AULA 16 - PANCREATITE CRONICA E COLECOES

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<p>22/08/2024</p><p>1</p><p>CLÍNICA CIRÚRGICA I</p><p>Prof. Adorísio Bonadiman</p><p>Centro Universitário Ingá</p><p>bonadiman.cirurgia@gmail.com</p><p>1</p><p>PANCREATITE</p><p>CRÔNICA.</p><p>Prof. Adorísio Bonadiman</p><p>Centro Universitário Ingá</p><p>bonadiman.cirurgia@gmail.com</p><p>2</p><p>22/08/2024</p><p>2</p><p>CONCEITO</p><p>� PROCESSO</p><p>INFLAMATÓRIO</p><p>CRÔNICO</p><p>IRREVERSÍVEL, COM</p><p>FIBROSE PROGRESSIVA</p><p>E PERDA DE TECIDO</p><p>FUNCIONAL EXÓCRINO</p><p>E/OU ENDÓCRINO DO</p><p>PÂNCREAS.</p><p>3</p><p>ETIOLOGIA</p><p>� CONSUMO DE ALCOOL</p><p>� CAUSA MAIS COMUM</p><p>� CONSUMO MÉDIO DE 150</p><p>A 200 G DE ALCOOL POR</p><p>DIA POR PERÍODO DE 10 A</p><p>20 ANOS</p><p>� TEMPO MAIOR EM</p><p>HOMENS QUE EM</p><p>MULHERES</p><p>� PROVAVELMENTE SURTOS</p><p>DE PANCREATITE AGUDA</p><p>� HEREDITÁRIA OU FAMILIAR</p><p>� AUTOIMUNE (LUPUS,</p><p>ESCLERODERMIA...)</p><p>� IDIOPÁTICA</p><p>4</p><p>22/08/2024</p><p>3</p><p>DIAGNÓSTICO</p><p>� QUADRO CLÍNICO</p><p>COMPATÍVEL</p><p>� TESTES LABORATORIAIS</p><p>� EXAMES DE IMAGEM</p><p>5</p><p>QUADRO CLÍNICO</p><p>� DOR RECORRENTE EM</p><p>FAIXA EM ABDOME</p><p>SUPERIOR</p><p>� SINAIS DE INSUFICIÊNCIA</p><p>PANCREÁTICA</p><p>ENDÓCRINA E/OU</p><p>EXÓCRINA</p><p>� ESTEATORREIA</p><p>� DM</p><p>� GERALMENTE</p><p>RELACIONADA A</p><p>CONSUMO DE ALCOOL</p><p>6</p><p>22/08/2024</p><p>4</p><p>TESTES LABORATORIAIS</p><p>7</p><p>EXAMES DE IMAGEM</p><p>TC CPRE</p><p>� DILATAÇÃO DO DUCTO DE</p><p>WIRSUNG</p><p>� CÁLCULOS</p><p>� ATROFIA DO</p><p>PARÊNQUIMA</p><p>� CALCIFICAÇÕES DIFUSAS</p><p>� LESÕES CÍSTICAS</p><p>ASSOCIADAS</p><p>� DILATAÇÃO DUCTAL</p><p>DIFUSA</p><p>� CÁLCULOS</p><p>� TORTUOSIDADE DUCTAL</p><p>8</p><p>22/08/2024</p><p>5</p><p>EXAMES DE IMAGEM</p><p>TC CPRE</p><p>9</p><p>TRATAMENTO</p><p>� TRATAMENTO DA INSUFICIÊNCIA EXÓCRINA DO</p><p>PÂNCREAS</p><p>� ENZIMA PANCREÁTICA (30000 UI/DIA)</p><p>� TRATAMENTO DO DIABETES</p><p>� HIPOGLICEMIANTES OU INSULINA</p><p>� TRATAMENTO DA DOR</p><p>� CLÍNICO</p><p>� ANALGÉSICOS ESCALONADOS</p><p>� CONTROLE DIETÉTICO</p><p>� CIRÚRGICO</p><p>10</p><p>22/08/2024</p><p>6</p><p>TRATAMENTO CIRÚRGICO</p><p>� DOR DE DIFÍCIL CONTROLE OU INTRATÁVEL</p><p>� BASEADA NA DILATAÇÃO DUCTAL</p><p>� RESSECÇÃO</p><p>� GASTRODUODENOPANCREATECTOMIA (GDP)</p><p>� DERIVAÇÃO</p><p>� CIRURGIA DE BEGER</p><p>� CIRURGIA DE FREY</p><p>� CIRURGIA DE PUESTOW</p><p>11</p><p>GDP</p><p>� PSEUDOTUMORAÇÃO</p><p>COM OBSTRUÇÃO</p><p>CEFÁLICA</p><p>� CIRURGIA MUITO</p><p>AGRESSIVA</p><p>� MORBIMORTALIDADE</p><p>ELEVADA</p><p>12</p><p>22/08/2024</p><p>7</p><p>PROCEDIMENTO DE</p><p>BEGER</p><p>� RESSECÇÃO DA CABEÇA PANCREÁTICA COM</p><p>PRESERVAÇÃO DUODENAL E PANCREATOJEJUNO-</p><p>ANASTOMOSE TÉRMINO-TERMINAL</p><p>� PODE SER REALIZADA COM POUCA DILATAÇÃO</p><p>DUCTAL</p><p>13</p><p>PROCEDIMENTO DE FREY</p><p>� RESSECÇÃO DA CABEÇA PANCREÁTICA COM</p><p>PRESERVAÇÃO DUODENAL</p><p>� PANCREATOJEJUNO-ANASTOMOSE LÁTERO-LATERAL</p><p>� REQUER DILATAÇÃO DUCTAL</p><p>14</p><p>22/08/2024</p><p>8</p><p>PROCEDIMENTO DE</p><p>PUESTOW</p><p>� PANCREATOJEJUNO-ANASTOMOSE LÁTERO-LATERAL</p><p>� REQUER DILATAÇÃO DUCTAL</p><p>� PRESERVAÇÃO DA CABEÇA PANCREÁTICA</p><p>15</p><p>LESÕES CÍSTICAS</p><p>INFLAMATÓRIAS DO</p><p>PÂNCREAS</p><p>16</p><p>22/08/2024</p><p>9</p><p>n engl j med 375;20 nejm.org November 17, 20161976</p><p>T h e n e w e ngl a nd j o u r na l o f m e dic i n e</p><p>(hemoconcentration and azotemia).27-30 On the</p><p>basis of retrospective studies suggesting that</p><p>aggressive fluid administration during the first</p><p>24 hours reduces morbidity and mortality,31,32</p><p>current guidelines provide directions for early</p><p>and vigorous fluid administration.27,28</p><p>Vigorous fluid therapy is most important dur-</p><p>ing the first 12 to 24 hours after the onset of</p><p>symptoms and is of little value after 24 hours.