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There you go. I didn't, I didn't know he was part of the meeting. Hello, everyone. Good evening. My name is um um the coordinator of today's session. Sorry, we are starting late again. It's, it was some mix up as well again, apologies. Um Without further ado when the topic today would be acute pancreatitis, it'd be taken by a friend and a colleague. His name is Mrs and Bose. He's a registrar in the teaching hospital in Glasgow. Um He will be introducing himself shortly and just listen and try to make it as interactive as possible because it's going to be an interesting session at the end. We will be sending feedbacks to everyone. So um please endeavor to feel the feedbacks, please. If you can hear me, just type in the chat box and say yes, you can hear me. So I know that I'm not talking to myself. Oh, good, good. M Doctor Ugo Chu has, has indicated that he can inhale. So s sorry once again, s for the delay as well. No, that's fine. Uh Hello, everyone. Thanks for joining um Santon Booth. Uh I'm currently registered in Queen Elizabeth Hospital in Glasgow. Um, and the topic today is acute pancreatitis. It's very familiar, uh, topic for all of us. And, uh, now it's, uh, we, we see these patients every day, almost every day in any hospital. If it's medicine, if it's surgery, we all see it. Uh, so initially I'll start talking about the basics or the anatomy physiology a little bit and then move on to more surgical aspects. Only thing I can say is, uh it's a spectrum from mild to severe. We all know most cases we see are mild and can be treated by any specialty uh like medicine. But in this country or in most hospitals in this country, the protocol is uh all acute pancreatitis go under surgical specialty, but the severe ones are really complex and can be really difficult to manage given by a good surgical team. And they always need a specialized, very specialized team of doctors, nurses, surgeons, and uh dieticians, etcetera, etcetera. So it's a big spectrum. Hopefully we don't see the severe cases very often, but the ones that are severe are really difficult. Some epidemiologies to start with. Um it's a very common and actually increasing in incidence worldwide, mainly because of lifestyle, probably alcohol, especially in this country, but still the leading cause of a pancreat is in this country's gallstone. Um mortality, overall mortality is about 1 to 2%. But if it's severe, especially the infected ones, mortality can be very high, almost 30 to 40%. And uh we, we, even after investigating, we find cause in about 60% cases, about 40% cases, we cannot find a cause. Um So it's difficult to even diagnose or prevent further attacks in those cases. But recently, it has been studied and found that though even in this 40% cases, uh it's still due to gallstone or sludge that were not detected on ultrasound. And the recommendation is to repeat ultrasound. If not, then M RCP, if still not found, then uh endoscopic ultrasound and do after doing all those steps, uh almost 60% of the undiagnosed cases will have a diagnosis, for example, sludge or anatomical variations, anatomy. Uh It's well known to all of us structure. I'm not going to all those details, but we know it's a retro structure and it's surrounded by so many important organs and especially blood vessels, big ones, scary ones. So it's a, it's an area we don't like to go in. Um And as you can see, Duodenum, Jejunum, those are the simple ones compared to the other ones we see, especially the splenic veins, the SM ESM V all running behind it. And any kind of surgery of pancreas carries so high risk just because of the location. And obviously, the gland itself is so different from any other gland uh because of its digestive products and that causes more complications like leaks, surgery of other organs like spleen. Again, it's close, the tail is close related. And uh we all know it can cause uh a leak from the pancreatic duct due to injury to the tail. So the anatomy is very uh intricate and uh it's related to both laser sac and greater sac. As you can see just above it is laser sac. And that, that actually is useful sometimes to contain the infection uh somewhere rather than spreading, generalized in the peritoneum. And that's how a normal pancreas should look like. This fish like appearance there just above the vertebrae and behind it, you can see the splenic vein, micro anatomy. Um the cells, we all know exocrine and endocrine functions. So the exocrine is uh the acinar cells, glands and uh the endocrine function is in the islet of Langerhans and uh comprises of alpha cell, beta cell, uh delta cells. There are other cells uh as well which are very important. But um we don't, we uh the numbers are very small but there are other functions like secreting other hormones and enzymes. We know mainly chymotrypsin, trypsin and uh lipase amylase. And uh the endocrine functions. Uh insulin glucagon, somatostatin peptide Y and there are many other small hormones. This is the arteries, artery in relation and supply. So you, you can see very big vessels and that's why with acute pancreatitis or chronic pancreatitis, there are so many complications involving those vessels, both arteries and veins. So, acute pancreatitis, uh uh it's inflammation of pancreas but the definition or the diagnosis is based on these uh three features. Clinical biochemical imaging, we need two out of three and uh about biochemical lipase is more specific. We uh