Infektionen im Rahmen der nekrotisierenden Pankreatitis

Zusammenfassung

In der Praxis sollten Patienten mit Nachweis von > 50 % Nekrose im CT, einem erhöhten CRP und Prokalzitonin wegen des erhöhten Risikos einer schweren Pankreatitis und septischer Komplikationen besonders überwacht werden. Eine ERCP und Sphinkterotomie ist bei Patienten mit biliärer Pankreatitis und impaktierten Gallensteinen, biliärer Sepsis oder obstrukivem Ikterus indiziert. Bei Patienten mit nekrotisierender Pankreatitis und septischem Krankheitsbild sollte eine FNA zur Differenzierung von sterilen und infizierten Nekrosen durchgeführt werden. Die symptomatische Basistherapie besteht aus einer ausreichenden Volumensubstitution. Die Antibiotikaprophylaxe bei nekrotisierender Pankreatitis führt zu einer Reduktion von septischen Komplikationen bei schwerer nekrotisierender Pankreatitis. Die chirurgische Therapie ist bei septischen Patienten mit infizierten Nekrosen indiziert. Das Therapieverfahren der Wahl ist weiterhin die offene Nekrosektomie und die anschließende geschlossene Lavage der Bursa omentalis und des Retroperitoneums.

Abstract

Patients with CT evidence of more than 50 % necrosis, or an increased CRP or procalcitonin are at risk of developing severe pancreatitis and septic complications and should be monitored in an intensive care unit. ERCP and sphincterotomy are indicated in patients with biliary pancreatitis and impacted gall stones, biliary sepsis, or obstructive jaundice. In septic patients with necrotizing pancreatitis, a FNA should be performed for differentiation of sterile and infected pancreatic necrosis. Adequate volume resuscitation and analgesic treatment are the most important treatment of acute pancreatitis. Antibiotic prophylaxis reduces septic complications in severe necrotizing pancreatitis and should be started early. Surgical therapy is indicated in patients with infected pancreatic necrosis. The surgical technique of choice is open necrosectomy with postoperative closed lavage of the lesser sac.

Schlüsselwörter

akute Pankreatitis - chirurgische Therapie - Antibiotikatherapie - infizierte Pankreasnekrosen

Key words

Acute pancreatitis - surgical therapy - antibiotics - infected pancreatic necrosis

