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IAP/APA evidence-based guidelines for the management of Acute Pancreatitis

Working Group IAP/APA Acute Pancreatitis Guidelinesa

Pancreatology 13 (2013) e1 - e15

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Recopilacion y Traducci n! "#$ %ergara. (Octubre 2013)

Recommendations
A. Diagnosis of acute pancreatitis and etiology 1. The definition of acute pancreatitis is based on the fulfillment of 2 out of 3! of the follo"ing criteria# clinical (upper abdominal pain)$ laboratory (serum amylase or lipase %3& upper limit of normal) and'or imaging ((T$ )*+$ ultrasonography) criteria.(GRADE 1B, strong agreement) 2. On admission$ the etiology of acute pancreatitis should be determined using detailed personal (i.e. pre,ious acute pancreatitis$ -no"n gallstone disease$ alcohol inta-e$ medication and drug inta-e$ -no"n hyperlipidemia$ trauma$ recent in,asi,e procedures such as .*(/) and family history of pancreatic disease$ physical e&amination$ laboratory serum tests (i.e. li,er en0ymes$ calcium$ triglycerides)$ and imaging (i.e. right upper 1uadrant ultrasonography). (GRADE 1B, strong agreement) 3. +n patients considered to ha,e idiopathic acute pancreatitis$ after negati,e routine "or-2up for biliary etiology$ endoscopic ultrasonography (.34) is recommended as the first step to assess for occult microlithiasis$ neoplasms and chronic pancreatitis. +f .34 is negati,e$ (secretin2stimulated) )*(/ (magnetic resonance cholangiopancreatography) is ad,ised as a second step to identify rare morphologic abnormalities. (T of the abdomen should be performed. +f etiology remains unidentified$ especially after a second attac- of idiopathic pancreatitis$ genetic counseling (not necessarily genetic testing) should be considered. (GRADE 2C, ea! agreement) 5. /rognostication'prediction of se,erity 6. 4ystemic inflammatory response syndrome (4+*4) is ad,ised to predict se,ere acute pancreatitis at admission and persistent 4+*4 at 67 hours. (GRADE 2B, ea! agreement) 8. During admission$ a 32dimension approach is ad,ised to predict outcome of acute pancreatitis combining host risfactors (e.g. age$ co2morbidity$ body mass inde&)$ clinical ris- stratification (e.g. persistent 4+*4) and monitoring response to initial therapy (e.g. persistent 4+*4$ blood urea nitrogen$ creatinine) .(GRADE 2B, strong agreement) (. +maging 9. The indication for initial (T assessment in acute pancreatitis can be# 1) diagnostic uncertainty$ 2) confirmation of se,erity based on clinical predictors of se,ere acute pancreatitis$ or 3) failure to respond to conser,ati,e treatment or in the setting of clinical deterioration. Optimal timing for initial (T assessment is at least :2e;9 hours after onset of symptoms. (GRADE 1C, strong agreement) :. <ollo" up (T or )* in acute pancreatitis is indicated "hen there is a lac- of clinical impro,ement$ clinical deterioration$ or especially "hen in,asi,e inter,ention is considered. (GRADE 1C, strong agreement)

