Pancreatitis and Groin - Forum

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Hans

Pancreatitis and Groin - Ärzteforum

Post#1 »

I will appreciate your opinion about this case,

42 y.o man presents with 1 week history of pain in the left groin.
Physical examination-symptomatic left groin mass, hard, fixed, touching-painful.
Temp.38 C, WBC-18 000, Lipase, Amylase, Bilirubin, Electrolyte-normal.
The patient has multiple risk factors: obese, smoker-50/day, beer-10/day.

Emergency Op-incarcerate Hernia.

However, in the operation I did not find neither incarcerate hernia or groin
hernia. I found only necrotic fat tissue in the groin.
Lower midline incision-minimal abdominal fluid-(bacteriology negativ), extensive
necrosis of retroperitoneal fat and mesentery on the left side, pancreas
swollen. Drain, antibiotics-intraop, intravenous nutrition postop.

Post Op abdomen CT-Pancreatitis with necrosis of retroperitoneal fat.

Lab.Lipase, amylase normal, WBC 10 ooo.

The patient is asymptomatic and he seems to be doing well, for now.

What would you recommend now ? Options,

1.Observation
2.Conservative policy of management -antibiotic, intravenous nutrition
3.Early debridement of necrosis
4.any other suggestions ?


User avatar
Surgeon

Re: Pancreatitis and Groin - Ärzteforum

Post#2 »

Observation and nasojejunal tube feedings.

forceps

Re: Pancreatitis and Groin - Ärzteforum

Post#3 »

My impression was that extensive fat necrosis signals more severe
pancreatitis (at least this is the case with ecchymotic manifestations like
Turner's sign). Your patient seems clinically to be much more stable than I
would have expected. Was the CT scan performed with fast IV contrast
injection? Were you able from the CT scan to draw any conclusion about the
perfusion of the pancreas itself (and thus, pancreatic necrosis)?

BTW the conservative treatment for pancreatitis does not include IV
antibiotics as a matter of routine.

Finally, I read an abstract about extensive retroperitoneal fat necrosis not
related to pancreatitis.

Hans

Re: Pancreatitis and Groin - Ärzteforum

Post#4 »

We have performed CT with IV contrast injection. He has pancreas necrosis in
the corpus and tial of pancreas with left retroperitoneal fat necrosis .
Histopath.- fat necrosis.

I agree with you too, although many doctors advocate the routine administration
of antibiotics to patients with acute pancreatitis but randomized trials have
indicated that antibiotic administration does not alter the incidence of septic
complications of pancreatitis.

User avatar
A Doctor

Re: Pancreatitis and Groin - Ärzteforum

Post#5 »

Was his abdomen benign? No pain , no tenderness? No GI symptoms, no ileus
on AXR?

No pre-op suggestion which would have resulted in pre-op CT?

Drains- bad idea- in this situation will in 99% convert the STERILE
NECROSIS to INFECTED PANCREATIC NECROSIS (IPN).


> 1.Observation

YES. The patient is asymptomatic; the amount of necrosis not always
correlate with the severity of SIRS. The vast majority of sterile PN can
be managed conservatively (see articles by Ed Bradely)

As surgeon says: feed into the gut. Prospective-randomized evidence suggests
that this is better than TPN in severe pancreatitis.

> 2.Conservative policy of management -antibiotic, intravenous nutrition

Antibiotics-YES. The current state of art in severe pancreatitits- defined
by Ranson's criteria>3, or APACHE II >8 or finding of necrosis on CT -is
to administer prophylactic antibiotics- imipenem has been recommended- in
order to prevent the PN becoming IPN. (IPN is a killer- ON much less)

> 3.Early debridement of necrosis.

NO, NO, NO. The indication for operation would be:

1. Evidence that infection develops
2. Clinical deterioration

In general for sterile PN you wait as long as possible- the longer you wait
the easier and safer is the "necrosectony".

> 4.any other suggestions ?

