Real-World Adherence to the Step-Up Strategy in Pancreatic Necrosis Management: A Tertiary Center Experience

Abstract

Acute pancreatitis is a clinically heterogeneous condition that can become life-threatening, particularly in the presence of infected pancreatic necrosis (IPN). Over the past two decades, the step-up approach has emerged as a preferred management strategy, evolving with advances in technique and clinical experience. This retrospective study aimed to evaluate the real-world adherence to the step-up approach in a tertiary care hospital and to assess associated short- and long-term outcomes. A total of 146 patients meeting the inclusion and exclusion criteria were analyzed and divided into two groups: the adherence group (n=134), managed according to the step-up protocol, and the non-adherence group (n=12), who underwent upfront surgical intervention. Outcomes including mortality, complication rates, incidence of multiorgan failure, and predictors of poor prognosis were compared. The adherence rate to the step-up approach was 91.8%. Mortality rates were similar between the two groups (16.42% in the adherence group vs. 16.67% in the non-adherence group, p>0.05). However, new-onset multiorgan failure occurred significantly less frequently in the adherence group (9.7%) compared to the non-adherence group (25%, p<0.05). The overall complication rate was notably lower in the adherence group (12.66%) versus the non-adherence group (50%). These findings suggest that the step-up approach is feasible and effective in managing IPN, with high adherence rates and favorable outcomes. Future studies should aim to refine patient selection and explore adjunctive therapies that may further improve prognosis in this high-risk population.