</p><p>Administration of a balanced crystalloid solu-</p><p>tion has been recommended at a rate of 200 to</p><p>500 ml per hour, or 5 to 10 ml per kilogram of</p><p>Figure 1. Time Course and Management of Acute Pancreatitis.</p><p>The natural history of acute pancreatitis is shown, with a timeline of specific interventions.</p><p>Admission 48−72 Hours 2 Weeks 4 Weeks 6 Weeks</p><p>Therapy</p><p>Aggressive fluid</p><p>resuscitation</p><p>in the first 24 hours</p><p>Mortality</p><p>Half of all deaths occur in the first 2 weeks and are</p><p>mainly due to failure of multiple organ systems</p><p>Half of all deaths occur after 2 weeks and are mainly</p><p>due to pancreatic and extrapancreatic infections</p><p>Enteral nutrition after</p><p>day 5 if no tolerance</p><p>for oral feeding</p><p>Antibiotics for documented infection</p><p>Minimally invasive therapy</p><p>for local complications</p><p>(e.g., infected necrosis)</p><p>Pancreatitis</p><p>Transient organ failure</p><p>Acute fluid collections</p><p>Mortality <2%</p><p>Transient organ failure</p><p>Moderately severe</p><p>acute pancreatitis</p><p>Mortality <5%</p><p>Infected necrosis</p><p>“Critical” acute</p><p>pancreatitis</p><p>Mortality 30%</p><p>Sterile necrosis</p><p>Mortality ~10%</p><p>Resolution</p><p>Walled-off</p><p>pancreatic</p><p>necrosis</p><p>Walled-off</p><p>pancreatic</p><p>necrosis</p><p>~70%</p><p>~30%</p><p>80 to 85%</p><p>15 to 20%</p><p>During first</p><p>2 weeks</p><p>During first</p><p>2 weeks</p><p>Persistent organ failure</p><p>Severe acute pancreatitis</p><p>Mortality 15−20%</p><p>Acute pancreatitis</p><p>Resolution of</p><p>fluid infiltration</p><p>or pseudocyst</p><p>Interstitial pancreatitis</p><p>Necrotizing pancreatitis</p><p>The New England Journal of Medicine</p><p>Downloaded from nejm.org by JAIRO TABACOW HIDAL on November 16, 2016. For personal use only. No other uses without permission.</p><p>Copyright © 2016 Massachusetts Medical Society. All rights reserved.</p><p>NEJM 2016</p><p>17</p><p>COLEÇÃO FLUIDA</p><p>PERIPANCREÁTICA (CFPP)</p><p>� PRESENÇA DE LÍQUIDO</p><p>PERIPANCREÁTICO.</p><p>� FASE AGUDA DA PANCREATITE.</p><p>� HOMOGÊNEA AOS EXAMES DE</p><p>IMAGEM.</p><p>� NÃO POSSUEM PAREDE</p><p>DEFINIDA.</p><p>� LIMITADA POR PLANOS</p><p>FASCIAIS OU VISCERAIS.</p><p>� ÚNICA OU MÚLTIPLAS.</p><p>� NORMALMENTE ESTÉREIS.</p><p>� RARAMENTE REQUEREM</p><p>TRATAMENTO (INFECÇÃO):</p><p>� CIRURGIA</p><p>� PODEM EVOLUIR PARA</p><p>PSEUDOCISTO (4 SEMANAS).</p><p>bonadiman.cirurgia@gmail.com Banks PA, 2012</p><p>18</p><p>22/08/2024</p><p>10</p><p>PSEUDOCISTO</p><p>PANCREÁTICO (PCP)</p><p>� COLEÇÃO PERIPANCREÁTICA</p><p>BEM DELIMITADA à EVOLUÇÃO</p><p>DE UMA CFPP.</p><p>� 4-6 SEMANAS DE APÓS A PA.</p><p>� LIMITADA POR UMA PAREDE</p><p>NÃO EPITELIAL (FIBROSE) –</p><p>PSEUDOCÁPSULA.</p><p>� HOMOGÊNEO (NÃO CONTÉM</p><p>MATERIAL SÓLIDO).</p><p>� SINTOMAS VARIADOS.</p><p>� TRATAMENTO DEPENDE DA</p><p>PRESENÇA E INTENSIDADE DOS</p><p>SINTOMAS E/OU INFECÇÃO.</p><p>� DRENAGEM INTERNA</p><p>(ESTÔMAGO OU ALÇAS</p><p>JEJUNAIS).</p><p>� EXTERNA (CIRÚRGICA OU</p><p>PERCUTÂNEA).