Reviewer ’s report  
 
Title: Double -catheter lavage combined with percutaneous flexible endoscopic debridement for  
infected pancreatic necrosis failed to percutaneous catheter dr ainage  
 
Version: 0 Date: 21 Jun 2017  
 
Reviewer: Enver Zerem  
 
Reviewer's report:  
 
Manuscript Number: BMGE -D-17-00187, ti tled „Application of double -catheter lavage in 
combination with percutaneous flexible endoscopic debridement treatment on infected pancreatic 
necrosis failed to percutaneous catheter drainage ". The aim of this study is to evaluate the 
effectiveness and sa fety of percutaneous catheter drainage, followed by large aperture double 
catheter lavage combined with percutaneous flexible endoscopic debridement as compared with 
open necrosectomy. The authors concluded that double -catheter lavage in combination with 
percutaneous flexible endoscopic debridement showed superior effectiveness, safety, and 
convenience in patients with IPN after PCD failure as compared to open necrosectomy.  
 
 
 
General Comments:   
 
Major Strengths of the Study: The authors investigated an intere sting and important issue.  
 
 
 
 
Major Weaknesses:  
 
* The title of the article is too long and needs better formulation.  
 
 
 
* The step -up approach, which can be summarized as: delayed intervention, catheter drainage 
and minimally invasive drain -guided endoscopic debridement, may be considered as the 
reference standard intervention for infected necrotizing pancreatitis. It is tr ue that the individual 
components of the step -up approach may be subject to improvement, however, the concept of the 
step-up approach, i.e. delay, drain, debride, seems here to stay (see references below).  
 
 
 
1. Besselink MG, van Santvoort HC, Nieuwenhuijs VB, et al. Minimally invasive 'step -up 
approach' versus maximal necrosectomy in patients with acute necrotizing pancreatitis 
(PANTER trial): design and rationale of a randomized controlled multicenter trial 
[ISRCTN13975868]. BMC Surg 2006; 6:6.  
 
 
 
2. van Sant voort HC, Besselink MG, Bakker OJ, et al. A step -up approach or open 
necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362:1491 -502.  
 
 
 
3. Horvath K, Freeny P, Escallon J, et al. Safety and efficacy of video -assisted 
retroperitoneal debridement f or infected pancreatic collections: a multicenter, 
prospective, single -arm phase 2 study. Arch Surg 2010; 145:817 -25. 
 
 
 
4. Zerem E, Imamović G, Sušić A, Haračić B. Step -up approach to infected necrotising 
pancreatitis: a 20 -year experience of percutaneous dr ainage in a single centre. Dig Liver 
Dis. 2011; 43:478 -83 
 
 
 
5. Zerem E. Treatment of severe acute pancreatitis and its complications. World J 
Gastroenterol 2014; 20: 13879 -13892  
 
 
 
 
The new studies could focus on the optimal techniques of catheter drainage an d minimally 
invasive endoscopic debridement (e.g. endoscopic transluminal, percutaneous retroperitoneal or 
video -assisted retroperitoneal).  
 
 
 
Considering the above, the design of this study is not appropriate. Authors declared that the aim 
of their study i s to evaluate the effectiveness and safety of percutaneous catheter drainage, 
followed by large aperture double catheter lavage combined with percutaneous flexible 
endoscopic debridement as compared to open necrosectomy. The authors concluded that double -
catheter lavage in combination with percutaneous flexible endoscopic debridement showed 
superior effectiveness, safety, and convenience in patients with IPN after PCD failure as 
compared to open necrosectomy, regarding the rate of new -onset multiple organ f ailure and ICU 
length of stay. The fact is that if the patient's condition does not improve or if it deteriorates after 
percutaneous or endoscopic drainage, minimally invasive endoscopic debridement should be 
performed - is confirmed in several studies (in  order to lower the possibility of new -onset 
multiple organ failure [see ref. above]). The novelty, in this study, is the fact that "classic" 
endoscopic approach was modified by using large aperture double catheter lavage combined with 
percutaneous flexibl e endoscopic debridement. So, in my opinion, appropriate design of the 
study would be to compare outcomes of classic endoscopic approach and double catheter lavage 
combined with percutaneous flexible endoscopic debridement, which have similar roles in the 
step-up approach in the treatment of IPN.  
 
