Necrotizing Pancreatitis: Necrosectomy and Closed Continuous Lavage of the Lesser Sac. The Ulm Experience

  • M. Büchler
  • W. Uhl
  • R. Isenmann
  • R. Bittner
  • H. G. Beger

Abstract

Acute pancreatitis ranges from a mild, self-limiting disease to a severe illness with sometimes fatal outcome. In about 80% of patients, acute pancreatitis takes the cause of an edematous—interstitial inflammation mainly caused by gallstones (30%) or overindulgence in alcohol (50%). A necrotizing form of acute pancreatitis develops in up to 20% of patients [1–3]. This type of acute pancreatitis, even if with slight or moderate morphologic alterations, often proceeds to local or systemic complications and may become life threatening. From a morphologic point of view, necrotizing pancreatitis shows an interstitial—edematous inflammation combined with more or less extensive necrosis of the pancreatic exocrine and endocrine parechyma, and sometimes even extensive fatty tissue necrosis in the peripancreatic and retroperitoneal tissue compartments [4]. The fluid collection around the pancreatic area in necrotizing pancreatitis contains vasoactive and toxic substances such as phospholipase A2, endotoxin, prostacyclin, activated trypsin, complement break-down products, thromboxane, elastase, and many other undefined harmful substances [5]. The crucial risk in necrotizing pancreatitis is a bacterial infection of pancreatic necrosis [6–8].