</p><p>bonadiman.cirurgia@gmail.com Banks PA, 2012</p><p>19</p><p>COLEÇÃO NECRÓTICA</p><p>PANCREÁTICA AGUDA (NPA)</p><p>� PRESENÇA DE MATERIAL</p><p>NECRÓTICO (PANCREÁTICO</p><p>OU PERIPANCREÁTICO).</p><p>� FASE AGUDA DA</p><p>PANCREATITE</p><p>NECROTIZANTE.</p><p>� PRIMEIRAS 4 SEMANAS.</p><p>� DELIMITADA POR PLANOS</p><p>FASCIAIS OU VISCERAIS.</p><p>� HETEROGÊNEA (MATERIAL</p><p>NECRÓTICO).</p><p>� HABITUALMENTE ESTÉRIL.</p><p>� PODE EVOLUIR PARA WOPN.</p><p>� RARAMENTE REQUER</p><p>TRATAMENTO (INFECÇÃO):</p><p>� CIRURGIA</p><p>bonadiman.cirurgia@gmail.com Banks PA, 2012</p><p>20</p><p>22/08/2024</p><p>11</p><p>WALLED OFF</p><p>PANCREATIC NECROSIS (WON)</p><p>� HABITUALMENTE</p><p>EVOLUÇÃO DE NPA (4 –</p><p>SEMANAS).</p><p>� NECROSE DELIMITADA</p><p>POR PAREDE MAIS</p><p>ORGANIZADA DE TECIDO</p><p>REATIVO.</p><p>� HETEROGÊNEA AO</p><p>EXAME DE IMAGEM.</p><p>� TRATAMENTO DEPENDE</p><p>DE SINTOMAS E/OU</p><p>PRESENÇA DE INFECÇÃO:</p><p>� DRENAGEM INTERNA OU</p><p>EXTERNA</p><p>bonadiman.cirurgia@gmail.com Banks PA, 2012</p><p>21</p><p>LESÕES CÍSTICAS</p><p>INFLAMATÓRIAS DO PÂNCREAS</p><p>bonadiman.cirurgia@gmail.com</p><p>syndrome.” Pseudocysts contain amylase-rich fluid, have</p><p>essentially no solid debris, and possess a well-defined,</p><p>non-epithelialized wall.</p><p>Approximately 20% of individuals with acute pancrea-</p><p>titis will develop necrosis, with secondary infection occur-</p><p>ring in 30% of these patients.8,9 Acute necrotic collections</p><p>(ANCs) develop during the initial 4 weeks of pancreatitis</p><p>and contain variable amounts of fluid and necrotic</p><p>pancreatic and peripancreatic tissue. On imaging, ANCs</p><p>may be multiple, appear loculated, contain variable</p><p>amounts of liquid and debris, and generally appear similar</p><p>to acute peri-PFCs. However, ANCs contain necrotic</p><p>tissue, often are associated with main pancreatic duct</p><p>disruption, and are more likely to become infected. The</p><p>distinction between ANCs and acute peri-PFCs typically</p><p>becomes clear after 1 week. WON is a collection of</p><p>pancreatic and/or peripancreatic necrosis with a mature,</p><p>encapsulated enhancing wall of reactive tissue. This</p><p>typically occurs !4 weeks after the development of necro-</p><p>tizing pancreatitis. WON may be multiple, become</p><p>infected, and be present some distance from the</p><p>pancreas. Although contrast-enhanced CT often is used</p><p>to assess the pancreas initially, magnetic resonance imag-</p><p>ing (MRI) and MRCP may be superior to CT for detection</p><p>of debris within fluid collections (to distinguish between</p><p>pseudocysts and WON) and provide information concern-</p><p>ing integrity of the main pancreatic duct.10 It may also</p><p>more accurately predict the severity and prognosis of</p><p>pancreatic inflammation.11</p><p>EUS also may aid in character-</p><p>ization of these collections.12</p><p>TABLE 1. GRADE system for rating the quality of evidence for guidelines</p><p>Quality of evidence Definition Symbol</p><p>High quality Further research is very unlikely to change our confidence in the estimate of effect. 4444</p><p>Moderate quality Further research is likely to have an important impact on our confidence in the estimate of</p><p>effect and may change the estimate.</p><p>444B</p><p>Low quality Further research is very likely to have an important impact on our confidence in the</p><p>estimate of effect and is likely to change the estimate.