different hospitals in this country uses either MLA S or lipase. But the, it's more common to use MLS because it's cheaper and it's quite reliable. Uh especially if it's uh more than three fold uh elevated. Sometimes we may find difficulties in some patients who has hyperamylasemia but not pancreatitis. And in those cases, you, you we can use lipase because it's more specific from pancreas. And also uh we should keep in mind other conditions that can lead to high MLS, especially in Children like um mesenteric adenitis or viral infections or even gastroenteritis. Those things can cause hyperamylasemia. And that's when lipi can be useful instead of imaging, everyone causes. Um I would have asked uh what, what, how do you remember the causes? I know the most common uh method of uh memorizing is I get smashed, which is OK. Um But II would say mainly for exam purpose. But if, if you classify according to incident, then this is actually II would say a better way of classifying, especially if you are going for MRC S. Um Then I would probably use this, this is mainly for medical student. I should say leading causes cause in this country. But in other parts of the world, alcohol can be leading cause as well. Uh the other way of dividing. This classification would be uh mechanical uh toxins, infections like that mechanical is like gallstone trauma, post E RCP. Uh toxin would be alcohol drugs. Um And uh infections like viruses, there are parasites as well which can cause pancreatitis. Um Now, pathogenesis, it's very simple, mostly in the mechanical cause. Um it's basically blockage of the duct. Uh but there are so many um changes in the environment within the uh duct and the glands of pancreas and then cascade of reactions that lead to pancreas, which is quite complex. And after the inflammation starts again, there are so many uh interleukins and tnfs that are released that lead to the systemic um findings or systemic complications. So it starts very simple. But there are some, there are very complex um chemical reactions going on inside enzyme activations due to various reasons because if you imagine pancreas has trypsin, gmo trypsin and all the enzymes constantly in its uh duct and its glands, but it's not causing inflammation. So there has to be something else that causes it. And basically, that's slight change in ph and pressure that activates some enzymes and then moves on to a vicious cycle of water activation. Uh even for toxins, it's the similar kind of mechanism. So there is some injury to the uh to the glands uh that causes uh release of enzymes from lyso uh the lysosomes and that activates um the some of the enzymes which leads to a cascade of reaction and then injury. And uh it recently it has been found that obviously alcohol, many people drink alcohol, but most of them won't have pancreatitis. And uh it has been investigated and found that some, there are some genetic factors, some uh mm uh, some people with uh like um genetic variations that who are predisposed to um, injury due to alcohol and other drugs more than others. And that's why uh there are specialized centers who study those things and try to find out if they're, they, they're potentially predisposed to have pancreatitis due to alcohol. And these are the chemical reactions, release of cytokines, enzyme activation, et cetera. Um The severity classification. Um we still use revised uh Atlanta classification. It's very useful and uh it's useful for the patient to know as well for prognostication. There are many methods. But I think this is the most widely used in this country or anywhere in the world. For example, mild pancreatitis, no organ failure, no systemic or local complication. So, an imaging is needed uh which can be ultrasound, which can be ct um moderate. There is transient organ failure and see there is more than 48 hours of persistent and organ failure. There is act classification as well. Um But most of the scans here do not report it, but it's useful for prognostication again, depending on the amount of necrosis and the amount of uh edema. Now, this equity. So there are two types or initially, there are two types of pancreatitis. It can be either radius and otherwise, uh the next one is necrotizing and they follow their own pathway. So either they will just settle radima pancreatitis, they will just settle gradually and that's it. Or they usually, they form a collection and which later on after six weeks form a mature capsule around it or pseudocapsule around it forming a pseudocyst. And uh the contents are still pancreatic enzymes and that can cause more problems directly due to pressure or due to invasion into other parts of the body, other organs. And uh I'll speak about this later on. And the necrotizing again, this is initially, it forms a collection without a mature wall, but gradually the wall matches and forms a thick uh wall of necrosis which is after six weeks. So if it's EDS, they will usually form pseudocyst. If it's necrotizing, they will form world of necrosis after six weeks. And that's when the uh specialized teams, the surgical management start not in every cases, but in some cases who are symptomatic or worsening, there are other complications. But, oh, sorry, let me show you the images. So this is just fluid around pancreas, just edematous pancreatitis. Um But otherwise, the gland is well enhancing, which means there isn't any necrosis. We it's, it's also important about when to do the scan. And usually if you have a diagnosis with