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IAP Guidelines for the Surgical Management of Acute Pancreatitis

2003; Elsevier BV; Volume: 3; Issue: 2 Linguagem: Inglês

10.1159/000071181

1424-3911

Waldemar Uhl, Andrew L. Warshaw, C W Imrie, Claudio Bassi, Colin J. McKay, P. G. Lankisch, Ross Carter, Eugene Di Magno, Peter A. Banks, David C. Whitcomb, Christos Dervenis, Charles D. Ulrich, Kat Satake, Paula Ghaneh, Werner Hartwig, Jens Werner, Gerry McEntee, John P. Neoptolemos, Markus W. Büchler,

Pancreatic and Hepatic Oncology Research

During 2002 the International Association of Pancreatology developed evidenced-based guidelines on the surgical management of acute pancreatitis. There were 11 guidelines, 10 of which were recommendations grade B and one (the second) grade A. (1) Mild acute pancreatitis is not an indication for pancreatic surgery. (2) The use of prophylactic broad-spectrum antibiotics reduces infection rates in computed tomography-proven necrotizing pancreatitis but may not improve survival. (3) Fine-needle aspiration for bacteriology should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome. (4) Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention including surgery and radiological drainage. (5) Patients with sterile pancreatic necrosis (with negative fine-needle aspiration for bacteriology) should be managed conservatively and only undergo intervention in selected cases. (6) Early surgery within 14 days after onset of the disease is not recommended in patients with necrotizing pancreatitis unless there are specific indications. (7) Surgical and other forms of interventional management should favor an organ-preserving approach, which involves debridement or necrosectomy combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudate. (8) Cholecystectomy should be performed to avoid recurrence of gallstone-associated acute pancreatitis. (9) In mild gallstone-associated acute pancreatitis, cholecystectomy should be performed as soon as the patient has recovered and ideally during the same hospital admission. (10) In severe gallstone-associated acute pancreatitis, cholecystectomy should be delayed until there is sufficient resolution of the inflammatory response and clinical recovery. (11) Endoscopic sphincterotomy is an alternative to cholecystectomy in those who are not fit to undergo surgery in order to lower the risk of recurrence of gallstone-associated acute pancreatitis. There is however a theoretical risk of introducing infection into sterile pancreatic necrosis. These guidelines should now form the basis for audit studies in order to determine the quality of patient care delivery. The following is a summary of the official IAP guidelines on the surgical management of acute pancreatitis. The grading of each recommendation is given and these are based on the evidence reviewed in the text. These guidelines should now form the basis for audit studies in order to determine the quality of patient care delivery. 1 Mild acute pancreatitis is not an indication for pancreatic surgery (recommendation grade B). 2 The use of prophylactic broad-spectrum antibiotics reduces infection rates in CT-proven necrotizing pancreatitis but may not improve survival (recommendation grade A). 3 FNAB should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome (recommendation grade B). 4 Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention including surgery and radiological drainage (recommendation grade B). 5 Patients with sterile pancreatic necrosis (FNAB negative) should be managed conservatively and only undergo intervention in selected cases (recommendation grade B). 6 Early surgery within 14 days after onset of the disease is not recommended in patients with necrotizing pancreatitis unless there are specific indications (recommendation grade B). 7 Surgical and other forms of interventional management should favor an organ-preserving approach, which involves debridement or necrosectomy combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudate (recommendation grade B). 8 Cholecystectomy should be performed to avoid recurrence of gallstone-associated acute pancreatitis (recommendation grade B). 