</p><p>44BB</p><p>Very low quality Any estimate of effect is very uncertain. 4BBB</p><p>Adapted from Guyatt et al.1</p><p>TABLE 2. Definitions of inflammatory pancreatic fluid collections</p><p>Term Definition Contrast-enhanced CT findings</p><p>Acute peripancreatic fluid</p><p>collection (peri-PFC)</p><p>Peripancreatic fluid associated with interstitial edematous</p><p>pancreatitis with no associated peripancreatic necrosis. This</p><p>term applies only to areas of peripancreatic fluid seen within</p><p>the first 4 weeks after onset of interstitial edematous</p><p>pancreatitis and without the features of a pseudocyst.</p><p>Homogeneous collection with fluid density</p><p>Confined by normal peripancreatic fascial planes</p><p>No definable wall encapsulating the collection</p><p>Adjacent to the pancreas (no intrapancreatic</p><p>extension)</p><p>Pancreatic pseudocyst An encapsulated collection of fluid with a well-defined</p><p>inflammatory wall usually outside the pancreas with minimal</p><p>or no necrosis. This entity usually requires >4 weeks after</p><p>onset of interstitial edematous pancreatitis to mature.</p><p>Well circumscribed, usually round or oval</p><p>homogeneous fluid density</p><p>No non-liquid component</p><p>Well-defined wall (completely encapsulated)</p><p>Maturation usually requires >4 weeks after onset</p><p>of acute pancreatitis</p><p>Occurs after interstitial edematous pancreatitis</p><p>Acute necrotic collection A collection containing variable amounts of both fluid and</p><p>necrosis associated with necrotizing pancreatitis; the necrosis</p><p>can involve the pancreatic parenchyma and/or the</p><p>peripancreatic tissues.</p><p>Occurs only in the setting of acute necrotizing</p><p>pancreatitis</p><p>Heterogeneous and non-liquid density of</p><p>varying degrees in different locations (some</p><p>appear homogeneous early in the course)</p><p>No definable wall encapsulating the collection</p><p>Can be intrapancreatic and/or extrapancreatic</p><p>Walled-off necrosis A mature, encapsulated collection of pancreatic and/or</p><p>peripancreatic necrosis that has developed a well-defined</p><p>inflammatory wall. This usually occurs >4 weeks after the</p><p>onset of necrotizing pancreatitis.</p><p>Heterogeneous with liquid and non-liquid</p><p>density with varying degrees of loculations</p><p>(some may appear homogeneous)</p><p>Well-defined wall (completely encapsulated)</p><p>Intrapancreatic and/or extrapancreatic location</p><p>Maturation usually requires 4 weeks after onset</p><p>of acute necrotizing pancreatitis</p><p>Adapted from Banks et al.6</p><p>Endoscopy in inflammatory pancreatic fluid collections</p><p>482 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 3 : 2016 www.giejournal.org</p><p>ASGE 2016</p><p>22</p><p>22/08/2024</p><p>12</p><p>TRATAMENTO COMPLICAÇÕES PA</p><p>� TRATAR INSUFICIÊNCIAS ORGÂNICAS (RENAL,</p><p>PULMONAR...):</p><p>� VENTILAÇÃO MECÂNICA.</p><p>� HEMODIÁLISE.</p><p>� NECROSE PANCREÁTICA INFECTADA:</p><p>� ANTIBIOTICOTERAPIA.</p><p>� NECROSECTOMIA.</p><p>� DRENAGEM PERCUTÂNEA.</p><p>� DRENAGEM ENDOSCÓPICA.</p><p>23</p><p>TRATAMENTO COMPLICAÇÕES PA</p><p>PÓS</p><p>ATB</p><p>24</p><p>22/08/2024</p><p>13</p><p>TRATAMENTO COMPLICAÇÕES PA</p><p>� LESÕES CÍSTICAS PANCREÁTICAS</p><p>INFECTADAS:</p><p>� INTERVENÇÃO EM CASO DE INFECÇÃO OU</p><p>SINTOMAS.</p><p>� TRATAMENTO ENDOSCÓPICO, PERCUTÂNEO OU</p><p>CIRÚRGICO (SE INDICADO).