Skip to main content
Erschienen in:

01.08.2013 | Review Article

Surgical treatment of acute pancreatitis

verfasst von: Hein G. Gooszen, Marc G. H. Besselink, Hjalmar C. van Santvoort, Thomas L. Bollen

Erschienen in: Langenbeck's Archives of Surgery | Ausgabe 6/2013

Einloggen, um Zugang zu erhalten

Abstract

Background

Acute pancreatitis remains an unpredictable, potentially lethal disease with significant morbidity and mortality rates. New insights in the pathophysiology of acute pancreatitis have changed management concepts. In the first phase, characterized by a systemic inflammatory response syndrome, organ failure, not related to infection but rather to severe inflammation, dominates the focus of treatment. In the second phase, secondary infectious complications largely determine the clinical outcome. As infection is associated with increased mortality in acute pancreatitis, numerous prophylactic strategies have been explored in the past two decades.

Purpose

This review describes the strategies that have been developed to lower the infection rate, in an attempt to lower mortality. Antibiotic prophylaxis has been the subject of many RCT’s without showing convincing evidence of their efficacy. Probiotics, although theoretically capable of lowering the rate of infection, also had no effect on infectious complications, and consequently, no effective strategy to lower the rate of infectious complications is currently available. In the second part of this review, new approaches for necrosectomy that have been designed by different centers around the world are discussed. All the interventional techniques have in common their aim to lower the invasive character, hypothesizing that lowering the surgical trauma will improve survival and lower complication rates. Recent advances include postponing intervention as a strategy to facilitate necrosectomy and improve prognosis and the “step-up approach” in case of infected necrosis. The step-up approach includes percutaneous catheter drainage as the first step, to be followed by necrosectomy, either through a minimally invasive approach or by open necrosectomy, as the next step.

