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June 27, 2012

Necrosectomy for Infected Necrotizing Pancreatitis

Author Affiliations

Author Affiliations: Department of Surgery, Massachusetts General Hospital, Boston (pfagenholz@partners.org).

JAMA. 2012;307(24):2584-2585. doi:10.1001/jama.2012.5970

To the Editor: The findings of the PENGUIN (Pancreatitis, Endoscopic Transgastric vs Primary Necrosectomy in Patients With Infected Necrosis) trial1 suggest that endoscopic transgastric necrosectomy reduces death or complications compared with surgical necrosectomy for the treatment of infected necrotizing pancreatitis. These results are heavily influenced by an unusually high 40% mortality rate in the surgical necrosectomy group, which we believe calls into question the reported superiority of endoscopic transgastric necrosectomy. The latest published data from our institution show an 11% mortality rate after open surgical necrosectomy in 167 patients.2 Other contemporary surgical series have demonstrated a mortality of 4% to 18%.3 Based on these data, the advantages of endoscopic necrosectomy are less clear. Future studies will continue to define the role of endoscopic necrosectomy in patients with infected necrotizing pancreatitis, but unless surgical therapy is performed with acceptable mortality, the effect will be questionable. At centers achieving comparable results with other techniques, the limitations of endoscopic transgastric debridement—the need for multiple procedures, the requirement for favorable anatomy, and the difficulty of acquiring adequate expertise—may supersede small advantages in morbidity and mortality.