Preoperative Investigation and Preparation for Procedure

■ The diagnosis of acute pancreatitis is one of exclusion (exclude other surgical conditions) based on history, physical examination, and biochemistry.

■ Initial assessment and continuous intensive care unit monitoring of severity (APACHE-II score).

■ Laboratory assessment - CBC and electrolytes, liver function tests, and coagulation profile; some groups utilize serum C-reactive protein as a diagnostic/prognostic guide.

■ Cardiovascular, respiratory, and metabolic resuscitation; aggressive management of SIRS for the first 10-14days of acute pancreatitis.

■ Contrast-enhanced dynamic CT about 1 week from onset of acute pancreatitis to assess the presence and extent of pancreatic and/or peripancreatic tissue necrosis, as well as extraluminal retroperitoneal gas.

■ Early "prophylactic" administration of appropriate antibiotics (Imipenem) to prevent pancreatic superinfection from the gut is adopted by most, but not all, surgeons;

use of oral antifungal agents is favored.

■ Initiation of parenteral nutrition with early conversion to intrajejunal feeding (using a nasojejunal tube with its tip distal to the fourth portion of the duodenum); if possible, intragastric feeding may be effective.

■ In severe gallstone pancreatitis, if choledocholithiasis is present, early endoscopic sphincterotomy and stone removal decreases morbidity and mortality.

■ When operation is planned, the preoperative CT serves as the "road map" for necrosectomy to delineate all fluid collections in areas remote from the pancreas, especially for the retroperitoneal paracolic gutters and perinephric spaces.

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