General Surgery Conference wk 3-pt 1

Necrotizing Pancreatitis

- 21 yrs old, acute gallstone pancreatitis
lap chole
cholelithiasis
AF VSS ERCP
amylase lipase
necrosectomy - removal, debridement of necrotic tissue

- causes
gallstone
EtOH
idiopathic
metabolic hyperlipidemia
vascular - vasculitis

- mild vs severe acute
mild - interstitial edematous, self-limiting, subsides spontaneously
severe acute - organ failure, abscess, pseudocyst formation

- assessment of severity
Ranson's criteria
APACHE II
both not great
CRP(creatine phosphate) - predicts severe pancreatitis and pancreatic necrosis

- in CT
necrotic area don't enhance
glandular necrosis more than 30%
periperitoneal inflammation
air in (debridment) necrotic tissue, why do ppl get air? due to bacteria
demarcated fluid collection
very thick walls

- sterile vs. infected pancreatitis
infected - higher mortality, usually requires surgical treatment

- CT guided FNA(fine needle aspiration)
septic
deteriorate
no improvement with conservative management

- infected necrosis
risk increases with amount of pancreatic glandular necrosis
indication for surgical debridement

- microbiology
gut derived organisms
primarily more microbial, gram(-)

- 3 ways to decrease infection
enteral feeding
selective decontamination of the gut
efficacy - eliminating gram(-), greater morbidigy/mortality
prophylactic ABX(antibiotics) => current trend away from this method
shouldn't start b/c of problem of selecting other resistant organisms

- sterile necrosis
no need for surgery, conservative strategy
debridement for failure to thrive or deterioration

- timing of intervention, early vs. late
delay 4 wks
may allow for definitive drainage procedure
decreases the risk of bleeding
preserve viable tissue
no need to rush

- surgical debridement
conventioanl drainage
necrosectomy, standard drainage like JP
open/semi-open
necrosectomy/scheduled repeated laparatomy or open packing of pancreas
closed
necrosectomy/ closure over large bore drains for continuous lavage of lessor sac

- interventions
percutaneous therapy(CT guided)
endoscopic
limited treatment
laproscopic

- severe acute pancreatitis or associated with SIRS( systemic inflammatory response syndrome)
non-contrast CT is useless
hydrate'em, wait for few days to allow visible CT
timing of intervention for sterile pancreatitis remains controversial

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Main Entry: cho·le·li·thi·a·sis
Pronunciation: k-li-lith---ss
Function: noun
Inflected Form(s): plural -a·ses /-sz/
: production of gallstones; also : the resulting abnormal condition

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Main Entry: de·bride·ment
Pronunciation: di-brd-mnt, d-, -mänt, -mäⁿ
Function: noun
: the usually surgical removal of lacerated, devitalized, or contaminated tissue

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Main Entry: id·io·path·ic
Pronunciation: id---path-ik
Function: adjective
: arising spontaneously or from an obscure or unknown cause : PRIMARY <idiopathic epilepsy> <idiopathic thrombocytopenic purpura>

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Main Entry: vas·cu·li·tis
Pronunciation: vas-ky-lt-s
Function: noun
Inflected Form(s): plural -lit·i·des /-lit--dz/
: inflammation of a blood or lymph vessel -- called also angiitis
- vas·cu·lit·ic /vas-ky-lit-ik/ adjective

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Main Entry: hy·per·lip·id·emia
Variant(s): or chiefly British hy·per·lip·id·ae·mia /-lip--d-m-/
Function: noun
: the presence of excess fat or lipids in the blood
- hy·per·lip·id·emic or chiefly British hy·per·lip·id·ae·mic /-mik/ adjective

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Main Entry: in·ter·sti·tial
Pronunciation: int-r-stish-l
Function: adjective
1 : situated within but not restricted to or characteristic of a particular organ or tissue -- used especially of fibrous tissue
2 : affecting the interstitial tissues of an organ or part <interstitial hepatitis>
3 : occurring in the part of a fallopian tube in the wall of the uterus <interstitial pregnancy>

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Main Entry: edem·a·tous
Variant(s): or chiefly British oe·dem·a·tous /-dem-t-s/
Function: adjective
: affected with edema edematous patient> edematous lung>

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Main Entry: de·mar·cate
Pronunciation: di-mär-kt, d-
Function: transitive verb
Inflected Form(s): -cat·ed; -cat·ing
1 : to mark or determine the limits of
2 : to set apart clearly or distinctly as if by definite limits or boundaries
- de·mar·ca·tion also de·mar·ka·tion /d-mär-k-shn/ noun

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Needle aspiration biopsy (NAB), also known as fine needle aspiration cytology (FNAC), fine needle aspiration biopsy (FNAB) and fine needle aspiration (FNA), is a procedure performed to diagnose certain kinds of medical conditions, such as lumps in the neck. In this technique a thin needle is inserted into a mass or lump to extract cells that will be examined under a microscope. Fine needle aspiration biopsies are very safe, minor surgical procedures. Often, a major surgical (excisional or open) biopsy can be avoided by performing a needle aspiration biopsy instead.

A needle aspiration biopsy is safer and less traumatic than an open surgical biopsy. Sometimes, surgery is needed to treat complications of a needle aspiration biopsy. But in such a case, the patient would have had to undergo a similar surgical procedure to obtain a diagnosis had the needle aspiration biopsy not been attempted.

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Main Entry: mor·bid·i·ty
Pronunciation: mr-bid-t-
Function: noun
Inflected Form(s): plural -ties
1 : a diseased state or symptom morbidity -- Journal of the American Medical Association>
2 : the incidence of disease : the rate of sickness (as in a specified community or group) morbidity has been rising -- Time> -- compare MORTALITY 2

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Main Entry: per·cu·ta·ne·ous
Pronunciation: pr-ky-t-n-s
Function: adjective
: effected or performed through the skin <percutaneous removal of renal calculi -- G. M. Preminger et al>
- per·cu·ta·ne·ous·ly adverb