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Moderne interdisziplinäre Therapie der nekrotisierenden Pankreatitis

Modern interdisciplinary treatment of necrotic pancreatitis

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Zusammenfassung

Die akute Pankreatitis manifestiert sich in ca. 15% der Fälle als schwere Verlaufsform und ist durch (peri)pankreatische Nekrosen und (Multi)organversagen sowie eine beträchtliche Mortalität gekennzeichnet. Entsprechend wird die moderne interdisziplinäre Therapie in Abhängigkeit vom Schweregrad anhand von Klinik, Laborparametern und Bildgebung adaptiert. Die Patienten sind intensivmedizinisch zu überwachen, unter besonderer Beachtung von Flüssigkeitsbedarf, Nierenfunktion und Atmung. Prophylaktische Antibiotika zur Vorbeugung von Infektionskomplikationen werden an zahlreichen Zentren verabreicht, werden aber immer noch kontrovers diskutiert. Hintergrund ist die ungünstigere Prognose bei Nekroseninfektion, bei der in der Vergangenheit immer die Indikation zur chirurgischen Intervention gestellt wurde. Infizierte Nekrosen lassen sich oft konservativ therapieren; in refraktären Fällen und/oder bei lokalen Komplikationen sind konventionelle chirurgische Verfahren unverändert Standard. Man wird jedoch versuchen, den Operationszeitpunkt bis 4–6 Wochen nach Erkrankungsbeginn hinauszuzögern. Debridementverfahren mit einer postoperativ fortgesetzten Evakuation von Debris und Exsudat sind wegen einer verminderten Relaparotomierate und Morbidität zu bevorzugen (kontinuierliche postoperative Lavage und „closed packing“). Der Stellenwert der an Zentren eingesetzten minimalinvasiven Verfahren (retroperitoneoskopisch oder transgastral-endoskopisch) ist derzeit noch nicht abschließend zu beurteilen.

Abstract

About 15% of patients with acute pancreatitis have a severe course, which is characterized by (peri)pancreatic necrosis, (multi)organ failure, and a substantial mortality rate. Modern interdisciplinary therapy is adapted to the severity of disease according to clinical findings, laboratory parameters, and imaging methods. Patients need intensive care treatment with special attention to fluid replacement, renal function, and ventilation. Antibiotics are used prophylactically in many institutions to prevent infectious complications, although this is still a matter of debate. The rationale for using antibiotics is an adverse outcome in the case of infected necrosis, which used to be an established indication for surgical intervention. However, many cases of infected necrosis can be treated conservatively; in refractory cases and local complications, conventional surgery is still standard therapy, but modern therapeutic concepts aim at postponing surgery until 4–6 weeks after the onset of symptoms. Debridement procedures with postoperative continuous evacuation of debris and exudate are associated with a low rate of relaparotomy and morbidity and are preferred (continuous postoperative lavage and „closed packing“). The clinical role of minimally invasive treatment modalities as practiced by several expert centers (minimally invasive retroperitoneoscopic/ transgastric-endoscopic procedures) cannot be finally assessed yet.

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Authors and Affiliations

  1. Medizinische Klinik, Israelitisches Krankenhaus in Hamburg, Orchideenstieg 14, 22297, Hamburg, Deutschland

    U. Rosien, J. Keller & P. Layer

  2. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Chirurgische Universitätsklinik Heidelberg, Heidelberg, Deutschland

    W. Hartwig, M.W. Büchler & J. Werner

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  1. U. Rosien
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  2. W. Hartwig
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  3. J. Keller
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  4. M.W. Büchler
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  5. P. Layer
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  6. J. Werner
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Correspondence to U. Rosien.

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U. Rosien und W. Hartwig haben gleichen Anteil an dieser Arbeit und teilen sich die Erstautorenschaft.

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Rosien, U., Hartwig, W., Keller, J. et al. Moderne interdisziplinäre Therapie der nekrotisierenden Pankreatitis. Gastroenterologe 4, 411–418 (2009). https://doi.org/10.1007/s11377-009-0292-4

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