A.Familiare: negativa per ipertensione, diabete, neoplasie M. 62 aa A.Familiare: negativa per ipertensione, diabete, neoplasie A.Fisiologica: buona mangiatrice, no fumo, no alcool A.P. Recente: Dolore crampiforme in ipocondrio destro, irradiato a cintura insorto dopo pasto copioso Dolore non recede con FANS Nausea e Vomito biliare Canalizzato ai gas ed alle feci Esame obiettivo: Addome trattabile, non dolente, non disteso, non tumefazioni

Patologia chirurgica o medica ? Appendicite acuta Ulcera peptica perforata Pancreatite acuta Colecistite acuta Colica renale destra Pleurite basale destra Epatite acuta Infarto del miocardio

? ? ? Esami di laboratorio: Emocromo=leucocitosi neutrofila Hb lievemente ridotta Biochimici =funzione renale nella norma funzione epatica lievementa alterata indici di colestasi nella norma amilasi, lipasi molto elevate ipocalcemia, glicemia elevata >200 mg/dL PCR elevata ? ? ?

Patologia chirurgica o medica ? Appendicite acuta Ulcera peptica perforata Pancreatite acuta Colecistite acuta Colica renale destra Pleurite basale destra Epatite acuta Infarto del miocardio

VBP, VBI modicamente dilatate Ecografia addome: Calcolosi colecisti, VBP, VBI modicamente dilatate Dopo 48-72 ore

la pancreatite acuta ..l’eziologia… Sekimoto e Coll. 2006

…in crescita…. …calo degenza…

…scelte del chirurgo… ..la gravità… %

JPN guidelines for the management of acute pancreatitis: severity assessment of acute pancreatitis Hirota e Coll J Hepatobiliary Pancreat Surg 2006

INDICI MULTIFATTORIALI IN CORSO DI P.A. Indice di Glasgow Indice di Ranson Apache Score Proteina C reattiva Elastasi granulocitaria Interleuchine Rx Torace + creatininemia Età > 55 anni Globuli bianchi > 15.000/mm3 Glicemia > 200 mg/100 ml Azotemia > 45 mg/100 ml Ca2+ < 8 mg/100 ml Albuminemia < 32 g/L LDH > 600 U/L AST > 200 U/L PaO2 < 60 mm Hg

INDICI MULTIFATTORIALI IN CORSO DI P.A. I.Ranson all’ingresso Correlazione tra I.Ranson e mortalità in corso di pancreatite acuta Età > 55 anni Globuli bianchi > 16.000/mm3 Glicemia > 200mg/100ml LDH > 350 U/L AST > 250 U/L I.Ranson a 48 ore % Ematocrito Riduzione > 10% Azotemia Incremento > 5 mg/100 ml Ca2+ < 8 mg/100 ml PaO2 < 60 mm Hg Deficit basi > 4 mEq/L Sequestro liquidi > 6 L 0-2 3-4 5-6 >7 SCORE

Balthazar 1994 Moertele 2004

…la mortalità in corso di pancreatite acuta… 5.2-7.8% 22-38% 14-80% Sekimoto 2006

Pancreatite acuta biliare ProInf AISP 2001 981 n. casi 741 240 totale lieve severa

…come fare la diagnosi di pancreatite acuta biliare…

lieve severa via biliare Pancreatite acuta biliare trattamento pancreas Mild acute pancreatitis is not an indication for pancreatic surgery Recommendation grade B

Pancreatite acuta biliare lieve …recurrence of acute pancreatitis in patients with gallstones has been reported in 29-63% of cases if the patient is discharged from the hospital without additional treatment… Cholecystectomy should be performed to avoid recurrence of gallstone-associated acute pancreatitis Recommendation grade B ERCP + ES solo se: OSTRUZIONE COLANGITE Cholecystectomy should be performed as soon as the patient has recovered and ideally during the same hospital admission Recommendation grade B

Pancreatite acuta biliare lieve Proinf AISP 2001 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 biliary pancreatitis Recommendation grade B 68 % 65 32 35 No colecistectomia Colecistectomia durante il ricovero ERCP + ES