Conclusions

All attempts to develop treatment strategies to lower the infection rate in acute pancreatitis have failed. Accumulating evidence is emerging to show that the combination of centralization, the use of catheter drainage as the first step of invasive treatment, and the development of minimally invasive techniques, improve the outlook for patients with infected necrosis. It is uncertain at this point in time as to which of the three effects is dominant in the improvement of prognosis.
Literatur
1.
Zurück zum Zitat Fagenholz PJ, Fernandez-del Castillo C, Harris NS, Pelletier AJ, Camargo CA (2007) Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas 35(4):302–307PubMedCrossRef Fagenholz PJ, Fernandez-del Castillo C, Harris NS, Pelletier AJ, Camargo CA (2007) Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas 35(4):302–307PubMedCrossRef
2.
Zurück zum Zitat Shaheen NJ, Hansen RA, Morgan DR, Gangarosa LM, Ringel Y, Thiny MT et al (2006) The burden of gastrointestinal and liver diseases. Am J Gastroenterol 101(9):2128–2138PubMedCrossRef Shaheen NJ, Hansen RA, Morgan DR, Gangarosa LM, Ringel Y, Thiny MT et al (2006) The burden of gastrointestinal and liver diseases. Am J Gastroenterol 101(9):2128–2138PubMedCrossRef
3.
Zurück zum Zitat Banks PA, Freeman ML (2006) Practice guidelines in acute pancreatitis. Am J Gastroenterol 101(10):2379–2400PubMedCrossRef Banks PA, Freeman ML (2006) Practice guidelines in acute pancreatitis. Am J Gastroenterol 101(10):2379–2400PubMedCrossRef
4.
Zurück zum Zitat Besselink MG, Van Santvoort HC, Boermeester MA, Nieuwenhuijs VB, van Goor H, Dejong CH et al (2009) Timing and impact of infections in acute pancreatitis. Br J Surg 96(3):267–273PubMedCrossRef Besselink MG, Van Santvoort HC, Boermeester MA, Nieuwenhuijs VB, van Goor H, Dejong CH et al (2009) Timing and impact of infections in acute pancreatitis. Br J Surg 96(3):267–273PubMedCrossRef
5.
Zurück zum Zitat Petrov MS, Shanbhag S, Chakreborty M et al (2010) Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 139:813–820PubMedCrossRef Petrov MS, Shanbhag S, Chakreborty M et al (2010) Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 139:813–820PubMedCrossRef
6.
Zurück zum Zitat Working Party of the British Society of Gastroenterology, Association of Surgeons of Great Britain and Ireland, Pancreatic Society of Great Britain and Ireland, Association of Upper GI Surgeons of Great Britain and Ireland (2005) UK guidelines for the management of acute pancreatitis. Gut 54 Suppl 3:iii1–iii9 Working Party of the British Society of Gastroenterology, Association of Surgeons of Great Britain and Ireland, Pancreatic Society of Great Britain and Ireland, Association of Upper GI Surgeons of Great Britain and Ireland (2005) UK guidelines for the management of acute pancreatitis. Gut 54 Suppl 3:iii1–iii9
7.
Zurück zum Zitat Mao EQ, Tang YQ, Fei J, Qin S, Wu J, Li L et al (2009) Fluid therapy for severe acute pancreatitis in acute response stage. Chin Med J (Engl) 122(2):169–173 Mao EQ, Tang YQ, Fei J, Qin S, Wu J, Li L et al (2009) Fluid therapy for severe acute pancreatitis in acute response stage. Chin Med J (Engl) 122(2):169–173
8.
Zurück zum Zitat Warndorf MG, Kurtzman JT, Bartel MJ, Cox M, Mackenzie T, Robinson S, Burchard PR, Gordon SR, Gardner TB (2011) Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol 8:705–709CrossRef Warndorf MG, Kurtzman JT, Bartel MJ, Cox M, Mackenzie T, Robinson S, Burchard PR, Gordon SR, Gardner TB (2011) Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol 8:705–709CrossRef
9.
Zurück zum Zitat Van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH et al (2010) A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 362(16):1491–1502PubMedCrossRef Van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH et al (2010) A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 362(16):1491–1502PubMedCrossRef
10.
Zurück zum Zitat Eckerwall GE, Tingstedt BB, Bergenzaun PE, Andersson RG (2007) Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery–a randomized clinical study. Clin Nutr 26(6):758–763PubMedCrossRef Eckerwall GE, Tingstedt BB, Bergenzaun PE, Andersson RG (2007) Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery–a randomized clinical study. Clin Nutr 26(6):758–763PubMedCrossRef
11.
Zurück zum Zitat Petrov MS, Zagainov VE (2007) Influence of enteral versus parenteral nutrition on blood glucose control in acute pancreatitis: a systematic review. Clin Nutr 26(5):514–523PubMedCrossRef Petrov MS, Zagainov VE (2007) Influence of enteral versus parenteral nutrition on blood glucose control in acute pancreatitis: a systematic review. Clin Nutr 26(5):514–523PubMedCrossRef
12.
Zurück zum Zitat Petrov MS, Loveday BP, Pylypchuk RD, McIlroy K, Phillips AR, Windsor JA (2009) Systematic review and meta-analysis of enteral nutrition formulations in acute pancreatitis. Br J Surg 96(11):1243–1252PubMedCrossRef Petrov MS, Loveday BP, Pylypchuk RD, McIlroy K, Phillips AR, Windsor JA (2009) Systematic review and meta-analysis of enteral nutrition formulations in acute pancreatitis. Br J Surg 96(11):1243–1252PubMedCrossRef