9 In mild gallstone-associated acute pancreatitis chole- cystectomy should be performed as soon as the patient has recovered and ideally during the same hospital admission (recommendation grade B). 10 In severe gallstone-associated acute pancreatitis, chole- cystectomy should be delayed until there is sufficient resolution of the inflammatory response and clinical recovery (recommendation grade B). 11 Endoscopic sphincterotomy is an alternative to chole- cystectomy, in those who are not fit to undergo surgery in order to lower the risk of recurrence of gallstone- associated acute pancreatitis. There is, however, a theoretical risk of introducing infection into sterile pancreatic necrosis (recommendation grade B). Acknowledgements The following were participants at the IAP meeting to discuss the Guidelines on June 22nd 2002 and made active contributions to their formulation - Brazil: Jose Eduardo Cunha, Sonia Penteado (Sao Paulo); Bulgaria: Oleg Tcholakav (Sofia); Czech Republic: Peter Balaz (Prague); Denmark: Steen Larsen (Glostrup), Else K Philipsen (Bispebjerg); Finland: Marko Lempinen (Helsinki); France: René Laugier (Marseille); Germany: Hans-Guenter Becker (Kaiserslautern), Pascal Berberat, Markus W. Buechler, Fabio F. Di Mola, Pierluigi Di Sebastiano, Ahmed Guweidhi, Mark Hartel, Werner Hartwig, Jorg Kleeff, Christophe Mueller, Bruno Schmied, Waldemar Uhl, Jens Werner (Heidelberg), Tobias Keck (Freiburg); Greece: E. Chatzitheoklitos (Thessaloniki), Gregory Tsiotos (Athens); Hungary: Laszlo Czako, Tamas Takacs (Szeged), D. Dezso Kelemen (Pecs), Attila Olah (Gyor), Tibor F. Tihanyi (Hungary); Ireland: Gerry Mc Entee (Dublin); Italy: Claudio Bassi (Verona); Japan: Kat Satake (Osaka), Tooru Shimosegawa (Sendai); Mexico: Guillermo Robles- Diaz, Andres Duarte-Rojo (Mexico DF); : Andrzej Dabrowski, Jan Dlugosz, Wereszczynska-Sremietkowska (Bialystok), Zycmuni Warzecha (Krakow); Portugal, Antonio Marques (Lisbon), Faustino P Reis (Amarente); Romania: Barbu Traian-Sorin (Cluj-Napoca); Slovenia: Alojz Pleskovic (Ljubljana); Spain: J. Enrique Dominguez- Munoz, Julio Iglesias Garcia, Augusto Villanueva (Santiago De Compostela), Luisa Guarner, Donald-Jose Vasquez-Cruz (Barcelona), Miguel Perez-Mateo (Alicante); Sweden: Anders Borgstöm (Malmö), Fernando Ruizjasbon (Göthenburg), Berit Sternby (Lund); Switzerland; Beat Gloor (Bern); UK: Malcolm Aldridge (Welwyn Garden City), Derek O'Reilly, Paula Ghaneh, John P. Neoptolemos (Liverpool), Peter Hegyi (Newcastle), Clement Imrie, Colin J. Mc Kay (Glasgow), Rohit Makhija (Plymouth), Mark Midwinter (Southampton), Satvinder S. Mudan (London), Ioannis Virlos (London); Ukraine: Andre A. Perejaslov, Roman E. Vatseba (Lviv); USA: Peter A. Banks, Andrew L. Warshaw (Boston), Woody Denham (Chicago), E.P. Di Magno (Rochester), William H. Nealon (Galveston), Charles D. Ulrich (Cincinnati), David Whitcomb (Pittsburgh); Yugoslavia: Tamara Alempijevic, Knezevic Djordje, Lili Petronije- vic, Dejad Radeukovic, Dugalic Vladimir (Belgrade). The following IAP Council members reviewed and approved the final version of the IAP Guidelines: Prof. J.P. Neoptolemos, Liverpool, UK (President); Prof. A.L. Warshaw, Boston, USA (Past-President); Prof. S. Matsuno, Sendai, Japan (President-Elect); Prof. P.G. Lankisch, Lüneburg, Germany (Secretary); Prof. M. Büchler, Heidelberg, Germany (Treasurer); Prof. K. Kashima, Kyoto, Japan (Co- Treasurer); Prof. M.V. Singer, Mannheim, Germany and Prof. C.W. Imrie, Glasgow, UK (Co-Editors, Pancreatology); Prof. C. Bassi, Verona, Italy; Prof. P. Bornman, Cape Town, South Africa; Prof. E. Dominguez-Monoz, Santiago de Compostela, Spain; Dr. C.F. del Castillo, Boston, USA; Prof. K. Inoue, Kyoto, Japan; Prof. M. Lerch, Münster, Germany; Prof. P. Levy, Clichy, France; Prof. J.E. Monteiro Cunha, Brazil; Prof. A. Pap, Budapest, Hungary; Prof. R. Pezzili, S. Lazzaro di Savena, Italy; Prof. C. Pitchumoni, New York, USA; Prof. G. Robles-Diaz, Co Toriello-Guerral, Mexico; Prof. K. Satake, Youkouchoi Ashiya, Japan; Prof. R. Schmid, Heidelberg, Germany; Prof. T. Shimosegawa, Sendai, Japan; Prof. M. Tempero, San Francisco, USA; Dr. G.G. Tsiotos, Athens, Greece; Dr. M. Vaccaro, Buenos Aires, Argentina; Prof. D. Whitcomb, Pittsburgh, USA; Prof. J. Wilson, New South Wales, Australia.