Akute Pankreatitis: Wann ist der Chirurg gefragt?

Zusammenfassung

Die Behandlung der akuten Pankreatitis erfolgt heutzutage primär konservativ. Insbesondere die zunehmend interdisziplinäre Behandlung und optimierte Intensivtherapie hat in den letzten Jahren zu einer deutlichen Verbesserung der Prognose der schweren nekrotisierenden Pankreatitis geführt. Die frühzeitige Operation wurde aufgrund hoher Morbidität und Mortalität verlassen und durch ein primär konservatives intensivtherapeutisches Management ersetzt. Im Verlauf der Erkrankung gibt es jedoch weiterhin bestimmte Indikationen zur chirurgischen Therapie. Die Cholezystektomie bei biliärer Pankreatitis, die Nekrosektomie bei infizierter Nekrose und progressiver Sepsis und die Notfalloperation bei Hohlorganperforation oder Blutung gehören dazu. Der folgende Artikel gibt einen Überblick über chirurgische Indikationen, optimale Terminierung der Operation und konkurrierende chirurgische und nichtchirurgische Behandlungskonzepte wie laparoskopische oder endoskopische Verfahren. Alle hier genannten Verfahren erfordern ein erfahrenes Team aus Gastroenterologen, Viszeralchirurgen, Radiologen und Intensivmedizinern, das den potentiell vital bedrohlichen Komplikationen jederzeit gewachsen ist. Für die Therapie einer schweren nekrotisierenden Pankreatitis sollte der Patient in ein entsprechendes Zentrum verlegt werden.

Abstract

The treatment of acute pancreatitis is primarily non-surgical. An interdisciplinary approach as well as timely and aggressive intensive care has led to a significant improvement of the prognosis in severe necrotising pancreatitis. Early surgical procedures were associated with high morbidity and mortality and therefore were abandoned and replaced with forceful conservative treatment. However, there are still specific indications for surgery during the course of acute pancreatitis. These include cholecystectomy for biliary pancreatitis, surgical debridement of infected necrosis in septic patients and emergency operations for gastrointestinal perforations or haemorrhage. The following article focuses on surgical indications, optimal timing of surgery and competing surgical and non-surgical concepts like laparoscopic or endoscopic management. All mentioned procedures demand the cooperation of an experienced team of gastroenterologists, surgeons, radiologists and intensive care specialists, who are able to manage the potentially life-threatening complications of this disease. All patients with severe necrotising pancreatitis should be transferred to a specialised centre for interdisciplinary therapy.

Schlüsselwörter

Pankreatitis - nekrotisierenden Pankreatitis - chirurgische Therapie - Nekrosektomie - Endoskopie - FNP

Key words

pancreatitis - pancreatic necrosis - surgical treatment - necrosectomy - endoscopy - FNP

