finds that the primary indication for en-
develop, including early satiety, epigastric discomfort, im- doscopic treatment is concomitant cholangitis [40]. If the pre-
paired gastric emptying and gastro-oesophageal reflux [35]. sentation of a patient with AP and cholangitis has been de-
Pressure on adjacent major veins can lead to portal and/or layed beyond 72 h, it may be safer to decompress the biliary
splenic thrombosis and segmental portal hypertension. The tree by percutaneous transhepatic biliary drainage since duo-
fluid content of a pseudocyst is enzyme-rich (including pan- denal oedema and patient instability can significantly increase
creatic elastase) and this can lead to weakening of blood ves- the risks of an endoscopic approach. Note that cholestasis per
sels in the wall of the pseudocyst, leading to pseudoaneurysm se does not require urgent endoscopic intervention; indeed,
formation and bleeding. Pseudocysts can also rupture leading testing liver function tests over 48 h will often reveal improve-
to pancreatic ascites. ment which suggests that the offending CBD stone has passed
Treating a pseudocyst by percutaneous drainage without into the duodenum already.
first ensuring that there is no distal obstruction in the main Patients with gallstone acute pancreatitis warrant cholecys-
pancreatic duct by MRCP is ill advised. The presence of a tectomy. There is now significant body evidence indicating
pancreatic duct stricture or stone increases the likelihood that that this should take place during the same admission for those
percutaneous drainage will result in an external pancreatic with mild and moderate AP [41]. There is a significant risk of
fistula [36]. In this setting, it is best to perform internal drain- recurrent AP if this is not done during the index admission.
age. Historically, this has meant performing a cysto- More challenging is the timing of cholecystectomy in those
gastrostomy or Roux en Y cysto-jejunostomy, and more re- with severe and critical AP, especially when there has been
cently, these have been performed laparoscopically [35]. But significant inflammation and collections in the subhepatic
today, it is preferable to consider treating a pseudocyst using space. Usually, the cholecystectomy is delayed until the pa-
an endoscopic transmural approach, either through the poste- tient has recovered and undergoes an interval elective chole-
rior stomach wall or medial duodenal wall. The insertion of a cystectomy [42]. In patients who survive a severe episode of
double pigtail stent, or multiple stents, is all that is required for gallstone AP and are not fit enough for surgery, there is a trend
a pseudocyst. This is in contrast to walled off necrosis, where to perform an endoscopic sphincterotomy as a definitive pro-
it is best to use a purpose designed, wall-opposing, self- cedure on the basis that it reduces the risk of recurrent acute
expanding metal stent that also permits endoscopic debride- pancreatitis [43]. If these patients develop symptoms of biliary
ment [37]. Rarely, it is possible to successfully treat a colic, an interval cholecystectomy will be required [44].
pseudocyst by the placement of a transampullary drain direct-
ly into the pseudocyst cavity after first defining a communi-
cation between the main pancreatic duct and the pseudocyst Conclusion
cavity by endoscopic retrograde pancreatography [38].
A pseudocyst is more likely to persist and become symp- The role of the surgeon has diminished in the treatment of
tomatic when there has been disruption of the main pancreatic severe acute pancreatitis, but it has not disappeared. This
duct by the necrotising process. Internal drainage of the ‘dis- chapter has highlighted the rise of less invasive ap-
connected duct syndrome’ is advisable because conservative proaches and the important roles played by intervention-
management will not achieve resolution of the pseudocyst. If al radiologists and therapeutic endoscopists. More than
an endoscopic approach is not feasible because of the location ever, the management of acute pancreatitis is multi-dis-
and topography of the pseudocyst, then a surgical approach is ciplinary, and the pancreatic surgeon remains a vital
warranted [39]. member of the team.

Compliance with Ethical Standards

Surgical Treatment of Gallstones
Conflicts of Interest The authors declared that they have no conflict of
interest.
Patients with gallstone acute pancreatitis can present with as-
sociated cholestasis and cholangitis, suggestive of choledo-
cholithiasis. While there is no longer any role for surgical
exploration of the common bile duct in the acute setting, there
is a well-defined role for urgent bile duct decompression by References
ERCP, biliary sphincterotomy and/or stenting. Too often,
ERCP has been undertaken for predicted severe acute pancre- 1. Windsor JA, Petrov MS (2013) Acute pancreatitis re-classified. Gut
atitis and for cholestasis. The inaccuracy of predicting severe 62:4–5
Indian J Surg (September–October 2015) 77(5):446–452 451

2. Radenkovic DV, Bajec D, Ivancevic N, Bumbasirevic V, Milic N, 22. Rau B, Bothe A, Beger HG (2005) Surgical treatment of
Jeremic V et al (2010) Decompressive laparotomy with temporary necrtotising pancreatitis by necrosectomy and closed lavage:
abdominal closure versus percutaneous puncture with placement of changing patient characteristics and outcome in a 19 year, single
abdominal catheter in patients with abdominal compartment syn- centre series. Surgery 138(1):28–39
drome during acute pancreatitis: background and design of multi- 23. Windsor JA (2007) Minimally invasive pancreatic necrosectomy.
