Comparative analysis of step-up approach and primary open drainage via mini-access in necrotizing pancreatitis with different grade of retroperitoneal extension of acute fluid collection

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Abstract

Background. Acute pancreatitis remains one of the most common conditions among emergency surgical pathologies. Despite the widespread adoption of step-up minimally invasive strategies, the optimal choice of primary drainage for necrotizing pancreatitis (NP), particularly in patients with different grade of retroperitoneal extension of acute fluid collection (RE), remains controversial.

Aim. To evaluate the effectiveness of the step-up approach and primary open drainage via mini-access in patients with NP depending on the grade of RE.

Materials and methods. The retrospective–prospective study included 116 patients with NP treated in a municipal hospital between 2015 and 2025. The grade of RE was assessed according to the Ishikawa classification, and disease severity according to the revised Atlanta criteria. The comparative analysis was performed between patients managed using a step-up approach (group 1, n = 21) and those who underwent primary open drainage via mini-access (group 2, n = 12). The study endpoints included the need for surgery, the effectiveness of percutaneous catheter drainage (PCD) as definitive treatment, mortality, incidence of erosive hemorrhage and gastrointestinal fistulas, and the need for laparotomy in patients with different grade of RE.

Results. RE of grade III, IV, V was associated with a higher incidence of severe NP and an increased need for drainage of necrotic areas (OR = 6.85; 95% CI = 1.46–32.09; p = 0.0069 and OR = 3.75; 95% CI = 1.42–9.90; p = 0.0071, respectively). PCD served as definitive treatment in 33% of patients. No significant association was found between the grade of RE (OR = 3.33; 95% CI = 0.50–22.1; p = 0.345), timing (OR = 1.78; 95% CI = 0.28–11.1; p = 0.659), or indications for PCD (OR = 2.75; 95% CI = 0.38–19.7; p = 0.354) and the need for a surgical necrosectomy. Mortality in the step-up group was 14% and did not differ significantly from that in the primary mini-access group (p = 0.643), despite a higher proportion of severe NP in the latter. The use of mini-access approaches provided adequate drainage and effective control of the septic process without an increase in mortality.

Conclusion. The step-up approach and primary open drainage via mini-access demonstrate comparable effectiveness in the treatment of patients with NP regardless of the grade of RE. In patients with a predominance of solid necrotic components over fluid collections, primary drainage via mini-access may be considered a reasonable alternative to PCD.

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About the authors

Victoria G. Firsova

City Clinical Hospital No. 35, Nizhny Novgorod; National Research Lobachevsky State University of Nizhny Novgorod

