Step-up Approach for the Management of Acute Necrotizing Pancreatitis (ANP): Single Institution Experience

Introduction: Acute necrotizing pancreatitis causing infected pancreatic necrosis is a severe disease with high morbidity and mortality that needs critical care and judicious management decisions. With a step-up approach in the management of acute necrotizing pancreatitis, there is a significant reduction in complications. The aim of this study is to analyze the outcome of the step-up approach in a single tertiary care centre.

Methodology: Prospective observational study conducted between January 2021 and December 2022. Patients with pancreatic necrosis or peripancreatic necrosis detected on contrast-enhanced computed tomography scans were included in the study.

Results: A total of 53 patients were included in the study. Ethanol (75.5%) and biliary (11.3%) were the two most common etiology. 32 patients (60.4%) were managed conservatively initially and 19 (35.8%) with a step-up approach. Interventions were done in 24 patients (45.3%) –image-guided percutaneous drainage-14(26.4%) patients, Percutaneous drainage followed by necrosectomy- 5(9.4%) patients, Conservative management followed by direct necrosectomy -5 (9.4%) Patients. 14(73.7%) Patients were managed with Percutaneous drainage alone successfully. Overall mortality- 4 patients. Primary end points were- mortality 02(10.5%), Enteric fistula 03(15.9%), secondary end points- biliary stricture and Pseudocyst formation 01(5.3%), need of pancreatic enzymes 02(10.5%).

Conclusion: Step-up approach management reduces morbidity and mortality in patients with necrotizing pancreatitis and infected pancreatic necrosis, in two-thirds of patients percutaneous drainage obviated the need for necrosectomy.