A phone rings when I am on-call. Usually, phone calls at 3 o’clock in the morning do not bring fantastic news. Good news can wait until I am perfectly awake, bad news come at any time. Half asleep I answer the phone… and hear the voice of my good friend and colleague who works at another hospital. He has been struggling with a patient for some hours but feels the patient cannot survive if he is not transferred to a tertiary pancreatic centre. Hence his phone call to me. He begs me to accept XY as soon as possible, and take over his care. He feels that the resources at his hospital are not enough to offer a minimal hope of survival to this guy. The patient – my friend tells me – is a 43 year-old man who was brought in by the ambulance for sudden onset abdominal pain. The ambulance found him lying on the ground at his flat – he lives alone – with signs of recent vomiting. He was folded in two with pain and his skin appeared yellowish and pale. There were a few bottles of beer scattered on the floor. The ambulance crow could only pack him and bring him to the nearest hospital. As soon as he saw him, my colleague was perfectly aware of a severe acute condition. At the admission, the patient was tachycardic (i.e., his heart rate was high) and tachypnoeic (i.e., his respiratory rate was high), his oxygen saturation (the amount of oxygen in his blood) and his body temperature are quite low. Doctors and nurses at the hospital started immediately the “sepsis six”, as the patient was clearly in septic shock. They started intravenous fluids and antibiotics and oxygen by mask and sent blood tests, blood culture and urinalysis. Blood tests showed high lactate and high amylase, along with high inflammatory markers (high C-reactive protein and white cells) and deranged liver function tests (high transaminase, gamma-glutamyl-transpeptidase and bilirubin) and electrolytes (low sodium, high potassium, low calcium). The patient responded well to the first line treatment, and a CT scan was performed. It revealed a swollen and necrotic pancreas, with a big collection of dense fluid just behind the stomach and free fluid all around the abdomen, dilatation of the bile ducts and the gallbladder and stones in the gallbladder and perhaps in the common bile duct. It is a clear picture of a severe complicated pancreatitis. While a simple, mild pancreatitis can be treated easily in any hospital and even at home in selected cases, the treatment of severe acute pancreatitis must be done in a tertiary hospital with specific expertise and with the possibility to offer the whole range of treatments, from intensive care and nutritional support to interventional radiology, endoscopy and complex surgery. Feeling that his hospital is not the safest place for this patient, as it does not have everything this patient may need, my colleague wants to transfer this guy to my care. Even if it is not going to be an easy case to deal with, and probably exactly for this reason, I accept the transfer, trying to make good use of the window of opportunity we have at the moment as the patient is responding to the initial treatment. XY arrives at my hospital with blue lights less than half an hour after that phone call, and I meet him at the Emergency Department. He is not perfectly conscious, probably due to the opioids he was given to try and control his pain, and looks in terrible conditions. I take the time to see the blood tests and examine the images of the CT scan with our radiologist (also her forced out of bed…) and, while the fluid resuscitation continues, I summon the intensive care doctor to see the patient and she agrees with me that he needs immediate transfer onto a monitored bed.