Keywords

Dopamine Pancreatitis Pseudomonas Hyperglycemia Glucagon 

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References

  1. 1.
    Warshaw AL (1980) A guide to pancreatitis. Compr Ther 6:49–55PubMedGoogle Scholar
  2. 2.
    Beger HG, Büchler M (1986) Decision-making in surgical treatment of acute pancreatitis: operative or conservative management of necrotizing pancreatitis? Theor Surg 1:61–68Google Scholar
  3. 3.
    Büchler M (1991) Severity staging of acute pancreatitis. Hepatogastroenterology 38:101–108PubMedGoogle Scholar
  4. 4.
    Beger HG, Uhl W (1990) Severe acute pancreatitis. II. The surgical approach. Clin Int Care 1:223–227Google Scholar
  5. 5.
    Beger HG, Bittner R, Büchler M, Hess M, Schmitz JE (1986) Hemodynamic data pattern in patients with acute pancreatitis. Gastroenterology 90:74–79PubMedGoogle Scholar
  6. 6.
    Beger HG, Krautzberger W, Bittner R, Büchler M, Block S (1986) Bacterial contamination of pancreatic necrosis. A prospective clinical study. Gastroenterology 91:433–438Google Scholar
  7. 7.
    Gerzof SG, Banks PA, Robbins AH, Johnson WC, Spechler SJ, Wetzner SM, Snider JM, Langevin RE, Jay ME (1987) Early diagnosis of pancreatic infection by computed tomography-guided aspiration. Gastroenterology 93:1315–1320PubMedGoogle Scholar
  8. 8.
    Bassi C, Falconi M, Girelli R, Nifosi F, Elio A, Martini N, Pederzoli P (1989) Microbiological findings in severe pancreatitis. Surg Res Commun 5:1–4Google Scholar
  9. 9.
    Ranson JHC, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC (1974) Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 139:69–81PubMedGoogle Scholar
  10. 10.
    Bank S, Wise L, Gerstin M (1983) Risk factors in acute pancreatitis. Am J Gastroenterol 78:637–640PubMedGoogle Scholar
  11. 11.
    McMahon MJ, Bowen M, Mayer AD, Cooper EH (1984) Relation of a2- macroglobulin and other antiproteases to the clinical features of acute pancreatitis. Am J Surg 147:164–169PubMedCrossRefGoogle Scholar
  12. 12.
    Warshaw A, Lee K (1979) Serum ribonuclease elevations and pancreatic necrosis in acute pancreatitis. Surgery 86:227–232PubMedGoogle Scholar
  13. 13.
    Block S, Maier W, Clausen C, Bittner R, Büchler, M, Malfertheiner P, Beger HG (1986) Identification of pancreas necrosis in severe acute pancreatitis. Gut 27:1035–1042PubMedCrossRefGoogle Scholar
  14. 14.
    Kivisaari L, Somer K, Standertskjöld-Nordenstam CG, Schröder T, Kivilaakso E, Lempinen M (1984) A new method for the diagnosis of acute hemorrhagic necrotising pancreatitis using contrast-enhanced CT. Gastrointest Radiol 9: 27–30PubMedCrossRefGoogle Scholar
  15. 15.
    Balhazar EJ (1989) CT diagnosis and staging of acute pancreatitis. Radiol Clin North Am 27:19–37Google Scholar
  16. 16.
    Bradley EL, Murphy F, Ferguson C (1989) Prediction of pancreatic necrosis by dynamic pancreatography. Ann Surg 210:495–504PubMedCrossRefGoogle Scholar
  17. 17.
    Büchler M, Malfertheiner P, Schoetensack C, Uhl W, Beger HG (1986) Sensitivity of antiproteases, complement factors and C-reactive protein in detecting pancreatic necrosis. Results of a prospective clinical study. Int J Pancreatol 1:227–235PubMedGoogle Scholar
  18. 18.
    Puolakkainen P, Valtanen V, Paananen A, Schröder T (1987) C-reactive protein and serum phospholipase A2 in the assessment of severity of acute pancreatitis. Gut 28:764–771PubMedCrossRefGoogle Scholar
  19. 19.
    Wilson C, Heads A, Shenkin A, Imrie CW (1989) C-reactive protein, antiproteases and complement factors as objective markers of severity in acute pancreatitis. Br J Surg 76:177–181PubMedCrossRefGoogle Scholar
  20. 20.
    Uhl W, Büchler M, Malfertheiner P, Martini M, Beger HG (1991) PMN-elastase in comparison with CRP, antiproteases and LDH as indicators of necrosis in human acute pancreatitis. Pancreas 6:253–259PubMedCrossRefGoogle Scholar
  21. 21.
    Gudgeon AM, Heath D, Hurley P, Shenkin A, Jehanli A, Patel G, Wilson C, Austen BM, Imrie CW (1988) Trypsinogen activation peptide (TAP) assay in severity assessment of acute pancreatitis. Pancreas 3:598Google Scholar
  22. 22.
    Gudgeon AM, Heath D, Jehanli A, Patel G, Hurley P, Austen B, Shenkin A, Imrie CW, Hermon-Taylor J (1989) Zymogen activation peptide (ZAP) assay in the severity prediction of acute pancreatitis. Digestion 43:145Google Scholar
  23. 23.
    Büchler M, Malfertheiner P, Schädlich H, Nevalainen TJ, Frieß H, Beger HG (1989) Role of phospholipase A2 in human acute pancreatitis. Gastroenterology 97:1521–1526PubMedGoogle Scholar
  24. 24.
    Leser H-G, Gross V, Scheibenbogen C, Heinisch A, Sal R, Lausen M, Rückauer K, Andreesen R, Farthmann EH, Schölmerich J (1991) Elevation of serum interleukin-6 concentration precedes acute-phase response and reflects severity in acute pancreatitis. Gastroenterology 101:782–785PubMedGoogle Scholar
  25. 25.
    Büchler M, Malfertheiner P, Frieß H, Bittner R, Vanek E, Schlegel P, Beger HG (1989) The penetration of antibiotics into human pancreas. Infection 17: 20–25PubMedCrossRefGoogle Scholar
  26. 26.
    Cox AG (1977) Death from acute pancreatitis. M.R.C. multicentre trial of glucagon and aprotini. Lancet 2(24):632–635Google Scholar
  27. 27.
    Imrie CW, Benjamin IS, Ferguson JC, Kay AJ, Mackenzie IM, O’Neill J, Blumgart LH (1978) A single-centre double-blind trial of Trasylol therapy in primary acute pancreatitis. Br J Surg 65:337–341PubMedCrossRefGoogle Scholar
  28. 28.
    Goebell H, Ammann R, Herfarth C, Horn J, Hotz J, Knoblauch M, Schmid M, Jager J, Akovbiantz A, Linder E, Abt K, Nüesch E, Barth E (1979) A double blind trial of synthetic salmon calcitonin in the treatment of acute pancreatitis. Scand J Gastroenterol 14:881–889PubMedCrossRefGoogle Scholar
  29. 29.
    Usadel KH, Überla KK, Leuscher U (1985) Treatment of acute pancreatitis with somatostatin: results of the multicenter double-blind trial (APTS-study) (Abstr). Dig Dis Sci 30:992Google Scholar
  30. 30.
    Büchler M, Malfertheiner P, Uhl W, Stöckmann F, Schölmerich J, Adler G, Rolle K, Ditschuneit H, Beger HG (1990) The German multicenter doubleblind randomized study of gabexate mesilate (4g/day i.v.) in acute pancreatitis Gastroenterology 1993 (in press)Google Scholar
  31. 31.
    Gerzof SG, Banks PA, Robbins AH (1984) Role of guided percutaneous aspiration in early diagnosis of pancreatic sepsis. Dig Dis Sci 29:950Google Scholar
  32. 32.
    Bradley EL III (1984) Management of infected pancreatic necrosis by open drainage. Ann Surg 206:542–550CrossRefGoogle Scholar
  33. 33.
    Warshaw AL, Jin G (1985) Improved survival in 45 patients with pancreatic abscess. Ann Surg 202:408–417PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1993

Authors and Affiliations

  • M. Büchler
    • 1
  • W. Uhl
  • R. Isenmann
  • R. Bittner
  • H. G. Beger
  1. 1.Department of SurgeryUniversity of UlmUlmGermany

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