center, randomised, controlled study. BMC Surg 10:22 Br J Surg 94(2):132–133
3. Bhandari V, Jaipuria J, Singh M, Chawla AS (2013) Intra- 24. Loveday BP, Petrov MS, Connor S, Pancreas Network of New
abdominal pressure in the early phase of severe acute pancreatitis: Zealand et al (2011) A comprehensive classification of invasive
canary in a coal mine? Results from a rigorous validation protocol. procedures for treating the local complications of acute pancreatitis
Gut Liver 7(6):731–738 based on visualization, route and purpose. Pancreatology 11(4):
4. Keskinen P, Leppaniemi A, Pettila V, Piilonen A, Kemppainen E, 406–413
Hynninen M (2007) Intra-abdominal pressure in severe acute pan- 25. van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS,
creatitis. World J Emerg Surg 2:2 Boermeester MA, Dutch Pancreatitis Study Group et al (2010) A
5. Aitken EL, Gough V, Jones A, Macdonald A (2014) Observational step-up approach or open necrosectomy for necrotizing pancreati-
study of intraabdominal pressure monitoring in acute pancreatitis. tis. N Engl J Med 362(16):1491–1502
Surgery 155(5):910–918 26. Van Branschot S, Bakker OJ, Besselink MG, Fockens P, Gooszen
6. Deitch EA (2010) Gut lymph and lymphatics: a source of factors HG, Dutch Pancreatitis Study Group et al (2012) Treatment of
leading to organ injury and dysfunction. Ann N Y Acad Sci necrotizing pancreatitis. Clin Gastroenterol Hepatol 10(11):
1207(S1):E103–E111 1190–1201
7. Fanous MYZ, Phillips AJ, Windsor JA (2007) Mesenteric lymph: 27. Working Group IAP/APA Acute Pancreatitis Guidelines (2013)
the bridge to future management of critical illness. J Pancreas 8(4): IAP/APA evidence-based guidelines for the management of acute
374–399 pancreatitis. Pancreatology 13(4 Suppl 2):e1–15
8. Cheathem ML, Malbrain ML, Kirkpatrick A, Sugrue M, Parr M 28. Van Santvoort HC, Besselink MG, Horvath KD et al (2007)
et al (2007) Results from the international conference of experts on Videoscopic assisted retroperitoneal debridement in infected necro-
intra-abdominal hypertension and abdominal compartment syn- tizing pancreatitis. HPB 9(2):156–159
drome II. Recommendations. Intensive Care Med 33:951–962 29. Carter CR, McKay CJ, Imrie CW (2000) Percutaneous
9. Valle RGL, Godoy FL (2014) Neostigmine for acute colonic pseu- necrosectomy and sinus tract endoscopy in the management of
do-obstruction: a meta-analysis. Annals Med Surg 3:60–64 infected pancreatic necrosis: an initial experience. Ann Surg
10. Loveday BPT, Srinivasa S, Vather R, Mittal A, Petrov MS, Phillips 232(2):175–180
ARJ, Windsor JA (2010) High quantity and variable quality of 30. Windsor JA (2011) Infected pancreatic necrosis: drain first, but do it
guidelines for acute pancreatitis: a systematic review. Am J better. HPB (Oxford) 13(6):367–368
Gastroenterol 105:1466–1476 31. Werner J, Feuerbach S, Uhl W, Büchler MW (2005) Management
11. Trikudanathan G, Vege SS (2014) Current concepts of the role of of Acute pancreatitis: from surgery to interventional intensive care.
