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Global Translational Medicine Prognostic indicators and management of SAP

necrosis (51% vs. 35%). Sterile necrosis was operated on Surgery has a place in the treatment of etiologies,
earlier (1 week) than infected necrosis (3 week). particularly biliary, by removing the reservoir of stones by
st
rd
88
All this shows that there is a growing trend toward a cholecystectomy, with more or less exploration of the bile
non-operative approach to SAP with sterile necrosis. ducts and their drainage after the complete evacuation of
The surgical strategy is based on two approaches: (i) A the stones that have migrated to their level. This treatment
necrosectomy followed by drainage (the so-called closed is carried out laparoscopically. In SAP, cholecystectomy
or step-up approach). Video-assisted retroperitoneal should be performed within 4 – 6 weeks post-critical with
45
drainage (VARD) is used, with a direct approach to the a 2C guard of the recommendation. When the gallbladder
retroperitoneum without contamination of the peritoneal is left in place after an episode of acute biliary pancreatitis,
cavity. (ii) Debridement followed by abdominal packing or 80% of patients will have recurrent episodes of pancreatitis
a pancreatectomy chimney (open technique or step-down within a year. 88
approach). This technique is generally used when the
closed technique has failed. 4. Long-term future
A meta-analysis comparing the two techniques 4.1. Recurrences and progression to chronicity
concluded that the open technique is associated with Riaz et al. have demonstrated that multiple recurrent
89
greater morbidity (incisional hernias) and a possible episodes of AP lead to chronicity. Notably, recurrent
increase in the mortality rate, while the closed technique episodes are more frequent in ethylic patients, 32,90 affecting
47
reduces the rate of post-operative complications. 82 up to 32% of cases. Nordback et al. reported a recurrence
90
The operation is generally performed through a rate of 46% among 568 patients with alcoholic AP, and
bi-subcostal approach. More recently, the retroperitoneal 83,84 80% of recurrences occurred within 4 years of the first
and laparoscopic 85-87 approaches have been used with episode. This underscores the importance of management
acceptable results in selected cases. The retroperitoneum following an alcoholic AP. In addition, a Japanese study
is penetrated after opening the lesser sac. Debridement demonstrated that the rate of recurrence in patients with
is performed with a finger and is stopped as soon as the pancreatic necrosis was higher than in patients without
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pancreatic tissue starts to bleed, which attests to its vitality. necrosis (32% vs. 5%). In the same study, the prognostic
Extension of the necrosis to the para-colic and mesenteric factors that exhibited a significant difference in recurrence
fat must also be gently debrided. If all the necrotic material were hyperleukocytosis and CRP levels. Similarly, the rate
has been removed, the abdomen can be closed with suction of transition to chronicity was higher in patients with
drains: on the left, the drain is positioned next to the left necrosis than in patients without necrosis (30% vs. 13%).
colonic angle, under the lower splenic pole; on the right, The prognostic factors favoring this transition are a high
the drain is slid into the subhepatic space. white blood cell count, a fall in hematocrit, and base excess
(BE).
In the case of extensive extra-pancreatic necrosis, other
drains must be placed opposite the debrided areas. The 4.2. Development of diabetes mellitus (DM)
gastrocolic and duodeno-colic ligaments are sutured, and
hypertonic saline lavage is started at a rate of 2 L/h. When The factors that correlate with the development of DM in
the septic signs improve, the drainage volume is reduced, PAS are blood glucose and BE on admission. There appears
and when no necrotic debris is recovered, the drains are to be no relationship between the extent of necrosis and
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removed. However, when the necrosectomy is incomplete, the development of DM. Alcoholic SAP is correlated with
a pancreaticostomy tube should be left in place to allow a significant increase in the rate of DM compared with
3
the pancreatic cavity to communicate with the outside biliary SAP. The highest rate of DM was noted in patients
environment through a Mikulicz bag in anticipation of who have undergone pancreatic resection after an episode
iterative necrosectomies. However, the necrosectomy is of SAP; depending on the study, this rate varies between
not without risk. Surgical necrosectomy is often followed 54% and 90% of cases. 92-94
by re-accumulation of peripancreatic fluids, but these 4.3. Impairment of exocrine function
collections can be drained percutaneously. Pancreatic
or enterocutaneous fistulae and parietal complications Early exocrine pancreatic insufficiency is a common
(sepsis, evisceration) may occur. Bleeding is rare, and denominator after an episode of SAP. In the case of SAP,
10
can be managed by arterial embolization. Non-surgical this failure correlates with the degree of extension of
complications of necrosectomy include impaired renal pancreatic necrosis. Exocrine function tests are disturbed
94
function when performed during the inflammatory phase, in 10 – 75% of patients 1 month after an episode of SAP.
and exocrine and endocrine pancreatic insufficiency. 20 Recovery is not the general rule. 95,96

Volume 3 Issue 2 (2024) 9 doi: 10.36922/gtm.2480