Strengths and limitations
critically ill, infections
DISEASE, CRITICALLY ILL, INFECTIONS
We acknowledge some limitations in this study, mainly related to the retrospective nature of the analysis.The MANCTRA-1 study included centres having different levels of experience in treating AP. So, it is possible that the risks associated with infections and mortality were more significant if the patients were managed at centres with more limited experience, mainly when critically ill patients were not referred to specialist HPB units. This study was also limited by the variability in practice, different indications for surgical intervention, and quality of the prognostic modelling strategies due to the low adherence level to guidelines recommendations, as demonstrated in our previous audit [Nevertheless, the results of our study underlined that the best outcomes in patients with IPN are achieved when the guidelines are followed and that, as for other conditions, the discrepancy between what is recommended and the current daily practice is often significant.Finally, there is a residual chance of having missed relevant variables, especially those showing a dynamic evolution during the course of the disease. However, there are also several strengths of the present study. First, the strict inclusion criteria of patients with IPN ensured homogeneity in the study population, whereas previous studies looking at different interventions enrolled both infected and non-infected pancreatic collections, which are associated with different mortality rates. Moreover, as a multinational study with 150 participating centres across 41 different countries, the generalisability of our study results is high. Finally, our study emphasised two relevant issues: the need for evidence-based standardisation of the management of IPN and the importance of a timely referral to a specialist unit for patients with extensive necrotizing forms who may require ICU care and 24-h interventional radiological, endoscopic, or HPB surgical services. Indeed, managing patients with IPN involves the availability of many specialty services (gastroenterology, interventional endoscopy, surgery, critical care, and interventional radiology) and the experience of coordinating a multidisciplinary team. Therefore, if the full range of specialists is unavailable in the receiving hospital, a nominated team for managing severe AP patients should coordinate local treatments, where possible, and the referral to a specialist unit where appropriate.