Author for correspondence.
Email: victoria.firsova@mail.ru

M.D., Associate Professor, Department of Surgical Diseases

Russian Federation, Nizhny Novgorod; Nizhny Novgorod

Maria A. Labutina

City Clinical Hospital No. 35

Email: labutinamariya@yandex.ru

Head of Operating Unit, Surgeon

Russian Federation, Nizhny Novgorod

References

  1. Revishvili ASh, Olovyannyy VE, Sazhin VP, Markov PV, Gogiya BSh, Gorin DS, Ushakov AA. Orudzheva SA, Kuznetsov AV, Shelina NV, Ovechkin AI. Surgical care in the Russian Federation: Information and analytical report for 2022. Moscow. 2023; 186. (in Russ.)
  2. Iannuzzi JP, King JA, Leong JH, Quan J, Windsor JW, Tanyingoh D, Coward S, Forbes N, Heitman SJ, Shaheen AA, Swain M, Buie M, Underwood FE, Kaplan GG. Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis. Gastroenterology. 2022;162(1):122–134. doi: 10.1053/j.gastro.2021.09.043.
  3. Knudsen JS, Heide-Jørgensen U, Mortensen FV, Sørensen HT, Ehrenstein V. Acute pancreatitis: 31-Year trends in incidence and mortality - A Danish population-based cohort study. Pancreatology. 2020;20(7):1332–1339. doi: 10.1016/j.pan.2020.09.011.
  4. Oskarsson V, Hosseini S, Discacciati A, Videhult P, Jans A, Ekbom A, Sadr-Azodi O. Rising incidence of acute pancreatitis in Sweden: National estimates and trends between 1990 and 2013. United European Gastroenterology Journal. 2020;8(4):472–480. doi: 10.1177/2050640620913737.
  5. Minzdrav Rossii. Klinicheskie rekomendatsii: Ostryi pankreatit. Razdel 903_1. URL: https://cr.minzdrav.gov.ru/preview-cr/903_1 (data obrashcheniya: 11.01.2026). (in Russ.)
  6. Leppаniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H, Gamberini E, Kirkpatrick AW, Ball CG, Parry N, Sartelli M, Wolbrink D, van Goor H, Baiocchi G, Ansaloni L, Biffl W, Coccolini F, Di Saverio S, Kluger Y, Moore E, Fausto Catena F. 2019 WSES guidelines for the management of severe acute pancreatitis. World Journal of Emergency Surgery. 2019;14:27. doi: 10.1186/s13017-019-0247-0.
  7. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013; 13(4): e1–15. doi: 10.1016/j.pan.2013.07.063.
  8. Ikeda M, Hamada S, Kikuta K, Takikawa T, Yoshida N, Matsumoto R, Tanaka Y, Kataoka F, Sasaki A, Tarasawa K, Fujimori K, Fushimi K, Masamune A. Acute Pancreatitis in Japan: Comparison of Before and After Revision of the Clinical Guidelines. Pancreas. 2022;51(3):261–268. doi: 10.1097/MPA.0000000000002009.
  9. Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology. 2020;158(1):67–75.e1. doi: 10.1053/j.gastro.2019.07.064.
  10. Arvanitakis M, Dumonceau JM, Albert J, Badaoui A, Bali MA, Barthet M, Besselink M, Deviere J, Oliveira Ferreira A, Gyökeres T, Hritz I, Hucl T, Milashka M, Papanikolaou IS, Poley JW, Seewald S, Vanbiervliet G, van Lienden K, van Santvoort H, Voermans R, Delhaye M, van Hooft J. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy. 2018;50(5):524–546. doi: 10.1055/a-0588-5365.
  11. Li G, Li S, Cao L, Mao W, Zhou J, Ye B, Zhang J, Ding L, Zhu Y, Ke L, Liu Y, Tong Z, Li W. Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patients: a retrospective cohort study. International Journal of Surgery. 2023;109(6):1677–1687. doi: 10.1097/JS9.0000000000000415.
  12. Luckhurst CM, El Hechi M, Elsharkawy AE, Eid AI, Maurer LR, Kaafarani HM, Thabet A, Forcione DG, Fernández-Del Castillo C, Lillemoe KD, Fagenholz PJ. Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort. Journal of the American College of Surgeons. 2020;230(6):873–883. doi: 10.1016/j.jamcollsurg.2020.01.038.
