Akute Pankreatitis

Acute pancreatitis is an acute inflammatory process of the pancreas mainly due to biliary obstruction or alcohol consumption. Most episodes of acute pancreatitis are mild and resolve under conservative treatment. Severe forms of acute pancreatitis, especially the necrotising form, still have a high mortality rate and can be difficult to treat. The problem today is to identify the few cases that should be treated operatively. Infected necroses are well accepted as an indication for operative treatment. Surgery consists of débridement and necrosectomy followed by closed or open lavage. In biliary pancreatitis, ERCP is performed early in cases of biliary obstruction, with or without cholangitis. In these patients cholecystectomy should be performed electively after clinical recovery.     

Pancreonecrosis and its complications,basic principles of surgical approach

Results of treatment of 4970 patients with acute pancreatitis are presented. Acute destructive pancreatitis was seen in 572 (11.5%) cases. The disease severity was the basis of differential approach to treatment. Necessity of differential approach to choice of treatment policy is demonstrated. Mild and moderate acute destructive pancreatitis in the period of arising early postnecrotic aseptic complications requires combined conservative treatment, laparoscopic sanation and drainage of abdominal cavity and omental sac are indicated when peritoneal symptoms increase. Surgical treatment in patients hospitalized with mild and moderate acute destructive pancreatitis is indicated in early (on day 5-7 after the disease onset) and late (at least 2 weeks) postnecrotic septic complications requiring delayed and late miniinvasive and extended surgeries. Severe acute destructive pancreatitis in the period of developing early postnecrotic aseptic complications associated with severe endogenous intoxication, immunosuppression, polyorganic insufficiency is indication to early (the disease day 1-3) and delayed (day 5-7) surgeries, which are regarded as one of methods of surgical detoxication.     

Acute pancreatitis in Bergen, Norway. A study on incidence, etiology and severity.

BACKGROUND: Studies on the incidence and etiology of acute pancreatitis show large regional differences. This study was performed to establish incidence, etiology and severity of acute pancreatitis in the population of Bergen, Norway. METHODS: A study of all patients with acute pancreatitis admitted to Haukeland University Hospital over a 10-year period was performed. Information was obtained about the number of patients with acute pancreatitis admitted to the Deaconess Hospital in Bergen. RESULTS: A total of 978 admissions of acute pancreatitis were recorded in these two hospitals giving an incidence of 30.6 per 100,000. Haukeland University Hospital had 757 admissions of acute pancreatitis in 487 patients. Pancreatitis was severe in 20% (96/487) of patients, more often in males (25%) than in females (14%). Mortality due to acute pancreatitis was 3% (16/487). Gallstones were found to be an etiological factor in 48.5% and alcohol consumption in 19% of patients. The risk of recurrent pancreatitis was 47% in alcohol induced and 17% in gallstone induced pancreatitis. The last five years of the study period, endoscopic sphincterotomy of patients with gallstone pancreatitis, resulted in drop in relapse rate from 33% to 1.6%. CONCLUSION: The incidence of acute pancreatitis was found to be 30.6 per 100,000 with 48.5% associated with gallstones and 17% alcohol induced. Incidence of first attack was 20/100,000. Pancreatitis was classified as severe in 20% of cases with a mortality of 3%.     

Frequency and severity of acute pancreatitis in chronic dialysis patients.

BACKGROUND: The incidence and severity of acute pancreatitis in patients undergoing dialysis treatment are unknown. METHODS: A questionnaire asking for the incidence and the severity of a first attack of acute pancreatitis in chronic dialysis patients in the year 2002 was sent to the members of QuaSi-Niere gGmbH, an organization representing almost all dialysis centres in Germany. A second questionnaire was sent to those who reported such patients. RESULTS: Response rates for the first and second questionnaire were 72% (832 out of 1150 centres) and 100% (72 out of 72 centres), respectively. After the exclusion of patients with invalid data, 55 patients with acute pancreatitis remained: 46 patients out of 68 715 haemodialysis (HD) patients (incidence rate 67/100 000/year; 95% confidence interval, 49 to 89/100 000/year) and 9 out of 3386 peritoneal dialysis (PD) patients (incidence rate 266/100 000/year; 95% confidence interval, 122 to 504/100 000/year; Fisher's exact test: P = 0.002). Twenty-eight patients (51%) had a known risk factor for acute pancreatitis. When these were excluded, the incidence of pancreatitis of unknown aetiology was 32/100 000/year (20-48) for HD patients (n, 22) and 148/100 000/year (48-345) for PD patients (n, 3; Fisher's exact test: P = 0.016). PD patients required hospital admission more frequently than HD patients (100% versus 76%) and suffered more frequently from necrotizing pancreatitis (50% versus 19%). CONCLUSIONS: Dialysis-especially PD-is another risk factor that increases the susceptibility of the pancreas to acute pancreatitis. Acute pancreatitis in patients undergoing PD is more frequent and seems to be more severe than in those receiving HD treatment.     

