Nieuwe evidence-based richtlijn acute pancreatitis Marc Besselink HPB chirurg, AMC Amsterdam
[email protected]
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)
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Tijdspad • • • • • • • • •
Februari 2011: Mei-november: December: Jan-Maart 2012: April: Mei-oktober: November: Mei 2013: Oktober:
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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)
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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”?
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