</p><p>25</p><p>TRATAMENTO COMPLICAÇÕES PA</p><p>Da Costa et al, BJS ,</p><p>2013</p><p>Management strategies for necrotizing pancreatitis</p><p>a b</p><p>Pancreas Ribs</p><p>Infected</p><p>necrosis</p><p>CT-guided</p><p>percutaneous</p><p>drain</p><p>Patient’s feet Patient’s head</p><p>Area of detail</p><p>Pancreas Infected</p><p>necrosis</p><p>Posterior</p><p>Liver</p><p>Stomach</p><p>Peritoneal space</p><p>Peripancreatic</p><p>fluid collection</p><p>with necrotic tissue</p><p>Access to</p><p>retroperitoneal</p><p>space</p><p>Fig. 3 Preferred route for percutaneous catheter placement for drainage of a typical infected peripancreatic collection. Via the left flank,</p><p>a catheter can be manoeuvred retroperitoneally between the spleen, descending colon and kidney using computed tomography (CT)</p><p>guidance</p><p>of PCD, different strategies are applied. A positive FNA</p><p>culture during the second or third week leads to PCD</p><p>in some institutions, whereas in others antibiotics are</p><p>started first, with PCD in this disease phase only following</p><p>further clinical deterioration. Early PCD may substantially</p><p>improve a patient’s condition but can also introduce infec-</p><p>tion in a sterile collection, thereby leading to deterioration,</p><p>so it is important that infection be documented clearly first.</p><p>In the past decade, several specialized centres have</p><p>reported successful treatment of infected necrotizing</p><p>pancreatitis with PCD alone in 35–55 per cent of</p><p>patients105–107. The PANTER trial compared PCD</p><p>as the first step of a step-up approach with primary</p><p>open necrosectomy for infected necrotizing pancreatitis.</p><p>Interestingly, more than 30 per cent of those enrolled</p><p>in the step-up group did not need additional surgical</p><p>necrosectomy107. Available evidence indicates that a</p><p>subgroup of patients with infected necrotizing pancreatitis</p><p>can be treated successfully with PCD alone. Unfortunately,</p><p>it remains unclear which patients will recover successfully</p><p>after PCD alone and which will need an additional</p><p>endoscopic or surgical necrosectomy. Therefore, the first</p><p>step in treatment should be percutaneous or endoscopic</p><p>drainage, followed by surgical or endoscopic necrosectomy</p><p>only if clinically necessary.</p><p>Management during the fourth, fifth and sixth</p><p>weeks</p><p>A second peak in mortality is seen in this phase of</p><p>the disease, mostly associated with infection of the</p><p>pancreatic or extrapancreatic necrosis14. In general, only</p><p>patients with infected necrosis should undergo invasive</p><p>interventions14,20,108. Interventions such as endoscopic</p><p>transluminal drainage and necrosectomy, and minimally</p><p>invasive or open necrosectomy should be delayed if</p><p>possible to around 4 weeks after the onset of symptoms102.</p><p>This allows the collection to become walled-off, which is</p><p>believed to facilitate necrosectomy9 (Fig. 2).</p><p>Minimally invasive surgical necrosectomy</p><p>Two minimally invasive surgical techniques have gained</p><p>widespread acceptance: sinus tract endoscopy (also referred</p><p>to as minimal access retroperitoneal pancreatic necrosec-</p><p>tomy, MARPN)109,110 and video-assisted retroperitoneal</p><p>© 2013 BJS Society Ltd www.bjs.co.uk BJS</p><p>Published by John Wiley & Sons Ltd</p><p>D. W. da Costa, D. Boerma, H. C. van Santvoort, K. D. Horvath, J. Werner, C. R. Carter et al.