**4. Conclusion**

*Digestive System - Recent Advances*

pancreatic pseudocyst.

*3.6.2 Severe disease*

significant resolution of acute symptoms.

tion, in which case immediate operation is warranted.

used in contemporary management.

However, the duration of hospitalization may be dependent on the local complications related to pancreatic injury. Edematous pancreatitis with an APFC should resolve relatively quickly, whereas sterile necrosis may cause persistent symptoms and limit per oral intake, necessitating institution of enteral nutrition. For patients who have sterile necrosis, follow-up CECT is recommended to ensure resolution of the pancreatic injury without complicating features such as the development of a

Laparoscopic cholecystectomy should be offered to patients with mild GSP during the index hospitalization, generally as soon as the patient is stable with

Patient with severe disease should be treated aggressively in a higher center with well-equipped intensive care units, endoscopy and operative rooms all of which are staffed by critical care experts, gastroenterologists, interventional radiologists and surgeons. These patients develop a profound SIRS response and often have rapid deterioration requiring intubation and mechanical ventilation, renal replacement therapy and inotropic support. This critical period is driven by cytokine response and may last for 1–2 weeks. Aggressive fluid resuscitation is the cornerstone of initial therapy in severe. The goals of therapy during this period of critical illness include maintenance of oxygen delivery to the central nervous system and viscera by mechanical ventilation, adequate resuscitation with Lactated Ringer's solution, inotropic administration as needed to support blood pressure and decrease heart rate, maintenance of renal function with or without renal replacement therapy and nutritional support. Enteral nutrition should be tried, though less often possible, because of less incidence of infected pancreatic necrosis. Antibiotics are often used to prevent conversion of sterile necrosis to infected necrosis, if the necrosis is <30%. As the systemic inflammatory response wanes over 1–2 weeks, these patients will develop local complications of necrotizing pancreatitis. An early ERCP plus sphincterotomy along with conservative management can help decrease complications of severe disease. By 4–6 weeks these complications mature and management to be guided according to symptoms. Unlike in mild disease, an early operation should be avoided in severe pancreatitis, whether for cholecystectomy or pancreatic debridement. There are, however, a few notable exceptions, such as abdominal compartment syndrome, refractory hemorrhage and colonic necrosis or perfora-

An ANC accompanying pancreatic necrosis may be sterile or infected. Sterile necrosis often requires no intervention, and patients recover over time except for the infrequent patient who develops failure-to-thrive syndrome as a result of sterile necrosis. Patients with failure-to-thrive syndrome may require percutaneous drainage or endoscopic or operative debridement for full recovery. Those patients with infected necrosis require drainage and debridement of infected pancreatic tissues with vigorous antibiotic therapy. The mode of drainage or debridement can vary from percutaneous drainage, endoscopic or laparoscopic debridement to dualmodality drainage (combined percutaneous and endoscopic drainage). The open surgical approaches are heterogenous, and some of these approaches are no longer

Importantly, before debridement, a CECT should be obtained to ascertain the presence of the disconnected pancreatic duct syndrome. A viable pancreatic remnant in the tail separated by a substantial area of pancreatic necrosis in the neck of the gland should lead to the suspicion of a disconnected pancreas. This warrants the need for distal pancreatectomy and splenectomy accompanied by pancreatic

**98**

Acute gallstone pancreatitis represents a wide spectrum of disease ranging from mild disease that resolves spontaneously to severe disease with SIRS and necrotizing pancreatitis. These patients are best managed by a multidisciplinary approach to combat complications. Finally they should have a timely cholecystectomy to treat the cause of disease.
