Konservative Therapie der chronischen Pankreatitis

Pancreatic Pseudocysts: Interventional or Surgical Drainage? Pancreatic pseudocyst, the most common cystic lesion of the pancreas, is a localized collection of fluid rich in amylase within or adjacent to the pancreas, enclosed by a nonepithelialized wall. Pseudocysts are a frequent complication of both acute and chronic pancreatitis, pancreatic trauma or a result of pancreatic duct obstruction. Most pseudocysts are asymptomatic, and spontaneous regression may occur. Treatment is indicated only in cases of bleeding, rupture or infection of the pseudocyst, compression of surrounding organs (i.e., main bile duct, duodenum, portal vein) by the pseudocyst, when a pseudocyst is the main cause of pain or when suspicion of a cystic tumour exists. The size of a pseudocyst is no criterion for therapeutic decisions. Treatment options include percutaneous external drainage, endoscopic transgastric or transduodenal internal drainage, and surgical internal drainage or resection. Interventional procedures seem to be the first choice in emergency situations and in critically ill patients. Elective surgery may be of advantage when there is additional pancreatic (duct) pathology or suspicion of a tumour. Comparative studies between surgical, endoscopic and percutaneous interventional therapies are still missing. The potential role of octreotide either as monotherapy or in combination with the above-mentioned therapies needs to be further evaluated in controlled studies. Thus, the choice of the therapeutic procedure is frequently influenced by local conditions such as availability of the respective method and expertise of the radiologist, endoscopist, and surgeon.

Section: Diagnostische Vorgehensweiseunclassified

Pankreaspseudozysten: Endoskopische Drainage oder Operation?

Schulz¹,

Kahl²,

Glasbrenner³

et al. 2001

“…Mit der Entwicklung und der erfolgreichen Etablierung endoskopisch-retrograder Techniken am biliären System sind seit den 80er Jahren des vergangenen Jahrhunderts auch endoskopische Interventionen am Pankreasgangsystem in den Mittelpunkt des Interesses gerückt [7][8][9][10]. Viele dieser Therapieansätze haben unter streng wissenschaftlich Aspekten geringe Evidenzgrade, weil nach wie vor prospektiv randomisierte Studien fehlen [3,11]. Doch sind in den letzten Jahren eine Vielzahl mono-und multizentrischer Studien zu den verschiedenen endoskopisch-interventionellen Therapieansätzen publiziert worden, die die Effektivität der Maßnahmen -unter den genannten Einschränkungen -dokumentieren.…”

unclassified

Endoskopische Therapieansätze bei chronischer Pankreatitis

Jakobs¹,

Riemann²

2001

Endoscopic Therapy Modalities in Patients with Chronic Pancreatitis Several endoscopic interventional techniques have been introduced in the treatment of symptomatic chronic pancreatitis during the past years. Transpapillary and transmural drainage have been established as effective treatment options for pancreatic pseudocysts. Biliary endoprostheses are helpful to alleviate acute cholangitis and obstructive jaundice at once. During long-term biliary stenting several problems occur due to stent clogging. The treatment of pancreatic duct stones and pancreatic duct strictures is still a matter of debate. Several nonrandomized prospective and retrospective studies demonstrated, at least medium-term, a benefit of pancreatic duct stenting and extracorporeal shock wave lithotripsy.

Organ erhaltende Operationsverfahren bei chronischer Pankreatitis – die Duodenum erhaltende Pankreaskopfresektion

Tempia-Caliera¹,

Fischer²,

Hennig³

et al. 2001

Organ-Preserving Surgical Techniques in Patients with Chronic Pancreatitis – Duodenum-Preserving Pancreatic Head Resection Chronic pancreatitis is a benign inflammatory process of the pancreas that leads to permanent damage of the gland and loss of functional parenchyma. The evolution of the disease is progressive and associated with development of exocrine and endocrine pancreatic insufficiency, with a higher risk of developing pancreatic cancer. Alcohol abuse is the most frequent etiology for chronic pancreatitis in Western industrialized countries. The predominant symptom of chronic pancreatitis is pain, and it is often difficult to control pain sufficiently with analgesics. Other symptoms are diabetes mellitus, steatorrhea and weight loss. The diagnosis of chronic pancreatitis is usually made on a medical history, but retrograde endoscopic pancreaticography (ERCP) and an abdominal contrastenhanced CT scan are still the gold standards for diagnosis and staging. However, the conventional MRI combined with MR angiography and MR cholangio-pancreaticography is a very challenging alternative. Indications for surgery are severe abdominal pain with pancreatic head enlargement, common bile duct stenosis, intestinal obstruction, compression of retropancreatic vessels or suspicion of malignancy. The duodenum-preserving pancreatic head resection (DPPHR) is an organ-preserving operation, which was developed to replace the Whipple procedures in patients with chronic pancreaitis. It eliminates chronic pancreatitis-related complications and leads to pain relief. In this procedure, the pancreatic head is resected subtotally, and the body and tail of the pancreas, the stomach, the duodenum, and the extrahepatic bile duct are preserved. In an own series of 298 patients, hospital mortality was 1% and the most frequent perioperative complication was bleeding in 5.7% of the patients. Pancreatic fistulas occurred in 2.7% of the patients, and the total reoperation rate was 5.7%. After an average follow-up of 5.7 years, 91% of the patients with DPPHR were free of pain or with minimal signs of disease. 63% of the patients were professionally active. Late mortality was 12.6%. DPPHR in chronic pancreatitis is a safe and effective operation procedure providing long-term pain relief in treating chronic pancreatitis-related complications. Therefore, this organ-preserving procedure should be considered as first procedure to treat chronic pancreatitis-related complications.