A novel mini-invasive step-up approach for the treatment of severe acute pancreatitis with extensive infected necrosis: A single center case series study

Abstract

Rationale: Complete removal of necrosis is critical for treating patients with severe acute pancreatitis (SAP) presenting infection of pancreatic necrosis (IPN). Frequently used mini-invasive methods include the surgical step-up approach suitable for necrosis extending laterally, whereas the endoscopic step-up approach is suitable for medial necrosis. However, in patients with extensive IPN, either approach alone usually has limited treatment effects. Patient concerns: We describe a case series of combined mini-invasive step-up approach for treating extensive IPN. Diagnoses: Patients were diagnosed with SAP and had extensive IPN. Interventions: Seven patients with SAP and extensive IPN were enrolled. All patients underwent a combined step-up approach comprising 4 steps: percutaneous catheter drainage, continuous negative pressure irrigation (CNPI), percutaneous endoscopic necrosectomy (PEN), and transgastric necrosectomy (TN). Outcomes: The median interval from symptom onset to percutaneous catheter drainage and CNPI was 11 days (range, 6–14) and 18 days (range, 14–26), and the median CNPI duration was 84 days (range, 54–116). The median interval from the onset of symptoms to PEN and TN was 36 days (range, 23–42) and 41 days (range, 34–48), respectively, and the median number of procedures was 2 (range, 1–2) for PEN and 3 (range, 2–4) for TN. Only a minor case of abdominal bleeding and a pancreatic-cutaneous fistula were reported, both resolved after conservative treatment. The median length of stay in the intensive care unit was 111 days (range, 73–133); all patients survived. Lessons: This mini-invasive step-up approach shows promising clinical effects and is relatively safe in critically ill patients with extensive IPN and high-risk surgical intervention.