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Akute Pankreatitis Der chirurgische Bauch - Eine interdisziplinäre Herausforderung Symposium 08. November 2018 Dr. Stefan Gutknecht LA Chirurgie Stadtspital Triemli Zurich

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Page 1: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Akute Pankreatitis

Der chirurgische Bauch -Eine interdisziplinäre HerausforderungSymposium 08. November 2018

Dr. Stefan Gutknecht LA ChirurgieStadtspital Triemli Zurich

Page 2: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 2Dr. med. Stefan Gutknecht

08 – 11 - 2018

Basics Incisional Hernias

• Inzidenz 10-30/100’000 /a in Westeuropa

• M:F = 3:2

• 2-5% Mortalität aller Pankreatitiden

ABER 10-30% Mortalität bei schwerer Pankreatitis- Multiorganversagen (MOF) / SIRS

- infektiöse Komplikationen

Inzidenz

Roberts S et al. Aliment Pharmacol Ther. 2013;38:539–48.

Koutroumpakis E et al. Pancreatology 2017;17:32–40.

IAP/APA Guidelines. Pancreatology. 2013;13:e1–e15.

Page 3: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 3Dr. med. Stefan Gutknecht

08 – 11 - 2018

Basics Incisional HerniasÄthiologie

1. Mechanisch/Obstruktive Pankreatitis

a) Biliäre Pankreatitis 40-60%

b) Choledochuszyste/Duodenaldivertikel

2. Toxisch / metabolisch

a) Alkohol 20-40%

b) Hyperparathyreodismus, Hypertriglycerinämie,

Hämochromatose, Schwangerschaft, Urämie

c) Medikamentös: Aazathioprin, Tetracykline, ACE Hemmer

3. Idiopatische Pankreatitis 10-20%

4. Autoimmun

5. Infektiös: Mumps, CMV, Echovirus, Coxsackie, HIV, Salmonellen

6. Genetisch: Cystische Fibrose

7. Systemerkrankungen: LED, Sjörgen Synrom,

8. Iatrogen: postoperativ, nach ERCP 1- 5%

Page 4: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 4Dr. med. Stefan Gutknecht

08 – 11 - 2018

Basics Incisional HerniasDiagnose

Dx der akuten Pankreatitis falls 2 von 3 Kriterien:

1. Akuter Beginn von persistierenden epigastrischen

Schmerzen mit Ausstrahlung in den Rücken

2. Lipase oder Amylase im Serum um 3-fache über der

Norm

3. Charakteristische Befunde in der Schnittbildgebung

(CT, MRI, US)

- Lipase hat bessere Spezifität als Amylase

- Schmerzbeginn definiert den Beginn der Pankreatitis

x

Page 5: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 5Dr. med. Stefan Gutknecht

08 – 11 - 2018

Basics Incisional HerniasDiagnose

Obligate Abdomen-Sonografie zur Beurteilung von:

• Gallenwege und -blase• ? Steine, Sludge

• ? Cholestase

• ? Entzündung

• Pankreasstruktur• ? Ödem

• ? Kalzifikationen

• Freie Flüssigkeit

Ev. Ergänzung mit Rx Thorax

oder CT mit KM (nach 48-72h bei fehlender Besserung: ? Lok Ko)

Banks PA et al. Gut 2013; 62: 102-111.

Page 6: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 6Dr. med. Stefan Gutknecht

08 – 11 - 2018

Basics Incisional HerniasClassification

History

Bradley EL et al. Arch Surg 1992; 128: 586-590.

Banks PA et al. Gut 2013; 62: 102-111.

Classification for severity of pancreatitis

1992 Atlanta Classification 2 cat

mild - severe

2012 revised Atlanta Classification 3 cat

mild - moderately severe - severe

Page 7: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 7Dr. med. Stefan Gutknecht

08 – 11 - 2018

Basics Incisional HerniasClassification

Revised Atlanta Classification 2012

Banks PA et al. Gut 2013; 62: 102-111.

