摘要:

Endoscopic treatment of acute biliary pancreatitis is restricted to the treatment of bile duct stones. Three prospective randomized trials demonstrate the superiority of early ERCP/papillotomy (within 96 h) over conservative treatment of severe acute biliary pancreatitis, as well as safety and effectivity of the endoscopic procedure. The timing of the early ERCP/papillotomy (emergency vs. within 96 h) is at discussion. Although no significant benefit of immediate and early ERCP/papillotomy over the conservative approach has been shown in cases of predicted mild acute pancreatitis, the Hong Kong group advocates this procedure independent of the severity of the disease. We prefer this latter approach because potentially lethal complications are treated in time, papillotomy prevents further ampullary occlusion by stones and may early relieve pancreatic duct hypertension.

ISSN:0253-4886    

DOI:10.1159/000172259

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Despite progress in recent years in the diagnostics, surgical treatment and intensive care therapy, severe acute pancreatitis remains a major challenge to the medical profession and a serious threat to the patients. In its most severe form, acute pancreatitis is characterised by a profound inflammatory process in the pancreas leading to partial or total necrosis of the parenchyma. Acute pancreatitis also frequently causes dysfunction of remote organs as well as local complications (pancreatic infection, haemorrhage and pseudocysts). The majority of the attacks of acute pancreatitis (85-90%) are, however, mild and can be dealt with by simple routine treatment. It is essential to identify at an early stage those patients who will develop a severe form of the disease, to allow timely vital organ system monitoring and support in an intensive care unit. Early intervention may have a significant influence on the course of the disease. As soon as the pancreatic inflammation has progressed to necrosis, anti-enzyme or anti-inflammatory therapy and/or treatment which may enhance the pancreatic microcirculation is not likely to change the course of the disease and leaves the treating physician with symptomatic measures only. On arrival to the ICU the patients are frequently hypovolaemic, have diminished blood flow to the abdominal organs, resulting not only in more severe local disease, but also frequently causing failure of remote organs such as the lungs (adult respiratory distress syndrome), kidneys, liver and the intestine (possibly encouraging translocation of enteral bacteria). The aim of therapy in severe pancreatitis is obviously to halt the progress of the local disease and to prevent remote organ failure. So far, very limited experimental and clinical research has been performed on the effects of different modes of intensive care therapy on pancreatic blood flow or on the progress of the panceatic necrosis. Based on clinical experience and available research data, the following procedures are currently recommended in the ICU management of severe pancreatitis. (l)Use invasive monitoring. (2) Optimise oxygen transport by maintaining hyperdynamic circulation (at least during the first 3 days), for example by using isovolaemic or hypervolaemic haemodilution, administration of low dose dopexamine and if necessary other cardio-inotropic drugs. (3) Indications for assisted ventilation should be liberal in order to guarantee high blood oxygen content and to decrease energy expenditure. (4) Start nutrition early to minimise negative nitrogen balance, but avoid overfeeding. (5) Use crystalloids for replacement of insensible fluid loss only and synthetic colloids such as pentastarch for plasma substitution. (6) Provide effective pain relief, for example, by continuous epidural or coeliac block. (7) In cases of extensive necrosis, prophylactic antibiotic therapy (imipenem) should be considered. (8) Follow the clinical course of the patient very closely and monitor the degree of necrosis and possible pancreas infection for timely surgical intervention when necessary.

ISSN:0253-4886    

DOI:10.1159/000172260

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Infection complicating pancreatic or peripancreatic necrosis is the single most accepted criterion for surgical intervention in severe acute pancreatitis. A failure to improve after 72 h of high-quality intensive care should also stimulate clinicians to reappraise the claims for surgical therapy. It is wise to remove the gallbladder in all cases which come to surgery, whether stones are proven or otherwise.

ISSN:0253-4886    

DOI:10.1159/000172261

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Surgical treatment in patients with severe acute pancreatitis is still a controversial subject, ranging from sole conservative to an aggressive approach. This article gives an overview of the literature with regard to indications for surgery, timing and techniques of operative treatment concepts in severe acute pancreatitis with special attention to the recommended necrosectomy and closed continuous lavage of the involved retroperitoneum. Taking into account recent findings from microbiological data we developed a new algorithm in patients with acute pancreatitis. All patients with proven acute necrotizing pancreatitis receive an antibiotic therapy for 2 weeks beside the intensive care measures. So far only one third (33%) had infected pancreatic necrosis in the 3rd week of the onset of the disease and were managed surgically. The delay resulted in optimal surgical conditions for necrosectomy and a mortality rate of 0%. This new concept and therapeutic approach with the early suitable antibiotic therapy in patients with proven necrotizing pancreatitis is recommended to (1) decrease the infection rate and (2) delay surgical intervention to the 3rd week of the disease with optimal surgical conditions. It seems more and more likely that only patients with proven infected pancreatic necroses are candidates for surgical intervention.

ISSN:0253-4886    

DOI:10.1159/000172262

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Management of the peripancreatic bed after necrosectomy for surgical complications of acute necrotizing pancreatitis remains controversial. Since 1985, we have adopted a technique of planned, reoperative necrosectomy/debridement with eventual primary wound closure over peripancreatic drains. Using this approach in 47 patients, we have experienced an operative mortality of 23% and a recurrent intra-abdominal abscess rate of 13%, all but one of which were treated by simple percutaneous drainage. In contrast, 18 patients were managed by a single operative necrosectomy with placement of peripancreatic drains; their operative mortality was 33%, and all 3 patients who developed intra-abdominal abscesses required reoperation. We believe that a planned reoperative necrosectomy with eventual primary abdominal closure maximizes the success of complete necrosectomy and minimizes the incidence of recurrent (or persistent) intra-abdominal sepsis.