Surgical treatment in severe acute pancreatitis. Last 15 years of experience in Emergency County Hospital of Baia Mare

The aim of this study is to investigate the particular course of the patients operated for severe acute pancreatitis in a period of 15 years in surgical department of Emergency County Hospital of Baia Mare. Medical records of 202 patients admitted and operated for severe acute pancreatitis, were studied. Follow-up parameters were: age, gender, etiology, moment of operation, the type of operations and postoperative evolution of this patients. In the group of deceased patients alcoholic etiology of pancreatitis was prevailing. Almost a half of patients were operated in the first day of admission. A high number of patients were operated for diagnosis of acute abdomen with intention of exploratory laparotomy. In the last years, besides the usual closed drainage, open drainage and planning drainage were performed. Postoperative mortality is still high. The diagnose of severe acute pancreatitis is difficult in emergency. Global mortality in pancreatitis remains high, especially in the period of enzymatic shock, and is correlated with masculine gender, alcoholic etiology and somewhat with precocity of operation.     

Influence of the etiology of pancreatitis on the natural history of pancreatic pseudocysts.

We reviewed our experience with 90 patients with pancreatic pseudocysts to determine if the cause of pancreatitis influenced the patients' outcome. Acute pancreatitis (AP) occurred in 57 (63%) patients due to alcoholic (n = 15), postoperative (n = 14), biliary (n = 12), and other etiologies (n = 16). Thirty-three (37%) patients had chronic pancreatitis (CP) secondary to alcohol use (n = 27) or other causes (n = 6). Multiple pseudocysts were significantly more frequent in patients with acute alcoholic pancreatitis than in patients with chronic pancreatitis (47% versus 19%, p < 0.05). Spontaneous resolution occurred within 8 weeks in 10 (11%) patients with pseudocysts (AP = 9%, CP = 15%, p = NS). However, no patient with pseudocyst associated with biliary or postoperative pancreatitis underwent spontaneous resolution. Although pseudocysts associated with chronic pancreatitis were smaller in size (8.0 +/- 4.7 versus 5.7 +/- 3.8 cm, p < 0.05), a similar proportion of them required operation compared with AP pseudocysts (56% versus 58%). There were significantly more deaths in patients with postoperative pancreatitis compared with all other groups (29% versus 7%, p < 0.05). The outcome of pseudocysts was similar regardless of size (greater than 6 cm versus less than 6 cm) and presentation (acute versus delayed). Thus, the etiology of pancreatitis was a more important determinant of pseudocyst outcome than pseudocyst size or presentation.     

JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis

Acute pancreatitis is a common disease with an annual incidence of between 5 and 80 people per 100 000 of the population. The two major etiological factors responsible for acute pancreatitis are alcohol and cholelithiasis (gallstones). The proportion of patients with pancreatitis caused by alcohol or gallstones varies markedly in different countries and regions. The incidence of acute alcoholic pancreatitis is considered to be associated with high alcohol consumption. Although the incidence of alcoholic pancreatitis is much higher in men than in women, there is no difference in sexes in the risk involved after adjusting for alcohol intake. Other risk factors include endoscopic retrograde cholangiopancreatography, surgery, therapeutic drugs, HIV infection, hyperlipidemia, and biliary tract anomalies. Idiopathic acute pancreatitis is defined as acute pancreatitis in which the etiological factor cannot be specified. However, several studies have suggested that this entity includes cases caused by other specific disorders such as microlithiasis. Acute pancreatitis is a potentially fatal disease with an overall mortality of 2.1%–7.8%. The outcome of acute pancreatitis is determined by two factors that reflect the severity of the illness: organ failure and pancreatic necrosis. About half of the deaths in patients with acute pancreatitis occur within the first 1–2 weeks and are mainly attributable to multiple organ dysfunction syndrome (MODS). Depending on patient selection, necrotizing pancreatitis develops in approximately 10%–20% of patients and the mortality is high, ranging from 14% to 25% of these patients. Infected pancreatic necrosis develops in 30%–40% of patients with necrotizing pancreatitis and the incidence of MODS in such patients is high. The recurrence rate of acute pancreatitis is relatively high: almost half the patients with acute alcoholic pancreatitis experience a recurrence. When the gallstones are not treated, the risk of recurrence in gallstone pancreatitis ranges from 32% to 61%. After recovering from acute pancreatitis, about one-third to one-half of acute pancreatitis patients develop functional disorders, such as diabetes mellitus and fatty stool; the incidence of chronic pancreatitis after acute pancreatitis ranges from 3% to 13%. Nevertheless, many reports have shown that most patients who recover from acute pancreatitis regain good general health and return to their usual daily routine. Some authors have emphasized that endocrine function disorders are a common complication after severe acute pancreatitis has been treated by pancreatic resection.     