uh clinical history and uh MLS or LIPAS, then you don't need a scan initially and it's not useful as well because these changes, these collections or necrosis take a few days to appear or be evident on scan. So usually it's recommended and not to do a scan immediately unless you have a diagnostic dilemma or for example, you are worried about peptic perforation or something else, bowel obstruction. Yes, of course, we need to scan in that case, but otherwise avoid a scan. And if it's a mild pancreatitis, clinical uni and with other scoring systems, then uh maybe they don't need a scan at all. But if they don't show improvement in, in four or five days, then if you do a scan, then you will see uh what's the type of pancreatitis, what, how much damage has occurred. So, uh the recommendation usually followed is uh do a scan if they don't improve in four or five days. And uh this is a necrotic pancreatitis, necrotizing pancreatitis, you can see the area of pancreas is all dark. Now, hypoenhancing, there is a bit of tail of pancreas visible here, but this is all necrotic and it's very important in these cases that uh uh we have, we, we often forget, forget about the nutrition part. Yes, we will put them on NJ or NG feed or if they are eating orally, that's fine, but we forget that they are not secreting enough enzymes. And uh we, we, we have found that uh putting them on Creon on or pancreatic enzyme replacements can improve the outcome quite significantly. And also, Creon has a bit of analgesic effect and reduces the opioid requirement. So it's very important to keep that in mind. If they have necrosis like that, almost 80% of destruction of the pancreas, then they will definitely develop uh pancreatic exocrine insufficiency may be transient, may be permanent, but it's always good to put them on. Uh Creon, it's not going to cause them harm um but not putting them on. Creon has shown the outcome is worse in the long term and uh it will also help them um eat better and absorb better. So, nutritionally, they will be much better. It's difficult to diagnose pancreatic insufficiency espe especially in the acute setting because we mainly rely on ct features of chronic pancreatitis which means like calcifications or dilatations. Um clinically also it's very difficult to diagnose because weight loss takes a while. Diabetes takes a while and also steatorrhea. Again, it's not reliable. Initially, fecally less test can be used. But again, initially, it might be difficult to diagnose pancreatic exocrine insufficiency. So, uh severe necrosis can be initiated on Creon then comes the worst ones. So a necrotic collection or a necrotic area has become infected, which is very clearly even on with the gas. Now, this is very straightforward and simple, but often we face that it's not that straightforward. Uh we don't see that amount of gas very often. If we see that good, then we know a diagnosis. But if we don't, but still the patient is uh uh septic, then it creates a problem or diagnostic dilemma, whether the patient is uh developing in infected necrosis or not. And the more severe form is cemento pancreatitis, which is basically a lot of gas in the collection. And these things can be really difficult to treat Uh because one, they're very septic, they're very sick and two draining these large collections is also very difficult. It poses a big challenge and that's why these specialized centers and uh various kind of surgeries and protocols have been started. Initial investigations we all know. Um so I have added this bit other than obviously a BCU N ES. Um This is mainly for scoring um or categorizing the severity like a two score or gla gy score. Uh some bloods for etiology like calcium parathormone, uh triglycerides, all those things um important is chest X ray. Often it's difficult to differentiate between uh peptic perforation and pancreatitis, especially if the amylosis marginally raised above three fold, it might be difficult. And if the patient is spial tachycardic, then it becomes more and more difficult. Uh So chest X ray can be useful to rule out any gas under the diaphragm or also it helps in scoring because you need uh to know if the patient has pleural effusion. So chest X ray is uh a good idea. Otherwise, if you're in diagnostic dilemma, again, ct and obviously in elderly patients or even more than 50 years old, cardiac causes should be ruled out. Now, scoring system, there are many, many scoring systems and uh which just means that none of them are perfect. But that's um uh if, if you follow a particular protocol in the hospital, that should be ok because this is mainly for uh explaining to the patient. And nothing else really, if you look at the specialized centers, they hardly use any of these scores because uh it doesn't mean anything in terms of treatment because we all we always have to treat clinically and just do what's best for the patient. So the scoring system is mainly to give numbers to the patient and family. But uh there are studies done regarding which score is best and Apache two is actually the best score or at 48 hours is the better score. Uh a better way of categorizing the severity of uh pancreatitis. But again, in the periphery or TG H, it's difficult. For example, you need LDH and you always need a blood cast to do all these things. So you can use something simpler like bicep score. So that's the Apache to score. Bicep is quite simple and can be done at bed at bedside. The complications uh again divided into