Schoenberg M H, Rau B, Beger H G
Rotkreuz-Krankenhaus, Munich, Germany.
Digestion. 1999;60 Suppl 1:22-6. doi: 10.1159/000051449.
Despite many prospective randomized clinical studies a specific pharmacotherapy for severe acute pancreatitis is not in sight. To date, the only possibility to influence the prognosis of this severe illness is early diagnosis and prevention of intra- and extrapancreatic necrosis and its subsequent infection. In severe necrotizing pancreatitis the incidence of infected necrosis amounts to 40-70% of all patients within 3 weeks. Thereby, the clinical picture often varies to large extent. Ultrasonographically or computer tomography-guided fine-needle aspiration (FNAC) is a fast and reliable technique for diagnosis with an overall sensitivity of 88% and specificity of 90%. This method should however not be applied too early in the course of necrotizing pancreatitis. Since infection of pancreatic necrosis determines significantly the prognosis of disease, various studies have assessed the efficacy of prophylactic antibiotic treatment in patients. Three prospective randomized studies have shown that prophylaxis significantly minimizes septic complications, only in one study, however, the mortality rate could be improved. Although randomized studies are still mandatory to resolve the controversy, it seems justified to recommend prophylaxis with antibiotics which are capable of penetrating the pancreatic tissue and juice. Sterile necrosis should be treated conservatively, with prophylactic antibiotic treatment for as long as possible. Only if patients worsen despite intensive care medicine, surgical debridement should be considered. In contrast, in patients with infected necrosis immediate surgery is in most cases mandatory. Although in one prospective study conservative treatment did not lead to an enhanced mortality rate, possible delay of surgical treatment may endanger the patient. In order to improve the prognosis of the disease, timely and adequate treatment in specialized units provides the best chances for a good prognosis whereby the severely ill patient should not be treated according to a scheme but to his/her individual needs.
尽管进行了许多前瞻性随机临床研究，但仍未找到针对重症急性胰腺炎的特效药物治疗方法。迄今为止，影响这种重症疾病预后的唯一可能性是早期诊断以及预防胰腺内和胰腺外坏死及其随后的感染。在重症坏死性胰腺炎中，感染性坏死的发生率在3周内占所有患者的40%-70%。因此，临床表现往往在很大程度上有所不同。超声或计算机断层扫描引导下的细针穿刺抽吸（FNAC）是一种快速可靠的诊断技术，总体敏感性为88%，特异性为90%。然而，这种方法不应在坏死性胰腺炎病程早期应用。由于胰腺坏死的感染显著决定疾病的预后，各种研究评估了患者预防性抗生素治疗的疗效。三项前瞻性随机研究表明，预防性治疗可显著减少脓毒症并发症，但只有一项研究显示死亡率有所改善。尽管仍需进行随机研究以解决争议，但推荐使用能够穿透胰腺组织和胰液的抗生素进行预防性治疗似乎是合理的。无菌性坏死应采取保守治疗，并尽可能长时间进行预防性抗生素治疗。只有在尽管采取了重症监护治疗但患者病情仍恶化的情况下，才应考虑手术清创。相比之下，对于感染性坏死的患者，大多数情况下立即手术是必要的。尽管在一项前瞻性研究中保守治疗并未导致死亡率升高，但手术治疗的可能延迟可能危及患者。为了改善疾病的预后，在专科单位进行及时、充分的治疗为良好预后提供了最佳机会，因此重症患者不应按照固定方案治疗，而应根据其个体需求进行治疗。
