ANTIBIOPROPHYLAXIS

Selective gut decontamination

One human clinical study
Luiten EJT and al Ann Surg 222,57,1995
102 patients with severe AP
Oral colistin,amphoB and norfloxacin plus rectal
enema
Decrease moratlity 35% vs 22%
Decrease of laparotomy/pts 0,33 vs 0,08
INDICATIONS FOR SURGERY
IN SEVERE AP
Infected necrosis
Pancreatic abscess
Local complications
Massive bleeding
Perforation of the bowel
Portal vein thrombosis
Sterile necrosis with MOF ???
 SURGICAL TECHNIQUES
Conventionnal technique

Dbridement an penrose/sump drainage

Highest mortality rate ( around 40% )
More than 35% of the patients need reexploration
Low threshold for rexploration is imperative
 SURGICAL TECHNIQUES
Open and semi-open technique
Laparotomy then packing with gaze
Use of syntetic mesh or zipper thereafter
As needed bedside rexploration under anesthesia
Healing by secondary intention
 SURGICAL TECHNIQUES
Open technique=> the zipper

suture of a marlex sheet to the abdo. fascia or skin

a zipper is sewn in the middle of the marlex

daily manual exploration of the abdomen and lavage

SURGICAL TECHNIQUES
 SURGICAL TECHNIQUES
Closed technique
Closing of the abdominal wall
Intraoperative and postoperative lavage of the lesser
sac and the necrosectomy area
Continuous lavage by large bore single or double-
lumen catheters
SURGICAL TECHNIQUES

BEGER and al Surg Clinics N A,79;4 1999

 BEGER and al Surg Clinics N A,79;4 1999
 Retrospective study of 73 consecutives
patients
The presence of infected vs non-infected
necrosis do not correlate with mortality
 retrospective study
No control group for sterile necrosis
Surgical indication ?
Conclusion of the study is not to the good
question
 So it does not answer to the question if the
patient has only sterile necrotic pancreatitis
and no other surgical indication
The better study show that observation is
adequate in almost all patient even with
MOF
Bradley EL 1991 Am J Surg;161:19-24
 NUTRITION

Putting the pancreas to rest

traditionnaly NPO and TPN
Now four prospective studies with enteral
feeding
 NUTRITION
Role of the gut in SIRS
modulation of inflammatory response
bacteria translocation
mucosal injury
downregulation of the acute phase reaction with
enteral feeding
 NUTRITION
TEN feasible with jejunostomy on patients
requiring laparotomy for AP
Kudsk K and al Nutr Clin Pract1990;5:14

Enteral feeding decrease the acute phase

response in AP compare to TPN
Windsor ACJ and al Gut 1998;42:431-435
 NUTRITION
TEN decrease the risk of infection and the
total number of complications vs TPN
Kalfarentzos F and al Br Jour Surg 1997;84,1665

TEN is well tolerated in almost all patients

with severe pancreatitis
Eatok F and al Br Jour Surg 1998;85,10
 OCTREOTIDE
Recent multicenter RCT on octreotide
Uhl W and al Gut 1999,Jul;45(1):97-104
302 pts with severe acute pancreatitis
Octreotide vs placebo
No difference in death, MODS,
complications, LOS and surgery
 OCTREOTIDE
Recent review article on octreotide
Uhl W and al Digestion 1999;60 Suppl 2:23-31

A lot of controversial studies with a small

amount of patients
No strong evidence of any benefit as
treatment of severe AP
 LEXIPAFANT
Systemic complications of acute
pancreatitis are associated with pro-
inflammatory response cytokines
Platelet-activating factor is one of them
induced plts aggregation and activation
increase vascular permeability
activation of monocyte...
 LEXIPAFANT
Two human studies
Multicenter RCT severe pancreatitis ( 11 cewnters )
Severe pancreatitis
Lexipafant vs placebo
Result
Decrease in MODS and systemic complications
Trend in reduce mortality
Mckay CJ and al Brit Jour Surg 1997,84,1239-1243
Ongoing multicenter trial
 Conclusion
All significant acute pancreatitis should be
evaluated with prognosis scale to assess the
risk of mortality and morbidity and to
determine the patients more likely to benefit
from agressive monitoring and treatment
either with
clinical scale
and/or ct-scan
 Conclusion
All necrotizing pancreatitis should be
considered for an antibioprophylaxis of 14
days with an appropriate antibiotic.
 Conclusion
All severe pancreatitis should have a trial of
enteral feeding with NJT if there is no
contraindications.
All acute severe pancreatitis should be
considered for a jejunostomy if they have a
laparotomy.
 Conclusion
Patients with infected necrosis need
necrosectomy for most of them by
laparotomy.
The type of surgical approach thereafter is
quite unclear with the actual litterature in
the absence of control trial. The main factor
is the local surgical expertise.
 Conclusion
There is no clear indication for surgery in
patient with sterile necrosis.
 Conclusion
Patients with severe acute pancreatitis
associated with cholestasis,suspected
cholangitis or progressive jaundice should
be considered for early ERCP to reduce the
local complications and the severity of the
disease
 Conclusion
There is no actual clear role for
gabexate,lexipafant and other antiproteinase
in the treatment of acute severe pancreatitis
otherwise than inside a study protocol