Interstitial oedematous pancreatitis- 85% of cases, mortality 5%

- Diffuse enlargement of pancreas due to oedema

- CT: parenchyma with homogenous enhancement,

peripancreatic inflammatory changes (haziness)

Necrotising pancreatitis- 15% of cases, mortality 17%

- Necrosis of the pancreatic parenchyma

- CT: patchy, variable attenuation before demarcation is seen

- Natural history of necrosis is variable

- Remain solid or liquefy

- Remain sterile or become infected

- Persist or disappear

TY

PE

Page 8: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 8Dr. med. Stefan Gutknecht

08 – 11 - 2018

Banks PA et al. Gut 2013; 62: 102-111.

Mild acute pancreatitis- No organ failure

- No local or systemic complications

Moderately severe acute pancreatitis- Single organ failure that resolves within 48 h

(transient organ failure) and/or

- Local or systemic complications

without persistent organ failure

Severe acute pancreatitis- Persistent single organ failure (>48 h) or

- multiple organ failure (MOF)

Classification

Revised Atlanta Classification 2012S

EV

ER

ITY

Page 9: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 9Dr. med. Stefan Gutknecht

08 – 11 - 2018

Banks PA et al. Gut 2013; 62: 102-111.

Mild acute pancreatitis- No organ failure

- No local or systemic complications

Moderately severe acute pancreatitis- Single organ failure that resolves within 48 h

(transient organ failure) and/or

- Local or systemic complications

without persistent organ failure

Severe acute pancreatitis- Persistent single organ failure (>48 h) or

- multiple organ failure (MOF)

Single Organ Failure (SOF):

- renal failure

- respiratory failure

- cardiac failure

Classification

Revised Atlanta Classification 2012S

EV

ER

ITY

mod Marshall Scoring Sys

score ≥ 2

Page 10: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 10Dr. med. Stefan Gutknecht

08 – 11 - 2018

Basics Incisional HerniasClassification

Modified Marshall Scoring System

Banks PA et al. Gut 2013; 62: 102-111.

Mild acute pancreatitis- No organ failure

- No local or systemic complications

Moderately severe acute pancreatitis- Single Organ failure that resolves within 48 h

(transient organ failure) and/or

- Local or systemic complications

without persistent organ failure

Severe acute pancreatitis- Persistent single organ failure (>48 h) or

- multiple organ failure (MOF)

Single Organ Failure:

= exacerbation of preexisting comorbidities- renal failure

- respiratory failure score ≥ 2

- cardiac failure mod Marshall Scoring Sys

one score ≥ 2

Single Organ failure

- PaO2/FiO2 <300

- Crea >170mmol/L

- sysBP <90, NorAd, inotrops

Page 11: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 11Dr. med. Stefan Gutknecht

08 – 11 - 2018

Basics Incisional HerniasClassification

Revised Atlanta Cl. 2012

Banks PA et al. Gut 2013; 62: 102-111.

Mild acute pancreatitis- No organ failure

- No local or systemic complications

Moderately severe acute pancreatitis- Single organ failure that resolves within 48 h

(transient organ failure) and/or

- Local or systemic complications

without persistent organ failure

Severe acute pancreatitis- Persistent single organ failure (>48 h) or

- multiple organ failure (MOF)

SE

VE

RIT

Y Systemic Complications:

= exacerbation of preexisting comorbidities- congestive heart disease

- chronic liver failure

- chronic lung disease

Local Complications:

= interstital pancreatitis

- acute peripancreatic fluid collection APFC CT after

- pancreatic pseudocyst PC 5-7 days

= necrotizing pancreatitis

- acute necrotic collection ANC

- walled-off necrosis WON

Page 12: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 12Dr. med. Stefan Gutknecht

08 – 11 - 2018

Banks PA et al. Gut 2013; 62: 102-111.

