tratamiento endoscopico de pancreatitis grave

TRATAMIENTO ENDOSCOPICO DE PANCREATITIS GRAVE

A Step-up Approach or Open Necrosectomy for Necrotizing Pancreatitis

Hjalmar C. van Santvoort, M.D., Marc G. Besselink, M.D., Ph.D., Olaf J. Bakker, M.D., H. Sijbrand Hofker, M.D., Marja A. Boermeester, M.D., Ph.D., Cornelis H. Dejong, M.D., Ph.D., Harry van Goor, M.D., Ph.D., Alexander F. Schaapherder, M.D., Ph.D., Casper H. van Eijck, M.D., Ph.D., Thomas L. Bollen, M.D., Bert van Ramshorst, M.D., Ph.D., Vincent B. Nieuwenhuijs, M.D., Ph.D., Robin Timmer, M.D., Ph.D., Johan S. Laméris, M.D., Ph.D., Philip M. Kruyt, M.D., Eric R. Manusama, M.D., Ph.D., Erwin van der Harst, M.D., Ph.D., George P. van der Schelling, M.D., Ph.D., Tom Karsten, M.D., Ph.D., Eric J. Hesselink, M.D., Ph.D., Cornelis J. van Laarhoven, M.D., Ph.D., Camiel Rosman, M.D., Ph.D., Koop Bosscha, M.D., Ph.D., Ralph J. de Wit, M.D., Ph.D., Alexander P. Houdijk, M.D., Ph.D., Maarten S. van Leeuwen, M.D., Ph.D., Erik Buskens, M.D., Ph.D., and Hein G. Gooszen, M.D., Ph.D. for the Dutch Pancreatitis Study GroupDutch Pancreatitis Study Group

N Engl J Med 2010; 362:1491-1502

Drenaje con ecoendoscopia o endoscopia

Endoscopic Ultrasound Drainage of Pancreatic Pseudocyst: A Prospective Comparison with Conventional Endoscopic Drainage. M. Kahaleh; V. M. Shami; M. R. Conaway;

J. Tokar; T. Rockoff; S. A. De La Rue; E. de Lange; M. Bassignani ;S. Gay; R. B. Adams; P. Yeaton. Endoscopy 2006; 38 (4): 355-359

Necrosis pancreatica infectada: evolución

Outcome of severe acute pancreatitis: Is there a role for conservative management of infected pancreatic necrosis?. Amarapathy Sivasankar, Devy Gounder Kannan, Palaniappan Ravichandran, Sathyanesan Jeswanth, Tirupporur Govindasamy Balachandar and Rajagopal Surendran. Hepatobiliary Pancreat Dis Int 2006; 5: 599-604

N:52 pt IN, 18 surgery y 6 conservative

Tto conservador comparable a cia en pacientes con necrosis infectada

Endoscopic and Percutaneous Drainage of Symptomatic Walled-Off Pancreatic Necrosis Reduces Hospital Stay and Radiographic Resources. Michael Gluck,* Andrew Ross,* Shayan Irani,* Otto Lin,* Ellen Hauptmann,‡ Justin Siegal,‡ Mehran Fotoohi,‡ Robert Crane,‡ David Robinson,‡ and Richard a. Kozarek*. Clinical Gastroenterology and Hepatology 2010,8(12):1083-88.

Tto conservador comparable a cia en pacientes con necrosis infectada

Primary Conservative treatment Results in Mortality comparable to surgery in PAtients with Infected Pancreatic Necrosis. Pramod Kumar Garg,* Manik Sharma,* Kaushal Madan,* Peush Sahni,‡ Debabrata Banerjee,* and Rohit Goyal*. Clinical Gastroenterology and Hepatology 2010;8:1089–1094

Se puede evitar cirugía en el 76% de NI y el 54,5% de las NI se pueden manejar de forma conservadora

Tto de colecciones pancreáticas con protesis autoexpandibles

• Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents. Jayant P Taljera, Vanessa M. Shami, Jennifer Ku, Tanya D. Morris; Kristi ellen, M Kahaleh. Gastrointestinal Endoscopy 2008;68(8):1199-1203.

N:18 patients ( Jan 2007-Sep 2008)

Resolución completa del 78%, respuesta 95%;Media de dias hasta resolución: 77+-80 dias

Complications:

Superinfection 5

Bleeding 5

Migración interna 1

• Temporary cystogastostomy with self-expanding metallic stents for pancreatic necrosis. S. Belle, P Collet, S Post, G Kaehler. Endocopy 2010;42:493-95.

