EUROPEAN ENDOSCOPY TRAINING CENTER · andrea tringali endoscopia digestiva chirurgica universita’...

Andrea TringaliE N D O S C O P I A D I G E S T I V A C H I R U R G I C AUN IVERS I TA’ C ATTOL ICA DEL SACRO CUOREPOLICLINICO AGOSTINO GEMELLI ROMAPOLICLINICO AGOSTINO GEMELLI – ROMA

E U R O P E A N E N D O S C O P Y T R A I N I N G C E N T E R

1 ENDOSCOPIA DIGESTIVA CHIRURGICAUNIVERSITA’ CATTOLICA DEL SACRO CUOREEUROPEAN ENDOSCOPY TRAINING CENTER

Roma, 5 luglio 2012

Acute pancreatitis: issues

• Diagnosis and staging• Diagnosis and staging

• Understand the etiologyUnderstand the etiology

• Medical treatment of the acute phase

• ERCP / cholecystectomy: when?

• Surgery: when?

• Management of complications







• Surgery: when?



Acute pancreatitis. Diagnosis.

Pain+Pain+tenderness ≥ 2 manifestations

to diagnose AP

↑ A l

to diagnose AP

↑ Amylase↑ Lipase(> sensitivity,

Not established cut-off

> specificity)

Ab lAbnormal US/CT/MRI


JPN Guidelines 2010Kiriyama et al J Hapatobil Pancreat Sci 2010

Acute pancreatitis. Staging.

Ranson score 1974Ranson score 1974


Acute pancreatitis. Staging.

APACHE II-III (Acute Physiology And Chronic Health Evaluation)

ICU scoring

Score > 8 at 24 h: 11-18%mortality

Knaus et al, Crit Care Med 1985Knaus et al, Chest 1991

www sfar orgwww.sfar.org


Acute pancreatitis. Staging – CT severity index.

> 7 pointsM t lit 17%

Balthazar et al, Radiology 1990

Mortality 17%

Mortele et al, AJR 2004


Acute pancreatitis. Staging – CT severity index.

Assessing severity of AP (397 pts)

CT severity index APACHE IIVsCT severity index APACHE IIVs

CT: more accurately diagnosed clinically severe disease

CT: better correlation with the need for intervention

Bollen et al, AJR 2011


Bollen et al, AJR 2011

Acute pancreatitis. Staging – CT: timing.


Acute pancreatitis.

The revised Atlanta classification (2008)

Incidence Mortalityy

Interstitial edematous pancreatitis (IEP) 80% 3%

Necrotizing AP 6-20% 12-30%







• Surgery: when?



Acute pancreatitits. Etiology.

Biliary(60%*)

Non A-Non B(30%*)

Alcohol(10%*) ( ) ( )( )

N lN l ↑ ALT AST AP GT NormalNormal ↑ ALT, AST, AP, GT


* Cavallini G et al, DLD 2004

Acute BILIARY pancreatitits.

↑ Bilirubin↑ ALT Abdominal US↑ ALT↑ AP↑ GT

Abdominal US(…and its limitations)+

To diagnose Biliary pancreatitis:To diagnose Biliary pancreatitis:

Specificity 95-98%

Sensitivity 100%Kiriyama et al J Hapatobil Pancreat Sci 2010Pezzilli R et al, DLD 2008Ammori BJ et al, Pancreas 2003


Wang SS et al, Pancreas 1988






• Surgery: when?



Acute pancreatitis: treatment

21/30 !!! 1988-2008

Am J Gastroenterol 2010

The many clinical guidelines for acute pancreatitis

range widely in qualityrange widely in quality.

Further research is required to determine whether

guideline quality alters clinical outcomes.


Acute pancreatitits. Medical treatment.

Support therapy Crystalloid fluid volume TPN TPN Analgesia (Buprenorphine) Albumin – Blood transfusion – O2

Reduction of secretions Fasting Naso‐gastric tube (paralytic ileus) PPI (only to prevent stress ulcer)

Prophylactic antibiotics (Carbapenems, to preventinfection in severe AP)

“Pancreatic” therapy Gabexate (Continuous Regional Arterial Infusion,

recommended from JPN guidelines only)


recommended from JPN guidelines only)

Takeda et al, JPN Guidelines 2006Pezzilli R et al, Pancreatology 2010






• Surgery: when?



