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

Abstract

their poor general condition and because it would be difficult to discriminate between necrotic and normal tissue during the sur-gery. Besides, the risk of uncontrolled hem-orrhage during or immediately after the surgery would be very high. Open necrosectomy results in signifi-cant deterioration of organ dysfunction scores after the procedure [2]. M IPN is less aggressive compared to open surgery but it is a much more aggressive method com-pared to percutaneous catheter drainage (PCD) using 8- or 10-Fr catheters under ultrasound or CT control (general anes-thesia, progressive dilatation of the drain tract to 30 Fr allowing insertion of a trocar, using grasping forceps for removal of ne-crotic tissue) [1, 3]. P CD seems technically feasible in the vast majority of patients with necrotizing pancreatitis [4, 5] . B-esides, with this method a few catheters can be simultaneously introduced into liquid areas of necroses (into different pancreatic and peripancreatic regions) without gen-eral anesthesia and with fewer traumas, performing vigorous irrigation with simi-lar or better effects than by MIPN. On the basis of our long-term experi-ence [4, 6] , we believe that necrosecto-my (including MIPN) as a primary treat-ment may represent overtreatment of IPN. Therefore, we consider that sole conserva-tive treatment with proper intravenous hy-dration and administration of proper an-tibiotics should be performed at the begin-ning of the disease. PCD with vigorous D e a rE d itor, We read with great interest the article by Ahmad et al. [1] published in issue 1 of Pancreatology 2 011, volume 11. The article describes a case series outlining the expe-rience and results of retroperitoneal mini-mally invasive pancreatic necrosectomy (MIPN) and demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The authors note that multiple MIPNs may be needed to eradicate the necrosis satisfactorily [1] . However, we wish to highlight certain issues regarding the statement that multiple MIPNs represent the optimal treatment for infected pancre-atic necroses (IPN). In the beginning of acute necrotizing pancreatitis, pancreatic and peripancreatic necroses are solid and the discrimination between necrotic tissue and normal tissue is very difficult. However, during the course of IPN, after the transition from solid ne-crotic tissue to more liquid contents takes place, there is a chance of a higher success rate in evacuating the necrotic tissue from the cavities, regardless of the method that is used. The presence of infection and vigor-ous irrigation can accelerate the process of transition from solid necrotic tissue to more liquid content. In those conditions, patients with necrotizing pancreatitis are not good candidates for surgery because of