Читать книгу Clinical Pancreatology for Practising Gastroenterologists and Surgeons - Группа авторов - Страница 170

Acute pancreatitis is frequently a mild disease. However, about one in every five patients develops a more severe disease with (peri)pancreatic necrosis. Early organ or multiorgan failure develops in severe disease, usually within the first week of onset, due to systemic inflammatory response syndrome. Late development of organ failure is usually due to sepsis secondary to infection of (peri)pancreatic necrosis. Infected necrotizing pancreatitis is therefore one of the most severe complications of acute pancreatitis and one of the greatest therapeutic challenges in this disease.

Infected (peri)pancreatic necrosis was historically considered an indication for early open necrosectomy [1]. However, this approach was associated with a high rate of complications and death. Because of this, prevention of infection of pancreatic necrosis became the main therapeutic aim in acute necrotizing pancreatitis, and prophylactic administration of antibiotics, mainly imipenem, was included as part of the standard of care of these patients [2,3].

Several landmark studies and publications over the last 15 years have led to a dramatic change in the management of patients with acute necrotizing pancreatitis.

1 Several double‐blind randomized controlled trials and meta‐analyses have shown that prophylactic antibiotics are ineffective for preventing severe complications and death in patients with acute necrotizing pancreatitis [4–9].

2 Local complications of acute pancreatitis have been redefined based on scientific evidence and consensus among experts in the so‐called revised Atlanta classification [10]. Acute fluid collections and pseudocysts, and acute necrotic collections and walled‐off necrosis (WON) are clearly defined as local complications of acute edematous interstitial pancreatitis and acute necrotizing pancreatitis, respectively.

3 A minimally invasive step‐up surgical approach using percutaneous drainage and laparoscopic or video‐assisted retroperitoneal debridement has been shown to be superior to open necrosectomy for the treatment of infected (peri)pancreatic necrosis [11,12].

4 Delaying intervention of infected pancreatic necrosis is associated with better outcomes compared with an early approach [13,14]. Therefore, intervention should be delayed as much as possible, at least four weeks from onset of the disease, when WON with mature wall has developed.

5 An endoscopic approach has been established as a valid and probably safer alternative to the minimally invasive surgical approach for the step‐up treatment of patients with infected (peri)pancreatic necrosis [15–17].