Limitations and suggestions for emphysematous pancreatitis: Diagnosis, treatment, and prognosis

Abstract

We read with great interest the article by Cao et al on 15 cases of emphysematous pancreatitis (EP). The study highlights the high mortality rate associated with EP and emphasizes the role of next-generation sequencing (NGS) in identifying its etiology. Additionally, it suggests treatment strategies such as antimicrobial therapy and early percutaneous catheter drainage, which may improve patient outcomes. However, we have identified certain limitations related to case selection, the evaluation of NGS technology, and the timing of computed tomography scans. To enhance the study’s findings, we recommend expanding the study population, systematically evaluating the role of NGS in EP, and providing a more detailed analysis of the antibiotic initiation and duration. Furthermore, specifying the timing of computed tomography scans would improve clarity. Addressing these concerns could strengthen the study’s contribution to the evidence-based management of EP, offering valuable insights for clinical practice.

Key Words: Emphysematous pancreatitis; Next-generation sequencing; Computed tomography; Diagnosis; Treatment

Core Tip: The results section of the abstract states that 5 cases of extensive emphysematous pancreatitis accounted for 33.3%, not 66.7%, and 7 cases of early-onset emphysematous pancreatitis accounted for 46.7%, not 47.1%. We recommend including details on the timing of antibiotic initiation and duration, as well as the timing of EP detection by computed tomography.

TO THE EDITOR

We read with great interest the recent publication by Cao et al[1], which retrospectively examines the diagnosis, treatment, and prognosis of 15 cases of emphysematous pancreatitis (EP). The study highlights the alarmingly high mortality rate of EP and emphasizes the role of next-generation sequencing (NGS) in its etiological diagnosis. Furthermore, it introduces potential treatment strategies, including antimicrobial therapy and early percutaneous catheter drainage, which may significantly improve patient prognosis. While this work provides valuable insights, we would like to highlight some important limitations that warrant further discussion.

First, the study reported a mortality rate of 60% (9 of 15 cases), which is notably higher than the rates observed in previous studies[2]. This raises concerns about potential case selection bias. Clarification of the inclusion criteria would help contextualize these findings. Second, EP is characterized by the presence of gas within or around necrotic pancreatic tissue, often due to gas-forming bacterial infections or enteric pancreatic fistulas. Considering that patients with EP may have diabetes or immune disorders, single bacterial cultures may fail to detect all pathogens. Although NGS enhances pathogen identification, it is important to consider the potential presence of conditional pathogens. Additionally, previous studies emphasize the necessity of timely antibiotic administration targeting gram-negative bacteria[3]. However, the study did not provide details on antibiotic initiation or duration, which are critical for optimizing treatment. Although NGS was performed in cases 1 to 5, three of these patients succumbed to the disease, reinforcing the importance of early recognition and timely intervention.

Third, computed tomography (CT) imaging remains the gold standard for diagnosing EP due to its high specificity and sensitivity in detecting intraparenchymal and free gas around the pancreas[4]. However, the study did not specify the timing of the initial CT scan. Delayed CT evaluations may contribute to diagnostic delays, potentially missing the optimal therapeutic window and leading to increased mortality[5]. Timely CT assessment, followed by immediate empirical antibiotic therapy targeting gram-negative bacteria (most commonly, Escherichia coli), is crucial[5]. NGS should be used concurrently to identify causative pathogens, allowing for subsequent antibiotic adjustments to improve outcomes[6]. An integrated approach that combines imaging and molecular diagnostics could optimize EP management. Finally, the management of EP necessitates a multidisciplinary team, involving radiologists, gastroenterologists, infectious disease specialists, critical care physicians, and emergency surgeons[5].

In conclusion, this study provides valuable insights into EP but could be further strengthened by addressing the aforementioned limitations. Expanding the study population, providing more detail on antibiotic administration, and specifying CT timing would enhance the robustness of the findings and further contribute to the evidence-based management of EP. We greatly appreciate the authors’ contributions to this critical area of research.