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Extrapancreatic necrosis without pancreatic parenchymal necrosis: a separate entity in necrotising pancreatitis?
  1. Olaf J Bakker1,
  2. Hjalmar van Santvoort1,
  3. Marc G H Besselink1,2,
  4. Marja A Boermeester2,
  5. Casper van Eijck3,
  6. Kees Dejong4,
  7. Harry van Goor5,
  8. Sijbrand Hofker6,
  9. Usama Ahmed Ali1,
  10. Hein G Gooszen7,
  11. Thomas L Bollen8,
  12. for the Dutch Pancreatitis Study Group
  1. 1Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
  2. 2Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
  3. 3Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
  4. 4Department of Surgery and NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
  5. 5Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
  6. 6Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
  7. 7Department of Operation Room, Evidence Based Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
  8. 8Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
  1. Correspondence to Dr Olaf J Bakker, University Medical Center Utrecht, PO Box 85500, HP G04.228, 3508 GA, Utrecht, The Netherlands; o.j.bakker{at}


Objective In the revised Atlanta classification of acute pancreatitis, the term necrotising pancreatitis also refers to patients with only extrapancreatic fat necrosis without pancreatic parenchymal necrosis (EXPN), as determined on contrast-enhanced CT (CECT). Patients with EXPN are thought to have a better clinical outcome, although robust data are lacking.

Methods A post hoc analysis was performed of a prospective multicentre database including 639 patients with necrotising pancreatitis on contrast-enhanced CT. All CECT scans were reviewed by a single radiologist blinded to the clinical outcome. Patients with EXPN were compared with patients with pancreatic parenchymal necrosis (with or without extrapancreatic necrosis). Outcomes were persistent organ failure, need for intervention and mortality. A predefined subgroup analysis was performed on patients who developed infected necrosis.

Results 315 patients with EXPN were compared with 324 patients with pancreatic parenchymal necrosis. Patients with EXPN less often suffered from complications: persistent organ failure (21% vs 45%, p<0.001), persistent multiple organ failure (15% vs 36%, p<0.001), infected necrosis (16% vs 47%, p<0.001), intervention (18% vs 57%, p<0.001) and mortality (9% vs 20%, p<0.001). When infection of extrapancreatic necrosis developed, outcomes between groups were equal (mortality with infected necrosis: EXPN 28% vs pancreatic necrosis 18%, p=0.16).

Conclusion EXPN causes fewer complications than pancreatic parenchymal necrosis. It should therefore be considered a separate entity in acute pancreatitis. Outcome in cases of infected necrosis is similar.

  • Pancreas
  • pancreatitis
  • necrosis
  • peripancreatic
  • extrapancreatic

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  • Funding The study was supported by a research grant from the Dutch Organization for Health Research and Development (ZonMw, grant numbers 945-06-910). OJB is sponsored by The Netherlands Organization for Health Research and Development (ZonMw, grant number 17 099.2902) to perform clinical studies on necrotising pancreatitis. The sponsors had no involvement in any stage of the study design, data collection, data analysis and interpretation of the study results.

  • Competing interests None.

  • Ethics approval Ethics approval was obtained from the Institutional Review Board of Utrecht University Medical Center.

  • Provenance and peer review Not commissioned; externally peer reviewed.