13.
Zurück zum Zitat De Vries AC, Besselink MGH, Van der Kraats CIB, Buskens E, van Erpecum KJ, Gooszen HG (2005) Antibiotic prophylaxis in acute necrotising pancreatitis: methodological quality of randomised controlled trials in relation to outcome. Gut 54(Supplement VII):A38–A39 De Vries AC, Besselink MGH, Van der Kraats CIB, Buskens E, van Erpecum KJ, Gooszen HG (2005) Antibiotic prophylaxis in acute necrotising pancreatitis: methodological quality of randomised controlled trials in relation to outcome. Gut 54(Supplement VII):A38–A39
14.
Zurück zum Zitat Wittau M, Mayer B, Scheele J, Henne-Bruns D, Dellinger EP, Isenmann R (2011) Systematic review and meta-analysis of antibiotic prophylaxis in severe acute pancreatitis. Scand J Gastroenterol 46(3):261–270PubMedCrossRef Wittau M, Mayer B, Scheele J, Henne-Bruns D, Dellinger EP, Isenmann R (2011) Systematic review and meta-analysis of antibiotic prophylaxis in severe acute pancreatitis. Scand J Gastroenterol 46(3):261–270PubMedCrossRef
15.
Zurück zum Zitat Besselink MGH, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman H, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJ, Rosman C, Ploeg RJ, Brink M, Schaapherder AF, van Dejong CH, Wahab PJ, van Laarhoven CJHM, van der Harst E, van Eijck CHJ, Cuesta MA, Akkermans LMA, Gooszen HG (2008) Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet 371(9613):651–659PubMedCrossRef Besselink MGH, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman H, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJ, Rosman C, Ploeg RJ, Brink M, Schaapherder AF, van Dejong CH, Wahab PJ, van Laarhoven CJHM, van der Harst E, van Eijck CHJ, Cuesta MA, Akkermans LMA, Gooszen HG (2008) Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet 371(9613):651–659PubMedCrossRef
16.
Zurück zum Zitat Luiten EJ, Hop WC, Lange JF, Bruining HA (1995) Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis. Ann Surg 222(1):57–65PubMedCrossRef Luiten EJ, Hop WC, Lange JF, Bruining HA (1995) Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis. Ann Surg 222(1):57–65PubMedCrossRef
17.
Zurück zum Zitat Petrov MS, Van Santvoort HC, Besselink MG, van der Heijden GJ, van Erpecum KJ, Gooszen HG (2008) Early endoscopic retrograde cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials. Ann Surg 247(2):250–257PubMedCrossRef Petrov MS, Van Santvoort HC, Besselink MG, van der Heijden GJ, van Erpecum KJ, Gooszen HG (2008) Early endoscopic retrograde cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials. Ann Surg 247(2):250–257PubMedCrossRef
18.
Zurück zum Zitat Van Santvoort HC, Besselink MG, De Vries AC, Boermeester MA, Fischer K, Bollen TL et al (2009) Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study. Ann Surg 250(1):68–75PubMedCrossRef Van Santvoort HC, Besselink MG, De Vries AC, Boermeester MA, Fischer K, Bollen TL et al (2009) Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study. Ann Surg 250(1):68–75PubMedCrossRef
19.
Zurück zum Zitat Mier J, Luque-de León E, Castillo A, Robledo F, Blanco R (1997) Early versus late necrosectomy in severe pancreatitis. Am J Surg 173(2):71–75PubMedCrossRef Mier J, Luque-de León E, Castillo A, Robledo F, Blanco R (1997) Early versus late necrosectomy in severe pancreatitis. Am J Surg 173(2):71–75PubMedCrossRef
20.
Zurück zum Zitat Cheatham ML, Malbrain ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J et al (2007) Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome II. Recommendations. Intensive Care Med 33(6):951–962PubMedCrossRef Cheatham ML, Malbrain ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J et al (2007) Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome II. Recommendations. Intensive Care Med 33(6):951–962PubMedCrossRef
21.
Zurück zum Zitat Zerem E, Imamovic G, Omerovic S, Imsirovic B (2009) Randomized controlled trial on sterile fluid collections management in acute pancreatitis: should they be removed? Surg Endosc 23:2770–2777PubMedCrossRef Zerem E, Imamovic G, Omerovic S, Imsirovic B (2009) Randomized controlled trial on sterile fluid collections management in acute pancreatitis: should they be removed? Surg Endosc 23:2770–2777PubMedCrossRef
22.
Zurück zum Zitat Besselink MG, Van Santvoort HC, Bakker OJ, Bollen TL, Gooszen HG (2010) Draining sterile fluid collections in acute pancreatitis? Primum non nocere! Surg Endosc 25(1):331–332CrossRef Besselink MG, Van Santvoort HC, Bakker OJ, Bollen TL, Gooszen HG (2010) Draining sterile fluid collections in acute pancreatitis? Primum non nocere! Surg Endosc 25(1):331–332CrossRef
23.
Zurück zum Zitat Van Baal MC, Van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG et al (2011) Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg 98(1):18–27PubMedCrossRef Van Baal MC, Van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG et al (2011) Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg 98(1):18–27PubMedCrossRef
24.
