Maurer Lydia R, Fagenholz Peter J
Department of Surgery, Massachusetts General Hospital, Boston.
Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston.
JAMA Surg. 2023 Jan 1;158(1):81-88. doi: 10.1001/jamasurg.2022.5695.
For decades, infected or symptomatic pancreatic necrosis was managed by open surgical necrosectomy, an approach that has now been largely supplanted by an array of techniques referred to as the step-up approach.
This review describes the evidence base behind the step-up approach, when to use the different techniques, and their technical basics. The most common treatment strategies are included: percutaneous drainage, video-assisted retroperitoneal debridement, sinus tract endoscopy, endoscopic transgastric necrosectomy, and surgical transgastric necrosectomy. Also included is the evidence base around management of common complications that can occur during step-up management, such as hemorrhage, intestinal fistula, and thrombosis, in addition to associated issues that can arise during step-up management, such as the need for cholecystectomy and disconnected pancreatic duct syndrome.
The treatment strategies highlighted in this review are those most commonly used during step-up management, and this review is designed as a guide to the evidence base underlying these strategies, as surgeons tailor their therapeutic approach to individual patients.
数十年来，感染性或有症状的胰腺坏死一直通过开放性手术坏死组织清除术进行治疗，而如今这种方法在很大程度上已被一系列称为逐步升级法的技术所取代。
本综述描述了逐步升级法背后的证据基础、何时使用不同技术及其技术要点。其中包括最常见的治疗策略：经皮引流、视频辅助腹膜后清创术、窦道内镜检查、内镜经胃坏死组织清除术和手术经胃坏死组织清除术。此外还包括逐步升级管理过程中可能出现的常见并发症（如出血、肠瘘和血栓形成）的管理证据基础，以及逐步升级管理过程中可能出现的相关问题（如胆囊切除术的必要性和胰腺导管离断综合征）。
本综述中强调的治疗策略是逐步升级管理过程中最常用的策略，本综述旨在作为这些策略背后证据基础的指南，以便外科医生根据个体患者情况调整其治疗方法。
