Page 23 - Acute Pancreatitis (Viêm tụy cấp)

914 PART VII Pancreas

In summary, in patients with AP regardless of severity, once
can initiate a clear liquid diet immediately if vomiting is not pro-
nounced. Advancing to a low-fat diet can be instituted quickly
if eating does not exacerbate pain or cause vomiting. For those
patients who can do not tolerate anything by mouth due to vom-
iting and/or worsening pain after 3 to 5 days, a low-fat diet given S
by nasogastric tube and, if not tolerated, a postpyloric feeding F
should be given. One should rarely require TPN.

Other Non-Interventional Treatments
In one trial, 300 a single brief alcohol counselling during admission is P
superior to subsequent outpatient counseling in terms of reduction
in overall admissions. This approach is further supported by stud-
ies that suggested the benefit of such counseling in certain chronic
alcohol-related diseases. Another recent study suggested that the
brief intervention during hospitalization is not sufficient, par-
ticularly in younger individuals with high Alcohol Use Disorders
Identification Test (AUDIT) scores that indicate heavy alcoholism
and high rates of recurrence. 301 High rates of recurrence of acute
alcoholic pancreatitis were observed in the 4-year follow-up in the
study after the brief intervention during hospitalization. Along the
same lines, smoking cessation counseling is important.
Fig. 58.6 CT showing walled-off pancreatic necrosis. A 5.4-cm pus-
filled fluid collection (arrows) with the tip of an aspirating needle in its
Interventional Treatments lumen is seen. The abscess is anterior to the pancreas (P) and medial
to the stomach (S). A right sub-hepatic fluid collection (F) is present.
Cholecystectomy
These include urgent (24 to 72 hours) ERCP, elective ERCP to detect necrotizing pancreatitis that had not manifested on
before cholecystectomy for gallstones, and cholecystectomy as the initial CT scan.
the definitive treatment. The role of urgent ERCP was discussed
earlier and in Chapter 61. Interventions for Pancreatic Fluid Collections
The recurrence of further attacks of AP is 18% in 6 weeks if
cholecystectomy is not performed at the time of index attack of After the initial phase of 2 weeks, pancreatic fluid collections
biliary pancreatitis. 302 In the past, surgeons were not prepared appear to become more demarcated and develop a wall, usually by
to operate on the gallbladder during an attack of AP due to 4 weeks. As acute (peri-)pancreatic fluid collections usually have
concerns about inflammation in the abdomen at the time of resolved by that time, those that persist and have a wall usually
surgery. However, in patients with mild, interstitial pancre- represent WON rather than pseudocysts (Fig. 58.6). The mere
atitis, the experience with cholecystectomy evolved, and more presence of these local complications is not any indication for
recent guidelines recommend same-admission cholecystec- intervention. Approximately two thirds of patients with necrotiz-
tomy for cases of mild and interstitial pancreatitis. 9,211 These ing pancreatitis resolve without any interventions. The indica-
guidelines also recommended waiting and performing interval tions for minimally invasive drainage or debridement have been
cholecystectomy subsequently in moderately severe to severe clarified further and include infected (peri) pancreatic necrosis,
(necrotizing) pancreatitis. The recommendations varied from obstruction of the GI or biliary tract, persistently unwell state
after the inflammation subsides, and all the fluid collections with loss of weight and debility, disconnected PD syndrome, and
stabilize to 6 weeks after the attack. A recent RCT where cho- complications such as perforation of a hollow viscus or a fistu-
lecystectomy was performed within 72 hours of randomiza- lous tract. An RCT of endoscopic drainage versus surgical cyst
tion in patients with acute biliary pancreatitis compared with gastrostomy for symptomatic pseudocysts in AP found that sur-
cholecystectomy performed after 25 to 30 days demonstrates gical cyst gastrostomy was not superior to endoscopic therapy;
a significantly reduced number of pancreaticobiliary complica- however, endoscopic therapy was associated with shorter hospital
tions and readmissions with early surgery but no difference stay, better mental and physical health of the patient, and reduced
in mortality (see the previous discussion). There was also no costs. 304 For a long time, pancreatic fluid collections were treated
difference in the rate of conversion to open cholecystectomy. by open necrosectomy in those with signs of infection of such col-
In high-risk patients who cannot undergo cholecystectomy lections or whose clinical condition was worsening. Subsequently,
and in necrotizing pancreatitis patients waiting for interval an RCT demonstrated that operating early (within 2 weeks)
cholecystectomy, a biliary sphincterotomy can prevent further increases mortality and morbidity, 305 and subsequent recommen-
attacks of AP but would not prevent biliary events like biliary dations emphasized operating later in the course after the fluid
pain and acute cholecystitis. A recent report observed that in collections develop a wall, which is usually around 4 weeks.
patients who underwent same admission cholecystectomy with The types of necrosectomy operations that have been recom-
a mistaken diagnosis of mild, interstitial pancreatitis, the sub- mended include necrosectomy with closed continuous irrigation
sequent evolution of their necrotizing pancreatitis had worse via indwelling catheters, necrosectomy with closed drainage with-
outcomes (e.g., infected pancreatic necrosis) compared with out irrigation, or necrosectomy and open packing. A large body
age- and sex-matched necrotizing pancreatitis patients who of reports favored minimally invasive treatments like percutane-
had not undergone such same admission cholecystectomy. 303 ous, video-assisted retroperitoneal, laparoscopic, endoscopic, and
If the patient is diagnosed as having interstitial acute biliary combination methods over open surgical necrosectomy because
pancreatitis and is being evaluated for same admission chole- of less morbidity and mortality. 306 One RCT showed superior-
cystectomy, and if the white count is elevated before such cho- ity of the minimally invasive step-up approach with percutane-
lecystectomy, a repeat CT scan should be performed in order ous drainage initially and later video-assisted retroperitoneal