</p><p>Pancreas Infected</p><p>necrosis</p><p>Posteriora</p><p>b</p><p>Pancreas</p><p>Peripancreatic</p><p>fluid collection</p><p>with necrotic tissue</p><p>Laparoscope</p><p>Necrotic</p><p>tissue</p><p>Long grasping</p><p>forceps</p><p>Stomach</p><p>Spleen</p><p>Costal margin</p><p>Fig. 4 Video-assisted retroperitoneal debridement. a Using the</p><p>percutaneous catheter as retroperitoneal guide, a 5-cm subcostal</p><p>incision is made. b The first solid debris that is encountered can</p><p>be removed bluntly using a long grasping forceps. Subsequently</p><p>a 0◦ laparoscope is introduced into the necrotic cavity and more</p><p>central necrotic debris can be removed</p><p>debridement (VARD)106 (Fig. 4). In both procedures,</p><p>access to the necrotic pancreas is achieved by following</p><p>the tract of a radiologically placed drainage catheter.</p><p>In sinus tract endoscopy, pioneered in the Glasgow</p><p>Royal Infirmary, Glasgow, UK, a nephroscope is inserted</p><p>into the infected collection after dilatation of the drain</p><p>tract to 30 Fr under fluoroscopic guidance. Debridement</p><p>is carried out using a long forceps, and the necrotic cavity</p><p>is flushed using jet irrigation and suction devices. The</p><p>procedure is repeated if the patient fails to recover and</p><p>residual infected necrosis is suspected. A median of three to</p><p>five procedures is needed for adequate necrosectomy109,110.</p><p>A large retrospective cohort series indicated that survival</p><p>rates are potentially better with MARPN compared with</p><p>open necrosectomy (mortality</p><p>rate: 19 per cent of 137</p><p>patients versus 38 per cent of 52 patients)111. Additionally,</p><p>postoperative organ failure and complication rates may be</p><p>lower in the minimally invasive group.</p><p>The VARD technique was developed in the University of</p><p>Washington Medical Center, Seattle, Washington, USA. It</p><p>uses a 5-cm subcostal incision in the left flank near the exit</p><p>point of the percutaneous drain112. The drain is followed</p><p>closely into the collection. After opening the collection</p><p>bluntly and clearing the first liquid and solid debris</p><p>encountered with suction and a long grasping forceps, a 0◦</p><p>camera used for laparoscopy is introduced into the necrotic</p><p>cavity. The camera is placed through a laparoscopic port,</p><p>which is placed directly through the incision. Carbon</p><p>dioxide is infused through the percutaneous drain to inflate</p><p>the cavity. After surgery continuous lavage is started using</p><p>two large-diameter drains. This technique allows vigorous</p><p>debridement of the necrotic cavity with a median of one</p><p>procedure106. In the years following the introduction</p><p>of VARD in Seattle, it became clear that percutaneous</p><p>drainage alone could also be sufficient in some patients,</p><p>instead of just serving as a bridge to necrosectomy. This</p><p>finding generated the hypothesis behind the PANTER</p><p>trial113. In this trial, 88 patients were allocated randomly to</p><p>either primary necrosectomy via laparotomy or the step-</p><p>up approach. A significantly lower rate of the composite</p><p>endpoint of major morbidity or death was found in the step-</p><p>up group (40 versus 69 per cent; P = 0·006). New-onset</p><p>multiple organ failure was also significantly less common</p><p>in the step-up group (12 versus 40 per cent; P = 0·002).