Infektionen im Rahmen der nekrotisierenden Pankreatitis

 

 Buy Article Permissions and Reprints

Zusammenfassung

In der Praxis sollten Patienten mit Nachweis von > 50 % Nekrose im CT, einem erhöhten CRP und Prokalzitonin wegen des erhöhten Risikos einer schweren Pankreatitis und septischer Komplikationen besonders überwacht werden. Eine ERCP und Sphinkterotomie ist bei Patienten mit biliärer Pankreatitis und impaktierten Gallensteinen, biliärer Sepsis oder obstrukivem Ikterus indiziert. Bei Patienten mit nekrotisierender Pankreatitis und septischem Krankheitsbild sollte eine FNA zur Differenzierung von sterilen und infizierten Nekrosen durchgeführt werden. Die symptomatische Basistherapie besteht aus einer ausreichenden Volumensubstitution. Die Antibiotikaprophylaxe bei nekrotisierender Pankreatitis führt zu einer Reduktion von septischen Komplikationen bei schwerer nekrotisierender Pankreatitis. Die chirurgische Therapie ist bei septischen Patienten mit infizierten Nekrosen indiziert. Das Therapieverfahren der Wahl ist weiterhin die offene Nekrosektomie und die anschließende geschlossene Lavage der Bursa omentalis und des Retroperitoneums.

Abstract

Patients with CT evidence of more than 50 % necrosis, or an increased CRP or procalcitonin are at risk of developing severe pancreatitis and septic complications and should be monitored in an intensive care unit. ERCP and sphincterotomy are indicated in patients with biliary pancreatitis and impacted gall stones, biliary sepsis, or obstructive jaundice. In septic patients with necrotizing pancreatitis, a FNA should be performed for differentiation of sterile and infected pancreatic necrosis. Adequate volume resuscitation and analgesic treatment are the most important treatment of acute pancreatitis. Antibiotic prophylaxis reduces septic complications in severe necrotizing pancreatitis and should be started early. Surgical therapy is indicated in patients with infected pancreatic necrosis. The surgical technique of choice is open necrosectomy with postoperative closed lavage of the lesser sac.