Recomendaciones
A. Diagn=stico y .tiolog>a de la pancreatitis aguda 1 . ?a definici=n de pancreatitis aguda se basa en cumplimiento de @2 de 3 @ de los siguientes criterios # cl>nico (dolor abdominal superior ) $ laboratorio ( amilasa o lipasa % 3& l>mite superior de lo normal ) y ' o imagen (TA( $ *)$ ultrasonograf>a ) ( Gra"o 1B , #$erte ac$er"o ) . 2 . Al ingreso$ la etiolog>a de la pancreatitis aguda se debe determinar obteniendo una historia detallada personal y familiar (p.eA.$ pancreatitis aguda anterior$ colelitiasis conocida $ ingesta de alcohol$ medicamentos y consumo de drogas $ hiperlipidemia conocida $ trauma$ procedimientos in,asi,os recientes como (/*. ) y $ la e&ploraci=n f>sica $ las pruebas de laboratorio ( p.eA. en0imas hepBticas $ calcio $ triglicCridos ) y de imagen ( p.eA.$ ecograf>a del cuadrante superior derecho ) . ( Gra"o 1B , #$erte ac$er"o ) 3 . .n los pacientes considerados como pancreatitis aguda idiopBtica $ despuCs de descartar la etiolog>a biliar $ se recomienda la ultrasonograf>a endosc=pica ( .34) como el primer paso para e,aluar microlitiasis ocultas $ neoplasias y pancreatitis cr=nica. 4i la .34 es negati,a$ la *)(/$ ( secretina estimulada ) se recomienda como unsegundo paso para identificar anomal>as morfol=gicas raras . 4e debe reali0ar T( abdominal. 4i la etiolog>a permanece sin identificar $ sobre todo tras un segundo ata1ue de pancreatitis idiopBtica $ debe considerarse asesoramiento genCtico (no necesariamente pruebas genCticas). (GRADE 2C , ac$er"o "%&'l) 5. /ron=stico ' predicci=n de la gra,edad 6 . *ecomiendan ,aloraci=n del s>ndrome de respuesta inflamatoria sistCmica ( 4+*4 ) para predecir la pancreatitis aguda gra,e en el ingreso y 4+*4 persistente a las 67 horas. (GRADE 2B , ac$er"o "%&'l) 8 . Durante el ingreso $ se recomienda un enfo1ue basado en 3 aspectos para predecir el resultado$ combinando los factores de riesgo del suAeto ( p.eA edad $ comorbilidad $ >ndice de masa corporal) $ D la estratificaci=n cl>nica de riesgo ( p.eA.$ 4+*4 persistente) D monitori0aci=n de la respuesta al tratamiento inicial (p. e. 4+*4 persistente $ 53E $ creatinina ) . (GRADE 2B , #$erte ac$er"o) (. imagen 9 . ?a indicaci=n para la e,aluaci=n inicial con (T en la pancreatitis aguda puede ser# 1 ) la incertidumbre de diagn=stico $ 2 ) la confirmaci=n de la gra,edad sobre la base de los predictores cl>nicos de pancreatitis aguda gra,e$ o 3 ) la falta de respuesta al tratamiento conser,ador o en el conte&to de deterioro cl>nico . .l momento =ptimo para la e,aluaci=n inicial con (T es al menos :22;9 horas despuCs de la aparici=n de los s>ntomas (GRADE 1C, #$erte ac$er"o ) . : . .l 4eguimiento con T( o *) en la pancreatitis aguda estB indicado cuando no hay meAor>a cl>nica $ hay deterioro cl>nico $ o especialmente cuando se considera proceder a inter,enci=n in,asi,a. (GRADE 1C, m$y "e ac$er"o )