</p><p>A few case series have been published on laparo-</p><p>scopic necrosectomy. This transperitoneal route offers</p><p>access to the lesser sac and simultaneous manage-</p><p>ment of intra-abdominal organs (for example concurrent</p><p>cholecystectomy)114. However, it also has the disadvantage</p><p>of introducing a continuum between the peritoneal cavity</p><p>and the retroperitoneum containing infected pancreatic</p><p>necrosis112,114,115.</p><p>Endoscopic transluminal drainage or necrosectomy</p><p>Parallel to the development of minimally invasive surgical</p><p>strategies, endoscopic transluminal approaches have been</p><p>developed116,117. Under direct vision or endoscopic</p><p>ultrasound guidance, the gastric or duodenal wall is</p><p>punctured to reach the walled-off necrosis (Fig. 5). The</p><p>© 2013 BJS Society Ltd www.bjs.co.uk BJS</p><p>Published by John Wiley & Sons Ltd</p><p>PERCUTÂNEO</p><p>Video-assisted</p><p>retroperitoneal</p><p>debridement (VARD).</p><p>26</p><p>22/08/2024</p><p>14</p><p>TRATAMENTO COMPLICAÇÕES PA</p><p>Da Costa et al, BJS ,</p><p>2013</p><p>Management strategies for necrotizing pancreatitis</p><p>Endoscopic</p><p>transluminal</p><p>drainage</p><p>a</p><p>Infected</p><p>necrosis</p><p>Double pigtail</p><p>stent</p><p>Endoscopic</p><p>transluminal</p><p>necrosectomy</p><p>Nasocystic</p><p>catheter</p><p>b</p><p>Further</p><p>dilatation of tract</p><p>Fig. 5 Under direct vision or endosonographic guidance, the gastric or duodenal wall is punctured to evacuate the infected necrotic</p><p>material. a After serial dilatation of this transluminal tract, two double-pigtail catheters are placed to establish a patent drain tract.</p><p>b Should the need for endoscopic necrosectomy arise, the tract is dilated further so that various endoscopic necrosectomy instruments</p><p>can be introduced</p><p>transluminal tract is dilated sequentially using a balloon.</p><p>Short pigtail catheter drains or a stent can be used to</p><p>prevent the access to the retroperitoneum from closing</p><p>after the first procedure. A nasocystic catheter is placed</p><p>in the necrotic cavity for continuous irrigation46. The use</p><p>of multiple transluminal gateways has been suggested to</p><p>improve drainage of the infected material, and successful</p><p>drainage without the need for additional interventions</p><p>was achieved in up to 90 per cent in a small cohort</p><p>of selected patients118. Patients in whom endoscopic</p><p>drainage proves insufficient may benefit from endoscopic</p><p>necrosectomy. Like sinus tract endoscopy, the transluminal</p><p>drain tract is dilated further for introduction of an</p><p>endoscope. Various instruments are used for the actual</p><p>necrosectomy, such as endoscopic baskets, snares, jet</p><p>irrigation and forceps117,119. A recent systematic review117</p><p>showed that 197 (75·8 per cent) of 260 patients were</p><p>treated with endoscopic treatment alone, with only two</p><p>reported deaths. Although these results seem promising,</p><p>they must be interpreted with caution as they are</p><p>based predominantly on non-randomized findings in</p><p>selected patients from experienced institutions. The first</p><p>randomized trial52 compared endoscopic necrosectomy</p><p>with surgical necrosectomy in 22 patients with infected</p><p>necrotizing pancreatitis. This pilot trial showed that</p><p>the inflammatory response (interleukin 6 levels) and a</p><p>composite endpoint of death or major complications were</p><p>significantly reduced following endoscopy compared with</p><p>surgery. A large clinical trial following on from this pilot</p><p>study is currently being conducted. Ninety-eight patients</p><p>will be randomized to an endoscopic step-up approach</p><p>or the surgical step-up equivalent (percutaneous drainage</p><p>followed by VARD or, if not feasible, open necrosectomy)</p><p>(TENSION trial; ISRCTN 09186711).