ISSN:0253-4886    

DOI:10.1159/000172263

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

From March 1, 1991 to December 31, 1994, a total of 76 patients with acute pancreatitis were treated at the surgery division. Out of these, 16 (21%) were treated for necrotizing pancreatitis with open packing and programmed lavage. They were 12 men and 4 women with an average age of 51.5 years. The Ranson score on admission averaged 5.6. The total duration of hospitalization was 58.25 days, the average stay in the intensive care unit 23.7 days. In 6 (37.5%) patients, there were serious surgical complications: pancreas fistulae (n = 5), colon perforations (n = 3) and errosion hemorrhages (n =2). 12 patients developed a cicatricial hernia owing to the laparostoma, and 2 developed diabetes requiring insulin administration after the operation. The hospital mortality was 16.7% (n = 2). Considering the severity of the disease and the initial situation, acceptable results can hence be obtained with the method of open packing and programmed lavage.

ISSN:0253-4886    

DOI:10.1159/000172264

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Chronic pancreatitis is a regressive disease, sometimes progressing to the point of insufficient secretion from both the exocrine and the endocrine pancreas. Functional decline is matched by morphological changes in the parenchyma and stroma. Acinar cells redifferentiate to produce tubular complexes and degenerate, resulting in a larger proportion of ductular cells than normal. The decrease in parenchyma is more than made up for by an increase in stroma. Characteristically, marked fibrosis occurs. Chronic inflammatory cells are prominent, frequently occurring as clusters. The large pancreatic ducts are altered as well. They may be denuded of their epithelium, eliminating the barrier that normally exists. Plasma cells and inflammatory cells in their walls contribute to the extra components that are found in pancreatic juice. Pancreatic stones, consisting of calcium carbonate precipitated in an organic matrix, may form in the ducts. Chronic inflammatory cells cluster around nerves in and around the pancreas, inducing damage to the perineurium and eventually affecting nerve fibers. This direct damage, coupled with abnormal access of foreign substances to the interior of the nerves due to lack of the perineurial barrier, may provide a partial explanation for the chronic pain that is associated with the disease.

ISSN:0253-4886    

DOI:10.1159/000172265

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Some pertinent problems related to the long-term course of chronic pancreatitis are reviewed like progression and nonprogression of the disease, etiology and outcome, the different postulated pain mechanisms and the relationship of acute and chronic pancreatitis. Chronic pancreatitis is clinically a nonhomogeneous entity but some typical clinical patterns can be related to morphologic (histopathologic) and functional changes in the evolution from early to late stages. Clinical and histologic evidence is discussed, which suggests a close relationship between alcoholic acute and chronic pancreatitis.

ISSN:0253-4886    

DOI:10.1159/000172266

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Advances in molecular and cellular biology have generated a clearer understanding of the putative biological mechanisms interrelated in the genesis of inflammation and neoplasia. The worldwide incidence of chronic pancreatitis is 3%, with alcohol etiologically responsible for approximately two thirds of cases. The incidence of pancreatic cancer, steadily increasing over the past 60 years, is presently 2%. Risk factors epidemiologically correlated with the development of pancreatic cancer include smoking, diet, coffee, diabetes mellitus, and previous peptic ulcer surgery. A strong causal association exists for smoking and previous peptic ulcer surgery, while the relationship to diet, coffee, and diabetes mellitus is dubious. Several epidemiological studies suggest chronic pancreatitis is associated with an increased risk of developing pancreatic carcinoma, citing the risk in this population as 3%. The reports documenting the association are epidemiological in nature, with modest scientific data supporting the relationship. These studies do not demonstrate a convincing correlation between the two diseases. Theoretically, however, support for the association is derived from historical awareness of the effects of the chronic inflammatory state on epithelial tissues. It is likely that a weak association of uncertain relevance exists between chronic pancreatitis and the development of cancer of the pancreas. This observation may represent a correlatable epiphenomenon. This review documents existing epidemiological and experimental studies and suggests the definitive nature of the relationship between chronic pancreatitis and pancreatic carcinoma may be determined through the study of peptide growth factors expressed in normal, inflammatory, and neoplastic pancreatic tissue.

ISSN:0253-4886    

DOI:10.1159/000172267

出版商:S. Karger AG    

年代:1994

数据来源: Karger

摘要:

Diagnosis and staging of chronic pancreatitis is based on patient history, clinical findings, and various diagnostic tools. Usually, a combination of both, investigations of pancreatic function and pancreatic structure are necessary for an accurate diagnosis. This paper gives an overview of the most widely used function tests (PABA Test, Pancreolauryl Test, Secretin Test) and the various imaging techniques (plain X-ray, ultrasound, CT scan, ERCP). Currently, ERCP is the most sensitive method for analyzing the structure of the pancreatic duct system and it provides valuable information for the selection of patients who may benefit from surgical or endoscopic therapy.

ISSN:0253-4886    

DOI:10.1159/000172268

出版商:S. Karger AG    

年代:1994

数据来源: Karger