7. +t is recommended to perform multidetector (T "ith thin collimation and slice thic-ness (i.e. 8mm or less)$ 100e180 ml of non2ionic intra2,enous contrast material at a rate of 3m?'s$ during the pancreatic and'or portal ,enous phase (i.e. 80e:0 seconds delay). During follo" up only a portal ,enous phase (monophasic) is generally sufficient. <or )*$ the recommendation is to perform a&ial <42T2 and <42T1 scanning before and after intra,enous gadolinium contrast administration. (GRADE 1C, strong agreement) D. <luid therapy ;. *inger!s lactate is recommended for initial fluid resuscitation in acute pancreatitis. (GRADE 1B, strong agreement) 10a. Foal directed intra,enous fluid therapy "ith 8e10 ml'-g'h should be used initially until resuscitation goals (see G10b) are reached .(GRADE 1B, ea! agreement) 10b. The preferred approach to assessing the response to fluid resuscitation should be based on one or more of the follo"ing# 1) non2in,asi,e clinical targets of heart rate H120'min$ mean arterial pressure bet"een 98278 mmIg (7.:e11.3 -/a)$ and urinary output % 0.8e1ml'-g'h$ 2) in,asi,e clinical targets of stro-e ,olume ,ariation$ and intrathoracic blood ,olume determination$ and 3) biochemical targets of hematocrit 38266J. (GRADE 2B, ea! agreement) .. +ntensi,e care management 11. /atients diagnosed "ith acute pancreatitis and one or more of the parameters identified at admission as defined by the guidelines of the 4ociety of (ritical (are )edicine (4(()). <urthermore$ patients "ith se,ere acute pancreatitis as defined by the re,ised Atlanta (lassification (i.e. persistent organ failure) should be treated in an intensi,e care setting. (GRADE 1C, strong agreement) 12. )anagement in$ or referral to$ a specialist center is necessary for patients "ith se,ere acute pancreatitis and for those "ho may need inter,entional radiologic$ endoscopic$ or surgical inter,ention. (GRADE 1C, strong agreement) 13. A specialist center in the management of acute pancreatitis is defined as a high ,olume center "ith up2to2 date intensi,e care facilities including options for organ replacement therapy$ and "ith daily (i.e. : days per "ee-) access to inter,entional radiology$ inter,entional endoscopy "ith .34 and .*(/ assistance as "ell as surgical e&pertise in managing necroti0ing pancreatitis. /atients should be enrolled in prospecti,e audits for 1uality control issues and into clinical trials "hene,er possible. (GRADE 2C, ea! agreement) 16. .arly fluid resuscitation "ithin the first 26 hours of admission for acute pancreatitis is associated "ith decreased rates of persistent 4+*4 and organ failure. (GRADE 1C, strong agreement)

7 . 4e recomienda lle,ar a cabo T( multidetector con colimaci=n fina y cortes finos ( es decir$ 8 mm o menos ) $ 100 2180 ml de material de contraste intra 2 ,enosa no i=nico a un ritmo de 3 ml ' s $ durante la fase pancreBtica y ' o ,enosa portal ( es decir 802:0 segundos de retardo ) . Durante el seguimiento s=lo la fase ,enosa portal ( monofBsica ) es generalmente suficiente . /A*A ?A rm$ la recomendaci=n es reali0ar a&ial <4 y <4 2T2 2T1 scanning antes y despuCs de la administraci=n intra,enosa de contraste de gadolinio (GRADE 1C . #$erte ac$er"o ) &$ 'luidoterapia ; . 4e recomienda ?actato de *inger para la reanimaci=n inicial con l>1uidos de la pancreatitis aguda (GRAD( 1B, #$erte ac$er"o ) . 10a . 4e debe utili0ar inicialmente fluidoterapia intra,enosa con 8210 ml ' -g ' h hasta lograr los obAeti,os de reanimaci=n (,er G10b ) se alcan0an . ( Gra"o 1B , "%&'l ac$er"o) 10b . .l enfo1ue preferido para la e,aluaci=n de la respuesta a la reanimaci=n con l>1uidos debe basarse en uno o mBs de los siguientes # 1 ) obAeti,os cl>nicos no in,asi,os de frecuencia card>aca H 120'min $ presi=n arterial media entre 98278 mmIg $ y diuresis % 0.821ml'-g'h $ 2 )obAeti,os cl>nicos in,asi,os de ,ariaci=n de ,olumen sist=lico y determinaci=n del ,olumen sangu>neo intratorBcico $ y 3 ) obAeti,os bio1u>micos de hematocrito 38266 J. (GRAD( 2B , ac$er"o "%&'l ) ($ )ane*o en cuidados intensivos 11 . ?os pacientes con diagn=stico de pancreatitis aguda y uno o mBs de los parBmetros identificados en admisi=n como se define en las directrices de la 4ociedad de (uidados (r>ticos )edicine ( 4(() ) . /or otra parte $ los pacientes con pancreatitis aguda gra,e segKn la definici=n de la (lasificaci=n de Atlanta re,isada ( es decir fallo orgBnico persistente) deben ser tratados de una unidad de cuidados intensi,os. (GRAD( 1C, m$y "e ac$er"o ) 12 . .l ingreso $ o la remisi=n a un centro especiali0ado es necesario en los pacientes con pancreatitis aguda gra,e y en a1uellos 1ue puedan necesitar procedimiento radiol=gico inter,encionista$ o endosc=pico o 1uirKrgico (GRAD( 1C, ac$er"o #$erte ) . 13 . 3n centro especiali0ado en el tratamiento de la pancreatitis aguda se define como un centro de alto ,olumen con instalaciones de cuidados intensi,os al d>a las$ incluyendo opciones de reempla0amiento orgBnico $ y con acceso diario (es decir$ : d>as a la semana ) a radiolog>a inter,encionista$ endoscopia inter,encionista con .34 y (/*.$ y e&periencia 1uirKrgica en el maneAo de la pancreatitis necroti0ante . ?os pacientes deben inscribirse en auditor>as prospecti,as sobre problemas de control de calidad y en ensayos cl>nicos siempre 1ue sea posible. (GRAD( 2C , "%&'l ac$er"o) 16 . ?a Administraci=n preco0 de l>1uidos en las primeras 26 horas de ingreso de pancreatitis aguda se asocia con disminuci=n de las tasas de 4+*4 persistente y de insuficiencia orgBnica (GRAD( 1C . m$y "e ac$er"o )