  13. Liu Y, Wang X, Wang H, Tian Y, Fu X. Application and Value of Percutaneous Catheter Drainage in Contemporary Surgical Treatment of Pancreatic Necrosis. Digestive Diseases and Sciences. 2025;70(9):2977–2989. doi: 10.1007/s10620-025-09110-y.
  14. Bhatia H, Farook S, Bendale CU, Gupta P, Singh AK, Shah J, Samanta J, Mandavdhare H, Sharma V, Sinha SK, Gupta V, Yadav TD, Dutta U, Sandhu MS, Kochhar R. Early vs. late percutaneous catheter drainage of acute necrotic collections in patients with necrotizing pancreatitis. Abdominal Radiology. 2023;48(7):2415–2424. doi: 10.1007/s00261-023-03883-4.
  15. Verma N, Maurya M, Gupta P, Samanta J, Mandavdhare H, Sharma V, Dutta U, Kochhar R. Retroperitoneal versus transperitoneal percutaneous catheter drainage of necrotic pancreatic collections: a comparative analysis. Abdominal Radiology. 2022;47(5):1899–1906. doi: 10.1007/s00261-022-03476-7.
  16. Ishikawa K, Idoguchi K, Tanaka H, Tohma Y, Ukai I, Watanabe H, Matsuoka T, Yokota J, Sugimoto T. Classification of acute pancreatitis based on retroperitoneal extension: application of the concept of interfascial planes. European Journal of Radiology. 2006; 60(3): 445–52.
  17. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS. Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis - 2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013; 62(1): 102–11. doi: 10.1136/gutjnl-2012-302779.
  18. Xu Y, Ye C, Tan B. Evaluation of Inflammatory Infiltration in the Retroperitoneal Space of Acute Pancreatitis Using Computer Tomography and Its Correlation with Clinical Severity. Contrast Media & Molecular Imaging. 2023;2023:7492293. doi: 10.1155/2023/7492293.
  19. Wos-Wroniewicz E, Caban M, Malecka-Panas E. Role of adipokines in the assessment of severity and predicting the clinical course of acute pancreatitis. Journal of Physiology and Pharmacology. 2020;71(5). doi: 10.26402/jpp.2020.5.01.
  20. Yang J, Liu M, Wang S, Gan Y, Chen X, Tao Y, Gao J. Alteration of Peripheral Resistin and the Severity of Acute Pancreatitis: A Meta-Analysis. Frontiers in Medicine. 2022;9:915152. doi: 10.3389/fmed.2022.915152.
  21. Greer PJ, Lee PJ, Paragomi P, Stello K, Phillips A, Hart P, Speake C, Lacy-Hulbert A, Whitcomb DC, Papachristou GI. Severe acute pancreatitis exhibits distinct cytokine signatures and trajectories in humans: a prospective observational study. American Journal of Physiology-Gastrointestinal and Liver Physiology. 2022;323(5):G428–G438. doi: 10.1152/ajpgi.00100.2022.
  22. Kiss L, Fur G, Pisipati S, Rajalingamgari P, Ewald N, Singh V, Rakonczay ZJr. Mechanisms linking hypertriglyceridemia to acute pancreatitis. Acta Physiologica. 2023;237(3):e13916. doi: 10.1111/apha.13916.
  23. Onnekink AM, Boxhoorn L, Timmerhuis HC, Bac ST, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SAW, Bruno MJ, van Brunschot S, Cappendijk VC, Consten ECJ, Dejong CH, Dijkgraaf MGW, van Eijck CHJ, Erkelens WG, van Goor H, van Grinsven J, Haveman JW, van Hooft JE, Jansen JM, van Lienden KP, Meijssen MAC, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Rоmkens TEH, van Santvoort HC, Scheepers JJ, Schwartz MP, Seerden T, Spanier MBW, Straathof JWA, Timmer R, Venneman NG, Verdonk RC, Vleggaar FP, van Wanrooij RL, Witteman BJM, Fockens P, Voermans RP. Dutch Pancreatitis Study Group. Endoscopic Versus Surgical Step-Up Approach for Infected Necrotizing Pancreatitis (ExTENSION): Long-term Follow-up of a Randomized Trial. Gastroenterology. 2022;163(3):712–722.e14. doi: 10.1053/j.gastro.2022.05.015.
  24. Novikov SV, Rogal ML, Yartsev PA, Teterin YuS. Technical aspects of minimally invasive percutaneous surgical treatment of local complications of acute pancreatitis. Annals of HPB Surgery. 2021;26(3):60–69. doi: 10.16931/1995-5464.2021-3-60-69. (in Russ.)