Combined treatment of acute pancreatitis and its complications

Results of combined treatment of 314 patients with acute pancreatitis, including 58 (15.1%) with pancreonecrosis were analyzed. Etiologic factors of acute pancreatitis were alcohol (59% patients), diseases of the bile ducts (31.5%), surgery (2.5%). Up-to-date diagnostic criteria of severe pancreatitis are presented, character of complications is analyzed. Treatment policy in acute edematous pancreatitis was conservative. In calculous cholecystitis cholecystectomy was performed after regress of acute pancreatitis. Fermentative ascitis-peritonitis was the indication for laparoscopy in aseptic phase of pancreonecrosis. US- and CT-guided puncture and drainage were often used. Surgeries were performed only for complications of pancreonecrosis, more often through mini-approaches. General lethality in acute pancreatitis was 1.9%, in pancreonecrosis - 10.7%, postoperative lethality in pancreonecrosis was 16.6%.     

急性胆源性胰腺炎合并急性重症胆管炎处理策略

急性胆源性胰腺炎合并急性重症胆管炎病情凶险，病死率高。早期诊断，在内科治疗的同时，积极手术，合理选择内镜胆道引流、经皮经肝胆道引流、开放胆总管探查等治疗策略，以期阻止或延缓病情进展，降低并发症发生率及病死率。     

Conservative treatment as an option in the management of pancreatic pseudocyst

BACKGROUND: Management of pancreatic pseudocysts is associated with considerable morbidity (15-25%). Traditionally, pancreatic pseudocysts have been drained because of the perceived risks of complications including infection, rupture or haemorrhage. We have adopted a more conservative approach with drainage only for uncontrolled pain or gastric outlet obstruction. This study reports our experience. PATIENTS AND METHODS: A consecutive series of 36 patients with pancreatic pseudocysts were treated over an 11-year period in one district general hospital serving a population of 310,000. This study group comprised of 19 men and 17 women with a median age of 55 years (range, 10-88 years). Twenty-two patients had a preceding attack of acute pancreatitis whilst 12 patients had clinical and radiological evidence of chronic pancreatitis. The aetiology comprised of gallstones (16), alcohol (5), trauma (2), tumour (2), hyperlipidaemia (1) and idiopathic (10). RESULTS: All patients were initially managed conservatively and intervention, either by radiological-assisted external drainage or cyst-enteric drainage (by surgery or endoscopy), was only performed for persisting symptoms or complications. Patients treated conservatively had 6 monthly follow-up abdominal ultrasound scans (USS) for 1 year. Fourteen of the 36 patients (39%) were successfully managed conservatively, whilst 22 patients required intervention either by percutaneous radiological drainage (12), by endoscopic cystogastrostomy (1) or by open surgical cyst-enteric anastomosis (9). Median size of the pancreatic pseudocysts in the 14 patients managed conservatively (7 cm) was nearly similar to that of the 22 patients requiring intervention (8 cm). The most common indications for invasive intervention in the 22 patients were persistent pain (16), gastric outlet obstruction (4), jaundice (1) and dyspepsia with weight loss (1). Although one patient required surgery for persistent pain, no other patients required urgent or scheduled surgery for complications of untreated pancreatic pseudocysts. Two of the 12 patients treated by percutaneous radiological drainage had recurrence of pancreatic pseudocysts requiring surgery. Two patients developed an intra-abdominal abscess following cyst-enteric drainage of pancreatic pseudocysts and one patient had a pulmonary embolism. On the mean follow-up of 37.3 months, one patient with alcoholic pancreatitis died 5 months after surgical cyst-enteric bypass. CONCLUSIONS: These results suggest that many patients with pancreatic pseudocysts can be managed conservatively if presenting symptoms can be controlled.     