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18. Abdominal compartment syndrome (A(4) is defined as a sustained intra2abdominal pressure % 20 mmIg that is associated "ith ne" onset organ failure. (GRADE 2B, strong agreement) 19. )edical treatment of A(4 should target 1) hollo"2,iscera ,olume$ 2) intra'e&tra ,ascular fluid and 3) abdominal "all e&pansion. +n,asi,e treatment should only be used after multidisciplinary discussion in patients "ith a sustained intra2abdominal pressure %28mmIg "ith ne" onset organ failure refractory to medical therapy and nasogastric' rectal decompression. +n,asi,e treatment options include percutaneous catheter drainage of ascites$ midline laparostomy$ bilateral subcostal laparostomy$ or subcutaneous linea alba fasciotomy. +n case of surgical decompression$ the retroperitoneal ca,ity and the omental bursa should be left intact to reduce the ris- of infecting peripancreatic and pancreatic necrosis. (GRADE 2C, strong agreement) 18 . .l 4>ndrome compartimental abdominal ( 4(A ) se define como una presi=n intraabdominal sostenida % 20 mmIg 1ue estB asociada con insuficiencia de =rganos nue,a aparici=n . (GRAD( 2B, #$erte ac$er"o ) 19 . .l tratamiento mCdico del 4(A debe dirigirse a 1 ) reducir el ,olumen de las ,>sceras $ 2 ) reducir el fluido intra ' e&tra ,ascular)$ y 3) la e&pansi=n de la pared abdominal. .l tratamiento in,asi,o s=lo debe utili0arse tras la discusi=n multidisciplinar en pacientes con presi=n intra 2abdominal sostenida % 28 mmIg e inicio de un nue,o fallo orgBnico refractario al tratamiento mCdico y a la descompresi=n nasogBstrica ' rectal . ?as Opciones terapCuticas in,asi,as incluyen drenaAe percutBneo de la ascitis $ laparostom>a de l>nea media $ laparostom>a subcostal bilateral $ o fasciotom>a subcutBnea l>nea alba . .n caso de descompresi=n 1uirKrgica $ la ca,idad retroperitoneal y la bolsa omental deben deAarse intactas para reducir el riesgo de infecci=n peripancreBtica y necrosis pancreBtica . (GRAD( 2C, m$y "e ac$er"o )

'$ Preventing infectious complications 1:. +ntra,enous antibiotic prophyla&is is not recommended for the pre,ention of infectious complications in acute pancreatitis. (GRADE 1B, strong agreement) 17. 4electi,e gut decontamination has sho"n some benefits in pre,enting infectious complications in acute pancreatitis$ but further studies are needed. (GRADE 2B, ea! agreement) 1;. /robiotic prophyla&is is not recommended for the pre,ention of infectious complications in acute pancreatitis. (GRADE 1B, strong agreement)

