Abstract
The care of patients with severe acute pancreatitis is complex. Although numerous medical therapies have been proposed, few interventions have been shown to be of benefit in patients with severe disease. This review summarizes the nonoperative management of patients with acute pancreatitis, including therapies shown to be of little value, the role of antibiotics in patients with acute pancreatitis, the importance of monitoring and supportive care, and the rationale of endoscopic and surgical intervention.
Résumé
Le traitement des patients atteints de pancréatite aiguë sévère est complexe. La plupart des patients sont admis en soins intensifs. Parfois surviennent des complications qui nécessitent des interventions radiologiques, endoscopiques et/ou chirurgicales. Bien que beaucoupde de thérapeutiques médicales aient été proposées, peu ont été démontrées comme efficaces chez les patients ayant une pancréatite aiguë sévère. La définition de la pancréatite aiguë sévère a évolué. Au début, on a utilisé pour la définir les symptômes tels que la douleur, les nausées et les vomissements. D’autres l’ont définie par la survenue des complications telles que le faux-kyste, l’abcès et le décès, ou encore par des scores comme ceux de Ranson ou d’Imrie. Beger a développé un nouveau critère de gravité, la nécrose. Des études ultérieures ont utilisé la nécrose comme indication de gravité. En 1992, 40 spécialistes en matière de pancréatite se sont réunis à Atlanta pour développer une classification de pancréatite aiguë et ses complications. La conclusion de ce symposium a été que la gravité devait se définir par l’existence de défaillance viscérale et/ou de complications locales, comprenant la nécrose, le faux-kyste et l’abcès. A présent, il est difficile d’extrapoler les résultats de telle ou telle thérapeutique car la définition de sévérité a varié d’une publication à une autre. De plus, plusieurs publications n’ont pas fait état du nombre exact de patients atteint de nécrose ou de défaillance viscérale. Le traitement non chirurgical est résumé y compris 1) les thérapeutiques prouvée de peu de valeur, 2) le rôle des antibiotiques, 3) l’importance de la surveillance et de la réanimation et 4) les facteurs qui doivent indiquer une intervention endoscopique ou chirurgicale.
Resumen
El manejo de los pacientes con pancreatitis aguda es complejo. La mayoría de los pacientes requieren admisión a una unidad de cuidado intensivo. Algunos desarrollan complicaciones para las cuales se hace necesaria la interventión radiológica, endoscópica y/o quirúrgica. Aunque numerosas terapias médicas han sido propuestas, son muy pocas las que han demostrado beneficio en pacientes con pancreatitis severa. La definitión de enfermedad severa, o grave, en pacientes con pancreatitis aguda ha evolucionado. Los primeros estudios destinados a evaluar las terapias médicas se valieron de la presencia de sìntomas severos tales como dolor, náusea y vómito, como criterio de definitión de severidad. La mayoría de los estudios han definido severidad en función de complicaciones como pseudoquistes, abscesos y muerte o de sistemas de gradatión de la gravedad, entre los cuales se incluyen los criterios de Ranson y de Imrie Beger desarrolló una nueva definitión de severidad: la presencia de necrosis pancreática. Estudios subsiguientes han utilizado la presencia de necrosis pancreática como un indicador de severidad. En 1992, 40 especialistas en pancreatitis aguda, asistieron al Simposio de Atlanta celebrado con el propósito de desarrollar un sistema de clasificación, basado en el cuadro clínico de la pancreatitis y sus complicaciones. La conclusión del Simposio fue que la severidad de la pancreatitis debe ser definida por la presencia de falla orgánica y/o complicaciones locales, incluyendo necrosis, pseudoquistes y absceso. En el momento actual, resulta dificil extrapolar el resultado de una determinada terapia, siendo que la definición de severidad ha variado entre los diferentes estudios publicados y siendo que muchos de ellos no reportan el número de pacientes con necrosis pancreática o con falla orgánica. La presente revisión resume el manejo operatorio de los pacientes con pancreatitis aguda, incluyendo: las terapias que han demostrado ser de poco valor, el rol de los antibióticos en pacientes con pancreatitis aguda, la importancia de la monitoría y de los regímenes de soporte y los factores que Ilevan a interventión endoscópica y quirúrgica.
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Tenner, S., Banks, P.A. Acute pancreatitis: Nonsurgical management. World J. Surg. 21, 143–148 (1997). https://doi.org/10.1007/s002689900206
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DOI: https://doi.org/10.1007/s002689900206