|Year : 2022 | Volume
| Issue : 1 | Page : 88-89
A 'One step' or 'Step-up' approach for infected pancreatic necrosis – Which is more suitable for a developing country?
Amitabh Yadav, Samiran Nundy
Department of Surgical Gastroenterology and Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
|Date of Submission||18-Mar-2022|
|Date of Decision||21-Mar-2022|
|Date of Acceptance||21-Mar-2022|
|Date of Web Publication||28-Apr-2022|
Dr. Amitabh Yadav
33/13, First Floor, East Patel Nagar, New Delhi - 110 008
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Yadav A, Nundy S. A 'One step' or 'Step-up' approach for infected pancreatic necrosis – Which is more suitable for a developing country?. J Med Evid 2022;3:88-9
|How to cite this URL:|
Yadav A, Nundy S. A 'One step' or 'Step-up' approach for infected pancreatic necrosis – Which is more suitable for a developing country?. J Med Evid [serial online] 2022 [cited 2022 Jul 5];3:88-9. Available from: http://www.journaljme.org/text.asp?2022/3/1/88/344287
| Background|| |
Infected pancreatic necrosis (IPN) is a serious complication of acute pancreatitis and carries a high morbidity and mortality., Early radical surgical intervention in the form of open necrosectomy was once considered to be the mainstay of treatment and usually the endpoint in the therapeutic armamentarium of IPN. However, in 2006, the Dutch pancreatitis study group in the PANTER – Randomized Controlled Trial introduced a new 'step-up' approach for treating IPN. The approach included percutaneous or endoscopic intervention to drain/gain access to the necrotic cavity followed by a minimally invasive technique to remove the necrosum. They demonstrated that the step-up approach was associated with lower complications such as new-onset multiple organ failure, diabetes mellitus and incisional hernia. However, the step-up approach requires multiple interventions and a prolonged hospital stay. Feng Cao et al. from Beijing, China, have in their article compared the one-step laparoscopic assisted necrosectomy and the step-up approach with respect to their complications, death, total number of interventions and the total hospital stay in a retrospective analysis of 94 patients with IPN.
Infected necrosis in the study was diagnosed if the patient had a positive fine-needle aspiration fluid culture from the necrotic cavity, gas within the necrotic collection on a computed tomography scan or a deteriorating general condition despite the best possible ICU support. The patients, who all had localised necrosis, were divided into two groups – those who had the
- One-step approach (45 patients) – i.e., the direct surgical laparoscopic-assisted necrosectomy, through a 5-8 cm incision through the lesser sac or a retroperitoneal muscle cutting entry
- Step-up approach (49 patients) – percutaneous drainage followed by a surgical intervention if necessary.
No significant differences were observed between both the groups (one step vs. step-up) in terms of new onset organ failure (14.29 vs. 14.33%, P = 0.832), mortality (8.89 vs. 8.17%, P = 0.949) and long term complications (18.37 vs. 15.56%, P = 0.717). However, the hospital stay (50.62 +/- 35.58 vs. 63.98 +/- 25.07 days, P = 0.040) and the number of interventions (2.36 +/- 1.54 vs. 3.96 +/- 1.47) were less in the one-step group.
| Commentary|| |
Infected pancreatic necrosis is a difficult condition to treat and is associated with major mortality and prohibitive hospital costs. It is a heterogenous disease which may have varied presentations including localised walled off to widespread necrosis. The treatment options are multiple including percutaneous or endoscopic drainage, laparoscopic or open procedures. Sometimes, it is difficult to decide about the best modality for intervention – a radical open approach is thought to be associated with a higher mortality while a step-up approach is less traumatic and may have a lower mortality. This involves initial percutaneous drainage, which may have to be repeated 3 or 4 times, after which 35% of patients may avoid operation. In a developing country like India where nearly 60-70% of health care is provided by private sector, the cost of treatment and length of hospital stay are important factors to take into consideration and this study demonstrated that a one-time procedure was not inferior to the step-up approach in terms of mortality and morbidity but was associated with fewer interventions and a shorter hospital stay.
However, we must be aware that the patients treated in this study did not represent all patients with pancreatic necrosis, i.e., they had localised necrosis for which the trans lesser sac, retroperitoneal or combined laparoscopic approach was possible for its extraction. In widespread necrosis, this is not possible and open necrosectomy is indicated.
The time interval between the onset of the disease and surgical intervention in both the groups (73 vs 53 days) was sufficiently long for the necrosis to become loose and easily removed. However, the longer waiting time in treating established infected necrosis may be associated with more vascular or bowel complications such as thrombosis, aneurysmal bleeding or internal bowel fistulae with the duodenum or adjacent colon, which may affect outcomes.
We consider percutaneous drainage to be appropriate if there is a localised collection which is mainly fluid, a minimally invasive VARD (video-assisted retroperitoneal debridement) for localised solid necrosis and in patients with widespread necrosis, we perform a one-time open necrosectomy.
The present study suggests that even in patients with localised necrosis, a one-step procedure may be preferable to the step-up approach.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Aparna D, Kumar S, Kamalkumar S. Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit. World J Gastrointest Surg 2017;9:200-8.
Maheshwari R, Subramanian RM. Severe acute pancreatitis and necrotizing pancreatitis. Crit Care Clin 2016;32:279-90.
van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al.
A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-502.
Leppäniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H, Gamberini E, Kirkpatrick AW, et al.
2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg 2019;14:27.