Nieuwe evidence-based richtlijn
acute pancreatitis
Marc Besselink
HPB chirurg, AMC Amsterdam
m.g.besselink@amc.nl
Pancreatitis.nl
Het idee
• Update van de 2002 acute pancreatitis richtlijn van de
“International Assocation of Pancreatology”
– 38 klinische vragen op 12 hoofdonderwerpen, beantwoord
door review groepen
– Internationale, multidisciplinaire review groepen van 4-5
mensen die reeds over deze onderwerpen publiceerden
– Consensus meeting & referees om hele ‘pancreasgemeenschap’ bij proces te betrekken
De uitwerking
• Geen individuele auteurs
• Vier groepen
– Steering committee
(6x incl 3 coördinatoren)
– Executive committee (9x, klankbord)
– Reviewers
(33x, multidisciplinaar, internationaal)
– Referees
(52x, beoordelen laatste versie)
• Tijdens de IAP/APA meeting:
– Presentatie reviews (antwoord op klinische vraag) met
opmerkingen
– GRADE rating evidence
– Stemming obv agreement: door de zaal
30-10-2014
Nederlandse inbreng
• Coördinatoren:
Marc Besselink, Hjalmar van Santvoort (+1)
• Executive cie:
Hein Gooszen (+8)
• Reviewers:
Thomas Bollen, Mark van Baal, Marco Bruno,
Hein Gooszen, Marc Besselink, Hjalmar van
Santvoort (+27)
• Referees:
Paul Fockens, Harry van Goor, Paul Fockens,
Olaf Bakker, Marja Boermeester (+48)
30-10-2014
Tijdspad
•
•
•
•
•
•
•
•
•
Februari 2011:
Mei-november:
December:
Jan-Maart 2012:
April:
Mei-oktober:
November:
Mei 2013:
Oktober:
30-10-2014
Idee, overleg met Hjalmar en Jens Werner
Overleg aanpak
IAP/APA goedkeuring
Schrijven protocol, commentaar fase
Protocol verstuurd
Reviews gedaan door 12 groepen
IAP/APA consensus meeting
Manuscript verstuurd
Guidelines online gepubliceerd
Onderwerpen
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Diagnosis / etiology
Prognostication / predicting severity
Imaging
Fluid therapy
Intensive care management
Preventing infectious complications
Nutritional support
Biliary tract management
Indications for intervention in necrotizing pancreatitis
Timing of intervention in necrotizing pancreatitis
Intervention strategies in necrotizing pancreatitis
Timing cholecystectomy / sphincterotomy
IAP/APA consensus meeting
• 171 aanwezigen;
– 71x Noord-Amerika
– 54x Europa,
– 39x Azie/Oceanie,
– 7x Zuid-Amerika
• 38 recommendations
– 21 (55%): ‘strong recommendation’
(door reviewers gescoord)
– 34 (89%): ‘strong agreement’
(tijdens plenaire stemming)
30-10-2014
Q28. What are the indications for intervention in necrotizing
pancreatitis?
Q28. What are the indications for intervention in necrotizing
pancreatitis?
Q28-A. Recommendation (1/2):
Common indications:
1. Clinical suspicion of or documented infected necrotizing pancreatitis
with clinical deterioration, preferably when the collection with
necrosis has become walled-off, a process that typically takes 4 weeks.
2. Ongoing organ failure for several weeks after the onset of acute
pancreatitis, preferably when the collection with necrosis has become
walled-off, a process that typically takes 4 weeks.
GRADE: 1C
Recommendation:
Based on evidence:
strong = grade 1/ weak=grade 2
high=grade A/moderate=grade B
/low=grade C
Q28. What are the indications for intervention in necrotizing
pancreatitis?
Q28-A. Recommendation (2/2):
Less common indications:
3. Abdominal compartment syndrome
4. Acute bleeding
5. Bowel ischemia with/without perforation.
6. Gastric outlet obstruction with persisting / enlarging collection
more than 4-8 weeks after onset of acute pancreatitis.
7. Pancreaticopleural fistula
8. Pancreatic ascites
GRADE:1C
Recommendation:
Based on evidence:
strong = grade 1/ weak=grade 2
high=grade A/moderate=grade B
/low=grade C
Q29. What is the role of fine needle aspiration to diagnose infected
necrosis?
Q29. What is the role of fine needle aspiration to diagnose infected
necrosis?
Q29-A. Recommendation:
FNA can confirm infection in necrotizing pancreatitis but is not
mandatory because clinical and imaging signs (gas in peripancreatic
collections) are sufficient in the majority of cases. Fine needle
aspiration can provide false-negative results.
GRADE: 1C
Recommendation:
Based on evidence:
strong = grade 1/ weak=grade 2
high=grade A/moderate=grade B
/low=grade C
Q30. What are the indications for intervention in sterile necrotizing
pancreatitis?
Q30. What are the indications for intervention in sterile necrotizing
pancreatitis?
Q30-A. Recommendation:
1. Ongoing gastric outlet or biliary obstruction due to mass effect of a
large WOPN (arbitrarily > 4-8 weeks)
2. Persistent symptoms (e.g. pain, “persistent unwellness”) in patients
with large collection(s) with necrosis (arbitrarily >8 weeks)
3. Disconnected duct syndrome with persisting symptomatic (e.g. pain,
obstruction) collection(s) (arbitrarily > 8 weeks)
4. Pancreaticopleural fistula
5. Pancreatic ascites
6. Obstructive jaundice
GRADE: 2C
Recommendation:
Based on evidence:
strong = grade 1/ weak=grade 2
high=grade A/moderate=grade B
/low=grade C
Q30. What are the indications for intervention in sterile necrotizing
pancreatitis?
Q30-B.Remarks concerning the recommendation:
• Less than 1% of patients with necrotizing pancreatitis will have
symptoms of obstruction necessitating intervention.
• Data is lacking on the proportion of patients that will require
intervention in the months after an episode of necrotizing
pancreatitis.
• Data is lacking on the optimal timing of intervention
Stand van zaken
• PWN heeft IAP/APA richtlijn overgenomen
• Richtlijn beschikbaar via
– App stores (pancreatitis guidelines)
– iBook via pancreatitis.nl)
– PDF via Google/Pubmed (zoek: IAP/APA)
30-10-2014
Toekomst
• Commentaar NV-MDL, NVVH, NIV integreren en publiceren
• Gebruik richtlijn bevorderen
• Regelmatige update borgen
• Richtlijn gebruiken als indicator voor toekomstige PWN
studies: “waar ontbreekt evidence”?
30-10-2014
19