Review for 10.1186/s12876-024-03539-7 (2024)

Title: Efficiency of laparoscopic retroperitoneal pancreatic necrosectomy for treating infected
pancreatic necrosis with duodenal fistula: A single-center retrospective cohort study
Version: 0 Date: 15 Aug 2024
Reviewer's report:
Authors in the present report concluded that for patients with IPN and DF, the LRPN-centered
step-up strategy was safe and effective  and that DF prolongs hospital stay and increases
hospitalization costs for patients.
From literature we already know that gastrointestinal fistulas occurred in about 6-8% of NP
patients. Independent risk factors are low albumin and early intervention, while early enteral
nutrition is a protective factor. However we also learned that the majority of patients with
gastrointestinal fistulas treated with step-up approach  could avoid surgery.
In addition is also clear that Iatrogenic injury is one of the causes of duodenal fistula in patients
with severe pancreatitis. report exist for laparoscopic assisted debridement through the right
retroperitoneal approach as an effective treatment for duodenal fistula
This article, although of some interest, presents several problems.
1. Abstract : please spell PDC in result section
2. Although Authors have an higher  conversion rate to open surgery  in the DF group than in
the non-DF group (13.5% vs. 3.8%) even if not significant haw they can assume that  the LRPN-
centered step-up strategy is safe and effective? Please discuss better this point
3.Author reported that the first step was  percutaneous catheter drainage (PCD) under
ultrasound or CT guidance to drain the accumulation of infected fluid around the pancreas.
and if drainage was ineffective, laparoscopic-assisted retroperitoneal drainage of the pancreatic
necrotic aggregates was performed. From figure 1 this is not really clear. How many of the 197
pts underwent PDC? All 197 underwent LRPN procedure? Please better define the numbers
3. All 197 pts underwent LRPN procedure  and some of these patients  developed DFs after
debridement, indicating that both the debridement process and the placement of double-sleeve
tubes after debridement may be risk factors for DF. if this statement is correct then the approach
of the work falters. It would be more correct for readers to have clearer tables and perhaps a
separate analysis of patients with iatrogenic fistula from post-pancreatitis fistula. In addition,
if all patients underwent a lap, how can an iatrogenic fistula be distinguished from post-
pancreatitis? This requires a better description of patients
4. Authors  speculate in the discussion that, after the occurrence of DF, necrotic material may
block the perforation site, leading to a lack of significant leakage of digestive fluid into the
abdominal cavity. As a result, severe clinical symptoms of gastrointestinal perforation may not
occur; instead, nonspecific clinical manifestations, such as recurrent or worsening fever, may be
present, which may not attract clinical attention. This is a pure speculation and must be removed
or better supported by the analysis of patients
5. If Authors  found that the proportion of patients undergoing surgical debridement and the
number of PCD and surgical procedures were higher in the DF group than in the non-DF group
how that cal assume that the LRPN-centered step-up strategy is safe and effective?
6. In the case of DF before the LRPN the patient was positioned in the lateral decubitus position
at 80°–90°, and a 2-cm incision was made along the posterior axillary line in the space between
the lower rib margin and the iliac crest right or left? Please clarify the  surgical approach
7. Author assume that for patients suggested of having DF, infected necrotic aggregates around
the duodenum were cleared, and a double-sleeve tube was placed around the fistula site for
continuous postoperative irrigation. Was any case where the tube migrated in the duodenum
itself? Was any patients receiving a digiunostomy for enteral feeding? If not why? Please clarify
7. Finally, although the bias of the study are very evident and the lack of a control group makes
the study  weak, I personally ask myself what is really new about this study compared to what
is already present in the literature? Is it just my feeling? Please clarify this concept to me first
and to the readers too