Literatur

• 1 Balthazar E, Robinson D, Megibow A, Ranson J. Acute pancreatitis: value of CT in establishing prognosis.  Radiology. 1990;  174 331-336
  CrossrefPubMedGoogle Scholar
• 2 Banks P, Gerzof S, Langevin R, Silverman S, Sica G. et al . CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome.  Int J Pancreatol. 1995;  18 265-270
  PubMedGoogle Scholar
• 3 Beger H G, Bittner R, Block S, Büchler M. Bacterial contamination of pancreatic necrosis - a prospective clinical study.  Gastroenterology. 1986;  91 433-441
  PubMedGoogle Scholar
• 4 Beger H G, Buchler M, Bittner R, Block S, Nevalainen T. et al . Necrosectomy and postoperative local lavage in necrotizing pancreatitis.  Br J Surg. 1988;  75 207-212
  CrossrefPubMedGoogle Scholar
• 5 Bradley A, Allen K. A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis.  Am J Surg. 1991;  161 19-24
  CrossrefPubMedGoogle Scholar
• 6 Bradley E L 3rd. Operative management of acute pancreatitis: ventral open packing.  Hepatogastroenterology. 1991;  38 134-138
  PubMedGoogle Scholar
• 7 Buchler M, Malfertheiner P, Friess H, Isenmann R, Vanek E. et al . Human pancreatic tissue concentration of bactericidal antibiotics.  Gastroenterology. 1992;  103 1902-1908
  PubMedGoogle Scholar
• 8 Buchler M W, Gloor B, Müller C A, Friess H, Seiler C A. et al . Acute necrotizing pancreatitis: treatment strategy according to the status of infection.  Ann Surg. 2000;  232 619-626
  CrossrefPubMedGoogle Scholar
• 9 Büchler M W, Malfertheiner P, Schoetensack C, Uhl W, Beger H G. Sensitivity of antiproteases, complement fctors and C-reactive protein in detecting pancreatic necrosis: results of a prospective clinical trial study.  Int J Pancreatol. 1986;  1 227-235
  PubMedGoogle Scholar
• 10 Carter C, McKay C J, Imrie C. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pacreatic necrosis: an initial experience.  Ann Surg. 2000;  232 175-180
  CrossrefPubMedGoogle Scholar
• 11 Dervenis C, Johnson C D, Bassi C, Bradley E, Imrie C W. et al . Diagnosis, objective assessment of severity, and management of acute pancreatitis.  Int J Pancreatol. 1999;  25 195-200
  PubMedGoogle Scholar
• 12 Fan S T, Lai E C, Mok F P, Lo C M, Heng S S. et al . Early treatment of acute biliary pancreatitis by endoscopic papillotomy.  N Engl J Med. 1993;  328 228-232
  Google Scholar
• 13 Fernandez-del Castillo C, Rattner D W, Makary M A, Mostafavi A, McGrath D. et al . Debridement and closed packing for the treatment of necrotizing pancreatitis.  Ann Surg. 1998;  228 676-684
  CrossrefPubMedGoogle Scholar
• 14 Fölsch U R, Nitsche R, Ludtke R, Hilgers R A, Creitzfeld W. Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis.  N Engl J Med. 1997;  336 237-242
  Google Scholar
• 15 Gastroenterology: BSo . United Kingdom guidelines for the management of acute pancreatitis.  Gut. 1998;  42 S1-S13
  PubMedGoogle Scholar
• 16 Gloor B, Müller C, Worni M, Martignoni M, Uhl W. et al . Late mortality in patients with severe acute pancreatitis.  Br J Surg. 2001;  88 975-979
  CrossrefPubMedGoogle Scholar
• 17 Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis.  J Gastrointest Surg. 1998;  2 496-503
  CrossrefPubMedGoogle Scholar
• 18 Guidelines UK . UK guidelines for the management of acute pncreatitis.  Gut. 2005;  54 1111-1119
  PubMedGoogle Scholar
• 19 Gullo A, Berlot G. Ingredients of organ dysfunction or failure.  World J Surg. 1996;  20 430-436
  CrossrefPubMedGoogle Scholar
• 20 Heath D, Alexander D, Wilson C, Larvin M, Imrie C. et al . Which complications of acute pancreatitis are most lethal? A prospective multicenter clinical study of 719 episodes.  Gut. 1995;  36 478
  PubMedGoogle Scholar
• 21 Isenmann R, Rau B, Beger H. Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis.  Br J Surg. 1999;  86 1020-1024
  CrossrefPubMedGoogle Scholar
• 22 Isenmann R, Runzi M, Kron M, Kahl S, Kraus D. et al . Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial.  Gastroenterology. 2004;  126 997-1004
  CrossrefPubMedGoogle Scholar
• 23 Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos C. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial.  Br J Surg. 1997;  84 1665-1669
  CrossrefPubMedGoogle Scholar