Literatur

• 1 Uhl W, Warshaw A, Imrie C. et al . IAP Guidelines for the Surgical Management of Acute Pancreatitis.  Pancreatology. 2002;  2 565-573
• 2 Working Party of the British Society of Gastroenterology; Association of Surgeons of Great Britain and Ireland; Pancreatic Society of Great Britain and Ireland, Association of Upper GI Surgeons of Great Britain and Ireland . UK guidelines for the management of acute pancreatitis.  Gut. 2005;  54 (Suppl 3) 1-9
• 3 Banks P A, Freeman M L. Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis.  Am J Gastroenterol. 2006;  101 2379-2400
• 4 Runzi M, Niebel W, Goebell H. et al . Severe acute pancreatitis: nonsurgical treatment of infected necroses.  Pancreas. 2005;  30 195-199
• 5 Secknus R, Mössner J. Inzidenz- und Prävalenzveränderungen der akuten und chronischen Pankreatitis in Deutschland.  Chirurg. 2000;  71 249-252
• 6 Appelros S, Borgström A. Incidence, aetiology and mortality rate of acute pancreatitis over 10 years in a defined urban population in Sweden.  Br J Surg. 1999;  86 465-470
• 7 Garg P K, Tandon R K, Madan K. Is biliary microlithiasis a significant cause of idiopathic recurrent acute pancreatitis? A long-term follow-up study.  Clin Gastroenterol Hepatol. 2007;  5 75-79
• 8 Tenner S, Dubner H, Steinberg W. Predicting gallstone pancreatitis with laboratory parameters: a meta-analysis.  Am J Gastroenterol. 1994;  89 1863-1866
• 9 Heinrich S, Schäfer M, Rousson V. et al . Evidence-based treatment of acute pancreatitis: a look at established paradigms.  Ann Surg. 2006;  243 154-168
• 10 Venneman N G, Buskens E, Besselink M G. et al . Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?.  Am J Gastroenterol. 2005;  100 2540-2550
• 11 Ando T, Tsuyuguchi T, Okugawa T. et al . Risk factors for recurrent bile duct stones after endoscopic papillotomy.  Gut. 2003;  52 116-121
• 12 Nealon W H, Bawduniak J, Walser E M. Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections.  Ann Surg. 2004;  239 741-749
• 13 Kimura Y, Takada T, Kawarada Y. et al . JPN Guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis.  J Hepatobiliary Pancreat Surg. 2006;  13 56-60
• 14 Fan S T, Lai E C, Mok F P. et al . Early treatment of acute biliary pancreatitis by endoscopic papillotomy.  N Engl J Med. 1993;  328 228-232
• 15 Nowak A, Nowakowska-Dulawa E, Marek T. et al . Final results of the prospective, randomized, controlled study on endoscopic sphincterotomy versus conventional management in acute biliary pancreatitis.  Gastroenterology. 1995;  108 A380
• 16 Fölsch U R, Nitsche R, Ludtke R. et al . 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
• 17 Leser H G, Gross V, Heinisch A. et al . Frühpapillotomie bei schwerer akuter Pankreatitis ohne Choledocholithiasis. Ergebnisse einer Multicenter-Studie.  Z Gastroenterol. 1993;  31 A544
• 18 Tang E, Stain S C, Tang G. et al . Timing of laparoscopic surgery in gallstone pancreatitis.  Arch Surg. 1995;  130 496-499
• 19 Uhl W, Muller C A, Krähenbühl L. et al . Acute gallstone pancreatitis: timing of laparoscopic cholecystectomy in mild and severe disease.  Surg Endosc. 1999;  13 1070-1076
• 20 Schachter P, Peleg T, Cohen O. Interval laparoscopic cholecystectomy in the management of acute biliary pancreatitis.  HPB Surg. 2000;  11 319-322
• 21 Lankisch P G, Weber-Dany B, Lerch M M. Clinical perspectives in pancreatology: compliance with acute pancreatitis guidelines in Germany.  Pancreatology. 2005;  5 591-593
• 22 Chang L, Lo S K, Stabile B E. et al . Gallstone pancreatitis: A prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones.  Am J Gastroenterol. 1998;  93 527-531
• 23 Schäfer M, Müllhaupt B, Clavien P A. Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis.  Ann Surg. 2002;  236 137-148