local and systemic. It's a very complex disease, hopefully not in most patients in about 80% cases, it's simple, but uh 20% pa patients can be complex with various complications. Uh The initial local complications are uh like collection, pseudocyst, uh not pseudocyst sorry collection or necrosis, um which are just fluid and damage to the pancreas itself. And then the complications are when these uh these collections, which is basically enzymes of pancreas and as you know, they can digest anything in our body. So they erode into other organs and cause other complications. For example, if they go into a vessel, then they can cause huge amount of bleeding and can be either hemorrhagic pancreatitis or if they go into an artery, they tend to form a pseudoaneurysm and thrombosis as well. Bleeding from artery is relatively easier or slightly better than bleeding from vein, especially in terms of managing them because artery, they tend to seal off by forming a pseudoaneurysm or even if they are bleeding, ir is a good option to um control those, but venous bleeding is really difficult uh to control and to stop. Ir is also it's possible but difficult again to control a venous bleeding with IR. So it comes down to if, if, if it's not stopping spontaneously, it comes down to almost all the surgery. Again, that's not really what we want. These patients are really difficult to control. Even on surgery with so much inflammation, it's very difficult to see anything and the other local complications can be uh affecting the bowel, mechanical obstruction or ileus and uh systemic complications. Um One is A R DS affecting lung. It can affect anything AK I kidneys, A R DS. And uh so, and then MS, so this is ac it's a late complication from uh um collection and this is wall of necrosis. It's difficult to appreciate from just single slice. But if you go up and down, then you can see there are areas, small areas of necrosis. Uh but this is just a slice slide showing the slightly hyper enhancing rim around which is basically the capsule or pseudocapsule forming uh around the necrotic area. Uh With time, this, this should match your more and more and sometimes they don't cause any symptoms, but often they cause mechanical problems to stomach elicit or gastric obstruction and that's when you need to drain them. But again, those drainage procedures are preserved for late and we tend to avoid any kind of intervention as long as possible. These are the um aneurysms or the arteries that can be affected. Most commonly splenic artery, nearly um often near the tail area, body and tail and the head of pancreas affects mostly the gastroduodenal artery. So these are the known or common arteries affected due to the pancreatic collections or eroding of the vessels causing pseudoaneurysms. It can be other vessels as you can see hepatic artery, uh the sma and the gastro uh the pancreatic Aden arteries as well. Uh This is a classical uh sign. The of hemorrhagic pancreatitis, Cullen sign and gray turner sign because it's a retroperitoneal structure. The bleeding often is also retroperitoneal. It goes into the layers of muscle and then tracks from below uh from behind into the muscle, uh layers and then on the flank, it forms this uh greater sign and it can seep again through the layers into the umbilicus. It's not very commonly seen nowadays. But if you see this, uh it's uh hemorrhage pancreatitis. Um Next, it, as I said, it can erode into anything, the collections because it's containing uh enzymes. So it can erode into bowel into stomach, into duodenum gallbladder, colon. Um And even through diaphragm into the chest, as you can see, pancreatic approval, fistula, um these things again becomes very difficult to manage and should be managed in a specialized center and they will need drainage. Uh They will need both chest drain and drainage of the cyst or the collection as well. Um This is the overall picture uh published by B MJ recently or not recently a few years ago. Um showing the incidence of pancreatitis. As you can see most common. It's mild and they carry very low mortality rate, but about 1/5 of them can be severe and uh ha carry high motility rate. If it's sterile, then it's about 15%. But if it becomes infected, mortality can be very high, 30 to 40% management. So it's mainly supportive, there is nothing that can prevent uh stop the inflammation process. And usually when the patient presents, uh the inflammation has occurred already and has stopped and he is improving now and those are the mild ones and they should improve with analgesia and IV fluids only. Um, nutrition is also very important in these patients. And uh we have seen that feeding inter uh reduces the chances of infection. Patients who are fed by PN uh do not do very well just because they develop, they are more, more prone to develop infected collections. And the definitive management, which basically means uh if they have gallstones, then of course, they will leave their gallbladder taken out. Um Sometimes if they have CBD stone, they may need er CP initially. Now, uh the volume of fluid, historically, we used to infuse them with huge amounts of fluids. Um but we have seen now that it's not really needed and it should be stratified according to the patient, their age comorbidities and also the severity of uh the uh inflammation and uh disease. I think the better way or the accepted way now is to go by the urine output and see what how much fluid they are requiring or producing and their BP