</p><p>Open surgical necrosectomy</p><p>Primary open surgical necrosectomy has been the standard</p><p>treatment of infected necrosis for decades. The classical</p><p>approach is to enter the retroperitoneum through a</p><p>laparotomy, after which the necrotic tissue is removed by</p><p>blunt dissection120. Healthy pancreatic tissue is preserved</p><p>as much as possible, and by doing so the risk of</p><p>postoperative bleeding or pancreatic fistula is minimized.</p><p>Different surgical techniques have been developed over the</p><p>years, such as open packing, closed packing with planned</p><p>reoperation or postoperative continuous lavage to remove</p><p>any residual material108. Open necrosectomy remains</p><p>associated with substantial morbidity121–123. These high</p><p>morbidity rates are generally attributed to the exacerbation</p><p>of stress induced by the trauma of surgery in an already</p><p>critically ill patient, but are also closely associated with</p><p>© 2013 BJS Society Ltd www.bjs.co.uk BJS</p><p>Published by John Wiley & Sons Ltd</p><p>ENDOSCÓPICO</p><p>27</p><p>TRATAMENTO – PERCUTÂNEO OU</p><p>ENDOSCÓPICO</p><p>� DETERIORAÇÃO CLÍNICA E/OU SUSPEITA DE INFECÇÃO.</p><p>� APÓS 4 SEMANAS DO INÍCIO DOS SINTOMAS:</p><p>� PIORA CLÍNICA OU FALÊNCIA ORGÂNICA SEM SINAIS DE INFECÇÃO;</p><p>� SINTOMAS OBSTRUTIVOS POR WONP / PSEUDOCISTO VOLUMOSO;</p><p>� SÍNDROME DA DESCONEXÃO DUCTAL;</p><p>� APÓS 8 SEMANAS:</p><p>� DOR OU DESCONFORTO PERSISTENTE.</p><p>Leppa ̈niemi et al. World Journal of Emergency Surgery,</p><p>2019.</p><p>28</p><p>22/08/2024</p><p>15</p><p>TRATAMENTO – CIRÚRGICO</p><p>� FALHA OU INDISPONIBILIDADE DO TRATAMENTO PERCUTÂNEO / ENDOSCÓPICO</p><p>(step-up approach).</p><p>� SÍNDROME COMPARTIMENTAL ABDOMINAL.</p><p>� HEMORRAGIA COM INDISPONIBILIDADE OU FALHA ENDOVASCULAR.</p><p>� ISQUEMIA INTESTINAL.</p><p>� COLECISTITE AGUDA.</p><p>� FÍSTULAS ENTÉRICAS.</p><p>Leppa ̈niemi et al. World Journal of Emergency Surgery,</p><p>2019.</p><p>29</p><p>TRATAMENTO CIRÚRGICO – ESTRATÉGIAS</p><p>� NA NECROSE INFECTADA: step-up approach. GR 1A.</p><p>� NECROSECTOMIA ENDOSCÓPICA E VARD GERAM MENOR</p><p>RESPOSTA INFLAMATÓRIA. GR 1B.</p><p>� CONSIDERANDO A MORTALIDADE, NÃO HÁ EVIDÊNCIAS</p><p>SUFICIENTES PARA APOIAR A ABORDAGEM CIRÚRGICA</p><p>ABERTA, MINI-INVASIVA OU ENDOSCÓPICA. GR 1B.</p><p>Leppa ̈niemi et al. World Journal of Emergency Surgery,</p><p>2019.</p><p>30</p><p>22/08/2024</p><p>16</p><p>TRATAMENTO CIRÚRGICO – ESTRATÉGIAS</p><p>� NA SÍNDROME COMPARTIMENTAL ABDOMINAL REFRATÁRIA A</p><p>MEDIDAS CLÍNICAS, A ABORDAGEM CIRÚRGICA COM</p><p>PERITONIOSTOMIA É EFETIVA. GR 2C.</p><p>� NÃO REALIZAR DESBRIDAMENTO OU NECROSECTOMIA PRECOCE CASO</p><p>HAJA NECESSIDADE DE DESCOMPRESSÃO ABDOMINAL. GR 1A.</p><p>� CURATIVOS A VÁCUO AJUDAM NAS PERITONIOSTOMIAS. GR 1B.</p><p>Leppa ̈niemi et al. World Journal of Emergency Surgery,</p><p>2019.</p><p>31</p><p>TRATAMENTO – ESTRATÉGIAS</p><p>32</p><p>22/08/2024</p><p>17</p><p>TRATAMENTO – ESTRATÉGIAS</p><p>33</p><p>TRATAMENTO – ESTRATÉGIAS</p><p>34</p><p>22/08/2024</p><p>18</p><p>TRATAMENTO – ESTRATÉGIAS</p><p>35</p><p>TRATAMENTO – ESTRATÉGIAS</p><p>36</p><p>22/08/2024</p><p>19</p><p>Prof. José Francisco de Mattos Farah</p><p>37</p><p>38</p>