Tto de colecciones pancreáticas con protesis plásticas

Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage . Marianna Arvanitakis, MD, Myriam Delhaye, MD, PhD, Maria Antonietta Bali, MD, Celso Matos, MD, Viviane De Maertelaer, PhD, Olivier Le Moine, MD, PhD, Jacques Devie`re, MD, PhD. Gastrointestinal Endoscopy 2008;68(8):1199-1203.

N: 44 pacientes, seguidos 14 meses

Recurrencia:

•5 del grupo B

• 0 del grupo A

•Ninguno del grupo no randomizado

Necrosectomia: Gepard study

Tranasluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow up (the GEPARD Study). H Seifert, M Biermer, W Schmitt et al. Gut 2009; 58:120-1266

Necrosectomia en necrosis pancreatica organizada

Endoscopic transmural debridement of symptomatic organized pancreatic necrosis. Rogier P. Voermans, MD, Marie¨lle C. Veldkamp, MD, Erik A. Rauws, MD, PhD,Marco J. Bruno, MD, PhD, Paul Fockens, MD, PhD. Gastrointestinal Endoscopy 2007;66(5):909-916.

Complications:

Severe complications 2 pt (7%): arterial bleeding ( cia)

perforation of cyst wall

Minor bleeding 8pt (30%)

No mortality

Outcome:

Hospital stay 5 days

Recurrence seudocysts 2 pt

Necrosectomia Vs drenaje en necrosis pancreatica organizadaA comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis. Timothy B. Gardner, MD, Prabhleen Chahal, MBBS, Georgios I. Papachristou, MD,Santhi Swaroop Vege, MD, Bret T. Petersen, MD, Christopher J. Gostout, MD,Mark D. Topazian, MD, Naoki Takahashi, MD, Michael G. Sarr, MD, Todd H. Baron, MD. Gastrointestinal Endoscopy 2009;69(6):1085-1094

Pancreatitis necrotizante manejo conservador

Necrotizing Pancreatitis Contemporary Analysis of 99 Consecutive Cases. Stanley W. Ashley, MD, Alexander Perez, MD, Elizabeth A. Pierce, BS, David C. Brooks, MD, Francis D. Moore, Jr., MD, Edward E. Whang, MD, Peter A. Banks, MD, and Michael J. Zinner, MD. Annals of Surgery Vol. 234, No. 4, 572–580

Cirugia en la necrosis pancreatica

SURGERY IN THE TREATMENT OF ACUTE PANCREATITIS –MINIMAL ACCESS PANCREATIC NECROSECTOMY. S. Connor1, M. G. T. Raraty1, N. Howes1, J. Evans2, P. Ghaneh1, R. Sutton1, J. P. Neoptolemos1. Scandinavian Journal of Surgery 94: 135–142, 2005.

Cirugia en la necrosis pancreatica

MANAGEMENT OF ACUTE PANCREATITIS: FROM SURGERY TO INTERVENTIONAL INTENSIVE CAREJ Werner, S Feuerbach, W Uhl, M W Bu¨chler. Gut 2005;54:426–436

Tratamiento de la necrosis infectada

PANCREATITIS AGUDA GRAVE

• Cirugia• Endoscopia• Drenaje percutaneo • Otros

• JPN Guidelines for the management of acute pancreatitis: surgical treatment. Isaji S, TaKada T, Kawarada Y et al. J Hepatobiliary Pancreat Surg 2006; 13:48-55

•CQ1. Which procedure will best result in a definite diagnosis of infected pancreatic necrosis ?

•CQ2. What is the indication for surgical intervention in necrotizing pancreatitis ?

•CQ3. How should sterile pancreatic necrosis be managed ?

•CQ4. What is the optimal timing for surgical intervention ?

•CQ5. What is the optimal surgical procedure for infected pancreatic necrosys?

•CQ6. What is the optimal drainage procedure after necrosectomy ?

•CQ7. How should pancreatic abscess be managed ?

•CQ8. What is the indication for surgical drainage in pancreatic abscess?

•CQ9. What are the indications for drainage treatment in pancreatic pseudocysts?

•CQ10. What is the indication for surgical intervention in pancreatic pseudocysts ?


• What is the optimal surgical procedure for infected pancreatic necrosys?

Necrosectomia. RECOMENDACIÓN A


NECROSECT OMIA

PANCREATICA

DRENAJE SEUDOQUISTE

tratamiento endoscopico de pancreatitis grave

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