So, remove your useless port of entry for bacteria (sorry -drains), give
antibiotics, feed into the gut and wait. F/U with serial CT's.

Clinical deterioration- CT + FNA for Gram stain and bacteriology. Evidence
of IPN- mandates operation.

Hans

Re: Pancreatitis and Groin - Ärzteforum

Post#6 »

> Was his abdomen benign? No pain , no tenderness? No GI symptoms, no ileus
> on AXR?

Yes, his abdomen was very benign, no abdominal tenderness and guarding.


> No pre-op suggestion which would have resulted in pre-op CT?

I was sure that it was incacerate hernia with omental.(What is sure?)
Compliance of the patient is very low I am not psychiatrist but I think his
IQ = level of potassium.


> Drains- bad idea- in this situation will in 99% convert the STERILE
> NECROSIS to INFECTED PANCREATIC NECROSIS (IPN).

You are right it was no good idea .

> > 1.Observation

Yes I did the same I feed into the gut .

> > 2.Conservative policy of management -antibiotic, intravenous nutrition

Why severe pancreatitis, we found necrosis on CT but my patient is very well.
I have learnt I shall treatment the patient no CT.

Why imipenem has been recommended ?

I thought that the antibiotics administration does not alter the incidence of
septic complications of pancreas.

> > 3.Early debridement of necrosis.

Here I am agree with you.

> So, remove your useless port of entry for bacteria (sorry -drains), give
> antibiotics, feed into the gut and wait. F/U with serial CT's.

I removed drain next day, bacteriology-negativ.

User avatar
A Doctor

Re: Pancreatitis and Groin - Ärzteforum

Post#7 »

> Why severe pancreatitis, we found necrosis on CT but my patient is very
well.
> I have learnt I shall treatment the patient no CT.

Because conceptually necrosis= severe pancreatitis. Your patient may
appear well now but superinfection of his diffuse necrosis-i.e. IPN- has a
mortality of around 30-50%.


> Why imipenem has been recommended ?

It penetrates well the pancreas. Shown in studies to prevent IPN in
patients with severe acute pancreatitis.

Look at the current literature. Go to PUBMED and search "pancreatitis" AND
"antibiotics"

User avatar
Lady Surgeon

Re: Pancreatitis and Groin - Ärzteforum

Post#8 »

My comment on the antibiotics in acute pancreatitis was: "the
conservative treatment for pancreatitis does not include IV antibiotics
as a matter of routine" indicating that prescribing IV antibiotics
should not be an automatic response to a diagnosis of acute
pancreatitis. The clinical condition seemed to be far from being severe,
and the statement was made before posting the data of the results of the
perfusion CT scan. But still at that time I did want to know what the CT
scan showed. The subsequent answer that there is actually necrosis of
the pancreas proves that you did the right thing by starting the IV
antibiotics. The most effective antimicrobial agents are
imipenem-cilastatin, the fluoroquinolones, and metronidazole, which
achieve adequate penetration into pancreatic juice and necrotic tissue
and inhibit the growth of enteric bacteria.

Dottore

Re: Pancreatitis and Groin - Ärzteforum

Post#9 »

When you find such a necrosis of the retroperitoneum, you must re-op the pt
many times, until the necrotic proccess has stopped. I guess you did a
laparostomy, which is indicated in your case. If the laparotomy was a little
one I'd advice a bilateral subcostal incision (bilateral Kocher) and do a
Pancreatostomy.

User avatar
Doctor Green

Re: Pancreatitis and Groin - Ärzteforum

Post#10 »

The presence of, or the extent of necrosis per se is not the indication foroperation in acute pancreatitis. The thought that by doing so you are aborting the process of the systemic inflammatory response syndrome = (SIRS) lead surgeons to operate earlier, but the follow-up data proved that this is not
the case.

So far, infection of pancreatic necrosis has been the agreed-upon indication for surgery. On the other hand, if the clinical condition deteriorates, diagnose infection and you'll have another indication for surgery. Otherwise, the pendulum these days is swinging towards conservatism.

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