Title: Step-up approach for the treatment of infected necrotising pancreatitis: real life data from
a single-centre experience with long-term follow-up
Version: 1 Date: 03 Oct 2023
Reviewer:  Arnaldo Amato
Reviewer's report:
This article describes the step-up approach treatment for walled-off necrosis (WON).
English writing is challenging in most sections. The article should be reviewed and corrected
by a native English speaker.
Background
-“Only few studies have focused in the "step up strategy as a whole” :
Actually, the ESGE 2018 guidelines have already proposed the step-up approach as the best
approach in the management of necrotizing pancreatitis ( Strong recommendation, moderate
quality of evidence) in the article:” Endoscopic management of acute necrotizing pancreatitis:
European Society of Gastrointestinal Endoscopy (ESGE) evidence-based
multidisciplinary guidelines”
-“ This procedure must be carried out at best after 4 weeks of evolution at the stage of so called
walled-off necrosis (WON).”
In the literature,  despite being recommended, the need to wait for four weeks is considered
weak. The clinical and collection characteristics should be assessed on a case-by-case basis.
Methods
- “The Organ Failure were defined as previously described” Previously described where? In the
literature? The study did not define the criteria for organ failure .
-“ decrease of at least 50% of CRP serum level, decrease of at least 25% of total leucocytes
count”
The decrease in leukocyte count could also be attributed to sepsis. One of the criteria for SIRS
is a Leukocyte count less than 4000/microliter. So it could be misleading to consider a decrease
in leukocyte count as a response to therapy. Furthermore, it might also be worth considering the
PCT levels, which are a more indicative marker of infection than PCR alone
- I find it interesting that the center chose to use only LAMS without HOT AXIOS technology.
However, with the widespread availability of these stents, which facilitate the placement of the
prosthesis, describing the use of only one technique may be a limitation of the study
- I believe it could be interesting to know what criteria were used to choose between the
endoscopic and radiological techniques, or the use of both methods. The division into the two
groups does not appear to be randomized.
- “We collected all clinical, biological and radiological” the sentence is a bit generic, especially
because the tables only contain certain patient information. This sentence should be more
specific.
Results
-“ Unfortunately, these four patients died at least one week after surgery”
It would be interesting to reflect on the fact that all patients who underwent surgery died. Perhaps
these are patients who underwent surgery due to an advanced stage?
-Table 4 detailed the risk factors associated with death. Among the etiologies of pancreatitis,
only the biliary cause has been analyzed. It would be interesting to investigate whether alcoholic
etiology (or other etiologies) could be a risk factor for an unfavorable outcome
DISCUSSION
- “..treatment of infected pancreatic necrosis. It should be emphasized that "infected pancreatic
necrosis"and "walled-off necrosis" are not synonymous. The study appears to be more focused
on the treatment of walled-off necrosis.
-“To evaluate the efficacy of our protocol we applied a simple composite score that included
new onset or persistence of OF and clinico-biological criteria “. Which score is being referred
to? How was it applied?
- “In the present study the mortality at 6 months (19%) was similar to that observed in
randomised studies evaluating minimally invasive treatments of infected WON. “ If the six-
month mortality is similar to the mortality in studies that used only a minimally invasive
approach, what is the advantage of the step-up approach?
- “ In the same way we have placed in more than two third of our patients with LAMS a 10 F
nasocystic drain at the same time followed by washing and drainage by gravity during at least
3 days 29. These drains allowed probably to liquify necrosis, drain the cavity and avoid LAMS
obstruction.” The placement of the naso-cystic tube is not a separately analyzed element, so it's
challenging to draw conclusions without an analysis of this data.
Abbreviations
LAM : The correct abbreviation is LAMS
Title: Step-up approach for the treatment of infected necrotising pancreatitis: real life data from
a single-centre experience with long-term follow-up
Version: 1 Date: 03 Oct 2023
Reviewer:  Arnaldo Amato
Reviewer's report:
This article describes the step-up approach treatment for walled-off necrosis (WON).
English writing is challenging in most sections. The article should be reviewed and corrected
by a native English speaker.
Background
-“Only few studies have focused in the "step up strategy as a whole” :
Actually, the ESGE 2018 guidelines have already proposed the step-up approach as the best
approach in the management of necrotizing pancreatitis ( Strong recommendation, moderate
quality of evidence) in the article:” Endoscopic management of acute necrotizing pancreatitis:
European Society of Gastrointestinal Endoscopy (ESGE) evidence-based
multidisciplinary guidelines”
-“ This procedure must be carried out at best after 4 weeks of evolution at the stage of so called
walled-off necrosis (WON).”
In the literature,  despite being recommended, the need to wait for four weeks is considered
weak. The clinical and collection characteristics should be assessed on a case-by-case basis.
Methods
- “The Organ Failure were defined as previously described” Previously described where? In the
literature? The study did not define the criteria for organ failure .
-“ decrease of at least 50% of CRP serum level, decrease of at least 25% of total leucocytes
count”
The decrease in leukocyte count could also be attributed to sepsis. One of the criteria for SIRS
is a Leukocyte count less than 4000/microliter. So it could be misleading to consider a decrease
in leukocyte count as a response to therapy. Furthermore, it might also be worth considering the
PCT levels, which are a more indicative marker of infection than PCR alone
- I find it interesting that the center chose to use only LAMS without HOT AXIOS technology.
However, with the widespread availability of these stents, which facilitate the placement of the
prosthesis, describing the use of only one technique may be a limitation of the study
- I believe it could be interesting to know what criteria were used to choose between the
endoscopic and radiological techniques, or the use of both methods. The division into the two
groups does not appear to be randomized.
