Hackert Thilo, Büchler Markus Wolfgang
Department of General, University of Heidelberg, Heidelberg, Germany.
Dig Dis. 2016;34(5):517-24. doi: 10.1159/000445232. Epub 2016 Jun 22.
The management of acute necrotizing pancreatitis (ANP) has undergone a change of paradigms during the last 2 decades with a decreasing impact of surgical interventions. Modern ANP management is done conservatively as long as possible and therapeutic approaches aim at volume resuscitation, pain management and early enteral nutrition. The diagnostic gold standard of contrast-enhanced CT scan helps to evaluate the extent of necrosis of the pancreas, which correlates with the risk of tissue infection. The crucial point for decision making is the proven existence of infected pancreatic necrosis. This can be achieved by diagnostic needle aspiration of the necrotic material and staining to prove bacterial and/or fungal infection. In case of infected necrosis - besides calculated antimicrobial treatment - an interventional or surgical approach is required to prevent systemic septic progression of the disease. As the first step, percutaneous interventional drainage and spilling of the necrosis are preferable. In case of insufficient clearing of the infectious focus, a step-up approach must be considered, which implies a retroperitoneoscopic or transabdominal minimally invasive necrosectomy and drain placement. Postoperatively, a continuous lavage should be performed using these drains. In case of further deterioration of the patient or development of associated intra-abdominal complications (e.g. bowel perforation or uncontrolled bleeding), an open surgical intervention must always be regarded as a salvage therapy and this offers the possibility to control complications and perform a further necrosectomy and extensive lavage for focus control. However, associated morbidity (e.g. pancreatic fistula, fluid collections, pseudocysts) is about 50-60% and mortality up to 20%. In summary, ANP is managed primarily by a conservative therapy. In case of infected necrosis, interventional and minimally invasive approaches are the therapy of choice. Open surgery should be considered for patients deteriorating despite other measures and should be postponed as long as possible.
在过去20年中，急性坏死性胰腺炎（ANP）的治疗模式发生了变化，手术干预的影响逐渐减小。现代ANP管理尽可能采用保守治疗，治疗方法旨在进行容量复苏、疼痛管理和早期肠内营养。增强CT扫描的诊断金标准有助于评估胰腺坏死的程度，这与组织感染风险相关。决策的关键在于证实存在感染性胰腺坏死。这可以通过对坏死物质进行诊断性穿刺抽吸并染色以证明细菌和/或真菌感染来实现。对于感染性坏死，除了计算抗菌治疗外，还需要采用介入或手术方法以防止疾病的全身脓毒症进展。作为第一步，经皮介入引流和坏死组织清除是首选。如果感染灶清除不充分，则必须考虑逐步升级的方法，这意味着进行后腹腔镜或经腹微创坏死组织切除术并放置引流管。术后，应使用这些引流管进行持续灌洗。如果患者病情进一步恶化或出现相关的腹腔内并发症（如肠穿孔或无法控制的出血），开放手术干预必须始终被视为挽救性治疗，这提供了控制并发症、进一步进行坏死组织切除术和广泛灌洗以控制病灶的可能性。然而，相关的发病率（如胰瘘、积液、假性囊肿）约为50 - 60%，死亡率高达20%。总之，ANP主要通过保守治疗进行管理。对于感染性坏死，介入和微创方法是首选治疗方法。对于尽管采取了其他措施仍病情恶化的患者，应考虑开放手术，并且应尽可能推迟。
