Der Chirurg

, Volume 82, Issue 6, pp 507–513

Pankreasnekrose: Pro chirurgische Therapie

Leitthema

Zusammenfassung

Patienten mit nekrotisierender schwerer Pankreatitis benötigen heute nur noch selten eine intervententionelle oder chirurgische Therapie. Bei Verdacht auf infizierte Nekrosen und septischem Krankheitsbild sollten sie im Rahmen des „step up approach“ primär eine interventionelle oder ggf. eine endoskopische Drainage des infizierten Pankreasareals erhalten. Bei fehlender klinischer Stabilisierung muss die Nekrosektomie erfolgen. Der ideale Zeitpunkt ist die 3. bis 4. Krankheitswoche, da sich zu dieser Zeit die Nekrosen demarkiert haben. Die konventionelle offene Nekrosektomie ist durch eine niedrige Mortalität, geringe Morbidität und guten Langzeitverlauf charakterisiert. In den letzten Jahren sind mit den perkutanen in der Regel retroperitoneoskopischen minimal-invasiven Techniken Alternativen entwickelt worden, die heute in ca. 70% der Fälle erfolgreich eingesetzt werden können. Der theoretische Vorteil ist die Reduktion des operativen Traumas und damit die Reduktion des postoperativen Organversagens. Bisher gibt es jedoch noch keine Studien die dieses belegen. Bei Notfällen wie Darmischämie oder Blutungen ist das offene Operationsverfahren weiterhin die Methode der Wahl.

Schlüsselwörter

Nekrotisierende Pankreatitis Operationstechnik Chirurgische Nekrosektomie Minimal-invasive Operationsverfahren Operationsindikation 

Pancreatic necrosis: pro surgical therapy

Abstract

Currently, patients with severe necrotizing pancreatitis rarely need interventional or surgical treatment. However, in case of pancreatic infection and septic complications they should be treated with the step up approach, primarily with an interventional or endoscopic drainage. If further clinical deterioration occurs necrosectomy is indicated. This should ideally be postponed until the third or fourth week after onset of pancreatitis to optimize surgical conditions including demarcation of the necrosis. Open necrosectomy with postoperative continuous lavage is a valid treatment option with low mortality, low morbidity and good long-term outcome. In recent years, several minimally invasive techniques for necrosectomy have been developed and are alternative approaches in about 70% of cases. In most cases, the retroperitoneoscopic approach is used, although the endoscopic transgastric route is also being used more and more frequently. While the reduced operative trauma should theoretically also reduce the onset of postoperative organ failure, no study has actually proven this.

Keywords

Necrotizing pancreatitis Technique of necrosectomy Surgical necrosectomy Minimally invasive necrosectomy Indication for necrosectomy 