map. Uh their hematocrit can be very useful hemoglobin and hematocrit can be useful lactate. Those are the things that's better than just uh using large amount of volumes because it causes more volume overload. And it's not really needed for the patient type of fluid has been studied as well. And Harman's is the best one that has been found. Ring is lactator. Harman's uh normal saline is actually not very good because it's slightly acidic and can worsen uh the inflammation. So heart is better antibiotics not needed. As we all know, even if it's necrosis, do not use antibiotics. Even if they are spiking temperatures or uh if they are tachycardic, still it's just sepsis. And sir, and not infected unless you can of course, see evidence of infection in the form of gas bubbles, but it's difficult, as I said, mm, of sometimes we don't see gas bubbles initially and still they may have infected necrosis. And uh I did some research and found uh that procalcitonin is very good uh marker to stratify that uh procalcitonin is uh one of the acute phase reactants like CRP. It's costly to diagnose or test or procalcitonin. But it's very useful in this kind of patients because uh it's very specific to bacterial infection. So if someone has bacterial infection, then procalcitonin will be very high other infections like virus or chest inflammation, it can be raised but slightly margin in risk. And if you do procalcitonin in these patients where you are doubting whether they are infected, it can be very useful um to guide antibiotic therapy. CT scan. So initially at four or five days after in uh onset of symptoms if they are not improving, if they're improving, you don't need to. But if they're not improving or you have a diagnostic dilemma. PL CT, um sometimes if you couldn't find a cause, then A R might be useful. One to look for uh gallstones and second to look for anatomical um variations C is also useful in cases of um trauma. Of course, in trauma, you need to go ahead with CT initially and also for malignancies. After the first CT scan, I, if the patient uh showed signs of collection initially or necrosis, then often we have to repeat the CT scan and usually it's in about 2 to 3 weeks if they don't show improvement or after six weeks, once the uh capsule is matured, if they have shown marked improvement, you may delay it by six weeks. Once the capsule is fully matured and then decide on further intervention or further steps. Uh If they're not improving, then often they get a CT every two weeks to look at the collection or if they're becoming infected. So have low threshold. In those severe cases for scanning and nutrition when to start is the answer is immediately uh as soon as possible. So once you have reached the diagnosis and once you are sure that this is pancreas is nothing else, then start nutrition and eating orally or enteral uh route is the best. If they can't eat because of pain or vomiting, then ng and there is no difference between NG or NG. Uh in terms of nutritional benefit or symptomatic benefit. Uh It's really depending on uh the scans and the local complications that whether NG or NJ uh would be more useful. For example, if they have large collection, causing gastric obstruction or compression, and that's why there is hold up in stomach, then maybe NJ is better. But otherwise, there is not much difference between uh benefits of NJ versus NG. In these cases. BN is really uh preserved or tend we tend not to use parental nutrition because it causes translocation of bacteria into the collection and high risk of uh infected necrosis or infected collections. That's why the internal root is better. It controls the um gut flora, increases the good bacteria or the common cells and reduces the pathogenic ones reduces uh translocation. And that's why there were studies regarding probiotics. Um and nothing has been found useful in those regards. It's only uh enteral nutrition by any means like NGN G or oral, but probiotics not indicated or not useful interventions. Um Role of E RCP in and gallstone pancreatitis. It's very controversial. Um And the guy, the recommendation is not to do E RCP in the acute phase because um as you all probably know, it's the micro sludge or microcalcifications or sludge that is more prone to cause pancreatitis. So that is same like a very small stones and they often don't cause obstruction of CBD and they can pass easily. It's just uh a transient blockage of the uh CBD or the common channel uh that causes pancreatitis. And hence, uh often they are dislodged by the time you see them or uh even if they have mild raises in bilirubin, that's because of edema um around the head of pancreas. So it's not recommended only if you have evidence that there is a stone blocking it. Then yes, a sphincterotomy can be done but have to keep in mind that splenectomy or CP has its own complications, especially pancreatitis. And with someone already inflamed pancreas, this can be even higher. So the decision is very difficult and should be taken by specialized centers regarding CP and spicy. If they have cholangitis or simultaneous biliary infection, uh start on antibiotics initially and that should be enough to control the infection. They may need drainage, but it's better to wait for pancreatitis to settle down before draining. And even uh the, although there is recommendation to take their gallbladder out in the same index admission and not to discharge before cholecystectomy, still, the recommendation is to wait for