Zurück zum Zitat Raraty MG, Halloran CM, Dodd S, Ghaneh P, Connor S, Evans J et al (2010) Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 251(5):787–793PubMedCrossRef Raraty MG, Halloran CM, Dodd S, Ghaneh P, Connor S, Evans J et al (2010) Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 251(5):787–793PubMedCrossRef
25.
Zurück zum Zitat Horvath K, Freeny P, Escallon J, Heagerty P, Comstock B, Glickerman DJ et al (2010) Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study. Arch Surg 145(9):817–825PubMedCrossRef Horvath K, Freeny P, Escallon J, Heagerty P, Comstock B, Glickerman DJ et al (2010) Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study. Arch Surg 145(9):817–825PubMedCrossRef
26.
Zurück zum Zitat Horvath KD, Kao LS, Wherry KL, Pellegrini CA, Sinanan MN (2010) A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess. Surg Endosc 15(10):1221–1225CrossRef Horvath KD, Kao LS, Wherry KL, Pellegrini CA, Sinanan MN (2010) A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess. Surg Endosc 15(10):1221–1225CrossRef
27.
Zurück zum Zitat Van Santvoort HC, Besselink MGH, Horvath KD, Sinanan M, Bollen TL, Ramshorst B et al (2007) Videoscopic assisted retroperitoneal debridement in infected necrotizing pancreatitis. HPB 9(2):156–159PubMedCrossRef Van Santvoort HC, Besselink MGH, Horvath KD, Sinanan M, Bollen TL, Ramshorst B et al (2007) Videoscopic assisted retroperitoneal debridement in infected necrotizing pancreatitis. HPB 9(2):156–159PubMedCrossRef
28.
Zurück zum Zitat Papachristou GI, Takahashi N, Chahal P, Sarr MG, Baron TH (2007) Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 245(6):943–951PubMedCrossRef Papachristou GI, Takahashi N, Chahal P, Sarr MG, Baron TH (2007) Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 245(6):943–951PubMedCrossRef
29.
Zurück zum Zitat Seifert H, Biermer M, Schmitt W, Jurgensen C, Will U, Gerlach R et al (2009) Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 58(9):1260–1266PubMedCrossRef Seifert H, Biermer M, Schmitt W, Jurgensen C, Will U, Gerlach R et al (2009) Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 58(9):1260–1266PubMedCrossRef
30.
Zurück zum Zitat Voermans RP, Bruno MJ, van Berge Henegouwen MI, Fockens P (2007) Review article: translumenal endoscopic debridement of organized pancreatic necrosis—the first step towards natural orifice translumenal endoscopic surgery. Aliment Pharmacol Ther 26(Suppl 2):233–239PubMedCrossRef Voermans RP, Bruno MJ, van Berge Henegouwen MI, Fockens P (2007) Review article: translumenal endoscopic debridement of organized pancreatic necrosis—the first step towards natural orifice translumenal endoscopic surgery. Aliment Pharmacol Ther 26(Suppl 2):233–239PubMedCrossRef
31.
Zurück zum Zitat Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL et al (2012) Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 307(10):1053–1061PubMedCrossRef Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL et al (2012) Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 307(10):1053–1061PubMedCrossRef
32.
Zurück zum Zitat Rau B, Bothe A, Beger HG (2005) Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series. Surgery 138(1):28–39PubMedCrossRef Rau B, Bothe A, Beger HG (2005) Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series. Surgery 138(1):28–39PubMedCrossRef
33.
Zurück zum Zitat Rodriguez JR, Razo AO, Targarona J, Thayer SP, Rattner DW, Warshaw AL et al (2008) Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 247(2):294–299PubMedCrossRef Rodriguez JR, Razo AO, Targarona J, Thayer SP, Rattner DW, Warshaw AL et al (2008) Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 247(2):294–299PubMedCrossRef
34.
Zurück zum Zitat Besselink MG, Verwer TJ, Schoenmaeckers EJ, Buskens E, Ridwan BU, Visser MR et al (2007) Timing of surgical intervention in pancreatitis. Arch Surg 142(12):1194–1201PubMedCrossRef Besselink MG, Verwer TJ, Schoenmaeckers EJ, Buskens E, Ridwan BU, Visser MR et al (2007) Timing of surgical intervention in pancreatitis. Arch Surg 142(12):1194–1201PubMedCrossRef
35.
Zurück zum Zitat Dutch Pancreatitis Study Group, van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM et al (2011) A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 141(4):1254–1263PubMedCrossRef Dutch Pancreatitis Study Group, van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM et al (2011) A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 141(4):1254–1263PubMedCrossRef
36.
Zurück zum Zitat Nealon WH, Bawduniak J, Walser EM (2004) Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections. Ann Surg 239(6):741–749PubMedCrossRef Nealon WH, Bawduniak J, Walser EM (2004) Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections. Ann Surg 239(6):741–749PubMedCrossRef
Metadaten
Titel
Surgical treatment of acute pancreatitis
verfasst von
Hein G. Gooszen
Marc G. H. Besselink
Hjalmar C. van Santvoort
Thomas L. Bollen
Publikationsdatum
01.08.2013
Verlag
Springer Berlin Heidelberg
Erschienen in
Langenbeck's Archives of Surgery / Ausgabe 6/2013
Print ISSN: 1435-2443
Elektronische ISSN: 1435-2451
DOI
https://doi.org/10.1007/s00423-013-1100-7

