Designing an Optimal Study for the Management of Infected Pancreatic Necrosis

Abstract

One of the greatest challenges facing those treating pancreatic disease is the optimum treatment of infected pancreatic necrosis (IPN). IPN may consist of either infected necrotic pancreatic tissue and/or infected peripancreatic fat necrosis. Despite many improvements in management, the treatment algorithm for IPN remains for the most part defined by “expert opinion” rather than based on data from randomized controlled trials (Nieuwenhuijs et al. 2003; Werner et al. 2005). In the past decade, the most important developments in the management of IPN have arguably been minimally invasive (peri-) pancreatic necrosectomy (MIPN) and the trend toward delayed intervention. The drive toward the use of less invasive techniques has been fueled by the high morbidity and mortality rates (up to 25%) (Besselink et al. 2006a) associated with necrosectomy by laparotomy (Windsor 2007). The timing of surgical intervention has been addressed frequently in recent years. Early proponents of delayed intervention reasoned that operative intervention should be avoided during the initial 1-2 weeks, the “systemic inflammatory response syndrome (SIRS)-phase,” but recently, it has been suggested that intervention in IPN should be delayed even further to allow for encapsulation of the infected necrosis. This latter approach greatly facilitates the use of minimally invasive techniques (Forsmark and Baillie 2007). In order to design adequate future prospective studies we performed a systematic literature review and critical appraisal of the available evidence on the use of MIPN and delayed intervention in IPN.