• 24 Adler G, Seufferlein T, Bischoff S C. et al . S3-Leitlinie Exokrines Pankreaskarzinom 2007.  Z Gastroenterol. 2007;  45 487-523
• 25 Kleespies A, Albertsmeier M, Obeidat F. et al . The challenge of pancreatic anastomosis.  Langenbecks Arch Surg. 2008;  393 459-471
• 26 Cerwenka H, Bacher H, El-Shabrawi A. et al . Management of pancreatic trauma and its consequences – guidelines or individual therapy?.  Hepatogastroenterology. 2007;  54 581-584
• 27 Bazuro G E, Amadei E, Luchetti R. et al . Acute recurrent ischemic pancreatitis treated by stent-revascularization.  J Clin Gastroenterol. 2004;  38 726-727
• 28 Mofidi R, Duff M D, Wigmore S J. et al . Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis.  Br J Surg. 2006;  93 738-744
• 29 De Waele J J, Hoste E, Blot S I. et al . Perioperative factors determine outcome after surgery for severe acute pancreatitis.  Crit Care. 2004;  8 504-511
• 30 Bradley E L. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992.  Arch Surg. 1993;  128 586-590
• 31 Bollen T L, Santvoort H C, Besselink M G. et al . The Atlanta Classification of acute pancreatitis revisited.  Brit J Surg. 2008;  95 6-21
• 32 Werner van J, Feuerbach S, Uhl W. et al . Management of acute pancreatitis: from surgery to interventional intensive care.  Gut. 2005;  54 426-436
• 33 Bradley E L, Allen K. A prospective longituidinal study of observation versus surgical intervention in the management of necrotizing pancreatitis.  Am J Surg. 1991;  161 19-24
• 34 Büchler M W, Gloor B, Müller C A. et al . Acute necrotizing pancreatitis: treatment strategy according to the status of infection.  Ann Surg. 2000;  232 619-626
• 35 Bradley E L. Indications for debridement of necrotizing pancreatitis.  Pancreas. 1996;  13 219-223
• 36 Farkas G, Marton J, Mandi Y. et al . Surgical strategy and management of infected pancreatic necrosis.  Br J Surg. 1996;  83 930-933
• 37 Besselink M G, Santvoort H C, Nieuwenhuijs V B. et al . Minimally invasive ‘step-up approach’ versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial.  BMC Surg. 2006;  6 6
• 38 Tenner van S, Sica G, Hughes M. et al . Relationship of necrosis to organ failure in severe acute pancreatitis.  Gastroenterology. 1997;  113 899-903
• 39 Lankisch P G, Pflichthofer D, Lehnick D. No strict correlation between necrosis and organ failure in acute pancreatitis.  Pancreas. 2000;  20 319-322
• 40 Beger H G, Bittner R, Block S. et al . Bacterial contamination of pancreatic necrosis. A prospective clinical study.  Gastroenterology. 1996;  91 433-438
• 41 Isenmann R, Rau B, Beger H G. Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis.  Br J Surg. 1999;  86 1020-1024
• 42 Gloor B, Müller C A, Worni M. et al . Late mortality in patients with severe acute pancreatitis.  Br J Surg. 2001;  88 975-979
• 43 Bassi C, Larvin M, Villatoro E. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.  Cochrane Database Syst Rev. 2003;  4 CD002941
• 44 Villatoro E, Bassi C, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.  Cochrane Database Syst Rev. 2006;  18 CD002941
• 45 Toouli J, Brooke-Smith M, Bassi C. et al . Guidelines for the management of acute pancreatitis.  J Gastroenterol Hepatol. 2002;  17 (Suppl) 15-39
• 46 Windsor A C, Kanwar S, Li A G. et al . Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis.  Gut. 1998;  42 431-435
• 47 Koretz R L, Avenell A, Lipman T O. et al . Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials.  Am J Gastroenterol. 2007;  102 412-429
• 48 Meier R, Ockenga J, Pertkiewicz M. et al . ESPEN Guidelines on Enteral Nutrition: Pancreas.  Clin Nutr. 2006;  25 275-284
• 49 Banks P A, Gerzof S G, Langevin R E. et al . CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome.  Int J Pancreatol. 1995;  18 265-270
