Chapter 57

In the foregoing chapters, the authors have comprehensively reviewed the pathophysiology of patients with severe acute pancreatitis and the different approaches to the diagnosis and management of the disease. The reviews are extensive, particularly in regard to various medical and surgical interventional techniques. In an effort to simplify the management of these complex patients, we present here our own high-yield approach using the experience gathered over a 25-year period at a single center. This management strategy has resulted in excellent results with morbidity and mortality rates amongst the lowest reported.1

There is general agreement that patients with severe acute pancreatitis should be referred early in the course of their disease to a tertiary high-volume medical center where an experienced multidisciplinary team can provide coordinated care. In practice, however, the referral is often delayed for several weeks or more while the patient continues to deteriorate or the physicians in charge are frustrated because there is no improvement in the patient's condition. There may be a question as to whether surgery is indicated. Thus, the patients we see are often at least several weeks into their illness, and may have failure of one or more organ systems when they arrive at our center. Some may require ventilatory support; some have developed renal failure. They usually have been placed on antibiotics and may have one or more abdominal drains that were inserted by an interventional radiologist at the referring institution. Their management is outlined in the subsequent discussion (Fig. 57-1).

###### Figure 57-1

An overview of the management of patients with severe acute pancreatitis.

### First 24–48 Hours

Upon admission, patients are placed in the intensive care unit (ICU). Appropriate intravenous (IV) fluid resuscitation is continued and central monitoring is established. After the medical records from the referring hospital are reviewed, consults from indicated disciplines (eg, cardiology, pulmonary, nephrology, gastroenterology, etc) are requested. The outside imaging is assessed with the radiologists. At this point, we usually repeat the abdominal imaging to provide up-to-date information about the patient's condition.

At that time, the pancreatic parenchyma and surrounding tissues are evaluated for evidence of inflammation, necrosis, fluid collections, and/or infection. These findings are best displayed by a high-resolution pancreatic protocol CT scan. The pancreatic protocol calls for a precisely timed IV contrast infusion to enhance the pancreatic parenchyma, and surrounding tissue and vessels. Following the injection of the contrast, successive 2- to 3-mm images of the pancreas are obtained during the “pancreatic arterial phase” followed by 5-mm images during the “venous phase.” Oral contrast is not administered. During the pancreatic phase the pancreatic parenchyma and the distribution of the celiac axis and superior mesenteric arteries are enhanced with contrast; the venous phase demonstrates the areas drained or supplied by the superior mesenteric, portal, and splenic veins. The parts of the pancreatic parenchyma ...

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