abdominal compartment syndrome in acute pancreatitis :An oppor- Gut 54(3):426–436
tunity or merely an epiphenomenon. Pancreatology 14(4):238–243 32. Tsiotos GG, Smith CD, Sarr MG (1995) Incidence and manage-
12. Mentula P, Hienonen P, Kemppainen E, Puolakkainen P, ment of pancreatic and enteric fistulas after surgical management of
Leppäniemi A et al (2010) Surgical decompression for abdominal severe necrotizing pancreatitis. Arch Surg 130(1):48–52
compartment syndrome in severe acute pancreatitis. Arch Surg 33. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD,
145(8):764–769 Acute Pancreatitis Classification Working Group et al (2013)
13. Melis M, Fichera A, Ferguson MK (2006) Bowel necrosis associ- Classification of acute pancreatitis.- 2012: revision of Atlanta clas-
ated with early jejunal tube feeding: a complication of postoperative sification and definitions by international consensus. Gut 62(1):
enteral nutrition. Arch Surg 141(7):701–704 102–111
14. Marvin RG, McKinley BA, McQuiggan M, Cocanour CS, Moore 34. Cheruvu CV, Clarke MG, Prentice M, Eyre-Brook IA (2003)
FA (2000) Non occlusive bowel necrosis occurring in critically Ill Conservative treatment as an option in the management of pancre-
trauma patients receiving enteral nutrition manifests no reliable atic pseudocyst. Ann R Coll Surg Engl 85:313–316
clinical signs for early detection. Am J Surg 179(1):7–12 35. Draganov PV (2009) Pancreatic pseudocyst. World J Gastroenterol
15. Besselink MG, van Santvoort HC, Buskens E, Boermeester MA, 15(1):38–47
van Goor H, Dutch Acute Pancreatitis Study Group (2008) 36. Nealon WH, Walser E (2002) Main pancreatic ductal anatomy can
Probiotic prophylaxis in predicted severe acute pancreatitis: a direct choice of modality for treating pancreatic pseudocysts (sur-
randomised, double-blind, placebo-controlled trial. Lancet gery versus percutaneous drainage). Ann Surg 235(6):751–758
371(9613):651–659 37. Itoi T, Reddy N, Yasuda I (2013) New fully-covered self expand-
16. Watts GT (1963) Total pancreatectomy for fulminant pancreatitis. able metals stent for endoscopic ultrasonography-guided interven-
Lancet 2(7304):384 tion in infectious walled-off pancreatic necrosis (with video). J
17. Alexandre JH, Guerri MT (1981) Role of total pancreatectomy in Hepatobiliary Pancreati Sci 20:403–406
the treatment of necrotizing pancreatitis. World J Surg 5:369–377 38. Varadarajulu S, Rana SS, Bhasin DK (2013) Endoscopic therapy
18. Kivilaakso E, Fraki O, Nikki P et al (1981) Resection of the pan- for pancreatic duct leaks and disruptions. Gastrointest Endosc Clin
creas for acute fulminant pancreatitis. Surg Gynecol Obstet 152: N Am 23(4):863–892
493–498 39. Tann M, Maglinte D, Howard TJ, Sherman S, Fogel E, Madura JA,
19. Aldridge MC, Ornstein M, Glazer G et al (1985) Pancreatic resec- Lehman GA (2003) Disconnected pancreatic duct syndrome: imag-
tion for severe acute pancreatitis. Br J Surg 72:796–800 ing findings and therapeutic implications in 26 surgically corrected
20. Mier J, Leon EL, Castillo A et al (1997) Early versus late patients. Abdom Imaging 27(4):577–582
necrosectomy in severe necrotizing pancreatitis. Am J Surg 173: 40. Tse F, Yuan Y (2012) Early routine endoscopic retrograde
71–75 cholangiopancreatography strategy versus early conservative man-
21. Branum G, Galloway J, Hirchowitz W et al (1998) Pancreatic ne- agement strategy in acute gallstone pancreatitis. Cochrane
crosis: results of necrosectomy, packing, and ultimate closure over Database Syst Rev 5, CD009779. doi:10.1002/14651858.
drains. Ann Surg 227:870–877 CD009779.pub2
452 Indian J Surg (September–October 2015) 77(5):446–452

41. Tenner S, Baillie J, DeWitt J, Vege SS, American College of 43. Sanjay P, Yeeting S, Whigham C, Judson H, Polignano FM, Tait IS
Gastroenterology (2013) American College of Gastroenterology (2007) Endoscopic sphincterotomy and interval cholecystectomy
guideline: management of acute pancreatitis. Am J Gastroenterol are reasonable alternatives to index cholecystectomy in severe acute
108(9):1400–1415, 1416 gallstone pancreatitis (GSP). Surg Endosc 22(8):1832–1837
42. Van Baal MC, Besselink MG, Bakker OJ, Van Santvoort HC, 44. Bakker OJ, van Santvoort HC, Hagenaars JC, Besselink MG,
Schaapherder AF, Nieuwenhuijs VB et al (2012) Timing of chole- Bollen TL, Gooszen HG, Schaapherder AF, Dutch Pancreatitis
cystectomy after mild biliary pancreatitis: a systematic review. Ann Study Group (2011) Timing of cholecystectomy after mild biliary
Surg 255:860–866 pancreatitis. Br J Surg 98(10):1446–1454