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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
Rivista di Chirurgia Vascolare ed Endovascolare
Italian Journal of Vascular and Endovascular Surgery 2004 September;11(3):135-8
Acute pancreatitis following abdominal aortic aneurysm repair
Bajardi G., Talarico F., Calì F., Ricevuto G.
Unit of Vascular Surgery University of Palermo, Palermo, Italy
Aim. Occasional increase of amilasemia is variably reported in literature as a complication of abdominal aortic aneurysm (AAA) repair; besides, acute pancreatitis (AP) is seldom reported in the same clinical setting. Clinical reports indicate 0.7% incidence of AP following AAA repair. When AP occurs after AAA repair early survival is severely lowered, as mortality ranges from 40% (mild pancreatic edema) to 100% (in case of necrotic-hemorrhagic pancreatitis). This paper aims to define risks factors of AP after AAA repair for a prompt identification, a correct prophylaxis, and appropriate therapy.
Methods. Between November 1999 and November 2000, 54 infrarenal AAA (34 as an emergency and 20 electively) were treated at the Vascular Surgery Unit of the University of Palermo. We observed 1 case of AP following AAA repair and 4 cases of simple postoperative pancreatic enzymes blood level rise.
Results. All patients with postoperative AP and simple postoperative pancreatic enzymes blood level rise survived. Symptomatic case subsided on the 15th postoperative day with normalization of serological enzymes. In the asymptomatic cases, resolution was achieved earlier (between 6th and 8th postoperative days). CT scanning, performed at the 30th postoperative day, showed a complete resolution of endoperitoneal fluid collection in the single patient showing this complication.
Conclusion. As to etiology, several risk hypotheses have been advanced by literature: a) hypoperfusion injury due either to supraceliac cross clamping or severe perioperative hypotension; b) atheroembolism to pancreatic nutritive vessels due to surgical manipulation of a severely diseased aorta; c) direct trauma to pancreatic parenchyma during difficult surgical approach to aneurysmal neck, as in case of juxtarenal aneurysms or inflammatory aneurysms; d) postoperative occlusion of papilla for concomitant biliary tract disease. This last hypothesis is usually the main risk factor for AP in all clinical situations. This consideration justifies the routine preoperative screening for cholelitiasis and the staged preventive or contemporary surgical cholecistectomy at the time of elective aortic surgery. AP following AAA repair remains a severe complication, even if rare in the most aggressive variety of necrotic-hemorrhagic AP. Prompt identification, correct prophylaxis, and opportune therapy of the mildest involvements, consisting in simple rise of pancreatic enzymes or pancreatic edema, can prevent the dreadful evolution toward a more serious pancreatic damage, usually leading to patient death.