De Waele, Jan

Ghent University Academic Bibliography

Th e  n e w  e ngl a nd  j o u r na l  o f  m e dic i n en engl j med 363;13 nejm.org september 23, 20101286in-hospital mortality; careful selection of oxy-gen saturation targets in clinical practice is also warranted.Waldemar A. Carlo, M.D.University of Alabama at Birmingham  Birmingham, AL  wcarlo@peds.uab.eduNeil N. Finer, M.D.University of California at San Diego  San Diego, CAMarie G. Gantz, Ph.D.RTI International  Research Triangle Park, NCSince publication of their article, the authors report no fur-ther potential conflict of interest.1. Duc G, Sinclair JC. Oxygen administration. In: Sinclair JC, Bracken MB, eds. Effective care of the newborn infant. New York: Oxford University Press, 1992:178-94.2. Askie LM, Henderson-Smart DJ, Ko H. Restricted versus lib-eral oxygen exposure for preventing morbidity and mortality in preterm or low birth weight infants. Cochrane Database Syst Rev 2009;1:CD001077.3. Tin W, Gupta S. Optimum oxygen therapy in preterm babies. Arch Dis Child Fetal Neonatal Ed 2007;92:F143-F147.4. Laptook AR, Shalhab W, Allen J, Saha S, Walsh M. Pulse oximetry in very low birth weight infants: can oxygen saturation be maintained in the desired range? J Perinatol 2006;26:337-41.A Step-up Approach, or Open Necrosectomy for Necrotizing PancreatitisTo the Editor: The results from the study by van Santvoort et al. (Minimally Invasive Step-up Ap-proach versus Maximal Necrosectomy in Patients with Acute Necrotizing Pancreatitis [PANTER]) (April 22 issue)1 show that percutaneous drain-age (PCD) alone is a valuable strategy in selected patients, helping to avoid the need for surgery in 40% of step-up patients.The reduced morbidity associated with the procedure may largely be due to the avoidance of harm from surgery: when PCD-only patients are not considered, the complication rate appears to be similar in the two study groups. Moreover, PCD was often inadequate, leading to a delay in source control. Since PCD appears to be less suc-cessful in patients with multiple organ failure,2 and since mortality dramatically increased when it was used as a sole strategy for these patients,3 an important element of the treatment is poten-tially delayed. Early identification of patients who will not be helped by PCD is desirable.Rather than using a step-up approach for all patients, a strategy tailored to the patient’s spe-cific needs, based on the results of computed tomography and on clinical condition, using the source-control strategy most likely to adequately drain collected fluid and débride infected ne-crotic tissue may be the best approach after all. PCD, video-assisted retroperitoneal débridement, and open necrosectomy may all be effective tools to use in reaching this goal.Jan J. De Waele, M.D., Ph.D.Ghent University Hospital  Ghent, Belgium  jan.dewaele@ugent.beNo potential conflict of interest relevant to this letter was re-ported.1. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-502.2. Mortelé KJ, Girshman J, Szejnfeld D, et al. CT-guided percu-taneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol 2009;192:110-6.3. Rocha FG, Benoit E, Zinner MJ, et al. Impact of radiologic intervention on mortality in necrotizing pancreatitis: the role of organ failure. Arch Surg 2009;144:261-5.To the Editor: The PANTER study group teaches us that “minimally” invasive surgery is associat-ed with a lower morbidity than open necrosec-tomy in patients who have necrotizing pancreati-tis with infected necrotic tissue. Although this article is a milestone in the surgical literature, its results are disappointing. There was no signifi-cant difference in the mortality of the two study groups (16% vs. 19%) despite the fact that inter-vention was withheld for at least 4 weeks. The complications in the group receiving “minimal-ly” invasive treatment included enterocutaneous fistulas (in 22% of patients), intra-abdominal bleeding (16%), pancreatic fistulas (28%), and in-cisional hernias (7%).1 The surgery these patients received was clearly not “minimally” invasive.But is there another approach? Does infected necrotic tissue need drainage at all? Several case reports and series have recorded reasonable sur-vival rates among patients treated with antibiot-ics alone.1-4 Now that withholding intervention for at least 4 weeks seems to be ensconced in good surgical practice, perhaps a longer wait, coupled with the judicious use of antibiotics, can The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITEIT GENT on February 7, 2011. For personal use only. No other uses without permission.  