胰腺巨大假性囊肿27例的外科治疗

目的 探讨巨大胰腺假性囊肿的临床特点,并对各种外科治疗方法进行评价.方法 对1991年2月至2008年2月收治的27例巨大胰腺假性囊肿(长径>10cm)的临床资料进行回顾性分析.结果 27例巨大胰腺假性囊肿约占同期全部胰腺假性囊肿的20.9%;病因分类:急性胰腺炎所致占51.9%,胰腺外伤和手术所致占33.3%,慢性胰腺炎所致占11.1%;病程小于6周者占绝大多数(21/27);30%患者出现上消化道梗阻(8/27);影像学上虽然囊肿巨大,但均为单房囊肿;ERCP检查发现多数囊肿与胰管相通(9/11).手术方式包括囊肿外引流术9例,均失败,改行其他内引流术.囊肿胃吻合术10例,1例失败,改行囊肿空肠引流术,ERCP胰腺导管囊肿内支架引流术2例,1例失败,改行囊肿空肠引流术,囊肿空肠Roux-en-Y吻合术17例(其中11例为采用其他手术方式治疗失败者).所有患者均临床治愈.结论 胰腺巨大假性囊肿多数出现胰管解剖学改变,外科治疗时机和适应证有别于一般性胰腺假性囊肿.     

Continuous retroperitoneal infusion of a novocaine cocktail in the combined treatment of severe forms of acute pancreatitis

Severe forms of acute pancreatitis were treated in 53 patients (25 with a destructive form, 28 with an edematous form) with using permanent infusions of a novocaine cocktail into the retroperitoneal space. General lethality was reduced to 5.7%. In the group of patients with a destructive form of acute pancreatitis lethality was 12%. Nobody died in the group of patients with the edematous form. No complications were noted resulting from the method.     

Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis

BACKGROUND: Experience with minimal access, transoral/transmural endoscopic drainage/debridement of walled-off pancreatic necrosis (WOPN) after necrotizing pancreatitis is limited. We sought to determine outcome using this technique. METHODS: Retrospective analysis. RESULTS: From 1998 to 2006, 53 patients underwent transoral/transmural endoscopic drainage/debridement of sterile (27, 51%) and infected (26, 49%) WOPN. Intervention was performed a median of 49 days (range, 20-300 days) after onset of acute necrotizing pancreatitis. A median of 3 endoscopic procedures/patient (range, 1-12) were performed. Twenty-one patients (40%) required concurrent radiologic-guided catheter drainage of associated or subsequent areas of peripancreatic fluid and/or WOPN. Twelve patients (23%) required open operative intervention a median of 47 days (range, 5-540) after initial endoscopic drainage/debridement, due to persistence of WOPN (n = 3), recurrence of a fluid collection (n = 2), cutaneous fistula formation (n = 2), or technical failure, persistence of pancreatic pain, colonic obstruction, perforation, and flank abscess (n = 1 each). Final outcome after initial endoscopic intervention (median, 178 days) revealed successful endoscopic therapy in 43 (81%) and persistence of WOPN in 10 (19%). Preexistent diabetes mellitus, size of WOPN, and extension of WOPN into paracolic gutter were significant predictive factors for need of subsequent open operative therapy. CONCLUSIONS: Successful resolution of symptomatic, sterile, and infected WOPN can be achieved using a minimal access endoscopic approach. Adjuvant percutaneous drainage is necessary in up to 40% of patients, especially when WOPN extends to paracolic gutters or pelvis. Operative intervention for failed endoscopic treatment is required in about 20% of patients.     

Acute pancreatitis]

Acute pancreatitis is an acute inflammatory process of the pancreas mainly due to biliary obstruction or alcohol consumption. Most episodes of acute pancreatitis are mild and resolve under conservative treatment. Severe forms of acute pancreatitis, especially the necrotising form, still have a high mortality rate and can be difficult to treat. The problem today is to identify the few cases that should be treated operatively. Infected necroses are well accepted as an indication for operative treatment. Surgery consists of débridement and necrosectomy followed by closed or open lavage. In biliary pancreatitis, ERCP is performed early in cases of biliary obstruction, with or without cholangitis. In these patients cholecystectomy should be performed electively after clinical recovery.     

Acute pancreatitis following aortic aneurysm repair: Report of three cases

This paper reports three cases of acute pancreatitis that occurred after repair of an abdominal aortic aneurysm. The aneurysms were ruptured in two patients and asymptomatic in one. No patient had biliary disease or history of pancreatitis or alcohol abuse. Two of the patients required operation for drainage and debridement; one died. The etiology and diagnosis are discussed.     