  25. Valentin C, Le Cosquer G, Tuyeras G, Culetto A, Barange K, Hervieu PE, Carrère N, Muscari F, Mokrane F, Otal P, Bournet B, Suc B, Buscail L. Step-up approach for the treatment of infected necrotising pancreatitis: real life data from a single-centre experience with long-term follow-up. BMC Gastroenterology. 2024;24(1):213. doi: 10.1186/s12876-024-03289-6.
  26. Pavlek G, Romic I, Kekez D, Zedelj J, Bubalo T, Petrovic I, Deban O, Baotic T, Separovic I, Strajher IM, Bicanic K, Pavlek AE, Silic V, Tolic G, Silovski H. Step-Up versus Open Approach in the Treatment of Acute Necrotizing Pancreatitis: A Case-Matched Analysis of Clinical Outcomes and Long-Term Pancreatic Sufficiency. Journal of Clinical Medicine. 2024;13(13):3766. doi: 10.3390/jcm13133766.
  27. Brunschot S, Hollemans RA, Bakker OJ, Besselink MG, Baron TH, Beger HG, Boermeester MA, Bollen TL, Bruno MJ, Carter R, French JJ, Coelho D, Dahl B, Dijkgraaf MG, Doctor N, Fagenholz PJ, Farkas G, Castillo CF, Fockens P, Freeman ML, Gardner TB, Goor HV, Gooszen HG, Hannink G, Lochan R, McKay CJ, Neoptolemos JP, Olаh A, Parks RW, Peev MP, Raraty M, Rau B, Rоsch T, Rovers M, Seifert H, Siriwardena AK, Horvath KD, van Santvoort HC. Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients. Gut. 2018;67(4):697–706. doi: 10.1136/gutjnl-2016-313341.
  28. Mihoc T, Pirvu C, Dobrescu A, Brebu D, Macovei AMO, Popa ZL, Pantea S. Risk Factors Influencing Mortality in Open Necrosectomy for Acute Pancreatitis: A Comparative Analysis. Journal of Clinical Medicine. 2024;13(23):7151. doi: 10.3390/jcm13237151.
  29. Xiao J, Quan X, Liu F, Li W. Comparison of Different Surgical Methods for Necrotizing Pancreatitis: A Meta-Analysis. Frontiers in Surgery. 2021;8:723605. doi: 10.3389/fsurg.2021.723605.
  30. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990; 174(2): 331–6.
  31. Husu HL, Kuronen JA, Leppаniemi AK, Mentula PJ. Open necrosectomy in acute pancreatitis-obsolete or still useful? World Journal of Emergency Surgery. 2020;15(1):21. doi: 10.1186/s13017-020-00300-9.
  32. Sahu B, Abbey P, Anand R, Kumar A, Tomer S, Malik E. Severity assessment of acute pancreatitis using CT severity index and modified CT severity index: correlation with clinical outcomes and severity grading as per the Revised Atlanta Classification. Indian Journal of Radiology and Imaging. 2017;27(2):152–160. doi: 10.4103/ijri.IJRI_300_16.
  33. Metri A, Bush N, Singh VK. Predicting the severity of acute pancreatitis: Current approaches and future directions. Surgery Open Science. 2024;19:109–117. doi: 10.1016/j.sopen.2024.03.012.

Supplementary files

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2. Fig. 1. Study flow-chart.

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3. Fig. 2. Primary open drainage via two mini-accesses using pass-throw large bored drainage.

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4. Fig. 3. CT, axial projection. Patient K., 47 years old. Necrotizing pancreatitis, complicated by large acute necrotic collection: a) deep necrosis in the neck of the pancreas (yellow arrow), b) viable parenchyma of the pancreatic tail.

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5. Fig. 4. (a, b – computed tomography, coronal view; c – intraoperative photograph). NP complicated by RE of grade V, with the formation of walled-off necrosis in the retroperitoneal space on the right (a) and left (b); (c) postoperative status following bilateral drainage of infected necrotic foci and necrosectomy performed via mini-retroperitoneal approaches.

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