Zusammenfassung
Grundlagen
Spätfolgen nach akuter Pankreatitis umfassen Störungen morphologischer und funktioneller Art. Die postakute Pseudozyste, der Pankreasabszeß und Pankreasfisteln zählen zu den morphologischen, exokrine Insuffizienz und Diabetes mellitus zu den funktionellen Störungen, die sich im späten klinischen Verlauf manifestieren.
Methodik
In einer Übersicht werden die Spätfolgen nach akuter Pankreatitis und ihre Therapie dargestell.
Ergebnisse
Postakute Pseudozyste und Pankreasabszeß werden mit einer Inzidenz von 2% bis 6% vier bis sechs Wochen nach Symptombeginn der akuten Pankreatitis beobachtet. Die kontrastmittelverstärkte Computertomographie (CT) hat sich mit einer diagnostischen Treffsicherheit von >90% als “Goldstandard” unter den bildgebenden Verfahren etabliert. ERCP und Feinnadelaspiration sind im Rahmen der Therapieplanung unverzichtbar geworden. Grundsätzlich stellt der Nachweis einer Infektion des Punktates die Indikation zur interventionellen oder operativen Drainage. Die Operation liefert bevorzugt beim Pankreasabszeß sowie bei länger als 6 Wochen bestehenden und mehr als 5 cm messenden Pseudozysten gute Ergebnisse.
Klinisch-chemisches Korrelat der inneren und äußeren Pankreasfisteln ist der hohe Amylase-und Lipasegehalt des Fisteleffluats. Die äußere Pankreasfistel tritt abhängig vom vorausgehenden operativen Verfahren bei nekrotisierender Pankreatitis mit einer Häufigkeit von 12%–40% auf. Ein Fistelverschluß kann in 70%–80% aller Fisteln innerhalb drei bis vier Monaten unter konservativer Therapie erreicht werden. Persistiert die Fistel trotz zusätzlicher medikamentöser Therapie, ist eine operative Intervention unumgänglich.
Im Gegensatz zur leichten Verlaufsform werden bei schwerer nekrotisierender Pankreatitis in mehr als 50% der Fälle Störungen der exo- und endokrinen Funktion beobachtet, deren Ausmaß vom Anteil des untergegangenen Pankreasgewebes und im Falle einer Operation von der Radikalität des Operationsverfahrens abhängt.
Schlußfolgerungen
Insbesondere die schwere, nekrotisierende Verlaufsform der akuten Pankreatitis ist durch eine Vielzahl morphologischer und funktioneller Spätfolgen belastet. Orientiert sich der Einsatz konservativer bzw. operativer Therapiekonzepte am Pathomechanismus und am Ergebnis gezielter Diagnostik, sind bei den jeweiligen Komplikationen hohe Erfolgsraten zu verzeichnen.
Summary
Background
Late complications after acute pancreatitis include morphological and functional disorders. Postacute pseudocyst, pancreatic abscess, and pancreatic fistula represent morphological complications whereas impaired exocrine secretion and diabetes mellitus are functional sequelae, which both occur in the late clinical course.
Methods
The late complications after acute pancreatitis and their treatment are reviewed.
Results
Postacute pseudocyst and pancreatic abscess are morphological complications, which are seen in 2% to 6% of all patients with acute pancreatitis in the following four to six weeks after onset of symptoms. Nowadays, contrast-enhanced computed tomography (CT) is the “oold standard” among all imaging procedures with an accuracy of >90%. ERCP and fine needle aspiration are mandatory to stratify therapeutic concepts. If infection of the aspirate is proven, interventional or surgical drainage are generally indicated. Operative management of pancreatic abscess as well as pseudocysts older than 6 weeks and larger than 5 cm in diameter carries favourable results.
Internal and external pancreatic fistulae are characterized by fistula output with high Amylase- and Lipase concentration. External pancreatic fistulae usually occur with an incidence between 12% to 40$ depending on the operative technique after surgical therapy of necrotizing pancreatitis. By conservative means spontaneous closure is achieved in 70%–80% of all pancreatic fistulae within three to four months. Persisting fistulae despite additional drug therapy require surgical intervention.
In contrast to a mild course of the diseas exocrine insufficiency and diabetes arise in more than half of the patients with severe necrotizing pancreatitis. The degree of functional impairment correlates with the extent of devitalized pancreatic parenchyma and the radicality of the surgical technique.
Conclusions
A variety of morphological and functional complications afflict the late course predominantly after serve necrotizing pancreatitis. If conservative or surgical therapy is based on pathophysiological aspects and the results of adequate diagnostic procedures, each complication can be managed with high success rates.
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Rau, B. Spätfolgen nach akuter Pankreatitis. Acta Chir Austriaca 27, 206–211 (1995). https://doi.org/10.1007/BF02616524
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DOI: https://doi.org/10.1007/BF02616524