inflammation to settle down before going for a cholecystectomy. Now infected necrosis. Uh This is more and more complex. Uh timing of intervention. We all think that uh we have to remove that necrosis or that uh collection. But uh the uh best way to treat those is not to do that and to wait and wait as long as possible. So currently the recommendation is to or the it's not recommendation. The saying is uh do as little as possible for as long as possible. Even if they are necro uh pancreas, just make sure they have good analgesia, they're hydrated and nutrition, especially uh if uh they have pancreatic exocrine insufficiency that should be put on Creon and just wait often they will settle down just by that. And if they have some collection, they may need. If they're symptomatic, they may need some intervention, but that should be delayed and delayed. Not, not anytime within the six weeks period. If they form infected necrosis, of course, they will need uh drainage of those areas, but those are complex things and I'll show you later on. Um Well, in terms of intervention, if they have necro necrosis, uh necrosis collection, um then again, initially, it's just antibiotics, IV antibiotics and weight and weight. If they're improving just with antibiotics, fine, uh don't do anything else if, if uh the and of course this uh referral to the specialized centers. So what they do is basically same thing, antibiotics and nutrition. And if they don't show improvement, that's your uh sign of now it's time to intervene. And in terms of intervention, there are few, few choices, you probably all know uh endoscopic uh is one option, endoscopic drainage, percutaneous drainage and open surgical techniques. The preference is for the least invasive way which is endoscopic or sometimes percutaneous depending on where the collection is, where the infection is. Um But again, if they are improving on antibiotics, then none of these are done. If they don't improve or they worsen, then go for the least invasive way. This is the uh B MJ recommendation regarding treatment. It's called step of approach, which means you don't do anything for as long as possible. If the patient is showing improvement, then don't do anything. If the patient is not improving or deteriorating, then you do the least invasive method, which initially can be uh endoscopic or percutaneous drainage. Again, if they're not improving or uh deteriorating, then repeat scan and then decide whether they need uh endoscopic step up or surgical step up, for example, direct drainage. So this is the type of approach gradually increasing the invasive procedures uh as long uh uh uh if they're not improving and the mistake we or sometimes we make is we wait for them to crash and pancreatitis can crash in our, it's very quick. So the key thing is not to wait for that to uh pick up those subtle changes. For example, they're not gaining weight or they're not improving in terms of pain or their infection markers are not improving. Those are the subtle things that we should pick up before they're actually hemodynamically unstable. Uh It's very unpredictable. But if, if, if we keep our eyes open that this patient is not improving, even after changing the treatment. Even after changing the antibiotic regimen, then that means that it's not working, then we should not wait further. Uh, 48 hours, 78 hours, do something else. Do something more for, to see changes, to see improvement. And that's very important and that's what these specialized centers do as well. They don't wait for the patient to crash. Now, if the patients crash, they can crash in any way. Uh It's not just septic shock, they can cause bleeding because those collections again, uh they can grow bigger and bigger and they can erode into vessels at any point. It's not just the immediate or early phase where they cause bleeding. There are cases where they R to S MA or S MV and torrential bleeding, uh even six weeks or 32 months later on down the line. Um So it can happen and the, it's difficult to predict. But as long as we are uh open to uh reviewing the patient clinically and keeping an eye on the improvement, it should not happen. Now, the procedures. So percutaneous drainage is basically a pigtail drainage and uh depending on the location, uh it can be put in various places. And the key is to, it's the principle is same for any collection which is you have to drain the most dependent part. So if the collection is in the laser sac, then uh probably a retroperitoneal approach is fine. But if the collection can be anywhere. But if the collection is, let's say, tracking down to pelvis, then that may not be adequate. And you may need more than one R one in Pelvis, one in laser sac or one in upper abdomen. Sometimes they may need um two approaches. For example, one endoscopic approach, one drainage by endoscopy and one drainage uh percutaneously depending again, what's the dependent area. Sometimes they may chest drain if they have uh uh pancreaticopleural fistula. The others. Uh The surgical technique is video assisted retroperitoneal debridement, which is like uh um laparoscopic surgery. And basically, it's opening of the retroperitoneal area uh with ultrasound or CT guidance and um usually ultrasound guidance and just using instruments to take out the nec necrotic materials. So, this procedure is really preserved for patients who are not showing any improvement because the mortality is very high even after the procedures. And uh it, it we have