Therapeutic strategy in acute necrotizing pancreatitis

We describe our therapeutic principles in connection with the treatment of 43 patients (30 male and 13 female) with acute necrotizing pancreatitis. The etiology of the disease was alcohol in 72.1%, gallstones in 23.3%, trauma, hyperlipidemia, ERCP and unknown in 4.7%. In all patients, the necrosis was proved by CT and histological examination. The patients were treated in intensive care unit. It involved prophylactic antibiotics (Imipenem) and early nasojejunal feeding. In each case, we endeavoured to delay surgery, which was a wide necrosectomy extending to the retroperitoneum. In 13 patients (30.2%) CT-guided percutaneous drainage was performed because of extensive peripancreatic fluid. Ten such patients were operated on at a later time. In 81.4% (35 patients) an average of 1.8 operations were performed. The first indications were acute abdomen, septic necrosis and multi-organ failure (MOF) unreactive to conservative therapy. Five patients (11.6%) were cured with conservative treatment and 3 patients (7%) were cured by treatment which included percutaneous drainage. Twenty-seven reoperations were performed in 12 patients because of sepsis, suspected peritonitis, abscess, bleeding and gastro-intestinal perforation. The average hospital stay was 44.5 days (3-120 days) long, and mortality was 16.2%. In our opinion in addition to intensive therapy, prophylactic antibiotics, early nasojejunal feeding and late, delayed surgery are important in the treatment of acute necrotizing pancreatitis. Percutaneous peripancreatic drainage is a useful way to delay operation. These therapeutic possibilities improve the survival rate of patients with pancreatic necrosis.     

急性胆源性胰腺炎合并急性重症胆管炎处理策略

急性胆源性胰腺炎合并急性重症胆管炎病情凶险，病死率高。早期诊断，在内科治疗的同时，积极手术，合理选择内镜胆道引流、经皮经肝胆道引流、开放胆总管探查等治疗策略，以期阻止或延缓病情进展，降低并发症发生率及病死率。     

JPN Guidelines for the management of acute pancreatitis: surgical management

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.     

胰腺坏死组织感染并发十二指肠瘘诊治及预后研究

目的 研究胰腺坏死组织感染(IPN)病人并发十二指肠瘘的诊治以及预后情况.方法 回顾性分析2018年1月至2019年12月东部战区总医院重症胰腺炎治疗中心 510例IPN病人资料,其中并发十二指肠瘘病人46例,按照倾向性评分(卡钳值0.2)进行1∶1匹配,将其与非十二指肠瘘病人进行1∶1匹配分析.结果 IPN并发十二指...     

Improved survival in 45 patients with pancreatic abscess.

The reported mortality due to pancreatic abscesses after acute pancreatitis has been 30 to 50%, a statistic that has remained unchanged for decades. This is a report of 45 patients treated over 10 years, showing a dramatic improvement in survival during that period. They represent 2.5% of admissions at the Massachusetts General Hospital for acute pancreatitis. The identifiable antecedents included alcohol (38%), gallstones (11%), and surgical trauma (16%), or were unknown in 24%. Computerized tomography (CT) was clearly the best means of specific diagnosis (unequivocal evidence in 74%, suggestive in 21%). Treatment in 44 patients was surgical debridement and catheter drainage, and in one it was resection of the pancreatic head. Multiple abscesses were present at the first operation in 21 patients. Seven had second drainage procedures for additional abscesses. In the first 5 years (1974-1978), 10 of 26 patients died (38%). In the second 5 years (1979-1983), one of 19 died (5%) (p less than 0.01). Postoperative complications (84%) included wound hemorrhage (9 of 26 vs. 1 of 19), systemic sepsis (7 of 26 vs. 1 of 19), pancreatic fistula (14/45, 13 of which closed spontaneously), colonic perforation (4), duodenal perforation (2), and gastric perforation (1). The causes of death were renal and respiratory failure with sepsis (7), hemorrhage (3), and pulmonary emboli (1). Analysis of the findings shows in the second 5-year period more frequent use of CT to certify the diagnosis of pancreatic abscess earlier, a more aggressive attitude producing earlier surgical intervention, and more extensive drainage and debridement of associated necrotic tissue. Transcatheter arterial embolization was used successfully to control postoperative hemorrhage from the abscess cavity. CT-guided percutaneous catheter drainage was used occasionally for drainage of recurrent abscesses. Neither open packing of major pancreatic abscesses nor lavage of the abscess cavity, as recently advocated, was necessary.