Reply to Organ Failure and Infection in Necrotizing Pancreatitis: What Are the Predictors of Mortality?

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Reply:
We thank the authors for their interest in our article and welcome further discussions on this issue.1 The role of infection and organ failure in acute pancreatitis has been widely discussed over the past 2 decades because they are 2 important factors affecting the clinical course of acute pancreatitis.
The authors suggest that patients who were admitted to the hospital directly should be evaluated separately for prognostic scoring. Many clinical scoring systems have been developed, and the existing scoring systems seem to have reached their maximal efficacy in predicting persistent organ failure in acute pancreatitis.2 We believe that a better scoring system must have the following characteristics: (a) the ability to predict the severity of acute pancreatitis accurately and (b) easy applicability. We agree that further research on this area is highly necessary.
In our study, routine fine-needle aspiration was not performed. Thus, diagnosis of infected necrosis relied on positive cultures of pancreatic or peripancreatic necrosis from the first operation or the presence of gas in the peripancreatic collection during contrast-enhanced computed tomography. Patients with severe clinical deterioration or development of clinical signs of sepsis persisting or recurring without the presence of gas in the peripancreatic collection during contrast-enhanced computed tomography were also advised to receive surgical intervention. These patients consistently showed persistent organ failure. International Association of Pancreatology/American Pancreatic Association evidence-based guidelines for the management of acute pancreatitis suggest that ongoing organ failure for several weeks after the onset of acute pancreatitis in the absence of documented infected necrotizing pancreatitis is an indicator of intervention, especially when the necrosis has become walled off.3 However, the duration of organ failure was not clearly mentioned. Should a patient receive intervention after ongoing organ failure for 2, 3, or even 4 weeks wait until the necrosis has become walled off? In our study, the mortality rate of patients with persistent organ failure who received conservative treatment was 72% (18/25), which is significantly higher than the mortality rate of patients who received interventional treatment (32%, 26/82; P < 0.001). The median time between presentation and death in patients with persistent organ failure who received conservative treatment was 26 days (range, 8–68 days), which indicates that some patients with persistent organ failure cannot wait 4 weeks before intervention. We will investigate the optimal indicator of the need for intervention in this group in further randomized trials.
It is questioned whether antibiotic usage, proportion of walled-off pancreatic necrosis, and surgical types would affect our results. The limitations of our antibiotic usage and interventional strategy have already been discussed in our article. In this study, 37 of the 223 patients initially received percutaneous catheter drainage; 11 of them required a second open pancreatic necrosectomy. Forty-five of the 223 patients received retroperitoneal pancreatic necrosectomy, and none of the patients required a second open pancreatic necrosectomy. No difference in antibiotic usage, proportion of walled-off pancreatic necrosis, or proportion of open necrosectomy between the sterile and infected necrosis groups was observed.
We do not agree with the authors’ view that the Clavien-Dindo grade of complications should be applied in patients undergoing surgical treatment. Mortality rate is the only outcome we evaluated—it may not be optimal. Intra-abdominal bleeding, enterocutaneous fistula, new-onset organ failure, and reintervention were commonly described in some important previous studies.4,5 As we discussed in the article, many patients with necrotizing pancreatitis who received intervention had already been treated in the intensive care unit before intervention. As a severe disease, we believe that application of this classification system of surgical complications is unnecessary.

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