found all these specialized centers. We, we all know that uh the more invasive procedures carry higher risk of mortality. So we tend to preserve those for the patients who are really not improving with other things. And this is really a game changer uh endoscopic procedure. So the idea is to go through one of the hollow viscous and just drain it. So this is showing necrosectomy, which is actually the step up for endoscopic procedures. The first step that is done is uh uh lambs lumen, uh opposing metal stent and this is called axios stent. And this is just uh so the method of doing it is using an endoscopic ultrasound, uh localizing the collection and hoping that we are not going through a vessel because that can happen uh in stomach. And also uh the ultrasound can help us locate major vessels and making a hole in stomach and going through the collection and just putting the stent across. Sometimes this is just enough to control infection and the patient won't need anything else. Sometimes if they're not improving as a step up, you can put a scope through that uh stent and then do a necrosectomy, endoscopically. Sometimes they may need this plus percutaneous drainage. As I said, if the collection is huge and there are some components in the lower abdomen, then this may not be enough to drain the whole collection and they may need another drainage percutaneously uh in the lower abdomen or pelvis. Um This is just a picture of uh video assisted uh necrosectomy. So the collections usually they will uh go towards the left side. Uh it can go anywhere but this is the usual location and uh making a small cut, it's easily accessible. The procedure is not very difficult to do but uh it's not uh good for the patient in terms of uh mortality and morbidity. And if you imagine these patients, it's not, these procedures are not done in weeks, they stay in the hospital for months and months. Uh So there are several other specialties including psychologist or physiotherapist who are involved in care of these patients dieticians. So it's really a multidisciplinary uh approach. And uh these patients are very complex and they need many inputs from various specialized teams. That's why they, they are always treated in the specialized centers. And if you see any of these patients who have complex necrotic collections or huge collections, then they should always be referred to specialized centers even in these specialized centers. The treatment is not simple. Um As you can see, they stay in hospital for weeks and weeks. That's all for today. If you have any questions. Thank you very much, Santon. Um There is a question on the chat box and I have one question as well. Um It says uh what cla what class of analgesia is best for pain control? OK. Um So we know about the wh O step ladder but uh we have found that nsaids are really good. We don't tend to use them especially uh because we're worried about stress ulcers, gastritis, et cetera, et cetera. But uh Diclofenac or naproxen, nsaids, any nsaids are very useful. Um There are studies um regarding post ercp pancreatitis and probably it's almost standard practice. In most case, most places, at least where I work, it's standard practice to use prophylactic diclofenac before CP. And it has been shown that it reduces the incidence of pancreatitis. So use NSAID. Um of course, morphine is strong. Um And we may need to use morphine, we may need to use PCA fentaNYL, et cetera, et cetera. But uh also use nsaids. So what's the best in acute pancreatitis? It's type of approach, a a later approach. But uh don't be worried about using nsaids. That's what I mean to say in acute pancreatitis. Use nsaids, diclofenac. It's very good. Yes. Becau yeah, because the pain in pancreatitis is quite severe And yeah, from my experience most times, especially when it becomes complicated. Nsaids don't cut it most times. No. In, in the acute phase. It it can help to reduce the inflammation to some extent, uh reduce the damage to some extent. Yes, you, you need to use opioid but also use diclofenac. That's what I mean. You use nsaids plus something else like top up. It can be dihydrocodeine or codeine. If the patient is tolerating that you may find that after using nsaids, you may need not to need uh you may not need that high dose of morphine or uh you, you can use dihydrocodeine. So uh recommendation is to use nsaids in acute pancreatitis. Yes. So there is um so sorry. II don't know if I if I didn't, if I didn't get that in the um diagnosis, I know it may be obsolete now. But like in the practice, what we do during diagnosis that there are three ways we can diagnose and there are three things that we need or two or three things that we need to diagnose hepatitis, right? Where we talked about CT scans, um ambulate, um ra raise ambulate of more than three of the baseline or um clinical symptoms and signs. Right? Yes. So, I II don't know. And from what you've taught us now, ct scans may not really uh may not be indicated in like presentation if you already have diagnosis. Yeah, exactly. So, so what is the role of CT scans now or are they beginning? Like what's your advice regarding doing CT scans on presentation for diagnosis of pancreatitis? We don't need them. Uh If you already know the patient has pancreatitis and nothing else, then he shouldn't do it because it's not going to add anything. You're not going to gain any more information. What would be more useful is if they're not improving four or five days down the line, uh