Local Complications

Classification

Acute peripancreatic Pseudocyst (PC)

fluid collection (APFC)• Interstitial pancreatitis

• Homogenous fluid

• <4 weeks

• No fully definable wall

Acute necrotic collection Walled-off necrosis (WA)

(ANC)• Necrotizing pancreatitis

• Heterogeneous collection

• <4 weeks

• No fully definable wall

• Interstitial pancreatitis

• Homogenous fluid

• >4 weeks

• Well definable wall

• Necrotizing pancreatitis

• Heterogeneous collection

• >4 weeks

• Well definable wall

Page 13: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 13Dr. med. Stefan Gutknecht

08 – 11 - 2018

Banks PA et al. Gut 2013; 62: 102-111.

Local Complications

Classification

Acute peripancreatic Pseudocyst (PC)

fluid collection (APFC)

Acute necrotic collection Walled-off necrosis (WA)

(ANC)

Gastric outlet dysfunction

Splenic and portal vein thrombosis

Colonic necrosis

Page 14: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 14Dr. med. Stefan Gutknecht

08 – 11 - 2018

Banks PA et al. Gut 2013; 62: 102-111.

Local Complications

Classification

Acute

peripancreatic

fluid

collection

(APFC)

Pseudocyst

(PC)

Page 15: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 15Dr. med. Stefan Gutknecht

08 – 11 - 2018

Banks PA et al. Gut 2013; 62: 102-111.

Local Complications

Classification

Acute

necrotic

collection

(ANC)

Walled-off

necrosis (WA)

Page 16: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 16Dr. med. Stefan Gutknecht

08 – 11 - 2018

Banks PA et al. Gut 2013; 62: 102-111.

Local Complications

Classification

Acute

necrotic

collection

(ANC)

Walled-off

necrosis (WA)

Infected

necrosis

Page 17: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 17Dr. med. Stefan Gutknecht

08 – 11 - 2018

1. Kausale Therapie

Nur bei biliärer Pankreatitis wirklich anwendbar

ERCP zur Steinextraktion

Cholezystektomie zur Sanierung

2. Supportive Therapie

sekundäre Komplikationen verhindern, somit senken der Mortalität

3. Komplikationsbehandlung

Intensivmedizin bei SOF bzw MOF

Step-up Approach bei lokalen Komplikationen

Therapie

Page 18: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 18Dr. med. Stefan Gutknecht

08 – 11 - 2018

Fan ST et al. NEJM 1993;328:228.

Petrov MS et al. Ann Surg 2008;247:250. (Meta 6 RCT)

Tse F et al. Cochrane Database Syst Rev 2012; 5:CD0099779.

Akute Pankreatitis

+ biliäre Obstruktion

+ akute Cholangitis

ERCP inkl Papillotomie notfallmässig (<24h)

oder chirurgische Sanierung

Akute Pankreatitis

ohne Cholangitis

Zeitpunkt der ERCP keinen Einfluss auf Outcome

- Mortalität

- SOF / MOF

1. Kausale Therapie

ERCP

Page 19: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 19Dr. med. Stefan Gutknecht

08 – 11 - 2018

Da Costa DW et al. Lancet 2015; 386: 1261–68. PONCHO Trial

Hernandez V et al. Am J Gastroenterol 2004;99:2417.

PONCHO Trial (NL, 2015 )

Multicentre, RCT N=266

Intervall-CZE (25-30d, N=137) vs same admission CZE (3d, N=129)

Bei verzögerter / ausbleiben der CZE

25-30% Risiko in 6-18 Wochen für

- erneute Akute Pankreatitis

- Cholecystitis

- Cholangitis

Bei der ‘Moderately Severe Pancreatitis’ mit biliärer Genese soll

CZE während Index-Hospitalisation durchgeführt werden

1. Kausale Therapie

Cholezystektomie

Page 20: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 20Dr. med. Stefan Gutknecht

08 – 11 - 2018

sekundäre Komplikationen verhindern, somit senken der Mortalität

• Volumensubstitution 300-500 ml/h bzw 5-10ml/kg/h

• Pressoren: notwendig, aber CAVE: Nekrose durch

Minderdurchbutung

• Beatmung: O2 Gabe, allenfalls Intubation

In den ersten 48h muss Oligurie verhindert werden

• Antibiotikagabe

• Ernährung

2. Supportive Therapie

Page 21: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 21Dr. med. Stefan Gutknecht

08 – 11 - 2018

2. Supportive Therapie

Prophyl. Antibiotika

Lim CL et al. J Gastrointest Surg 2015;19:480-491.