• 50 Rau B, Pralle U, Mayer J M. et al . Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis.  BR J Surg. 1998;  85 179-184
• 51 King N K, Siriwardena A K. European survey of surgical strategies for the management of severe acute pancreatitis.  Am J Gastroenterol. 2004;  99 719-728
• 52 Fernandez-del Castillo C, Warshaw A L. Parenchymal necrosis: infection and other indications for debridement and drainage.  Chirurg. 2000;  71 269-273
• 53 Hartwig W, Werner J, Müller C A. et al . Surgical management of severe pancreatitis including sterile necrosis.  J Hepatobiliary Pancreat Surg. 2002;  9 429-435
• 54 Rattner D W, Legermate D A, Lee M J. et al . Early surgical débridement of symptomatic pancreatic necrosis is beneficial irrespective of infection.  Am J Surg. 1992;  163 105-109
• 55 Besselink M G, Santvoort H C, Witteman B J. et al . Management of severe acute pancreatitis: it’s all about timing.  Curr Opin Crit Care. 2007;  13 200-206
• 56 Pancreatic Disease Group, Chinese Society of Gastroenterology & Chinese Medical Association . Consensus on the diagnosis and treatment of acute pancreatitis.  Chin J Dig Dis. 2005;  6 47-51
• 57 Kivilaakso van E, Fraki O, Nikki P. et al . Resection of the pancreas for acute fulminant pancreatitis.  Surg Gynecol Obstet. 1981;  152 493-498
• 58 Nordback I CH, Auvinen O A. Long-term results after pancreas resection for acute necrotizing pancreatitis.  Br J Surg. 1985;  72 687-689
• 59 Mier J, Leon E L, Castillo A. et al . Early versus late necrosectomy in severe necrotizing pancreatitis.  Am J Surg. 1997;  173 71-75
• 60 Hartwig W, Maksan S M, Foitzik T. et al . Reduction in mortality with delayed surgical therapy of severe pancreatitis.  J Gastrointest Surg. 2002;  6 481-487
• 61 Bradley E L. Management of infected pancreatic necrosis by open drainage.  Ann Surg. 1987;  206 542-550
• 62 Tsiotos G G, Luque-León de E, Söreide J A. et al . Management of necrotizing pancreatitis by repeated operative necrosectomy using a zipper technique.  Am J Surg. 1998;  175 91-98
• 63 Sarr M G, Nagorney D M, Mucha P J. et al . Acute nectrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains.  Br J Surg. 1991;  78 576-581
• 64 Beger H G, Buchler M, Bittner R. et al . Necrosectomy and postoperative local lavage in necrotizing pancreatitis.  Br J Surg. 1988;  75 207-212
• 65 Larvin M, Chalmers A G, Robinson P J. et al . Debridement and closed cavity irrigation for the treatment of pancreatic necrosis.  Br J Surg. 1989;  76 465-471
• 66 Fernández-del Castillo C, Rattner D W, Makary M A. et al . Débridement and closed packing for the treatment of necrotizing pancreatitis.  Ann Surg. 1998;  228 676-684
• 67 Foitzik T, Klar E, Buhr H J. et al . Improved survival in acute necrotizing pancreatitis despite limiting the indications for surgical debridement.  Eur J Surg. 1995;  161 187-192
• 68 Branum G, Galloway J, Hirchowitz W. et al . Pancreatic necrosis: results of necrosectomy, packing, and ultimate closure over drains.  Ann Surg. 1998;  227 870-877
• 69 Tsiotos G G, Luque-León de E, Sarr M G. Long-term outcome of necrotizing pancreatitis treated by necrosectomy.  Br J Surg. 1998;  85 1650-1653
• 70 vanSonnenberg E, Wittich G R, Chon K S. et al . Percutaneous radiologic drainage of pancreatic abscesses.  Am J Roentgenol. 1997;  168 979-984
• 71 Mithöfer K, Mueller P R, Warshaw A L. Interventional and surgical treatment of pancreatic abscess.  World J Surg. 1997;  21 162-168
• 72 Balachandra S, Siriwardena A K. Systematic appraisal of the management of the major vascular complications of pancreatitis.  Am J Surg. 2005;  190 489-495
• 73 Balthazar E J, Fisher L A. Hemorrhagic complications of pancreatitis: radiologic evaluation with emphasis on CT imaging.  Pancreatology. 2001;  1 306-313
