Necrosectomy for Infected Necrotizing Pancreatitis—Reply

In Reply: We agree with Drs Fagenholz and Fernández-del Castillo that 40% mortality after surgical necrosectomy is high. We believe, however, that this is not necessarily unusually high. The higher mortality rate compared with the studies referenced by Fagenholz and Fernández-del Castillo^1- 2 may be explained by differences in case mix. The patient population that underwent surgical necrosectomy in the PENGUIN trial was a selected subgroup from the entire clinical spectrum of patients who needed to undergo intervention for necrotizing pancreatitis. First, all patients who underwent surgery in the PENGUIN trial had undergone previous percutaneous drainage that failed to temporize sepsis and obviate the need for necrosectomy. They represent selection of more severely ill patients with infected necrosis. Second, the rate of proven infected necrosis was 95% in the PENGUIN trial, much higher than the 72% in the referenced series.^1- 2 Therefore, the study population of the PENGUIN trial is not comparable with other unselected cohorts of patients undergoing surgical necrosectomy.