Literatur

• 1 Balthazar E, Robinson D, Megibow A, Ranson J. Acute pancreatitis: value of CT in establishing prognosis.  Radiology. 1990;  174 331-336
• 2 Banks P, Gerzof S, Langevin R, Silverman S, Sica G. et al . CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome.  Int J Pancreatol. 1995;  18 265-270
• 3 Beger H G, Bittner R, Block S, Büchler M. Bacterial contamination of pancreatic necrosis - a prospective clinical study.  Gastroenterology. 1986;  91 433-441
• 4 Beger H G, Buchler M, Bittner R, Block S, Nevalainen T. et al . Necrosectomy and postoperative local lavage in necrotizing pancreatitis.  Br J Surg. 1988;  75 207-212
• 5 Bradley A, Allen K. A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis.  Am J Surg. 1991;  161 19-24
• 6 Bradley E L 3rd. Operative management of acute pancreatitis: ventral open packing.  Hepatogastroenterology. 1991;  38 134-138
• 7 Buchler M, Malfertheiner P, Friess H, Isenmann R, Vanek E. et al . Human pancreatic tissue concentration of bactericidal antibiotics.  Gastroenterology. 1992;  103 1902-1908
• 8 Buchler M W, Gloor B, Müller C A, Friess H, Seiler C A. et al . Acute necrotizing pancreatitis: treatment strategy according to the status of infection.  Ann Surg. 2000;  232 619-626
• 9 Büchler M W, Malfertheiner P, Schoetensack C, Uhl W, Beger H G. Sensitivity of antiproteases, complement fctors and C-reactive protein in detecting pancreatic necrosis: results of a prospective clinical trial study.  Int J Pancreatol. 1986;  1 227-235
• 10 Carter C, McKay C J, Imrie C. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pacreatic necrosis: an initial experience.  Ann Surg. 2000;  232 175-180
• 11 Dervenis C, Johnson C D, Bassi C, Bradley E, Imrie C W. et al . Diagnosis, objective assessment of severity, and management of acute pancreatitis.  Int J Pancreatol. 1999;  25 195-200
• 12 Fan S T, Lai E C, Mok F P, Lo C M, Heng S S. et al . Early treatment of acute biliary pancreatitis by endoscopic papillotomy.  N Engl J Med. 1993;  328 228-232
• 13 Fernandez-del Castillo C, Rattner D W, Makary M A, Mostafavi A, McGrath D. et al . Debridement and closed packing for the treatment of necrotizing pancreatitis.  Ann Surg. 1998;  228 676-684
• 14 Fölsch U R, Nitsche R, Ludtke R, Hilgers R A, Creitzfeld W. Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis.  N Engl J Med. 1997;  336 237-242
• 15 Gastroenterology: BSo . United Kingdom guidelines for the management of acute pancreatitis.  Gut. 1998;  42 S1-S13
• 16 Gloor B, Müller C, Worni M, Martignoni M, Uhl W. et al . Late mortality in patients with severe acute pancreatitis.  Br J Surg. 2001;  88 975-979
• 17 Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis.  J Gastrointest Surg. 1998;  2 496-503
• 18 Guidelines UK . UK guidelines for the management of acute pncreatitis.  Gut. 2005;  54 1111-1119
• 19 Gullo A, Berlot G. Ingredients of organ dysfunction or failure.  World J Surg. 1996;  20 430-436
• 20 Heath D, Alexander D, Wilson C, Larvin M, Imrie C. et al . Which complications of acute pancreatitis are most lethal? A prospective multicenter clinical study of 719 episodes.  Gut. 1995;  36 478
• 21 Isenmann R, Rau B, Beger H. Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis.  Br J Surg. 1999;  86 1020-1024
• 22 Isenmann R, Runzi M, Kron M, Kahl S, Kraus D. et al . Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial.  Gastroenterology. 2004;  126 997-1004
• 23 Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos C. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial.  Br J Surg. 1997;  84 1665-1669
• 24 Kemppainen E, Sainio V, Haapiainen R, Kivisaari L, Kivilaakso E. et al . Early localization of necrosis by contrast-enhanced computed tomography can predict outcome in severe acute pancreatitis.  Br J Surg. 1996;  83 924-929
• 25 Klar E, Werner J. New pathophysiological findings in acute pancreatitis.  Chirurg. 2000;  71 253-264
• 26 Lankisch P, Pflichthofer D, Lehnick D. No strict correlation between necrosis and organ failure in acute pancreatitis.  Pancreas. 2000;  20 319-322
• 27 Levin D, Bret P. Percutaneous fine-needle aspiration biopsy of the pancreas resulting in death.  Gastrointest Radiol. 1991;  16 67-69
• 28 Neoptolemos J P, Carr-Locke D L, London N J, Bailey I, Fossard D P. Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones.  Lancet. 1988;  2 979-983
• 29 Neoptolemos J P, Raraty M, Finch M, Sutton R. Acute pancreatitis: the substantial human and financial cases.  Gut. 1998;  42 886-891
• 30 Rau B, Pralle U, Mayer J, Beger H. Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis.  Br J Surg. 1998;  85 179-184
• 31 Rünzi M, Layer P, Büchler M. The therapy of acute pancreatitis. General guidelines. Working group of the society for scientific-medical specialities.  Z Gastroenterol. 2000;  38 571-581
• 32 Sarr M G, Nagorney D M, Mucha Jr P, Farnell M B, Johnson C D. Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy / debridement and delayed primary wound closure over drains.  Br J Surg. 1991;  78 576-581
• 33 Sharma V K, Howden C W. Prophylactic antibiotic sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis.  Pancreas. 2001;  22 28-31
• 34 Sigurdson G. Acute pancreatitis: therapeutic options in multiple organ failure. In: Büchler M, Uhl W, Friess H et al. (eds). Acute pancreatitis: novel concepts in biology and therapy. Blackwell Science Ltd, Oxford 1999; 395-410
• 35 Sitzmann J V, Steinborn P A, Zinner M J, Cameron J L. Total parenteral nutrition and alternate energy substrates in treatment of severe acute pancreatitis.  Surg Gynecol Obstet. 1989;  168 311-317
• 36 Tsiotos G G, Luque-de Leon E, Sarr M G. Long-term outcome of necrotizing pancreatitis treated by necrosectomy.  Br J Surg. 1998;  85 1650-1653
• 37 Uhl W, Roggo A, Kirschstein T, Anghelcopoulos S, Gloor B. et al . Influence of contrast-enhanced computed tomography on course and outcome in patients with acute pancreatitis.  Pancreas. 2002;  24 191-197
• 38 Uhl W, Warshaw A, Imrie C, Bassi C, McKay C. et al . IAP guidelines for the surgical management of acute pancreatitis.  Pancreatology. 2002;  2 565-573
• 39 Villatoro E, Larvin M, Bassi C. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.  The Cochrane Database of Systematic Reviews. 2005;  4 CD002941
• 40 Werner J, Feuerbach S, Uhl W, Büchler M. Management of acute pancreatitis: from surgery to interventional intensive care.  Gut. 2005;  54 426-436
• 41 Werner J, Hartwig W, Uhl W, Müller C, Büchler M. Acute pancreatitis: Are there useful markers for monitoring disease progression.  Pancreatology. 2003;  3 115-127
• 42 Werner J, Uhl W, Büchler M. Surgical treatment of acute pancreatitis.  Curr Treatm Opt Gastroenterol. 2003;  6 359-368
• 43 Widdison A L, Karanjia N D. Pancreatic infection complicating acute pancreatitis.  Br J Surg. 1993;  80 148-154
• 44 Wilson C, Heads A, Shenkin A, Imrie C W. C-reactive protein, antiproteases and complement factors as objective markers of severity in acute pancreatitis [see comments].  Br J Surg. 1989;  76 177-181