Title: Early encapsulation of peripancreatic fluid/necrosis collections on imaging (CECT) in
acute pancreatitis: influential factors and clinical significance for prognosis
Version: 1 Date: 16 Dec 2023
Reviewer:  Marianna Arvanitakis
Reviewer's report:
This retrospective study focuses on the factors related to early encapsulation of collections
encountered in patients with acute pancreatitis. From 289 patients with AP and peripancretaic
collections identified on the CECT performed during the period 4-10 days from the onset of the
disease, early encapsulation was identified to up to 48.7% of patients. APACHE scores, ALT
levels and time were identified predictive factors of early encapsulation.
The authors try to answer a very important question: when does encapsulation occur? This
is important as encapsulation provides the possibility for drainage, either surgical (as the
authors describe) but mostly by endoscopic and radiological means. Furthermore, they describe
predictive factors related to encapsulation within the first 10 days (early encapsulation), which
have not been identified previously.
Nevertheless, the authors did not take into account an important cohort study from the
Netherlands which described the natural history of encapsulation of WONs. According to the
study,  clinically relevant walled-off necrosis (largely or fully encapsulated necrotic collections)
was seen in 162/379 (43%) patients within the first 3 weeks, which largely lower that the results
reported from the current study. This underlines the weakness of the study, meaning the lack of
clear definition regarding encapsulation.
Comments:
1. Into: the authors refer to the surgical treatment of drainage, which has been largely replaced
by radiological and endoscopic drainage . Please comment.
2. Inclusion: All patients with AP were included? How was that defended?
3. Definition: What was the exact definition of early encapsulation? What we the degree of the
encapsulation?
3. Definition: was the presence of gas in the collection taken into account? How was infected
collection defined?
4. Results: Describe more clearly identified factors: ex longer time duration between onset and
CECT, high? ALT and high APACHE scores?
5. Results: "Results of clinical outcomes show that there is no statistical difference on the
incidence of infected pancreatic necrosis (4.1% vs 8.2%, p = 0.673), surgical intervention (6.1%
vs 10.2%, p = 0.673), and in-hospital mortality (2% vs 0%, p = 1) between two groups". The
% are  very low, as if the patients had mostly mild AP; how can Thisbe explained? There is a
vary high % of hyper TG AP compared to AP which is very unusual regarding epidemiology;
please comment.
6. Discussion: "In Olivier’s study, extra-pancreatic necrosis volume provides more reliable
information for predicting organ failure and infection than do the current scoring systems ". this
is the authors first name, please change
7. Discussion: Include the role of radiological and endoscopic drainage which has a clear
advantage over surgical approaches
8. Discussion:"A high APACHEII score and worse liver function could delay the encapsulation
of the peri-pancreatic collections". can te authors elaborate more on these findings? Are high
ALT levels a surrogate of a more severe disease? What about size of the collection? was this
included in te logistic regression?
9. references : Add the ref from the Dutch group "Van Grinven et al. Natural History of Gas
Configurations and Encapsulation in Necrotic Collections During Necrotizing Pancreatitis.J
Gastrointest Surg 2018 Sep;22(9):1557-1564. doi: 10.1007/s11605-018-3792-z. Epub 2018
May 11.
Title: Early encapsulation of peripancreatic fluid/necrosis collections on imaging (CECT) in
acute pancreatitis: influential factors and clinical significance for prognosis
Version: 1 Date: 16 Dec 2023
Reviewer:  Marianna Arvanitakis
Reviewer's report:
This retrospective study focuses on the factors related to early encapsulation of collections
encountered in patients with acute pancreatitis. From 289 patients with AP and peripancretaic
collections identified on the CECT performed during the period 4-10 days from the onset of the
disease, early encapsulation was identified to up to 48.7% of patients. APACHE scores, ALT
levels and time were identified predictive factors of early encapsulation.
The authors try to answer a very important question: when does encapsulation occur? This
is important as encapsulation provides the possibility for drainage, either surgical (as the
authors describe) but mostly by endoscopic and radiological means. Furthermore, they describe
predictive factors related to encapsulation within the first 10 days (early encapsulation), which
have not been identified previously.
Nevertheless, the authors did not take into account an important cohort study from the
Netherlands which described the natural history of encapsulation of WONs. According to the
study,  clinically relevant walled-off necrosis (largely or fully encapsulated necrotic collections)
was seen in 162/379 (43%) patients within the first 3 weeks, which largely lower that the results
reported from the current study. This underlines the weakness of the study, meaning the lack of
clear definition regarding encapsulation.
Comments:
1. Into: the authors refer to the surgical treatment of drainage, which has been largely replaced
by radiological and endoscopic drainage . Please comment.
2. Inclusion: All patients with AP were included? How was that defended?
3. Definition: What was the exact definition of early encapsulation? What we the degree of the
encapsulation?