 
 
Therefore, authors need to respond to my given comments or to adjust the design of their study 
(if it is possible).  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include t he necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to ass ess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering t he following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I decla re that I have no competing interests' below. If your reply is yes to any, please give details 
below  
 
I agree to th e open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with  the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Double -catheter lavage combined with percutaneous flexible endoscopic debridement for  
infected pancreatic necrosis failed to percutaneous catheter dr ainage  
 
Version: 0 Date: 21 Jun 2017  
 
Reviewer: Enver Zerem  
 
Reviewer's report:  
 
Manuscript Number: BMGE -D-17-00187, ti tled „Application of double -catheter lavage in 
combination with percutaneous flexible endoscopic debridement treatment on infected pancreatic 
necrosis failed to percutaneous catheter drainage ". The aim of this study is to evaluate the 
effectiveness and sa fety of percutaneous catheter drainage, followed by large aperture double 
catheter lavage combined with percutaneous flexible endoscopic debridement as compared with 
open necrosectomy. The authors concluded that double -catheter lavage in combination with 
percutaneous flexible endoscopic debridement showed superior effectiveness, safety, and 
convenience in patients with IPN after PCD failure as compared to open necrosectomy.  
 
 
 
General Comments:   
 
Major Strengths of the Study: The authors investigated an intere sting and important issue.  
 
 
 
 
Major Weaknesses:  
 
* The title of the article is too long and needs better formulation.  
 
 
 
* The step -up approach, which can be summarized as: delayed intervention, catheter drainage 
and minimally invasive drain -guided endoscopic debridement, may be considered as the 
reference standard intervention for infected necrotizing pancreatitis. It is tr ue that the individual 
components of the step -up approach may be subject to improvement, however, the concept of the 
step-up approach, i.e. delay, drain, debride, seems here to stay (see references below).  
 
 
 
1. Besselink MG, van Santvoort HC, Nieuwenhuijs VB, et al. Minimally invasive 'step -up 
approach' versus maximal necrosectomy in patients with acute necrotizing pancreatitis 
(PANTER trial): design and rationale of a randomized controlled multicenter trial 
[ISRCTN13975868]. BMC Surg 2006; 6:6.  
 
 
 
2. van Sant voort HC, Besselink MG, Bakker OJ, et al. A step -up approach or open 
necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362:1491 -502.  
 
 
 
3. Horvath K, Freeny P, Escallon J, et al. Safety and efficacy of video -assisted 
retroperitoneal debridement f or infected pancreatic collections: a multicenter, 
prospective, single -arm phase 2 study. Arch Surg 2010; 145:817 -25. 
 
 
 
4. Zerem E, Imamović G, Sušić A, Haračić B. Step -up approach to infected necrotising 
pancreatitis: a 20 -year experience of percutaneous dr ainage in a single centre. Dig Liver 
Dis. 2011; 43:478 -83 
 
 
 
5. Zerem E. Treatment of severe acute pancreatitis and its complications. World J 
Gastroenterol 2014; 20: 13879 -13892  
 
 
 
 
The new studies could focus on the optimal techniques of catheter drainage an d minimally 
invasive endoscopic debridement (e.g. endoscopic transluminal, percutaneous retroperitoneal or 
video -assisted retroperitoneal).  
 
 
 
Considering the above, the design of this study is not appropriate. Authors declared that the aim 
of their study i s to evaluate the effectiveness and safety of percutaneous catheter drainage, 
followed by large aperture double catheter lavage combined with percutaneous flexible 
endoscopic debridement as compared to open necrosectomy. The authors concluded that double -
catheter lavage in combination with percutaneous flexible endoscopic debridement showed 
superior effectiveness, safety, and convenience in patients with IPN after PCD failure as 
compared to open necrosectomy, regarding the rate of new -onset multiple organ f ailure and ICU 
length of stay. The fact is that if the patient's condition does not improve or if it deteriorates after 
percutaneous or endoscopic drainage, minimally invasive endoscopic debridement should be 
performed - is confirmed in several studies (in  order to lower the possibility of new -onset 
multiple organ failure [see ref. above]). The novelty, in this study, is the fact that "classic" 
endoscopic approach was modified by using large aperture double catheter lavage combined with 
percutaneous flexibl e endoscopic debridement. So, in my opinion, appropriate design of the 
study would be to compare outcomes of classic endoscopic approach and double catheter lavage 
combined with percutaneous flexible endoscopic debridement, which have similar roles in the 
step-up approach in the treatment of IPN.  
 