Weitere Artikel der Ausgabe 6/2013

Langenbeck's Archives of Surgery 6/2013 Zur Ausgabe

Neu im Fachgebiet Chirurgie

Nach größerer Op.: Wie lang in der PACU überwachen?

Ein etwa vier- bis sechsstündiges Monitoring im Aufwachraum (PACU) scheint in den meisten Fälle auszureichend zu sein, um anhand klinischer Kriterien zu entscheiden, ob es nach einer größeren Op. auf die Normalstation gehen kann.

Vertraute Bedingungen reduzieren Stress bei Operierenden

Vertrautes Personal und bekannte Räumlichkeiten tragen offenbar dazu bei, dass Operierende bei einem Eingriff weniger gestresst sind. Das zeigen Daten von vier französischen Unikliniken.

Unterarmfraktur: Tipps für ein zielgerichtetes Vorgehen

Bei Verdacht auf eine Unterarmfraktur seien 1000 Entscheidungen in 15 Minuten zu treffen, so der Kinderchirurg Dr. Stephan Rohleder auf dem Kongress für Kinder- und Jugendmedizin. Seine Tipps für ein zielgerichtetes Vorgehen erleichtern die adäquate Versorgung.

Wenige Komplikationen nach Mesh-verstärktem Bauchdeckenverschluss

Langzeitdaten der PRIMA-Studie sprechen dafür, dass das Komplikationsrisiko von Mesh-Implantaten bei bauchoperierten Personen mit hohem Risiko für Narbenhernien niedrig ist.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.