3. Definition: was the presence of gas in the collection taken into account? How was infected
collection defined?
4. Results: Describe more clearly identified factors: ex longer time duration between onset and
CECT, high? ALT and high APACHE scores?
5. Results: "Results of clinical outcomes show that there is no statistical difference on the
incidence of infected pancreatic necrosis (4.1% vs 8.2%, p = 0.673), surgical intervention (6.1%
vs 10.2%, p = 0.673), and in-hospital mortality (2% vs 0%, p = 1) between two groups". The
% are  very low, as if the patients had mostly mild AP; how can Thisbe explained? There is a
vary high % of hyper TG AP compared to AP which is very unusual regarding epidemiology;
please comment.
6. Discussion: "In Olivier’s study, extra-pancreatic necrosis volume provides more reliable
information for predicting organ failure and infection than do the current scoring systems ". this
is the authors first name, please change
7. Discussion: Include the role of radiological and endoscopic drainage which has a clear
advantage over surgical approaches
8. Discussion:"A high APACHEII score and worse liver function could delay the encapsulation
of the peri-pancreatic collections". can te authors elaborate more on these findings? Are high
ALT levels a surrogate of a more severe disease? What about size of the collection? was this
included in te logistic regression?
9. references : Add the ref from the Dutch group "Van Grinven et al. Natural History of Gas
Configurations and Encapsulation in Necrotic Collections During Necrotizing Pancreatitis.J
Gastrointest Surg 2018 Sep;22(9):1557-1564. doi: 10.1007/s11605-018-3792-z. Epub 2018
May 11.
Please review this paper.
user
Title: Early encapsulation of peripancreatic fluid/necrosis collections on imaging (CECT) in
acute pancreatitis: influential factors and clinical significance for prognosis
Version: 1 Date: 16 Dec 2023
Reviewer:  Marianna Arvanitakis
Reviewer's report:
This retrospective study focuses on the factors related to early encapsulation of collections
encountered in patients with acute pancreatitis. From 289 patients with AP and peripancretaic
collections identified on the CECT performed during the period 4-10 days from the onset of the
disease, early encapsulation was identified to up to 48.7% of patients. APACHE scores, ALT
levels and time were identified predictive factors of early encapsulation.
The authors try to answer a very important question: when does encapsulation occur? This
is important as encapsulation provides the possibility for drainage, either surgical (as the
authors describe) but mostly by endoscopic and radiological means. Furthermore, they describe
predictive factors related to encapsulation within the first 10 days (early encapsulation), which
have not been identified previously.
Nevertheless, the authors did not take into account an important cohort study from the
Netherlands which described the natural history of encapsulation of WONs. According to the
study,  clinically relevant walled-off necrosis (largely or fully encapsulated necrotic collections)
was seen in 162/379 (43%) patients within the first 3 weeks, which largely lower that the results
reported from the current study. This underlines the weakness of the study, meaning the lack of
clear definition regarding encapsulation.
Comments:
1. Into: the authors refer to the surgical treatment of drainage, which has been largely replaced
by radiological and endoscopic drainage . Please comment.
2. Inclusion: All patients with AP were included? How was that defended?
3. Definition: What was the exact definition of early encapsulation? What we the degree of the
encapsulation?
3. Definition: was the presence of gas in the collection taken into account? How was infected
collection defined?
4. Results: Describe more clearly identified factors: ex longer time duration between onset and
CECT, high? ALT and high APACHE scores?
5. Results: "Results of clinical outcomes show that there is no statistical difference on the
incidence of infected pancreatic necrosis (4.1% vs 8.2%, p = 0.673), surgical intervention (6.1%
vs 10.2%, p = 0.673), and in-hospital mortality (2% vs 0%, p = 1) between two groups". The
% are  very low, as if the patients had mostly mild AP; how can Thisbe explained? There is a
vary high % of hyper TG AP compared to AP which is very unusual regarding epidemiology;
please comment.
6. Discussion: "In Olivier’s study, extra-pancreatic necrosis volume provides more reliable
information for predicting organ failure and infection than do the current scoring systems ". this
is the authors first name, please change
7. Discussion: Include the role of radiological and endoscopic drainage which has a clear
advantage over surgical approaches
8. Discussion:"A high APACHEII score and worse liver function could delay the encapsulation
of the peri-pancreatic collections". can te authors elaborate more on these findings? Are high
ALT levels a surrogate of a more severe disease? What about size of the collection? was this
included in te logistic regression?
9. references : Add the ref from the Dutch group "Van Grinven et al. Natural History of Gas
Configurations and Encapsulation in Necrotic Collections During Necrotizing Pancreatitis.J
Gastrointest Surg 2018 Sep;22(9):1557-1564. doi: 10.1007/s11605-018-3792-z. Epub 2018
May 11.
assistant