Transgastral Retroperitoneal Endoscopy in Septic Patients with Pancreatic Necrosis or Infected Pancreatic Pseudocysts

Zusammenfassung

Einführung: Peripankreatische Flüssigkeitsansammlungen sind eine bekannte Komplikation einer akuten Pankreatitis bzw. einer akuten Exazerbation einer chronischen Pankreatitis. Der Sinn der Studie war es, die Machbarkeit und Komplikationsrate der sich neu entwickelnden endoskopischen Methoden mit einem standardisierten endoskopischen Vorgehen zu überprüfen. Material und Methode: Von 2000 – 2006 wurden insgesamt 30 Patienten (Alter 57 ± 10 Jahre, Spanne: 34 – 74 Jahre) mit infizierten pankreatischen Pseudozysten bzw. infizierter Pankreasnekrose in die Studie eingeschlossen. Die transgastrische Drainage wurde mithilfe eines Endosonografiegeräts (Pentax 38 UX, Olympus UCT 140) mit Einführung eines 8 Fr-Doppelpigtailstents in die Höhle durchgeführt. Unmittelbar nach der Stentanlage erfolgte eine Ballondilatation des Zugangswegs auf 12 mm und nachfolgend die direkte Spiegelung der retroperitonealen Höhle mit einem normalen Gastroskop. Unter Sicht wurde die Flüssigkeit in der Höhle aspiriert, Nekrosen entfernt und die Höhle gespült. Nach abgeschlossener endoskopischer Behandlung erfolgte die Entfernung der liegenden Prothese nach 4 Wochen. Ergebnis: Der technische Erfolg stellt sich in 96,7 % der Fälle ein. Ein Langzeiterfolg war in 83,4 % der Fälle zu beobachten. Im Mittel erfolgten bis zur vollständigen Reinigung der Höhle 2,7 Prozeduren (1 – 16). Relevante Komplikationen wurden in 10 % der Fälle beobachtet (Blutung, Perforation, Fistelbildung). In 10 % war eine sekundäre Operation erforderlich. Die Mortalitätsrate betrug 6,6 %. Diskussion: Die endoskopische Therapie der infizierten Pseudozyste und der infizierten postakuten Pankreasnekrose mithilfe von endoskopischen Techniken stellt ein minimalinvasives und effektives Verfahren bei der Behandlung der akuten bzw. chronischen Pankreatitis dar.

Abstract

Objective: Peripancreatic fluid collections are common complications of acute pancreatitis or acute exacerbations of chronic pancreatitis. Surgery is required when these fluid collections become infected or cause obstruction or pain. However, morbidity and mortality after surgery in these cases are still too high, therefore minimally invasive approaches have been encouraged. The aim of this study was to evaluate the feasibility of endoscopic ultrasound-guided transmural drainage with intracystic endoscopy and necrosectomy. Material and Methods: From 2000 to 2006 30 patients (age: 57 ± 10 years, range: 34 – 74 years) with an infected pancreatic pseudocyst or infected pancreatic necrosis were included in the study. The diagnosis of infection in patients who had fever despite an adequate antibiotic regime was confirmed by endoscopic fine needle aspiration with a positive bacterial or mycological result. The mean C-reactive protein value before treatment was 202 ± 58 mg/L and the mean leukocyte count was 13.25 ± 4.75 GPt/L. Transgastric cyst drainage was performed using a therapeutic endoscopic ultrasound probe (Pentax 38 UX or Olympus GF UCT 140) with insertion of an 8-Fr double pigtail prosthesis. After balloon dilatation (12 mm) a normal gastroscope was inserted into the cavity and all the fluid and easy removable necrosis were removed. The prosthesis was removed 4 weeks after the end of the endoscopic treatment. Clinical and ultrasound follow-up were carried out 3 and 6 months after removal of the prosthesis. The mean follow-up was 60 weeks. Results: The technical success of the procedure was 96.7 %, the long-term success was 83.4 %. On average 2.7 (range: 1 – 16) procedures were necessary for complete removal of necrosis and the remaining fluid. Major complications (bleeding, perforation, fistulation) occurred in 10 %. In 10 % a secondary operation was necessary. The overall mortality rate was 6.6 %. Discussion: Endoscopic treatment of infected pseudocysts and infected postacute pancreatic necrosis using transgastral retroperitoneal endoscopy with fluid and necrosis removal is a minimally invasive and effective procedure in patients with acute pancreatitis or acute exacerbation of chronic pancreatitis. However, the mortality rate of 6.6 % has to be taken into account.

Schlüsselwörter

endoskopische Drainage - infizierte pankreatische Pseudozyste - endoskopische Sonografie - Zystogastrostomie - Pankreasnekrose

Key words

endoscopic drainage - infected pancreatic pseudocyst - endoscopic ultrasound - cystogastrostomy - pancreatic necrosis

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