Acute BILIARY pancreatitits. Urgent ERCP when? (24‐72h)

Significant benefitbidi liMorbidity Mortality

Neoptolemos Yes No Benefit if severe disease(Lancet 1988)(Lancet 1988)

Fan Yes No Benefit if severe disease(NEJM 1993)

Nowak Yes Yes Benefit in mild and severe AP(Gastroenterology 1995) ABSTRACT!

Fölsch No No Excluded pts with jaundiceFölsch No No Excluded pts with jaundice(NEJM 1997)


Acute BILIARY pancreatitits (ABP). Urgent ERCP when?

• Severe ABP (Controversial)

ABP ith i f bili b t ti• ABP with signs of biliary obstruction(jaundice) or cholangitis (Cochrane Database, 2012)(jau d ce) o c o a g t s ( , )



Acute BILIARY pancreatitits (ABP). Mild to moderate

Abdominal US: gallstoneswithout evidence of CBD dilation or CBD stones

Bilirubin BilirubinAST/ALT APGT

AST/ALT APGT

Elective cholecystectomyduring the same admission

EUS / MRC

-+

If CBD dilation

(> 7-8 mm)during the same admission

Takeda et al, JPN Guidelines 2006

+

ERCP+ES

(> 7-8 mm)


Pezzilli R et al, Pancreatology 2010 ERCP+ES

Acute BILIARY pancreatitits (ABP).

• Spontaneous passage of stones frequent• Spontaneous passage of stones frequent

• Stones recovered from the stool in 85-94%• Stones recovered from the stool in 85-94%of patients with recent ABP

A t NEJM 1974Acosta, NEJM 1974Kelly, Surgery 1976


Acute BILIARY pancreatitits (ABP).


Acute BILIARY pancreatitits (ABP). Mild to moderate

Abdominal US: gallstones/alithiasicwithout evidence of CBD dilation or CBD stones

BilirubinAST/ALT APGT

P ti t fit fPatient unfit for surgery

Cholecystectomized

Alithiasic gallbladderAlithiasic gallbladder

ERCP+ES


Acute BILIARY pancreatitits (ABP). Pregnancy

70% antepartum recurrences

Swisher, Am Surg 1994

ES t ABP d i t ti ES prevent ABP recurrence during gestation

Barthel Surg Endosc 1998Barthel, Surg Endosc 1998


Acute BILIARY pancreatitits (ABP). ERCP when?

High surgical risk gallbladder in situ (to avoid

recurrence ABP)

Alithiasic gallbladder

Ch l t t i d ti t Cholecystectomized patients

Pregnancy Pregnancy







• Surgery: when?



Acute pancreatitits. Surgery when?

Early surgery (< 14 d) not recommendedy g y ( )

Unless specific indication

( i MOF t t d )(worsening MOF, compartment syndrome)

Infected pancreatic necrosis diagnosed by

CT guided needle aspiration / cultureCT-guided needle aspiration / culture



gy






• Surgery: when?



Acute pancreatitits. Pancreatic pseudocyst.


Acute pancreatitits.Walled‐off pancreatic necrosis.

GIE 2011

Retrospective Success 95/104 (91%)

JAMA 2012

(vs laparoscopic surgery)


Acute pancreatitits.Walled‐off pancreatic necrosis.


Practical approach to acute pancreatitis (AP).

i i l d i i

The revised Atlanta classification (2008) Interstitial edematous pancreatitis

Acute peripancreatic fluid collection Medical / Surgical Txp p / g

Pancreatic pseudocyst (infected or not) Endoscopic / Surgical Tx

Necrotizing pancreatitis

Post‐necrotic peripancreatic fluid collections Medical / Surgical Tx

Walled‐off pancreatic necrosis (infected or not) Endoscopic / Surgical Tx Walled‐off pancreatic necrosis (infected or not) Endoscopic / Surgical Tx


Acute pancreatitis: key points

• Multidisciplinary approach• Multidisciplinary approach

• Selection of candidates to ERCPSelection of candidates to ERCP

• Timing for surgical approach

• Endoscopic management of pseudocysts

• … post-ERCP pancreatitis: hopefully never!


EUROPEAN ENDOSCOPY TRAINING CENTER · andrea tringali endoscopia digestiva chirurgica universita’...

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