• 24 Kemppainen E, Sainio V, Haapiainen R, Kivisaari L, Kivilaakso E. et al . Early localization of necrosis by contrast-enhanced computed tomography can predict outcome in severe acute pancreatitis.  Br J Surg. 1996;  83 924-929
  PubMedGoogle Scholar
• 25 Klar E, Werner J. New pathophysiological findings in acute pancreatitis.  Chirurg. 2000;  71 253-264
  PubMedGoogle Scholar
• 26 Lankisch P, Pflichthofer D, Lehnick D. No strict correlation between necrosis and organ failure in acute pancreatitis.  Pancreas. 2000;  20 319-322
  CrossrefPubMedGoogle Scholar
• 27 Levin D, Bret P. Percutaneous fine-needle aspiration biopsy of the pancreas resulting in death.  Gastrointest Radiol. 1991;  16 67-69
  CrossrefPubMedGoogle Scholar
• 28 Neoptolemos J P, Carr-Locke D L, London N J, Bailey I, Fossard D P. Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones.  Lancet. 1988;  2 979-983
  Google Scholar
• 29 Neoptolemos J P, Raraty M, Finch M, Sutton R. Acute pancreatitis: the substantial human and financial cases.  Gut. 1998;  42 886-891
  PubMedGoogle Scholar
• 30 Rau B, Pralle U, Mayer J, Beger H. Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis.  Br J Surg. 1998;  85 179-184
  CrossrefPubMedGoogle Scholar
• 31 Rünzi M, Layer P, Büchler M. The therapy of acute pancreatitis. General guidelines. Working group of the society for scientific-medical specialities.  Z Gastroenterol. 2000;  38 571-581
  Article in Thieme ConnectPubMedGoogle Scholar
• 32 Sarr M G, Nagorney D M, Mucha Jr P, Farnell M B, Johnson C D. Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy / debridement and delayed primary wound closure over drains.  Br J Surg. 1991;  78 576-581
  CrossrefPubMedGoogle Scholar
• 33 Sharma V K, Howden C W. Prophylactic antibiotic sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis.  Pancreas. 2001;  22 28-31
  CrossrefPubMedGoogle Scholar
• 34 Sigurdson G. Acute pancreatitis: therapeutic options in multiple organ failure. In: Büchler M, Uhl W, Friess H et al. (eds). Acute pancreatitis: novel concepts in biology and therapy. Blackwell Science Ltd, Oxford 1999; 395-410
  Google Scholar
• 35 Sitzmann J V, Steinborn P A, Zinner M J, Cameron J L. Total parenteral nutrition and alternate energy substrates in treatment of severe acute pancreatitis.  Surg Gynecol Obstet. 1989;  168 311-317
  PubMedGoogle Scholar
• 36 Tsiotos G G, Luque-de Leon E, Sarr M G. Long-term outcome of necrotizing pancreatitis treated by necrosectomy.  Br J Surg. 1998;  85 1650-1653
  CrossrefPubMedGoogle Scholar
• 37 Uhl W, Roggo A, Kirschstein T, Anghelcopoulos S, Gloor B. et al . Influence of contrast-enhanced computed tomography on course and outcome in patients with acute pancreatitis.  Pancreas. 2002;  24 191-197
  CrossrefPubMedGoogle Scholar
• 38 Uhl W, Warshaw A, Imrie C, Bassi C, McKay C. et al . IAP guidelines for the surgical management of acute pancreatitis.  Pancreatology. 2002;  2 565-573
  CrossrefPubMedGoogle Scholar
• 39 Villatoro E, Larvin M, Bassi C. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.  The Cochrane Database of Systematic Reviews. 2005;  4 CD002941
  PubMedGoogle Scholar
• 40 Werner J, Feuerbach S, Uhl W, Büchler M. Management of acute pancreatitis: from surgery to interventional intensive care.  Gut. 2005;  54 426-436
  CrossrefPubMedGoogle Scholar
• 41 Werner J, Hartwig W, Uhl W, Müller C, Büchler M. Acute pancreatitis: Are there useful markers for monitoring disease progression.  Pancreatology. 2003;  3 115-127
  CrossrefPubMedGoogle Scholar
• 42 Werner J, Uhl W, Büchler M. Surgical treatment of acute pancreatitis.  Curr Treatm Opt Gastroenterol. 2003;  6 359-368
  PubMedGoogle Scholar
• 43 Widdison A L, Karanjia N D. Pancreatic infection complicating acute pancreatitis.  Br J Surg. 1993;  80 148-154
  PubMedGoogle Scholar
• 44 Wilson C, Heads A, Shenkin A, Imrie C W. C-reactive protein, antiproteases and complement factors as objective markers of severity in acute pancreatitis [see comments].  Br J Surg. 1989;  76 177-181
  PubMedGoogle Scholar

Prof. Dr. Dr. h. c. mult. M. W. Büchler

Chirurgische Universitätsklinik Heidelberg · Abteilung für Allgemeine und Viszerale Chirurgie

INF 110

69120 Heidelberg

Phone: 0 62 21 / 56 62 00

Fax: 0 62 21 / 56 54 50

Email: Markus.Büchler@med.uni-heidelberg.de