Copyright © 2010 Massachusetts Medical Society. All rights reserved. correspondencen engl j med 363;13 nejm.org september 23, 2010 1287further reduce mortality and the need for any invasive intervention.William M. Steinberg, M.D.Rockville Internal Medicine Group  Rockville, MDNo potential conflict of interest relevant to this letter was re-ported.1. Baril NB, Ralls PW, Wren SM, et al. Does an infected peri-pancreatic fluid collection or abscess mandate operation? Ann Surg 2000;231:361-7.2. Dubner H, Steinberg W, Hill M, et al. Infected pancreatic necrosis and peripancreatic fluid collections: serendipitous re-sponse to antibiotics and medical therapy in three patients. Pan-creas 1996;12:298-302.3. Adler DG, Chari ST, Dahl TJ, Farnell MB, Pearson RK. Con-servative management of infected necrosis complicating severe acute pancreatitis. Am J Gastroenterol 2003;98:98-103.4. Runzi M, Niebel W, Goebell H, Gerken G, Layer P. Severe acute pancreatitis: nonsurgical treatment of infected necroses. Pancreas 2005;30:195-9.The Authors Reply: We first want to clarify sev-eral issues discussed by Dr. Andrew Warshaw in the editorial he wrote about our article.1 War-shaw stated that the step-up approach has nar-row applicability. This is not correct. The feasi-bility of the step-up approach was 98%, with just one patient excluded because a drain could not be placed. Warshaw also stated that the feasibil-ity of using a retroperitoneal access route was a criterion for inclusion in the trial. This was not the case: percutaneous or endoscopic catheter drainage of fluid could proceed through any route (retroperitoneal, transabdominal, or endo-scopic transgastric). Nevertheless, a retroperito-neal access route for drainage, and if needed, video-assisted retroperitoneal débridement, was possible in 80 of the 88 patients (91%) who un-derwent randomization. It was also noted that the rate of death in our study (17%) compares unfavorably to rates in recent North American studies.2,3 This difference can probably be attri-buted to differences in case mix, since these studies showed lower percentages of infected ne-crotic tissue (72 to 74% vs. 92%) and lower pre-operative scores on the Acute Physiology and Chronic Health Evaluation (APACHE) II (9.0 to 9.5 vs. 15). Notably, in the Boston study refer-enced by Warshaw, the rate of death among pa-tients with infected necrotic tissue (i.e., the sub-group similar to that in our study) was 15%.3In his letter, De Waele suggests that PCD was often inadequate, leading to a delay in source control. However, we do not consider PCD to have failed when surgery is still needed. PCD is appreciated as a means of stabilizing sepsis and thereby improving the patient’s condition for sub-sequent surgery. Basing his remarks on retro-spective studies, De Waele also suggests that PCD is less successful in patients with multiple-organ failure. In our study, PCD was successful in 35% of patients, irrespective of single or multi-ple organ failure. It is also suggested that mor-tality increases dramatically when PCD is used as a sole strategy. This was not the case in our study: the rate of death among patients undergo-ing PCD only was 12% (2 patients of 17) as com-pared with 23% (6 of 26) among those undergo-ing PCD and surgery. We therefore conclude that PCD should be the first treatment whenever pos-sible.Steinberg suggests that the mortality rate in our study is disappointing. However, recent series from expert centers in Boston and Liverpool show similar mortality rates.3,4 We agree that a very small subgroup of patients with infected necrotic tissue might be treated with antibiotics alone, but this approach has been discussed only in case reports and very small series, and multi-ple-organ failure still develops in these patients.5 In our study, a nationwide multidisciplinary ex-pert panel agreed on the indication for interven-tion in each patient.Hjalmar C. van Santvoort, M.D. Marc G. Besselink, M.D., Ph.D.University Medical Center, Utrecht  Utrecht, the NetherlandsHein G. Gooszen, M.D., Ph.D.Radboud University Nijmegen Medical Center  Nijmegen, the Netherlands  h.gooszen@ok.umcn.nlSince publication of their article, the authors report no fur-ther potential conflict of interest.1. Warshaw AL. Improving the treatment of necrotizing pan-creatitis — a step up. N Engl J Med 2010;362:1535-7.2. Howard TJ, Patel JB, Zyromski N, et al. Declining morbidity and mortality rates in the surgical management of pancreatic necrosis. J Gastrointest Surg 2007;11:43-9.3. Rodriguez JR, Razo AO, Targarona J, et al. Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 2008;247:294-9.4. Raraty MG, Halloran CM, Dodd S, et al. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbid-ity and mortality with a less invasive approach. Ann Surg 2010; 251:787-93.5. Runzi M, Niebel W, Goebell H, Gerken G, Layer P. Severe acute pancreatitis: nonsurgical treatment of infected necroses. Pancreas 2005;30:195-9.The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITEIT GENT on February 7, 2011. For personal use only. No other uses without permission.  Copyright © 2010 Massachusetts Medical Society. All rights reserved. 

A step-up approach, or open necrosectomy for necrotizing pancreatitis

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A step-up approach, or open necrosectomy for necrotizing pancreatitis

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