 
 
Therefore, authors need to respond to my given comments or to adjust the design of their study 
(if it is possible).  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include t he necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to ass ess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering t he following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I decla re that I have no competing interests' below. If your reply is yes to any, please give details 
below  
 
I agree to th e open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with  the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Double -catheter lavage combined with percutaneous flexible endoscopic debridement for  
infected pancreatic necrosis failed to percutaneous catheter dr ainage  
 
Version: 0 Date: 21 Jun 2017  
 
Reviewer: Enver Zerem  
 
Reviewer's report:  
 
Manuscript Number: BMGE -D-17-00187, ti tled „Application of double -catheter lavage in 
combination with percutaneous flexible endoscopic debridement treatment on infected pancreatic 
necrosis failed to percutaneous catheter drainage ". The aim of this study is to evaluate the 
effectiveness and sa fety of percutaneous catheter drainage, followed by large aperture double 
catheter lavage combined with percutaneous flexible endoscopic debridement as compared with 
open necrosectomy. The authors concluded that double -catheter lavage in combination with 
percutaneous flexible endoscopic debridement showed superior effectiveness, safety, and 
convenience in patients with IPN after PCD failure as compared to open necrosectomy.  
 
 
 
General Comments:   
 
Major Strengths of the Study: The authors investigated an intere sting and important issue.  
 
 
 
 
Major Weaknesses:  
 
* The title of the article is too long and needs better formulation.  
 
 
 
* The step -up approach, which can be summarized as: delayed intervention, catheter drainage 
and minimally invasive drain -guided endoscopic debridement, may be considered as the 
reference standard intervention for infected necrotizing pancreatitis. It is tr ue that the individual 
components of the step -up approach may be subject to improvement, however, the concept of the 
step-up approach, i.e. delay, drain, debride, seems here to stay (see references below).  
 
 
 
1. Besselink MG, van Santvoort HC, Nieuwenhuijs VB, et al. Minimally invasive 'step -up 
approach' versus maximal necrosectomy in patients with acute necrotizing pancreatitis 
(PANTER trial): design and rationale of a randomized controlled multicenter trial 
[ISRCTN13975868]. BMC Surg 2006; 6:6.  
 
 
 
2. van Sant voort HC, Besselink MG, Bakker OJ, et al. A step -up approach or open 
necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362:1491 -502.  
 
 
 
3. Horvath K, Freeny P, Escallon J, et al. Safety and efficacy of video -assisted 
retroperitoneal debridement f or infected pancreatic collections: a multicenter, 
prospective, single -arm phase 2 study. Arch Surg 2010; 145:817 -25. 
 
 
 
4. Zerem E, Imamović G, Sušić A, Haračić B. Step -up approach to infected necrotising 
pancreatitis: a 20 -year experience of percutaneous dr ainage in a single centre. Dig Liver 
Dis. 2011; 43:478 -83 
 
 
 
5. Zerem E. Treatment of severe acute pancreatitis and its complications. World J 
Gastroenterol 2014; 20: 13879 -13892  
 
 
 
 
The new studies could focus on the optimal techniques of catheter drainage an d minimally 
invasive endoscopic debridement (e.g. endoscopic transluminal, percutaneous retroperitoneal or 
video -assisted retroperitoneal).  
 
 
 
Considering the above, the design of this study is not appropriate. Authors declared that the aim 
of their study i s to evaluate the effectiveness and safety of percutaneous catheter drainage, 
followed by large aperture double catheter lavage combined with percutaneous flexible 
endoscopic debridement as compared to open necrosectomy. The authors concluded that double -
catheter lavage in combination with percutaneous flexible endoscopic debridement showed 
superior effectiveness, safety, and convenience in patients with IPN after PCD failure as 
compared to open necrosectomy, regarding the rate of new -onset multiple organ f ailure and ICU 
length of stay. The fact is that if the patient's condition does not improve or if it deteriorates after 
percutaneous or endoscopic drainage, minimally invasive endoscopic debridement should be 
performed - is confirmed in several studies (in  order to lower the possibility of new -onset 
multiple organ failure [see ref. above]). The novelty, in this study, is the fact that "classic" 
endoscopic approach was modified by using large aperture double catheter lavage combined with 
percutaneous flexibl e endoscopic debridement. So, in my opinion, appropriate design of the 
study would be to compare outcomes of classic endoscopic approach and double catheter lavage 
combined with percutaneous flexible endoscopic debridement, which have similar roles in the 
step-up approach in the treatment of IPN.  
 
 
 
Therefore, authors need to respond to my given comments or to adjust the design of their study 
(if it is possible).  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include t he necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to ass ess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering t he following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I decla re that I have no competing interests' below. If your reply is yes to any, please give details 
below  
 
I agree to th e open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with  the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant