Comments on the article about the treatment of infected pancreatic necrosis

Abstract

To the Editor, We read with interest the article by Wronski et al. [1] about evaluation of the safety and efficacy of sonographically guided percutaneous catheter drainage (PCD) for infected pancreatic necrosis (IPN). In their retrospective study, they analyzed the patient group of 16 men and 2 women, concluding that ultrasound-guided PCD used in IPN was a technique with acceptably low morbidity and mortality that could be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of PCD. Although the outcome of this series shows less success rate as definitive treatment for IPN (33 %) compared to the outcomes (84 %) of ours [2] and most of the previously reported similar studies [3, 4], there are certain limitations to this conclusion as a result of the clinical characteristics and the severity of the state of enrolled patients being different—and to a certain extent incomparable—among the studies. However, despite our long experience (over 20 years) in performing ultrasound-guided PCD in the treatment of necrotizing pancreatitis [5–9], we would like to comment on the possible reasons of the poor outcome of treatment in this study. Wronski et al. performed PCD via the preferably retroperitoneal approach through the left lumbar access (in 13 of 18 patients), placing catheters in tail areas of the pancreas, where collections would usually be located at the onset of the necrotizing pancreatitis. However, acute pancreatitis is a complex disease where, after the evacuation of collections from the tail of the pancreas, liquefaction of necroses continues and fluid collections can still be developed into other pancreatic and peripancreatic regions that are unavailable for the catheters placed in this manner. This causes the reemergence or continuation of sepsis and therefore may be the most common reason for crossover to surgical intervention rather than introduction of additional catheters into the new collections. But we consider that necrosectomy may represent overtreatment in these patients with a usually poor general condition, with the main difficulties being the discrimination between necrotic tissue and normal tissue during the procedure and a very high risk of bleeding from necrotized tissue vessels during or immediately after the intervention. Therefore, in such clinical settings, we would rather introduce additional catheters into new collections and perform percutaneous drainage with vigorous irrigation (up to 6 times in our series) [2]. Wronski et al. noted that ‘‘the indication for crossover to surgical debridement was lack of improvement despite percutaneous drainage with large-bore catheters or complications requiring surgery.’’ However, on the basis of our long-term experience, we believe that the removal of the infected necrotic tissue at the onset of the disease is difficult regardless of the size of the catheters used. However, during the course of the disease, the transition from solid necrotic tissue to more liquid content leads to higher success rate in evacuation of necrotic tissue from the cavities, regardless of the catheter size. We believe that the use of large-bore catheters cannot improve the success rate of the evacuation of the necrotic tissue, and it carries an increased risk of complications. Even though we used smaller catheters E. Zerem (&) Department of Gastroenterology, University Clinical Center Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina e-mail: zerem@live.com