'$ Prevenci n de complicaciones infecciosas 1: . ,a profila-is con antibi ticos por v.a intravenosa no se recomienda para la prevenci n de las complicaciones infecciosas en la pancreatitis aguda (GRAD(1B, #$erte ac$er"o ) . 17 . ?a Descontaminaci=n digesti,a selecti,a ha demostrado algunos beneficios en la pre,enci=n de las complicaciones infecciosas de la pancreatitis aguda $ pero se necesitan mBs estudios . (GRAD( 2B , "%&'l ac$er"o) 1; . ?a /rofila&is con probi=ticos no se recomienda para la pre,enci=n de las complicaciones infecciosas en la pancreatitis aguda (GRAD( 1B, #$erte ac$er"o ) .

G$ +utritional support 20. Oral feeding in predicted mild pancreatitis can be restarted once abdominal pain is decreasing and inflammatory mar-ers are impro,ing. (GRADE 2B, strong agreement) 21. .nteral tube feeding should be the primary therapy in patients "ith predicted se,ere acute pancreatitis "ho re1uire nutritional support. (GRADE 1B, strong agreement) 22. .ither elemental or polymeric enteral nutrition formulations can be used in acute pancreatitis. (GRADE 2B, strong agreement) 23. .nteral nutrition in acute pancreatitis can be administered ,ia either the nasoAeAunal or nasogastric route. (GRADE 2A, strong agreement) 26. /arenteral nutrition can be administered in acute pancreatitis as second2line therapy if nasoAeAunal tube feeding is not tolerated and nutritional support is re1uired. (GRADE 2C, strong agreement)

G$ apoyo nutricional 20 . ?a alimentaci=n oral en pancreatitis presumiblemente le,e se puede reiniciar una ,e0 1ue el dolor abdominal es decreciente y los marcadores inflamatorios estCn meAorando (GRAD( 2B, m$y "e ac$er"o ) . 21 . ?a Alimentaci=n por sonda enteral debe ser el tratamiento primario en pacientes con pancreatitis aguda presumiblemente gra,e 1ue re1uieren apoyo nutricional (GRAD( 1B, m$y "e ac$er"o ) . 22 . (ual1uiera de las formulaciones de Eenteral elementales o polimCricas se pueden usar en la pancreatitis aguda (Gra"o 2B , #$erte ac$er"o ) . 23 . ?a E enteral en la pancreatitis aguda se puede administrar ya sea a tra,Cs de la ruta nasoAeAunal o nasogBstrica (GRAD( 2A, #$erte ac$er"o ) . 26 . ?a nutrici=n parenteral se puede administrar en la pancreatitis aguda como terapia de segunda l>nea si la alimentaci=n por sonda naso2yeyunal no se tolera y el apoyo nutricional es necesario. (GRAD( 2C, m$y "e ac$er"o )

