4. LOCAL COMPLICATIONS
ACUTE FLUID COLLECTION
• Collection of fluid in and around pancreas
• Wall which encompasses the fluid is ill defined
• Peripancretic or intrapancreatic
• Regresses spontaneously
• Large collections:percutaneous
aspiration,transgastric drainage under US
guidance
5. PANCREATIC NECROSIS
• Focal or diffuse area of non viable parenchyma
associated with peripancreatic fat necrosis
• Streile initially,infected later
• Absence of contrast enhancement on CT
• Management
- sterile:no intervention
- If signs of sepsis is present
: percutaneous drainage
: microbiological assessment
: frequent flushing under aseptic conditions if
fluid is thick with necrotic material
6. - Sepsis worsens
• Pancreatic necrosectomy
• Surgical approach
- head:midline laparotomy
- Body and tail:retroperitoneal approach through
left flank incision
• Minimally invasive procedure
- Rigid laparoscope is inserted into peripancreatic
area by retroperitoneal approach;vigorous
irrigation and suction;gradual removal of
necrotic debris
7. • To prevent further formation of necrotic tissue
- Closed continuous lavage
tube drains are left in and raw area is flushed
- Closed drainage
incision is closed and cavity is packed with gauze
filled penrose drains
- Open packing
- Closure and relaparotomy
- Incision closed with drains for doing
relaparotomies
8. PANCREATIC PSEUDOCYSTS
• Collection of amylase rich pancreatic fluid
enclosed in a wall of fibrous or granulation tissue
• Develops in
- Acute pancreatitis
- Chronic pancreatitis
- Pancreatic trauma
- Single or multiple
9. • Sites
In the lesser sac in association with
stomach,duodenum,jejenum,splenic hium,colon
• Types
- Communicating
- Non communicating
- Acute or chronic
10. • D Egidio classification
- Type 1:
acute pancreatitis
anatomy of duct-normal
no fistula/communication
- Type 2:
acute on chronic pancreatitis
abnormal duct anatomy without strictures
- Type 3:
chronic pancreatitis
abnormal anatomy of duct with strictures
always communicating
appears as retention cyst
11. • Unformed-thin cyst wall
• Formed- thickened and fibrosed cyst wall
• Lined by fibrin and not by epithellium
• Contains
- brownish fluid with necrotic material
- infected pseudocyst and pancreatic abscess
- high amylase content
12. • Cinical features
- Swelling in epigastric region
soft,smooth,not mobile,does not move on
respiration,hemispherical,upper border-
diffese,lower border-well defined,resonant or
impaired resonance on percussion,transmitted
pulsation in knee elbow position
- infection: tender,fever and chills
- Baid test:Ryles tube can be felt per abdomen
14. • Investigations
- US abdomen:size and thickness of cyst
- CT scan:size,shape,number,wall thickness,extent
of necrosis,calcification,regional vessels
- MRCP and ERCP:communication with duct and
ductal anomalies,chronic pancreatitis
- EUS guided apiration
to differentiate from cystic neoplasm
*CEA-low
*amylase level-high
*cytology-infected cells
15. • Treatment
- Resolves by itself
- Indications for surgery
>6cm
formed cyst
infected cyst
cyst persisting after 6 weeks
multiple cyst
communicating cyst/pain
thick walled
16. - Surgery
Percutaneous transgastric cystgastrostomy
Endoscopic drainage under EUS guidance
ERCP and placement of a pancreatic stent across
ampulla
Surgical drainage into the gastric or jejunal lumen
17. - Complications
Infections- abscess,sepsis
Rupture –gut:GI bleeding
-peritoneum: peritonitis
Enlargement-pressure effects:bowel obstruction
and obstructive jaundice
-pain
Erosion into a vessel-haemorrhage
-hemoperitoneum
18. PANCREATIC ABSCESS
• Circumscribed intraabdominal collection of pus
• Proximal to pancreas
• Due to infection of acute fluid collection and
pseudocyct
• Single or multiple
• Area- head/body/tail/entire gland
• Features
sepsis,tender palpable epigastric
swelling,leucocytosis
19. • Management
- Percutaneous drainage
- Antibiotics and supportive care
- Repeated scans and reinsertion
- Open drainage
• Complications
- Torrential bleed
- Rupture into viscera or other parts of abdomen
20. PANCREATIC ASCITES
• Chronic,generalised,peritoneal effusion
rich in enzyme seen associated with
pancreatic duct disruption.
• High amylase levels
• Percutaneous drainage
• ERCP-demonstration of duct disruption
and placement of pancreatic stent
21. PANCREATIC EFFUSION
• Encapsulated collection of fluid in pleural cavity
• Can be due to ascites or intraabdominal
connection
• Percutaneous drainage under imaging guidance
22. PANCREATIC
PSEUDOANEURYSM
• Due to enzymatic digestion of wall leading to
weakening and dilatation of
splenic,gastroduodenal,inf and superior
pancreaticoduodenal vessel
• Rupture
- Life threatening haemorrhage
- Massive upper GI bleed
- Haemosuccus pancreatitis
23. • Management
- CT angiogram
- Treatment:critical care,blood
transfusion,emergency angiographic
embolisation,open surgery and ligation
24. PANCREATIC FISTULA
• Ductal wall disruption and necrosis or after
surgical intervention for acute pancreatitis
• Internal or external
• Low output or high output
• Straight or curved
• Detection by:biochemical
analysis,ERCP,fistulogram
• Treatment:
- Fistula resection with pancreatic resection
- Pancreaticojejunostomy
- sphincterectomy
