What is the best approach to manage perioperative pancreatitis in a patient, considering their potential for organ dysfunction, history of gallstones, and need for pain management and nutritional support?

Management of Perioperative Pancreatitis

Initial Assessment and Monitoring

All patients with perioperative pancreatitis require severity stratification within 48 hours using clinical and laboratory markers to determine appropriate level of care, with severe cases (persistent organ failure >48 hours, >30% necrosis, or sepsis) mandating ICU/HDU admission with continuous monitoring. 1

• Continuous vital signs monitoring in a high dependency or intensive care unit is essential if organ dysfunction occurs 1
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate as markers of adequate tissue perfusion 1
• Dynamic contrast-enhanced CT scanning should be obtained within 3-10 days of admission to assess pancreatic necrosis 1
• Patients with predicted severe pancreatitis must be managed in specialist units with access to interventional radiology, endoscopy, and surgical capabilities 2

Fluid Resuscitation

Moderate fluid resuscitation with lactated Ringer's solution is preferred over aggressive resuscitation, as recent high-quality evidence demonstrates aggressive protocols increase fluid overload without improving outcomes. 3

• Lactated Ringer's solution is superior to normal saline for reducing SIRS in the first 24 hours and may have anti-inflammatory effects 1, 4
• Moderate resuscitation protocol: 10 ml/kg bolus only if hypovolemic (no bolus if normovolemic), followed by 1.5 ml/kg/hour 3
• Aggressive resuscitation (20 ml/kg bolus followed by 3 ml/kg/hour) resulted in 20.5% fluid overload versus 6.3% with moderate resuscitation, without reducing pancreatitis severity 3
• Fluid resuscitation must be adjusted to patient's age, weight, and pre-existing renal/cardiac conditions 1

Critical pitfall: Over-resuscitation is a common error that increases complications without benefit; measure intra-abdominal pressure regularly to avoid abdominal compartment syndrome 1

Pain Management

Dilaudid (hydromorphone) is the preferred opioid for non-intubated patients with perioperative pancreatitis, with morphine as an alternative; all patients must receive analgesia within the first 24 hours. 1, 2

• Patient-controlled analgesia (PCA) should be integrated with multimodal pain management strategies 1
• Epidural analgesia should be considered as an alternative or adjunct for severe pain requiring high-dose opioids for extended periods 1
• NSAIDs must be avoided in patients with acute kidney injury 1, 2
• Laxatives must be routinely prescribed to prevent opioid-induced constipation 2
• For renal impairment (eGFR <30), fentanyl and buprenorphine are safer than morphine 2

Nutritional Support

Enteral nutrition via nasogastric or nasojejunal feeding is strongly recommended over total parenteral nutrition to prevent gut failure and infectious complications, and should be initiated early in severe pancreatitis. 1

• Enteral feeding maintains gut mucosal barrier and prevents bacterial translocation that seeds pancreatic necrosis 1
• Both gastric and jejunal feeding can be delivered safely; continuous infusion is preferred over bolus administration 1
• In mild-to-moderate pancreatitis, oral diet can be attempted after 2-5 days of fasting once pain resolves 1
• Total parenteral nutrition should be avoided, but partial parenteral supplementation is acceptable if enteral route does not meet caloric requirements 1
• Target nutritional requirements: 25-35 kcal/kg/day energy, 1.2-1.5 g/kg/day protein 1
• If using parenteral lipids, monitor triglycerides to maintain levels <12 mmol/L 1

Critical pitfall: Do not delay nutritional support in severe pancreatitis; early enteral nutrition reduces infectious complications, organ failure, and mortality compared to TPN 1

Pharmacological Treatment

No specific pharmacological treatment beyond organ support, pain control, and nutrition has proven effective for acute pancreatitis; medications such as gabexate mesilate and somatostatin analogues are not recommended. 1

• Antibiotics should be used judiciously and only in the presence of documented infection or sepsis, not prophylactically 5
• No restriction on pain medications is warranted, but adjust for renal function 1

Management of Gallstone-Related Perioperative Pancreatitis

For severe gallstone pancreatitis with cholangitis (fever, rigors, deranged liver function), urgent ERCP with sphincterotomy must be performed immediately; for severe cases without cholangitis, ERCP should be performed within 72 hours if no clinical improvement occurs. 1

• ERCP must always be performed under antibiotic cover 1
• Facilities for 24-hour ERCP with sphincterotomy and stone extraction should be available 1
• For mild gallstone pancreatitis, laparoscopic cholecystectomy should be performed during the same admission, ideally within 2 weeks and no longer than 4 weeks 1, 6
• In severe cases with peripancreatic fluid collections, defer cholecystectomy until inflammation subsides and collections resolve or stabilize 1

Critical pitfall: Delaying definitive biliary treatment beyond 2-4 weeks significantly increases risk of recurrent pancreatitis and other biliary complications 6

Mechanical Ventilation

Institute mechanical ventilation when high-flow nasal oxygen or CPAP fails to correct tachypnea and dyspnea; both non-invasive and invasive techniques can be used, but invasive ventilation is mandatory for bronchial secretion management or airway protection. 1

Abdominal Compartment Syndrome

Surgical decompression with open abdomen should be reserved only for severe intra-abdominal hypertension unresponsive to conservative management; avoid open abdomen after necrosectomy unless severe IAH mandates it. 1

• Do not debride or perform early necrosectomy if forced to use open abdomen for abdominal compartment syndrome 1
• Regular intra-abdominal pressure monitoring is essential to prevent over-resuscitation complications 1

Surgical Intervention for Infected Necrosis

Infected pancreatic necrosis requires intervention only when the patient is clinically stable, preferably after 4 weeks when walled-off necrosis has formed; minimally invasive step-up approaches are preferred over open necrosectomy. 1

• Sterile necrosis can be monitored closely without necrosectomy unless clinical deterioration occurs 5
• Minimally invasive approaches (endoscopic or video-assisted retroperitoneal debridement) result in less new-onset organ failure but may require multiple interventions 1