Letter to the Editor Pancreatology 2011;11:610–611 611

Reply

Hairul Ahmad

School of Surgery, The University of Western Australia, Perth, W.A. , Australia

Dear Editor, I read with interest the comments made

by E. Zerem, N. Pavlović-Čalić and M. Bevanda: ‘Is minimally invasive retroperi-toneal pancreatic necrosectomy too aggres-sive in treating infected pancreatic necro-sis?’ . The authors raised a few interesting points. I would like to address some of these.

Firstly, the authors stated that our study made the claim that minimally inva-sive retroperitoneal pancreatic necrosec-tomy (MIRPN) represents the optimal treatment for infected pancreatic necrosis. No such statement was made in our study. In fact it was pointed out that MIRPN suf-fered from some shortcomings. These in-cluded the multiple procedures needed to completely deal with the infected pancre-atic necrosum and the inability to deal with all cases of infected pancreatic ne-crosis.

There is no doubt at all that the treat-ment of the early stages of severe acute pancreatitis consists principally of organ support. In contrast, the later stages of this pathology are dominated by the various complications of the disease process. These include infection of the pancreatic necrosum. Various approaches have been developed and described to deal with this entity. These included open necrosectomy, percutaneous drainage with necrosectomy

and endoscopic necrosectomy. Each of these methods has its own strengths and weaknesses.

One of the main findings of the study was that the timing of the MIRPN was crit-ical. There is increasing evidence support-ing a delayed intervention protocol [2–4] . In our study, all patients were operated on in or after the third week of diagnosis, with the most procedures done in week 5 [1] . This rationale allowed for increasing ‘liq-uefaction’ of the pancreatic necrosum and also discrimination of devitalized from normal tissue.

The acceptance criteria for patients to be included in this study [1] were: (i) a di-agnosis of infected pancreatic necrosis, (ii) ongoing sepsis, and (iii) the possibility of a retroperitoneal access route to the affected pancreatic area.

The initial step for MIRPN was the in-troduction of a drainage catheter (care was taken to ensure that this was through the retroperitoneal route) into the affected pancreatic area. There was an interval be-tween the catheter insertion and MIRPN dates. MIRPN was therefore ‘reserved’ for patients who had failed less aggressive treatment modalities.

MIRPN was able to combine features of different approaches to manage the pa-thology. It was able to deal with the pan-

creatic necrosum under direct vision. The use of a closed irrigation system in the postoperative stage enables ongoing dy-namic separation of non-viable compo-nents from viable tissue.

We would like to highlight the fact that MIRPN is a viable approach in dealing with infected pancreatic necrosis that has failed a less invasive approach. As stated, it carries certain advantages but also con-curs certain disadvantages. Its role in indi-vidual patients must be carefully consid-ered prior to use.

References

1 Ahmad HA, Samarasam I, Hamdorf JM: Minimally invasive retroperitoneal pancre-atic necrosectomy. Pancreatology 2011; 11: 52–56.

2 Mier J, Luque-de-Leon E, Castillo A, et al: Early vs. late necrosectomy in severe necro-tizing pancreatitis. Am J Surg 1997; 173: 71–75.

3 Hartwig W, Maksan SM, Foitzik T, et al: Re-duction in mortality with delayed surgical therapy of severe pancreatitis. J Gastrointest Surg 2002; 6: 481–487.

4 Flint R, Windsor J, Bonham M: Trends in the management of severe acute pancreatitis: in-terventions and outcome. ANZ J Surg 2004; 74: 335–342.