The new england journal of medicine n engl j med 363;13 nejm.org september 23, 2010 1286 in-hospital mortality; careful selection of oxy- gen saturation targets in clinical practice is also warranted. Waldemar A. Carlo, M.D. University of Alabama at Birmingham Birmingham, AL wcarlo@peds.uab.edu Neil N. Finer, M.D. University of California at San Diego San Diego, CA Marie G. Gantz, Ph.D. RTI International Research Triangle Park, NC Since publication of their article, the authors report no fur- ther potential conflict of interest. 1. Duc G, Sinclair JC. Oxygen administration. In: Sinclair JC, Bracken MB, eds. Effective care of the newborn infant. New York: Oxford University Press, 1992:178-94. 2. Askie LM, Henderson-Smart DJ, Ko H. Restricted versus lib- eral oxygen exposure for preventing morbidity and mortality in preterm or low birth weight infants. Cochrane Database Syst Rev 2009;1:CD001077. 3. Tin W, Gupta S. Optimum oxygen therapy in preterm babies. Arch Dis Child Fetal Neonatal Ed 2007;92:F143-F147. 4. Laptook AR, Shalhab W, Allen J, Saha S, Walsh M. Pulse oximetry in very low birth weight infants: can oxygen saturation be maintained in the desired range? J Perinatol 2006;26:337-41. A Step-up Approach, or Open Necrosectomy for Necrotizing Pancreatitis To the Editor: The results from the study by van Santvoort et al. (Minimally Invasive Step-up Ap- proach versus Maximal Necrosectomy in Patients with Acute Necrotizing Pancreatitis [PANTER]) (April 22 issue) 1 show that percutaneous drain- age (PCD) alone is a valuable strategy in selected patients, helping to avoid the need for surgery in 40% of step-up patients. The reduced morbidity associated with the procedure may largely be due to the avoidance of harm from surgery: when PCD-only patients are not considered, the complication rate appears to be similar in the two study groups. Moreover, PCD was often inadequate, leading to a delay in source control. Since PCD appears to be less suc- cessful in patients with multiple organ failure, 2 and since mortality dramatically increased when it was used as a sole strategy for these patients, 3 an important element of the treatment is poten- tially delayed. Early identification of patients who will not be helped by PCD is desirable. Rather than using a step-up approach for all patients, a strategy tailored to the patient’s spe- cific needs, based on the results of computed tomography and on clinical condition, using the source-control strategy most likely to adequately drain collected fluid and débride infected ne- crotic tissue may be the best approach after all. PCD, video-assisted retroperitoneal débridement, and open necrosectomy may all be effective tools to use in reaching this goal. Jan J. De Waele, M.D., Ph.D. Ghent University Hospital Ghent, Belgium jan.dewaele@ugent.be No potential conflict of interest relevant to this letter was re- ported. 1. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-502. 2. Mortelé KJ, Girshman J, Szejnfeld D, et al. CT-guided percu- taneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol 2009;192:110-6. 3. Rocha FG, Benoit E, Zinner MJ, et al. Impact of radiologic intervention on mortality in necrotizing pancreatitis: the role of organ failure. Arch Surg 2009;144:261-5. To the Editor: The PANTER study group teaches us that “minimally” invasive surgery is associat- ed with a lower morbidity than open necrosec- tomy in patients who have necrotizing pancreati- tis with infected necrotic tissue. Although this article is a milestone in the surgical literature, its results are disappointing. There was no signifi- cant difference in the mortality of the two study groups (16% vs. 19%) despite the fact that inter- vention was withheld for at least 4 weeks. The complications in the group receiving “minimal- ly” invasive treatment included enterocutaneous fistulas (in 22% of patients), intra-abdominal bleeding (16%), pancreatic fistulas (28%), and in- cisional hernias (7%). 1 The surgery these patients received was clearly not “minimally” invasive. But is there another approach? Does infected necrotic tissue need drainage at all? Several case reports and series have recorded reasonable sur- vival rates among patients treated with antibiot- ics alone. 1-4 Now that withholding intervention for at least 4 weeks seems to be ensconced in good surgical practice, perhaps a longer wait, coupled with the judicious use of antibiotics, can The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITEIT GENT on February 7, 2011. For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved.