Einteilung des Schweregrads der akuten Pankreatitis

Zusammenfassung

Ziel: Entwicklung einer neuen, internationalen Klassifikation des Schwergrads der akuten Pankreatitis, basierend auf einem pathophysiologisch rationalen Konzept sowie der publizierten Evidenz und einem interdisziplinären, globalen Konsensusprozess.

Hintergrund: Die Atlanta-Definitionen der Schwere der akuten Pankreatitis sind zwar breit akzeptiert, weisen aber grundlegende Schwächen auf, weil sie vorwiegend auf empirischen, deskriptiven, nicht-kausalen Parametern beruhen.

Methoden: 1.) Persönliche Einladung an alle auf dem Gebiet der akuten Pankreatitis aktiv forschenden Gastroenterologen, Chirurgen, Internisten, Intensivmediziner und Radiologen, bei der Entwicklung dieser Klassifikation mitzuarbeiten; es gab keine Beschränkungen auf bestimmte Länder oder Mitglieder bestimmter Fachgesellschaften. 2.) Durchführung einer globalen internetbasierten Befragung. 3.) Diskussion und Konsensbildung zu Konzepten und Definitionen, auf einem internationalen Symposium.

Ergebnisse: Die Schweregrade werden auf Basis pathogenetisch wirksamer, lokaler und/oder systemischer Determinanten neu definiert. Als lokale Determinante zählt die (peri-)pankreatische (sterile oder infizierte) Nekrose, als systemische Determinante das (transiente oder persistierende) Organversagen. Die Determinanten können sich wechselseitig beeinflussen: So kann z. B. die Kombination aus Nekroseninfektion und persistierendem Organversagen die Schwere stärker beeinflussen als die einzelnen Determinanten. Aus diesen Determinanten leiten sich 4 Schweregrade ab: milde, mäßig schwere, schwere und kritische Pankreatitis.

Folgerungen: Diese internationale, multidisziplinäre Klassifikation bietet ein System einfacher, pathogenetisch begründeter Definitionen, welche standardisiert die Zuordnung des Schweregrads einer akuten Pankreatitis erlauben. Sie eignet sich daher für eine einheitliche klinische und wissenschaftliche Anwendung.

Abstract

Objective: The aim of this study was to develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation.

Background: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric descriptions of occurrences that are merely associated with severity.

Methods: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensive medicine specialists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organised to bring contributors from different disciplines together and discuss the concept and definitions.

Result: The new international classification is based on the actual local and systemic determinants of severity, rather than descriptions of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity – mild, moderate, severe, and critical.

Conclusions: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Schlüsselwörter

akute Pankreatitis - Klassifikation - Einteilung - Definition - Schweregrad - Organversagen - Pankreasnekrosen - infizierte Nekrose Komplikationen

Key words

acute pancreatitis - classification - definition - severity - organ failure - pancreatic necrosis - peripancreatic necrosis - pancreatic infectious complications

^* Bei der vorliegenden Arbeit handelt es sich um die leicht gekürzte deutsche Version der folgenden Originalpublikation: Determinant-Based Classification of Acute Pancreatitis Severity (Dellinger et al., PMID 22735715), in der auch die vollständige Liste aller Mitwirkenden verzeichnet ist [1].

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