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The DBC was created through a consensus of international experts from 49 countries [13]. The DBC uses the local determinant (i.e. infected necrosis) and/or systemic determinant (i.e. organ failure) of mortality to categorize AP into four levels of severity: mild, moderate, severe, and critical (see Table 3.1) [31]. Mild AP is defined as no pancreatic or peripancreatic necrosis and no organ failure. Moderate AP is defined as sterile necrosis and/or transient organ failure. Severe AP is defined as either infected necrosis or persistent organ failure. A fourth category termed “critical AP” is defined by the presence of both persistent organ failure and infected necrosis.

Organ failure is defined by a Sepsis‐related Organ Failure Assessment (SOFA) score of 2 or more, or when the following thresholds are met.

1 Cardiovascular: use of inotropic agent.

2 Renal: creatinine ≥171 μmol/l (≥2.0 mg/dl).

3 Respiratory: PaO 2/FiO 2 ≤300 mmHg (≤40 kPa).

As in the RAC, persistent organ failure is defined as lasting for 48 hours or more. Transient organ failure is defined as lasting less than 48 hours.

The RAC and DBC share many similarities, and multiple independent validation studies have found no significant differences in performance between the two classification systems [1–8].

The primary distinction between the two classification systems is the emphasis the DBC places on infected necrosis as a determinant of outcomes; however, the contribution of infected necrosis to mortality may be limited. While previous studies have shown infected necrosis to be a risk factor for mortality independent of persistent organ failure, these studies were largely performed in an era when patients with infected necrosis underwent early surgical debridement [31]. More recent studies performed after the advent of direct endoscopic necrosectomy have shown that mortality of infected necrosis in the absence of organ failure is much lower (<5%) [3,4,8,24]. Conversely, in the setting of persistent organ failure, neither the presence nor absence of infected necrosis affects the overall high mortality rates [3,8,24]. If these observations are confirmed in future studies, revisions of the DBC should no longer classify infected necrosis in the absence of persistent organ failure as severe AP, nor should the presence of both infected necrosis and persistent organ failure be separated into its own “critical” category.