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.
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.
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Werner, J., Büchler, M. Pankreasnekrose: Pro chirurgische Therapie. Chirurg 82, 507–513 (2011). https://doi.org/10.1007/s00104-010-2060-x
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DOI: https://doi.org/10.1007/s00104-010-2060-x
Schlüsselwörter
- Nekrotisierende Pankreatitis
- Operationstechnik
- Chirurgische Nekrosektomie
- Minimal-invasive Operationsverfahren
- Operationsindikation