Accelerated focused open necrosectomy-based step-cross versus conventional step-up approach in infected necrotizing...

Infected necrotizing pancreatitis (INP) patients requiring open necrosectomy (ON) as part of the step-up approach generally face high postoperative mortality. Our center proposed the step-cross approach as a supplement, but supporting evidence remains limited. This study aimed to compare clinical outcomes between the step-cross and step-up approaches in INP patients.

This retrospective cohort study included adult INP patients admitted to our center from 2017 to 2022. The step-cross approach consisted of percutaneous catheter drainage, followed by accelerated focused ON and personalized drainage or debridement as needed. Propensity score matching (PSM) was used to adjust for confounders.

Of 509 included patients (median age 46 [34-55] years, 67.6 % male), 454 (89.2 %) and 55 (10.8 %) underwent the step-up and step-cross approach respectively. Overall, 180-day mortality was 20.2 % (103/509): 83 (18.3 %) in the step-up group and 20 (36.4 %) in step-cross group. After PSM (53 matched pairs), 180-day mortality did not differ significantly (35.9 %vs 49.1 %, relative risk [RR] and 95 % confidence interval [CI] with the step-cross approach = 0.73 [0.46-1.15], P = 0.169), but the step-cross group was associated with lower CRRT duration (2 [0, 16] vs 15 [3.5, 22] days, P = 0.005) and fewer minimally invasive necrosectomy procedures. Complications, hospital stays and costs were comparable between groups.

The step-cross approach is a safe complementary strategy to the step-up approach, demonstrating trends toward lower mortality and reduced organ support requirements in selected INP patients. Nevertheless, these findings require validation through large-scale prospective studies.