• 74 Beattie G C, Hardman J G, Redhead D. et al . Evidence for a central role for selective mesenteric angiography in the management of the major vascular complications of pancreatitis.  Am J Surg. 2003;  185 96-102
• 75 Waltman A C, Luers P R, Athanasoulis C A. et al . Massive arterial hemorrhage in patients with pancreatitis. Complementary roles of surgery and transcatheter occlusive techniques.  Arch Surg. 1986;  121 439-443
• 76 Perrot de M, Berney T, Bühler L. et al . Management of bleeding pseudoaneurysms in patients with pancreatitis.  Br J Surg. 1999;  86 29-32
• 77 Rosso E, Alexakis N, Ghaneh P. et al . Pancreatic pseudocyst in chronic pancreatitis: endoscopic and surgical treatment.  Dig Surg. 2003;  20 397-406
• 78 Yeo C J, Bastidas J A, Lynch-Nyhan A. et al . The natural history of pancreatic pseudocysts documented by computed tomography.  Surg Gynecol Obstet. 1990;  170 411-417
• 79 vanSonnenberg E, Wittich G R, Casola G. et al . Percutaneous drainage of infected and noninfected pancreatic pseudocysts: experience in 101 cases.  Radiology. 1989;  170 757-761
• 80 Nealon W H, Walser E. Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas.  Ann Surg. 2005;  241 948-957
• 81 Ferrucci 3 rd J T, Mueller P R. Interventional approach to pancreatic fluid collections.  Radiol Clin North Am. 2003;  41 1217-1226
• 82 Freeny P C, Hauptmann E, Althaus S J. et al . Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results.  Am J Roentgenol. 1998;  170 969-975
• 83 Mann S, Gmeinwieser J, Schmidt J. et al . Möglichkeiten und Grenzen der interventionellen Therapie bei nekrotisierender Pankreatitis.  Zentralbl Chir. 2001;  126 15-22
• 84 Echenique A M, Sleeman D, Yrizarry J. et al . Percutaneous catheter-directed debridement of infected pancreatic necrosis: results in 20 patients.  J Vasc Interv Radiol. 1998;  9 565-571
• 85 Gouzi J L, Bloom E, Julio C. et al . Percutaneous drainage of infected pancreatic necrosis: an alternative to surgery.  Chirurgie. 1999;  124 31-37
• 86 Szentkereszty Z, Kerekes L, Hallay J. et al . CT-guided percutaneous drainage in the treatment of acute necrotizing pancreatitis.  Magy Seb. 2001;  54 11-14
• 87 Carter C R, McKay C J, Imrie C W. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience.  Ann Surg. 2000;  232 175-180
• 88 Adkinson K, Morgon D, Baron T H. Long term outcome following successful endoscopic ndrainage of organized pancreatic necrosis.  Gastrointest Endosc. 1997;  45 514
• 89 Seifert H, Wehrmann T, Schmitt T. et al . Retroperitoneal endoscopic debridement for infected peripancreatic necrosis.  Lancet. 2000;  356 653-655
• 90 Seewald S, Groth S, Omar S. et al . Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm.  Gastrointest Endosc. 2005;  62 92-100
• 91 Seifert H, Wehrmann T. Endoskopisches retroperitoneales Debridement-sinnvolle Intervention?.  Gastroenterologe. 2007;  2 100-109
• 92 Ammori B J. Laparoscopic transgastric pancreatic necrosectomy for infected pancreatic necrosis.  Surg Endosc. 2002;  16 1362
• 93 Zhu J F, Fan X H, Zhang X H. Laparoscopic treatment of severe acute pancreatitis.  Surg Endosc. 2001;  15 146-148
• 94 Hamad G G, Broderick T J. Laparoscopic pancreatic necrosectomy.  J Laparoendosc Adv Surg Tech A. 2000;  10 115-118
• 95 Gambiez L P, Denimal F A, Porte H L. et al . Retroperitoneal approach and endoscopic management of peripancreatic necrosis collections.  Arch Surg. 1998;  133 66-72
• 96 Castellanos G, Piñero A, Serrano A. et al . Infected pancreatic necrosis: translumbar approach and management with retroperitoneoscopy.  Arch Surg. 2002;  137 1060-1063
• 97 Connor S, Ghaneh P, Raraty M. et al . Minimally invasive retroperitoneal pancreatic necrosectomy.  Dig Surg. 2003;  20 270-277