CLINICAL OUTCOMES OF STEP-UP VERSUS OPEN NECROSECTOMY IN SEVERE NECROTIZING PANCREATITIS: A RETROSPECTIVE OBSERVATIONAL COHORT STUDY
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Keywords
Necrotizing Pancreatitis, Step-Up Approach, Open Necrosectomy, Infected Necrosis, Outcomes.
Abstract
The management of infected pancreatic necrosis has evolved from primary open necrosectomy (ON) to a step-up approach (SUA) encompassing percutaneous drainage followed, if needed, by minimally invasive necrosectomy. While randomized trials established SUA’s superiority, real-world outcomes in contemporary, non-trial settings require further evaluation. This study compares clinical outcomes of SUA versus ON in a tertiary care center.
Methods: A retrospective observational cohort study was conducted on consecutive patients with confirmed infected necrotizing pancreatitis admitted between January 2020 and September 2024. Patients were categorized into the SUA group (initial percutaneous or endoscopic drainage) or the ON group (primary surgical necrosectomy). Primary outcome was a composite of major complications (new-onset organ failure, bleeding, enteric fistula, or death) within 90 days. Secondary outcomes included individual complications, hospital length of stay (LOS), and need for re-interventions.
Results: Of 112 included patients, 68 underwent SUA and 44 underwent ON. The groups were comparable in baseline severity (APACHE-II, CT severity index). The primary composite outcome occurred in 22 patients (32.4%) in the SUA group versus 28 patients (63.6%) in the ON group (p=0.001). New-onset multi-organ failure (20.6% vs. 43.2%, p=0.01) and enteric fistulae (4.4% vs. 20.5%, p=0.008) were significantly lower in the SUA group. Mortality was 10.3% (SUA) vs. 22.7% (ON) (p=0.08). Median hospital LOS was 42 days (SUA) vs. 58 days (ON) (p=0.02). Re-intervention rates were not significantly different.
Conclusion: In this real-world observational study, the step-up approach was associated with a significantly lower rate of major complications and a shorter hospital stay compared to primary open necrosectomy. These findings reinforce SUA as the standard of care for managing infected pancreatic necrosis in contemporary clinical practice.
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Venu Bhargava Mulpuri
Department of Surgical Gastroenterology, ESIC Medical college, Hyderabad, India. Email: [email protected]
