Comments on the article about the treatment of peripancreatic infection

Abstract

We read with great interest the article by Tang et al published in issue 4 of World Journal of Gastroenterology 2010. The results of their study indicate that percutaneous catheter drainage in combination with choledochoscope-guided debridement is a simple, safe and reliable treatment procedure for peripancreatic infections secondary to severe acute pancreatitis. However, there are some points that need to be addressed, including data about the patients in the study and their clinical characteristics, data about infection and superinfection during the treatment and type of treatment of patients with acute necrotizing pancreatitis.

Minimally Invasive Management of Acute Necrotizing Pancreatitis

“…Although no universally accepted treatment algorithm exists, the step-up approach may be considered as the reference standard intervention for this disorder. Recent studies support [14][15][16][17][18][19]24] the current body of evidence on the merits of the step-up approach to infected necrotizing pancreatitis. The probable greater safety of the "step-up" approach to severe necrotizing acute pancreatitis lies in synthesis and integration of evolving techniques [47].…”

“…Generally, at the begining of disease catheter drainage of infected necrotic tissue is poor and several authors consider that surgical resection of necrotic tissue is mandatory [3,4,[7][8][9][25][26][27]. But, some authors deem [12][13][14][15][16][17][18][19] that solid tissue and necrotic debris could be removed with draining fluid and that the use of vigorous irrigation through large-bore catheters could effectively remove the tissue. The rationale for this strategy is that large bore catheters may be more effective for mobilizing solid tissue and evacuating the necrotic tissue from the cavities.…”

“…Surgical intervention is postponed for as long as possible so that the infected collection may become encapsulated [18,19] and is performed when the patient's condition does not improve or if it deteriorates. Several recently published studies [14][15][16][17][18][19]24] compared outcome of the step-up approach with primary open necrosectomy and showed that the step-up approach was clearly superior as it reduced morbidity, mortality and costs per patient.…”

“…It has been suggested that the invasiveness of open surgery in an already critically ill patient may be the cause of high morbidity rates. Therefore, several groups worldwide have developed new minimal invasive approaches using conservative treatment, endoscopic necrosectomy or drainage therapy in the management of infected necrotizing pancreatitis [14][15][16][17][18][19].…”

Is Minimally Invasive Retroperitoneal Pancreatic Necrosectomy Too Aggressive in Treating Infected Pancreatic Necrosis?

“…On the basis of our long-term experience [4,6] , we believe that necrosectomy (including MIPN) as a primary treatment may represent overtreatment of IPN. Therefore, we consider that sole conservative treatment with proper intravenous hydration and administration of proper antibiotics should be performed at the beginning of the disease.…”