Draining sterile fluid collections in acute pancreatitis? Primum non nocere!

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Draining sterile fluid collections in acute pancreatitis? Primum
non nocere!
Marc G. H. Besselink•Hjalmar C. van Santvoort•
Olaf J. Bakker•Thomas L. Bollen•
Hein G. Gooszen
Published online: 7 April 2010
? The Author(s) 2010. This article is published with open access at Springerlink.com
With interest we read the randomized study by Zerem et al.
[1] regarding the drainage of sterile fluid collections in
acute pancreatitis. The authors are to be commended for
performing a randomized trial in a difficult patient
population.
Nearly all international guidelines advocate conserva-
tive management of sterile fluid collections in acute pan-
creatitis: (a) the American Gastroenterological Association
(2007): ‘‘Acute fluid collections around the pancreas in the
setting of acute pancreatitis require no therapy in the
absence of infection or obstruction of a surrounding hollow
viscus’’ [2], (b) the American College of Gastroenterology
(2006): ‘‘Most peripancreatic fluid collections remain
sterile and will disappear during the recovery from acute
pancreatitis’’ [3], and (c) the international consensus
meeting on treatment of acute pancreatitis (2004): ‘‘Rou-
tine operative or percutaneous drainage of the former
(…peripancreatic fluid collections and pancreatic necro-
sis…) is not necessary and may infect otherwise sterile
tissues’’ [4]. Nevertheless, guidelines should be put to the
test of evidence-based medicine and accordingly the
authors routinely aspirated peripancreatic fluid collections
in 58 patients and subsequently randomized 40 patients
with sterile peripancreatic fluid collections. Group A
(n = 20) received conservative management, whereas
group B (n = 20) underwent prolonged percutaneous
catheter drainage of sterile collections. As the primary end
point the authors chose ‘‘conversion to more aggressive
procedure,’’ which included percutaneous catheter drainage
and surgery. In group A, 11 patients required additional
treatment (mostly percutaneous drainage, n = 8), whereas
in group B three patients required surgical intervention (11/
20 vs. 3/20, P = 0.02). The authors concluded that ‘‘pro-
longed catheter drainage is more effective for management
of recurrent sterile fluid collections in acute pancreatitis
than is conservative management’’.
We consider the primary end point of ‘‘conversion to
more aggressive procedure’’ rather inappropriate. Why not
study clinically relevant outcome measures such as mor-
tality, organ failure, secondary infection of peripancreatic
collections, length of hospital stay, or a composite of these
events? Notably, it is our interpretation, in line with the
definition of the author’s primary outcome measure, that all
patients in group B underwent an ‘‘aggressive procedure,’’
that being percutaneous drainage! Along this line of rea-
soning, all 20 patients in group B had an interventional
procedure versus 11 of 20 patients in group A (P = 0.001).
Furthermore, the prolonged percutaneous drainage in group
B led to a significant increase in infected collections (4 vs.
11, P = 0.048), that became fatal in one patient.
In conclusion, is the conservative strategy not to be
considered the superior strategy? The conservative strat-
egy, compared to prolonged catheter drainage, (1) reduces
the risk of requiring an intervention by 55% (9/20 vs. 20/20
patients) and (2) reduces the risk of infection by 35% (4/20
vs. 11/20 patients) without a noticeable negative impact on
On behalf of the Dutch Pancreatitis Study Group.
M. G. H. Besselink (&) ? H. C. van Santvoort ? O. J. Bakker
Department of Surgery, University Medical Center Utrecht,
P.O. Box 85500, HP G04.228, 3508 GA Utrecht, The
Netherlands
e-mail: m.besselink@umcutrecht.nl
T. L. Bollen
Department of Radiology, St. Antonius Hospital, Nieuwegein,
The Netherlands
H. G. Gooszen
Department of Surgery, Radboud University Nijmegen Medical
Centre, Nijmegen, The Netherlands
123
Surg Endosc (2011) 25:331–332
DOI 10.1007/s00464-010-1051-9

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hospital stay and mortality. Previous studies have already
demonstrated that percutaneous drainage of sterile collec-
tions is associated with increased risk of infections. Walser
et al. [5] demonstrated that the risk of infecting sterile
collections with catheter drainage is 59% (13/22 patients)
vs. 20% (3/15 patients) in collections that were only
aspirated.
In most experienced centers worldwide, sterile fluid
collections are treated conservatively, in accordance with
international guidelines. Unnecessary aspiration and/or
drainage of sterile collections increases the risk of sec-
ondary infection with the subsequent need for surgical
intervention and, ultimately, increased mortality.
Disclosures
Gooszen have no conflicts of interest or financial ties to disclose. The
Dutch Pancreatitis Study Group also has no interests or financial ties
to disclose.
Drs. Besselink, Van Santvoort, Bakker, Bollen, and
Open Access
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
This article is distributed under the terms of the
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