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Interventionelle endoskopische Therapie bei akuter Pankreatitis

Interventional endoscopic treatment in acute pancreatitis

Zusammenfassung

Hintergrund

Die akute Pankreatitis (AP) stellt eine häufige gastrointestinale Erkrankung dar. Bei etwa 80 % der Patienten verläuft sie mild, eine konservative Therapie ist ausreichend. Bei etwa 20 % tritt eine schwere Verlaufsform mit lokalen und systemischen Komplikationen auf. Der vorliegende Beitrag soll einen Überblick über das aktuell empfohlene endoskopische Management der schweren AP geben.

Fragestellung

Einteilung der AP anhand der revidierten Atlanta-Klassifikation und des Auftretens lokaler sowie systemischer Komplikationen. Darstellung der aktuellen Evidenz hinsichtlich des endoskopischen Managements.

Material und Methoden

Sichtung aktueller Literatur aus fachrelevanten Journalen und Leitlinien.

Ergebnisse

Die AP wird in eine milde, moderate und schwere Verlaufsform eingeteilt. Die Einordnung richtet sich nach dem Auftreten von systemischen (Kreislaufdepression, Nierenversagen, Lungenversagen) und/oder lokalen Komplikationen (akute peripankreatische Flüssigkeitskollektionen [APFC], peripankreatische Pseudozysten [PPZ], akute nekrotische Kollektionen [ANC] und „walled-off necrosis“ [WON]). In den letzten Jahren hat sich die stufenweise endoskopische Therapie bei infizierter ANC, WON und PPZ etabliert. Zunächst erfolgt eine mit endoskopischem Ultraschall gestützte Punktion und Drainageanlage mit Plastik- oder lumenadaptierenden Metallstent. Bei soliden Anteilen bzw. nicht ausreichender Drainage wird eine endoskopische transgastrische Nekrosektomie durchgeführt. Die Therapie der schweren AP erfordert ein interdisziplinäres Management in Zentren mit entsprechender Expertise und eine regelmäßige Reevaluation der Therapiefortschritte.

Schlussfolgerungen

Die interventionelle Endoskopie hat sich als Standard bei der Therapie der schweren AP etabliert.

Abstract

Background

Acute pancreatitis (AP) represents a frequent gastrointestinal diseases. Approximately 80% of patients have a mild course of the disease and conservative treatment is sufficient; however, 20% of patients develop a severe AP with local and systemic complications. This article focuses on the currently recommended endoscopic management of severe AP.

Objective

Classification of AP by the revised Atlanta classification and the occurrence of local or systemic complications. Summary of current evidence with respect to endoscopic management.

Material and methods

Inspection of the current literature from specialist journals and current guidelines.

Results

The AP is classified as mild, moderate or severe based on systemic (hypotension, renal failure, lung failure) and/or local complications, such as acute peripancreatic fluid collections (APFC), peripancreatic pseudocysts (PPC), acute necrotic collections (ANC) and walled-off necrosis (WON). In recent years the staged endoscopic treatment of infected ANC, WON and PPC has become established. The initial step is the endoscopic ultrasound-guided puncture and drainage with plastic or lumen-apposing metal stents. For solid components or insufficient drainage, a transgastric endoscopic necrosectomy is recommended. The treatment of severe AP requires an interdisciplinary management in specialized centers and regular re-evaluation of the therapeutic efficacy.

Conclusion

Interventional endoscopy has become established as the standard for treatment of severe AP.

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Abbreviations

ANC:

„Acute necrotic collection“

AP:

Akute Pankreatitis

APFC:

Akute peripankreatische Flüssigkeitskollektion

CARS:

„Compensatory anti-inflammatory reaction syndrome“ (kompensatorisches Antiinflammationssyndrom)

CP:

Chronische Pankreatitis

ERCP:

Endoskopische retrograde Cholangiopankreatikographie

EUS:

Endoskopischer Ultraschall/Endosonographie

FCSEMS:

„Fully covered self-expandable metal stents“ (vollgecoverte selbstexpandierende Metallstents)

FNA:

Feinnadelaspiration

LAMS:

„Lumen-apposing metal stent“

MRCP:

Magnetresonanzcholangiopankreatikographie

PPI:

Protonenpumpeninhibitoren

PPZ:

Peripankreatische Pseudozyste

PS:

Plastikstent

SIRS:

„Systemic inflammatory response syndrome“ (systemisches Inflammationssyndrom)

WON:

„Walled-off necrosis“

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Danksagung

Wir danken Herrn Prof. Dr. Timm Denecke, Direktor der Klinik und Poliklinik für diagnostische und interventionelle Radiologie, Universitätsklinikum Leipzig, für die freundliche Überlassung der CT-Aufnahmen.

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Correspondence to Marcus Hollenbach.

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Interessenkonflikt

M. Hollenbach erhielt Vortrags- und Beratungshonorare von FUJI. J. Feisthammel und A. Hoffmeister geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Markus M. Lerch, München

Joachim Mössner, Leipzig

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Hollenbach, M., Feisthammel, J. & Hoffmeister, A. Interventionelle endoskopische Therapie bei akuter Pankreatitis. Internist 62, 1055–1064 (2021). https://doi.org/10.1007/s00108-021-01154-2

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Schlüsselwörter

  • Nekrotisierende Pankreatitis
  • Peripankreatische Pseudozysten
  • Transgastrische Drainage
  • Endoskopische Nekrosektomie
  • Lumenadaptierende Metallstents

Keywords

  • Pancreatitis, necrotizing
  • Pancreatic pseudocysts
  • Drainage, transgastric
  • Endoscopic necrosectomy
  • Metal stents, lumen-apposing