Understanding the composite failure rate of the step-up approach in infected necrotizing pancreatitis: a scoping...

Infected necrotizing pancreatitis (INP) represents one of the most severe complications of acute pancreatitis, traditionally managed by early open necrosectomy. Over the past decade, a paradigm shift toward a minimally invasive, staged "step-up approach" starting with percutaneous or endoscopic drainage followed by necrosectomy only if necessary has markedly improved outcomes. Nevertheless, the actual composite failure rate of this algorithm remains undefined. A scoping review was conducted following PRISMA-ScR guidelines to map the highest-level evidence (randomized controlled trials and systematic reviews) published between 2010 and 2025. Fourteen studies met the inclusion criteria-five RCTs and nine systematic reviews/meta-analyses. The PANTER, TENSION, POINTER, PENGUIN, and DESTIN trials established the step-up approach as standard of care, consistently demonstrating lower morbidity and comparable mortality versus open surgery. Across studies, percutaneous drainage alone resolved infection in 35-50% of cases, while an additional 30-40% required minimally invasive necrosectomy. Despite these successes, 15-20% of patients ultimately required open surgical intervention. Marked heterogeneity persists regarding the definition of "failure," outcome measures, and timing of intervention. Current evidence supports the superiority of the step-up approach in reducing complications and healthcare burden in INP. Yet, no study has quantified the cumulative failure rate across combined radiologic and endoscopic pathways. Future trials and registries should adopt unified definitions and integrated reporting frameworks to clarify true efficacy and guide personalized, escalation-based management of necrotizing pancreatitis. We propose a structured pattern classification of failure after a step-up approach to INP.