Acute pancreatitis is an acute inflammation of the pancreas. It is classified as “mild”, “moderate” and “severe” according to its gravity, being the “mild” type a usually benign condition, easily treated and of quick resolution. In the “moderate” and severe” types there is some form of transient or long term organ failure, meaning a severe dysfunction of one or more systems (heart, lung, kidney, liver…). In the “moderate” type organ dysfunction is transient. In the “severe” type there is permanent organ disfunction associated with local complications such as abscesses, necrotic collections. The severe acute pancreatitis is associated with high risk of mortality (up to 1 in 3 patients die for this condition, and even more in the presence of severe sepsis). Diagnosis can be suspected on the basis of the clinical presentation, but blood tests and imaging (CT scan) are necessary. Imaging studies can also give us an idea of the causes of the pancreatitis. In the western world most of cases are due to alcohol abuse or gallstones. Much less frequent are the cases of pancreatitis due to high triglycerides or infection. The treatment of severe acute pancreatitis is never easy or straightforward and must follow a “step-up” approach. Usually, the first line is the treatment of the suspected sepsis at the presentation of the patient, with fluids, oxygen and antibiotics, if necessary. Management of pain and nutrition are the two other pillars of the treatment of pancreatitis. Pain control may need high dose opioids along with other drugs. Oral nutrition is always the best option, but this may not be tolerated in particular in the most acute phase of the disease. Therefore, intravenous nutrition may be necessary. In case of collections of pus and necrotic pancreatic tissue, in particular if they are infected, a drainage may be necessary. This should be performed preferably through the stomach by endoscopy, but sometimes this is not possible, and a drain must be inserted through the abdominal wall under CT guidance. Occasionally, endoscopic or percutaneous drainage is not possible and if the patient is septic a surgical operation might be necessary. The philosophy of the “step-up” approach suggests not to embark into anything invasive if less invasive options are available and effective. Therefore, a surgical operation is really the last resort. Operations can be performed by laparoscopic or open surgery, according to local conditions and expertise. However, we try our best to avoid any operation as surgical mortality rate is awfully high even if the operation can be quick and relatively easy. Other collateral conditions can be treated accordingly. For instance, a continuous bleeding within the inflamed pancreas can be treated by embolization, which is a low invasiveness technique that entails entering a large artery of the groin with a probe and push it up until one of the small arteries of the pancreas to inject glue or other clotting material to create a plug to close the artery and stop the bleeding. If this does not work, a surgical operation may be needed. The presence of obstructing stones in the bile ducts can be one of the causes of acute pancreatitis. They must be removed (or bypassed) with an endoscopic procedure called endoscopic retrograde cholangiopancreatography that aims to clear the bile ducts and allow free flow of bile and pancreatic juice. As stones usually originate from the gallbladder, it must be removed as soon as the patient is able to tolerate an operation safely and the pancreatic inflammation has settled.
As the acute phase progresses and the inflammation reduces, other complications may arise. The content of large necrotic collections with a wall may liquify and form a “pseudocyst”. If symptomatic, pseudocysts can be drained endoscopically into the stomach.
Sometimes, these patients may develop obstruction of the stomach due to compression or encasement within the inflammatory tissue. Usually, this obstruction resolves spontaneously within few weeks, but if it does not, a bypass operation may be required to allow oral feeding.
Rarely, life threatening forms of severe hyperacute pancreatitis where each and every procedure failed, including surgical drainage and open abdomen, require that an emergency pancreatectomy is considered. Emergency pancreatectomy is the very last resort to be considered only in patients whose sepsis cannot be treated in any other way and is rapidly bringing them close to death. It is an extremely risky and difficult operation associated with a mortality rate approaching 90%, not for technical reasons but because those patients come from weeks, if not months, of ongoing sepsis and organ failure and their general conditions are extremely poor anyway. For this very high risk of dying, some surgeons believe that emergency pancreatectomy in complicated severe acute pancreatitis is a futile operation and must not be done, to avoid adding further pain and discomfort to a patient who will die anyway.
Rehabilitation after an episode of severe acute pancreatitis is long and difficult, and may entail a long hospital stay with continuous input of the physiotherapists and dieticians along with the acute care multispecialists.
The treatment of the severe acute pancreatitis is multimodal and therefore must involve the input of several different specialists, including surgeons, radiologists, interventional radiologists, endoscopists, gastroenterologists, intensivists, nutritionists…, who gather together into a proper “Pancreatic Unit” whose components have large expertise on pancreatic disorders and are able to offer state-of-the-art treatments supported by the most recent evidence and guidelines. As those advanced options may not be available in any hospital, a hub-and-spoke system should be implemented where tertiary surgical units with pancreatic expertise working within formal or informal pancreatic units must play the role of “hubs” and be available at any time to accept those patients coming from “spoke” hospitals.