Pancreatite acuta biliare severa ERCP + ES entro 48/72 ore SEMPRE (Neoptolemos, Fan) ITTERO COLANGITE ACUTA VB DILATATA (Folsch) TERAPIA MEDICA INTENSIVA In severe gallstone-associated acute pancreatitis, cholecystectomy should be delayed until there is sufficient resolution of the inflammatory response and clinical recovery Recommendation grade B No early surgery (entro 48 ore) Si delayed surgery (dopo 48 ore)

Proinf AISP 2001 Pancreatite acuta biliare severa 65 60 35 40 si no % esecuzione ERCP tempo esecuzione ERCP 65 % 60 35 40 si no entro 72 ore dopo 72 ore

100% 66.3% 33.7% Pancreatite acuta severa ProInf AISP 2001 n = 1005 PA 252 casi 66.3% % 167 casi 33.7% 85 casi totale casi PA necrotica non operati operati

Drenaggio percutaneo TC-guidato

Percutaneous catheter drainage Alone for infected walled-off necrosis has a success rate as low as 25% to 45% Brunschot et Al, 2012

DRENAGGIO ENDOSCOPICO

DRENAGGIO ENDOSCOPICO

Endoscopic transluminal drainage and necrosectomy Overall treatment success was 76% Mortality 5% Procedure-related morbidity was 27% (bleeding, perforation and embolism) Bang et Al, 2013 Seewald et Al, 2012 Haghshenasskashani et Al, 2011

all’intervento chirurgico… Pancreatite acuta severa ProInf AISP 2001 …indicazioni all’intervento chirurgico… JPN guidelines Necrosi infetta 57.8% Peritonite 44.6% Necrosi sterile 20.5% MOF 19.3% Pseudocisti 8.4% Tadahiro 2006

…la necrosi infetta… Infected pancreatic necrosis in patients with …the mortality rate for patients with infected pancreatic necrosis is higher than 30%... The conservative management of infected pancreatic necrosis associated with multiple organ failure has a mortality rate of up to 100% 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

…la necrosi sterile… Surgery in patients who develop organ failure associated with sterile pancreatic necrosis ? …the extent of pancreatic sterile necrosis is related to organ failure… Patients with sterile pancreatic necrosis (FNAB negative) should be managed conservatively and only undergo intervention in selected cases Recommendation grade B (IAP 2002) (JPN guidelines 2006)

Timing chirurgico Pancreatite acuta severa …in the early course of the disease, patients are at high risk of death from cardiovascular or pulmonary failure… Delayed surgical therapy if the patients continue to respond positively to conservative management… permits a proper demarcation of pancreatic and peripancreatic necrosis… decreases the risk of bleeding and minimizes the surgery-related loss of vital tissue that predispose to surgery-induced endocrine and esocrine pancreatic insufficiency…

Timing chirurgico Pancreatite acuta severa ProInf AISP 2001 Early surgery within 14 days after the onset of the disease is not recommended in patients with necrotizing pancreatitis unless there are specific indications Recommendation grade B 70 30 <15 gg >15gg (JPN guidelines)

Pancreatite acuta severa Quale chirurgia ? JPN guidelines 2006

Lavaggio faccia anteriore Lavaggio faccia posteriore

Il trattamento delle complicanze JPN guidelines 2006

JPN guidelines 2006

…chirurgia… Derivazioni Interne (cisto-gastro cisto-duodeno cisto-digiuno) Drenaggio esterno (raro) 1) video-assisted retroperitoneal debridment (VARD) 2) laparoscopic transperitoneal debridment (LTPD) Cannon JW et al Am College of Surgeon 2010

Banks et Al, 2013

MANAGEMENT OF WOPN In accordance with international guidelines, patients with sterile necrosis can be successfully managed conservatively (ie, without any form of radiological, endoscopic, or surgical intervention). Indications for treatment of WOPN are: infection a rapid increase in size pain biliary or duodenal obstruction Bang et Al, 2013 Ramia et Al, 2012 Brunschot et Al, 2012

6% CA ≤ cm. 2 ..la pancreatite acuta lieve può essere una manifestazione di un carcinoma… REGISTRO NAZIONALE GIAPPONESE DEL CANCRO PANCREATICO 6% CA ≤ cm. 2 Imamura – Hepatobiliary Pancreat Surg. 2002

..la pancreatite acuta lieve può essere una manifestazione di un IPMN… M., 67 aa Precedenti episodi di PA Pancreasectomia sinistra spleen preserving