34 Colonic perforation and ischemia in acute pancreatitis

Abstract Introduction Management of complicated acute pancreatitis (AP) has changed significantly in the last decades, especially in terms of step-up approach introduction, delayed surgery, early enteral feeding, restrictions in antibiotic prophylaxis and volume therapy. Severe colonic complications—ischemia and perforation—remain a rare but extremely challenging complication of severe acute pancreatitis. World literature reports mostly about individual case reports, and there is no current guideline for treatment of this complication. Methods Records of Bratislava University Hospital were searched for all treated cases of acute pancreatitis in a 15 years period (2009–2023). In the next step, all patients who required major abdominal surgery for complications of acute pancreatitis were selected, and their surgery records were analyzed for signs of colon ischemia and/or colon perforation. Data on surgical therapy, previous surgeries, outcome, interval since the onset of AP and hospital length were collected. Results 1386 cases of AP were treated in the analyzed period (735 males, 53%). 35 (2.53%) required major surgery. In seven of these (5 males, 2 females, age 27–71) AP associated colonic ischemia and/or perforation occurred. 5 of these patients died, 2 survived (female 27 years, male 40 years). Colonic resection with ileostomy was performed in 4 cases, simple ileostomy in 3 cases. 1 case was diagnosed by CT scan, the resting 6 were diagnosed during surgery. The period of occurrence since the onset of AP varied from 1day to 8 months. Hospital stay varied from 18 days to 230 and 256 days (both survivors). In 3 cases, colonic complication occurred in the early phase of AP (within the first 7 days). In 4 cases colonic complication was observed during the first surgery. Conclusion Our data underwrite huge variability and rareness of this issue, hindering statistical analysis and consensus on universal recommendation. Colonic perforation should be considered following sepsis outbreak during the early aseptic phase of AP, as well as following backsets during the course of the disease. Due to its rareness and severity, colonic perforation and ischemia remains a dark field in the management of AP. Early onset perforation might be a pitfall of strict guideline adherence—delayed CT staging, restriction of antibiotics and early enteral feeding, as well as delayed open surgery.