Reply to: doi:10.1007/s00464-012-2257-9: Endoscopic ultrasound-guided endoscopic necrosectomy of the pancreas: is irrigation necessary?

Abstract

With interest we read the letter by Zerem and Mavija [1] regarding our article on endoscopic management of necrotizing pancreatitis [2]. The authors described their experience with percutaneous drainage as a management modality for necrotizing pancreatitis [3]. We agree that percutaneous drainage has a role as first-line treatment in patients with symptomatic pancreatic necrosis who are not candidates for initial endoscopic or surgical therapy. We also agree that mobilization of pancreatic necrosis by vigorous irrigation and large-diameter catheters could be feasible. However, a solely percutaneous treatment is associated with some drawbacks. Percutaneous drainage is associated with a substantial rate of pancreatocutaneous fistula formation [4], leading other groups to combine this treatment with internal drainage [5]. Additionally, treatment is often lengthy, with a reported median drainage lasting 80 days [5]. Finally, reduction of the diameter of the pancreatic necrosis by successful percutaneous drainage results in technical difficulties if a secondary endoscopic transmural approach is needed. In our report, we were able to demonstrate that neither endoscopic nor external irrigation is needed to achieve good shortand long-term results in symptomatic necrotizing pancreatitis treated by endoscopic necrosectomy. However, rigorous randomized trials will be necessary to compare the outcomes of different treatment approaches to pancreatic necrosis. Such trials are complicated by the heterogeneous presentation of this disorder and the different levels of expertise of surgeons at individual centers. Thus, the treatment of necrotizing pancreatitis is likely to remain a challenge necessitating the cooperation of subspecialists and a broad spectrum of methods.