Crockett SD et al. Gastroenterology 2018; 154:1096.

Viel diskutiert, aktuellste Empfehlungen/Studien:

KEINE prophylaktische Antibiotika Gabe bei nekrotisierender

Pankreatitis da KEINE Reduktion der Infektion von Nekrosen

• Negative Effekte der Abx auf die intestinale mikrobiologische Barriere

werden diskutiert.

ABER: 20% der Patienten erleiden extrapankreatischen Infekt

(Bakteriämie, Pneumonie, HWI)

Steigert Mortalität

ABx Gabe bevor Quelle identifiziert.

Page 22: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 22Dr. med. Stefan Gutknecht

08 – 11 - 2018

Wereszcynska-Siemiatkowska U et al. Pancreas 2013;42:640-646.

Zhao et al. Nutrition 2015;31:171-175.

Wann? Verabreichungsweg (oral vs enteral vs parenteral)?

Enterale Ernährung der parenteralen Überlegen!

Tendenz zu

- frühzeitige (Hungergefühl)

- orale Ernährung

kürzere Hospitalisation

kürzere Nahrungskarenz

gleiche Komplikationsrate

2. Supportive Therapie

Ernährung

Page 23: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 23Dr. med. Stefan Gutknecht

08 – 11 - 2018

Van Santvoort HC et al. NEJM 2010;362:1491. PANTER Trial (NL)

FNA to prove infected necrosis

1. Percutaneous or transgastric Drainage

2. Minimally invasive retroperitoneal necrosectomy

(=VARD: video assisted retroperitoneal debridement)

= control of the source of infection, rather than complete removal of

infected necrotic tissue minimize surgical trauma

3. Komplikations Therapie

Lokale Komplikationen

Page 24: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 24Dr. med. Stefan Gutknecht

08 – 11 - 2018

Karsten T et al. NEJM 2010;362:1491. PANTER Trial (NL)

3. Komplikations Therapie

Lokale Komplikationen

VARD: video assisted retroperitoneal

debridement

Page 25: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 25Dr. med. Stefan Gutknecht

08 – 11 - 2018

Van Santvoort HC et al. NEJM 2010;362:1491. PANTER Trial (NL)

Step-up Approach Open Necrosectomy

N=43 17 MCo/death (40%) N=45 31 MCo/death (69%) p=0.006

(35%) percutaneous

drain only

12% MOF 43% MOF p=0.002

19% death 16% death p=0.70

7% Inc Hernia 24% Inc Hernia p=0.03

3. Komplikations Therapie

Lokale Komplikationen

Page 26: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 26Dr. med. Stefan Gutknecht

08 – 11 - 2018

Acute Pancreatitis

Conclusion 1

• Die akute Pankreatitis ist ein sehr heterogenes Krankheitsbild mit häufig unklarem Verlauf

• Gute Studien sind schwierig auf Grund der Notfallsituation

• Studienergebnisse und Expertenmeinungen sind sehr unterschiedlich und häufig widersprüchlich

• Einteilung nach modifizierter Atlanta Klassifikation macht Vergleich von Studien möglich

Page 27: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 27Dr. med. Stefan Gutknecht

08 – 11 - 2018

Acute Pancreatitis

Conclusion 2

Gute Evidenz:

• Biliäre Pankreatitis Bei milder Pankreatitis biliärerGenese wird Cholezystektomie in gleicher Hospitalisation gefordert

• Bei infizierten Nekrosen ist ein Step-up Approach der offenen Chirurgie vorzuziehen

Page 28: Akute Pankreatitis - stadt-zuerich.ch das... · IAP/APA Guidelines. Pancreatology. 2013;13:e1 ... Mild acute pancreatitis - No organ failure - No local or systemic complications Moderately

Pancreatitis - 28Dr. med. Stefan Gutknecht

08 – 11 - 2018

Thanks for your attention