then a CT scan would show us the local complications collections. Uh Necrosis. That's when the CT scan would be useful. Uh some of the scoring systems or the device Atlanta, they need ac 24 48 hour CT scan. But uh if this, if it's mild pancreatitis and uh the patient is improving that it's not really needed. If you want really, you can also do an ultrasound that can show you gallstones, but that can also show the peripancreatic fluid and edema. Ok. So we have a couple of questions in the chat box. Um, one from, I can, I can read it. Yeah. Ok. What's the rule of stopping internal nutrition within the 1st 24 hours of acute pancreatitis and the use of total parenteral nutrition? Uh, no, it's the, there is no, uh, benefit or it's actually worse to use total parenteral nutrition. Um, why would someone stop enteral nutrition? Uh, any particular reason? I mean, is this something you have come across clinically? I'm just asking if we can type. Oh, ok. I'll, in the meantime, I'll answer the next one. which is quite interesting and uh, I don't know, it's truly under surgeons because I think we, we are, I mean, straightforward, probably I should, I should use my words carefully. So, uh uh well, II can see from both sides like most of the complications like of pancreatitis may require like not most, but some of the complications may require surgery in my, in the center here and so forth. I know that first incident, first diagnosis of pancreatitis is usually surgically surgically managed. But once the patient is having recurrent pancreatitis and it's not gallstones that causes the pancreatitis, then the med, the medics manage the pancreatitis really. So in other countries or in other areas of the world, acute pancreatitis is mostly treated by medicine. And if they find, yeah, if they find they have a surgical reason of pancreatitis like gallstone or if they have complications, that's when they refer to surgeons here, it's opposite. We start in and then move to, yeah, in many, in many countries. Exactly. She has written, uh, in many countries. Initially, it's treated by medicine in my country in India. Uh, it's treated by medicine and only if we find gallstone or a surgical cause. That's when they're referred to surgeons. Uh, in UK, the reason is very different. Uh, sometimes it's a nursing nursing issue more than a doctor's issue because they say that they are not able to manage that amount of pain like PCA, they don't manage PC in medical wards, they don't do strict free charging. That's what we need for those patients. And that's why uh that, that those are the usual reasons of sending those patients under surgery, not really gallstones. That's just a lie probably because it's uh I mean, they can, it can, the patients can be referred to surgery anyways and we know which patients have alcoholic pancreatitis. We know from the beginning that this pancreatitis is alcohol related yet they come under surgeons. So gallstone is not really the actual reason. It's very complex. So Mohammed Bulla has answered and said that he read somewhere that resting the gut within the 1st 24 hours improves incom of acute pancreatitis. This is probably the teaching uh 3040 years ago, it's changed now resting the worsens the outcome. Uh There is no indication because as I said, the insult to pancreas is probably a minute when the pain initially started. That's when the insult occurred. And soon after that, the process of healing starts but still because of the edema and the inflammation, it's still sore. But as we know inflammation, the healing process starts almost immediately. And that's the case in most pancreatitis, the healing process starts immediately. We just have to give them time, support them until the inflammation is fully settled. So, no gut resting is bad and internal footing, internal feed or feed should be started as soon as possible and continue. That's the current teaching. It can reduce the severity of uh outcome. Yeah. And like like s and said during the presentation, like because most pancreatitis patients may come in with reduced appetite. It's important to know all the stages of nutrition that, that are available for these patients including Creon and you know, um and um exogenous enzymes that we can give as well to help with digestion and all that you should be preserved for patients who has necrosis on CT like extensive necrosis. Most pancreatitis or mild pancreatitis won't need Creon just eat and drink. Normally you can advise low fat diet if that reduces sickness and nausea and uh pain. But otherwise just uh let the me if they're not eating uh ng. Yeah. OK. And you too. All right. I uh time is fast and I don't think there are any other questions on the chat box. Um Thank you very much again for this, very elaborate um session. Um We hope to have you here in the future to take other week. Um Thank you very much in the absence of any. Thank you just um end the session. Yes, that reminds me for the feedback. Um We will send the feedbacks to everybody individually and please endeavor to put your feedbacks and make sure that you, you know, encourage the, the, the tea, the teacher and also, you know, so that he can see, he can see what needs to be improved upon and what he has done well and all of that. Thank you very much, everybody. Thank you very much Xan for this presentation once again. Um I think there's one. Ok, everybody is saying thank you as well. Thank you. All right, have a good day. Everyone. Have a nice day, everyone. Bye.