Literatur

  1. 1.
    Babu BI, Sheen AJ, Lee SH et al (2010) Open necrosectomy in the multidisciplinary management of postinflammatory necrosis. Ann Surg 251:783–786PubMedCrossRefGoogle Scholar
  2. 2.
    Beger HG, Bittner R, Block S, Büchler M (1986) Bacterial contamination of pancreatic necrosis. A prospective clinical study. Gastroenterology 49:433–438Google Scholar
  3. 3.
    Besselink MG, Verwer TJ, Schoenmaeckers EJ et al (2007) Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 142:1194–1201PubMedCrossRefGoogle Scholar
  4. 4.
    Bosscha K, Hulstaert PF, Hennipman A et al (1998) Fulminant acute pancreatitis and infected necrosis: results of open management of the abdomen and „planned“ reoperations. J Am Coll Surg 187:255–262PubMedCrossRefGoogle Scholar
  5. 5.
    Bradley EL III (1993) A fifteen year experience with open drainage for infected pancreatic necrosis. Surg Gynecol Obstet 177:215–222PubMedGoogle Scholar
  6. 6.
    Branum G, Galloway J, Hirchowitz W et al (1998) Pancreatic necrosis: results of necrosectomy, packing, and ultimate closure over drains. Ann Surg 227:870–877PubMedCrossRefGoogle Scholar
  7. 7.
    Büchler MW, Gloor B, Müller CA et al (2000) Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 232:619–626PubMedCrossRefGoogle Scholar
  8. 8.
    Buter A, Imrie C, Carter C et al (2002) Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg 89:298–302PubMedCrossRefGoogle Scholar
  9. 9.
    Carter C, McKay CJ, Imrie C (2000) Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg 232:175–180PubMedCrossRefGoogle Scholar
  10. 10.
    Castellanos G, Piñero A, Serrano A, Parrilla P (2002) Infected pancreatic necrosis: translumbar approach and management with retroperitoneoscopy. Arch Surg 137:1060–1062PubMedCrossRefGoogle Scholar
  11. 11.
    Connor S, Raraty MGT, Howes N et al (2005) Surgery in the treatment of acute pancreatitis – minimal access pancreatic necrosectomy. Scand J Surg 94:135–142PubMedGoogle Scholar
  12. 12.
    Fagenholz PJ, Fernandez-del Castillo C, Harris NS et al (2007) Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas 35:302–307PubMedCrossRefGoogle Scholar
  13. 13.
    Farkas G, Marton J, Mandi Y, Leindler L (2006) Surgical management and complex treatment of infected pancreatic necrosis: 18 year experience at a single center. J Gastrointest Surg 10:278–285PubMedCrossRefGoogle Scholar
  14. 14.
    Fernandez-del Castillo C, Rattner DW, Makary MA et al (1998) Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg 228:676–684CrossRefGoogle Scholar
  15. 15.
    Halonen KI, Pettila V, Leppaniemi AK et al (2003) Long-term health-related quality of life in survivors of severe acute pancreatitis. Intensive Care Med 29:782–786PubMedGoogle Scholar
  16. 16.
    Hartwig W, Maksan SM, Foitzik T et al (2002) Reduction in mortality with delayed surgical therapy of severe pancreatitis. J Gastrointest Surg 6:481–487PubMedCrossRefGoogle Scholar
  17. 17.
    Horvath KD, Kao LS, Ali A et al (2001) Laparoscopic assisted percutaneous drainage of infected pancreatic necrosis. Surg Endosc 15:677–682PubMedCrossRefGoogle Scholar
  18. 18.
    Mier J, Leon E, Castillo A et al (1997) Early versus late necrosectomy in severe necrotzing pancreatitis. Am J Surg 173:71–75PubMedCrossRefGoogle Scholar
  19. 19.
    Nieuwenhuijs VB, Besselink MG, Minnen LP van, Gooszen HG (2003) Surgical management of acute necrotizing pancreatitis: a 13-year experience and a systematic review. Scand J Gastroenterol 239:111–116CrossRefGoogle Scholar
  20. 20.
    Olakowski M, Dranka-Bojarowska D, Szlachta-Swiatkowska E et al (2006) Management of necrotizing pancreatitis: flexible approach depending on intra-operative assessment of necrosis. Acta Chir Belg 106:172–176PubMedGoogle Scholar
  21. 21.
    Parikh PY, Pitt HA, Kilbane M et al (2007) Panceatic necrosectomy: north american mortality is much lower than expected. J Am Coll Surg 6:712–719Google Scholar
  22. 22.
    Petrov MS, Shangbhag S, Chakraborty M et al (2010) Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 139:813–820PubMedCrossRefGoogle Scholar
  23. 23.
    Raraty MG, Halloran CM, Dodd S et al (2010) Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 251:787–793PubMedCrossRefGoogle Scholar
  24. 24.
    Reddy MS, Jindal R, upta R et al (2006) Outcome after pancreatic necrosectomy: trends over 12 years at an Indian centre. ANZ J Surg76:704–709CrossRefGoogle Scholar
  25. 25.
    Rodriguez JR, Razo AO, Targarona J et al (2008) Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 247:294–299PubMedCrossRefGoogle Scholar
  26. 26.
    Sarr MG, Nagorney DM, Mucha P Jr et al (1991) Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains. Br J Surg 78:576–581PubMedCrossRefGoogle Scholar
  27. 27.
    Schneider L, Büchler MW, Werner J (2010) Acute pancreatitis with emphasis on infection. Inf Dis Clin N Am 24:921–941CrossRefGoogle Scholar
  28. 28.
    Seifert H, Biermer M, Schmitt W et al (2009) Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 58:1260–1266PubMedCrossRefGoogle Scholar
  29. 29.
    Tenner S, Sica G, Hughes M et al (1997) Relationship of necrosis to organ failure in severe acute pancreatitis. Gastroenterology 113:899–903PubMedCrossRefGoogle Scholar
  30. 30.
    Tsiotos GG, Luque-LE de, Soreide JA et al (1998) Management of necrotizing pancreatitis by repeated operative necrosectomy using a zipper technique. Am J Surg 175:91–98PubMedCrossRefGoogle Scholar
  31. 31.
    Uhl W, Warshaw A, Imrie C et al (2002) IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology 2:565–573PubMedCrossRefGoogle Scholar
  32. 32.
    UK Working Party on Acute Pancreatitis (2005) UK guidelines for the management of acute pancreatitis. Gut 54(Suppl 3):1–9Google Scholar
  33. 33.
    Santvoort HC van, Besselink MG, Bakker OJ et al (2010) A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 362:1491–1502PubMedCrossRefGoogle Scholar
  34. 34.
    Werner J, Feuerbach S, Uhl W, Büchler M (2005) Management of acute pancreatitis: from surgery to interventional intensive care. Gut 54:426–436PubMedCrossRefGoogle Scholar
  35. 35.
    Werner J, Hartwig W, Hackert T, Büchler MW (2005) Surgery in the treatment of acute pancreatitis – open pancreatic necrosectomy. Scand J Surg 94:130–134PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Klinik für Allgemein-, Viszeral- und TransplantationschirurgieUniversität HeidelbergHeidelbergDeutschland

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