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World J Gastroenterol. 2010 September 21; 16(35): 4497–4498.
Published online 2010 September 21. doi:  10.3748/wjg.v16.i35.4497
PMCID: PMC2941077

Walled-off pancreatic necrosis: Wishing our pancreatitis nomenclature was correct


The ultimate reason why pancreatologists have strived to establish definitions for inflammatory pathologies of the pancreas is to improve patient care. Although the Atlanta Classification has been used for around for 17 years, considerable misunderstanding of the key elements of the nomenclature still persists. While a recent article by Stamatakos et al aimed to deal with an entity not clearly defined in the 1993 document, it is replete with factual and conceptual errors as well as contradictory statements.

Keywords: Severe pancreatitis, Acute necrotizing pancreatitis, Walled-off pancreatic necrosis


I am puzzled as to why the editorial process did not identify the multitude of major factual and conceptual errors in the article “Walled-off pancreatic necrosis” by Stamatakos et al[1]. Without consistency in terminology among experts, our patients will not benefit from high-quality studies such as the Dutch PANTER trial which showed a reduction in morbidity of infected pancreatic necrosis managed with a step-up percutaneous approach compared with the Berger technique of open necrosectomy[2]. Walled-off pancreatic necrosis (WOPN) refers to (peri)pancreatic necrosis in a patient who has been nursed through 10-12 wk of illness and presents with pressure symptoms or rarely with infection[3]. This time-dependent maturation results in separation and demarcation of the solid component and sometimes liquefaction[3].

The authors have been permitted to perpetuate the misconception that a pancreatic pseudocyst contains necrosis when the Atlanta Classification clearly states that it does not[4].

Statements such as the following indicate that the authors do not understand the term of wall off pancreatic necrosis: “WOPN was formerly known as pancreatic abscess”, “WOPN occurs … in complicated cases of pseudocysts”, “little or no necrotic material is present”, “superinfection of pseudocysts is one way that WOPN may develop” and “bacterial flora … is the sine qua non of WOPN”. The authors stated that WOPN was defined in 2005 but have referenced articles from 2001 and 1993 when outlining the epidemiology and pathophysiology of this condition.

The authors seem confused about patient outcome from severe pancreatitis: the greatest predictor of mortality is deteriorating organ dysfunction rather than the extent of necrosis or infection[5]. On the one hand, they stated that “mortality rate approaches 100% if surgical intervention … (is) not undertaken for WOPN”. On the other hand, they stated that “if bacteremia can be restrained, necrosectomy can be avoided”.

With disregard for current evidence, the authors recommended total parenteral nutrition[6] and prophylactic antibiotics[7] for patients with severe pancreatitis.


Peer reviewers: Mansour A Parsi, MD, Center for Endoscopy and Pancreatobiliary Disorders, Digestive Disease Institute/A31, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OHIO, OH 44195, United States; Richard A Kozarek, MD, Department of Gastroenterology, Virginia Mason Medical Center, 1100 Ninth Avenue, PO Box 900, Seattle, WA 98111-0900, United States

S- Editor Tian L L- Editor Wang XL E- Editor Lin YP


1. Stamatakos M, Stefanaki C, Kontzoglou K, Stergiopoulos S, Giannopoulos G, Safioleas M. Walled-off pancreatic necrosis. World J Gastroenterol. 2010;16:1707–1712. [PMC free article] [PubMed]
2. van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, van Goor H, Schaapherder AF, van Eijck CH, Bollen TL, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362:1491–1502. [PubMed]
3. Carter R. Percutaneous management of necrotizing pancreatitis. HPB (Oxford) 2007;9:235–239. [PubMed]
4. Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg. 1993;128:586–590. [PubMed]
5. Buter A, Imrie CW, Carter CR, Evans S, McKay CJ. Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg. 2002;89:298–302. [PubMed]
6. Al-Omran M, Albalawi ZH, Tashkandi MF, Al-Ansary LA. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev. 2010:CD002837. [PubMed]
7. Wittau M, Hohl K, Mayer J, Henne-Bruns D, Isenmann R. The weak evidence base for antibiotic prophylaxis in severe acute pancreatitis. Hepatogastroenterology. 2008;55:2233–2237. [PubMed]

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