- “We collected all clinical, biological and radiological” the sentence is a bit generic, especially
because the tables only contain certain patient information. This sentence should be more
specific.
Results
-“ Unfortunately, these four patients died at least one week after surgery”
It would be interesting to reflect on the fact that all patients who underwent surgery died. Perhaps
these are patients who underwent surgery due to an advanced stage?
-Table 4 detailed the risk factors associated with death. Among the etiologies of pancreatitis,
only the biliary cause has been analyzed. It would be interesting to investigate whether alcoholic
etiology (or other etiologies) could be a risk factor for an unfavorable outcome
DISCUSSION
- “..treatment of infected pancreatic necrosis. It should be emphasized that "infected pancreatic
necrosis"and "walled-off necrosis" are not synonymous. The study appears to be more focused
on the treatment of walled-off necrosis.
-“To evaluate the efficacy of our protocol we applied a simple composite score that included
new onset or persistence of OF and clinico-biological criteria “. Which score is being referred
to? How was it applied?
- “In the present study the mortality at 6 months (19%) was similar to that observed in
randomised studies evaluating minimally invasive treatments of infected WON. “ If the six-
month mortality is similar to the mortality in studies that used only a minimally invasive
approach, what is the advantage of the step-up approach?
- “ In the same way we have placed in more than two third of our patients with LAMS a 10 F
nasocystic drain at the same time followed by washing and drainage by gravity during at least
3 days 29. These drains allowed probably to liquify necrosis, drain the cavity and avoid LAMS
obstruction.” The placement of the naso-cystic tube is not a separately analyzed element, so it's
challenging to draw conclusions without an analysis of this data.
Abbreviations
LAM : The correct abbreviation is LAMS
Please review this paper.
user
Title: Step-up approach for the treatment of infected necrotising pancreatitis: real life data from
a single-centre experience with long-term follow-up
Version: 1 Date: 03 Oct 2023
Reviewer:  Arnaldo Amato
Reviewer's report:
This article describes the step-up approach treatment for walled-off necrosis (WON).
English writing is challenging in most sections. The article should be reviewed and corrected
by a native English speaker.
Background
-“Only few studies have focused in the "step up strategy as a whole” :
Actually, the ESGE 2018 guidelines have already proposed the step-up approach as the best
approach in the management of necrotizing pancreatitis ( Strong recommendation, moderate
quality of evidence) in the article:” Endoscopic management of acute necrotizing pancreatitis:
European Society of Gastrointestinal Endoscopy (ESGE) evidence-based
multidisciplinary guidelines”
-“ This procedure must be carried out at best after 4 weeks of evolution at the stage of so called
walled-off necrosis (WON).”
In the literature,  despite being recommended, the need to wait for four weeks is considered
weak. The clinical and collection characteristics should be assessed on a case-by-case basis.
Methods
- “The Organ Failure were defined as previously described” Previously described where? In the
literature? The study did not define the criteria for organ failure .
-“ decrease of at least 50% of CRP serum level, decrease of at least 25% of total leucocytes
count”
The decrease in leukocyte count could also be attributed to sepsis. One of the criteria for SIRS
is a Leukocyte count less than 4000/microliter. So it could be misleading to consider a decrease
in leukocyte count as a response to therapy. Furthermore, it might also be worth considering the
PCT levels, which are a more indicative marker of infection than PCR alone
- I find it interesting that the center chose to use only LAMS without HOT AXIOS technology.
However, with the widespread availability of these stents, which facilitate the placement of the
prosthesis, describing the use of only one technique may be a limitation of the study
- I believe it could be interesting to know what criteria were used to choose between the
endoscopic and radiological techniques, or the use of both methods. The division into the two
groups does not appear to be randomized.
- “We collected all clinical, biological and radiological” the sentence is a bit generic, especially
because the tables only contain certain patient information. This sentence should be more
specific.
Results
-“ Unfortunately, these four patients died at least one week after surgery”
It would be interesting to reflect on the fact that all patients who underwent surgery died. Perhaps
these are patients who underwent surgery due to an advanced stage?
-Table 4 detailed the risk factors associated with death. Among the etiologies of pancreatitis,
only the biliary cause has been analyzed. It would be interesting to investigate whether alcoholic
etiology (or other etiologies) could be a risk factor for an unfavorable outcome
DISCUSSION
- “..treatment of infected pancreatic necrosis. It should be emphasized that "infected pancreatic
necrosis"and "walled-off necrosis" are not synonymous. The study appears to be more focused
on the treatment of walled-off necrosis.
-“To evaluate the efficacy of our protocol we applied a simple composite score that included
new onset or persistence of OF and clinico-biological criteria “. Which score is being referred
to? How was it applied?
- “In the present study the mortality at 6 months (19%) was similar to that observed in
randomised studies evaluating minimally invasive treatments of infected WON. “ If the six-
month mortality is similar to the mortality in studies that used only a minimally invasive
approach, what is the advantage of the step-up approach?
- “ In the same way we have placed in more than two third of our patients with LAMS a 10 F
nasocystic drain at the same time followed by washing and drainage by gravity during at least
3 days 29. These drains allowed probably to liquify necrosis, drain the cavity and avoid LAMS
obstruction.” The placement of the naso-cystic tube is not a separately analyzed element, so it's
challenging to draw conclusions without an analysis of this data.
Abbreviations
LAM : The correct abbreviation is LAMS
assistant