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/$ 0iliary tract management 28. .*(/ is not indicated in predicted mild biliary pancreatitis "ithout cholangitis.(GRADE 1A, strong agreement). .*(/ is probably not indicated in predicted se,ere biliary pancreatitis "ithout cholangitis (GRADE 1B, strong agreement). .*(/ is probably indicated in biliary pancreatitis "ith common bile duct obstruction (GRADE 1C, strong agreement). .*(/ is indicated in patients "ith biliary pancreatitis and c)olang't's (GRADE 1B, strong agreement) 29. 3rgent .*(/ (H26 hrs) is re1uired in patients "ith acute cholangitis. (urrently$ there is no e,idence regarding the optimal timing of .*(/ in patients "ith biliary pancreatitis "ithout cholangitis. (GRADE 2C, strong agreement) 2:. )*(/ and .34 may pre,ent a proportion of .*(/s that "ould other"ise be performed for suspected common bile duct stones in patients "ith biliary pancreatitis "ho do not ha,e cholangitis$ "ithout influencing the clinical course. .34 is superior to )*(/ in e&cluding the presence of small (H8mm) gallstones. )*(/ is less in,asi,e$ less operator2dependent and probably more "idely a,ailable than .34. Therefore$ in clinical practice there is no clear superiority for either )*(/ or .34. (GRADE 2C, strong agreement) +. +ndications for inter,ention in necroti0ing pancreatitis 27. (ommon indications for inter,ention (either radiological$ endoscopical or surgical) in necroti0ing pancreatitis are# 1) (linical suspicion of$ or documented infected necroti0ing pancreatitis "ith clinical deterioration$ preferably "hen the necrosis has become "alled2off$ 2) +n the absence of documented infected necroti0ing pancreatitis$ ongoing organ failure for se,eral "ee-s after the onset of acute pancreatitis$ preferably "hen the necrosis has become "alled2off. (GRADE 1C, strong agreement) 2;. *outine percutaneous fine needle aspiration of peripancreatic collections to detect bacteria is not indicated$ because clinical signs (i.e. persistent fe,er$ increasing inflammatory mar-ers) and imaging signs (i.e. gas in peripancreatic collections) are accurate predictors of infected necrosis in the maAority of patients. Although the diagnosis of infection can be confirmed by fine needle aspiration (<EA)$ there is a ris- of false2negati,e results. (GRADE 1C, strong agreement) 30. +ndications for inter,ention (either radiological$ endoscopical or surgical) in sterile necroti0ing pancreatitis are# 1) Ongoing gastric outlet$ intestinal$ or biliary obstruction due to mass effect of "alled2off necrosis (i.e. arbitrarily %627 "ee-s after onset of acute pancreatitis)$ 2) /ersistent symptoms (e.g. pain$ persistent un"ellness!) in patients "ith "alled2off necrosis "ithout signs of infection (i.e. arbitrarily %7 "ee-s after onset of acute pancreatitis)$ 3) Disconnected duct syndrome (i.e. full transection of the pancreatic duct in the presence of pancreatic necrosis) "ith persisting symptomatic (e.g. pain$ obstruction) collection(s) "ith necrosis "ithout signs of infections (i.e. arbitrarily %7 "ee-s after onset of acute pancreatitis). (GRADE 2C, strong agreement) /$ )ane*o del tracto biliar 28 . ?a (/*. no se indica en pancreatitis biliar le,e sin colangitis . ( Gra"o 1A , m$y "e ac$er"o ) . ?a (/*. es probable 1ue no estC indicada en pancreatitis biliar se,era sin colangitis ( GRAD( 1B, m$y "e ac$er"o ) . ?a (/*. estB probablemente indicada en la pancreatitis biliar con obstrucci=n del conducto biliar comKn (GRAD( 1C, m$y "e ac$er"o ). ?a (/*. estB indicada en pacientes con pancreatitis biliar y colangitis (GRAD( 1B, m$y "e ac$er"o ) 29 .s necesaria (/*. urgente ( H26 horas ) en pacientes con colangitis aguda. Actualmente $ no hay e,idencia en relaci=n con el momento =ptimo de la (/*. en pacientes con pancreatitis biliar sin colangitis (GRAD( 2C, m$y "e ac$er"o ) . 2: . ?a (/*) y .34 pueden desaconseAar un porcentaAe de (/*. 1ue de otra manera se reali0ar>a por sospecha de coledocolitiasis en pacientes con pancreatitis biliar 1ue no tienen colangitis $ sin influir en el curso cl>nico . .34 es superior a la (/*) en la e&clusi=n de la presencia de cBlculos biliares pe1ueLos ( H 8 mm ) . ?a (/*) es menos in,asi,a $ menos dependiente del operador y$ probablemente$ mBs accesible 1ue la 34. . /or lo tanto $ en la prBctica cl>nica no e&iste una clara superioridad de (/*) o .34 (GRADE 2C . m$y "e ac$er"o ) +. +ndicaciones para inter,enci=n en pancreatitis necroti0ante 27 . ?as indicaciones para inter,enci=n (sea radiol=gica $ endosc=pica o 1uirKrgica ) en pancreatitis necroti0ante son# 1 ) .n la sospecha cl>nica $ o infecci=n documentada de pancreatitis necroti0ante con deterioro cl>nico $ preferiblemente cuando la necrosis se ha en1uistado $ 2 ) .n ausencia de infecci=n documentada en pancreatitis necroti0ante $ insuficiencia de =rganos ,arias semanas despuCs de la aparici=n de la pancreatitis aguda $ la inter,enci=n se indica preferiblemente cuando la necrosis se ha en1uistado . ( GRAD( 1C , #$erte ac$er"o) 2; . Eo estB indicada de rutina la aspiraci=n percutBnea con aguAa fina de las colecciones peripancreBticas para detectar bacterias$ por1ue hay signos cl>nicos (p. eA.$ fiebre persistente $ aumento de marcadores inflamatorios ) y signos de imBgen ( p.eA$ gas en colecciones peripancreBticos ) 1ue son predictores precisos de necrosis infectada en la mayor>a de los pacientes . Aun1ue el diagn=stico de la infecci=n puede ser confirmado por aspiraci=n con aguAa fina ( <EA)$ hay riesgo de falsos negati,os ( GRAD( 1C , #$erte ac$er"o ) . 30 . ?as indicaciones de inter,enci=n (radiol=gica $ endosc=pica o 1uirKrgica ) en pancreatitis necroti0ante estCril son# 1 ) 4alida de contenido gBstrico$ intestinal o biliar por obstrucci=n debido al efecto de la masa de la necrosis en1uistada ( es decir$ arbitrariamente$ % 627 semanas despuCs de la aparici=n de pancreatitis aguda ) $ 2 ) s>ntomas persistentes ( por eAemplo$ dolor $ @ persistente malestar @ ) en pacientes con necrosis en1uistada y sin signos de infecci=n ( es decir$ arbitrariament$e % 7 semanas despuCs del inicio de la pancreatitis aguda) $ 3 ) 4>ndrome de ductus desconectado ( es decir$ transecci=n completa del conducto pancreBtico en presencia de necrosis pancreBtica ) con persistencia de s>ntomas ( p eA.$ dolor $ obstrucci=n ) colecci=n ( s ) con necrosis sin signos de infecci=n ( i.e. arbitrariamente % 7 semanas trasel inicio de la pancreatitis aguda) .

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(Gra"o 2C, m$y "e ac$er"o ) "$ Timing of intervention in necroti1ing pancreatitis "$ )omento de la intervenci n en pancreatitis necroti1ante 31. <or patients "ith pro,en or suspected infected necroti0ing pancreatitis$ in,asi,e inter,ention (i.e. percutaneous catheter drainage$ endoscopic transluminal drainage' necrosectomy$ minimally in,asi,e or open necrosectomy) should be delayed "here possible until at least 6 "ee-s after initial presentation to allo" the collection to become "alled2off!. (GRADE 1C, strong agreement) 32. The best a,ailable e,idence suggests that surgical necrosectomy should ideally be delayed until collections ha,e become "alled2off$ typically 6 "ee-s after the onset of pancreatitis$ in all patients "ith complications of necrosis. Eo subgroups ha,e been identified that might benefit from earlier or delayed inter,ention. (GRADE 1C, strong agreement) 31 . .n pacientes con pancreatitis necroti0ante comprobada o sospechosa de infecci=n $ la inter,enci=n in,asi,a ( es decir$ drenaAe percutBneo $ drenaAe endosc=pico transluminal ' necrosectom>a $ necrosectom>a m>nimamente in,asi,a o abierta ) se debe retrasar hasta donde sea posible $ al menos$ 6 semanas despuCs de la presentaci=n inicial 1ue permita a la recolecci=n con,ertirse en M amurallada M . (GRAD( 1C, m$y "e ac$er"o ) 32 . ?a meAor e,idencia a,alabe sugiere 1ue la necrosectom>a 1uirKrgica idealmente debe retrasarse hasta 1ue las colecciones se hayan amurallado $ normalmente 6 semanas tras la aparici=n de pancreatitis$ en pacientes con necrosis complicada. Eo se han identificado subgrupos 1ue puedan beneficiarse de una inter,enci=n mBs temprana o tard>a (GRADE 1C , #$erte . ac$er"o)

2$ Intervention strategies in necroti1ing pancreatitis 2$ (strategias de intervenci n en pancreatitis necroti1ante 33. The optimal inter,entional strategy for patients "ith suspected or confirmed infected necroti0ing pancreatitis is initial image2guided percutaneous (retroperitoneal) catheter drainage or endoscopic transluminal drainage$ follo"ed$ if necessary$ by endoscopic or surgical necrosectomy.(GRADE 1A, strong agreement) 36. /ercutaneous catheter or endoscopic transmural drainage should be the first step in the treatment of patients "ith suspected or confirmed ("alled2off) infected necroti0ing pancreatitis. (GRADE 1A, strong agreement) 38. There are insufficient data to define subgroups of patients "ith suspected or confirmed infected necroti0ing pancreatitis "ho "ould benefit from a different treatment strategy. (GRADE 2C, strong agreement) ,$ Timing of cholecystectomy 3or endoscopic sphincterotomy4 39. (holecystectomy during inde& admission for mild biliary pancreatitis appears safe and is recommended. +nter,al cholecystectomy after mild biliary pancreatitis is associated "ith a substantial ris- of readmission for recurrent biliary e,ents$ especially recurrent biliary pancreatitis.(GRADE 1C, strong agreement) 3:. (holecystectomy should be delayed in patients "ith peripancreatic collections until the collections either resol,e or if they persist beyond 9 "ee-s$ at "hich time cholecystectomy can be performed safely.(F*AD. 2($ strong agreement) 37. +n patients "ith biliary pancreatitis "ho ha,e undergone sphincterotomy and are fit for surgery$ cholecystectomy is ad,ised$ because .*(/ and sphincterotomy pre,ent recurrence of biliary pancreatitis but not gallstone related gallbladder disease$ i.e. biliary colic and cholecystitis. (GRADE 2B, strong agreement) 33 . ?a estrategia de inter,enci=n =ptima en pacientes con sospecha o confirmaci=n de infecci=n de pancreatitis necroti0ante es el drenaAel percutBneo con cateter guiado por imBgen o drenaAe endosc=pico transluminal $ seguido $ si es necesario $ por necrosectom>a endosc=pica o 1uirKrgica. ( Gra"o 1A , m$y "e ac$er"o ) 36 . .l drenaAe con catCter percutBneo o drenaAe transmural endosc=pico debe ser el primer paso en el tratamiento de pacientes con sospecha o confirmaci=n de pancreatitis necroti0ante infectado ( amurallada ). ( Gra"o 1A , m$y "e ac$er"o ) 38 . Eo hay datos suficientes para definir subgrupos de pacientes con sospecha o confirmaci=n de pancreatitis necroti0ante infectada 1ue se beneficiar>an de una estrategia de tratamiento diferente. (GRAD( 2C, m$y "e ac$er"o ) ,$ )omento de la colecistectom.a 3o esfinterotom.a endosc pica 4 39 . ?a colecistectom>a durante el ingreso en pancreatitis biliar le,e parece ser segura y se recomienda . ?a (olecistectom>a diferida despuCs de una pancreatitis biliar le,e se asocia con un riesgo importante de reingreso por e,entos biliares recurrentes $ especialmente pancreatitis biliar recurrente. (GRAD( 1C, m$y "e ac$er"o ) 3: . ?a colecistectom>a se debe retrasar en pacientes con colecciones peripancreBticos hasta 1ue las colecciones se resuel,an o si persisten mBs allB de 9 semanas$ momento en el 1ue la colecistectom>a puede reali0arse con seguridad . (F*ADO 2($ muy de acuerdo ) 37 . .n pacientes con pancreatitis biliar 1ue han sido obAeto de esfinterotom>a y son aptos para cirug>a$ se aconseAa colecistectom>a $ por1ue la (/*. y la esfinterotom>a pre,ienen la recurrencia de la pancreatitis biliar $ pero no la enfermedad biliar litiBsica$ es decir$ c=lico biliar y colecistitis. ( Gra"o 2B, m$y "e ac$er"o )