Has the Step-Up Approach Improved Prognosis in Severe Necrotizing Acute Pancreatitis?

Background/Objectives: Acute pancreatitis is a prevalent pathology with increasing incidence. Despite advances in treatment, some patients still present a severe clinical course with high morbidity and mortality rates. We evaluated the association between implementation of a step-up-based management strategy and clinical outcomes in patients with severe acute pancreatitis (SAP) treated at a tertiary referral center. Method: A retrospective observational study was conducted, including patients treated for SAP at a tertiary care center. Clinical outcomes, including mortality, morbidity, and length of hospital stay, were compared between two periods: Period A (1998-2010, classical treatment) and Period B (2011-2021, step-up approach). A subanalysis on minimally invasive techniques was also performed for Period B. Results: In total, 116 patients were included (39 Period A; 77 Period B). Pancreatic fistulas were reduced in Period B (15.38% vs. 5.33%; p = 0.088), as was mortality (30.76% vs. 18.67%; p = 0.15). Open surgeries decreased significantly in Period B (71.9% vs. 16.9%; p = 0.043), as did the mean hospital stay (60.5 ± 28 vs. 33.08 ± 28 days; p < 0.001). When comparing endoscopy management versus Video-Assisted Retroperitoneal Debridement (VARD), the rate of pancreatic fistulas was higher in the VARD group (0% vs. 57.1%; p < 0.01). Patients requiring VARD presented with larger collections (710 cc vs. 1737.9 cc; p = 0.03) and fewer procedures (4.2 ± 2.3 vs. 1.5 ± 0.5; p = 0.002). Conclusions: The step-up management in patients with SAP was associated with a decrease in open surgical approches and length of stay. VARD was performed in patients with higher volume collections and was associated with fewer interventions than patients treated by endoscopic necrosectomy; however, the incidence of pancreatic fistulas was higher.